G6PD Deficiency, Shigella, Keratosis Pilaris – PediaCast 145


  • Violent Video Games
  • Thinking
  • Gambling
  • Summer Jobs
  • G6PD Deficiency
  • Shigella
  • Keratosis Pilaris
  • Herpetic Skin Lesions
  • Baby Poop – Diarrhea



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


Welcome to PediaCast, a pediatric podcast for parents. And now direct from Birdhouse Studios, here's your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. It is Episode 145, 145 for April 27, 2009. That's a Monday. We're calling this one G6PD deficiency, Shigella and keratosis pilaris.


Now I know those are big words and we're going to break them down and make them easy to understand like we usually do here. But there are things actually that are fairly common. Well, maybe the Shigella is not quite as common as the others, at least in developed countries. So we'll talk about all these things.

Also swine flu. How can we not talk about swine flu. It's like all over the news right now. So we're going to talk…help you understand that and what's going on. That's coming up in our news section a little bit later on in the show.

We skipped a couple of weeks. Sorry about that. I asked for your donations and then leave you in the dust. I have a good excuse. This is a one-man show. I write the script, research the topics, record it, produce it. It's just me. And I had a couple of back-to-back illnesses, just viral illnesses, but they really got me down.


You would think working in the pediatric field that we would get sick a lot and you do in the beginning. I mean new people coming into pediatrics, medical students who are rotating through pediatrics residents, pediatrics residents when they first start. New nurses, nurse practitioner students, family medicine residents.

I mean all of us when you first go into pediatrics, you get sick a lot. And because you are exposed to all these different viruses many more than you were exposed to as a kid, and every time you get one strain of a virus, your immune system remembers it.

And then after a while, the illnesses slow way down because you have basically been exposed to all the local strains of virus in your community where you're working and so the next time each of those viruses come along, your immune system destroys it. We'll talk about this. It's how your immune system works. And it's all well and good until you do something crazy like move 1,000 miles away and start over and the result is that I think I've been exposed to some viral strains that are unique to Florida.


And so I have been sick a little bit more often than usual for me during this virus season, so to speak. You know, I wash my hands appropriately, you sterile technique when required. Nothing new there but I think it's just a new location with new strains of virus. And then it hit me and this is not necessarily a good thing. Florida, especially Central Florida, doesn't necessarily even have its own strains of virus because we get it all over the place because of tourists coming in from different parts of the country, different parts of the world.

In fact, a couple of the locations where I worked, we do see a lot of tourists who come in and they're bringing their local communities strain of viruses. So we get exposed to different ones every week from all over the world. And I'm here to tell you that was not in the job employment brochure. But I am hoping these frequent viral episodes will diminish in frequency.


So anyway, that's my excuse for missing a couple of shows. Plus, we had two sets of houseguests in that same time period. And I guess you'll have that when you're living a stone's throw from the Magic Kingdom at Disney World. And of course, we enjoy it. My father and his wife stopped in for a few days and we had a family friend from back in Ohio who is in town for a conference and stayed with us. So that's having some house guests too has sort of stolen some time away as well.

Okay, so let's get cooking on today's show. What do we have on the lineup? We're going to talk about… in the News department, we're going to talk about swine flu, as I mentioned. Spinal taps, thinking, gambling and summer jobs and then we'll get to your questions G6PD deficiency, Shigella, keratosis pilaris. Also we're going to talk about herpetic skin lesions, skin lesions caused by herpes and we had a question on baby poop, diarrhea. Baby poop, loose stools. So that will be coming up a little bit later on in the show.


By the way, during our Listener segment this week, it is international hour. So all of our questions are from overseas and we'll get to that. So if you or are a domestic listener in the United States, your question – we're not going to get to it this week, sorry. But it may be on the lineup for next week.
If you do have a question that you would like to ask or if you have a topic suggestion for us or a news article you'd like to pass along, it's really easy to get a hold of us. Just go to pediacast.org and click on the Contact link. You can also email us at pediacast@gmail.com or call the voice line at (347) 404-KIDS, that's (347) 404-5437.

I also want to mention, I kind of mention this just a second ago briefly. You can now donate to the cause here. We do have a lot of overhead expenses in getting this podcast out to you, the listener, with no charge and with lots of great information.


And an example of a charge that we have, there is a service called up-to-date that medical professionals can get memberships to. And you can basically look up any topic and get the latest research and the commentary from physicians and scientists. I mean it really is up-to-date. The problem with it is that it is extremely expensive to have a subscription to that. So that's again another example of some of the overhead expenses that you don't think about that we have here.

So if you find it within yourself to donate to a good cause, just go to PediaCast.org, click on the Donate button and join the ever-growing list of people who are helping us out.

Don't forget the information presented in this show is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. We are not a doctor's office.


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


Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.


Okay, our first topic in the News section here is swine flu. And usually, I have these news stories nicely packaged with little commentary at the end. And I worked on the script in these news stories a while ago. And the swine flu thing is really just come into the media spotlight in the last few days and I didn't… actually as I was getting ready to record, I thought, oh we need to talk about swine flu.

So I don't have a nice little package here for you. But let me just sum up sort of what's going on.
Different influenza viruses, this is a respiratory virus, causes high fever and respiratory symptoms. So runny nose, cough, congestion and it can lead to pneumonia. Both a viral and pneumonia caused by the influenza virus itself or a secondary bacterial pneumonia caused by your own mouth bacteria that migrate down into the trachea, into the lungs while your body's fighting the flu virus and then you get a bacterial pneumonia which can be serious. And some strains of flu influenza also in the know themselves can cause a severe viral pneumonia. And which can be very serious and without proper treatment and support, could possibly lead to death.


Now the issue with the swine flu is that… why is it called swine flu? Because this particular strain of virus started out as a pig virus. So it was a virus that only pigs can give each other. Kind of like the bird flu is a flu virus, an influenza virus that only birds can get. Well, this particular strain of pig virus has mutated and has some genetic characteristics of bird flu and human flu.

So when you look at the genetic DNA makeup of this flu virus, it has… it's mostly swine flu but it does have some characteristics from birds and humans. And that's… when you talk about genetics and mutations and if two viruses are in the same saliva can share DNA. And so you can get basically the creation of a new strain of virus in this fashion.


Now as long as it's still just infecting pigs, it's not a big deal for humans. And even if a human does get it from a pig, the key is it has the virus mutated enough to be able to be transmitted from person-to-person. And with this particular strain of this swine flu, pig flu, it appears that it has been enough of a genetic mutation for it to now be able to be transmitted from person-to-person.

And there's evidence of that because of the widespread nature of this particular virus and how quickly that it has spread. So it's unlikely that all these people who are coming down with swine flu in Mexico City are all around pigs. It's more likely they're getting it from other people.


And we do also think it may be on the verge of being a pandemic. And the pandemic is widespread severe flu that could potentially cause lots of deaths.

Now why would this particular flu virus be worse than the everyday flu that we saw all winter long? Well, a couple of reasons. One is that there is… that this strain is brand new. So it's not in any flu shot. So if you've got a flu shot this year, you're not protected because this particular strain of flu was not in the shot.

So basically the entire population can help spread it, the entire population of the world whereas when you have the regular flu viruses, you have people who are immunized which can help stop the spread from one person to another. So that's called herd immunity where being… having immunized people out there help to stop the spread of a disease. So there's no herd immunity with the swine flu because no one has had a flu shot against it.


And then the other thing that can cause a pandemic or create one… one of the key features of it is a high mortality rate is this particular strain has the potential to cause severe respiratory problems i.e. pneumonia or pneumonitis which can lead to decreased stability to oxygenate the blood.

And why is this strain able to be more serious, more virulent, more likely to cause severe disease? We don't know the answer to that. We just know that some strains are worse than others. Probably, the ability of this particular strain to infect lung tissue is my guess. But it's just a guess.


So I think that's why we have sort of the perfect storm here for a pandemic because we have a new virus that no one has their own immunity to because it's new. No one has any vaccine… have had vaccines against it so you don't have natural immunity or vaccination immunity. You also have a situation where it can spread from person to person easily and are virulent and cause the potential for high mortality.

So it's kind of scary and I think that if your child has flu symptoms at this point, you definitely want to get them to the doctor to be seen and tested for the flu. Now what are the flu symptoms? Again, the most likely are going to be sudden onset of high fever. So your kid's doing well and next thing you know, they're 104. So high fever with respiratory symptoms, cough, runny nose, congestion, make you worry about this.


So what can your doctor do about it? Well, they can test you for the flu. If they don't do flu testing in their office, they can suggest a place where you could get the flu testing done. This new strain of influenza is a type A influenza. So if you get a flu test and it comes back as type A, then does that mean you have swine flu? Not necessarily. Then the specimen would have to be sent out to be typed to see if it is this particular strain that we're all talking about.

Now is it practical to send everyone's off? No, not from your individual doctor's point of view and not from your family's point of view. Certainly from a public health point of view, it might be interesting, but that's going to get expensive very quickly.

So I think that at this point in the flu season, because we really have had sort of a die down of the flu in the United States over the last couple of weeks so we're not really seeing much of the normal run-of-the-mill flu anymore.


So that at this point, if you get someone with the flu and it is influenza A, I think you have to assume the worst that it is this new swine flu.

Now the good news with that is it appears to be very sensitive to the antiviral medication Tamiflu. The downside of that… and I want to mention this again, it seems to be sensitive to Tamiflu. The reason that's important is because during this past flu season, most of the influenza A virus that was out there was resistant to Tamiflu. So the Tamiflu work if he had type B influenza. But if you had type A, it wasn't likely to work. Now it's a little different because we're talking about a different strain of A that does appear to be sensitive to Tamiflu.

So that's the good news. The caveat here is that with any flu virus, you need to start the Tamiflu as soon as you can. So if you started within the first 24 to 36 hours of the onset of the fever, it's going to be most likely to work.


So this is the kind of situation where you don't want to wait two or three days to see if your kid's high fever is going to go away. You want to get them in, get them tested if they have flu A, I would ask for Tamiflu in order to knock it out as quickly as possible.

Okay, so that is sort of what's up right now with swine flu. In the coming week or two, I think we're going to… this is sort of going to play itself out and we'll see what happens and we will talk about it as it comes. If there's any brand new breaking news concerning this that I feel need some interpretation for my audience, we'll do a special show and get it right out for you, even if it's a slow 10-minute blurb just to keep you in the loop if I think things are sort of getting out of control and not being presented by the media in a way that is easily understandable for moms and dads.


Alright let's go ahead and move on to the package news items. Video Killed the Radio Star, the old song goes, but violent video games in new Tel Aviv University study finds also can improve the real world vision of the teens who play them.

"As a father and brain scientist, I was quite concerned when my kids were growing up and playing video games,… says Dr. Uri Polat of Tel Aviv University's Goldschlager Eye Institute who partnered with the University of Rochester in New York to carry out the new study. What we see now is that teens who play violent video games are also training their brains to see better. Results of the study were recently reported in the journal Nature Neuroscience.

Dr. Polat compared the effects of playing violent action games like Unreal Tournament 2004 and Call of Duty 2 to other video games which do not require high levels of visual motor coordination like The Sims. Administering a standardized visual test to game playing teenagers, Dr. Polat assess the teen's contrast sensitivity function, the primary factor used by eye specialist the measure the quality of an individual's eyesight. Usually improvements in CSF are only found when eye doctors prescribed eyeglasses and contact lenses or perform eye surgery.


Surprisingly, the researchers discovered playing violent video games enhances the ability of the young game players to discriminate between subtle contrast and color or shades of gray. The game playing teens were divided into two groups. One played the violent video games and the other played The Sims too. After playing 50 hours of the assigned game, over nine weeks, the students who played the more violent action games showed a 43% improvement on average in their ability to discern between very close shades of gray. The players assigned to The Sims game showed no improvement.

Dr. Polat says, "We think the games are taking the brains of visual cortex to the limits forcing it to adapt to the added stimuli of the action games…. Among the test subjects, researchers measured an improvement of up to 58% in contrast sensitivity and the effects were great as for players who were very skilled at playing first-person shooting games.


Until now, eye specialists believe that it was not possible to improve this kind of visual sensitivity without medical intervention. As scientists and clinicians would normally think about improving this aspect of vision by changing something in the optics of the eye through surgery, for example, but we were able to show that action-oriented video games can improve the brain's ability to process visual information, effects which seem to last months after the game-playing has stopped.

While the teen's social skills may suffer from addictive game playing, the effects on the visual system appears to be positive, the researchers concluded. Building on Dr. Polat's previous research in treating the lazy eye phenomenon, the research team hopes to apply video game playing to improve eyesight in adults, teens and children.

So we have another study here showing the benefit of video games. Of course, this effect only took 50 hours of playtime over a nine-week period which actually works out to less than an hour a day. That's important because other studies showed that too much screen time is associated with childhood obesity and I think we'd all agree that outdoor activities, exercise and reading are also very, very important ventures, right?


But there is some benefit associated with playing violent action video games and it takes less than an hour a day of gameplay to see that benefit. Now I do question whether the violent aspect is really important. I mean it would have been nice to have a third arm in the study that looked at nonviolent action games.

And then I got to thinking to myself, what is your definition of violent? Because I thought… well, it could use like those racing games like Mario Kart, but then you think well, you know, that's kind of violent in a roadrunner kind of way. And people from my generation all know what I'm talking about, roadrunner. Okay. Well, I guess everyone knows roadrunner, but because now, kids know roadrunner. Oh yeah, that's the online high-speed Internet. But it's pretty violent in a cartoonish way.


Alright. I still think moderation is important, I just want to point that out. Like all things in life, moderation, balance, it's all important. Okay, let's move on.

For parents who have found themselves repeating the same warnings or directions to their toddler over and over to no avail, which is everybody, a new research from the University of Colorado at Boulder offers them an answer as to why their toddler doesn't listen to their advice. They're just storing it away for later.

Scientists and many parents have long believed children's brains operate like those of little adults. The thinking was that over time, kids will learn things like proactively planning for and understanding how actions in the present affect them in the future. But the new study suggests this is not the case.

"The good news is that what we're saying to our kids doesn't go in one ear and out the other, like people might have thought," said Colorado University at Boulder psychology professor, Yuko Munokata, who conducted the study with doctors… with doctoral student Christopher Chatham and Michael Frank of Brown University.


It also doesn't go in and then put into action like it does with adults, but rather it goes in and get stored away for later. A paper on their study titled Pupillometric and behavioral markers of a developmental shift in the temporal dynamics of cognitive control appeared in the proceedings of the National Academy of Sciences the week of… the last week of last month. What am I talking about.

I went into this study expecting a completely different set of findings, said Munokata. There is a lot of work in the field of cognitive development that focuses on how kids are basically little versions of adults trying to do the same thing adults do. But they're just not as good at it yet. But we show here is that they are doing something completely different.

During the study, the researchers used a computer game designed for children, not sure if it was violent or not and a technique known as pupillometry, a process that measures the diameter of the pupil of the brain to determine the mental effort of the child, studied the cognitive abilities of three-and-a-half-year-olds and eight-year-olds.


The computer game involved teaching children simple rules about 2 cartoon characters, Blue from Blues Clues and SpongeBob Square Pants and their preference for different objects. In the directions for the game, children were told that Blue likes watermelon so they were to press the happy face on the computer screen only when they saw Blue followed by a watermelon and when SpongeBob appeared, they were told to press the sad face on the screen.

"The older kids found this sequence easy because they can anticipate the answer before the object appears,… Chatham said. But preschoolers failed to anticipate in this way. Instead, they slowed down and exert mental effort after being presented with the watermelon as if they're thinking back to the character they had seen only after the fact.

Using pupillometry to determine the time in which the child exerts mental effort, the speed of the response for each type of sequence and the relative accuracy of those responses, the researchers found that children neither plan for the future nor live completely in the present.


Instead they call up the past as they need it. For example, let's say it's cold outside and you tell your three-year-old to go get his jacket out of his bedroom and get ready to go outside. You might expect the child to plan for the future. Think okay, it's cold outside so the jacket will keep me warm. But what we suggest is that that isn't what goes on in a three-year-old's brain. Rather they run outside, discover it's cold then retrieve the memory of where their jacket is and then go get it.

Munokata doesn't claim to be a parental expert but she does think their new study has relevance to parents' daily interactions with their toddlers. "If you just repeat something again and again that requires your child to prepare for something in advance, it's likely not going to be effective,… she said.


What would be more effective would be to somehow try to trigger this reactive function. So don't do something that requires them to plan ahead in their mind but rather try to highlight the conflict they are going to face. Perhaps you can say something like, I know you don't want to take your coat now but when you're standing in the yard shivering later, remember, you can go back into your closet and get it. I got to love that. You can just hear her saying it.

Munokata said the findings have broader implications for research in the field of cognitive development. And further study could help people figure out why kids are doing poorly or well in different educational settings.

Okay, and now some news about childhood gambling. Children whose teachers rated them as more impulsive in kindergarten appear more likely to begin gambling behaviors by the sixth grade, that's according to a report in the March issue of the Archives of Pediatric and the Adolescent Medicine.

Gambling has become an increasingly common activity among U.S. teenagers. And when it persists into adulthood, gambling is often associated with substance use, depression and suicide. Also psychopathology, poor general health and a multitude of family, legal and criminal problems.


Dr. Linda Pagani of Sainte-Justine University Hospital Research Center in the University of Montréal studied 163 children who were in kindergarten in 1999. At the beginning of the school year, teachers were asked to complete a questionnaire rating the students' inattentiveness, distractibility and hyperactivity on a scale from one to nine, with higher values indicating a higher degree of impulsiveness.

After six years, the children were interviewed by phone and asked how often they played games or bingo, bought lottery tickets, played video games or video poker for money or placed bets at sports venues or with friends. After considering other behaviors that may be associated with youth gambling including parental gambling, a one unit increase on the universe… on the kindergarten impulsivity scale corresponded to a 25% increase in the child's involvement in gambling in sixth grade. So one level of increase in their kindergarten impulse scale resulted in a 25% increase in their involvement in gambling by sixth grade. That's incredible, really.


The authors say, "Our results suggest that behavioral features such as inattentiveness, distractibility and hyperactivity at school entry represents a vulnerability factor for precocious risk-taking behavior like gambling in sixth grade…. They go on to say it's very possible these childhood characteristics snowball into accumulative risk for youngsters which places them on a life trajectory toward gambling involvement in adolescence and emerging adulthood.

The authors also note that brain mechanisms underlying both impulsivity and problem with gambling may include reward pathways and areas associated with decision making and self-regulation. They say training and self-control and executive functions before first grade may prevent this downhill spiral.

My question is should playing cards and bingo have been included in the study? I mean was this penny poker, strip poker or just crazy eights and Uno? And was it family bingo at the kitchen table with the little fit… with the ball and you just put in the tag, the things on there. Or was the kid sneaking into church bingo? Or begging grandma Peggy to take the child with her so they could gamble.


I think it makes a little bit of a difference. And would the result be the same if you didn't count any kind of cards or games that had no money exchange? I don't know. The association is interesting and definitely something to watch in your own kids.

Alright, let's move on to summer jobs. A University of Iowa study found that when a friend of a friend attempts suicide, at-risk teens are more likely to seriously consider doing so. But at-risk teens are less likely to be suicidal if they hold a summer job, that's according to an upcoming report in the Journal of Health and Social Behavior.

As it turns out, summer employment is more of a deterrent than holding a job during the school year. Attending church, participating in sports or living in a two-parent home according to the research by Dr. Bob… I'm sorry, Dr. Rob Baller, Associate Professor of Sociology in the University of Iowa College of Liberal arts and Sciences, who co-author of the study with Kelly Richardson, a data analysis at the Iowa City VA Medical Center.


"Summer employment is thought to be beneficial because it creates self-esteem while reducing isolation and substance abuse and it does not conflict with school work in the way a job during school year could,… Baller said.

Risk factors for teen suicide include heavy alcohol consumption, physical fighting, obesity, same-sex attraction and rape victimization. Among adolescents with more of these risk factors, working a paid summer job 20 or more hours a week creates immunity against the friend-to-friend diffusion of suicidal thoughts and behavior. At-risk teens who are 16 or younger can work just 10 hours a week in the summer to reap the same benefit.

Unemployment rates for teens have continued to climb throughout the economic downturn. The latest figures from the U.S. Bureau of Labor statistics showed that percentage of unemployed teens approaches 22%, far higher than the rates for adults.


If unemployment continues to rise, teens may have a tough time finding jobs this summer, Richardson said. Possible solutions could include working for pay within the family or for a friend of the family. Of course then, would that reap the same benefits? I don't know.

The researchers do offer one caveat and in order for summer employment to be beneficial, it must not expose troubled teens to additional problems. Working teams can be vulnerable to workplace harassment because of their inexperience and the ease with which they can be replaced.

EJ Graff of the Schuster Institute for investigative journalism at Brandeis University found the problem of teen harassment in the workplace to be significant. Working teens should be empowered to be intolerant of workplace harassment, Baller said. Teens in the workforce should be encouraged to speak openly with parents and supervisors if they experience harassment.


Alright, that concludes our News Parents Can Use this week. We will be back to answer your questions right after this.


Alright, we are back and we're going to kick off our international listener questions with Stefan in Hong Kong. And Stefan says, "Dear Dr. Mike, I am a German father of two kids, a three-year-old girl and a one-year-old boy. My wife is Chinese and a carrier of the genetic defect G6PD which is rather common among Asians.


I was wondering if one of your topics in the podcast could be the talk about this disease and clear up some myths surrounding it such as can I drink soy milk. The topic should be interesting for your Asian-American listeners as about 5% of all Chinese newborn boys are affected. Thank you, Stefan….

Well thank you for your questions, Stefan. So let's talk about G6PD deficiency. First of all, what does that stand for? G6PD stands for Glucose-6-phosphate dehydrogenase. That's why we call it G6PD. And what is it? Well, it's an enzyme that is important for red blood cell metabolism. So it's important in the inter-workings of the cell.

It is what we would call an X-linked recessive disorder. If you remember back from like your high school genetic class, women have two X chromosomes; men have an X and a Y. Now it's recessive which means that you have to have two copies of the gene for it. So women who only have one copy are going to be a carrier and women with two copies are going to have the disease.


Now because men only have one X chromosome, they only need one copy to have the disease. So women are sort of protected by their other X chromosome as long as that other one does not carry the gene for the disease. So it's an X-linked recessive disorder which makes it more common in men because it's recessive and you can't have the normal gene there. And since men only have one X chromosome, it's more likely that they'll… they can't be carriers. They're always going to either have the disease or not have the disease whereas women can be carriers if they have one copy of the bad gene and one copy of the good gene, so to speak.

This is the most common enzymatic disorder of red blood cells in humans and it affects more than 400 million people worldwide and it is widely seen in those of Mediterranean and Asian descent. The enzyme is important in preventing oxidation stress of hemoglobin.


Because if hemoglobin becomes oxidized, then that changes the structure of the hemoglobin. It clumps and that it no longer floats free inside the red blood cell and it may cause the red blood cell to break apart and dump its contents into the bloodstream that it's called hemolysis.

There's a wide range of severity of this disease depending on the genetic variant that one inherits. So G6PD may be present in normal quantity, the enzyme may be present in normal quantity, but it may have a shorter half-life. So it doesn't last as long so you sort of have this low level of G6PD because you're making the normal amount but it's not lasting as long as it should.


It could be present a less quality… I'm sorry, in less quantity than normal so you just make less of it. It may be present in less quantity and have a shorter than expected half-life so you may not make as much as you should and then what you make doesn't last as long so you end up with this relative deficiency of this enzyme inside the red blood cells or it may be absent altogether.

So depending on exactly which genetic variant that you inherit will determine how severe of G6PD deficiency that you have because some people will be completely deficient in it and someone just have low levels either because what they make doesn't last as long as it should or they're making less of it but they're still making a little bit.

And so what this translates into is a wide variety of disease expression. As it turns out, most people with G6PD deficiency are asymptomatic, they don't have any symptoms because it's a really mild form, it's not a total deficiency. It's just a mild deficiency and so their red blood cells are still able to cope.


Many have episodic hemolysis and anemia. You get anemia because the red blood cells are breaking apart. And then a few who have the more severe kinds will have chronic hemolysis and anemia. Again, hemolysis is when the red blood cell breaks apart, spills its contents. Anemia is not having as many red blood cells and that's important because red blood cells are your primary means of carrying oxygen from the lungs to different issues and organs around the body. So you need red blood cells.

Okay, so what kind of symptoms do you see with G6PD deficiency? Well, in neonates, you get jaundice. And if you remember our discussion in the last episode about how jaundice gets made or how you get jaundice, breakdown of red blood cells is one of the ways because the bilirubin gets into the blood from the red blood cells that as the hemoglobin is broken down, you get bilirubin.


You also can get a hemolytic anemia, which again breaking apart and then less red blood cells, but when you use those terms together, hemolytic anemia, it's usually in the form of an acute crisis. So just suddenly you have an increase in hemolysis and then anemia follows very rapidly.

You can also have decreased hemoglobin and hematocrit because you have decreased red blood cells and so one of the ways that doctors measure how many red blood cells you have in your body, you would have a decreased hemoglobin and hematocrit when they do blood tests. It's not really a symptom, I guess. That's a sign, sorry.

You have decreased oxygen-carrying capacity of the blood which we talked about and then you get increased heart rate, increased respiratory rate. Why do you get those? Well, if you have less red blood cells, your body compensates by moving the small number of red blood cells that you have through the system faster so you get increased heart rate.


You also get increased respiratory rate because your body is sensing it's low on oxygen and the brain is saying, hey, breathe faster, we need more oxygen. That can lead to shortness of breath, exercise intolerance and it can lead to death if it's severe enough and your oxygen-carrying capacity of the blood diminishes below what vital organs like the heart and the brain need.

Also hemoglobin in the blood itself. So when you have the hemolysis and the contents of the red blood cell spills into the blood, that can damage the kidneys and it can result in renal failure. But that's rare, it's possible but it's rare. If you had a really severe hemolytic crisis then that could cause some kidney damage. So it's something to keep in mind.

Now what causes a crisis? Well. things which increase hemoglobin oxidation. So things that make hemoglobin become oxidated because remember that is what… and what does that… what are we talking about with the oxidation?


Basically, oxygen molecules get bound to the hemoglobin. And that changes the structure of the hemoglobin and causes it to clump and then the red blood cell can break apart. And G6PD is an enzyme that helps prevent that oxidation from happening.

So what kind of things can increase hemoglobin oxidation? There are several drugs that can do it and people who have G6PD should know this stuff. You should know what can cause your disease to get suddenly worse. So that's something that you need to know.

Some examples of drugs and the list is long and I'm just go to do the most common ones that you would come across. Antimalarial drugs, and this is actually how we found out about the disease and what causes it because of anemia following… a hemolytic anemia following people who were being giving anti-malarial drugs.


So antimalarial drugs like primaquine. Also, nitrofurantoin or macrodantin is a drug that can do it. The sulfa antibiotics such as Bactrim, Septra, trimethoprim, sulfamethoxazole. These kinds, so the sulfa drugs can do it. Aspirin can do it and other non-steroidal anti-inflammatory drugs like ibuprofen are less likely but still possible.

Also, a substance called methylene blue, which is used to treat methemoglobinemia. The doctors out there in the crowd would know what I'm talking about. There's a die basically called methylene blue that can cause oxidation of hemoglobin and blue food colorings are less likely but they are also possible. There are many others and again, those with the disease should know what they can and can't take from a drug standpoint.

The next thing that can do it and this is probably the most common inciting factor in a hemolytic crisis and those with G6PD deficiency and that is infection. And it's especially common with pneumonia.


In fact, 20% of those who have the disease do have an acute crisis when they get pneumonia. And then the pneumonia is going to sort of pack a double whammy because not only do you get decreased red blood cells, you'll have a decreased lung capacity for oxygen exchange because of the pneumonia as itself. And that's especially common when the pneumonia is caused by strep. Also, strep anywhere in the body can do it. E. coli infections anywhere in the body and salmonella infections anywhere in the body can also cause a problem.

Also, if you have viral hepatitis that can cause liver damage and if you have a damage liver plus hemolysis, then you get jaundice even in adults. So something else to keep in mind.

Also, diabetic ketoacidosis can trigger a crisis so if you're diabetic, you want to make sure that you are well-hydrated, that your blood sugars are well-controlled so that you don't go into a DKA. And those of you with diabetes know what I'm talking about.


And then there are foods. Foods, now the classic, the classic and the worst is fava beans. It always makes me think of The Silence of the Lambs. So fava beans are bad for those with G6PD deficiency because fava beans result in severe hemoglobin oxidation which results in severe hemolysis and it can easily be fatal without quick identification and transfusion. And that, by the way, is called favism when you have a very acute crisis which can be deadly caused by the ingestion of fava beans. It's called favism.

Now other legumes, including beans and peas, are less likely to cause a problem but possibly can depending on the variant or severity of the disease. So depending on what flavor of G6PD deficiency you inherit and how severe it is will determine how these different beans and peas affect your disease.


And some examples of things to think about. Cocoa beans which are involved in chocolate, lima beans, chili beans, Madagascar beans, Mexican red beans, garbanzo beans, black beans, navy beans, soybeans. Yes, Stefan, soybeans and soy milk might be a problem. Green peas, black-eyed peas, chickpeas, et cetera, et cetera, et cetera.

So do you have to avoid all of these? Do you have to avoid all soy products? Well, that depends on what variant and severity of disease you have. Fortunately, there are blood tests to determine the variant which may help predict severity and you can also look at your family history. If other people in the family have problems when they have soy products, you probably ought to avoid them.

Okay, so what to do with all this? Well first, you got to make the diagnosis based on symptoms and family history, blood tests, referral to a pediatric hematologist. And this is the expert who can really help you make the kind of choices that you want, Stefan. And even in Hong Kong, there are pediatric hematologists.


Elsewhere in the world, this may not be the case. But if you have high-speed Internet access and listening to my podcast, you're probably in an area where you can get this kind of expert help.

Bottomline on food, fava beans, no matter what form of G6PD deficiency you have, it should always be avoided and other beans are sort of dependent on the variety and severity of G6PD that you have inherited. Treatment of G6PD deficiency is avoidance of substances known to cause a problem, quickly identifying a problem when it occurs. And if the anemia gets to the point where it's life-threatening, then transfusion with red blood cells.

I do have some good resources for you in the Show Notes. If you go to pediacast.org, the Show Notes for this episodes 145, I have a link for you at G6PDdeficiency.org and they have there an extensive list of medicines and foods which may cause a problem.


And interestingly, they also showed the relative risks of each of these substances. So it's definitely worth a check out and you can find the link in the Show Notes at pediacast.org. So again, it's G6PDdeficiency.org.

Alright, let's move on to Israel. And this is Beth in Israel. She says, "Hi, Dr. Mike. I listen to your podcast whenever a new one is available and I really enjoy it. My family recently moved to Israel from Michigan. After being here for about six months, my daughter got a high fever and began vomiting. After 24 hours, the fever broke but she continued to have diarrhea. After five days, I called our family doctor who asked for a stool sample.

The sample came back with the diagnosis of Shigella and my daughter was treated with antibiotics. However, the diarrhea continued after she finished her antibiotics and three days later, she began vomiting again. The doctor prescribed a second course of antibiotics which she is now taking.


Can you discuss Shigella and other infections in the same category and specifically discuss how a parent can know whether a child has a stomach virus or something such as Shigella that needs to be treated with an antibiotic. Thank you, Beth in Israel….

Alright, so bacterial cause. Shigella is a bacterial cause of acute gastroenteritis. And that's opposed to a viral gastroenteritis. It spread primarily through contaminated food and water, also through person-to-person contact. It's most common in developing countries. And Shigella is actually a fairly acid-resistant so it passes, it survives passage through the stomach well. And so as few as 10 to 100 organisms can cause disease.

So if you are exposed to many infectious organisms in low amounts, your stomach acid destroys them. So you have to have a high microbe count to get through the intestine before it can make you sick. Well, Shigella is one that is highly resistant to stomach acids so it doesn't take many of them to infect you.


Okay, so what symptoms do you see with Shigella? Well, you see high fever, abdominal cramps and bloody, mucousy diarrhea. That's the classic, the classic set of symptoms for Shigella. High fever, abdominal cramps, bloody diarrhea with mucus in it.

Now other possibilities, you can have fever, not necessarily a high fever, but even a low-grade fever and 30% to 40% of people with Shigella get that. Abdominal pain doesn't have to be the severe cramping. It can even be mild abdominal pain and 70% to 93% of people with Shigella get that. The mucousy diarrhea, 70% to 85%. The bloody diarrhea, 35% to 55%. Watery diarrhea, 30% the 40%. And vomiting, 35%.

So there's a range of presentations. It can be the classic high fever, severe abdominal cramping, bloody mucousy diarrhea or it could be low-grade fever, mild abdominal pain, watery diarrhea with a little bit of vomiting.


So there's definitely overlap between the milder forms of Shigella and viral acute gastroenteritis. But there's not overlap with the severe classic form of Shigella. So how do you know when to test for it? If mild Shigella can seem like a viral gastroenteritis, how do you know when you need to test for it? We're going to talk about that in a minute. We'll get to that.

Incubation for Shigella, one to seven days with an average of three days. So you get it pretty quickly after you're expose to it. Stool frequency, typically, eight to ten stools per day, but it can be as high as a hundred per day. But here's the thing, the stools are typically of small volume. So you do get the diarrhea. It can be watery, but it's usually small volume of mucousy, bloody diarrhea. Small, small amounts each time but frequently.


So that means that significant fluid loss and dehydration is actually rare with Shigella, unless you have vomiting that just won't go away. The spectrum of severity with Shigella depends on the zero-type okay. So the strain, so to speak, of the infecting organism. So there's different strains of Shigella. For example, Shigella sonnei usually causes mild disease whereas Shigella dysenteriae or Shigella flexneri is more likely to cause severe disease.

Okay, so what can you expect tif you get Shigella? Well, here's where things get interesting. Most of the time, Shigella is self-limiting. That means your body's immune system can kill it and you don't need an antibiotic. Usually, it lasts no more than seven days when it's left untreated. So if you have Shigella, you don't need an antibiotic for it. And it goes away usually within a week and most common, it goes away even in like three or four days.


So why do we care then? I mean it rarely causes dehydration. It usually resolves on its own within a week. You don't have to have an antibiotic to kill it. So why do we even care? Why do we even want to diagnose it? Well, the answer, there is an answer. And the answer is that there are potential complications with Shigella that we need to know about. There are intestinal complications and then there are what we call systemic or whole body complications. And we're going to look at these separately.

The intestinal complications are rare and they only occur in the presence of severe disease. And these are things like proctitis, which is intense distal or the end of the colon and rectum inflammation and pain. You can get rectal prolapse where the rectum actually extends out of the anus.


Intestinal obstruction, something called toxic megacolon and colonic perforation where you actually get a tear in the colon wall. Now again, these are all really rare and only occur in the presence of severe disease. So you do want to know though if you have the classic high fever, abdominal cramps, bloody mucousy diarrhea, you want to know if it's Shigella so that you can be on the lookout for these potential intestinal complications.

Now the main reason that we treat Shigella is because of the systemic complications and the biggest one is going to be bacteremia. Bacteremia is where the Shigella leaves the intestine and goes into the bloodstream and causes a blood infection with the Shigella. And this occurs in about 4% of cases with severe Shigella. It is associated with an increase in mortality. So being septic or having a blood infection with Shigella can kill you. So the risk of this is why we test for Shigella and treat it when we find it to prevent sepsis.


There are also other possible systemic complications including metabolic disturbances, a leukemoid reaction which is a high white blood cell count greater than 50,000. You can have neurologic disease, febrile seizures, encephalitis which is actually likely related to a toxin that some strains of Shigella produce.

You can also get a reactive arthritis which is probably autoimmune in nature and you can also get what we call hemolytic uremic syndrome where the Shigella is making a toxin that causes red blood cells to break apart, hemolysis. And you get anemia and the hemoglobin in the blood, the free-floating hemoglobin can damage the kidneys and costs renal failure. And that is what we call hemolytic uremic syndrome or HUS. And that can happen with Shigella blood infections.


Now the bacteremia is… the 4% of those infected that's when it's severe disease. So this is when you have the high fever, abdominal cramps, bloody, mucousy diarrhea. If you have a mild form of Shigella that is mimicking being a virus, you don't get the systemic or the intestinal complications.

So the answer to your question, Beth, is how do you know when to test it? Well, you test it if it's classic severe symptoms because those are the ones that are most likely to have complications associated with them. If you have more… if you have the milder form of Shigella which looks like a virus, you don't need to test for it because it's going to be gone within a week. It doesn't cause these complications and so there's no reason to test for it.

So if you miss mild Shigella, it's not so much of a big deal. So that's why we don't test everyone who has just basic viral gastroenteritis type of symptoms. You don't test them all for Shigella. But if they have high fever, abdominal cramps or blood mucus in their diarrhea, then you test them for it.


Okay, so let's see. Sometimes I write down these notes of what I want to talk about and then I forget to look at the screen and kind of go off because I know these things in the back of my mind and start talking about it and then lose my place in my notes. Okay, here I found it.

So what do you do when you do find a severe Shigella? Well, you do the stool culture. You identify the strain so that you have some predictive value of whether you're going to have mild or severe disease. You get a blood culture, you do a blood count, check electrolytes and watch for the complications that we talked about.

Treatment of Shigella, if it is nonsevere, just supportive care and deal with complications including possible dehydration if they occur. If there is evidence of severe Shigella and or evidence of bacteremia or sepsis, then you do use antibiotics. And antibiotics will reduce the risk of these complications and most importantly, it would reduce the risk of bacteremia or sepsis caused by the Shigella.


Now what antibiotic do you use? Well, it gets a little tricky here because there is some emerging resistance. Sulfa antibiotics, unless you have G6PD deficiency, sulfa antibiotics and ampicillin were both routinely use and work but now there are resistant strains. So you do have to pay attention to the sensitivity of the isolate that you get in your stool culture.

So you do the stool culture, it comes back, you have the Shigella. Now you want the lab to test that particular Shigella against different antibiotics to see which one that it's sensitive to. You'll probably start with something that you think it's going to be sensitive to but if you have a resist… if you find that yes, it's a resistant strain, then you're going to have to go back and change the antibiotic.

Zithromax is an alternative and some of the cephalosporins like Rocephin or ceftriaxone and Omnicef may also work. Ciprofloxacin and the fluoroquinolones are also an option but then there is the question of safety in kids and that kind of goes beyond the scope of this discussion.


So that's Shigella in a nutshell, Beth. And okay, we may have incurred a little more than a nutshell's worth. So my question to you, Beth, is did your doctor do a blood culture? Was an antibiotic even needed in the first place? Because was it severe Shigella? Now I'm not going to go there. I'm not going to criticize your doctor. We're here for education and topic discussions, not critiques of medical practice.

Alright, let's move on. The next one is from Brussels, Belgium. And this is Kasia. Kasia says, "Dear Dr. Mike, I'm an avid listener to your podcast, thank you so much for doing it. I'm Polish and my husband is American. We live in Brussels with our two daughters, a three-year-old and a six-year-old. They've both been diagnosed with keratosis pilaris which they have mostly on their cheeks and a bit on their arms. I know it's genetic. I've been suffering from it myself on and off. Are there any good lotions or other treatments? I put some French emollient cream on their faces which they both dislike. And it doesn't seem to help much. Thanks a lot for your help. Keep up the good work, Kasia….


Alright, well thanks, Kasia from Belgium, from Brussels. I appreciate you writing in.

Keratosis pilaris is a common skin condition. You see it as rough patches in small acne-like bumps that are most common on the upper arms and the thighs and also sometimes on the face. And it has a rough sandpaper feel to it and sometimes the skin can be red and inflamed, sometimes not. Sometimes it can be a little itchy, sometimes not. It can lead to scarring if it's picked and pop frequency especially on the face.

The cause of this is actually genetic. And what happens is that some people in those areas get a buildup of keratin. And keratin is the hard protein that forms the basis of the protective barrier of the skin. But if you get too much keratin, then that blocks the opening of hair follicles. And usually, many plugs then form in that involved area which results in the characteristics patches or rough bumpy skin.


Why exactly does this happen? Well, we still don't know exactly. We do know that it often occurs in association with atopic dermatitis or eczema and that dry skin tends to worsen the condition. Now how is this different from acne?

Well, remember acne is caused by overactive sebaceous glands which is triggered by hormones and then you get dead skin cells not necessarily abnormal keratin that clog the opening to the sebaceous gland. You also get sebum or oil that is inside that gland that can't get out and that causes buildup of the oil and then an inflammatory response. There's also bacterial components involved with acne. So acne does have a different mechanism by which it happens and has a different look to it and a different distribution as well.


So how do you diagnose keratosis pilaris? Well, there's no skin or blood test. It's basically… you make the diagnosis based on history, physical exam and family history. Treatment is aimed at resolving dry skin if it's present.

So you want to treat any underlying atopic dermatitis or eczema that may be there and you can do that with emollients and topical steroid creams. And then it's also aimed at breaking down the excess keratin and there are different drugs you can use for that such as ammonium lactate or Lac-Hydrin, topical retinoids such as Retin-A or Tazorac and urea compounds such as Keralac.

So this is the sort of thing that if you're not happy with the way it looks and any treatment that you've tried, you probably want to see a pediatric dermatologist to come up with a really good treatment plan.


Incidentally, these things that we've talked about in terms of treating, often, they don't work. And often, the disease waxes and wanes with or without treatment. So it is frustrating, this is a frustrating disease. And you do have to look at your family history to sort of try to predict your own course of it. I mean if sort of mild keratosis pilaris runs in your family, that is probably what you're going to have. If it's more severe, you're more likely to inherit the severe forms.

Again, if it's persistent and bothersome and nothing's helping, you could try to see a pediatric dermatologist but there may be some limits into how much help they can actually give you which is frustrating. I understand that.

Alright, let's move on to Italy. This is Debbie in Paris, Italy. Debbie says, "I've enjoyed listening to your show because you do have a talent for making the most complicated information understandable and because, this is the more important, I grew up and the Gahanna, Ohio and went to the Ohio State University so I enjoy it when you mention Ohio…. So we have a Buckeye in Italy.


Okay, so maybe this is… and with the one end… one was from Michigan, was that our Brussels? I think so. So okay, its international hour on PediaCast but they're all displaced Americans. Oh, not all of them but some. So with that I go off on a tangent here.

Debbie. Debbie says, "I'm writing because my older son who is now 12 has just recovered from herpes virus under his chin. I have seen other people with these on or around their lips, but this one is much bigger, perhaps two inches and very painful. This was not the first time for him. The first time he was less than two and it was on his cheek. His father and I took him to the hospital and the doctors didn't know what it was so they recommended a diluted iodine mixture.

Since then, this turned up about four times and I have learned it's herpes so this time when the doctor saw it and agreed it was necessary to ease his pain, she prescribed a cycle of year and the relief began right away. He was very happy for the relief.

What I would like to know is what can be done to help prevent these outbreaks? I think he gets it when he's been outside in the sun and wind and the jacket zipper was rubbing the skin. Besides trying to avoid these elements, should he take any vitamins or cream to help make him less likely to suffer from these rashes?


Also on the side note, you mentioned probiotics recently which are very popular here. I heard the medical radio show about probiotics and the doctors said that studies have shown regular use of probiotics promote a healthy immune system. It was an Italian and my Italian is good but not so good that I am sure of what I understood him to say and I'd like to learn more about it. Thank you for all the great information and for the lively, not at all dry podcast….

Alright, well thanks for the kind words. Debbie, who's really from Gahanna, Ohio and a Buckeye. Thanks for writing in.

So let's talk a little bit about recurrent herpes or herpetic skin lesions. First, you have to have a primary infection of herpes as a young child and an example of that is a herpetic gingivostomatitis where you get a herpes infection in the mouth and the mouth gets loaded with little blisters. Or you can have other primary herpes infections elsewhere in the body.


And the thing to remember with this is that some of that herpes virus is going to remain live. It's going to remain alive through the rest of your child's life. But it's going to be dormant, inactive and living in a nerve cell body. And the immune system sort of keeps them in check.

But every now and then, they can reactivate. And usually, anything that decreases your immune system's ability to keep that dormant virus in check is going to make it more likely to reactivate. And when it does, the herpes virus marches down that nerve and causes skin lesions to the area of skin that is served by that nerve.

Now what kind of triggers can cause this to happen? So what kinds of things can cause the immune system to sort of hiccup and its ability to keep this dormant herpes virus in check? Well, infections anywhere in the body, if your immune system's busy fighting an infection, then that herpes virus can become reactivated and cause these skin lesions. Stress affects the immune system.


Mechanical trauma in an area of skin that's served by a nerve that happens to have a dormant herpes virus living in it, so a rubbing zipper could do it and sun exposure can do it as well. That seems… the skin that is exposed, if that particular area of skin has a dormant herpes virus living in the nerve cell body then it can… it's more likely, it can become reactivated.

Now the key here to prevent… you can't get rid of the dormant herpes virus. There's no way to go in and kill a virus that is in a dormant state because it's just sitting there. It's not really living. I mean it's… viruses are tough thing because to live, it uses the mechanics of your own cells. In order to really truly kill it, you'd have to kill it's home and you don't want to do that. I mean you don't want to kill the nerve, right? So there's no way to really kill the virus.


Now if the virus is in an act… once it gets to the skin, well now, you can kill the skin cells, that's okay. But that has the virus living in it and that's how you get rid of the lesion. And also, viruses that are replicating, they are vulnerable because you can interrupt that replication process which ultimately, kills most of the virus. But if it's in a dormant state, it's not reproducing and it's in an area of the body that you can't kill to get rid of its home, then you're sort of stuck with it.

So what can you do? Well, you have to pay attention to, first of all of course, avoiding the triggers. I mean that's obvious so you want… in an area where you are likely to get these lesions, you want to avoid sun exposure. You want to avoid mechanical trauma. And all of us need to reduce the stress on our lives. And if you have infection elsewhere, just be on the lookout that this could happen.

But the key. The key is pre-emergent symptoms. Often for a day, for two days, for an hour, you don't know how long exactly, but there are some symptoms associated with that virus waking up, marching down the nerve and starting to cause the skin lesion.


And the key is to get the acyclovir started as soon as those symptoms occur before the actual lesions occur. Now what am I talking about here? Typically, you have a burning or an itching or pain at the site prior to eruption. And you need to learn to recognize this and talk to your doctor about the possibility of having some acyclovir at home so that you can get it started right away when those pre-emergent symptoms start to occur. Because if you take the acyclovir at that point, you have a better chance at preventing significant progression of the skin lesion.

Once the lesion has… is there, the acyclovir may help but not… it's not going to prevent it and it's not going to really help it not get as bad as it might otherwise get. It's going to… the acyclovir, at that point, may help it go away a little bit quicker, may relieve some of the symptoms a little more. But it's not… it's not going to prevent it.


The best way to prevent it is to avoid the triggers and to recognize any pre-emergent symptoms such as burning, itching, pain of the skin, to recognize that and then get the medicine started at that point. There's no vitamins that will help. You shouldn't take acyclovir every day of your life to prevent it.

And incidentally, shingles is a similar issue except the offending virus is the chickenpox or varicella virus instead of the herpes virus. That's not too surprising because chickenpox and herpes viruses are in the same family of viruses, they're both herpes viruses in that family.

Alright, so your best bet, Debbie, is to avoid known triggers and watch for and recognize pre-emergent symptoms and start the acyclovir right away when those symptoms occur.


You also asked about probiotics. Very quickly, probiotics are good organisms in the GI tract, skin, mouth, genital region for women. They aid in the normal digestion and they're important for skin and mucosal health. And they also take up space so there's less room for pathologic organisms such as resistant bacteria and yeasts to grow.

And using supplements of probiotics or ingesting food with probiotics such as Dannon Activia Yogurt, some juices and soy drinks may help. It may help treat viral diarrhea, it can help to treat diarrhea that are caused by antibiotics because you're replacing the microbes that are supposed to live in the intestine and they can also prevent and treat vaginal yeast infections again by recolonizing the skin and mucosa with the microbes that are supposed to be there so that the yeast gets chased away. And again, they work by recolonizing the GI tract skin and mucosa with the organisms that are supposed be there.


Okay, does that help your immune system? Not sure what mechanism by which that happens.

Alright, and finally, I think this is our last one here. Now we're going to move on to Tamil Nadu, India and this is Khawi. And Khawi says, "Hi, my baby is 15 months old and exclusively breast-fed. My son is passing watery stools every two to three hours for the past two days. His passing urine normally once every two hours. The color of his stool is normal yellow color, but I'm concerned about the increase in frequency and the water content in his stool. Is it a worry? Is it because I consumed mangoes?…

Well first, this question is from a little while ago so hopefully your child's doesn't have the diarrhea anymore. But let's still talk about this.

First, again if you're concerned about your child's health, see your doctor. Don't write into PediaCast and tell me, hey, my kid's got bad diarrhea, what do I do right now? Okay. We can talk about is this normal, is it not normal? But when you have a baby who's having watery stools every two to three hours for two days and your concerned, take him to your doctor.


There are a couple of things here we can discuss. A watery stool every two to three hours in a 15-week-old baby is probably not normal. And the most likely cause is a viral infection of the intestinal tract. Yet, could it be Shigella? Okay, I'm not going to go there. Just click rewind.

Things that make me concerned in this particular situation are your child's age, three to four months. Also, is there fever? If there's fever, I'm more concerned. Is their blood in the stool? I'm more concerned because of things like Shigella. Is there vomiting, because you worry about dehydration. Is there a rash? And is there signs of dehydration such as decreased urine output, sunken eyes, dry mouth and lips, reduced skin turgor and prolonged capillary refill and elevated heart rate.


These are things that nonmedical people probably aren't going to feel too comfortable testing at home. And at this age, it's better to be seen than not.

Could it be the mangoes? It's unlikely for mom eating the mangoes. However, if you're feeding the baby mangoes, then that could be a possibility either because of contamination or because undigested sugar in the mangoes gets to the large intestine and causes an osmotic diarrhea.

So there's a lot of different issues here. I think the important thing is you've recognized the change in your baby's bowel habits. You think it's too much and it's too watery and by your description, I agree. You've paid attention to urine output which is a good sign of hydration status so kudos to you. But given your baby's age in this sort of situation, I would see your doctor to make sure it's just a virus and that there are no other signs of dehydration, that they're going to be better at checking skin turgor and capillary refill and is their heart rate elevated, those kind of things.


Okay, thanks to all of our international listeners this week. I appreciate you writing in even if some of you are really Americans. So… but that's fine. And we'll be back to wrap up the show right after this break.


Alright, as always, thanks go out to Nationwide Children's Hospital for helping us out with the bandwidth of the show. Also Vlad at Vladstudio who does all of our artwork for us and Medical News Today for helping us out with the News department and of course, thanks to listeners like you.


Don't forget, donations are definitely accepted here at PediaCast to help offset the cost of this program. We do have lots of overhead expenses and we do have some sponsors, but they don't cover even close to the expenses that we have. So your help is definitely loved. And so it's really easy.

If you just go to pediacast.org, click on Donations. You can give a one-time donation or you can schedule recurring ones. And our suggestion here is that $1 an episode. We do two or three episodes a month. So if you are to give $2 a month or $24 a year, then that would definitely help to support this project and keep it going.

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We also have a listener survey at pediacast.org. It doesn't take too long. It just helps us with the demographics of our audience. So don't forget those things. We will back and until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long, everybody.


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