Research Roundup, Expired Sunscreen, Toddler Tantrums – PediaCast 146
- Thimerosal Revisited
- Killing MRSA in Bath Water
- Constipation and Growth
- Expired Sunscreen
- Toddler Vomiting (When Upset)
- Immunization Podcast (WARNING: OLD SHOW)
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Announcer : Welcome to PediaCast. A pediatric podcast for parents. And now, direct from Birdhouse Studios, here is you host, Dr. Mike.
Dr. Mike : Hello everyone and welcome to this week edition of PediaCast, a pediatric podcast for parents. This is Dr. Mike coming to you from Birdhouse Studio. I'd like to welcome everyone to the program. It is episode 146. And we're calling this one Research Round Up. Expired sun screen, and toddler tantrums.
And of course, we'll have much more in store for you in terms of information. Before we get started, I just wanted to mention I had the family, we actually gone to see the Star Trek movie couple of times. It's a good show. Not really been a trekky. I mean I've been many, many years since I had seen a Star Trek episode. And I didn't really follow the movies very much when they came out years ago. But it was really cool. My daughter particularly wanted to see it because the guy that plays Spock has been in Hero and I think she kind of have a little crush on him. So, she wanted to see him in Star Trek and I think she sort of fell in love with the story line as well. So the kids wanted to see it again, so we saw it a second time around at an Imax screen. And that was pretty fun.
And then we watched a couple of old Star Trek episodes from the 60's which again I haven't seen those in years. So, I think they did a good job with the movie and you know, teenagers at home, I definitely recommend that you take them to see it.
Lots of good movies coming up this summer. Now I know this is not a movie podcast. It's pediatric podcast, but I just got to get this stuff in. Night in the Museum 2 with Ben Stiller, that looks good. And Disney's Up, I'm looking forward to seeing that one as well. So it look like it's going to be a good summer for movies, at least with the previews. Some sort of exciting ones and our family, we like to go to the movies together. Hopefully, you all do too.
All right, let's talk swine flu here for just a minute. There are now thousands of cases and there have been several deaths, but let's keep this in perspective still. The regular flu this year killed over a hundred children in the United States just from regular flu.
So the swine flu has, you know, its not really lived up to be quite as bad as everyone have feared, which is a good thing. Of course, the media blow things out of proportion a little bit. I mean there was the potential for it to be a bad pandemic, but as it turns out it doesn't seem like it's as deadly as First spots. So that's a good thing. We certainly in our clinic have had a lot fewer people come rushing in with fevers. I think because the media has stopped making a big deal out of it. So it's kind of out of people's mind already. So, I think we dodge the bullet on that one.
All right, let's go ahead and get to the meat of the program here. What are we going to talk about, we're getting actually have our Research Round Up back. We haven't had a Research Round Up in quite some time. Actually in months and months and months. So there's probably a lot of listeners out there who have no idea what a Research Round Up is. Basically what we do is take some topics that have recently been to pediatric literature and break down the research article.
What was the question for the researchers. What was the hypothesis? What was their method? What data did they get? What's their interpretation? And then what does it mean for you? So we're going to talk about thimerosal and immunizations. Sort of revisited 10 years later kids who had the thimerosal preservatives in the vaccines which is a mercury derivative. Is there brain problems in those kids 10 years later? We're going to talk about that. Also how do you kill staph? In particular MRSA, methicillin resistant staphylococcus aureus in bath water. So if your kid , We've been seeing these lots and lots more in the last couple of years where we have community acquired MRSA. A lot of time parents would come and say hey, they have a bug bite. It's basically a boil that's turn into an abscess. You get lots of puss out. If you have a child that had one of these, you know exactly what I'm talking about. When you give them a bath, how do you kill the staph in the bathtub?
So the next person who uses the tub doesn't get infected. There's a research study on that. Also constipation and its effect on growth, there's a research study on that one as well. And then we'll get to your questions on bed wetting, expired sun screen, toddler vomiting when they're upset. And then someone had a question on some of our old shows and we'll get to that as well.
Don't forget if there is a topic that you would like us to talk about, it's really easy to get a hold of me. Just go to pediacast.org and click on the Contact Link. You can also email email@example.com or call the voice line at 347-404-KIDS. Also remember 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.
OK, we are back. And we're going to do our Research Round Up. For those of you, again, who have not heard one of these before because it has been a while. We don't go into too much detail but we try to break things down for you.
But before we get started on that, I do want to remind you that if you have been a long time listener of PediaCast , and you feel like you've really gotten a lot of good information out of it. If you would consider donating to the cause. There is quite a bit of expense in putting these podcast together in terms of research and man hours and web hosting and that sort of thing, so, if you feel like you get something out of it, if you could give something back that would most certainly be appreciated to help offset the cost of producing this program. If you go to pediacast.org, right there on the front page there is donate button and you can click that and get , There are several options in terms of being able to donate. We suggest a dollar an episode certainly would be very helpful. We usually get a couple of episodes out a month. So if you do $2 a month there is a, one of the subscription options is to donate $2 a month or you could do $25 once a year, that would also be quite helpful. So, don't forget to think about that if you already done so and those of you who have done it, thank you very much.
All right, so thimerosal, this is, if you recall is a preservative that was used in virtually all vaccines up until just 2 or 3 years ago. It preserved the shelf life in multi dose vials. So, when your doctor's office would order a particular immunization that would come in a bottle that had enough of the vaccine in it to give to several kids. So this is something that you are going to be drawing into several times during the day. So you want a preservative in there to keep bacteria out as opposed to the single served vaccines which is how most of them come nowadays.
So, it was a mercury based preservative, and the question became was there somehow associated with autism, this mercury exposure or is there anything about this particular preservative that could have caused not only autism but other neurological effects on the child.
So an Italian research team basically did a research on the effects of thimerosal on kids who had the thimerosal vaccine 10 years later. 10 years after they received this vaccines, is there a difference in kids neurological development based on how much thimerosal that they were exposed to. And this was a research project that was done and published in the journal "Pediatrics…, February of this year. And the questions that the researchers had, among children who received thimerosal containing vaccines in infancy, are recipients of higher versus lower cumulative doses of thimerosal associated with any adverse neuro psychological outcomes.
And what they did is they looked at children who participated in a 1992 to 1993 randomized trial of two different DTAP vaccine, this is Diptheria Tetanus and A Cellular Pertussis, that's the kind of vaccine it was. And the initial study was not looking at thimerosal, the study was actually looking at just two different types to DTAP vaccine to see if there is a difference in the effectiveness. So they weren't even thinking about the thimerosal at that point. But as it turns out, one of those DTAP vaccines had thimerosal in it and the other one did not have that preservative in it. So they used this opportunity to see if there was a difference between these two groups. Now kids were excluded from the study if at the time of enrollment they had any known central nervous system disease. So you don't want them to start with a brain issue before they were ever exposed to the thimerosal.
If they have any kind of congenital anomalies or birth defects, then they were immediately not allowed to be enrolled in the study. And again a lot of congenital anomalies could have neurological consequences, so you want to eliminate that one variable. And then also, if they have any known or suspected problem with their immune system. Any immune deficiencies, HIV, other problems, then they were eliminated from the study because again, you want kids with normal immune systems to see how they're responding to these different vaccines. And you don't want to add that extra variable in there.
So all the children in the study at 2, 4,and 6 months, all of them hada hepatitis B vaccine which contained 12.5mcg of ethylmercury, which is the mercury content, the ethylmercury is the mercury component of thimerosal.
And then they were randomized from either the DTAP group that had the thimerosal in it versus the one that did not have thimerosal. The ones that did have thimerosal were exposed to an additional 37mcg of ethylmercury at each of those doses at 2,4, and 6 months. And then at 11 months of age, all of the receiptients in both groups received a DT vaccine that had 25mcg of ethylmercury. So, in the first year of life, we are looking at 1,403 kids altogether. And group 1, this is the group that was had the DTAP vaccine. They had no thimerosal in it. Their cumulative dose of ethylmercury exposure was 62.5mcg. And group 2 which had the DTAP vaccine that had the thimerosal in it. Their cumulative dose of ethylmercury was 137.5mcg.
And you had about 700 kids in each of those groups. So one group had a total cumulative exposure of 62.5mcg and the other one, 137.5mcg of ethylmercury. So the experimental group had over twice the exposure compared to the controlled group. Now why they did not have a 0 exposure group? Cause that will really be the best way to do this, right? To have a group of kids that had no thimerosal exposure and another group of kids who had quite a bit. And then tell the difference between the two. Well, the reason is because, remember all of these vaccines were given 10 years ago. And at that time all the vaccines contain thimerosal except for this one vaccine, this DTAP in question which contains 0. So if we want to study what were looking 10 years out, you have to go back to kids who received their vaccines 10 years ago and there weren't just any who did not have exposure to thimerosal. And now you can say what about comparing it to a group of unimmunized kids and using them for the control group.
And the problem with that is it's more difficult to find a large group of unimmunized children and the large groups that you do find are probably in different socio-economic populations and maybe even in a different country then the group that were exposed to the ethylmercury, to the thimerosal. So, you're more likely to introduce confounding factors. So they want these two group of kids to be as similar as possible and so the researchers did it this way.
Now the data was collected between 2003 and 2005. And all of the kids underwent 11 neuropsychological test. And this resulted in 24 different outcome measures in 6 domains of cognitive function including memory and learning, attention, executive function, visual spatial function, language and motor skills. So these kids all of them 10 years after they had the vaccines were really analyzed from a neuropsychological standpoint with lots of different tests and 24 different scores that were done.
And also all of them were screened for autism as a diagnosis by parent interview, to see if their children met the criteria for autism and also with the medical record review to see if any of the children had actually been diagnosed with autism. And the results are interesting. Out of the entire study, there was only one autistic child identified by age 10. And this particular child was in actually the lower exposure group. No autistic kids were found in the high exposure group. The mean scores on all 24 outcome measures in both high and low exposure groups were within normal ranges and all discrepancies between the groups were statistically insignificant except for poor performance on a finger tapping test. And that was a limited to the dominant hand among girls in the high exposure group.
There was no difference in the same tests for non-dominant hand in boys or girls. So the only test that had the significant difference was the girls in the high exposure group did poorer on a finger tapping test. And the other significant finding was that there was poor performance of the Boston naming test, where kids are asked to name different things quickly. There was poor performance on that, but it was limited to boys in the lower exposure group. So, higher exposure, they had more exposure to thimerosal, they did better on the Boston naming test.
So what did the authors conclude from all these? Well, they conclude that the magnitude of difference between low and high exposure thimerosal group were small and of doubtful clinical significance.
So this study would suggest that thimerosal is a safe preservative in vaccine materials at least when you look 10 years out at the kids with the mention exposure levels. And when we're talking about neuropsychological injury. If you're still leery about thimerosal, ask your doctor for the mercury free vaccines. Most vaccines in the USA are available now as a thimerosal free.
So why did we have thimerosal in there in the first place? Again, multi-dose vials keeping bacteria out of the vaccine product. And not having a good preservative is an issue because now that we have the single served vaccines, there is more packaging, there is more disposable components so that it's certainly is less green that having the multi dose vials. Also, there is the shorter shelf life with those. Because if they don't have a good preservative in them, they don't last long. So the expiration date of the vaccine is shorter with the new way and that has sometimes led to shortages of vaccines because we can't stock pile them like we used to be able to when we have thimerosal as a preservative.
So, taking thimerosal out of the vaccines, I think is an example of the science and medical community taking an action based on media hype rather than sound scientific research, in my very humble opinion.
All right, let's move on. Killing staph MRSA in bath water with bleach. This comes from researchers in Virginia and published in the journal of Pediatric Infectious Disease on October of 2008. The question before the researchers is what is the optimal concentration and exposure time for a non-toxic hypochlorite or bleach solution to kill community acquired MRSA in vitro. And in vitro means not in the body. Vivo is in the body. This is in vitro, so, on a surface.
OK, what is the optimal concentration and exposure time for bleach, a non-toxic bleach solution that adequately kills community acquired methicillin resistant staphylococcus aureus. So what they did is take 10 clinical isolates of MRSA. So they took 10 different cultures. They had the MRSA bug from 10 different people. Five were from children who had invasive MRSA infections. Which means they had a skin abscess or they have a blood infection with it. And then five were from children, they didn't really have an infection, they just found MRSA in their nose. So they had nasal pharyngeal colonization of the MRSA bacteria. So we have five from kids with invasive disease, five isolates from kids who just had colonization. And then they also have a control strain which was just a laboratory strain that they have on the shelf of staph aureus.
So all 11 sources of staph were cultured in agro plates and they were suspended in a sterile phosphate buffered saline at a concentration of 1 million colony forming units per milliliter.
So it was all standardized. They have the same amount of MRSA in each of these samples. And then 1 milliliter of each suspension was centrifuged to separate out the bacteria. Then each bacteria set were re-suspended in municipal tap water, had no bleach in it. And then each isolate, so they actually did two isolates from each of these sources. And the first one they put in municipal tap water that had no bleach in it and then the second set of each of these sources, they put in a solution of 6% hypchlorite or bleach diluted in municipal water to achieve a 2.5 micro liter of bleach in each milliliter of tap water.
In this particular concentration was selected because it was felt to be non-toxic to children if they came into contact with the bleach. And they wanted to standardized it, so that's the reason that we're getting sort of petty with 2.5 micro liters of bleach in each milliliter of tap water that the bacteria we're added to compared to the ones the bacteria was just added to municipal tap water without bleach in it. OK, so what did they do to all of these then. They got 11 samples of the bacteria that have been placed in the water and 11 samples that have been placed in the bleach water. Well after 10 minutes, the suspension were re-cultured and colony counts were obtained on each suspension to see if the remaining number was significant enough to result in infection. And the results, the staph grew very well in the tap water without bleach, no surprise there. All 11 of them. They grew lickity split and having staph in the bath water in the tub could be infectious to another person who takes a bath soon after the first bath was done.
Now, the bleach suspensions resulted in the killing ratio of 99.94 to 100 percent for all isolates used. So it killed 99.94 to 100 percent of all the colonies of bacteria. And this is a significant kill rate and would render the staph non-infectious.
So the authors conclude that a 2.5 micro liter per milliliter dilution of bleach, now how do you do that at home?, well that actually ends up being equivalent to about ½ cup of bleach. Just standard laundry bleach. ½ cup in a quarter filled bath tub. And leave it there for 10 minutes. So that resulted in significant killing of community acquired MRSA in vitro, on a surface. So, what does this all mean? If your child has MRSA, if they have methicillin resistant staphylococcus auerus, they're being treated for that, and you give them a bath, then when they're done, fill the bath tub one quarter full, add a half of cup of bleach, just laundry bleach. Let it set there for 10 minutes and you're good to go.
All right, let's move on to our third study. This one is constipation and growth. Something new to consider. I found this one really interesting. This one comes out of Taiwan, Chang Gung Univeristy, College of Medicine in Taiwan. It was published in the journal, Pediatric Research, March of 2008. So this is a little bit of an older article. But I thought it was interesting.
The question before the researcher was does successful treatment of constipation in otherwise healthy children improved their appetite and their growth. And this is a study that was done between 2002 and 2006. And researchers wanted to study the relationship between constipation and growth in children who were anywhere from 1 year of age up to 15 years of age. Now for the purposes of this study, constipation was defined as hard stools and or difficult defecation and or frequency of defecation less than three times per week for more than one month.
They also excluded some kids from the study to get rid of external variables. They excluded any patients with known gastro intestinal disease of any other cause other than the constipation. And they also excluded kids with chronical medical conditions of any kind. So all of these kids, they're only issue was constipation. And then they age matched healthy kids visiting a nutrition clinic as the control. So they took all of these kids who were, and actually the total number ended up being 2,426. So, they had over a thousand kids in each group. The first group had known constipation with no other medical concerns at all. And the second group of over a thousand kids, were the same age rages. So if you had so many percentage of your kids in that first group being teenagers, you have the same percentage being teenagers in the controlled group.
And this are kids who basically were healthy. They had no constipation problems and they had no other health problems at all.
OK. So what did they do then. Well, initially the constipated kids were treated with magnesium oxide. So they were basically put on that as a stool softener, magnesium oxide. Children with poor or fair response to treatment by 12 weeks were also treated with an additional medication either a GI stimulant such as sennosides or an osmotic laxative such as Miralax. OK, so the medicines were added in addition to the magnesium oxide if there constipation was not getting under control by 12 weeks on the magnesium oxide. And then what they did is they measured appetite once during the first 12 weeks on all the kids and again during the second 12 weeks to see if there was a difference between the first half of the study and the second half of the study in terms of their appetite.
And the following parameters were measured at baseline, so at the beginning of the study at 12 weeks and at 24 weeks. And what they measured were height, weight, height for their age, weight for their age, their body mass index, which is BMI, and their body mass index for age. And then they compared the two groups to see if there was any changes in height, weight, height for age, weight for age, BMI, and BMI for age.
So what were the results. Well, compared to the controls, children with constipation at the beginning of the study had significantly lower height, significantly lower weight, significantly lower height for age, significantly lower weight for age, significantly lower BMI, and significantly lower BMI for age. So that's a wow. So all of the kids at the beginning of the study, if you compared the group with constipation to the group who did not have constipation, the kids with constipation had significantly lower height, weight, height for age, weight for age, BMI, and BMI for age. That' interesting.
And then compared to controls, the treated constipation kids, so kids who are constipated and then were treated, when you compare them to the control group, and you look at them at 12 weeks and 24 weeks, they had significantly greater changes in their height and their weight. So, they grew better than the control groups once you got their constipation under control. Those who responded well to medications at 12 weeks had significantly greater height for age, weight for age, and BMI for age compared to those who had poor or fair initial response to medications. So when you look at just the constipation group, the kids who initially did well and the kids who didn't so well in the 12 weeks they needed another medication added. The kids that did well had better height growth, weight growth and BMI.
At 24 weeks of age, so this is the end of the study, those who responded well to additional therapies, so they had medication added, they had significantly greater height for age, weight for age, and BMI for age compared to those with poor response after the additional therapy. So, you have a sub-set of kids who even after you added more medicine or constipation still didn't get better and if you compared those to the kids who when you added the medicine, the constipation did get better, the kids who get better, grew better. And also, I should mention, when they analyze appetite at 12 weeks and 24 weeks, increased appetite was associated with greater height and weight gain at 12 and 24 weeks.
So the authors conclude, that chronic constipation may slow growth in childhood and successful medical treatment of constipation can be beneficial for growth. So this is another reason to take constipation seriously.
Many moms and dads sort of blow constipation off and stop giving constipation medicine because the problem seem to go away. Well, this study shows that 6 months of daily constipation therapy improves growth, 6 months. Now this should reinforce why chronic treatment is better than spotty and remittent treatment for constipation. And I've said it before, I wanted the big mistakes that parents make in treating constipation is things seem to be getting better so you stop the medicine. And things continue to go off for a little while. But then stools start to back up in the intestine and you're back to square one where you have the problem again and so you have this sort of cycle of using the medicine then not using it. Well this would suggest that you should really, if your kid has constipation issues, they should be on their stool softener all the time in order to keep them moving, to keep their appetite good, and to keep their growth good. In response to that, good appetite.
All right, that rounds up our Research Round for this week. Haven't done that in a while so it felt kind of good instead of our News Department. But we'll get back to new next week and we'll try to throw in some more Research Round Ups in the future as interesting articles cross my desk. All right, we are going to take a quick break now and we will be back to answer your questions right after this.
OK. We are back and it's time for our Listener's Segment. First up is Kirstin in Zebulon, North Carolina.
Kirstin says, " Your explanation of chronic constipation was unbelievably helpful…. She didn't write in just after that last segment it was from an earlier show. She says, "My nine year old daughter still had accidents year end both daytime and night time. And it's been the trigger for a lot of tears and angry lectures and not to mention embarrassment at school. I've always assumed that she is not constipated since she has bowel movements pretty much every day. However one thing we noticed is that whenever she walks into the kitchen, she'll need to scamper to the bathroom within a few moments which her father suspected was simply a chore of waiting's device. With your explanation now it suddenly makes sense. Her intestines must be having a pavlovian reaction to the kitchen. The issue has caused many frustrating years for us. Thank you for providing a glimmer of hope. Now I have a related question, could this be a source of night time accidents as well. I was a late bed wetter until age 11 or 12 I think. So I'm just assuming my daughter is destined to go the same route. Could you discuss cases for late bed wetting and the role of genetics in passing this along. I never thought I needed a pediatric podcast. I came by looking for information on ADHD and now I'm hooked because there is so much hopeful information here that I didn't even realized I needed. Thanks….
Well thanks, Kirstin. I appreciate your comments. So what Kirstin is talking about for those of you who have no idea, there was a past episode where we talked about chronic constipation being the cause of day time urgency with urination. So kids who have frequency and urgency to go to the bathroom, one of the things that can do that is constipation. Because if you have an intestine that is full of poop, then it can push on the bladder and make a child feel like they got to go to the bathroom even though their bladder isn't completely full and that kind of lead to frequent urination with small amount of urgency. Now of course, you should still see your doctor for this. Because there are other things that can do that as well. Like urinary tract infection, and you don't want to miss that. So, if your child has those things you just don't want to say " Oh, it's just constipation, let's treat it…. You want to see your doctor.
Again, this podcast is not diagnose your child's problem but it's just more to talk about this kind of issues. So that's something to think about. Now in terms of bed wetting, let's talk about that. Constipation is less likely to be the cause of bed wetting. But I supposed it can contribute to bed wetting to some degree again by pushing on the bladder. But the usual cause of bed wetting is a little bit different. So let's talk about that.
First I will say, it's certainly genetic. And, you don't get genes for bed wetting, it's just when we look at the mechanism for how bed wetting happens, you can understand then that it does typically ran in families because our bodily make up is similar. Our genetics is similar. So the kind of things that usually cause bed wetting are going to be kids who have a really deep sleep with total relaxation while they sleep.
And so what happens is the valve that keeps the urine inside the bladder, it's basically a muscle. And it has to stay contracted to be closed. And when that muscle relaxes, that valve opens and pee comes out. So if you have your genetic make-up as that your valve at the end of your bladder relaxes easily when you sleep through the teen age years, you're going to be a bed wetter.
So these are going to be kids who basically have a loose valve at the bottom of their bladder. And loose valve actually cause lots of problems in the body including gastro esophageal reflux, if we are talking about loose valve between the esophagus and the stomach. But that's for another show. It's more common in boys and it can persist through the mid teenage years. Are there ways to stop it? There are, but the question is, should you stop it? That's the question.
Traditionally different medications have been used which helps you make less urine, DDAVP is one of those. One of the side effect of that though is it can have, you can get salt imbalances and seizures are even possible if your sodium becomes too wacky. If your sodium becomes, if you aren't making enough urine, you can sort of dilute the blood and your sodium level drops and then that can lead to seizure. Now, it's unusual. It's very unusual. And I'm not saying that kids should not be on DDAVP, I'm just saying you got to look at the benefits versus the risk. And one of the risks with DDAVP is salt imbalances and seizures. Tricyclic anti-depressants were used in the distant past. And those aren't used so much anymore. Those carried some heart arrhythmia issues with them. So they're not used much. So the kind of medications that we have to treat bed wetting do have some significant issues associated with them.
That's not to say they should never be used. You should talk to your doctor and each case should be decided on a kid by kid basis whether they need to do that or not. There is also night time alarms. These are devices that at the first hint of moisture this loud alarm goes off and the idea is the kid starts to pee and this alarm wakes him up and hold it and run to the bathroom. My experience with this is that usually what happens is the kid is such a deep sleeper that the alarm does not wake him up, they still wet the bed and now they have alerted everyone in the house. He just wet the bed. He wakes everybody else up. And it doesn't really do what you wanted to do. Now if your experience with bed alarm has been different, sure it works in some cases. I just in my experience, that's usually the problem is the kid is such a deep sleeper anyway and they're totally relaxed that the alarm doesn't wake them up. Of course you can limit fluid intake before bed. You can try waking them up in the middle of the night to pee.
Some of these have limited success. I think that the mainstay these days are the use of pull ups. Because they are going to outgrow it some point. The pull ups have become thinner more absorbent. They keep a mess out of the bed. Back before the pull ups, when they were more like a diaper, then we would say we will put a plastic cover over the mattress and then a chucks pad underneath the child. But you still get leakage and have laundry issues to do. So I think the pull ups are really the way to go these days. Just let that sphincter mature and stiffen so it doesn't get so loose, it doesn't relax so much. And usually by the mid teenage years, this is a problem that's going away. And often times it's best just to let nature takes it's course and this is one of those cases in my opinion. Again though, if you have a child with bed wetting or with day time accidents, again you need to see your doctor because they need to have their urine checked and examined and to make sure that there is not some other issue going on that could be causing these things.
OK. Next we have a question on expired sunscreen. This comes from Jaymee in Flaming Island, Florida. Jaymee says, "Hey, Dr. Mike. I have a question about expired sunscreen. I wanted to take my kids to the pool. Their age is four and two and a half, I was running low on sunscreen. I did go out and buy some more but later that night I found the tab, they have an expiration date of 2 of 2008, February of 2008. How bad is it really. Is this safe enough to use on me or should I not use it all. The brand is Veeno Baby SPF 55 if that matters any. I usually do not check the expiration dates. Living in Florida, I tend to go through a lot of sunscreen. Thanks so much for your hard work in putting these podcast together, they are appreciated….
OK. So let's talk a little bit about sunscreen. In order to talk about whether the expiration date is important or not, you have to understand a little bit about how sunscreen works. You also have to know the FDA, why do they have expiration dates. Well, the FDA requires sunscreen to maintain it's effectiveness for 3 years from the day it's bottled. If there is an expiration date, that's going to be the 3 year mark. And if you have a bottle that hit s expiration date, you should throw it out. You should not use it on any children or adult and we'll talk about why that is in a minute.
If there is no expiration date on the bottle, the 3 year rule still applies. So if you have a bottle of sunscreen and you have no idea when it's from and there is no expiration date on it, if there is any likelihood it could be 3 years old or more, you should throw it out. OK. Why does sunscreen expires?
It is a conspiracy on the part of the sunscreen industry and the FDA to get you buy more of it?
No, there actually is a reason and again to understand the reason we have to talk a little bit about how sunscreen works. So how it works, well, remember the sun has ultraviolet light which kills skin cells and causes sunburn. Sunscreen protects our skin from that ultraviolet or UV radiation. And most products do this is two ways. There are inorganic ingredients, which act as a shield. So it causes the UV radiation to give a reflect or scatter away from the skin and this are going to be substances such as zinc oxide and titanium oxide. This is why sunscreens are white or haven't have a , You can't see through it, there opaque. Because they have this zinc oxide or titanium oxide. So you basically spreading a metal on your skin which can act as a shield to reflect or scatter away the UV radiation away from your skin. So that's one way in which they work. And that component of sunscreen does not expire, OK. That part of the sunscreen is fine.
The part of the sunscreen that's an issue are the organic ingredients. So these are the non-metal carbon based ingredients. And these are going to be substances like octyl methoxycinnamate and oxybenzone. So there are different ones, there is different , Depending on which brand of sunscreen that you are using. But these are organic chemicals that are volatile. Meaning they slowly react with other chemicals and change into different molecules. And the reason you want that to happen is because when, the way that this works is that the UV light that get through that shield. That gets through the zinc oxide and through the titanium oxide, it is going to react with these molecules. So instead of harming your skin, the UV light, the UV radiation is used up causing a chemical reaction with these organic molecules.
Now, they not only react with UV light, they also react with other chemicals that are in the sunscreen and with each other but it occurs very, very slow rate and it's slow enough that the product remains a full strength for three years. However, after three years, enough of these organic molecules have reacted with each other or with other substances in the bottle, with the plastic of the bottle or whatever, they basically, there is not enough of them there anymore to absorb the UV radiation like you need to. So, the sunscreen not only hasn't , I should mention this too, that also means that when you put sunscreen on, as long as the barrier part of it is still on your skin, that's always going to be working. But as the UV light is hitting your , is getting through that barrier and then reacting with these organic molecules to produce heat in other molecules, as a result of the chemical reactions, these organic chemicals are getting used up. And that is why you have to reapply sunscreen.
Now if you get into the water, you also worry about it washing off. But even if you don't get into the water, there also still going to be a need to reapply it because the organic molecule that's reacting with the UV light, so it doesn't react with your skin is getting used up. So that's something to consider as well and why it's important to reapply sunscreen frequently.
So sunscreen not only has a in bottle lifespan of 3 years, it also has an on skin life span as well. And that actually is where the concept of SPF comes in. What is SPF? You see the SPF 55, SPF is the Sun Protection Factor of a sunscreen. And that number tells you how many times longer it takes your skin to burn with the product applied compared to the length of time without the product.
So, for example, if it normally would normally take your skin 10 minutes to burn, then it will take 20 minutes if you use an SPF of 10. And it also means that it would you're getting basically 10 minutes of protection when you apply it. If you have an SPF of 10, then it's 10 times the amount. So 10 times the length of time. So if it were to take your skin 10 minutes to burn, if you use an SPF of 10, it's going to take a hundred minutes. And why does it takes longer, because first that UV light is reacting with the organic molecules in the sunscreen. But then once those are worn off, it's going to get to your skin. So eventually you are going to burn still. If you have an SPF of 20, you get 200 minutes, and if it's an SPF of 50 you get 500 minutes. It's just a factor of how many times longer you have compared to how long it will normally take your skin to burn if you weren't using any at all. And of course this assumes correct coverage.
So you use enough of it on all exposed skin and durability that it stays on and doesn't wash off. If you don't put enough on, or the product comes off because your swimming, sweating, your clothes are on and off, then you're not going to get the full length of the protection.
OK. So what are the sunscreen rules for kids. Let's talk about that too. You want to use the highest SPF you can find. 50 or more is going to be the best. You want to apply it liberally. You want to reapply it often. You want to monitor their skins for signs of burning and cover their skin with clothing as much as possible. Also use swimsuits and mash guards that offer UV protection. So what are the problems with sunscreen. We always talk about benefits and risks. What are the risk with using it. Well, allergic reactions are possible. Usually that's a result of a dyes or perfumes that are in the sunscreen. So the ones that smelled prettiest are the ones that are more likely to cause allergic reaction in the skin.
In my practice, it seems to me that Water Babies is one of the better ones in terms of the fewest skin reactions. This is not science based. It's relying only on my own recollection. But it seems like whenever I see allergic reaction to sunscreens, I always ask what brand they use and seldom is Water Babies the issues. Now this is not a beneficial endorsement. I can't promise that Water Babies is allergic reaction proof. It's the one that I usually recommend.
Also, another problem with sunscreen is over reliance. If you don't use enough of it, you don't apply it frequently enough. You don't monitor your child, they still get sunburn. So you slap the stuff on and think they're good to go. So we can't over rely on sunscreen. And this is what the notion of don't use sunscreen in kids less than six months come into play, is sunscreen dangerous for young infants? No. But it's possible that parents will miss a spot or not put enough on or forget to reapply it and not closely monitor their baby's skin.
And then when the baby gets a sunburn, if they're less than six months old, that could be very significant in terms of health wise to the child. So sunburn in young infants can actually be life threatening if enough skin area is involved and they can get dehydrated, over heating is also a real possibility for babies left out in the sun. So from a liability's stand point the safest thing to say is keep babies under six months of age out of the sun, period. And that's basically why we don't use sunscreen in young infants. We're trying to protect the baby from the parents from not using the sunscreen correctly. So sunscreen in babies under six months, the official word is don't do it. But again, it's not because of the sunscreen, it because you don't want to rely on that when you're talking about the health of your baby.
OK. Finally, a point about sunscreen type. I think lotions are the best, because you get the most barrier.
The solid rub-ons more difficult to apply enough of the product. And the spray, I mean, are you really getting enough of it on there to make a barrier. So I think your best bet is the lotion. Use it very liberally. Water Babies with an SPF of 50 or more I think is your best bet. And just put tons of it on and reapply it often. And make sure it hasn't expired. And now you know why.
OK. Next stop is Kelly in Yucaipa, California. Kelly says, "My 20 month old child, when he is upset, he cries to the point where he makes himself sick. He throws up his meals and at times he is so violent that he breaks blood vessels in his face. My two year old never did this. This is becoming a pretty frequent thing. I spoke to the pediatrician about it and was told to get him calm down on time so he doesn't do it. What advise do you have. Is this normal or something I should be worry about….
Well, let me first say, Kelly, in a 20 month old, your child is probably not vomiting on purpose.
Now there are kids as they get older they sort of learned if I throw up, I'll get what I want and so they start throwing up, gagging themselves to get what they want because then parents give in when the kids start throwing up. I have seen that before. In a 20 month old, I think that's a little less likely. What's probably happening is it your child is they want what they want, you're not giving it to them, so they cry hard, they throw a tantrum. They cry so hard, they start coughing, they gag and then they vomit because they gagged. So, what you want to avoid is again, as the child gets older though, learning when it gets to that point and they vomit, then they get their way. So they can , It starts out innocently. It starts out with crying hard, throwing a tantrum, coughing, gagging then they throw up. But as they get a little older, they can start to learn to associate, "Oh, when I vomited, that's when I got what I wanted". And then they go straight to the vomiting without the crying hard and coughing and gagging and them making themselves throw up.
So, you definitely want to get a handle on this so they don't learn to associate vomiting with getting their way as they get older. So what about what your doctor said anticipating the needs and avoiding the tantrums in the first place. Well that works fine if whatever their want and need is an appropriate thing. So, if they need or want something and it's something that's appropriate, you want to try to anticipate their need and give it to them before they brake down into the tantrum, that's very reasonable. But what if the reason they're upset is because of something they can't have or can't do, there's a real good reason for that. And they're still going to cry and get upset and throw their tantrums because you can't reason with them. Well you can try redirection in the early stages of the tantrum. Get their mind on something else. Trying to get them forget what it is they wanted or needed and to redirect them into something that's more appropriate, so that's one solution.
But what if that doesn't work? What if they really have their mind on what they want. You can't redirect them and now they're going full force into this tantrum, really, what can you do at that point to avoid the tantrum other than giving in. But we say we can't do that because it's not something that's appropriate. Their wants and their needs is not appropriate. So you try to distract them and it's not working. So at this point you give in to avoid the tantrum, no. Sometimes the tantrum cannot be avoided. It can be avoided when redirections doesn't work and when whatever it is that they want is not appropriate. So what do you do now? Well, now you let them have the tantrum. You just have to let them be. You make sure they're in a safe place. If he reaches the point where they vomit, you let them vomit, you let them have their tantrum and the biggest thing here is you don't give in, you don't try to redirect anymore during the tantrum. You just let them have it. Let them get it behind them. And then a few minutes after the tantrum is over, then you can try redirection again.
Now, what if their want and need is appropriate but they're already into the full pledge tantrum? So, it's something that they could have. It's something that they could have. It's an appropriate want or need that they're crying for, it's too late to anticipate. They already started to have the tantrum. But if it's early in the tantrum, fine. But if they reached the point where they're really crying hard and they're swinging their arms and their legs and they're coughing and gagging and they start to throw up, that is not the time to give in to their want or their need. Even if it's appropriate. Because in their mind, even in your mind, the reason you did it is because their want and need was fine. But in the baby's mind, "Oh, oh, this is what I was doing when I got what I wanted… and so that's getting more reinforcement, severe tantrum and vomiting. So you don't want to form that association. So you don't want to give in to him even if it's an appropriate want or need during the height of the tantrum.
Even if they vomit, even if they're breaking blood vessels on their face. Otherwise they will soon learn how to get their way, and you don't want that. So, I know it's tough. You see your child so upset they vomit but you really do have to wait it out. And I've seen school age kids who vomit they get their way and it's not a pretty sight. So you definitely want to avoid that.
Now, could it be something else? Could it be something else that is making them vomit and break blood vessels in their face. I mean sure it could. But if it's always associate with them being upset because they want or need something that they aren't getting, then it's less likely to be a disease state. If just out of the blue they started crying and throw up and break blood vessel in their face for no apparent reason, that's a whole different animal. So you got to know the context of this sort of thing.
All right, our last question in our Listener Segment this week comes from Elizabeth in Oxford, Missouri.
And Elizabeth says, "Dr. Mike, a couple of years ago, I listened to an episode of your podcast that really set my fears of immunization at ease. A friend of mine is going through that now and I'd like to share that podcast with her unfortunately I can't find it either on your website or on iTunes. Am I just not looking hard enough or if it's no longer available in these sites, is there any way for me to get it elsewhere? Thanks so much. Keep up the good work, Elizabeth….
Well, I believe Elizabeth, if I'm not mistaken that you are referring to episode number 14. We are 146 now, this is way back in episode number 14 which was in October of 2006. And we talked about mercury in vaccines, MMR and autism. Menactra and Guillain Barre syndrome, and we talked about some upcoming vaccines which are not upcoming anymore, they're actually out. Like hepatitis A vaccine for all infants. This episode number 14 is no longer in the feed. So it's not in the player at the website and it's not in iTunes. And the reason for that is we only keep the most recent 100 shows in the feed. That's to keep the feed at a reasonable size.
And it's also to keep the information fresh and current. You can however find all of the shows including episode 14 in the Show Notes Archives. And I actually did some digging for you and I found the link to episode 14's page. So that link will be in the Show Notes for this podcast. Just go to pediacast.org, click on Show Notes and in the Show Notes for this episode 146, there will be a link to episode 14. You can listen to it or download it right from the episode's website.
There is if you'll notice a side bar on the Show Note's page. It has months and years and if you click on any month or year, it will give you the episodes from that month and year. As you go back, it gets into lower episodes. But also remember that show is two and a half years old. So the content might be a little bit out of date, just keep that in mind. If that's not the episode you're thinking about, try exploring the archive or use the search feature at our website at pediacast.org.
If you still can't find it, shoot me another email and I'll see if I can help find it for you. But I bet episode 14 is the one that you are referring to. Because we do debunk some popular myths with that one.
All right, that concludes our Listener's Segment for this week. Thanks for all of you who contributed by asking questions, they're all excellent, great questions. And I hope everyone enjoys Research Round Up this week. We'll go ahead and have a quick break here and then we'll wrap up the show right after this.
All right, thanks go out to Nationwide Children's Hospital for helping us out with the bandwidth this week. Also Vlad, over at vladstudio.com. He always helps us with the artwork in the feed and at the website. We're very appreciative to him and his talents. If you like the pictures that we have at the website, you can find those at vladstudio.com. And they make great artwork for children's rooms and nurseries and decoration of any kind, really. And he does sell them as posters as well, his prints, so you definitely want to check that out. Of course, thanks to all of you, especially those of you who contribute by sending us questions. And again if you have a question that you like to have answered or if you have a topic you want to discuss or want to point out a new article or two, just go to pediacast.org and click on the Contact Link. You can also email firstname.lastname@example.org or call the voice line at 347404-KIDS.
Also remember, donations are very helpful. We are not talking about a lot of money here folks. $2 a month or $25 per year, just helps to keep this program going and it's certainly less than an office co-pay. And you get such great information here and it just take a lot of my time to research this articles and topics to go through the research to make sure you get up to date information and to put these show together, takes up a lot of time. And there is the expense of the bandwidth which even our bandwidth sponsor does not completely cover. So if you could help us out with donations, we really appreciate it. Just go to pediacast.org and over at the left hand side there is a button that says Donations. And you just click that and you get more information that way.
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All right, and until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.