Big News, Happy Holidays, Keratosis Pilaris – PediaCast 152


  • School Bullies
  • Head Injuries and Concussions in Student Athletes
  • Constipation on the Rise
  • Babies Sleeping Through the Night
  • Dangerous Teething Tablets
  • Cephalohematoma
  • Flu Vaccine Safety
  • Milk Protein Intolerance
  • Circumcision
  • Heel Cord Release
  • Keratosis Pilaris



Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital for every child, for every reason.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from Birdhouse Studio, here's your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. It's episode 152 for November 23rd, 2010 and we're calling this one Big News and it is really, really big news.


Of course, Happy Holidays. And Keratosis Pilaris, which is a fancy name for the condition when you get little bumps on your thighs and your upper arms; lots of kids and teenagers have that, so we're going to talk about it because a listener wanted us to. And that's what we do here at PediaCast, we really try to answer your questions. So, what's important to you is important to us, it really is. The whole goal here is to put information in the hands of parents and we try to do that with each and every episode. Now, I understand that the episodes have not been coming as fast as some of you would like and I've heard about that. We were on a very long sabbatical for personal reasons and we are back and I promise you a couple of weeks — it's been about a month ago now, that I will be back soon. And, you know, when you've gone for several months without having a podcast and then suddenly, you know, you're back and you're saying, "Hey, I'll be here every week or two", and then you're not, you know, some people are going to think, "Hey, he quit again."


No, it's not true. It's just it has to do with the big, big news that we're going to discuss and it has, honestly, kept me very, very busy the last few weeks because, of course, I have a whole time regular job; and then we're trying to, you know, run a family here; and then planning for the big thing that I'm going to tell you about has really taken up a lot of time. So, I'm going to give you, in suspense here, just a few minutes, OK? I'm not going to say, like, "Coming up after the break, we'll tell you what the big news is." And, you know — and keep doing it until the end of the program. I'm not going to do that, but I did want to give you some examples of people who've written in who – with their support for the show. And it's not really to toot my own horn here; honestly, it's not.


It's because I want, seriously, from the bottom of my heart, to thank all of you for your support over the years for this program. So, lots of parents, you know, of course, your questions and topic request and we will get to those. But several folks have written in expressing their happiness and support that we're back. For example, Kim in Brownsville, Texas said, "Yey!!! – with a whole bunch of exclamation points – I can only find three podcast from 2010, but I'm very excited that you have found the time and desire to do more podcast. I started listening to you when my son Nicholas was about 14 months old and he started kindergarten this year." Wow! We have been doing this a while. "I have missed you and I'm downloading the three podcast as we speak and we'll listen to them starting tonight. Also, I have to thank you for coming back. And because of you, I'm also a listener of the Manic Mommies podcast, which I love too. Happy podcasting and we'll enjoy hearing about you and your great, great point of view on all things. Kim in Brownsville, Texas."


You know, the Manic Mommies are wonderful and I'm so happy that they are continuing to produce and do their podcast as well. Stanton in Alameda, California says, "I was pleasantly surprised to hear a couple of your new podcasts. I have an 18-month old daughter and was a loyal listener especially when she was really young. I love the practical no nonsense approach you take to pediatric well-being. While I respect your need to create balance in your life, I was saddened to see the feeds stop last year." Well, the feed didn't really stop, we just started – we stopped adding to the feed, but the show have always been there. "When I saw the new casts, I thought it may have been an iTunes glitch."


Oh, thanks. "But was happy to hear that you are back. Thanks for doing this. Stanton in Alameda, California." And Joni in Wilmington, Delaware says, "Hi, Dr. Mike, I'm a resident physician with Nemours/Al DuPont Hospital for Children. Thanks for mentioning the website on your podcast. I just wanted to let you know that I enjoy listening to your podcast because it helps me learn about parent's concerns and ideas about how to answer them.


It also fits into my busy life. I listen while I do other things like house chores or exercising. Keep up the great work and thanks for the helpful resource. Joni." So, see, we even have pediatric residents, OK, pediatricians in training listening to PediaCast. And that, Joni, I really do appreciate your support. OK. So, what is the deal here? What is the big, big news? OK, folks, this is giant and this changes everything. We have been – we originally, as many of you know, lived in Ohio. I'm a Buckeye at heart. And so, in the early days of the program, you know, we play some marching band music and talk about Ohio State Football a little bit. I mean it's mostly pediatric stuff, but we get into some personal things as well. And then, I really got burnt out with doing private practice. It was just lots and lots of hours and Ohio, you know, it was cloudy a lot and we just –


– we've lived there all our lives and we really needed a change. So, about – it's – it will be – it's been just over two years and when all said and done, we have been down here about two and a half years, and it's been great. We love Florida. I thought I'd actually be able to do more podcasting because I'd have, you know – I wasn't working as many hours, but the problem is you're in Florida, right? And it's sunny and we're — I mean, literally, five minutes from Walt Disney World and so there has been a lot of distractions and plus work and, you know, 40 hour a week and then family time, it really does get pretty crazy and there's not a lot of free time left over. So, I got this idea, what if — kind of like a writer beginning a story. What if I could really incorporate PediaCast into my regular job. In other words, it wouldn't be on top of a 40-hour work week, but really could do the podcast and support myself with it.


Well, the only way to really do that and stay independent is by sponsorship. And the economy, the way that it is today as we all know – there's really not a lot of advertising dollars to be spent in the podcasting world; especially, when we're talking about just a single podcast. Now, if you have a group of podcast – and that – and I actually am part of a group with Wizard Media, but it just has panned out and the advertisers are really spending their – the few dollars that they for advertising on more mainstream media, so that has not worked out. And so, I had to, sort of, look for another place. Well, the folks at Nationwide Children's Hospital, which is the children's hospital affiliated with the Ohio State University back in Ohio, expressed an interest on taking PediaCast on board, building us a studio at the hospital, and transitioning PediaCast from being a private venture to really being a product of Nationwide Children's Hospital with me continuing as the producer and the host; and really, this is a win-win situation.


Other than having to move back to Ohio, which is – it – which really, honestly, we missed, but, you know, when you don't appreciate a place when you're there all the time and I think it takes being away from that place sometimes to really appreciate what it was like, and I think some of you understand what I'm saying. You've, you know, lived in the same place for a long time, you know, you, sort of, dream of moving to a magical place. And let me tell you, it's great and yet it's, you know – you also miss home. So, for us, for our family, it's a win because we're going back home and really, surprisingly, my kids, they really miss Ohio and, you know, you think, "Hey, you live five minutes from the Magic Kingdom"; but they, you know, they're excited to be reunited with friends and – so are we, and family.


And so, it's really a good move for our family, but it is a fantastic opportunity for all of you; and here's why, you know, right now, if a listener writes in a question and says, "Hey, I want to know about Keratosis Pilaris." OK. So, I research it, you know, I already know a lot about it, but I want to make sure that we have the latest information and so, you know – then you hear from me. We could do a Skype interview, but the quality, you know – the sound quality, even with Skype, is not that great. The same thing with phone line transmissions and – plus, when you're conducting an interview, you know – when you can't see the person, it loses a little bit of something. And so, what we'll be able to do with a studio actually, physically at the hospital is to be able to say, "OK. We have a listener who wants to know about Keratosis Pilaris. Let's get a pediatric dermatologist in the studio and let's talk about it in a way that, you know, of course, parents can understand and, of course, you know, we'll all elicit it that way so that when you get the information in your hands that you need to get, but in a little bit of a more interesting way."


So, I don't want to beat this into the ground because we've got a big show and lots of information to cover, but I'm really excited about this. When do we start? At the beginning of February is when we make the physical move there. So, I suspect that we'll get into a weekly shows and that's the plan – show every week. And they are allowing me plenty of time. I have clinical duties and some teaching duties with the Ohio State University College of Medicine and working in their – at the hospital – at Nationwide Children's in the Emergency Department and Urgent Care Network. So, I'll have some clinical responsibilities, but I'll have about half of my professional time.


So, about 20 hours a week to devote on education and marketing and podcasting, so it's going to be fantabulous, really. And again, you can – I'm sure you can tell I'm excited about this, but again, it's really going to make this program a much better resource for parents by being present physically on the campus of a very large children's hospital that's associated with a university. So, anyway, that's coming up, first quarter of 2011 and – so, you can look forward to that. All right. So, PediaCast 152, that's where our focus needs to be now.


What are going to talk about in the news department? We're going to talk about school bullies. I know I mention this a lot and it's because it's a big problem. I mean, the numbers are staggering in terms of how many kids get bullied or are bullies at school. So, parents you really need to pay attention to this because it affects the mental health and the development of your child.


We're going to talk about head injuries and concussions in student athletes; also, constipation is on the rise; babies sleeping through the night, at what point do they actually start doing that; and teething tablets that are dangerous. So, that's coming up in our News Parents Can Use. And then in our Listener Segment, we're going to talk about cephalohematoma, flu vaccine safety, milk protein intolerance, circumcisions, and heel cord release. And then our In Depth Disease Segment, we're going to discuss keratosis pilaris. Don't forget, if there's – if there is a topic that you would like us to discuss, really, the best way right now to get a hold of us is either go to the website at and click on the contact link or you can also email, We also have a voice line through Skype. That is actually less desirable right now. Again, I've just had lots of issues with the sound quality coming through Skype, but we're still available at (347)404-KIDS, (347)404-5437.


Once we have a physical studio, I'm really going to work on some way through broadband connect to the outside world. So, we can, sort of, bypass Skype and figure out a different way to make offsite interviews and your questions happen. All right. Don't forget 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 fact-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 And with all of that in mind, we will be back with News Parents Can Use right after the short break.



Our News Parents Can Use segment 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 Bullying and being bullied had become a part of life for a considerable number of American high school students that's according to a survey of more than 43,000 U.S. school children conducted by the Josephson Institute of Ethics. The study reports 47% of high school students were bullied to the point of becoming seriously upset over the last 12 months.


That's almost 50% people, and then another 50% admitted to being a bully. Michael Josephson, the institutes founder says that saying "sticks and stones may break my bones but names will never hurt me" simply is not true. Insults, name calling, relentless teasing, and malicious gossip often inflict deep and enduring pain. These days the internet has intensified the injury. What's posted on the internet is permanent, spreads like a virus, and offers no refuge. Some other troubling statistics from the report include 33% of U.S. high school students believe their school has a serious violence problem, 24% report not feeling safe at school, 52% say anger has led them to strike somebody, and 10% admit to taking a weapon to school at least once during the previous year. Seriously, 10 out of every 100 students have taken a weapon to school at least once during the previous year. And 16% admit to being drunk while at school on at least one occasion.


Josephson says, "The combination of bullying [0:16:11 inaudible] toward violence when one is angry, the availability of weapons, and the possibility of intoxication at school significantly increases the likelihood of school violence. Bullying often includes a combination of verbal abuse, written abuse, physical abuse, exclusion from activities, exclusion from social situations, coercion, and extortion. The effects of bullying can be serious, devastating, and sometimes fatal with the victims often suffering from loneliness, anxiety, low self-esteem, depression, and sometimes even suicide. OK. It's a bleak topic, I know and we definitely covered this before, but parents, really, think about these numbers. I mean, nearly, 50% of U.S. high school students feel bullied, which often leads to serious emotional problems; and another 50% admit to being a bully, which, of course, can lead to serious behavioral and criminal problem.


So, this is a major issue on our schools and one that leads to countless cases of unnecessary suffering, sometimes suicide, and rarely, but tragically, the major violence that we sometimes see in the news. So, I implore you moms and dads, ask your kids about this, ask their friends, ask their teachers, and if it's going on, whether your child is on the receiving or giving end, deal with it before it deals with your child and results in a serious long-term consequence. This past August, the American Academy of Pediatrics released a statement advising young athletes of any age who suffered a head injury and exhibits signs of concussion – that they should seek the advice of healthcare professional with experience in dealing with head injuries before returning to play. This month, the American Academy of Neurology followed suit with a similar recommendation. The catalyst for these statements is recent research confirming what has long been suspected, that concussions aren't just simple "bell ringing's".


They represent real brain damage and may have real long-term consequences including decreased mental ability, dementia, depression, anxiety, and the possibility of permanent personality changes. What's more, the risk of these problems rises exponentially when recurrent concussions occur. So, it's important for athletes with a history of head injury to sit out until concussion symptoms are completely gone. And if an athlete has more than one head injury during a season, they should think long and hard about when they return to play since they're now in a higher risk of a long-term effects, and subsequent head injuries raise that risk even higher. The sport of boxing gave us the first indication this might be true, with many famous boxers, including the great Muhammad Ali, suffering from dementia following years of recurrent head injuries and concussions. But as extreme as this example is, recent study suggest far fewer concussions and milder ones might, at that, might produce similar results. Take NFL football players for example, a survey of retired players showed repeat concussions led to a higher incidents of dementia and Alzheimer's disease.


The NFL has taken notice and expanded its list of concussion symptoms that keep players off the field. And the league has instituted new guidelines requiring players with significant head injuries to consult a neurologist before returning to play. Other sporting authorities have followed the NFL's example. For example, in the past 12 months, the NHL has banned shoulder hits to the head from a player's blind side. Major League Baseball has set up a new advisory panel on concussions and it's considering a new seven-day disabled list for any player experiencing a head injury in the course of play. The NCAA has also approved new rules with regard to head injuries in college athletes requiring those with concussions to see a medical professional experienced in dealing with head injuries before returning to play. The American Academy of Pediatrics and the American Academy of Neurologist would like to see these same measures applied to the high school, middle school, and even elementary school athletes. Here are the key points to their plan. Any student athlete suspected of suffering a concussion should be removed from competition until evaluated by a doctor trained in assessing and treating sports concussions.


Student athletes with ongoing symptoms of a concussion including headache, dizziness, and steadiness or problems with concentration and memory should not be allowed to return to sports participation until all symptoms have completely resolved. And following a concussion, student athletes should be required to have medical clearance by a doctor trained in managing head injuries and concussions before returning to play. The American Academy of Neurologist statement adds, that a certified athletic trainer should be present at all sporting events and practices for student athletes of all ages whenever there is a risk for head injury and concussion. Currently in the U.S., only 40% of high schools provide a certified athletic trainer in sporting activities and they are rarely present at any middle or elementary school athletic function. So, parents, is there a certified athletic trainer watching over your kids when they play school sports? If not, why not? Many times the answer to this boils down to funding, but it may also be due to ignorance and it may be up to you moms and dads to educate your local educational institution about the importance of having a certified trainer available.


Also, parents, you should know the warning signs of severe injury head injury, which require a child be seen ASAP possibly by calling 911, if need be. This include loss of consciousness, even briefly at the scene of injury or at any time afterward, vomiting, nausea, severe headache, seizure, or dramatic changes in personality. You should also know the symptoms of concussion, which again, include recurrent and/or persistent headache, dizziness, and steadiness, problems with concentration and memory and subtle personality changes. If any of these symptoms occur, your child should sit on the bench until all the symptoms have completely resolve and that may take a few weeks. And your child should not return to play until they have been examined by a doctor trained to deal with head injuries and concussions. In case you're wondering, a great to start is your child's pediatrician, as board-certified pediatricians are well-qualified to deal with minor head injuries and concussions.


Finally, moms and dads, remember it is up to you to deal with these matters. Don't leave it up to your school or the coach to determine if your child needs to see a doctor or when he or she is able to return to play. All right. Moving on from the head to the bottom, mild constipation in children is fairly common, but gastroenterologist have been seeing what they believe is the start of a troubling trend. More children with serious and chronic bouts of the condition and they attribute this problem to lack of physical activity, inadequate water intake, and low fiber diets. Doctors at Johns Hopkins Children's Center in Baltimore reported seeing a 30% jump in constipation related visits in the last two years. A jump, they say, stems from delayed diagnosis, insufficient treatment, and referral at more advanced stages. The reality is that too many children are either not treated at all, start treatment too late, or are treated inadequately leading to persistent, severe, and chronic constipation, that's according to Dr. Maria Hemker, Director of Pediatric Gastroenterology and Nutrition at Hopkins Children's.


She says the condition is easy to miss in young kids and its severity is often overlooked, which results into late treatment and worsening symptoms. Half-truths and full blown myths are partly to blame; including the notion that constipation usually goes away on its own, the child will outgrow it, or that a change in diet alone is enough to restore normal bowel movements. "Severe constipation needs to be treated early and aggressively", says Dr. Hemker. "And no amount of fiber or prune juice will help a child with serious chronic constipation". She goes on to say, "Most children have functional constipation, meaning that it's not caused by a disease or anatomic anomaly and is defined as having fewer than three bowel movements a week for three months in given year and these three months do not have to be consecutive months. Signs and symptoms that should prompt a visit to the doctor's office include abdominal bloating, and a feeling fullness, straining with bowel movements, lumpy or hard stools and/or small pellet-like stools accompanied by a sensation of incomplete emptying of the bowel."


Children may refuse to go to the toilet or hide in a private place or they may experience underwear soiling and bed wetting, both complications of serious constipation. Constipation develops insidiously over time and usually begins when a child starts to hold back bowel movements. Holding the stool gradually disrupts the brain and colon signaling mechanism that tells a child when stool needs to come out and stool builds up in the colon stretching it beyond its normal shape and size. The longer the stool stays in the colon, the harder and larger it gets making bowel movements difficult and painful. Toilet training in the start of a new school year are high risk periods that can trigger episodes. School aged children may not want to use the school bathroom or may not be allowed to use them except during lunch or recess. Other contributors include travel, camping, viral illness, and dietary changes. Research shows children with chronic constipation have a worse quality of life than those with more serious medical conditions like inflammatory bowel disease and gastroesophageal reflux, that's according to Hopkins Children's behavioral therapist, Dr. Tara Matthews, who goes on to say, "The dangers of untreated constipation extend beyond childhood".


A recent European study published in the journal Pediatrics shows that 25% of children with the condition continue to have symptoms as adults. Dr. Hemker believes the number of children in the United States may be similar, if not worse. There is a subset of the population suffering from this benign yet often debilitating condition. It is often untreated and only gets worse over time. And she adds, as more children with constipation grow into adults with constipation, their condition may worsen, increasing their use of medical testing and treatment. The first line of treatment for chronic constipation should be over-the-counter osmotic products like polyethylene glycol electrolytes; such as, Miralax, which is sold in powder form. They work by increasing the amount of water in the colon to promote soft bowel movements. And, you know, parents who listen to this program regularly know what she's talking about because we've talked about osmotic products before. Remember osmosis and the bowel walls [0:26:01 inaudible] permeable membrane. I think we just talked about that not too long ago.


These products are not laxatives. OK. Even though it has the name Miralax in it. It is not a laxative. They are not habit forming, but they do need to be taken regularly to work and the dose needs to be monitored and adjusted as needed. Children with serious constipation should start treatment with a thorough colon cleansing before switching to maintenance therapy. That just means using more often for a week or two and then backing off on it. To prevent constipation, parents should ensure their children drink plenty of water. Actually, drinking a lot of water doesn't help as much as you think it would because – I'm sorry Ms. – Director of Pediatric Gastroenterology at Johns Hopkins. The problem with drinking water is that water is primarily absorbed in the stomach and the small intestines. So, if you drink a lot of water, most of it doesn't actually make its way to the large bowels. So, you know, you're trying to loosen up the stool and so you think, hey, drink more water, but the body takes the water up before it gets to where you need it to go.


But, anyway, they say drink of plenty of water, stay physically active, and eat a diet rich in fiber including fruits and vegetables, avoid processed foods and foods that are high in fat and sugar and avoid holding or ignoring the urge to move one's bowels. And that's a tough one because once you start to get constipated, you know, it hurts and it's difficult. And so, kids feel the need to go and they just hold it because it's not a pleasant experience and that just make things worse. On the toilet seat, toddlers should not rush, but take their time to get everything out. And having their legs propped up on a stool or box for support with their knees bent at the right angle, may help them push better and evacuate all the stool. So, that would be stools helping stools. So, there you have it, constipation 101 in the form of a news story. Moving on to babies, when can they sleep through the night? Well, here, we have some encouraging news. Your baby will most likely to be able to sleep through the night within a few months of being born meaning that their sleep patterns can be synchronized, there is hope your constant yawning during daytime hours will be short-lived.


Researchers from the University of Canterbury, New Zealand report in the journal of Pediatrics that by the age of five months, over 50% of all infants are following their parent's sleeping times and sleeping right through the night. The investigators explain that reaching five plus hours of non-stop sleep does not take long but getting it to coincide with the parent's sleeping schedule may take a bit longer. Dr. Jacqueline Henderson and team set out to find how long it took infants to consolidate their self-regulated nocturnal sleep during their first 12 months of life. Criterion one aimed to find out when regular sleep through night from midnight to 5 a.m. occurred or when the baby managed to regularly sleep five hours non-stop. Criterion two is when 10 p.m. to 6 a.m. sleep occurred or when the baby managed to regularly sleep eight hours non-stop. And criterion three was when the parent and [0:29:00 inaudible] sleep patterns were fully synchronized.


The study involved parents of 75 [0:29:05 full term] healthy infants with typical development, the parents completed a sleep diary for six days per month for a total of 12 months. And intermittent videos sleep studies were used to enhance the accuracy of the parent's reports. So, exactly, what did the researchers discover? Well, the main increase in the length of self-regulated sleep took place from the end of the first month to the end of the fourth month. So, most babies reach criterion one, which was five hours of non-stop sleep at about two months of age. Pretty good. There was a 50% probability that babies reach criterion two, which was eight hours of non-stop sleep at three months of age. And a significant number of babies reach criterion three, which was synchronized pattern with their parents, at four months and 50% of babies reach criterion three by five months of age. This led the authors to conclude that the most rapid consolidation in infant sleep regulation occurs in the first four months of life with most infants sleeping five to eight hours through the night at two and three months of age; and by five months, more than half of the infants are sleeping concurrently with their parents.


Of course, there are exceptions. At 12 months of age, 14% of babies hadn't yet met criterion one, meaning they still weren't able to sleep five non-stop hours at night. So, this study good news for most parents. Most babies sleep five hours at a time by two months of age, eight hours a time by three months of age, and have synchronized sleep with their parents by five months of age, but there – this is not good news for those who don't follow that plan. There's still a good number of babies and parents not sleeping through the night even by 12 months of age. So, the next question on the minds of those moms and dads is how do we turn our non-sleeper into a sleeper? Well, unfortunately, the researchers did not address that all important question and since this is a news story, neither will we, at least for now.


But it sounds like a good future PediaCast topic because there are ways to turn your non-sleeper into a sleeper in ways that don't involve drugs. If you like to see the results of these infant study for yourself, surf on over to, look in the Show Notes and we'll have a link to the original article as published in the journal Pediatrics waiting for you there so you can look at it yourself if you are interested. And that brings us to our final news story in this installment of our News Parents Can Use and for that we're going to turn our attention to infant teething. And in particular, Hylands teething tablets, a homeopathic product aimed at relieving teething symptoms in babies. The FDA says these tablets contained inconsistent quantities of Belladonna, which can be harmful to humans in high doses. The makers are issuing a recall and parents who have them at home are urged to dispose of them. During the manufacturing process, small quantities of Belladonna are added to Hylands teething tablets. Large doses of Belladonna can be toxic and cause serious harm; hence, any tablet or medication containing Belladonna needs to be carefully controlled to make sure the doses are accurate.


FDA laboratories found that Hylands teething tablets do not contain consistent Belladonna doses. The FDA cites reports of adverse events in children taking Hylands teething tablets. Adverse events which may be linked to Belladonna toxicity. Other reports describe incidents of children consuming too many tablets because the container caps are not child-resistant. Signs and symptoms related to Belladonna toxicity include agitation, breathing difficulties, constipation, flushing of the skin, lethargy, sleeping too much, muscle weakness, problems urinating, and seizures. So, some of these are serious side effects. Now, in their defense, the makers of Hylands teething tablets, the standard homeopathic company says, Belladonna is included in the tablets to ease the redness, inflammation, and discomfort of the child's gums that often occurs during the teething process. They say Hylands teething tablets contain homeopathically prepared forms of Calcarea, Phosphorica, Chamomilla, coffee – no – coffea, sorry, Cruda, and Belladonna.


And that these ingredients are all prepared in accordance with the Homeopathic Pharmacopoeia of the United States, which the FDA has recognized since 1938. The FDA counters, that parts of the manufacturing process in the standard of homeopathic company have been found to be substandard and a manufacturing inspection is currently underway. All right. Kudos to the FDA for shutting down this operation. Parents, if you're using Hylands teething tablets, stop. If you have some at home, throw them out. That's what I'd do anyway. I mean, really, moms and dads, 1938? You might as well be using snake oil and Carter's Little Liver Pills, Kilmer's Swamp Root. I mean, how these guys get away with making and selling these stuff in the 21st century? Well, I'll tell you how. They pretend that homeopathy isn't really drugs. They say it's natural. But in the end of the day, they are drugs.


Herbs are drugs. They're drugs that haven't been well-studied or proven safe. They've slipped through the cracks under disguise of homeopathy. The FDA has allowed it, parents have bought it, and some babies have suffered because of it. Why? So, the standard of homeopathic company can keep turning a profit, but now it sounds like their little party is finally over. And speaking of finally over –


That wraps up our News Parents Can Use. We'll be right back again. And we'll some of your questions right after this.



OK. Cathy in Cyprus, yes, the country Cyprus. Cathy says, "Could you discuss cephalohematoma? My son, age one month, has two bumps on his head from this and I'm worried they'll stay that way. What is calcification? Is he going to have a bumpy head forever?" OK. So, cephalohematoma, it's a big word, it's cause by ruptured blood vessels between a skull bone and the periosteum, which the – is the thick connective tissue that covers the surface of a bone. The blood vessel ruptures because of mechanical forces of birth and it's more common if forceps or vacuum extraction is required. Now, babies are born prone to bleeding due to vitamin k deficiency. And at birth, a vitamin k injection is usually given shortly after birth to help them with this vitamin k deficiency, which helps them to be less prone to bleeding. Now, you may be asking yourself, why would babies, you know –


– sort of, what is the way then that babies normally – because, you know, before we – they start giving vitamin k injections to babies after birth, not a lot of babies were bleeding to death, right? I mean, babies have been born, you know, since the dawn of man and they weren't giving vitamin k injections in the Garden of Eden, right? OK. So, whether you are a god-believing, person such as myself, and believe in natural design or natural – I'm sorry – intelligent design or you are a follower of the natural, selection evolution kind of thing, either way, there is a check in the balance and that check in balance is that babies are born with an extra amount of blood, which is one of the reasons that they get jaundice after they're born because the body is breaking down that extra blood, but it's beyond the scope of this discussion. So, there is, sort of, a natural check in balance in there, but nonetheless, babies whether, you know, you say, OK, they're more prone to bleeding, but they have more blood, the fact remains that they are a little more prone to bleeding because of a vitamin k deficiency. And so, we give them a vitamin k injection in the delivery room to help with that.


So, the blood vessel bleeds because of trauma from the birth process and it takes a while to stop and the blood has nowhere to go and it becomes trapped between the bone and periosteum. Well, an advanced consideration, because we do have pediatric residents who listen and there are some parents who are interested, the cephalohematoma will not cross a sutra line, which is the line between the individual plates of skull before they all fuse together, and each individual skull bone has its own periosteum. So, one of the ways you know that this is a cephalohematoma is because it's isolated to being overlying one particular bone and does not cross the sutra line. So, if the swelling crosses a sutra line, you have to think, well, it's from something else and it's not really a cephalohematoma.


OK. So, how often does this happen? Well, one to two percent of all deliveries – so, that's one in every 50 to 100 deliveries – so, you're in good company Cathy. So, what does this look like? Well, it looks like a big goose egg. And it's most commonly on one side at the back of the head. Two or more are possible, if this happens at two or more sites. So, it happens to the blood because that's how you have to get it to go away, right? I mean, to get bump gone, like you want it gone, Cathy, is the blood has to go away. So, what happens to the blood? Well, the body breaks it down and the bump goes away. How long does this usually take for the body to break down this blood? Usually, several weeks, so this is not a quick process. At the other – on the other side, it's not something that's going to be there when you get pictures taken at six months of age, but it's going to be there for a little while. OK. So, what are some of the complications that can happen?


Well, you bring up one, Cathy, and that's calcification. What happens with this is the body replaces the resorbed blood with calcium, which may fuse with the skull and these results in a bony deformity that can last for several months or forever. The skull usually remodels itself but not always. Now, the question is, is this a big deal? Well, it depends, you know, if it's small bumps, probably not. I mean, many people have bumpy heads. In fact, a long time ago, fortune tellers would feel your skull and feel where the bumps were and tell you, your fortune based on the topography of your skull. Hair, of course, is going to hide them, but not forever for most people – most men. OK. Maybe not most, me.


If it really bothers you, there have been cases where the calcification can be removed surgically, but you have to weigh the benefit versus the risk. There's the risk of anesthesia. There's the risk that this is skull surgery because often times, this fuse with the skull and scarring might actually be worse than the actual bumps.


So – at, you know – in extreme cases, there have been instances where people had surgery for this, but that's not really the standard thing that happen. So, to address you concerns, Cathy, will the cephalohematoma go away? Yes. Will the calcium – calcifications go away? Most likely, yes. Could he have bumpy head forever? Probably not, but there's a small chance he could. Would I lose sleep over that possibility? Personally, I wouldn't. For you, maybe, that's up to you, Cathy. In the end, none of us have the 100% perfect baby we dream of and if the worse thing that's wrong with yours is a bumpy head that's going to be covered with hair in the years to come, I'd say you are doing quite well. Other possible complications, other than calcifications, from cephalohematomas; one, I've, kind of, eluded to it a little bit, jaundice, is that extra blood – especially really large cephalohematomas, as the blood breaks down, increased bilirubin has formed and that may lead to a more significant jaundice than would have otherwise occurred or it may lead to otherwise occurring jaundice lasting longer and –


So, we really ought to cover jaundice at some point in our – in one of our in depth segments because that's something that happens fairly often. And, in fact, I have a little baby nephew by the name of Owen. So, a little shout out to Owen out there who just had some prolonged jaundice that lasted for a week or two. So, I – I'd actually wanted to discuss it, you know, like, hey, I'll give my sister a little tidbit of information here, yeah, but I had to just tell her over the phone and I did – didn't make the program. So – see, now, even my own sister's question does not make it on the program, so don't feel bad if yours doesn't make it. Also, infection is an issue. The blood can be a good culture media for bacteria and the bacteria may enter through a skin defect.


Fetal probes are a risky entry point. And if a cephalohematoma becomes infected, it can lead to abscess, bone infection or osteomyelitis, blood infection or sepsis, and meningitis. So, this can become a life-threatening condition if a cephalohematoma becomes infected and is not identified and treated promptly. Unfortunately, most babies with abscess on their head are going to have a fever, vomiting, and just look sick. So, you know, if you have a baby with a cephalohematoma and they're doing great, growing great, your doctors look at it and isn't worried, you shouldn't worry that it's an abscess in there, but that's one of the things that can happen rarely. So, doctors should always check these things out. And if there's any changes of the cephalohematoma including, but not limited to, a changing appearance in size, color, feel of the skin, other than getting smaller and softer, if there's any purulence or pus, drainage, crusting, scabbing, fever, vomiting, difficulty feeding, unusual fuzziness or irritability, if there's a rush somewhere else on the body, blah, blah, blah –


Any of these things and your child has a cephalohematoma, have your doctor take a look. Fortunately, infections are rare, but because they can be life-threatening, you really need to keep a close eye and don't put off seeking help immediately if you're concerned. All right. Enough about cephalohematomas. Let's move on to flu vaccine safety. This comes from Erin in Virginia. Erin says, "Hi, Dr. Mike. I'm so glad you started the podcast again. I miss listening to you. One thing I wanted to suggest though is point to your listeners that there have been no studies to test the safety of having the flu vaccine at the same time as other vaccines. So, parents and – or so, patients should wait between these vaccines. Thanks. Keep the shows coming. They are great. Erin." No, no, no, no, no, no, no, no, no, Erin, no, no, no. Flu vaccines can be given at the same time as any combination of other childhood vaccines.


In fact, that very thing is being done every day this time of year at doctor's offices across America and around the world. There is no evidence that combining the flu shot with other vaccines is harmful or decreases the immune system or is in any way something you shouldn't do; however, delaying your child's flu vaccine because you have a concern about the number of immunizations your child is going to receive leaves them unprotected against the flu. And since influenza kills young children every year, it's important not to delay getting your child protected. The CDC and the American Academy of Pediatrics both recommend flu vaccines this year for all children age six months and older and they do not put any sort of rider on that recommendations stating parents should avoid flu vaccine at the same time as the other shots. So, Erin, while study of vaccine safety specifically looking at flu vaccine added to routine immunizations has not been done or published, something much more reliable than that is ongoing, OK?


If you do a study, you have a limited sample size, but we have this happening in the real world with a recording system, so that if there are any adverse reactions in any kid, we are – the CDC is going to know about it. So, millions of children get the flu vaccine with their regular shots, as we speak, and just as they did last year and the year before that and the year before that and the year before that and I could go on and on and many years back. Practitioners and parents can report any adverse reactions they suspect including those arising from concurrently given vaccines. And if significant patterns are seen, recommendations are changed. And that's better than a study because you're looking at the entire population, not just a sample of a thousand kids. And they – they've actually changed several times based on this in the past 15 years that I've been a pediatrician. We've stopped giving oral polio vaccine. The original rotavirus vaccine was withdrawn and a new introduced several years later. And I could cite other examples as well, but the reporting system has not raised any red flags with concurrent use of flu vaccine with other immunization.


And the CDC and American Academy of Pediatrics have not raised such concern, and those are the top doctors in the country. The top scientist in the country looking at this. So, if you have a concern about this, which sounds like the case may be for Erin, then by all means, discuss it with your doctor. I would also urge you to use reputable resources in getting your information; such as, your child's pediatrician, the CDC, and the American Academy of Pediatrics, and, of course, PediaCast. And watch out for the uninformed [0:46:39 inaudible] mongers out there who won't be standing by your side when your child is in the hospital dying from a vaccine preventable disease. OK. Moving on. Leslie in Colombia, South Carolina. "Hi, Dr. Mike. I'm a new listener and I'm slowly making my way through past episodes. I love your podcast and feel so much more informed and confident about pediatric health issues. I appreciate your time and effort that goes into making each episode. At our two-week well baby check, my son was diagnosed with milk protein intolerance.


He was irritable and had blood in his stool. I'm a breast-feeding mom so I cut out all dairy, even traces of it, in my diet. My son had an immediate improvement, improved temperament and physical symptoms. I've been reading as much as I can online, but I have not found sources with good evidence-based information that I have come to demand after listening to your podcast. Thanks. What can you tell me about this condition? How many babies are affected? When might it correct itself? Thanks for your podcast." Thanks for your question, Leslie. Let's talk about milk protein intolerance. First, what is it? There are two common problems babies can have with cow's milk. The first one, we talked about recently, lactose intolerance, which is a problem with digesting the milk sugar lactose and that results in an osmotic diarrhea and can also cause abdominal discomfort. For more on that, check out episode 151 – hey, that was our last show – in the answer to our listener question about chronic diarrhea in toddlers. The other component of cow's milk that frequently causes problems is milk protein and this causes a completely different problem and has a different of symptoms.


So, what happens with milk – cow milk protein problems? Well, the body recognizes the protein in the cow's milk as being foreign and it makes antibodies against it. And there are actually several proteins in cow's milk so you may be allergic to just one of them, all of them, or some combination of them. And how strong of an allergic reaction that you make also varies from person to person. But what this does is it sets up and inflammatory process in the intestines. So, you basically have the body fighting off the proteins as if they are an invader. A byproduct of this inflammation is swelling in the intestinal walls, which can lead to abdominal discomfort –


– can lead to abdominal discomfort, fuzziness, and blood in the stool. Now, you have to be careful with these same symptoms because a lot of things can cause abdominal discomfort, fuzziness, and blood in the stool; and some of them are dangerous and even life-threatening.


So, this is not a condition you want to diagnose yourself at home. OK. So, it may end up being that your fuzzy baby with blood in the stool has a milk protein intolerance, but there are other much worse things that could be too, that your doctor is trained to distinguish between. So, if your baby is fuzzy and has blood in the stool, go see your doctor. Do not pass [inaudible 0:49:27], do not clutch your $200, just see your doctor. Now, having said that and having seen your doctor and having been diagnosed with milk protein allergy, the treatment is simple. You avoid cow's milk protein in your baby's diet. If you're breast feeding, you avoid it in your diet. Your doctor can help you do this by recommending an appropriate formula that does not contain cow's milk protein in it. Soy formula works for many, although some babies have problems with soy proteins as well. And for these babies, often a formula with the proteins already broken down to their individual immuno acids may be necessary.


And examples of those kind of formulas include Alimentum, Nutramigen – they're expensive and they smell and taste bad to us, but babies drink them. If you're breast feeding again, cow's milk protein can make it into your breast milk so you may need to avoid it in your diet. But moms, you still need vitamin d and calcium, so if you're avoiding cow's milk while you breast feed, be sure to ask your doctor about appropriate supplementation for you. I should also mention the effect of cow's milk allergy can extend outside of the intestine. And the condition has been implemented in everything from allergic rhinitis, asthma, wheezing, eczema, or atopic dermatitis in babies. Why? Well, it's complicated and really beyond the scope of this question. Suffice it to say, the immune system is revved up and the inflammation can extend to other areas as well. Now, does that mean that every kid with cow milk protein allergy will have chronic runny nose or wheezing or dry skin? The answer is "No".


Does every kid with a chronic runny nose or wheezing or dry skin have cow's milk protein allergy? The answer to that is also "No". But there can be an association, so it's something to consider. Another issue is that some people can have life threatening allergic reactions to cow milk protein; such as, what we've called hives, and then the severe form anaphylaxis, which is hives, wheezing, air way swelling. It's rare but it's possible and it's extremely dangerous. But most people with cow's milk protein aren't going to have that severe overreaction but it's possible. Let's talk incidents. So, how often does this – does milk protein – cow milk protein allergy actually occur? How common is it? Well, two large population studies done in the 1990s have – there's no data for infants less than a year old. At 12 months of age, the prevalence was 2.5%, by age 3, the prevalence dropped to 0.6% and confirmed cow milk protein allergy in adults was just 0.2%.


So, if your baby has it, there's an excellent chance they'll outgrow it. Probably, by age three and almost certainly before adulthood, but some cases, a few, will persist beyond this. The best way to predict how long it will last, in my opinion, is to look at your family history if it's available. If many adults in the family had cow milk protein allergy and as adults, then that's not good news. If most who have had it, outgrow it at one year, then that will likely be your experience. You can't say for certain, but chances are good. If this has not been an issue in your family before, then you'll know when it ends when it ends. That's really the best you can do. There are blood test to follow the presence and quantity of those antibodies against the cow milk protein that your child is making. And this make it a little easier to determine when it's safe to introduce milk again. The blood test though are best at identifying those who are highly and potentially, dangerously allergic – and to follow those kids over time to see if that number is staying high or begins to drift down.


And this correlates best with kids who have the more dangerous reactions; such as, hives and anaphylaxis. Those with just abdominal discomfort, a little blood in the stool or reactive air way disease or allergic rhinitis or eczema/dry skin, those may actually not have greatly elevated blood test. So, those with – and also those with mildly elevated blood test may not have any symptoms at all. So, the blood test, especially when they're, kind of, mildly elevated or you have milder symptoms, may not correlate very well at all. You could have negative cow milk protein test, but then when you try them off the cow milk protein, they're symptoms go away so you think – and then when you reintroduce the cow milk protein, the symptoms come back. So, you feel pretty confident that the cow milk protein is the problem and yet the blood test is negative, so that sometimes happens.


You can also have kids with elevated blood test and no symptoms at all. So, it's really – the blood test is really for those who – you're pretty sure they have it and they have a severe cow milk protein allergy and you just want a method of knowing when it's safe to reintroduce it. That's really when the blood test is going to come into play. So, in the end, Leslie, you really want a good pediatrician guiding you down this road because it's not one of those problems with a black and white answer. All right. Enough about cow's milk protein allergies. Let's move on to Bianca in Sao Paulo, Brazil. And Bianca says, "Hello, Dr. Mike. I just found your podcast and love it. Thank you so much for your great service to us moms and dads. I have a four-year old boy and didn't want him to have him circumcised when he was born. During my pregnancy, I write about the subject and decided that as long as I keep his foreskin clean and was able to unglue it from his penis, he won't need that. Years later, his skin is still pretty attached even after his pediatrician prescribed the cream as an alternative.


The cream has helped a lot, but it still looks like it's going to take a long time to unattached the whole skin. Should I keep trying a little longer? My pediatrician tells me the longer I wait, the worse it will be on my boy if we decide to go under the knife later on. She said it's completely up to me if I want to do it now or if want to keep trying the cream. The situation makes me feel guilty and I did – that I didn't do it as soon as he was born, but I still think the cream might work since it has helped a lot already. Dr. Mike, please help me understand a little better why this is such a big deal. Honestly, I don't see why he has to have the circumcision at all, hence, my hesitation with the idea of having him go under the knife for something that shouldn't affect his health. Thank you so much. Bianca." Well, thanks for the question, Bianca. It's a good one. This is really a good question. And it's great to know we have listeners in Brazil. So, here's the deal, to circ or not to circ, really comes down to personal, cultural, and social preferences. Now, some studies do show an increase in infections and cancers in uncircumcised men, but other studies do not confirm this and suggest these risks are neutralized by proper foreskin care.


OK. So, what is proper foreskin care? Well, proper care is pulling the foreskin back and cleaning the area after puberty. Before puberty, there is no reason to pull or force the foreskin back. As long as your child is peeing OK, not having infections or pain or discharge, you should just let it stay attached and leave the penis alone. OK. Just let it be. During puberty, the skin epithelium changes from sticky layers to slippery layers and everything is going to unattached all by itself when it's supposed to. The system works as designed or selected without intervention by any surgical tools. Now, if your child is having recurrent urinary tract infections or an – skin infections or pain – yet, it's a different issue and you should talk to your doctor about treatment and options.


Incidentally, the cream you are using is a steroid cream and what it's doing is it's faking the penis into thinking puberty is here. OK. It's changing the skin from having a sticky epithelium to having a slippery one so that the foreskin will unattached. If you need the foreskin to unattached because there's problems as I've mentioned before then it helps and it work. But when you stop using the cream, over time the epithelium will revert back from slippery to sticky and things will attach again until puberty. As you also mentioned, we could have the same conversation about labial adhesions in girls. There's no need to undo them, to pull them apart, or to use cream on them to make them come apart unless there are problems; such as, infection, pain, bleeding. If there are problems, you use a steroid cream again to change the epithelium from sticky to slippery and if there aren't problems, you leave it alone. So, the key concept here is if it's not truly broken, don't try to fix it.


So, Bianca, if you want your child circumcised for cultural or social reasons, that's your decision and I wouldn't fight you for that. But based on your question, I don't think that's the case. If you want your child circumcised because they are having problems; such as, recurrent infections, bleeding, pain, and you're tired of using the cream recurrently or if the cream is not working, then you have a medical reason to do a circumcision. And if there are no problems, if the only issue is attachment, I say leave it alone. It will unattached on its own when it's ready. So, I agree with your pediatrician on one point though, if you decide to have your child circumcised, I agree the sooner, the better. Young kids tolerate it better than older ones. But in your case, Bianca, it doesn't sound like circumcision or even keeping the foreskin unattached is really necessary. I hope that helps. And be sure to tell all your English-speaking friends about PediaCast and who knows, maybe we'll get a Portuguese someday and then you can tell all your friends. All right. We have our final listener question.


It comes from Keri in Haymarket, Virginia. Keri says, "My son is 13 years old and has cerebral palsy. Thankfully, he is mildly affected and his biggest challenges are jumping and running. He also has trouble with balance and alternating movements; such as, swim kicking. Lately, the biggest issue has been that his left foot turns out so much that he actually walks on the outside edge of his foot. He wears orthotics on both legs most of the time. We've done Botox injection with and without follow up casting with little and no improvement. His walking ability and stamina has deteriorated in the last couple of years and now he uses a walker. Finally, to the question, we've been told that the next step is surgery called heel cord release. What are your thoughts and comments about this surgery? I'm not convinced it's a good idea, but he has wearing through the skin on the outside of his foot and I would appreciate your input." Thanks for your question, Keri. And this is just an awesome example of what we'll be able to do once we are actually, physically located at Nationwide Children's Hospital because this is one –


OK. I'm going to give you my answer, but I think it would mean a lot more coming from a pediatric physical medicine specialist and it – or a pediatric neurologist. So, let me first explain to the rest of our listeners exactly what we're talking about here. And you have to forgive me for simplifying things a little bit. At its basic level cerebral palsy occurs because there's a degree of brain damage that occurs in the womb or around the time of birth. Maybe from infection, from toxin exposure or most commonly, from a period of low oxygen. And this may result from a blood flow disruption from the placenta, complicated and traumatic births, or infections and low oxygen conditions in the neonatal period. So, a brain injury occurs during or shortly after birth. I'm sorry. It occurs before or during or shortly after birth. The part of the brain affected is the center that's responsible for fine coordination of muscle activity.


So, some muscles like to stay contracted in their natural state. And again, I'm simplifying this, but what happens is the muscle likes to stay contracted and signals from the brain relax them to the exact degree required for whatever activity you're doing. Also, many muscle movements begin as big clunky overestimated responses. So, in other words, your brain tells your forearm to move and if that's all that happen, your arm would swing wildly and knock something over instead of carefully grabbing one glass from a shelf full of glasses. But just as that big impulse is coming down the pike, another part of the brain modulates the response so that it's appropriate for the situation. In the case of spastic cerebral palsy, the center is where the problem lies. So, muscle movements can be over exaggerated, not finely tuned, and some muscles stay in active state of constant contraction without being told to properly relax. And that's what's happening with a tight heel cord.


The calf muscle also known as the gastrocnemius muscle is in constant spasm, kind of, like a charley horse, but not quite degree and not necessarily painful. And this pulls the Achilles tendon tight, which reduces, mobility of the ankle. In the case of Keri's son, they've tried several measures to improve ankle mobility. Botox injections – Botox temporarily paralyzes muscles, that's how it gets rid of face wrinkles. So, if you paralyze that big muscle, you lose that heel cord. So, it loosens the Achilles tendon and you get a little more ankle mobility. The problem with Botox is you still need the gastrocnemius muscle to extend the ankle. So, you don't want to paralyze the muscle completely. So, even though the tight heel cord is relieved, if you do too much Botox, you'll – still have lost some mobility. And not total loss because other muscles can, sort of, take over, but it's not always ideal.


And the gastrocnemius muscle is big so it – does – I mean, it's hard to get the right amount of Botox. And then, of course, that wears off so this is not a great long term fix. Follow up casting while the muscles relaxed with the Botox, cast – you cast the ankle into the shape you wanted and as the muscle wakes up and begin contracting it adapts to the ankle shape that you're maintaining with the cast, but you can't keep the cast on forever because you get infections, skin irritation, you know, it's bulky, it's mobility limitating in and of itself. So, you cut the cast and hope the muscle that the muscle Achilles ankle shape holds, but most of the time, there's a slow shift back to the position it was before. So, it helps for a while, but you're back to square one eventually and have to repeat the process. Keri, didn't mention physical therapy, but, of course, that's in the mix too before endearing the whole Botox and the casting stuff. So, when this fail, another option then becomes heel cord release.


And basically, you cut the Achilles tendon and take the spastic gastrocnemius muscle out of the picture. The muscle is contracting still, but it's no longer exerting its influence on the ankle by doing that. So, it's like a one-time huge dose of permanent Botox. As mentioned before, you lose some mobility because the gastrocnemius muscle can't extend the ankle, but, again, other muscles pick up the slack. So, overall, the mobility is better without the gastrocnemius muscle than when it's constantly contracting. It's still not ideal, but it's somewhat better. OK. So, that's where I'm good. Why would Keri be asking if this is even a smart thing to do? Well, there are potential problems. You know, it's a surgery, so there's anesthesia risk. It's a wound so you have healing and infection problems. And scar tissue can arise, which can end up causing more severe mobility problems than you had to begin with. So, on the other hand, you know, many kids don't experience some of those problems and do quite well with their heel cord release and have significantly improved mobility, but some kids don't do so well with it.


So, it comes down to a concept we've talked about here before and that's risk versus benefit. If ankle mobility is mild to – is a mild to moderate issue for you, it's probably not worth the risk. If ankle mobility is a severe issue, then it's probably worth it. And only you and your doctors can truly come up with the right decision. So, if you're in a good pediatric center with lots of experience dealing with this issue, I'd personally trust their opinion. On the other hand, if your doctors have limited experience with this, then I'd definitely get a second opinion. And even if your doctors are experienced, it's OK to get another opinion if it will make you feel better. If complications arise, but here you are with two world class pediatric physical medicine programs telling you this was the right thing to do, then I think it's easier to live with those complications. Hey, we did what we thought was the right thing given the right information we had and that information came from two different experienced pediatric programs, you know, then if things do not go well, then, you know –


– you really made the best decision that you could make at the time. So, that's my two cents, Keri. I hope it helps. All right. So, that wraps up our listener segment. We'll be back in just a couple of minutes. We're going to take a look at keratosis piralis. We're already passed the one-hour mark, but, you know, I build the keratosis piralis since from the beginning of the program including in the title, so we're going to cover it. You know, and the holidays are coming up, we're not going to have a show for a little while. So, OK, it's an extended show, but I'm sure you won't mind. Just break it up, you know, pause [1:06:34 inaudible] if you need to, maybe you already have, and listen at another time. So, anyway, we're going to be back and we'll talk about keratosis piralis right after this.


OK. In our end of segment, Sandra from Winnipeg, Manitoba. It's international day here at PediaCast, if you haven't notice already. Cyprus, Brazil, Canada, OK, not quite as exotic, but – anyway, Sandra, we appreciate you writing in. This actually came from our Facebook page. Yes. PediaCast has a Facebook page and you can submit questions there as well. So, Sandra – she was actually the 101st person to be – to like the PediaCast page and so, we had said, "Person 100, we'll answer your question". And person 100 didn't really have a question so we just skipped on to 101. And – but I will say this, question number 100 came from a good friend of mine, Rick, who is currently serving this nation in the military and I know him personally.


He's a good guy, great friend. So, Rick, thanks for being our friend number 100 on our new PediaCast page, which has only been out for less than a month, I believe, when we started it. So, anyway, he passed the baton onto Sandra. So, Sandra, we're going to answer your question about keratosis pilaris. Also, I – you know, while I'm thinking about it, we're talking about Facebook. Well, I have mentioned this, some of you may have it on your mind and it just popped onto mind. I have talked about iTunes store or the app store, I should say, for iPhones and iTouch and iPads having a PediaCast app and that is still – that has been submitted to iTunes for consideration. It has not been approved yet, but we're expecting that any day. So, you may want to be checking the app store here soon for a PediaCast application that you can download and directly access the feed and some other cool features.


OK. So, moving on to our question, keratosis piralis. "I know Dr. Mike addressed this before. My kids were actually affected with it, but I can't find the podcast that maybe there's updated information. My oldest has a mild keratosis piralis, just on her face. But my youngest has a severe and stubborn case on her upper legs and buttocks with a milder case on the backs of her arms." OK. So, let's talk about keratosis pilaris. We're going to do this – it's going to seem maybe a little bit forced, but I, kind of, have a – and since we're, sort of, short on time here – when we talk about diseases – sort of, a template for how we do this, introduction, we're going to talk about epidemiology, pathophysiology, how does it happen, why does it happen, symptoms, differential diagnosis, work up, medical decision-making, treatment, and then complications, prognosis, and prevention. So, if there's medical people out there, this is how a doctor looks at the disease.


These the, sort of, pillars – what you're looking at when you're studying a disease. Well, what is it? How does it happen? How do we differentiate it from other diseases? How do you decide what you're going to do to treat it? What is the treatment? How well does that treatment work? What's the prognosis when you use that treatment? And what complications can arise? And how do you prevent it? So, we're just going to go through those real quick with keratosis pilaris. So, what is it? It is a bumpy rash, could have been acne-like bumps. They're usually flush-colored or white. Sometimes, they can get red if the condition is inflamed. And the skin has rough, dry patches that feel like sandpaper. It doesn't hurt. It's sometimes mildly itchy and it most commonly occurs on the upper arms, the thighs, and the buttocks. Sometimes it's on the face and it really can resemble acne there. Although the size of the bumps, typically, are smaller than acne and they're often associated with dry, chap skin, which acne isn't unless the skin is dried from your treatment of the acne.


And on the face, keratosis pilaris can scar if you pick at it. So, you don't want your child to pick at it especially if it's on their face because it can scar if you try to pop them or pick at them. OK. Epidemiology. Who gets it? Well, it's seen most often in children, teens, and young adults. It usually disappears by the age of 30. It improves in summer months and it's seen less in humid climates. So, skin hydration makes a difference. If you have drier skin, you're going to see it more and in the summer or if you live in a humid climate, you're going to see it less. OK. Pathophysiology. So, what happens here. Well, keratin is the problem. Keratin is a hard protein component of the skin and it protects you from harmful substances and infection. Well, in keratosis pilaris, there is a buildup of too much keratin in certain areas and this forms a scaly plug that blocks the opening of a hair follicle. And usually, many plugs form resulting in a patch of rough bumps.


Now, why does the keratin build up in the first place and why does it occur in patches and why are certain areas more affected than others? We don't know. We don't know the answer to these questions. It often occurs and associated – again, in association with dry skin conditions as such – and I suspect – and again, I don't have any proof of this. But I suspect that if a skin is dry and it doesn't have hydration, maybe the body reacts by making more keratin to protect itself, but again, I don't know. We don't know. It often occurs in association with dry skin conditions; such as, eczema or atopic dermatitis, and ichthyosis vulgaris. And also often runs in – often times run in family so there's likely a genetic component to the disorder, symptoms. Well, they range from a few flushed-colored bumps, with no symptoms at all, to large patches of red inflamed bumps that are itchy and sort of everything in between.


All right. Differential diagnosis. You want to make sure it's not acne. It could be eczema or atopic dermatitis. It could be contact dermatitis. Something has touched the skin and irritated it. So, when you see your doctor and they're looking it, those are the kind of things going through your doctor's mind of what other things it could be, but it has a unique look to it; sort of, a unique distribution. It's there for a long time and doesn't go away and nothing you put on it really seems to help much, and it runs in the family. See, that's how your doctor – really, with the history and the physical exam, sort of, differentiates this from other conditions. So, how do you work it up? How do you figure out what it is? Well, again, clinical exam by a trained practitioner, family history – really, no lab or skin test are needed to diagnose this. Medical decision-making. This means how do you decide what you're going to do about it once you make the diagnosis. Well, treatment is going to depend on the symptoms and the severity.


So, if you really have a mild case, you may just want to leave it alone, not do anything at all. If you have a case of it that is, sort of, disfiguring in your mind or if it's really inflamed or itchy, then you may want to do something about it. The issue here is that any treatment that you do for it may have side effects and problems of their own. So, you have to decide, is it really worth treating in the first place? And if it's a mild case and it's not bothering you and it's covered up under your clothes, then it's probably not worth doing anything about it. So, it usually will resolve if it's left alone. But there are some options for severe symptomatic and troubling cases. So, what are these options? Well, how do we treat it? Well, one option is a topical exfoliant. So, you want something that's going to loosen and remove the excess keratin and the dry skin cells. Now, the problem with this is you're, kind of, opening yourself up to a little bit of infection issue because remember, your body made more keratin there for a reason. Probably, because you had – you didn't have enough skin hydration there and a healthy skin needs to be hydrated.


So, you are loosing a layer of protection when you exfoliate; so, just something to keep in mind. So, what is a topical exfoliant? Well, salicylic acids and alpha hydroxyl lactic acids – and over-the-counter examples of these are certain Clearasil products, Neutrogena, Maxima, OXY, and other products. Basically, they're alternatives to benzoyl peroxide in acne treatment. These are the products that are exfoliants. So, it maybe billed as an acne medicine, but if the active ingredient is a salicylic acid, it may also help with keratosis pilaris. There's also prescription examples of these and they just have a higher percentage of the salicylic acid. Now, these may cause, again, skin irritation, it may cause redness and peeling, and it could make things worse rather than better. Overdose these drugs are rare but possible and includes ringing in the ears, confusion, dizziness, rapid breathing, and if these symptoms sound familiar to medical folks out there, it's because aspirin is a salicylic acid.


It's a pseudo salicylic acid. So, any side effects from a salicylic acid products are going to be aspirin-like issues. OK. Another one – another treatment option is topical retinoids, and retinoids are derived from vitamin a, and they promote cell turn over and prevent hair follicle plugging. So, if you got all these keratin laying on the top of skin, one way to deal with it instead of taking off the keratin with an exfoliant, another way is to encourage the skin to make new skin cells so the dead skin cells that the keratin is stuck to get sloughed off and you make new skin. And the vitamin a product or topical retinoids will promote the cell turnover. And over-the-counter examples of these, Green Cream, Afirm, and some Neutrogina products. Just look for retinol and retinaldehyde in the active ingredient list.


And in some prescription examples, again, with a higher percentage of retinol in them, are things like Retin-A, Aveda, differin, Tazorac, these are all examples of prescription strength ones. But, again, you have to be careful here because these too can cause irritations including dryness, redness, and peeling. So, again, you don't want to make things worse. So, really, it's the more severe cases of keratosis pilaris that you want to treat. And then finally, topical corticosteroids, these are particularly used for if the condition is inflamed. So, if there's red, itchy, bumps – and also when there's associated eczema or atopic dermatitis, usually, the immune system is involved with the formation of that so that you use a corticosteroid to, kind of, calm the immune response down and we'll help with the inflammation part of this. Over-the-counter examples are half and one percent hydrocortisone creams like Cortaid is an example. And prescription examples, two and a half percent hydrocortisone creams, [1:17:59 Rescort], Elecon, and Triamcinolone products.


The problems with long term and recurrent use of topical corticosteroid, especially with a higher potency prescription products, they can cause adrenal suppression, so you basically shut down your own steroid manufacturing because your body is using what you're putting on the skin. That's not a good thing when you start messing with that. Skin atrophy or thinning, also skin hypo and/or hyperpigmentation can also be a complication of a long term high potency topical corticosteroid use. So, there are issues, again, you just want to make sure it is a severe case that you're treating. Complications. So, you – of keratosis pilaris again, one, is making it worse with – by treating it. Another is because of the side effects of what you're using. And skin infection, especially, if you're picking at it and scarring can also occur if you're picking at it. So, you want to leave it alone. Prognosis is excellent.


It usually goes away by itself by age 30. And prevention – there's really no prevention prior to the first outbreak, but if you're prone to it and know you're prone to it in certain areas, you may be able to prevent recurrence with a topical treatment regimen that you and your doctor come up with together. OK. So, keratosis pilaris in a nutshell. And we are definitely running over on time. So, we're going to take a quick break and we will be back to wrap up the show right after this.



All right. Thanks going out to all of you for supporting this program and not giving up on us and participating and writing in questions because without you, really, the – this program wouldn't mean anything. So, I just want to thank you. And I hope all of you, sincerely, have a Happy Holiday season here. Just really enjoy Thanksgiving, enjoy your family at Christmas, I know I'm going to do that. And just really be thankful for everything you have. It's a tough time. I understand that. It really is, for lots and lots of people. It's tough for us too. In this economy, it has, you know – we're going to – we are not going to get out of our house that we purchased here in Florida. Well, we put into it by any stretch. So, sacrifices are happening all around the country and all around the world and – so, just take this time to really focus in on family. And so, I just wish all of you from the bottom of my heart, really, a happy thanksgiving, a Merry Christmas. Think about the reasons for these seasons, what they mean to you and go with that.


I'm mentioning it because I really don't think we're going to have another show until January, at the earliest. And it maybe – we won't have another show until we get situated in Columbus at Nationwide Children's Hospital and really start with a new phase of this program and in – with this new opportunity. So, I'm going to try to have a show in January, but I don't know if it's going to happen or not, honestly. But, hey, we got an hour and a half show hear so, you know, savor it.


And keep – and write those questions, seriously. Go to the website, click on the contact link, email Go to the Facebook page and ask a question there or call in the Skype line and, you know, leave your question there. So, we're going to collect all these questions and as the show starts up again and we're at the hospital and can really have easy, easy access to world class physicians of, you know, all kinds of different specialties, we're going to utilize that.


Trust me. We are going to utilize it. And this program is going to – is really going to be amazing, and not because of me, but because of you and the questions that you ask and because of the resources that we're going to have available to us once we get moved. So, that's all coming up. So, thanks to you, thanks to Nationwide Children's Hospital for continuing to provide the bandwidth support and then all, you know – much, much, much more support coming up here in the future. So, thanks go out to them. Thanks to Vlad Studio for helping us out with artwork on the website, Medical News today, Wizard Media, and again, I want to also thank my family because it does take a lot of time and effort to put this together. It's not just the hour and a half of recording. There are hours and hours of research that goes into this. So, thanks to them for putting up with me trying to do all this in addition to a regular full-time job. Reminders, iTunes reviews, we need some more of those. If you have not taken the time to review PediaCast in iTunes, it really only takes five minutes.


And reviews are extremely helpful to get new people to listen to the program. So, they see this – all those stars on iTunes, read your reviews, and it makes them want to try us. And once they try us, they stay. So, please if you can write an iTunes review it would be most helpful. All right. That really wraps things up. I'm at a lost for anything else – we've said it all. So, we got the big news. I want all of you to have Happy Holiday season. And I will be back – and we'll be back with crazy goodness to come with PediaCast. So, really excited about the opportunities and doors that lie ahead. So, thanks to all of you and again, Happy Thanksgiving and a Merry Christmas!


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