Self-Gagging, Hiccups and Yawns, Urticaria Pigmentosa – PediaCast 138
- Cockroaches, Mice, and Asthma
- Kids Coping With Economic Stress
- Frequent Moves And Changing School
- Soft Contact Lenses
- Pediatricians Vs Family Doctors
- Self-Gagging 12 Month-Old
- Yawns and Hiccups
- Urticaria Pigmentosa
- Association Between Cockroaches And Asthma
- Helping Children Cope With Stress In Uncertain Times
- Dealing With The Stress Of Frequent Moves During Elementary School
- Soft Contact Lenses During Childhood
- PediaCast 48: Contagious Yawning
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 Summer Land Studio, here is your host Dr. Mike.
Hello, everyone and welcome to PediaCast. It is Episode 138 for Thursday November 20th 2008. It's an interesting show today; Self Gagging, Hiccups and Yawns, and then we'll wrap things up with Urticaria Pigmentosa, yes you heard me right. Urticaria Pigmentosa, that's coming up.
We also have News Parents Can Use like we always do. This is our big pre-Thanksgiving show. So if you're listening to this before the big Turkey Day, Happy Thanksgiving to everyone out there. There won't be a show next week because of Thanksgiving but we should resume the week after. But we have a big one for you today, so this one may take you a while to get through anyway.
As most of you know, I am doing the urgent care thing now. So I was in a private pediatric practice for 10 years and now I'm working at a pediatric urgent care in Central Florida and it's a nice gig. We have x-ray facilities, we have a procedure room for stitching and splinting, we can do IV fluids. And you know it's less than an ER and it's more presentable, it's pediatric friendly, it's really pretty cool. It's a nice setup from the doctor's perspective who has to work there, and from the parent-patient perspective I think it's a pretty cool place too. But there is a new dimension that I did not have to deal with in private practice, and that is the community pediatricians and the family physicians, in other words the primary care docs which is what I was for 10 years prior to this job.
Now, we don't want to directly compete with them which is nice. So our urgent care is only open from 5:00 to 11:00 on weekdays and then from 1:00 to 11:00 on Saturday, Sunday, and holidays. And we maintain a great communication with the community doctors; we fax summary sheets, we have patients follow up with their regular doctors, we don't do physicals, we don't give vaccines, we don't treat chronic illnesses, we don't do ADHD, there's no behavioral visits. Yey! In other words, we really just want to be an extension of the primary doctor's practice, not competition or a substitution. And the vast majority of community doctors appreciate what we do because we keep their kids out of the ER.
A few however, do view us as competition and don't really like us at all. It's not many but there's a few of them out there. And to them I say this, "Hey, you could provide the service yourself like we did back in my Ohio practice." We had evening hours during the week; we had weekend hours on Saturday and Sunday mornings and afternoons. We did have six doctors, so that certainly helps. We didn't have x-ray capability, we couldn't suture, we couldn't do IV fluids in the office although we could arrange those things easily enough.
So what's my point here?
Well, it's this, a lot of primary care doctors out there and not just in pediatrics, in adult medicine as well bemoan urgent care centers is destroying the doctor-patient relationship. You get a different doctor each time you go in, there's no real continuity of care necessarily and certainly business is taken away. But the explosion of urgent care centers is because, in my opinion, primary care doctors are failing to meet the needs of families in the 21st century. We are people on-the-go; we have instant access at our fingertips right? With the Internet we can shop 24 hours a day, we can any type of food anytime we want at hundreds of different restaurants.
I'm not saying this is a good thing or bad thing, I'm just telling you what it is. It is what it is and people want to see a doctor when it's convenient for them. They don't want to take their kids out of school for a physical, they don't want to miss work and traditional doctor hours don't work for a lot of people.
So coming from a practice that had very popular expanded hours, it's interesting to now be practicing expanded hours only in a community whose doctors don't really have those kind of hours. As I said most of the community doctors appreciate what we do but I have already come across some who are angry, they view us as competition and aren't afraid to voice their opinions about that to us or their parents. And to those doctors I say this, "Meet your patient's needs at the time they have the need and your patients won't need to feel like they need to skip going to your office."
Of course if all docs followed my advice, I'd be out of a job. But if only the complainers expand their schedule, and yes it does take partners in creative scheduling to pull that off, but it's by no means impossible. If only the complainers do it, then it's all good and we can work together.
In the mean time, if you aren't going to provide your patients with hours compatible with family life in the 21st century, then shut up already because complaining and whining is getting you nowhere. And that's coming from someone who used to be in your shoes.
All right. Let's go ahead and get started here. We have lots and lots of topics for you. In addition to the ones I told you about earlier in the intro, in other words in the news segment, we're going to talk about Cockroaches, Mice and Asthma and How They are Related. Also, Kids Coping with Economic Stress (sign of the times), Frequent Moves and Changing School and Soft Contact Lenses for Kids, that's all coming up in the news segment and then we'll talk about Self Gagging, Yawns, Hiccups and the infamous Urticaria Pigmentosa.
Don't forget if there's a topic that you would like us to talk about or you have a news article to point us toward, just go to Pediacast.org, click on the Contact link, you can get a hold of me that way, or you can e-mail email@example.com or call the voice line at 347-404-KIDS.
Also, I would like remind you that the information presented in PediaCast is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands on physical examination.
All right. Our News parents Can Use is brought to you in conjunction with news partner, Medical News Today the largest independent health and medical news website. You can visit them online at Medicalnewstoday.com.
A study released by researchers at the Columbia Center for Children's Environmental Health at Columbia University's Mailman School of Public Health shows that developing antibodies to cockroach and mouse proteins is associated with a greater risk of wheezing, hay fever, and eczema in preschool urban children as young as three years of age. The study, published in the November 2008 issue of the Journal of Allergy and Clinical Immunology, is the first to focus on the links between antibody responses to cockroach and mouse proteins and respiratory and allergic symptoms in such a young age group.
"These findings increase our understanding of the relationship between immune responses to indoor allergens and the development of asthma and allergies in very young children," said lead author of the study, Dr. Kathleen Donohue. The study found evidence that the likelihood of developing wheeze, hay fever, and eczema in preschool urban children was significantly increased among the children who demonstrated antibodies of both cockroach and mouse allergens.
This study is part of a broader multi-year research project launched in 1998 that examines the health effects of exposure of pregnant women and babies to indoor and outdoor air pollutants, pesticides, and allergens. The Center's prior research findings have shown that exposure to multiple environmental pollutants is associated with an increased risk for asthma symptoms among children. These latest findings contribute to a further understanding of how the environment impacts child health.
"Our findings have significant public health implications," said Dr. Rachel Miller, a senior physician working on the project. "These are valuable findings given the high prevalence of asthma in New York City and elsewhere. They highlight the importance of reducing exposure to cockroach and mouse allergens at a very early age for susceptible children."
The research suggest directing interventions toward reducing cockroach and mouse exposure and that may have long-term benefits to inner city children who are susceptible to these exposures.
The investigators controlled for exposure to tobacco smoke and maternal history of asthma, both of which may influence the likelihood of developing asthma or allergies. A prospective follow-up of this group of kids will determine whether the development of anti-cockroach, anti-mouse immunoglobulin by age three is associated with impaired lung function and/or persistent asthma.
So this is an interesting study and of course the mainstream media will present this as, "Cockroaches and Mice Cause Asthma." However, I'd like to point out that a cause and effect has not been demonstrated here, only an association. Because it could be, that children who are going to develop asthma anyway are more likely to have an immune response to cockroaches and mice. And while it would be nice of course to minimize kid's exposure to these pests anyway, limiting exposure may not really lead to less asthma. What you need to test that is a prospective study where you take two large groups of kids as identical as you can make them and expose one group to cockroaches and mice and restrict exposure to the other group and then you follow them along and see if they exposed group develops more asthma.
You could also look at the exposed group and see how many of them develop antibodies against the cockroach and mouse antigens and then see if there's a difference in the exposed kids between those who have and have not developed with regard to wheezing, hay fever, and eczema. But I realized that's a difficult study to pull off. I mean how do you get a group of parents to agree to intentional cockroach and mouse exposure and then how much exposure is enough, do the kids have to sleep in the same room as the cockroaches and the mice, by what means, how close are they? It's very difficult to design a study like that. In the mean time, keep your kids away from cockroaches and mice and I think that's good advise regardless of the asthma question, right?
But again, just because they have the antibodies to these things does not mean that those things are causing their asthma. So keep that in mind.
As families around the developed world face losses of jobs, homes, and nest eggs, their young children and teens need emotional support.
Dr. Michele Thorne a child psychologist at the Indiana University School of Medicine and the Riley Hospital for Children, says that parents should recognize that even newborn babies pick up on the emotional tones of adult stress. She says children of any age, including teens, need to be reassured they are safe and will be cared for no matter how the family is faring.
Children, especially those prone to anxiety, will jump to conclusions and worry. Dr. Thorne says, "If upheaval is occurring or is feared, it is better for children and teens to be prepared."
"Parents need to talk with their children and teens because they need time to adjust to change. But parents also should censor what they say and shouldn't burden their children with adult worries and concerns," she said
That's because children aren't ready to be saddled with adult burdens. The frontal lobe, the part of the brain that handles planning, attention, concentration, and reasoning isn't fully developed until late adolescence or early adulthood. Or as Dr. Thorne puts it, the main onboard computer which directs how an individual makes decisions isn't fully programmed in children and teens.
She recommends weekly family meetings, especially when a family is going through a difficult time. For example, parents might say that Dad will be home more often because he isn't working and that he will need to use the computer because it helps him locate job leads or keep up with financial markets.
It's best to talk with your children about what is going on and to explain the family's strategies for dealing with it.
While parents want their children to know that they can ask questions or offer suggestions Dr. Thorne counsels against involving children in decisions such as whether to move or how to handle situations outside their spheres of influence.
"You don't want to make your child or teen think you don't appreciate their advice so it's best not to solicit their opinions on things which they are unqualified to make a decision on," she said.
As media headlines carry daily updates on the global economic crisis and broadcast news of possible recession, children and teens may be facing an information overload even if not directly affected by the news. Dr. Thorne suggests that parents investigate what is being presented in their children's classrooms for guidance on discussions at home.
If a child appears to be having trouble coping with stress or appears anxious, parents should consult with the child's pediatrician or community mental health services or school counsellor. Parents should also make sure they have their own emotional supports in place, which will provide them with the ability to best help their children.
Dr. Thorne's research focuses on the relationship between psychological thriving and coping processes during major life transitions.
And speaking of major life changes, when children change schools in elementary years, dips in academic performance and classroom participation can follow. But having a supportive teacher who encourages other students to accept newcomers can go a long way toward helping children make a smooth transition.
That's the conclusion of a new longitudinal study that found moving during 2nd to 5th grade can lead to a decline in academic performance and classroom participation, but it's not always accompanied by declines in attitudes toward school.
The study, conducted by researchers at Western Washington University and the University of Washington, appears in the November-December 2008 issue of the journal Child Development. It seeks to expand our understanding of how moving during the elementary school years may contribute to disengagement with school just before the significant changes of adolescence.
"Our findings support the notion that school changes can negatively affect children, but we also show that supportive social contact with a teacher and peers can influence both academic and behavioral outcomes," that's according to Diana Gruman, assistant professor of psychology at Western Washington University and the study's lead author. "We show teachers can play a critical role in mitigating the negative effects of moving through their own caring response and by addressing the peer acceptance of newcomers in the classroom."
Researchers followed 1,040 elementary school students for four years to determine how moving disrupts children's attitudes toward school and their behavior in the classroom, such as how much they participate and whether they are cooperative. Although work in this area has been hampered by the difficulties involved in maintaining contact with students who move, the researchers in this study were able to keep in touch with 94 percent of the students. Many children who move also experience other stressors, such as poverty and divorce, but the study separated out those factors.
The researchers found that not all students suffer negative consequences from moving. In an effort to identify protective factors, they looked at the role of students' ties with teachers and peers at school. And they found that children who are accepted by their peers are more likely to do well academically and have better attitudes in and out of the classroom
But perhaps the most important factor in the equation was that of the teacher: Teachers who were supportive of mobile students had an especially strong influence on school attitude particularly for children who moved a lot.
The findings have important implications for educators, and the researchers call for effective interventions for students who move including intensive tutoring to address any academic deficits the children may have. They also recommend teacher training to raise awareness of the hardships faced by mobile students and encourage caring responses that address peer acceptance in the classroom.
And finally, soft contact lens wear does not result in clinically significant acceleration in the development of nearsightedness in children and does not cause relevant increases in axial length or corneal curvature, a new study shows. (Boy, that's a mouthful.) Findings from the three-year study, which is the largest randomized trial of its kind, appear in the November issue of Investigative Ophthalmology & Visual Science, the official journal of The Association for Research in Vision and Ophthalmology.
According to the multi-site wearing trial study, which tracked the myopic progression of 484 children ages 8 to 11 randomly assigned to wear glasses or contact lenses, there is no clinically meaningful difference between the two forms of vision correction, (glasses and contacts) for the treatment of nearsightedness, a vision problem experienced by approximately one-third of the population.
The new research further dispels a long held myth that soft contact lenses increase myopia progression also known as "Myopic Creep" in children any more than other vision correction options.
"Children as young as eight years old who require vision correction are capable of contact lens wear and this study confirms that they can safely be fit in soft contact lenses to correct their myopia," says Dr. Jeffrey Walline professor at the Ohio State University College of Optometry and leader of the Adolescent and Child Health Initiative to Encourage Vision Empowerment Study.
"Recent clinical studies have demonstrated that contact lenses provide a number of quality of life benefits to children beyond simply correcting their myopia," he adds. "The combined body of research should give both doctors and parents greater confidence in presenting children with the option of contact lens wear when vision correction is required."
Myopia affects approximately 15 percent of children in the United States, but is much higher in some other countries such as Singapore and China. It typically develops around 8 years of age and worsens until age 15 or 16. A nearsighted child has difficulty seeing objects clearly at a distance, like a blackboard, but can see clearly up-close, such as when reading a book. Myopia can be corrected with glasses, contact lenses and refractive eye surgery.
Doctors will typically evaluate a child's maturity and level of parental support in deciding whether the child is ready for contact lenses.
And that concludes our News Parents Can Use. And we will be back to answer your questions, right after this.
All right. We are back and we're going to answer your questions this time around.
The first one comes from Emily. Emily says, "Hi, Dr. Mike. I love your PediaCast and have been recommending it to all my friends which is the best way I know to thank you for doing this." Well thanks, Emily. "I have a quick question for you. We are moving again third and final time in three years for my husband's job. Finally got the 10 year track as a college professor. We have a two and a half year old and a nine month old and I'm trying to determine if we should take our children to our new family doctor or find a pediatrician again. In our various locations, we've seen three different pediatricians and one family doctor with our girls. Do you have a recommendation for how long a child should see a pediatrician rather than a family doctor. Thanks so much for your podcast. Regards, Emily."
All right. Well obviously Emily wants to get me in trouble again. [Laughs] This has been a hot topic before on PediaCast and every time I answer it I get hate mail from non-pediatricians. But you know this must be an important question that's on a lot of parent's minds because I keep getting the question.
Pediatrician versus family practice doctor and I'll add into the mix versus nurse practitioner because I've gotten that question a lot as well.
And what you folks have to realize is that you're asking this question to a pediatrician. So I might not be the most objective person to answer this question. And I will say this, my answer to this question over the last couple of years and as many times as I've been asked it has not changed despite all the hate mail.
I say see a board certified pediatrician until your child is working on their own with their own insurance or in other words until they're out of school. So I would say see a board certified pediatrician until after high school or even college. But again, that's my opinion.
Now the next question becomes, why do I have this opinion? And it's a valid question.
And I can answer the first question, why do I have this opinion and you'll have to decide on our own if my reasoning is valid.
So here's my thinking. Pediatricians are trained to treat kids and teenagers. Like family doctors they spend four years in college, four years in medical school, and three years in the residency program. But unlike the three year family practice residency, they don't waste time learning about adult diseases, surgery, OB GYN. So they get lots more experience dealing with sick kids. Also pediatric residencies tend to be at children's hospitals which are big referral centers so you see a much larger volume of kids and you see a much higher diversity of pediatric illness. Whereas family practice programs tend to be at community hospitals that see mostly adults and have a little pediatric floor off to the side.
Now, do the family practice doctors do some rotations at pediatric facilities and pediatric or children's hospitals? Sure they do.
Do they spend three years in a children's hospital and pediatric clinics, outpatient clinics? No they don't.
Now nurse practitioners aren't even close. They have four years of college and then two years in a master's level program. That's five years less of training compared to family practice doctors and pediatricians. Let me say that again, five years less training.
In addition to training of course, there is day to day experience once you're in practice. And in day to day practice, I think the average pediatrician sees m ore children and teenagers than the average family practice doctor or the average nurse practitioner and in many cases, lots more.
I don't have statistics to back me up on that, it's my own hypothesis that pediatricians see more kids and teenagers during the average day than a family practice doctor or a nurse practitioner, but you know it's my own hypothesis and I think it's a good one and you have to decide whether you agree with me or not.
And really, the more kids and teenagers you see, the better you get at diagnosing and managing illness in these age groups. And by the way, experience not only helps a doctor make the right diagnosis, but it also decreases the pain and cost of unnecessary tests because the more experience a doctor has, the more he or she trusts and relies on clinical skills over labs and x-rays.
Now that's not to say labs and x-rays aren't important, but they tend to be over utilized by the inexperienced.
Also pediatricians, especially ones who are board certified, so board certified pediatricians have to take a gruelling multi-day test that covers an enormous amount of child and teen health topics in great detail and they have to retake a test every seven years. They also have to maintain child and teenager specific continuing medical education hours and the other vigorous requirements and family practice doctors and nurse practitioners are not subject to the same degree of scrutiny with regard to child health topics.
So all in all, I would choose a pediatrician over a family practice doctor or a nurse practitioner through age 21 or until your child is out of school and that does include teenagers. Like children, teenagers are not small adults. They have unique problems and pediatricians are trained to anticipate, recognize, and manage these issues.
So pediatricians have more training, more experience, and are held to higher standards with regard to child health topics. That's not to say that there aren't excellent family practice doctors and nurse practitioners out there, there are and likely there are some family doctors and nurse practitioners that are better qualified and have more experience than some pediatricians. But I would have to say they are the exception and not the rule.
So in general I would recommend a board certified pediatrician for any child through the age of 21 or until they're out of school. And those who disagree with me feel free to write. It won't be the first time I've heard you complain and I doubt it'll be the last time. But I'm sticking to my guns on this one and you're not going to change my mind. So if you want to waste your time, fine.
OK. Let's move on to Dominique in Staten Island New York. Dominique says, "Dear, Dr. Mike. I have a son who will be one year old in two weeks and he's picked up a pretty interesting and annoying habit. He likes to stick his whole hand in his mouth and make himself gag. He's thrown up his meal many times and you can imagine my frustration, not only in losing his meal, but the clean up afterward. It seems he only does this while sitting in his highchair. Since we recently started introducing more finger foods, I thought maybe he felt like the solids were getting stuck in his throat. I asked my doctor and he said that some kids just like the feeling of gagging. I find that really hard to believe, so I'm coming to you. Any advice would be great. Love your show. My best, Dominique"
Well thanks for the question Dominique. And here is an example of experience helping out. This is a situation that all pediatricians here about on a regular basis and I would trust your doctor's answer.
My own son Nicholas was a gagger at this age, funny my daughter never did it, but my son gagged himself frequently. He would put his whole hand in his mouth and gag himself and it was about the same age that he did this and it's a story that we often hear.
I'm not sure kids this age really like the feeling of gagging as much as they probably, I say probably 'cause you know we can't really know what's going on in their mind. But I think they probably compelled to do it or any other self stimulation behavior and possibly they like your response to it.
It's the same for kids who bang their heads on the floor or bang their head on the crib or against the well, or kids who scratch their face, or kids who pinch and bite themselves. And your best bet I think is to first redirect them. If they're gagging themselves or pinching, biting, whatever, just simply don't draw attention to that bad behavior but rather redirect them, get their mind on something else. If that doesn't work and they go right back to doing it, then at that point I would ignore it.
What if they vomit? I would ignore it, I would ignore as much as you can. And I like in this to an older kid with a tick, which we've talked about recently. And I suspect the brain chemistry with kids who do these things is similar. There's a compulsion to do the action which is relieved once the action is done.
'Cause you got to remember, even babies' brains; they are human brains. They have the same chemicals and so they probably have the same pathways of feeling but it just manifest a little bit differently. So instead of a vocal tick or a head move or a little jerk, these ticks sort of manifest themselves in babies with more baby-type things, like scratching themselves, pinching, banging their head into the crib or gagging themselves. So that's just my opinion on this.
if that doesn't work, as I said I would suggest redirecting them first; if that doesn't work, then I would ignore it completely. And even if they vomit as I mentioned, if they vomit, do your best to leave it alone and clean it up later. Because the compulsion could be to see whatever behavior you are going to do in response to the gagging. Now most of the time that's not the case. I think most of the time, the kids feels compelled to do the gag and so they do it and that's it. That doesn't necessarily mean they like it. I hope that makes sense to you.
A kid with a tick doesn't necessarily like the fact that they're jerking their head all the time or that they're making a noise or clearing their throat. It's not that they like doing it. It's that you have this feeling of being compulsed to do it and that feeling goes away once you do it. There's a difference. So I don't think it's that they like the feeling of gagging. Although there may be a few kids out there who do. But I think most of them; this is an obsessive – compulsive type thing being that's just way it manifest in a kid that age. But there's going to be a few of them that like throwing up because they like seeing you have to deal with it. In other words, they want the attention and this is the way that they get the attention. So this would be a reason to even if the vomit with it, unless it's a dangerous situation, you know when they have it in their mouth and you're worried that they're going to choke on it that sort of thing; I would try to leave it as long as you can. Now I know, it's not fun to have dinner with vomit next to you.
But usually if you ignore these things, most of the time they'll go away on their own quicker than if you make it a big deal and a big fight. Having said that, self stimulation and self harm can be a symptom of a more serious problem. Autistic kids are more to self stimulation and self harm. Kids with some genetic disorders and mental retardation are more likely to do it. Blind kids, deaf kids are also more likely to do self stimulation and self harm.
So you do have to look at the big picture to some degree, but in the absence of developmental problems and a kid with normal vision, normal hearing, it's not much of a concern. And like the head banging and scratching and biting; self gagging will likely go away on its own and it will most likely go away sooner if less attention is paid to it.
So hope that helps, Dominique.
Next up is Kelly in Austin Texas. And Kelly says, "Dear, Dr. Mike. I'm a new listener having discovered your podcast just last week. I have a question about hiccups and yawning. My two month old son gets bad hiccups everyday. I have read two theories on hiccups. One is, no one knows what causes them and the other is that they are caused by over stimulation. So why do we hiccup? Are there things that I can do to help prevent some of my son's hiccups? The next question is about yawning. When does yawning become contagious? I have noticed that my son doesn't yawn in response to our yawns like we do his. Has anyone ever studied why we yawn in response to other people's yawns and when that response develops? Thanks. Keep up the great podcast. Oh, and my family is split with half of us being Michigan State fans and the other half being Ohio State fans. My mom grew up in Bowling Green and has always supported the Buckeyes. Being from Michigan originally, I feel it is my duty to support the Spartans."
OK. A little Big Ten talk here. It's OK to support the Spartans, Kelly. As long as you don't support the Wolverines, the University of Michigan. We can agree on not rooting for them, right? Unless of course it's non-conference play and if you want to support the Big Ten, but with the University of Michigan it's still iffy even then.
OK. So let's talk about hiccups and yawning. It's a fun topic, let's do hiccups first.
What are hiccups?
Hiccups are muscle spasms of the diaphragm which is the muscle that separates the chest from the abdomen and it's responsible for breathing in; for pulling down, making there'd be more room, more of a vacuum inside the chest cavity so air rushes in to equalize the pressure and so that's what the diaphragm does. And hiccups are a spasm, an intermittent muscle spasm of the diaphragm.
Hiccups often start in utero meaning when inside mom and moms whose babies hiccup often while still inside mom can tell you exactly when it's happening. So moms to be know when their baby is hiccupping most often. Also babies who hiccup often while inside mom usually continue to have frequent episodes after birth. And babies who don't hiccup much while inside mom, seldom hiccup after birth.
OK. So what causes these spasms of the diaphragm?
Well the short answer, we don't know. There are lots of hypothesis out there. One of the more interesting ones in my opinion is the phylogenetic hypothesis. And this hypothesis suggests that hiccups, at least in babies are an evolutionary remnant. So human fetuses have other evolutionary remnants that appear and disappear in the course of embryonic development.
For example, more than two nipples or supernumerary nipples which we've talked about before, as a fetus, human fetuses have more than two nipples but then they go away. Also branchial clefts which are slits in the region where fish and amphibians have gills, those develop during the course of embryonic development and then go away. And by the way those are things too that sometimes abnormally don't go away. So you can see a baby with more than two nipples, you can see a kid with clefs or tracks where the branchial clefts used to be and they didn't go away and so you have sinus tracts or empty groves, they're not really groves; they're pits deep pits so to speak. They're remnants that should've gone away and they didn't and you often times have to have surgery to get rid of those because they can get infection inside of them, that sort of thing.
OK. So along those same lines the motor pathway that allows a reflexive movement of the diaphragm is one of the first neuromotor pathways to form much earlier than the formation of other motor pathways involved in ventilation, like movement of muscles between the ribs. And the hiccup pathway as it turns out is identical to a reflex that's seen in amphibians which allows frogs and other amphibians to gulp air in the water. Also the same things that inhibit the frog pathway also inhibit the hiccup pathway. More specifically, high levels of carbon dioxide and the drug Baclofen which is a GABA B receptor agonist, for all you biology types out there. Those things stop both frog gulping and hiccups.
So some say that the reflex is not only important for amphibians, but maybe that reflex is important for human fetuses as well. And they hypothesize that hiccups help to strengthen respiratory muscles prior to birth and or protect the lungs from excess amniotic fluid entering them.
So I think that's interesting, hiccupping may be a primitive reflex that eventually dulls or goes away and certainly there are other reflexes alike that that we see in infancy like the parachute reflex, the finger and toe grasp reflex, the rooting reflex or if you brush a baby's cheek, they turn to that side and start sucking, the startle or Moro reflex or if you move a baby real quick, their arms go out and they start to cry. So there are other reflexes that come and go and hiccupping at least in babies, may be an example of that kind of reflex.
I think it's an interesting way to look at it. That's not to say that I'm 100% pro-evolution and there is no God, please don't mistake that. It's just it's interesting how biologically embryos develop into fetuses and then into babies and there are some things that are interestingly enough sort of correlate with other animals and so hiccupping may be a part of that.
OK. Incidentally, there're a whole list of things that have been known to set off hiccups in older kids. And I'm going to read through some of those 'cause they're interesting. And it could be that older kid and adult hiccups are different, they're a different animal than infant hiccups. Where infant hiccups is more of that reflex that just happens and in adults, the diaphragm like any other muscle can be prone to spasm by different things.
I mean you can get a muscle spasm if you use your leg muscles, you can get a Charlie Horse in your leg, you know what I'm talking about. So muscle fatigue can lead to spasms and maybe the diaphragm just shows spasm as these intermittent hiccups rather than a constant, you know if it's a constant thing, it'd kill you. 'Cause if the diaphragm couldn't relax and move, you're going to have a hard time getting air in. So people whose diaphragms responded in that way aren't going to live to give their genes and so, OK here we go I'm talking evolution again, natural selection. Sorry. Please all of you, non-evolutionary people, please don't unsubscribe from the podcast. I'm a believer, but maybe God used evolution. I don't know, on fast forward or something. Who knows?
Anyway, here is something I'm going way off here. This is not a religious podcast, folks.
There are lot of things that set off hiccups in older kids and adults such as lack of water, eating too fast, being hungry for too long. These are all things people have talked about over the years. Taking a cold drink while eating a hot meal, love that one. Frequent burping, eating very hot or spicy food, laughing vigorously, coughing, drinking alcoholic beverages in excess, crying out loud, because supposedly sobbing causes air to enter the stomach; electrolyte imbalances, talking too long; although after doing a show of PediaCast you think that then I would have hiccups and I don't. So how long do you have to talk to get hiccups, who knows? Clearing the throat too much; these by the way again, they're anecdotal, they're not based on any research.
So the bottom line is we don't know for sure why hiccups exist or how you get them. We really don't understand them to well at all, other than to say, "They seem to be kind of like a reflex you see in frogs." We do know this, they're not harmful, they usually aren't a signal for any underlying condition. The exception to that would be phrenic nerve irritation. The phrenic nerve controls the diaphragm, so the pressure on the nerve from a tumor could cause hiccups, but that kind of a tumor is really, really, really, really rare. I guess if someone had intractable hiccups just all the time constant hiccups, that's something to consider.
But in the vast majority of people and babies included, they're harmless, they're nothing to worry about and you don't need to worry about any interventions to make them not get them so much, 'cause they're no big deal. Just forget about it.
All right. Let's move on to yawning.
We do know a little bit more about yawning, not a lot more but a little more. There are many hypothesis regarding yawning. We do know that yawning opens the alveoli, they're the little tiny air sacs at the very end of the bronchial tubes. So yawning actually stretches the alveoli and then the alveoli cells release surfactant which is kind of like a soapy substance that helps them to open and stay open. So it does help to open up the air passages way down deep in the lungs.
Yawning also opens up the Eustachian tubes which helps to equalize the pressure on both sides of the eardrum. But is that important or is it just sort of a side effect of yawning? Do we yawn when we're tired? Is that a real association or nor? Do we yawn when we're bored? Why are yawns contagious and if they aren't contagious, is that a problem? Which is one of the questions you asked.
The answer to all of these remains, we still don't know for sure. But some things that are thought to cause yawning, so these are hypothesis.
In 2007 there was a study done at the University of Albany that hypothesize that increase flow of air in the head cools the brain. So if your brain temperature gets too high, maybe that's what causes a yawn and because increase flow of air in the head cools the brain. I don't know about that. It was a hypothesis, kind of a shaky study.
Could it be an unconscious communication of psychological decompression after a state of high alert? A psychologist came up with that one.
An unconscious communication of psychological decompression after of high alert. I think that's describing being tired isn't it? OK it's a way to show other people that you're tired.
Excess carbon dioxide and lack of oxygen in the blood. That makes sense when you consider yawn pops open the alveoli. If you have excess carbon dioxide and lack of oxygen in the blood, but if that's true, if I hold my breath shouldn't I start to yawn? And you don't.
So some of these things makes sense on the surface but then again, when you really think about it, not so much.
Apathy, boredom, tiredness – Do those things cause yawning? If so, how and why? And as a means of equalizing middle ear pressure, sure it makes sense but if you go up in an airplane and you feel the pressure on your eardrum, do you yawn more? I mean you do sort of maybe stretch your jaw to open up the Eustachian tube to make that feeling go away, but do you actually yawn? I don't think so.
And then the next question is why is yawning contagious?
Again some suggest that the contagiousness of yawning is a primitive reflex kind of like hiccupping, but this reflex deals with empathy. And there was a study that we talked about back in PediaCast number 48 way back when that suggest that lack of yawn contagiousness might be a marker for autism. So if yawn contagiousness is somehow related to feelings of empathy, then that sort of makes sense because autism does come with a decrease in feelings of empathy. And a study did show that autistic kids have a decrease in contagious yawning, so that's interesting.
On the other hand, no one would make a diagnosis of autism with lack of contagious as the only symptom. I mean you still have to look at the big picture. But there may be a relationship there and for more information on contagious yawning as it relates to autism, again that's Episode 48. It's the first item in the News Parents Can Use Segment. We'll have a link in the show notes for you.
So in terms of your question Kelly with regard to when does contagious yawning show up, when in the course of development? I don't have an answer for you because we really just don't know. As you can see there is a general lack of research on yawning and hiccupping and why? 'Cause they're benign conditions and while the questions are interesting, money to support questions that are just interesting is non-existent especially in this economy. So for now, hiccups and yawning will have to remain sort of mysterious. But hey, look at it this way, it means there's more things in the world left to discover.
OK. So let's move on to our final question and fortunately it's something we do know a lot about and this comes from Mary in Richmond Rhode Island. Mary says, "Hello, Dr. Mike. My daughter is currently 10 months old. When she was born my husband and I noticed a couple of slightly discolored patches of skin on her back. There're small spots about the size of a dime. We thought nothing of it at that time assuming they were your standard birthmarks. At approximately four months of age I was contacted by a daycare worker saying that my daughter had just flushed bright red from head to toe and the spots on her back had turned into large pus-filled blisters." I bet it wasn't pus. "By the time I picked her up from daycare about 30 minutes later, she was back to normal with the exception of the blisters. It took a few days for those to heal. Since that first incident, she has had a couple more occurrences that played out the same way. My daughter was eventually diagnosed with Urticaria Pigmentosa or Mastocytosis. There's a lot of conflicting information on this on the Internet. I was hoping you could give a brief overview and advise me of precautions I may need to take, if any. Thank you so much for you help. I very much enjoy listening to your podcast every week. Mary."
Thanks for your question, Mary.
Urticaria Pigmentosa, it's one of those diseases that just doesn't have a simpler name. So you just have to call it Urticaria Pigmentosa. So let's talk about it.
First let's kind of breakdown the name. Urticaria means hives. Pigmentosa means pigmented. So you have pigmented spots that get hives; Urticaria Pigmentosa.
It starts out as, I guess you'd say a rash, not really a rash. It's just you have some reddish-brown spots that usually are on the neck, the arms, the legs and the trunk. So they're mostly on areas that are covered. You see them less often in sun exposed areas. So you don't see them as much on the face, on the scalp, on the palms of the hands that sort of thing.
These spots are typically small but they can be sort of medium-ish size, they're not usually really, really big. These reddish-brown spots contain large numbers of mast cells. Mast cells are cells that contain and release chemicals that are important in the immune system and one of the major chemicals that is inside mast cells is the chemical histamine.
And if you want to know what histamine does, well think about what antihistamines do; so antihistamines like Benadryl help to decrease congestion, help hives go away, help itching to go away. So histamines do the opposite; they cause hives, they cause itching, they cause nasal congestion. So these mast cells or these reddish-brown spots contains lots of mast cells which contain histamine. Again histamine, its function is in the immune system.
Recent studies suggest that a large number of cases of people with Urticaria Pigmentosa is caused by a point mutation at amino acid number 816 of the Proto-Oncogene C-Kit. What does that mean? Well for our purposes it means there's a genetic component and we'll leave at that. You'll have to listen to a biochemistry podcast if you want more details on amino acid 816 of the Proto-Oncogene C-Kit.
Basically we have a collection of mast cells in the skin, that's what's causing the spots. Now what? If the mast cells release their chemical contents, then you are going to get some specific symptoms and these are symptoms that are primarily mediated by histamine and histamine is released when these spots are rubbed or scratched.
What does the histamine do? We kind of talked about that; you can have both localized symptoms, so symptoms at the site where the spot is. And then you can have systemic symptoms because the histamine gets in the bloodstream and goes to distant areas.
What do you get localized? You get redness, hives, itching and sometimes blisters. They are fluid-filled but they're not pus-filled. Pus-filled would be an infection. So these are just fluid filled blisters which it sounds like what your child had. So redness, hives, itching, sometimes some blisters at the point of contact. So you scratch the spot, you get these things.
But then the histamine travels to other places and you can get flushing of the skin redness of the skin all over. You can get headache, tachycardia; which is a rapid heart rate. It can cause diarrhea because it increases gut transit time. You can also get low blood pressure, and if the blood pressure goes low enough, it can cause syncope or fainting, so these are all things. And of course if the blood pressure goes really low, it causes shock and death but that's unusual.
Symptoms can also occur f mast cells release their content in response to other things. So the mast cells release the histamine if you scratch the skin. But the mast cells can release their stuff during periods of emotional stress, in response to bacterial toxins, the antibiotic Polymyxin B which is a Neosporin has been shown to do it, non-steroidal anti inflammatory drugs like Ibuprofen which is in Motrin and Advil; there are other ones like Naproxen those kind of things can do it, Aspirin has been shown to do it which is kind of a specialized non-steroidal anti inflammatory drug alcohol, also opiates such as Morphine and Codine. These are all things that can cause mast cells to release histamines. So if you're a person who has Urticaria Pigmentosa, you might want to avoid those things.
This is interesting, if you're a person who has a classic severe allergy such as an allergy to bee stings, or peanuts, or shellfish, sort of the allergies that are bad. If you have one of those allergies and you have Urticaria Pigmentosa then that can cause a massive histamine release because those allergies cause massive histamine release and you combine that with Urticaria Pigmentosa, then that might be a real issue. I mean then you might have what we call anaphylaxis which can be life threatening, a life threatening allergic reaction. So if you have Urticaria Pigmentosa and a bee sting allergy or peanut allergy or shellfish allergy. It's even more important that you have an EpiPen available 'cause that could save your life.
This is a relatively rare condition. Its true incidence is unknown and there's probably people out there who have it and don't know they have it because they have a mild form of it. But it's thought to affect around 200,000 individuals at any one time in the United States which is not a lot when you're talking 350,000,000 people; 200,000 I didn't do the math. It's a low percentage. And it's low enough that it makes it an orphan disease.
What's an orphan disease?
An orphan disease is a disease that doesn't get a lot of research money because there aren't a lot of people affected by it. But because it's an orphan disease it can qualify for some special government funding. Although that may go away in the present economy because it's not getting money elsewhere. So it's an orphan disease. It doesn't affect very many people.
Of the people that it affects most are kids and incidentally if it develops before age five, it usually resolves during the teenage years or in early adulthood. If it develops after age five, then there's more likelihood that it will persist longer. And if it develops during the teenage years or adulthood, it's likely that it will persist in the late adulthood and be accompanied by some complications that we will talk about later. So the earlier your child develops it, the better. And if it develops before age five which it usually does, then it most often resolves during the teenage years or early adulthood.
The diagnosis first is suspected on clinical grounds. So you have these spots, you scratch them, you get hives, that makes you suspect the diagnosis. It's confirmed with a skin biopsy, you do a little skin biopsy. Usually a dermatologist would do this and that confirms the presence of an increased number of mast cells in these lesions. You can also check urine; you check urine histamine level because if you have lots of histamine being released, you're going to have more of it in the urine, so an elevated histamine level in the urine would also suggest this diagnosis.
There're also some blood tests that can be done to rule out another condition that this could be and we'll talk about that more in just a minute.
In terms of treatment, you want to avoid rubbing and scratching those lesions, you also want to avoid agents which we know cause mast cell release; such as Aspirin, Codeine, Morphine, other opiates, alcohol, Polymyxin B which is a Neosporin that kind of thing.
You also want to avoid prolonged hot baths or showers as that can cause histamine release and then the next component of treatment would be antihistamines, right?
So if the symptoms are caused by histamines, antihistamines can help with the symptoms like Benadryl or Hydroxyzine is a prescription one.
If the histamine release is huge, if it's a huge release of histamines, antihistamines probably aren't going to help much and in that case if you have low blood pressure and it's anaphylaxis, death can ensue and that's where Epinephrine can help you out. So you want to have an EpiPen available if you're prone to huge releases of histamine with your Urticaria Pigmentosa.
Most kids don't have that unless they have another serious allergy condition like we mentioned before.
Interestingly enough, Aspirin, even though it can cause the mast cells to release, it also causes mast cells to not make a lot more histamine. So Aspirin can sometimes be used as a treatment for this because first though, it's going to cause a flare 'cause all the mast cells are going to want to release and so you're going to get flushing and hives and all that. But once you pass that point, daily Aspirin intake can keep the mast cells degranulated once their contents are released and so that can prevent the mast cells from getting more histamine inside of them, so it can prevent future flare ups caused by other things because the mast cells don't have histamine in them.
But I have to point out; do not try this at home. Do not try this at home. I'm going to say the third time, don't just give your kids Aspirin. You would only do this under physician supervision.
And the reason for that is because Aspirin combined with certain viral infections including chicken pox can lead to something called Reye's Syndrome which is very bad. It can cause liver failure, brain damage, high mortality, something you don't want. And that's why we don't recommend Aspirin routinely for kids anymore.
On the other hand, we're seeing a lot less Reye's Syndrome that we ever did, that's because a lot less kids take Aspirin. However it could also be that back in the 70's and 80's there were particular strains of virus, strains of chicken pox that were more likely to cause Reye's Syndrome when Aspirin was also present. And maybe that's also why we don't see this much so maybe Aspirin isn't so bad anymore but we don't know for sure.
It's another one of those benefit versus risk decisions. I mean if you had a kid who had a really bad bee sting, peanut, and shellfish allergies; I mean just a really allergic kid and they also had really bad Urticaria Pigmentosa with tons of spots, tons of potential histamine release, (as a doctor we say a lot of antihistamines a lot more that we say histamine) so in other words, if you had a kid whose life was at risk, if they had any kind of allergic reaction, maybe for that kid the benefit of daily Aspirin would outweigh the risk. But again that's something you have to discuss with your doctor. It should be done not on your own. So do not give your kids with Urticaria Pigmentosa Aspirin without talking to your doctor about it.
And again I would only recommend that for kids and I'm not recommending it. That should only be considered for kids who are prone to really bad reactions with their Urticaria Pigmentosa. And then again for those kids with severe reaction, Epinephrine would be the drug of choice.
One study suggests that Nifedipine which is a calcium channel blocker used to treat hypertension might also reduce mast cell granulation and keep them from building up and letting go of histamine. But there's just one study, it was small and again it's hard to do studies on these because it's an orphan disease and money just isn't out there. But one study suggested that Nifedipine could also be used. Just FYI there.
Prognosis. Urticaria Pigmentosa usually goes away by puberty in about half of the affected children and the remaining children, symptoms usually decrease drastically during young adulthood. So again as long as you have onset as a young child especially less that age five, it almost always goes away by the time they're teenager or young adult. If the onset is later, then the disease usually last longer and it's more likely to include complications and it's more likely to actually be Systemic Mastocytosis which we are going to talk about next.
Remember when I said the more to come part coming up in just a minute. I'll talk about that when we talk about blood work with the work up.
Systemic Mastocytosis; Urticaria Pigmentosa is also known as Cutaneous Mastocytosis. So let's break that down; cuteneous is skin, mastocytosis is a collection of mast cells. So Cutaneous Mastocysis – mast cells in the skin. Urticaria Pigmentosa – pigmented spots that get hives. Why do they get hives? Because there're mast cells in them and it's all in the skin. So this all makes sense, right? Urticaria Pigmentosa can also be called Cutaneous Mastocytosis.
So what is Systemic Mastocytosis?
mastocytosis is still collection of mast cells, systemic means throughout the body. So you can have problems in the skin but you can have problems throughout the rest of the body as well. This is a different animal and it's seen more often in adulthood. Kids can get it but usually don't. This is more if you have a teenager with new onset of Urticaria Pigmentosa or an adult with new onset Urticaria Pigmentosa. They could actually have not Cutaneous Mastocytosis but Systemic Mastoctosis. So they can get collections of mast cells that appear anywhere in the body.
And most common sites for that are going to be in the bone marrow and in the blood, the lining of the intestinal tract, and in the liver, the spleen, and in lymph nodes and the symptoms that you get a re going to depend on the location of those mast cells.
So if it's in the bone marrow or the blood stream, you are going to get decreases in other cells. So you can get what we call Neutropenia which is a decrease in white blood cells or thrombocytopenia which is a decrease in platelets which can cause then clotting problems. So this is all really important stuff because it can be very dangerous.
If you have really low white blood cell count, you're going to be prone to more infections. If you have really low platelet counts, you're going to be prone to bleeding problems. So if you have lots of mast cells in the bone marrow, there's not a room for these other cells to be made 'cause in the bone marrow's where we make blood cells. Also bone marrow involvement can lead to osteoporosis and easy bone fractures.
Also if it's in the GI tract, then you can get Peptic Ulcer Disease, malabsorption where you don't absorb nutrients; you start to lose weight, it can also cause chronic diarrhea
In the liver you're going to have an enlarged liver and then liver failure with ensuing jaundice and other problems.
In the spleen and lymph nodes you get an enlarged spleen, enlarged lymph nodes. Which interestingly enough, the spleen and lymph nodes are like filters for the blood. So if you have too many mast cells in the blood because it's in the bone marrow, then they're going to get trapped in the spleen and the lymph nodes because those act like a filter and then those get become enlarged. So it all makes sense.
So that's why the work up usually includes some blood work especially in older kids and adults who have Urticaria Pigmentosa 'cause you want to make sure it's not just in the skin.
Do you have to do this big work up for kids under five who have it? It's debatable.
Sort of a compromise, you could do complete blood count, just to make sure that their counts – the number of white blood cells and number of platelets, all that's normal. You could do some liver function tests that kind of thing. But you probably don't need to in a kid who's young who has this, but in older kids, teenagers, and adults, you definitely want to make sure that they don't have Systemic Mastocytosis and not just Cutaneous which we call Urticaria Pigmentosa.
I'm hoping this all makes sense. I know I'm using a lot of big words but if you break down what these words mean, it's not really that difficult of a thing to grasp.
Of course also then a thorough physical examination is important, you want to make sure they don't have hepatomegaly which is an enlarged liver, spleenomegaly which is enlarged spleen, or lymphadenopathy which are abnormally large lymph nodes.
All right so that's Urticaria Pigmentosa in a nutshell. Hope that helps, Mary. I don't know what conflicting information you're getting 'cause we do know a lot about this disease as opposed to yawning and hiccupping.
All right. We are definitely running over. We are well over an hour now so I apologize. I told you it was going to be a big show. It's our pre-Thanksgiving show, no show next week. I mentioned that at the beginning. Now it doesn't matter, you're already almost to the end. So I don't know I'm just talking.
Let's go ahead and take a break here and we'll be back and wrap up the show right after this.
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I've been talking a lot, we're going on like an hour and ten minutes here and I'm not yawning or hiccupping, so I'm not sure that long talking really does those things.
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Once again no show next week. Happy Thanksgiving to everyone. I will say, "Go Bucks beat Blue." To all my Michigan listeners, it's all in good fun most of the time.
All right and until next time, this is Dr. Mike saying, "Stay safe, stay healthy, and stay involved with your kids." So long everybody.