Cough-Variant Asthma, Language Development, Molluscum Contagiosum – PediaCast 137
- Bisphenol A (again)
- Breast-Milk Immunity
- Vaccines and Autism
- Anesthesia and Autism
- Cough-Variant Asthma
- Language Development
- Molluscum Contagiosum
- Bisphenol A Found To Have No Reproductive And Developmental Effects
- Study Shows How Breastfeeding Transfers Immunity To Babies
- Researcher Says No Proven Link Between Vaccines And Autism
- Anesthesia Exposure May Increase Risk For Childhood Developmental Disorders
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 Summerland Studio here is your host Dr. Mike.
Dr. Mike Patrick: Hello everyone and welcome to PediaCast. It is Episode 137 for Thursday, November 6th 2008.
What are we going to talk about today?
Well lots of things and among them; Cough Variant Asthma, also Language Development, and Molluscum Contagiosum; I love that name Molluscum Contagiosum, and there's really no other common name for that particular disorder so we got to tell parents, "Hey your kid has Molluscum Contagiosum." So what is that all about, we're going to talk about a little bit later on. And of course we have lots of new stories for you as well.
Now before we get started, I want to say first of, Congratulations to our new President Elect, Barrack Obama. Now I will be upfront with you as an audience, I did not vote for Barrack Obama. I voted for John McCain but I want to point out and I think this is important, I really hope that Mr. Obama does a fantastic job, I really do. I mean basically just shy of half the country did not vote for Barrack Obama, right? So I mean obviously he didn't get a majority but still it was close and OK not too close, 6 percentage points was the spread. But my only point is I think that almost half of the country that did not vote for the man, I think we need to rally behind them and obviously I don't want a socialist society and I'm sure that most Americans don't want that either and I have no idea what healthcare is going to look like four years from now.
It could be interesting, could be good, could be bad. My only point is that I think we need to come together as Americans and support our President. I really do even though I have been a Republican-type person for my entire life and probably will continue to be that way. But I do hope that he does a good job. I do not wish any ill will upon him like I have heard in some very conservative circles around the country.
OK this is not a politics show, so we are going to move on.
I want to say also, Beggars Night since we haven't met since then. You know Beggar's Night has changed a lot since I was a kid. When I was a kid and this was back when we lived in Ohio. Beggar's Night was always on Halloween, it seemed to last many hours to me, I mean I remember being out going from door to door for a long time and it included lots of darkness time. You know it would get dark and then usually you're going around trick or treating and I don't know, it was just kind of fun.
Ohio now in the last few years, the trick or treat is never on Halloween back in Ohio. It's called Beggar's Night; they avoid the weekends, I think they avoid Friday, Saturday, and Sunday so it has to be a Monday through a Thursday and each community decides exactly when their Beggar's Night is going to be that usually only lasts a couple hours and it all gets wrapped up before darkness falls, and of course it's for safety; they don't want drunk drivers on the road so they avoid the weekends, they don't want it to be after dark because you know you don't want a kid crossing the street and someone can't see them and they hit them.
Well Florida, now that we live in Florida, it is a lot more like Ohio used to be when I was a kid. Beggar's Night is on Halloween; it's the same night, same time everywhere. It last many, many hours and it includes lots of darkness time. So I guess from a safety perspective the new way that Ohio does it wins but, from a nostalgia perspective I love the way Florida does it and I don't know. Are there more accidents and injuries and that sort of thing in Florida compared to Ohio? I don't know, that would be an interesting question to ask. So I guess my point is I just sort of assumed that all States were doing it the same way, not on Halloween and while it's a daylight outside, from like 4:00 to 6:30, 7:00.
So how do they do it where you live and what do you think about that? I guess that's the question I'm posing to you, so let me know. Again from a safety perspective, I think it's safer to do it the way that Ohio does it now. But I got to love the way the Florida, I don't know maybe it made me feel like I was a kid again. No I was not trick or treating but you know what I mean.
OK let's go ahead and move on. We're going to talk about Bisphenol A, BPA again; one more new story for you. Also Breast Milk Immunity; How does that work? Vaccines and Autism also, Anesthesia and Autism and then of course we already mentioned; Cough Variant Asthma, Language Development, and my favorite Molluscum Contagiosum. That's all coming up in the big show.
Don't forget if you have a topic that you would like us to discuss, just go to Pediacast.org and click on the Contact link. You can also e-mail firstname.lastname@example.org or call the voice line at 347-404-KIDS.
And of course 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, be sure to 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.
Our News Parents Can Use is brought to you in conjunction with the news partner Medical News Today, the largest independent health and medical news website. You can visit them online at Medicalnewstoday.com.
We'll begin our news segment with a follow up story to last week's report of Canada banning products containing Bisphenol A, not in response to scientific data showing harm caused by the substance but because some worried moms complain to politicians.
This week we have scientific data concerning Bisphenol A to report because unlike the Canadian government, evidence based discussions are important to us here at PediaCast.
As you know Bisphenol A is a chemical predominantly used in the production of polycarbonate plastic and epoxy resins, has recently been the subject of public and scientific scrutiny regarding potential reproductive and developmental effects. People are exposed to minute levels of Bisphenol A, mostly through the ingestion of food in contact with such products as water bottles, baby bottles, and food containers made of polycarbonate plastic and food and beverage cans coated with epoxy resins.
Recently, an expert panel led by scientists at Gradient Corporation in Cambridge, Massachusetts completed an extensive scientific review of the reproductive and developmental effects of Bisphenol A. Based on its review of all the relevant scientific literature, the panel found no consistent evidence of reproductive or developmental effects of Bisphenol A at typical human exposure levels. The review considered all studies published through July 2008 that examined reproductive and developmental toxicity in animals at low Bisphenol A doses and no studies were excluded based on study design or source of funding.
According to Dr. Lorenz Rhomberg, the senior author of the review, "The hypothesis that the low levels of Bisphenol A exposure could disrupt reproduction and development is not supported by coherent, consistent, or compelling evidence."
Government agencies from the US, the European Union, and Japan have also concluded that Bisphenol A is not harmful at the low amounts to which people are normally exposed. Most recently, in a draft report, the US Food and Drug Administration concluded that the trace amounts of Bisphenol A that leach out of food containers are not a threat to infants or adults. These conclusions are partly based on the results of several large studies of the effects of Bisphenol A in rats and mice that were dosed with Bisphenol A continuously over multiple generations. In these studies, animals were exposed during all life stages from conception through adulthood and reproduction. Bisphenol A had no effects on these animals at doses including those similar to human exposure levels.
There is agreement among these panels and government agencies (Canada not included) that effects of Bisphenol A only occur at exposures approximately 100,000 times higher than a person would typically ingest. In addition, people are better at excreting ingested Bisphenol A than are rats and mice. In people, Bisphenol A in the body is converted to a metabolite that does not have estrogen-like activity, and it's rapidly eliminated in the urine. Despite the media attention suggesting otherwise, to date, the overwhelming majority of government and academic scientific panels have concluded that Bisphenol A is safe at the very low amounts that people normally ingest.
A BYU-Harvard-Stanford research team has identified a molecule that is key to mothers' ability to pass along immunity to intestinal infections to babies through breast milk.
The findings were published on November 1st in an issue of the Journal of Immunology.
The study highlights an amazing change that takes place in a mother's body when she begins producing breast milk. For years before her pregnancy, cells that produce antibodies against intestinal infections travel around her circulatory system as if it were a highway and regularly take an 'off-ramp' to her intestine. There they stand ready to defend against infections such as cholera or rotavirus. But once she begins lactating, some of these same antibody-producing cells suddenly begin taking a different 'off-ramp,' so to speak, that leads to the mammary glands. That way, when her baby nurses, the antibodies go straight to the baby's intestines and offer protection while the infant builds up his or her own immunity.
This is why previous studies have shown that formula-fed infants have twice the incidence of diarrheal illnesses as breast-fed infants.
Until now, scientists did not know how the mother's body signalled the antibody-producing cells to take the different off-ramp. The new study identifies the molecule that gives them the green light.
"Everybody hears that breastfeeding is good for the baby," said Eric Wilson, the Brigham Young University Microbiologist who is the lead author on the study. "But why is it good? One of the reasons is that mothers' milk carries protective antibodies which shield the newborn from infection, and this study demonstrates the molecular mechanisms used by the mother's body to get these antibody-producing cells where they need to be."
Understanding the role of the molecule, called CCR10, also has implications for future efforts to help mothers better protect their infants.
"This tells us that this molecule is extremely important, so if we want to design a vaccine for the mother so she could effectively pass protective antibodies to the child then it would be absolutely essential to induce high levels of CCR10," said Wilson.
Speaking broadly about the long-term applications of this research, BYU undergraduate Elizabeth Nielsen Low, a co-author on the paper, said, "If we know how these cells migrate, we'll be able to hit the right targets to get them to go where we want them."
To conduct their research, the team used so-called 'knock-out mice' that had been genetically engineered to lack the CCR10 molecule. Whereas normal lactating mice had hundreds of thousands of antibody-producing cells in their mammary glands, the BYU team found that the knock-out mice had more than 70 times fewer such cells. Tests verified that the absence of CCR10 was responsible for the deficiency.
Surprisingly, the research also showed that CCR10 does not play the same crucial role in signalling antibody-producing cells to migrate to the intestine. It only gets the cells to the mammary gland, a different molecule is the 'traffic light' to the gut.
The study was supported by Wilson's grant from the National Institutes of Health, funding which continues for another 18 months and supports his and his students' further investigation into the cells behind transfer of immunity in breast milk.
She seemed to be everywhere. Last fall, actress Jenny McCarthy could be found on a host of American talk shows, including Larry King Live, The View and The Oprah Winfrey Show promoting her book Louder than Words: A Mother's Journey in Healing Autism. During the Oprah appearance, she made several controversial claims, including the idea that vaccines had a role to play in causing her son's autism. "The nurse gave Evan the shot and soon thereafter boom the soul's gone from his eyes," that's what she said.
Seen by millions of Oprah viewers, hers was a compelling story, presented passionately and articulately. But was she right? "I'm just a mom," she said, adding she received her degree from "The University of Google."
Despite the lack of credible scientific evidence establishing a connection between vaccines and autism, debate rages on. The controversy seems to be everywhere, fueled by celebrities, bloggers, websites and the mainstream media. With autism rates continuing to rise estimated at one child in 150 in the US, now more than ever parents are finding themselves confused and doubtful about whether to vaccinate their children.
So what should parents believe? Is there a connection between autism and vaccines?
"We don't want to close our minds to further research and inquiry, but we really need to treat the vaccine-autism connection as highly speculative," says Susan Bryson, the Joan and Jack Craig Chair in Autism Research at Dalhousie University in Halifax, and one of the world's foremost autism experts.
"We should still ask questions and seek answers, but in the meantime, we need to follow paths that are evidence-based and make sense theoretically," she says. "Especially when we are concerned what the priorities are for focusing our attention and money."
While experts say there is no reliable way to track the impact of the controversy on North American vaccination rates, in other countries like Britain, MMR vaccination rates plummeted from 95 to 75%, although that figure has begun to recover. The British outbreak of Measles, Mumps, and Rubella disease can be traced directly to one of the only studies that suggested a link between autism and vaccines. And that study has since has been widely discredited, and retracted by most of its authors.
A quick Internet search uncovers dozens of articles, websites and discussion groups insisting the link between autism and vaccine exists. But scientific evidence establishing that link is much harder to come by.
Dr. Bryson notes the complexity of autism as a relatively new disorder only on the books since the 1940's may be a factor in the rise of some of the controversy. "There is so much we still don't know about autism. Wouldn't it be lovely if we discovered there was just one protein missing in our DNA that caused the disorder, or something simple like that? All we can say is that there is nothing in the science that has been discovered so far that suggests the answer will be that easy."
In the meantime, she and her team continue to focus their efforts on early detection and intervention. She conducted a landmark epidemiological study of autism, the first of its kind for North America, in Nova Scotia in the 1980's. Since then, she and her researchers have studied 350 families for more than 10 years in a project she began at Sick Kids Hospital in Toronto.
That study has led to her current research on developing earlier autism detection and intervention for babies. She also designed and played a leadership role in implementing an early intervention treatment program for autistic children in Nova Scotia, and together with Dr. Isabel Smith, is tracking the results.
"We know that if we can get in earlier with a diagnosis, and focus on early intervention, we are better able to help the child," she says. "The earlier the better." Currently, her team is identifying signs of autism in children between 12 and 18 months of age. So far, these signs including delayed or lost speech, lack of social smiling, fixating on certain objects, failing to respond when name is called and unusual responses to sensations are all behavioral. No reliable physical test exists.
As for the continuing debate over vaccines and autism, she says the focus needs to shift from speculation to proven fact. "There has been so much emphasis on the potential link between vaccines and autism, and not enough attention to the fact that diseases like measles can be fatal for children who are not immunized. That is a proven fact," she says.
"It's a lot sexier and more interesting to talk about what we think is fact, than to talk about the things we don't know. With autism, there is still so much we just don't know."
And finally, a new anesthesiology study presented at the 2008 Annual Meeting of the American Society of Anesthesiologists, indicates a possible link between childhood exposure to general anesthesia and an increased risk of behavioral and developmental disorders in young children.
Recent animal studies have shown that commonly used anesthetic agents may have serious neurotoxic effects on the developing brain. To assess whether the experimental animal data can be applied to humans, Dr. Lena S. Sun, Professor of Anesthesiology and Pediatrics at Columbia University performed an analysis of a group of children born into the New York State Medicaid Program between 1999 and 2000.
Over a 4 year period, 625 children under the age of three were exposed to general anesthesia as part of uncomplicated hernia repair. When compared to a random sample of 5,000 children with no history of anesthesia exposure, the children exposed to the anesthetic agents were twice as likely to be subsequently diagnosed with a developmental or behavioral disorder.
"Given that the study subjects were taken from a Medicaid population, one limitation of the data is the demographic factors of this group that may vary from the general population. The excess risk of developmental and behavioral disorders in the children exposed to anesthesia cannot be completely explained by any demographic factors or confounding health factors including premature birth or low birth weight."
Researchers stress the need for more rigorous studies to assess the long-term health effects of exposure to anesthesia in young children. "This current analysis only examined two or three years of post-exposure data. To determine long-term effects of exposure, it's essential to continue and expand the efforts of this study with continued follow-up with the study subjects and design additional studies in which direct neurodevelopmental outcomes could be assessed. It is important to emphasize that given the limitations and preliminary nature of the study, these results should be interpreted with caution; parents should not keep their children from having necessary surgical procedures," said Dr. Sun.
While a number of animal studies have provided useful direction for further research, it is important to note that animal studies are considered basic science, and their findings do not always translate to the complex physiological system of human beings.
All right that concludes our News Parents Can Use this week and we will be back to answer your questions, right after this break.
All right. First up in our Listener Segment this week is Sarah in Petaskala Ohio and Sarah says, "Hope all is well with the move. I am jealous you guys are skipping Ohio winters. I was hoping you could talk more about asthma, more specifically cough variant asthma. My son has had a cough primarily at night about 30% of the time for at least the past year. He sleeps for a few hours and then starts coughing many times to the point where he gags and even throws up. We finally got it across to our doctor at my son's two year check up that this happens all the time, not just when he's sick and how destructive this has been to our lives.
Our doctor prescribed Singulair to see if it was allergies not mentioning asthma, I was not at this doctor's appointment and my husband did not asked. But this is my son's only symptom and what made me think of asthma and subsequent research on Web MD was remembering my best friend growing up who has had bad asthma and had to sleep propped up on pillows every night. I was wondering how common cough variant asthma is, is it true as Web MD says that doctors avoid labelling it as asthma because so many outgrow it or maybe because so many things that could cause a cough on their own, such as allergies. Cold air, sinus infection are also triggers for asthma and therefore it can be hard to pin down asthma as a primary diagnosis? The Singulair does seem to be helping but of course it's also a treatment for asthma. Thanks for the great podcast. Best regards, Sarah."
Well thanks for your question, Sarah. So let's talk about asthma and cough variant asthma in particular.
First, I think to keep in mind is that allergies and asthma exist along a spectrum and the basic issue here is inflammation or tissue swelling and it's usually in response to an antigen which would be an allergic reason for having this problem. So you know you can have things in the environment that cause the inflammation or you can have infectious agents like viruses that can cause the inflammation in the airway.
Although the body's immune system, I should also point out can cause the swelling in the absence of an antigen and that's what we could call like an autoimmune-type inflammation where the body is just attacking itself so to speak and causing inflammation and we don't exactly understand exactly why that happens.
There's also an exercise induced inflammation in the airway and that mechanism also is not well understood. It could be that when you exercise, drying or cooling of the airway could cause the inflammation. And usually with these kids with exercise induced asthma, they have milder inflammation that's always present. Probably an allergic response to something and that gets worse with increase movement of air and drying or cooling of the airway.
So you basically have with allergies and asthma, you have tissue swelling and it's the immune system that makes the tissue swelling happen and it may be just the immune system doing it on its own for whatever reason or it could be because there is an allergen that your body is having a reaction to which could be something in the environment or an infectious agent.
Now the exact symptoms that you get depend on where along the airway that the inflammation occurs. So if this inflammation primarily occurs in the sinuses, the nose, the upper airway; you get a runny nose, congestion, and productive cough. The cough is productive because you have this mucus sliding down the back of the throat, landing around the vocal cords and then you cough and you cough that stuff up but the origin of the mucus is from the upper airway, even though you're coughing it up. 'Cause it' basically drained down first and then you're coughing it up.
Now you can also get inflammation around the middle airway; and this is going to be the throat, the larynx where the vocal cords are, the trachea which is the top part of the airway that goes down into the lungs, and the large bronchial tubes. And in this case, you're going to get more of a dry, barky cough in this area and it sounds like a bark because it's inflammation around the vocal cords. That's what gives it that barky sound. Typically there's not as much secretions in this area when it's primarily in the middle airway and that's why it's a dry cough. When you get inflammation in this middle airway by itself without any other place then you get the cough variant asthma, so these kids cough instead of wheeze.
Things usually don't always happen in an isolated part of the airway. Usually you have some mucus, you have some inflammation in the upper airway, you have some inflammation in the middle airway so you get cough, you get drainage, so you can get a mixture of these things and that's the most likely scenario that you're going to see. But when it is isolated to the middle airway around the throat, around the vocal cords, that's when you're going to get more of a cough variant asthma.
Now in the lower airway, so this is now going to be deep down in the lungs in the really small bronchial tubes, that's where you get the inflammation and that's when we call it asthma and you have wheezing, you also get some air trappings so that it's easy for you to get air in because with air in you move the diaphragm down, it's an active thing breathing in whereas breathing out is less forceful it's more of a relaxed expiration and so air can get trapped because you're using enough force to get the air in but you don't enough force to get the air out, so it gets trapped behind this inflammation in the lower airways. So you get hyper expansion of the lungs; you feel this difficulty of being able to expel air out of your lungs and you wheeze when you do exhale. And then when it's really bad you wheeze when you inhale as well.
So again if this inflammation is in the upper airway, you're going to get allergy-type symptoms. If it's in the middle airway, you're going to get a cough. If it's in the lower airway, you're going to get wheezing.
And whether you call it asthma or not really doesn't matter. I mean what matters is what's happening with your kid and what can we do to make it better. And in most situations it's not isolated to just the lower airway, just the middle airway, or just the upper airway. It's usually a combination of these things.
So how do we treat the symptoms?
Well really first is to reduce the inflammation, right? It would mean if the problem is caused by; I guess the first thing you could do is if there is a specific antigen that you know is causing the inflammation in the first place is you could try to avoid it.
If it's viruses and mom and dad both work and your child has to be in day care, it may be hard to avoid infectious antigens and so every time they get a cold, they wheeze with it. So I guess avoidance would be the first thing but that is difficult to do.
So how do we treat it once it's there?
Again first is to reduce the inflammation. We can use steroid medicines to do that in the lower and middle airway. It can be prednisone, prednisolone, or Orapred is one of the brand names. There's also inhaled steroids like Flovent, Pulmocort, that kind of thing.
If it's in the upper airway, we can reduce the inflammation again with steroids like Flonase, Rhinocort, Nasonex, there's a lot of different brand names of nasal spray-type steroid medication that can help with inflammation in the upper airway. But whether it's in the upper airway or lower airway, steroids are going to help reduce the inflammation, just which product and which delivery system is used is what's going to vary.
The next thing is going to be antihistamine type medication and these are most helpful in the upper airway because as an antihistamine they primarily help to clear secretions. And these are things like Benadryl and then the non-drowsy antihistamines like Claritin and the sometimes drowsy but usually not, Zyrtec.
And then are another group of drugs called the antileukotrienes and this also helps to reduce inflammation by a different pathway and Singulair is the example of that. And that's why Singulair can be used for allergies and for asthma because it helps reduce inflammation and inflammation is the primary problem with both of those diseases just at different levels of the airway.
Now the disadvantage to all of the things I just mentioned; so steroid medications, antihistamine medications and the antileukotriene medications, the disadvantage is that they have a very slow onset. One advantage is they have a longer duration, so that makes them good for maintenance therapy and to try to prevent problems. But they're not really good when you have an acute episode of wheezing that's really, really bad because they have a slow onset.
So what you want to do if you have wheezing in particular, 'cause that's the one that can be life threatening. I mean the cough with middle airway it's annoying and the runny nose and congestion you can get with allergy symptoms, allergic rhinitis; yeah it's irritating, but let's face it, it's not life threatening. But if you have inflammation in the lower airways that can interfere with oxygenation and that can cause death if you don't take care of it.
So what do you do in a kid who's wheezing?
You can use the steroid medicines but you don't want to use those as a rescue or life saving-type thing because again they have slow onset.
So what you use instead is a bronchodilator and what bronchodilators do is they relax the smooth muscle in the airway in the lower airway, so they make the diameter bigger, so the inflammation doesn't mean as much because the diameter of the inside of the airway gets bigger. So you help the smooth muscle in the airways to relax and then the inflammation doesn't matter quite so much.
So the bronchodilators things like Albuterol, Xopenex, Atrovent; these kind of medications and they have a fast onset but they have a short duration and that makes them good as a rescue medicine.
Now I also should mention, there are some combination products out there like Advair is an example. It has a steroid in it and a bronchodilator. However, the bronchodilator in a product like Advair is it's not quite as strong and it's not as fast of an onset as Albuterol or Xopenex, or Atrovent are so it is not good to use Advair as a rescue medicine even though it has a bronchodilator in it, it's more of a maintenance medicine to keep things opened up over a long period of time.
So this is really important. And now that I'm working in an urgent care environment, I'm seeing kids whose pediatricians are not explaining to them well the difference between a maintenance medicine and a rescue medicine and it's important to know the difference between those two.
So the steroids, the antihistamines, the Singulairs, the Advairs; these are all maintenance medications to help prevent problems with asthma. But the Albuterol and the Xopenex are your primary rescue medicines because they have a fast onset, a good response but they do have a short duration. So you got to keep all that in mind.
OK. So we've covered generally what causes allergic rhinitis and asthma, let's focus now into cough variant asthma.
So these kids have most of their inflammation in the middle portion of the airway. Kids with allergic rhinitis cough, but that's mostly from drainage and kids with regular just asthma also cough along with their wheeze. But kids with just cough variant asthma don't have much of a runny nose and congestion, they don't have much of the upper airway part, they don't have much of the lower airway or wheezing part. So they just have this cough and if you treat their cough as if it were a wheeze, it gets better and that's pretty much how we diagnose it sort of retrospectively.
To me Sarah, the way that you've described your son's problem, it sounds to me, now again I haven't seen you, I can't take adequate history, I can't do a physical exam which a doctor needs to do to come with a differential diagnosis. But I would say the way you've described your son's problem; coughing at night, it sounds to me like it's probably more of a drainage issue which would fall more toward the allergic rhinitis end of the spectrum.
Why does it sound like a drainage issue?
Well the fact it's only at night time, so it's when he's lying down flat that you start to have a problem and because he gags and throws up. So antihistamines like Zyrtec or Claritin, the antileukotrienes like Singulair, that sort of combination is probably your best bet. So like Zyrtec or Claritin in the morning, Singulair at night.
And I know Sarah; you're struggling with the label. Is it allergies? Is it asthma? Is it cough variant asthma? I wouldn't worry about the label so much. I mean the important question is this; Are your child's symptoms better, is he sleeping better and is the medicine improving his quality of life?
Now I know you want the label so you know what to expect. And if people say, "Does he suffer from any illnesses?" You can say, "Yeah he has allergies," or "Yeah he has asthma." But because we're talking about a disease that comes in a spectrum, not all kids fit neatly into a single point. You know on the one end you have allergies or allergic rhinitis, on the other end, you have asthma. The difference depends on the anatomical location of the inflammation and many, many kids fit somewhere in the middle, and many kids slide back and forth along that spectrum. They may wheeze as infants and toddlers but have more of allergic rhinitis issue as an adult or they may have a chronic runny nose as a baby and start wheezing later on.
And because the term asthma has so many negative connotations, we do often like to avoid using it. Not because it doesn't adequately describe what's going on, it's just because it freaks parents out. So we sort of avoid the asthma word and just label it reactive airway disease because that really does describe the spectrum better and so we do hide behind that term and I kind of like that name, reactive airway disease, just doesn't have the negative connotations that asthma has. But your kid has what your kid has whether your call it asthma or not. And when you look at the ICD9 Codes for reactive airway disease, I think they're the same as asthma, so you know the actual numbers.
From the doctor's point of view, the name doesn't matter. What matters is that we know what's causing the problem and we know how to fix it. And if the result is a child who has a better quality of life, then we're happy, the parent's happy, the kid's happy and that's what our job is all about.
Incidentally what's the best predictor of where your child with asthma or cough variant asthma or allergic rhinitis, sort of what's the best predictor of what their future is going to be like? In my opinion, family history. So if in the family, there are a lot of kids who wheeze as babies and they're better as adults, that's probably what you're going to find. On the other hand, if there's a lot of kids with asthma as babies and they have terrible asthma problems as adults, guess what? That's probably what you're looking at.
OK. Let's move on, Next is Christine in Washington State, the other side of the country. And Christine says, "Hi, Dr. Mike. I hope your move is going well. My daughter recently had her nine month appointment and her pediatrician asked me if she's making 'ma ma ma' or 'da da da' sounds and she is not. She does vocalize and she does respond to her name but she has not started making constant sounds yet like 'ma ma ma' or 'da da da'. She just kind of makes noises. The pediatrician was not too concerned at the nine month visit but told me I should let him know if she has not making constant sounds in the next month or so. I'm not too concerned but I am mom fretting. I was wondering if you could discuss language development a little, and what the pediatrician is concerned about if she doesn't start making these noises. I realized there's a big range of normal. In fact my daughter is practically walking; she's taken her first steps. She still uses crawling for her main means of transportation although she loves to push her little walker cart around and is getting bolder about trying to let go of furniture and walk more on her own. I realized since she's pretty far ahead in the walking department, she may be a little behind in the talking department. Any information or thoughts are appreciated. Thanks, Christine."
All right, Christine, well thanks for your question.
Language development is a tough one. I mean the classic expectation is that kids by the time that they're a year old know a handful of words. And they're not necessarily English words or Spanish words or whatever your primary language is. It's a handful of vocalizations that means something and that the parent knows what that vocalization means. So that would be a word. And at 12 months you should have a handful of words, again noises a baby makes to mean something and you as a parent understands what they're trying to say, that would be a word.
By age two, now they do know more real English words and they can put two of them together into a sentence and mom and dad understands what words the kid is using. A stranger may not, but mom and dad – they do understand.
And then by age three, they're using three word sentences, so more complex ideas, stringing words together. And this is sort of the classic expectation of 10 to 15 years ago when I was training; this is what you look for in language development.
Now as Christine mentioned there's a huge range of differences between kids, and in my own kids we saw that. My daughter Katie could recite nursery rhymes back to you when she was 18 months old and when my son Nick was turning three, he was still mostly grunting and pointing at things and he's 11 now and talks just fine.
From my own observations over the years and this is purely anecdotal, it's not based on any research, it's based solely on me seeing hundreds of kids every week. And my observations are; that girls generally develop language sooner than boys, first borns generally develop faster than subsequent siblings, and non first born boys develop language the slowest. So just in my own observation, it seems to me that girls develop it faster and first borns develop language faster.
Another observation that I've had is that receptive language matters. So in these kids who are developing a little bit slower than parents would like to see happen, if they have good receptive language, then that makes me feel better about their language delay. So in other words if you can say, "Hey, go pick up the ball," and they fell like doing it, they go pick up the ball. So in other words, they understand lots of English words even though they're not repeating them back or stringing them into words, they have good receptive language. And that always does reassure us as pediatricians.
Now having said that, there is ongoing research looking at early language issues as a marker for autism. And the results of this research are pretty inconclusive, I mean sure, most kids who have autism do have early language problems but they also have other problems too; problems with fixating on certain objects, problems with textures, problems with socialization in addition to the language problem.
While kids with autism do have early language problems, many, many, many, many more kids with early language problems or language delay end up not having end up not having autism.
It's kind of like RSV, you may have heard of RSV; it's a virus, lots of babies get it in the winter time. Most infants and toddlers, who are wheezing during that time of the year, test positive for RSV. And a lot of the kids who are in the hospital with their wheezing, they have RSV. So RSV would seem like this terrible viral disease that makes kids wheeze and put them in the hospital. But you got to look at who are we testing. You know, who are we putting in the hospital and who are we testing for RSV? It's the kids with really severe disease.
if we tested every kid who came in with a cold but was not wheezing, we'd find many, many, many kids with RSV who don't wheeze at all. In fact kids wheeze because of RSV are in the minority, the majority of kids with RSV don't wheeze at all. So it just seems that all kids with RSV wheeze because we don't test the kids who aren't wheezing with their cold.
And I suspect the same sort of thing holds true for language issue. I mean some kids with language delay will end up being autistic, but when you look back, most autistic kids did have early language delay. But the majority of kids with language delay don't end up having autism at all. It's just that their language is going to develop normally but at a slower pace.
So when is early language delay a concern? That's the million dollar question and I don't have a great answer for you, but that's OK because nobody else does either.
As a pediatrician, I'm reassured when a young child with language delay is a boy, is a second or third born, is someone who has an older sibling in the house and who has excellent receptive language skills, and whose motor and social development is normal; so those things make me feel better.
If it's a boy, boys are more likely to have language delay, if it's a second or third born, if they have excellent receptive language skills, and all of their other developmental milestones are being met, then you feel better about it.
On the other hand, if I see a first born girl with language delay who doesn't have good receptive language and who is developmentally delayed in other ways other than language, then I'm very concerned about that.
So you do have to trust the judgement of your pediatrician to some degree here because we see lots and lots of kids and not only do we see lots of kids, we see what they're like down the road you know, so if you see kind of patterns and you know, "Well this is the kind of kid who typically by the time they're three or four years old is talking just fine." So you do have to trust your pediatrician to some degree.
Now it is tough because if your child does end up having autism, the earlier that we initiate intervention, the better. But at the same time you don't want premature labels, you don't want to waste resources when there might be other kids out there who need the resource without any question. So it is tough and to answer your question Christine, you know a nine month old who isn't saying 'dada' and 'mama' doesn't concern me too much.
Now what if it was 12 month old instead or a 15 month old or an 18 month old, at what point do I become concerned? Well for me again, it's a whole picture thing. You know, is it a boy, is it a girl, or are there lots of other kids in the house, is there receptive language, are there other developmental issues beside language? And I ask all those questions and look at the big picture.
By the way, why is it that if there are older kids in the house, why does that make a difference?
I think it's because older kids, you know they're playing with their younger siblings a lot, they get to know them, they get to know what they need, what they want, what they're looking for and they do the talking for the younger sibling. So as a first born, you pretty much have to learn language or you're not going to be able to communicate very well. Whereas subsequent born kids, you have interpreters called siblings that help you out. That's my opinion, not based on research but just based on common sense.
OK. Also you know the other thing too is, again I love this when you know I do. What's the family history. You know is it family history that third born boys take a long time to talk. You know if, "Oh yeah, uncle so and so did that and he's fine now," then also that helps you out too. So you got to look at family history as well.
OK. Let's move on to our last question and this one comes from Jamie in Orange Park Florida. We were all over the country today aren't we? We had Washington State Ohio and now Orange Park Florida. And Jamie says, "Dear, Dr. Mike. I have a subject for you, Molluscum Contagiosum. I recently took my 20 month old to the doctor because of bumps that started on her stomach. The doctor said they were warts and as long as I kept them covered in lotion they would go away. After a few weeks, I noticed these bumps spreading to her arms and legs. I took her back to the doctor today and was told by another doctor that works in the same office as our pediatrician that she has Molluscum Contagiosum which she said are warts. She also said the only thing I can do is wait which could take up to three years or have them frozen off by a dermatologist. The doctor also said not to be surprised if more bumps form or even if my oldest daughter who's three years old starts to develop these bumps. I would love your opinion on the subject. What causes this? Is there really nothing else I can do? My daughter also has eczema and could the two be related. Another question I have is this, should I bathe my girl separately to try and prevent my oldest from getting it? Thanks so much. Love your podcast and enjoy listening to your point of view, Jamie."
Well, thanks for the question, Jamie.
So let's talk about Molluscum Contagiosum. This condition is not really warts, but like warts, it is caused by a virus. And in the case of warts, the virus is a human papillomavirus and it basically causes the skin cells to multiply resulting in a benign tumor of skin cells. Now Molluscum is a little bit different, it's caused by a pox virus and the infection does not result in a benign tumor of skin cells, instead these characteristic lesions form within the skin. The virus causes these lesions to occur and basically these lesions are flesh colored or pearly dome-shaped papules, and papules is just a fancy word for bump.
These dome-shaped bumps usually range in size from one to five millimeters; so they're very small. Although they can sometimes be as large as one centimeter which is like the head of a tack. So they can be a little bit larger, they're usually smaller, you know the size of a pencil eraser or a little bit smaller and they're domed-shaped pearly bumps that have a little dimpling right in the middle or what we call a central umbilication. So right in the middle, they'll have a little dimple down. That's the classic look for these things.
Unlike warts, which again is just a benign tumor of skin cells. Molluscum lesions have a little bit more of a structure to them. The center of the dome is not filled with cells, like a wart would be. The center is filled with a waxy core and this waxy core exist between cells and it's filled with a virus whereas the wart virus, the human papillomavirus that causes warts; it lives inside skin cells in this benign tumor. Whereas with Molluscum, the wart lives in this waxy core in between cells and this waxy core, it has collagen and lipid rich or fatty rich substance inside of it and it's thought that this waxy core or collagen and lipid rich substance is it's thought to protect the virus from immune system recognition.
So basically, the virus infects some skin cells, it instructs the cells to form this lesion, it instructs the cells to make this protective substance and then the viruses hangout in this safe haven. I'm simplifying it a little bit. And in the safe haven, the immune system has difficulty recognizing the virus as a foreign invader. So it's really pretty cool when you look at it from the virus' point of view, I mean they have this cool gig going you know. But of course it's not so cool for mom and dad.
Now these lesions can spread, which makes sense because they're viral in nature and they do last a long time, usually several months to a couple of years.
Why does it last so long?
Well because the immune system has trouble recognizing it. On the other hand, they don't last forever. So eventually the immune system does figure out the problem and it fights the infection and once it does, the lesions go away. And they're less likely to return because the immune system has memory. So the next time the pox virus enters, the immune system zaps it right away. And this is why they're much more common in young children compared with older children, teens, and adults, because older folks had it at some point in the past, their immunity has memory for it and they're protected to zap the virus as soon as it enters the body.
OK. So we know it's viral, we know it can spread, but we also know it goes away on its own although it takes a long time to do so. So the next question is, do you need to do anything about it?
Well there's not a right or wrong answer here and you have to take each case on its own merit. If there's only a few lesions and they're hidden by clothing and the child's not messing with them, then I would leave them alone and let the body do its thing even though it's going to take a while. On the other hand, if they're really spreading, there's 20, 30 or more of them, if a kid's picking at them like crazy and they're getting secondary skin infections right and left because they're picking at them, then it's easier to say, "Yeah, let's do something about these."
Of course most cases are neither extreme, they typically fall somewhere in the middle and what to do about them comes down to a decision between mom and dad and the doctor.
I tend to be more conservative with these, you know if they're not causing a problem I say, leave them alone, let the immune system do its thing even though it may take several months to a couple of years. And the reason for that is the treatments for them aren't benign, they can cause pain and in some cases scarring, the treatments can. So why create new problems when the thing's going to go away anyway? You know what I'm saying?
On the other hand, there are times when you must deal with them because you get recurrent skin infections, it's a cosmetic issue, other kids are making fun of them, and so you do start to have a decreased quality of life kind of stuff, and sometimes it's just because parents are demanding and they want the things gone and so as a doctor you do it because you want the parents to shut up, sometimes that happens unfortunately.
So let's talk about our options. One and I like this method. It's called Enucleation, don't try this at home because you can introduce infection if it's not done correctly. Or if you're going to do it at home, make sure your doctor shows you how to do it. And basically, you clean the skin off with some alcohol and you open the lesion and express that waxy core. So you want to do the alcohol because you don't want to introduce more skin bacteria into the skin. And then you use a needle like an 18 gauge sterile needle, so again this is something your doctor should do. And you pop open the lesion, you pinch out the waxy stuff and you get rid of it. And typically when you do that, typically they don't come back but, they can.
Disadvantages of enucleation; it hurts to do it, it can scar especially if a child keeps picking afterward, you can get infection from the skin and sometimes they do still come back even with enucleation. But that's one method that you can use.
Another method is topical agents. You can use tape stripping. So basically you put tape over the lesion and then you take the tape off and you put tape back on, you take it off, you put the tape back on, you take it off; and this just removes the outer layers of the epidermis and so then the waxy core finally gets expressed. So instead of using a needle to pop through, you're just removing layer after layer of cells to try to get it open.
The only problem with this is that once it does open the virus is on the tape and if you keep doing it, you may actually cause new lesions in a different location, you know unless you get the tape stuck exactly how you had it which is unlikely. So you know you put the tape down and then you move it half a centimeter or so and then now you have virus on the tape touching good skin and you get rid of that lesion but you get another one right next to it. So it's not the best way to do it, but it can be done.
Another way is to freeze it with something like liquid nitrogen and this doesn't work as well as it does for regular warts. Because for regular warts, what you're doing with the liquid nitrogen is you're killing the cells that the virus is living in, you take away the virus' home, you kill the virus. These viruses aren't all living in the cells or living in this waxy stuff and the liquid nitrogen probably doesn't affect that as well. But liquid nitrogen freezing is an option that you have.
There's also blistering agents. These are typically acids; usually you have to see a dermatologist to have this done. It requires multiple weekly applications and pain and scarring is still possible with blistering agents.
And then there's home agents like Retin A, this just basically cause break down of the skin, which then helps to express the substance and it requires daily application for a couple of weeks. And sometimes this is a good option, cause you're not going to get the spread that you can get with the tape, it's not quite as invasive as poking it with a needle, but you can help it to break down and the stuff to finally come out with agents like Retin A.
And then finally there are the systemic agents, meaning things you take by mouth. And Cimetidine or Tagamet which is an H2 blocker, it's a special type of antihystamine that's usually used to reduce the production of stomach acid for things like reflux; you've heard of heartburn, you've heard of Tagamet before. It's thought that Tagamet stimulates the immunes system of a person to better recognize the virus and the exact mechanism by which this happens is unknown. It was probably first seen anecdotally, meaning that some doctors noticed that when they put kids on Tagamet for heartburn or acid reflux that their Molluscum went away. I don't know the specifics on how this relationship was discovered but it happened.
And so there was one uncontrolled study that showed resolution of Molluscum in 9 out of 13 patients who were started on Tagamet over a two month period. And the authors recommend a larger controlled studies with larger sample sizes which to my knowledge have not been done. So this is not an official indication used for the drugs. So the people who make Tagamet don't advertise that it can be used for this, it's not in the package insert, it's not in the literature, it's what we call, 'using a drug off label.' And because we're treating a condition that's relatively benign and when the evidence that the drug works is marginal at best, it's mostly anecdotal, it's based on a really small sample size, do you use it? Is there possible unknowns with using something like that to get rid of a benign condition like Molluscum? And again that's up to parents and doctors to decide together.
But for kids with uncomplicated cases, I'm not convinced that the possible benefit of that drug outweighs any unknowns about the drug. If the kid is truly suffering from Molluscum, it's really affecting their quality of life and no other method is working, then would I use it? Maybe, but those kids are few and far between.
Two more questions that Jamie has, one is eczema. Pre-existing eczema may make infection of the virus that causes Molluscum more likely because you have a broken down skin barrier and it's easier for the virus to enter the skin. So that's one way that eczema can be related. But interestingly, in about 10% of cases of Molluscum, eczema develops around the lesion, so you get the Molluscum first and then you get eczema in that general area. And this is probably related to the immune system trying to fight the infection. And if it's severe, then that might be a reason to treat the Molluscum rather than to watch and wait.
Jamie also asked about co-bathing of siblings. This is another decision you have to make as a parent. It's contagious, on the other hand, there are lots of ways that siblings can spread it to one another, I mean they itch and pick their skin, they touch toys and doorknobs, they share food and drink. So, it's likely that it's going to spread anyway. It's also a relatively benign condition that almost everybody gets it at some point during childhood.
So, is co-bathing an absolute no-no?
For me, I'd say co-bathing is fine. I mean personally I think the advantages; parental ease, sibling bonding, play time, outweighs the increased risk of transmission. But again that's my opinion and you and your doctor may reach a different conclusion.
So I hope that helps, Jamie. And again thanks for writing in.
All right. Let's take a final break and we'll be back and wrap up the show right after this.
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Don't forget the Pediascribe blog, that's my lovely wife Karen's blog. She has a couple of posts that I want to tell you about. One is called, Here a Chad There a Chad. And it's some election observations, it was written before the vote so keep that in mind. Also she compares small town Ohio to big city Florida in Here a Chad There a Chad.
All right and then my 14 year old daughter Katie, she's got a couple of posts that I want to tell you about, one is called A New Kitty, Almost. And basically it's about bad parents who won't let their kid adopt a new kitten. She's bitter. So if you want a read a bitter post from a teenager, we wouldn't let her& a new kitten, then check out A New Kitty, Almost.
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