PediaCast 158 * Car Seats, Paronychia, ADHD

Join Dr. Mike as he talks about car seats, ear infections and how they affect taste, sudden death in competitive athletes, toy therapy for toddler autism, paronychia, and  answers one listener's question about the amount of calories that are in breast milk. 


  • Car Seat Safety
  • Ear Infections, Taste, and Obesity
  • Sudden Death in Competitive Athletes
  • Toy Therapy for Toddler Autism
  • Paronychia
  • Breast Milk Storage and Calories
  • Speech Delay
  • ADHD and the Placebo Effect‚Äč



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 is Episode 158 for March 29th, 2011. We're calling this one Car Seats, Paronychia, it's a big word, complicated word but we'll break it down for you. Pretty easy thing, really.


We're also going to talk about ADHD, Attention Deficit/Hyperactivity Disorder. There is a study out a few months back that looked at using placebo as part of the treatment for ADHD to see if that would help, and it actually came out with some interesting results. We'll talk about that a little bit later on in the show during our research segment.

But first, I just want to mention, we are here on the campus of Nationwide Children's Hospital, which is affiliated with the Ohio State University. I kind of had, and most of you know, too, I'm originally from here, I went to medical school at Ohio State, I actually trained here at Nationwide Children's, so I kind of had a vested interest in the NCAA March Madness this year. I mean, after all, Ohio State was the number one seed in the tournament. Notice the past tense, 'was'. Well, I guess they still are. They just lost. They're still the number one seed; they just aren't in the tournament anymore.


Friday night, when Ohio State was to play Kentucky, we actually had a family concert plan. We went and saw Tenth Avenue North. It's one of our favorite groups as a family. We had the tickets purchased before we actually even moved from Florida. So we were all excited to go to this concert, and then it ends up OSU is in the Sweet 16 and I'm going to miss the game because of a concert.

So as it turns out, Tenth Avenue North, there was several bands playing, so we got a seat, Tenth Avenue North, they finished up their set, and before the final band, just not too long after the final band got started, we went ahead and left. We left the concert early, and the family was all for it. We were going to go out and get pizza, we were going to watch Ohio State beat Kentucky, which would be kind of fun because my mom is married to a gentleman who is a die-hard Kentucky Wildcat fan, so it would be fun watching the Buckeyes beat Kentucky.


And then we have this close game, and I'm still getting over the disappointment of losing, but I guess we're in good company because there were no number one seeds left in the tournament at all. So even though I normally wouldn't root for someone who beat the Buckeyes, since we have family and friends who are Kentucky fans, I'll go ahead and say go, Wildcats, at least this time around. We'll see what happens coming up this weekend and then on Monday.

All right, let's get on to the show here. What are we going to talk about?

Car seat safety, some new guidelines from the American Academy of Pediatrics. I'm sure you've heard about these because they have been all over the news. It doesn't seem like you can turn on the TV or the radio without hearing about the new car seat guidelines from the American Academy of Pediatrics.

Of course, they're causing a little bit of a controversy. Some parents are all for it, others are really going to hate it, and there are a lot of kids out there who probably aren't going to be real eager with the new recommendations, either. But just stay tuned. We'll tell you exactly why that is and what the recommendations that the American Academy of Pediatrics are recommending.


We're also going to talk about ear infections and how they affect taste, and possibly obesity. It's kind of an interesting study that came out.

Sudden death in competitive athletes and toy therapy for toddler autism.

And then in our listeners' segment, we're going to answer a question about paronychia. Again, big word, but it's not really a long word, just lots of vowels in there. [Laughter] Paronychia. We'll discuss what that is and what you do for it.

Also, someone had a question about breast milk storage and the amount of calories that are in breast milk, so we'll answer that, also a listener question about speech delay.


And then finally in our research roundup we're going to talk about ADHD and treating it with placebo. Could that work? Could you augment your current therapy with a placebo, and would that actually help your child's behavior? There was a research study that looked at that, and we'll get to that in our research roundup a little bit later on in the show.

Don't forget, if there's a question or a comment that you have for us here at PediaCast, it's really easy to get a hold of us. Just go to and click on the Contact link. You can also email and our Skype line is reopen, so if you'd like to leave a message and leave a question that way, all you have to do is call 347-404-KIDS, that's 347, 404, K-I-D-S, which comes out to 5437 as the last four digits.

Incidentally, one of our questions today in our listeners' segment actually came from the Skype line, so you'll hear that. If you'd like to contribute that way and ask a question, again, just call 347-404-KIDS.


I do want to remind you that the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find online at

And with that in mind, we will be back with News Parents Can Use right after this break.



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

In the U.S., when most toddlers reach their first birthday, they switch from rear-facing to forward-facing car seats, but new advice from a leading group of pediatricians say that it's safer to keep them in rear-facing seats until they reach the age of two or until they reach the maximum height and weight for their seat. The new policy from the American Academy of Pediatrics is published in the April issue of the journal "Pediatrics" and it appeared online on March 21st.

It also says that most children should ride in a belt-positioning booster seat until they are four-feet nine-inches tall and between eight and 12 years of age, and children should also ride in the rear of the vehicle until they are 13 years old. The policy comes from the AAP's National Committee on Injury, Violence, and Poison Prevention, a body that investigates the causes of childhood injuries and recommends initiatives and guidance in response to those issues.


Recent research found that children are safer in rear-facing seats when traveling in road vehicles. In 2007, the journal "Injury Prevention" published a study showing children under the age of two are 75% less likely to die or be injured in a road accident if they are riding in a rear-facing seat.

Let me just say that again. Children under the age of two, according to a 2007 study, which was published in the journal "Injury Prevention", showed that kids under the age of two are 75% less likely to die or be severely injured in a road accident if they are riding in a rear-facing seat.

So those of you parents out there who are contemplating turning your kids who are now forward-facing, who are between one and two years of age, so they got to be a year old, you got all excited, you turn them forward-facing, and now you're like, 'Really? Do I have to turn them back backward until they're two?' And the question is, if you want them to be 75% less likely to die or be severely injured in a road accident, then, yes, you should.


The previous advice stemming from the AAP's 2002 policy said that it was safe for babies to ride rear-facing up to the limit of the car seat, but it also said this should be a minimum of one year of age and 20 pounds. Thus, the current practice for many parents is to turn the seats from rear-facing to forward-facing when their babies reach their first birthday and are 20 pounds in weight.

"The new advice will change all that," says Dr. Dennis Durbin, lead author of the AAP policy statement and the technical report that accompanies it in the same issue of "Pediatrics". "Parents often look forward to transitioning from one stage to the next, but these transitions should generally be delayed until they're necessary, when the child fully outgrows the limits for his or her current stage."


"A rear-facing child safety seat does a better job of supporting the head, neck and spine of infants and toddlers in a crash because it distributes the force of the collision over the entire body," explained Durbin.

If you think about that, in a forward-facing crash, the car stops but your body keeps moving, so if you have the entire back of the car seat against your child, the distribution of the force is going to be across the entire back of their body against that car seat. So that's the reason that it's safer.

For larger children, a forward-facing seat with a harness is safer than a booster, and a belt-positioning booster seat provides better protection than a seat belt alone until the seat belt fits correctly.

Durbin also stressed the age to recommendation is not a deadline as such but a guideline age for helping parents decide when to make the change. "Smaller children will benefit from remaining rear-facing longer while other children may reach the maximum height or weight before two years of age," he explained.


"After a rear-facing seat, children should move to a forward-facing seat with a harness until they reach the maximum weight or height for that seat," says the AAP. After that, they should use a booster seat so the lap and shoulder belts fit properly. The shoulder belt should lie across the middle of the chest and shoulder and well away from the neck or face. The lap belt should fit snug and low in the hips and upper thighs and should not cross the belly. The American Academy of Pediatrics says most children will need to sit on a booster seat until they are four-feet nine-inches tall and between the ages of eight and 12.

Although the rates of deaths in motor vehicle accidents in children under 16 in the U.S. has dropped by a dramatic 45% between 1997 and 2009, car crashes still kill more children four years and older than any other cause. There are more than 5,000 car crash deaths a year among American children and teenagers, and deaths are just the tip of the iceberg with more than 400 injured for every one that dies.


The new AAP policy also covers flying safety. It says that although the AAP allows children under two to ride on an adult's lap on a airplane, the best way to protect them is for children to ride in age- and size-appropriate restraints. "Children should ride properly restrained on every trip in every type of transportation on the ride and in the air," says Dr. Durbin.

Now, in the show notes, we will have the links for you to the actual policy statement from the American Academy of Pediatrics, which they call "Child Passenger Safety", so if you want to read the entire policy statement from the American Academy of Pediatrics, just go to Click on the Show Notes for Episode 158 and we'll have a link there for you to that policy statement.

We also have a link to a nicely done and updated car seat guide from, so you'll also be able to find that in the show notes at


So what's my take on this? Obviously, it's going to be controversial here among parents because moms and dads, let's face it, you like to look in the rearview and see your smiling kid. I get that. But safety first, right? I think these new recommendations were a long time in coming and really, I'm glad that they're finally here.

So let's sum up the new rules. Infants and toddlers should be rear-facing until they reach the height and weight limit for their particular seat, and that should be around age two for most kids, but it could be a little shorter or a little bit longer for some, depending on your child's growth. So all baby seats should always be rear-facing.

Now, once your child outgrows their baby seat, which really we should rename 'baby/toddler seat', so somewhere around the age of two, then you're going to transition them to a forward-facing seat with a harness, and you're going to use this until they reach the height and weight limit for this type of child seat.


Once your child outgrows the forward-facing harness seat, then you're going to transition them to a booster seat to ensure that the car's shoulder and lap harnesses fit properly, and they'll likely need to use a booster seat until they are four-feet nine-inches tall and eight to 12 years old. And then finally, no riding up front until at least age 13.

So there you have it. There should be thousands of parents out there right now turning back the clock on transitions that they've already made. So turn your babies back around, put your toddlers back in baby seats, take your kids off the booster and put them in a forward-facing harness seat, and take your older kids off the regular seat and put them back on their booster, and tell your older kids no more riding up front until you're at least 13. So no grandfathering kids in. Follow these new rules, even if you've already made the transition.


Now, will your kids bellyache about it? Sure. But remember, the noise of bellyaching and temper tantrums absolutely beats the silence of death.

Again, links in the show notes to the actual American Academy of Pediatrics' policy statement and a nice car seat guide from Where will you find those? In the show notes, and that, of course, is at

All right, moving on.

Children with chronic inflammation of the middle ear can experience changes in their sense of taste, and these changes may be related to childhood obesity, according to a report in the March issue of the "Archives of Otolaryngology".

Otitis media with effusion, also known as otitis media or a middle ear infection, has a high incidence in childhood that is a common cause of temporary hearing loss. Although most kids have a good prognosis, 10% of affected children develop recurrent or persistent inflammation and fluid in the middle ear space, which is a condition we call chronic otitis media with effusion, and these are the kids under the microscope in this particular study.


Dr. Il Ho Shin of Kyung Hee University in Seoul, South Korea and his colleagues conducted a case-control study to evaluate the association between chronic otitis media with effusion and the taste threshold, as well as the taste threshold's relationship with body mass index.

The authors hypothesize that chronic otitis media with effusion results in changes to taste function and that these changes may be associated with body weight. The researchers measured the taste thresholds of 42 children with chronic otitis media with effusion who underwent incision of ear tubes to keep the middle ear aerated and a control group of 42 children without ear infections. Four standard taste solutions, sugar, salt, citric acid and quinine hydrochloride, were used in the chemical taste test.

The authors found that children with chronic otitis media with effusion had a significantly higher body mass index than those in the control group. Test results also showed taste thresholds on the anterior or front part of the tongue were higher in children with chronic otitis media with effusion than in the control group.


In addition, chemical taste tests showed the threshold of sweet and salty tastes were elevated for children in the chronic otitis media with effusion group and the thresholds of bitter and sour tastes were also somewhat higher in the otitis media group, but these differences were not statistically significant.

These findings suggest an association between changes in taste and increased body mass index in pediatric patients with chronic otitis media with effusion, the authors conclude.

OK, so there's a little bit of a 'wow' factor here. Kids with chronic ear infections, who get ear infections sort of back-to-back-to-back and just have this fluid that's in the middle ear space or behind the eardrum over a prolonged period of time, these kids were shown in this study to have some disturbances in their taste and a higher body mass index or more likelihood to be obese.


Now, it's easy to jump to conclusions and say chronic ear infections affect your taste, which in turn affect your body mass index, but there is another possibility here. There could be a genetic factor that affects taste and the results of a higher incidence of otitis media.

For example, we know kids born with wide, floppy eustachian tubes have a higher incidence of ear infections. By the way, if you go back a few episodes, we did have one where we talked about ear infections and the role that the eustachian tube, which is the tube that connects the back of the throat up to the middle ear space, the role that the anatomy of that tube plays in getting any ear infection. So kids who are just born with wide, sort of more floppy eustachian tubes have a higher incidence of ear infection.


So whatever genetic thing causes wide, floppy eustachian tubes might also cause differences in taste. That is possible as well. To tease that out, you'd actually have to do a prospective study and see if these kids have taste disturbances before they start getting their ear infections. But since they typically start getting ear infections before you could reliably test their taste, because after all we're mostly talking about babies who get recurrent otitis media, that makes that study a little bit more difficult to do.

So we're left with this observation, and I'm not really sure what it means. Now, the relationship between taste sensitivity and obesity, to me this is a more interesting part of this study. Could it be that kids who have different thresholds of taste, could it be that they eat more because they don't taste things as well? Perhaps. And that leads to obesity, and that's the leap that this study is sort of taking in its conclusion.


Oh, I'd like to see that repeated on a larger scale and just throw out the otitis media with effusion component of this. Just get two large groups of kids, each with different taste sensitivities, and follow them along prospectively, and down the road see if one group has a statistically significant different, larger BMI than the other group.

That would be interesting. Could you taste-test young kids and develop a diet for those high-risk for obesity based on their taste profile? Maybe. I mean, that's pretty cool science, and maybe someone someday would do that.

All right, moving on.

Seemingly every year, there are reports of young apparently healthy athletes who die on the court or playing field, and these sudden deaths may have parents and coaches wondering if enough is being done to identify athletes at risk.

"We would like to develop a better screening program to help prevent sudden cardiac death, but there is not enough rigorous data to support what that should look like," says Dr. Sanjaya Gupta, clinical lecturer in the Division of Electrophysiology at the University of Michigan Health System.


Some communities have begun programs to perform more extensive heart-testing, including electrocardiograms and sometimes echocardiograms on students before they compete, yet a task force organized by the American Heart Association to evaluate pre-participation screening practices has not supported such community programs due to a lack of evidence that they are able to reduce the number of sudden deaths.

A large trial recently completed in Israel concluded that mandatory EKG testing of athletes prior to sports participation did not reduce the number of deaths from sudden cardiac arrests.

"A major obstacle to developing a better screening process is that no one heart test is best," says Dr. Mark Russell, a pediatric cardiologist at the University of Michigan C-S Children's Hospital.


"There are a number of different heart conditions that can cause sudden death in a young athlete. For some heart conditions, the EKG is the best test. For other heart problems, an echocardiogram is required," Russell says. Unfortunately, both of these tests are usually normal in some individuals whose heart problem can only be diagnosed with an exercise stress test.

Furthermore, some conditions such as hyperthropic cardiomyopathy, a thickening of the heart, or dilated cardiomyopathy, can develop over time, so a single screening may not detect the condition.

As many as 10 to 12 million young athletes in the United States participate in competitive athletics. Identifying which of those athletes is at significant risk of sudden death is a bit like finding a needle in a haystack. And since many kids with abnormal findings on EKG or echocardiography would never actually experience sudden death, how can you responsibly identify the student truly at risk without excluding thousands of other students from participating in sports?


The most important step maybe to ensure the screening process outlined by the American Heart Association is being performed as recommended. The American Heart Association recommends a screening form be used to document 12 specific aspects of the student's personal medical history, his or her family medical history, and a physical exam. If any concerns are identified based on the initial screen, then referral to a cardiologist is recommended.

Unfortunately, many physicians use an abbreviated screening form or don't use one at all. Dr. Russell urges all providers doing pre-participation physicals to cover the 12 topics outlined by the American Heart Association.

"Simply improving pre-participation screening forms and conducting electrocardiograms on properly selected children and adults may help reduce cardiac deaths," says Dr. Sharlene Day, Director of the Hypertrophic Cardiomyopathy Clinic at the University of Michigan Cardiovascular Center. "It is also very important for athletes, their families and their coaches to recognize potential warning signs like a seizure, passing out, or shortness of breath."


If there is still more that can be done to try to reduce the incidence of sudden cardiac death, University of Michigan experts support having automated external defibrillators available in schools and training coaches and other school personnel on use and maintenance of the device. Yearly training and basic life support or CPR for coaches and trainers will help them respond as quickly as possible in an emergency.

Emergency response training programs will have the added benefit of not only improving a school's ability to respond to an emergency that occurs on the sport field but to any emergencies that occur on school property. It will also prepare individuals who will take their emergency response skills to their homes and to their communities.

OK, so where can you find the 12-point pre-participation form from the American Heart Association? Well, it's a little trickier than you might think. If you Google the form, most results are actually for an older collegiate screening form which does not contain the 12 screening items.


The American Heart Association has not really put the 12-point form out there. Why not? Well, it contains some pretty technical jargon, and I think they really only want it in the hands of your doctor. I don't think they want parents Googling the form and trying to screen their own kids at home, and if that's their reasoning, it's a good point.

The issue is that that makes it more difficult for physicians to get that 12-point screening form because the American Heart Association, to my knowledge, at least it never arrived in my mailbox, has not really sent that out. So if you're a doctor saying, 'OK, I see this report that says we should be following the 12-point screening program from the American Heart Association, but I can't find the form,' that makes things a little bit difficult.

I did finally find it, and I'm going to tell you how to find it so you can let your doctor know how to find it. Or better yet, you just find it and print off a copy and take it to your doctor, because here at PediaCast we want to get information into your doctor's hands.


There is a link in the show notes to a journal article, and it's in the journal "Circulation" and it was published March 12, 2007. The article is called "Recommendations and Considerations Related to Pre-participation Screening for Cardiovascular Abnormalities in Competitive Athletes". It's an entire article on the American Heart Association's current screening recommendations and the scientific basis for these recommendations, and it does include their recommended 12-point screening question.

So I would recommend downloading the article, printing it, and just giving a copy to your doctor, and of course tell them you heard about it on PediaCast while you're at it.

Now, do not, I repeat, do not use this article and the 12 questions as a means to screen your own child. Go see your doctor, let your doctor ask the questions, let your doctor examine your child to see if they think other screening methods like a referral to a pediatric cardiologist or an EKG or an echocardiogram or a stress test kind of thing is required.


Again, look in the show notes at for that resource.

OK, let's move on finally in our news segment.

"Toddlers who played with a limited number of toys showed more improvement in their communication skills following parent-guided treatment than those receiving other community-based interventions," so says a recent report in "The Journal of Child Psychology and Psychiatry".

It's the first study to examine an autism treatment modality called Hanen's More Than Words, which is an autism intervention strategy for children younger than two who are showing early signs of an autism spectrum disorder. Caught early enough and treated with the right behavioral therapy, autism symptoms can improve dramatically.

"This report adds to our emerging knowledge about which interventions work for which kids. It will help match children with the right intervention and not waste time enrolling them in treatments that are not well-suited for them," said co-author Wendy Stone, Director of the University of Washington Autism Center.


Stone said that parents often detect autism symptoms when their children reach about 17 to 18 months of age. At that age, typical signs of autism include the child using fewer gestures and facial expressions to communicate and being less likely to initiate social exchanges such as pointing out something of interest than other children that are the same age.

One in 110 children has autism spectrum disorders, which include autism disorder, asperger syndrome, and pervasive developmental disorder not otherwise specified. More boys, one in 70, than girls are affected.

Few autism interventions focus on toddlers, children aged one to three, and those that do can be time-intensive and expensive. Stone and her collaborators wanted to study the effectiveness of a short-term, relatively low-cost intervention for toddlers showing warning signs. "Our ultimate goal is to catch the symptoms early and find effective preventive intervention so that these children can attain their full potential," Stone says.


Sixty-two children, 51 boys and 11 girls, younger than aged two and meeting criteria for autism disorders participated in this study with their parents. The researchers measured the toddler's baseline social and communication skills during a pre-test in which parents and their children played with toys and read books while a researcher observed.

Then the youngsters were randomly assigned either to Hanen's More Than Words program or to a no-treatment control condition. The Hanen's More Than Words program is intended to stimulate mature communication, language development and social skills.

The parents in the Hanen's treatment group learned strategies to help their toddlers communicate such as practicing taking turns, encouraging eye contact, and modeling simple sentences from the child's perspective. For instance, when the child pointed to crackers, the parents wouldn't just hand over the food; instead, the parents would get down on eye level with the child and say, "I want crackers."


"By age two, most kids have already learned how to interact and communicate with others," Stone said. "Children showing early signs of autism spectrum disorder don't seem to learn basic social interactions without coaching."

Now, to the researchers' surprise, the Hanen's More Than Words intervention did not, did not, make a difference in communication skills when they compared the 32 children in the intervention group and the 30 children in the no-treatment group.

OK, so you're asking why am I even reporting this study if it didn't seem to help. Well, they did find the intervention helped a subset of children. Kids who played with fewer toys during the pre-test showed more improvement if they received the treatment than if they didn't. Once they had the treatment, these kids showed more instances making eye contact, pointing to or reaching for objects of interest, and showing or giving the experimenter a toy, and this effect lasted at least four months after the intervention ended.

To Stone, playtime is a logical time to help children develop communication skills. "Playing with toys provides great opportunities for teaching social and communication skills," she said. "It enables children and caregivers to share a focus of attention."


So, kind of interesting. They were just wanting to see if the Hanen's More Than Words program helped when you looked to the group who had that program and then a group that didn't have the program, and there was no statistically significant difference when it was used, except in the kids who didn't play with toys. The Hanen's model sort of forces the kids to play with toys, and that seemed to help. So kind of interesting.

All right, that concludes our News Parents Can Use. We will be back and we'll answer your questions right after this.



Dr. Mike Patrick: All right, we are back with our listeners' segment.

I do want to point out, you've probably noticed that I'm a little bit stuffy. It's one of the hazards of being a pediatrician. In addition to doing PediaCast, I also do clinical work in the emergency department and our offsite urgent care centers here at Nationwide Children's. Just one of those things when you're around sick kids a lot; you tend to get colds here and there. I've got one now. So you've just to bear with me.

OK, Deb in Grand Rapids, Michigan says, "Hi, Dr. Mike. I am so glad you are back doing regular podcast again. I've been listening for several years and had missed it while you were on hiatus. I'm also so glad to see the resurrection of the PediaScribe blog and hope you can get Karen to write for it again as I've also missed reading her posts back when she had taken it over. She was part of my inspiration when I began blogging and I've missed her presence online."


All right, that's very sweet of you, Deb, and I'll be sure to pass that on to Karen.

OK, Deb continues, "I do have a medical question, which is the main reason for my note today. My five-year-old daughter recently had an infection in her right thumb underneath the nail. We're not sure exactly what caused the infection to begin with, but her thumb was red and swollen. There was pus leaking out from behind the nail where it joins the skin and her skin had peeled away from the nail."

"At first, I treated it with Neosporin and a band-aid, but it didn't seem to be improving, so I took her to our pediatrician a couple of weeks ago. The doctor thought that there was still a deep infection under the nail so prescribed an antibiotic by mouth, which my daughter just finished taking a few days ago. We went back in for a recheck this morning and the infection seems to be gone."

"My question, though, has to do with the thumbnail. During the time the infection was present, the nail began ripping right across the middle and the doctor today said she's sure the nail will end up coming off. She recommended just covering the thumbnail with gauze and tape during the day in order to keep it from catching on anything and ripping further and then leaving it uncovered at night."


"I've never dealt with a thumb or a fingernail falling off before, either with myself or any of my kids, so I'm not really sure what to expect when the nail does actually come off. Should we treat it with Neosporin again at that point or is there anything we should do to protect the thumb area other than gauze until the nail starts to grow back? How long does it usually take for a nail to regrow after it comes off? Trying to keep a band-aid on the right thumb was extremely difficult before, so I know keeping it covered with gauze won't be an easy thing, either."

"Thanks for everything you do for parents. It's so helpful to have this resource and I've learned so much from you over the years. I'm glad to see you on Twitter now, too, and I'm following you there as well. Deb. P.S., my sister-in-law and her daughter just moved to Columbus, Ohio in January and they love it down there so far."

All right. Well, thanks for the kind words, Deb, and glad to know your sister-in-law lives in my neck of the woods. They certainly have a fantastic children's hospital in their backyard here with Nationwide Children's Hospital.


Let's tackle your questions one by one. First of all, paronychia. That's what we call an infection around a fingernail or a toenail. Bacterial skin infections around a finger or toenail are called paronychia. P-A-R-O-N-Y-C-H-I-A. Paronychia.

Topical antibiotics like Neosporin typically do not work well for these, so we usually use oral antibiotics. Sometimes an abscess or a pocket of pus develops with this, which would either pop on its own or would need to be opened and drained by your doctor.

Now, rarely, as you indicated, the nail will separate from the nail bed and come off either partially or in its entirety. Now, that doesn't happen very often. Unfortunately though for you, Deb, it sounds like you were in the 'rarely' group.


So what do you do when this happens? Well, first you still need to fight the infection with oral antibiotics, and you did that. You saw your doctor for a recheck and it sounds like all is well on the infection front. But what do you do with that nail? Well, there are several reasons that you want to try to keep that nail as long as possible.

First, it protects the underlying nail bed and prevents abrasions and infections of the nail bed. Also, if properly inserted in the nail fold, now the nail fold is where the nail actually grows from, so sort of the closest to your knuckle, that area, that's called the nail fold, and that's where the nail grows. If the nail is properly inserted in that nail fold, it keeps the fold open so that the new nail can form properly. Otherwise, you can get a misshapen new nail. And then the nail also provides a template for the new nail to follow.


There are ways to secure the nail so it doesn't stick out and want to catch, and these involve trimming any areas that are sticking up so they don't catch and securing the nail at the level of the fold with suture or sterile glue. Now, these aren't procedures that most office-based pediatricians feel comfortable doing, but you could always request a referral to a hand specialist who could do that sort of thing in their office.

Now, let's say for the sake of argument you have a kid who loses the nail, the nail is lost, and you cannot use it to protect the nail bed, to open the nail fold, or to use as a guide for the new nail. Let's just say the nail is gone; what do you do then in that situation?

Well, there's really nothing you can do, and our bodies really do a remarkable job of healing themselves. I mean, the end result even without that nail would likely be a nail that grows back over the course of six to nine months, sometimes nine months to a year. Toenails typically take longer than fingernails. But over the course of, yeah, six to nine months.


It will likely be a little misshapen, not as smooth, and you run a little bit of a higher risk of infection and damage to the nail bed and malgrowth, but in the end, you'll likely have a new nail and life will go on.

But if you do have the nail and you're able to see a hand specialist, they would be able to use that nail to sort of prop open that nail fold, which will help new nail grow a little bit better, and you have protection of the nail bed.

So I think bottom line here, Deb, you could see if your pediatrician would refer you to a pediatric hand specialist at your nearest children's hospital and let them sort of work their magic on making that nail stay there for you so that the new nail really grows with its full potential.


But let me back up. That's only if the nail is out of the fold or comes off. As long as the nail bed is covered and the nail is in the fold, I would just keep up with the gauze or trim the nail as needed to avoid fragments that catch, just like your pediatrician told you.

OK, next up is Courtney in Houston, Texas. Courtney says, "Dear Dr. Mike. I am a mother of four-year-old twins. On a recent show you described how lactase works to break down lactose in breast milk. This reminded me of an unresolved question I had about my own experience pumping milk for my children. The short question is, could I have had a high level of lactase that caused my milk to taste and smell rotten faster than average?"

"Now the long back story. My children were born extremely premature at 23 weeks, five days gestation. They weren't able to consume much breast milk early on, so I stockpiled a lot of milk. When we defrosted it, we found that about half of it smelled like vomit. Of that, half also tasted like vomit. Some of this milk had only been frozen a couple of weeks and there was no visible trend to what milk was bad and what was still good."


"None of it made my baby sick, but once we started bottle-feeding instead of tube-feeding, they refused to drink the vomit milk. The best theory that the internet and I came up with was that I had high lactase levels."

"On a related note, and still part of my long, long story, I also suspect I produced skim breast milk. Although my NICU staff insisted that my milk, like all mothers' milk, was 22 calories per ounce, I found other sources, yeah, on the internet, that said calorie count varies throughout a pumping session and throughout the day."

"I theorized that it could also vary from person to person. I'm skinny and produced a high volume of milk that even to the naked eye looked watery, and my children couldn't gain weight on my breast milk plus eight-calorie-per-ounce formula should've been a total of 30 calories per ounce if I had 22 calories per ounce of milk before adding the eight-calorie-per-ounce formula."


"But my children did gain weight on 30-calorie-per-ounce formula with both formula and milk administered using the same bottles, techniques, time of day, etcetera. Yes, we are good experiment administrators. I didn't have time to set up a home lab experiment to see how long a flame would burn when powered by my breast milk, though I sure considered it. So that leads to my second question: could I have had low calorie breast milk?"

"Thank you very much for your podcast, Courtney."

All right, Courtney. Well, thanks for the questions. You have two of them. Let's take them one by one here. First, the lactose/lactase question.

Lactose, as you recall from a fairly recent episode, in fact it was number 151, is a milk sugar that does not get absorbed in its native form in the GI tract. Lactase is an enzyme in the GI tract that breaks lactose down into the simple sugars galactose and glucose, both of which can be absorbed by the gut.


Now as you recall, if you are lactose-intolerant, then you have a deficiency of the lactase enzyme, so lactose doesn't get broken down, it doesn't get absorbed in the GI tract, and you get osmotic diarrhea. For more information on that, again, listen to Episode 151 because we go into lots and lots of detail about lactose intolerance and diarrhea caused from it.

Now, breast milk does contain lactose, but it does not contain any appreciable amount of lactase, and if it did, then there wouldn't really be any lactose left in the breast milk. You just have the by-products of the reaction, which is galactose and glucose.

Now what I know what all you Chemistry heads out there are saying. In the body or in the breast, is the milk at the correct temperature and pH for that reaction to occur? Would that reaction occur while the milk is in the breast? What about in the fridge? What about in the freezer? Would it make a difference to know how much lactase is present if there is not much? Then lactase is the real limiting step and you still have some lactose left over, blah blah blah. We're not going there. Why? Because breast milk does not have any lactase in it, and if there was, it would just be a tiny amount.


So in its native form, breast milk does not have much lactase in it, the enzyme. It does have lactose, but not much lactase. So your points, though well taken, are moot points and we don't need to address them.

By the way, Courtney, glucose and galactose don't smell like vomit. Even if your breast milk was unlike everyone else's and didn't contain lots of lactose and lactase, the by-products of the reaction, glucose and galactose, would not smell like vomit.

OK, so the next question becomes, why does the old breast milk smell like vomit? And does the milk smelling like vomit mean you shouldn't use it? Also, you may be wondering how long is the fridge shelf life and the freezer shelf life for breast milk. So let's tackle these.


Why does some women's breast milk smell like vomit when you thawed out? Well, this is actually due not to the breakdown of lactose, which is sugar. It's due to the breakdown of fat in the milk. There is an enzyme that is in breast milk called lipase, and lipase breaks large complex fats into smaller free fatty acids, and it's these free fatty acids that actually give you that bad smell. Now as it turns out, these small fatty acids are better digested by the baby, and that's why there's lipase in the breast milk to begin with.

But here is the thing: most women just have a small amount of lipase. It sort of starts to pre-digest the fat for the babies to make it sort of gentler and easier for the baby to digest. But some women, and Courtney, I suspect you're one of them, have a high amount of lipase in the breast milk.

Now, when you chill the milk, that lipase can still function. So if you have a high lipase content, fat digestion continues in the refrigerator. As more fat gets broken down and you get more and more and more small free fatty acids, then, when all of the complex fats are turned into really small free fatty acids, we call that rancidification, where the milk has become rancid, and this is what causes the odor and taste of the milk to change.


Now what about freezing the milk in your freezer? Well, at truly frozen temperatures, lipase is inactivated. But here's the problem: most modern freezers don't stay below freezing. They cycle to just above freezing periodically as part of their anti-frost function. So there are periods when the lipase can work even while in the freezer, and if there's lots of lipase in your milk, then the milk can go rancid even while it's in the freezer.

So how can you prevent this? Well, if you heat expressed breast milk to a scald, now not a boil. If you heat it to a boil, there are some beneficial components in the breast milk that can become denatured and not work, things like antibodies and vitamins and proteins, so really, you don't want to boil the milk.


But if you bring it to a scald, so just before it boils, and then you chill and freeze the milk, then the lipase enzyme will be permanently inactivated and the breast milk will not turn rancid. So all you have to do, as soon as you express it, heat it up to a scald and then you can chill it and put it in the freezer.

Now there is a disadvantage to this. You do, but the scald does inactivate some nutrients in the milk, and the most notable one is ascorbic acid or Vitamin C. So if you do this, it's best to alternate between freshly-expressed milk and frozen product to ensure your baby's getting enough nutrients. Or ask your doctor about using an infant vitamin along with the frozen milk.


Now, how long can you store milk? Well, according to the La Leche League, at room temperature breast milk is good for four to six hours, in the refrigerator up to eight days, and in the freezer up to 12 months. For more information on storing breast milk, including length of storage, precise temperatures, storage containers, and best methods to thaw and warm milk, you can check out the La Leche League storage guidelines page, and we'll have a link to that for you in the show notes for Episode 158 at

All right, let's move on to Courtney's second question that has to do with calories. She wants to know, could she be making skim milk with a lower calorie count which causes her babies not to grow as well?

Breast milk, as you mentioned, Courtney, has 22 calories per ounce on average, and most of these calories come from the fat content. Now studies have shown that mothers' diet does not affect the amount of fat or the calorie count for the milk that she makes. Diet can, however, affect the types of fat that are in the milk. But this does not really alter the calorie count. So what does?


Well, this is interesting. When the breast is full, so when your breast is full, less fat gets deposited in the milk, which makes the milk have fewer calories. When the breast is empty, so when your body is really first filling up the breast with milk, more fat gets deposited in the milk, which makes the milk have more calories in it. So frequent feedings and pumping, sort of keeping that breast empty, frequent feedings and pumping so that you're constantly making more breast milk, that will increase the fat and calorie content.

Now, let's relate the calorie content to growth. Several studies have shown, when feeding from the breast, a volume of milk intake is the key to growth, and not calorie content, of an individual mom's milk. Now these studies only looked at feeding from the breast. Your situation is a little different, Courtney, because you're expressing the milk, mixing additives, and then bottle-feeding.


Now you stated that you added eight-calorie-per-ounce formula to the breast milk, which can't really be true because you'd be deluding the breast milk. In other words, if you have 22-calorie-per-ounce breast milk and you add formula that's only eight calories per ounce, the end product is actually going to have a lower calorie count.

So let's just say, for example, you had two ounces of breast milk at 22 calories per ounce, and you added two ounces of eight-calorie-per-ounce formula to it. Then you would have your 44 ounces of breast milk, and your other two ounces are only going to have 16 calories total, because there are eight calories per ounce, so total you would have 60 calories altogether and divide that by your four ounces, and you've deluded it from 22 calories per ounce down to 15 calories per ounce.


So I suspect that you were actually adding something that provided eight calories per cc, not ounce. So the grand total, if you're providing eight calories per cc, the grand total was still likely less than 30 calories per ounce, like the formula that you finally switched to.

Now I could be wrong about that, Courtney, since I don't know for sure what it was that you added, but I suspect that, really, when you were adding 22 calories per ounce and adding that eight kilocalories per cc, you probably still weren't quite to 30 calories per ounce.

Now, is it possible, though, Courtney, that your breast milk does have a lower calorie concentration? Sure, it's possible. And if you have another baby and you want to do the burn test to find out what your breast milk calorie count is, hey, do the experiment, send me the results, and I'll pass that info along to our listeners.


Thanks for your questions, though, Courtney. They're always appreciated.

We do have one more question, as I alluded to. This one comes from our Skype line, so let's take a listen.

Listener: Hi, Dr. Mike. This is Rebecca in Graceville, Tennessee outside of Chattanooga. I'm calling about my two-year-old son, well, two-and-a-half-year-old. He had ear tubes put in back in December. He failed a hearing test, passed it after the tubes. His speech is delayed some. We'll be going back next month to our pediatrician for a two-and-a-half-year-old developmental check, just to make sure that he's still on track after that.

I just wondered what your thoughts were on how speech should develop. After that, he was not severely delayed in his speech here at two-and-a-half. He's just really starting to put two words together like 'Nana's house' and sitting here desperately waiting for you to respond to each.


I just wondered about specifically seeing speech therapists, speech pathologists. I don't know how all that work. We have some things through our school system that are available at the age of three.

So I just wondered your thoughts, if it was your child, how aggressive would you be? He is a second child with an older brother who's pretty sharp. I try not to compare them, but I do at times, I know.

Thanks for all you do for all the parents out here. I appreciate your show. Thanks. Bye-bye!

Dr. Mike Patrick: All right. Well, thanks for calling in, Rebecca. And for the rest of you, again, the Skype line is a great way to get your question answered on the show. You just call 347-404-KIDS. 347, 404, K-I-D-S. If you forget that number, it is included in the title of each of our episodes.

So let's break down Rebecca's question into its component parts. Rebecca has a two-and-a-half-year-old son with frequent ear infections and persistent fluid behind the eardrums. You will remember from one of our earlier news stories, that's a condition that we call chronic otitis media with effusion, which apparently can affect your taste and maybe cause obesity.


Now, Rebecca's son experienced hearing loss because of this. There's really no surprise here. Normal hearing requires our middle ear space filled with air, not fluid. Now, the question becomes, does diminished hearing from this condition lead to problems with language development? And the answer to that question, as we now know it, is no, it doesn't.

There was actually a very nicely done prospective study a few years back that looked at a large number of kids with chronic otitis media with effusion. Half of them were just followed along, they were allowed to let the fluid just stay there for a while, and half of the kids got ear tubes to drain the fluid and prevent re-accumulation. Then they followed the language development for both of these groups, and there was not a statistically significant difference in language development between the two groups.


So the author of that study concluded that ear tubes are not necessary to treat chronic otitis media with effusion if the purpose of the treatment is to prevent language delay, because draining that fluid and improving hearing did not seem to make a difference in terms of language development.

So, Rebecca, your child's history of chronic otitis media with effusion and ear tube placement probably aren't affecting his language much at all.

But he does have a couple of factors that do affect language development. First, he's a boy, and boys tend to lag behind girls with regard to language development. But that's OK because girls lag behind boys in other areas of development. Just part of being a boy or being a girl.

The second thing that your son has going against him is that he has an older brother, and kids with older siblings also tend to lag behind in terms of language development.


Why is this? Well, I think it's probably because the older sibling typically talks a lot for the younger one. 'Mom, Johnny wants the ball,' 'Mom, Johnny wants the TV on,' 'Mom, Johnny is hungry,' 'Mom, Johnny has a poopy diaper.' You get the idea. Why talk when you don't want to?

Rebecca's next question is, is her son delayed and does he need to see a speech pathologist.

Well, two-and-a-half-year-olds in terms of language development, well, first let me say, what is Rebecca's son doing at two and a half? He's putting two words together. You didn't really tell me much more other than that in terms of where he is with his speech, but in terms of putting two words together, that's right about where you'd expect him to be at two and a half years of age.

But here's other things that are normal for a two-and-a-half-year-old boy in terms of language development. Two-and-a-half-year-old boys should be able to name a number of objects common to his surroundings, should be able to use at least two prepositions, usually chosen from the following, 'in', 'on', and 'under', so they should start to have that concept and be able to use 'in something' versus 'on something' versus 'under something', should be combining words into short sentences, largely noun-verb combinations.


But the mean length of sentence at two-and-a-half years of age would be 1.2 words. So sometimes they use one-word sentences, sometimes two-word sentences, more commonly one-word sentences, but starting to put the two words together. So the average sentence length is 1.2 words.

Approximately two-thirds of what your child says should be intelligible to the parent, not necessarily to a stranger, but as long as moms and dads, you understand two-thirds of what your child is saying, that's good.

Vocabulary of approximately 150 to 300 words, and that vocabulary should be receptive. In other words, they know the words for 150 to 300 things. It doesn't mean that they use 150 to 300 words, and they still may do a lot of pointing, but if you said, 'Hey, where's the chair?' they would point at the chair, if you said, 'Where's the refrigerator?' they could point to the fridge, or the dishwasher, or the dog, the cat, the bowl, the glass, the toothbrush, the toothpaste, whatever, 150 to 300 words that they know in terms of receptive language.


Their rhythm and fluency is often poor at two-and-a-half. Volume and pitch of voice are not yet well-defined. Although they can use two pronouns correctly, so 'I', 'me' and 'you', although 'me' and 'I' are often confused, 'my' and 'mine' are beginning to emerge, and they respond to such comments as 'Show me your eyes,' 'Show me your nose,' Show me your mouth,' 'Show me your hair.' They may not use all those words, but they know what they mean and can point to them.


There are some more guidelines for you to compare your son against, Rebecca, and if you'd like to see those guidelines in print, I'll put a link in the show notes to you from the good folks over at Just go to, click on the Show Notes for PediaCast Episode 158, and we'll have a link there for you to a nice language development guide that's divided up by ages.

So, Rebecca, it sounds to me like your two-and-a-half-year-old son is probably on target and doesn't need intervention. But as always, check with your child's doctor, and if she or he recommends a speech pathologist, do it. Even if your school's resource starts at age three, I'm sure your doctor could find a resource for you if your son needs one sooner than that.

All right, that wraps up our listeners' segment. We will be back. We're going to actually add to our research roundup. We have a pretty cool study that looks at ADHD and the placebo effect. That is coming up right after this.



Dr. Mike Patrick: All right, we are back, and we're going to add to our research roundup.

ADHD and the placebo effect. This is from a study done by Mission Children's Hospital in Asheville, North Carolina, along with the University of North Carolina at Chapel Hill. The authors were Adrian Sandler, Corrine Glesne, and James Bodfish, and this was published in the "Journal of Developmental and Behavioral Pediatrics" in June 2010.

So the question before the researchers, among children with ADHD, can the dose of stimulant medication be reduced while maintaining effective treatment of symptoms by placebo? This was a prospective placebo-controlled study.


They looked at children between the ages of six and 12, and all of them were being treated with a primary diagnosis of ADHD or Attention Deficit/Hyperactivity Disorder.

They excluded kids with an IQ of less than 80, so anyone who had really more mental delay, other things than just pure ADHD, they were going to eliminate them. So IQ less than 80, they eliminated. Those with any other major medical and neurological disorders such as epilepsy, cerebral palsy, autism, and those who are on other psychotropic drugs including anti-depressants, medicine for anxiety, antipsychotics such as risperdal.

So basically they're just looking at kids with simple ADHD without any comorbidity or any other diseases not related to the ADHD. So just healthy kids who only had simple ADHD who are between the ages of six and 12.


Altogether, they found 138 eligible subjects, and 99 of them decided to enroll in the study.

The first thing that they did with these 99 kids is they put them all on an optimal dose of an extended-released mixed amphetamine salt. So if you're familiar with Adderall XR or the generic equivalent of Adderall XR, that's what we're talking about. So they put all of these kids on optimal dose of that medicine.

Now, how did they find the optimal dose? Well, they did this by a double blind study. The parents and the examiners were blinded to what drug was being used and to what dose. Now, of course someone knew, obviously. They're going to use the right dose for the kids' age and size to start with and then titrate up and down from there. But the parents didn't know what drug was being used or what the final dose was, and the examiner who is asking the questions to see whether they were under good control also did not know what was going on with the dose.


OK, so once they got everybody, all 99 kids, on an optimum dose of the extended-released mixed amphetamine salt, then they randomized these 99 kids to three groups.

The first group would just get the full optimal dose for two months. That's the control group.

The second group would be on the optimal dose for a month, and then during the second month their dose would be reduced by 50%. This is the comparison group.

Now the experimental group, this is the third group, they were on their optimal dose for a month, and then the dose was reduced by 50%, but a placebo was added. The parents and children were explicitly informed that the placebo had no active ingredients. The parents and the kids knew that they were getting a placebo, and the placebo, though, was referred to as a non-medicated dose extender.


So they were told it's a placebo, and they did use the word 'placebo' and they said, 'This has no active ingredients,' but they also said it's a dose extender. They did that to maintain some positive expectancy, that, 'Hey, this might actually help.'

So how did they determine the optimal doses? What examination tools did they use? And then how did they evaluate the outcomes?

Well, the examiners used, and they did this, by the way, during the optimization process, and then at baseline, and then weekly during the two months, and what they looked at, and if you're a parent with a kid on any of these medicines, you know what these sort of scales look like where you circle the number that says, does this describe your child a little bit, or a lot, or somewhere in between.


So the scales that they used, the first one is the Inattentive, Over-activity With Aggression Conners scale or the IOWA Conners scale, and they used the parent version and the teacher version, and they sought to get parents to fill this out every week while the child was on the medicine. They also had the teachers fill them out every week while the children were on the medications.

The second subjective tool that they used was the Pittsburgh Side-Effects Rating scale, which just looked at side effects of ADHD medicines.

So the Conners scales and the Pittsburgh Side-Effect Rating scale, those are both subjective. The parents would fill those out, and the teachers with regards to the Conners scale, just subjectively when asked about the child's behavior or side effects.

They also used an objective tool called the Conners' Continuous Performance Test, and this is a computer-administrated test that really looks at how well is your kid paying attention as they interact with this computer, tests reaction time, omission errors, commission errors, and response time.


So it's really just a test of attention on the computer, and that was also administered just to the kids at baseline, during optimization, at the beginning of the study once they were on their optimal dose, and then weekly until the study ended.

All right, so what they did find? Well, 70 children completed the study. So 29 kids actually dropped out of the study. There was no difference in the dropout rate among the three groups. So now we're only going to look at the 70 children who completed the study, and again there's about an equal number in all three groups.

OK, so what happened with the parent IOWA test so that when you looked at the Conners parent scales, the reduced drug group demonstrated, when you reduced it by 50%, these kids demonstrated a statistically significant increase in symptom severity compared to the fully-dosed group and the reduced-dose plus placebo group.


So if you just decreased it by 50%, the dose, these kids had a significant increase in their ADHD symptoms. The reduced drug plus placebo group had symptom severity similar to the full-dosed group over time, even while the reduced-dose group deteriorated.

So what does that mean? It means that the kids who stayed on their full dose and the kids who had it decreased but were given placebo stayed pretty constant on their parent IOWA scores did not deteriorate and were comparable to one another during the entire two months, whereas the reduced-dose group who did not get the placebo, they just had their dose cut in half, they worsened, they deteriorated on the parent IOWA test.


The teacher IOWA test, unfortunately, they were not able to get teachers to consistently turn those in. So they had really a limited number of responses and no significant differences were noted in ADHD symptoms among the teachers. But they really fell in the study but that's because they just did not have a good response back from teachers consistently filling these things out.

OK, and then what about the computer test that looks at attention? Well, there's no significant differences in attentional performance among the three groups at all times during the two months. The computer test on attention, it didn't really matter whether you stayed on the full dose, you had your dose half, or you had your dose half plus the placebo added. All these kids did about the same on the computer test.

And then in terms of the side-effects scale that parents filled out, the reduced-dose group who had their dose reduced by 50% without the placebo, they demonstrated an increase in side effect severity relative to the fully-dosed and reduced-dose plus placebo groups. Now, the reduced-dose plus placebo group, they actually demonstrated a decrease in side effects over the eight weeks of the study.


So the authors conclude that pairing placebos with stimulant medication elicits a placebo response that allows children with ADHD to be effectively treated on 50% of their optimal stimulant dose.

So what the authors are saying is, hey, parents, if your kid's on Adderall XR or the generic equivalent, you could decrease their dose by half and add a placebo, but call it a dose extender, and your child is going to do just as well. That's basically what the authors are saying that this study showed.


So this is pretty crazy, really. I mean, if you believe that ADHD is caused by a chemical abnormality in the brain, and using a medicine like Adderall XR changes the chemical milieu in the brain and this is why it helps ADHD, it really doesn't make a lot of sense why you could half the dose and put in a placebo and still have the same outcome.

So, really, it's a pretty crazy study. If it's true and repeatable, it probably causes more questions to be asked about the mechanism of ADHD than it actually solves.

So, again, if you have kids on an optimal dose of ADHD medicine, according to this study, you leave a third of them on their dose and they sail along. You drop the dose by 50%, and they deteriorate. But if you drop the dose by 50% and add the placebo and call it a dose extender, then they sail right along and do fine.


So some questions I have about this. What would the results have been, number one, if you increased the sample size from 70 and repeat it? What if you hide the fact that you're using a placebo instead of explicitly telling the parents and the kids, 'Hey, this is a placebo dose extender that's non-medicated'? I mean, what if you hide that fact? What if you did a better job of recruiting teacher support so you can see is there a significant difference at the school, not just at home?

And then finally, what exactly is the placebo effect in this case? I mean, did parents in the placebo group cut their kids more slack because they knew the dose was cut but they wanted the non-medicated extender to work? Did they sort of look past some of their child's behaviors because they wanted this non-medicated extender to work? They wanted their kids on less medicine, so they cut their kids a little bit of slack?


Did the kids in the placebo group sort of control their own behavior a little bit better because they knew their dose was cut and they were testing an extender? In other words, did they do a little bit better job of managing their own behavior?

Because even with ADHD, there's choices that are made, and kids to some degree can control things. They may be more impulsive, they may need more frequent reminders, but they still do have some control of themselves. So maybe because these kids knew that they were on this placebo and they sort of wanted it to work, could they have been controlling themselves a little bit better?

Did the reduced-dose kids deteriorate because the parents and the kids knew their dose had been cut by 50% and they didn't have this extender that the other kids had? Were they maybe subjectively deteriorated more because they knew they had been cut by 50%?


Or did the placebo actually cause chemical changes in the brain that helped ADHD symptoms?

So I'd like to see a larger sample size. I'd really like to see better blinding as to which group each family is actually in so the family doesn't really know whether their dose was cut in half or not if you could do that, and the family doesn't know whether they actually had a placebo or not. I think that would make the study a little bit better.

If you did that, if you had a larger sample size and you did a little better job of blinding to that placebo, and those findings still hold true, then we certainly have some interesting new ideas about ADHD and certainly some different treatment options available for kids with ADHD.

And the kids I'm thinking of mostly here, and parents out there, you're going to know if I'm talking about your particular situation, these are the kids who are already titrated up to high doses but they still have deterioration of their ADHD in the evenings, and would a placebo or dose extender help those kids in the evenings is an interesting idea.


So we'll keep our eyes and ears open here at PediaCast for any future studies involving ADHD and placebos, and of course we'll pass that information on to you if more studies are done and it becomes available.

All right, so that wraps up our research roundup for this week. We will be back to wrap up the rest of the show right after this.


Dr. Mike Patrick: All right, as always, thanks go out to Nationwide Children's Hospital for hosting us here on their campus. We're very excited to be here.


Also thanks to Medical News Today, Vlad over at VladStudio who helps us out with our artwork, also Wizard Media. And of course to all the listeners out there, we really appreciate your continued support.

Don't forget we are on Facebook now and also Twitter. If you go to, there are links to find us on Facebook and Twitter, or you can just search on those social media apps and find us that way.

Also, I want to remind you, this is probably the most important way that you can spread the word about PediaCast, and we really do want to grow the audience because we want to put this information in the hands of more and more parents. As we've talked about in previous episodes, there's really a lot of bad information sources out there that are not evidence-based, do not follow along sort of what the FDA, CDC, American Academy of Pediatrics are saying based on good research studies and evidence-based medicine, so we really want to put this resource in the hands of parents.


And one way that you can do that is by telling your doctor about PediaCast. Just jot it down on a piece of paper, say, 'Hey, check this out:' And I think that's one way that you can really help us spread the word.

If you found us through iTunes and you've not left your own iTunes review, it really doesn't take long to do that. Reviews on iTunes are most helpful. And of course, if you could talk us up on your blogs and in Facebook and Twitter, that is always helpful as well.

Don't forget, if there is a topic or a comment that you'd like to make, just go to and click on the Contact link. You can also email or, again, call the Skype line at 347-404-KIDS.

All right, we have run way over today. I'm just very talkative. Sorry about that. But we'll try to keep it a little shorter next time. Until then, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids.

So long, everybody!



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