PediaCast 159 * Walking Balls, Spray-On Sunscreen, Head Freeze

On today's PediaCast listen as Dr. Mike discusses vaccine safety, pediatric CAT scans, water-walking balls, breastfeeding and HIV.  He also answers questions about dental procedures and sedation, while also touching on the topics of   the effectiveness of spray-on sunscreen, the science of the head freeze, and ear infections.

Topics

  • Vaccines

  • Pediatric CAT scans

  • Water-walking balls

  • Breastfeeding and HIV

  • Dental procedures

  • Sedation

  • Sunscreen

  • Head freeze

  • Ear infections

Links

Transcript

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

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from BirdHouse Studios, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone and welcome to PediaCast. It is episode 159, 1-5-9 for April 13th 2011. And we're calling this one Walking Balls, Spray-On Sunscreen and Head Freeze. Have you seen these walking balls? Do you know what I'm talking about? These giant bubbles, just a big transparent sphere and you can climb inside and you can actually walk on water with them. I mean it sounds fun, but the big question is are they safe? And the answer to that may surprise you. Well actually since I'm doing it as a teaser it probably won't surprise you now. But anyway that's coming up in just a few minutes along with lots of other topics.

First, I want to say though, spring is really here. Just in the last couple of days the trees have bloomed and so even up here in the middle portion of the Midwest, I won't say upper Midwest but we're within a couple hours drive to Canada, so we are pretty north. And I know it's been warm for a while in the southern part of the country where I used to live and I know that because we've been getting people writing in warm weather type questions and in fact we're going to cover one of them in this episode about spray-on sunscreen. So I know that you're going to the beaches and you're going to the pools, it's not quite that warm here in Ohio yet. But I'm adjusting. We're from here originally so we're, I guess used to it. But I tell you it doesn't take being in Florida long, just a few years, and you get spoiled because spring comes so soon, so early.

02:27

They do have a winter though. So for those of you who kind of rolling your eyes and saying what do you mean? It's spring all the time, all winter-long. Yeah, it can get cold and for long periods of time, but we're not here to talk about the weather of Florida. We're here to talk about pediatric issues and we have a big line-up for you today. In the news section, we're going to talk about vaccine safety and in particular, who do parents trust when it comes to giving information about vaccines. I think this is an important news story not just for parents but for doctors too, because there's some reassurance with this story. So we'll get to that.

Also pediatric CAT scans. Are we doing too many of them and are they dangerous or are they helpful? How do you decide? So that's coming up. And then of course water walking balls, we'll discuss those. Breastfeeding and HIV, we have a clarification to make and that's coming up here in the Listeners' segment.

Also dental procedures and sedation questions and family presence. Should you be there when your child is having a dental procedure done? What if the doctor kicks you out and says you have to wait in the waiting room, how do you handle that?

And then sunscreen spray-on, is it better, worse, no difference than lotion? Head freeze. When you take a big bite of ice cream and you get that instant headache, someone wants to know what causes it and we're going to get in to the details – the science behind head freeze. Only here on PediaCast folks.

And then finally, we're going to round things up with a Research Round-Up on ear infection treatment in kids who are less than two years old. For a while now we've doing sort of the wait and see approach to ear infections, especially in older kids. You know, they have a little earache but aren't toxic. They don't have a high fever and vomiting and you go in to see your doctor and they say, you know it looks like a there's a little bit of an ear infection but why don't we just watch and wait? The question becomes what about in a six-month old, can you watch and wait in kids six months to 23 months of age? And there's a new research out that may help doctors decide what to do in that situation. So we'll cover that, I should say, in the Research Round-Up later on in the program.

04:44

Don't forget if you would like to get a hold of us here for a comment or a question or you just have some steam to get off your chest, it's easy to get a hold of us at pediacast.org, just go to the Contact link and you can write in. And I say that, you think who's writing in, who have steam to release and we did have one this week and we'll get to that when we get to the Listeners segment.

Also you can email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-5437. Before we go any further, I 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 a specific individual. 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 and you can find at pediacast.org.

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

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06:21

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 medicalnewstoday.com.

Most parents get their information about immunizations from their child's doctor, but many also turn to public health officials, other parents, friends and family members and even celebrities as sources of vaccine information – so say the results of a national survey conducted by University of Michigan researchers and published in the journal Pediatrics. The objective of the study was to determine how much parents trust different sources of information in regard to vaccines and to determine what distribution methods would be most effective for those attempting to present evidence-based information about immunizations.

"We know parents get information about childhood vaccines from many sources," says Dr. Gary Freed, M.D., chief of the Division of General Pediatrics and director of the Child Health Evaluation and Research (CHEAR) Unit. "But the source trusted most by parents for vaccine-safety-related information is their child's doctor, which is consistent with the results of several previous studies."

The Michigan researchers surveyed 1,552 parents with children all under the age of 18 asking them to rate their degree of trust in various sources of vaccine information as 'a lot,' 'some' or 'none.'

Seventy-six percent of parents reported trusting their child's doctor 'a lot', which I think that's kind of funny. That means that a quarter of parents don't trust their child's doctor a lot. OK, maybe we need to fix that. You probably want to find a doctor who you trust a lot.

Twenty-six percent said that they trusted other healthcare providers 'a lot'. Twenty-three percent said they trusted government experts/officials. Only 23% trusted the government a lot. I think that says something as well. And only 2% said they trusted celebrities a lot. OK. That's good. I have faith again in parents that only 2% of them trust celebrities a lot with pediatric health information.

In the I trust them 'some' category, 67% of parents have some faith in family and friends; 65% have some fait in the information presented by parents who believe their own child was harmed by a vaccine and 24% have some faith in celebrity opinions.

08:46

The study found mothers were more likely than fathers to put 'some' or 'a lot' of trust in vaccine safety information provided by parents who claimed their child was injured by vaccines, celebrities, television shows, and magazines or news articles. So moms are more likely than dads to put 'some' or 'a lot' from information sources other than their child's doctor.

Trust also varied by race and ethnicity: white and Hispanic parents were more likely than black parents to trust family and friends 'a lot' or 'some,' and Hispanic parents were more likely than white or black parents to trust celebrities 'a lot' or 'some' for vaccine-safety information.

In fact, 40% of Hispanic parents placed a lot or some trust in celebrities. It's unclear from this study whether such celebrities are in the Spanish-language entertainment or in the mainstream English-language medium.

Dr. Freed says, "Those who design public health efforts to provide evidence-based information must recognize different strategies may be required to reach all groups of parents."

So here I say the American Academy of Pediatrics just needs a few celebrities and particularly Spanish-speaking celebrities on their side to get the message out and I think they need to look into that.

"Even if only a fraction of parents receive, believe, and act on misinformation about vaccine safety provided by these different sources, a child's health and the population's health may suffer because of vaccine preventable illness."

Take home here for parents, if you trust what your child's doctor is saying about vaccines you're in good company. And if you don't trust what your doctor is saying about vaccines, why are you still seeing that doctor? The take home for doctors who see kids and I think this is really important, rest in the fact that the overwhelming majority of parents trust what you are saying.

Too many doctors out there, in my opinion, are giving in to parents who want to follow the advice of the Jenny McCarthys of the world. They're letting parents design their own customized immunizations schedules because of irrational fears perpetuated by anecdotal accounts and poorly designed research. The vast body of evidence-based medicines supports the current immunization schedule and there is a history and precedent for changes in the schedule when problems do become evident.

No one's trying to hide the fact that immunizations are dangerous in some way or another. Here is a really cool thing for doctors out there, parents trust what you have to say. Sure you have to spend more time in the examination room defending your stance, but remember your stance is based on evidence and not anecdotal reports, emotions or poorly designed and later recanted studies. So please stand strong and be of advocate for your patient's health.

11:36

All right. Computerized Axial Tomography, also known as CAT scans, those examinations of children in hospital emergency departments increased substantially from 1995 to 2008. That's according to a new study to be published in an upcoming issue of the journal Radiology.

Researchers said the findings underscore the need for collaboration among medical professionals to ensure that pediatric CAT scans are appropriately ordered, performed and interpreted. The study's lead author, Dr. David Larson, M.D. said, " We need to think creatively about how radiologists, ordering clinicians and CT manufacturers can partner together to ensure all children are scanned only when it's appropriate and with appropriate techniques."

Advancements in CT technology like helical scanning have made it a vital tool for upper diagnostic evaluation of children in the emergency department. Decreased scan times are especially helpful in eliminating the need for sedation in many pediatric cases. However, the relatively higher radiation doses associated with these CAT scans compared to most other imaging exams have raised concerns over an increase in risk associated with ionizing radiation.

A child's organs are more sensitive to the effects of radiation than those of an adult and they have a longer remaining life expectancy in which cancer may potentially form. In addition to current prevalence of CT, make it more likely children will receive a higher cumulative lifetime dose of medically related radiation than those who are currently adults.

13:07

To study utilization trends in children, Dr. Larson and colleagues analyzed National Hospital Ambulatory Medical Care Survey data from 1995-2008. The number of pediatric emergency department visits that included a CT examination increased five-fold over the study period from roughly 330,000 to 1.65 million with a compound annual growth rate of 14.3%. The leading medical conditions among those receiving CT scans include head injuries, abdominal pain and headache.

The rate of imaging for abdominal pain increased the most owing to improvements in the technology. "We found abdominal CT imaging went from almost never being used in 1995 to being used in 15-21% of all radiology visits in the last four years of the study," Dr. Larson said. In 1995, abdominal CT took much longer, the resolution was not as good and the research hadn't been done to support it.

By 2008, helical scanning had helped make CT very useful for abdominal imaging. It's widely available, it's fast and there are a lot of great reasons to do it, but it does carry a higher radiation dose. Dr. Larson pointed out that abdominal CT's effective dose of radiation is up to seven times that of a head CT, which means kids aren't only getting more scans, they're also getting much bigger doses of radiation each time they slide into the machine.

Non-pediatric focused emergency departments made up 89.4% of emergency department visits associated with CAT scans in children and increased from 316,000 annual examinations to 1.4 million per year over the study period. Dr. Larson noted most of the radiologists who oversaw and interpreted these studies were adult radiologists not subspecialty-trained in pediatric radiology.

He says, "The performance of CT scans in children requires special oversight, especially in regards to the selection of size-based CT scan parameters and sedation techniques. It's important to consistently tailor CAT scanning to the body size of the pediatric patient."

15:13

OK. So what's the bottom line here? Well, there are several bottom lines really. First, kids are getting many, many, many more CAT scans in emergency departments across the country than they used to. And in many cases, each exam results in bigger doses of radiation than the scans of the past. Not because the machines let out more, it's just the type of scans that we're doing, abdominal and the helical ones, they do have more of a radiation exposure associated with them.

These newer scans look better, they're easier to interpret and they provide more reliable information, but the cost of that information is a lot more radiation exposure for our kids. So how would that affect cancer rate as today's kids grow up? And time will tell. Does that mean parents and doctors should avoid CT scan in kids? Of course not. There are many instances when a CAT scan can save a child's life or improve the quality of life by revealing the unknown. But, as is so common in medicine as well as in other areas of our lives, we have to looks at risk versus benefit. Is the benefit of information worth the risk of radiation exposure and that's something that has to be decided on a case by case basis.

And I think that this is also a big take home for parents. If you find yourself talking to a physician who is recommending that your child has a CT scan, simply ask the doctor if the benefit of the scan is worth the risk of radiation and they will take a step back if you ask them that. Seriously, if the doctor is saying hey, I think we need a CAT scan, don't argue with them. Just say hey, is the benefit of the scan worth the risk of radiation and it very well may be. And if it is your doctor should be able to educate you on his thought process.

Unfortunately, many doctors don't give it much thought. I mean, CAT scans are easy to order and they are chockful of information. They can rule out skull fractures and brain bleeds if your child has a head injury. They can rule out appendicitis, they can find tumors and masses. They're great except for the fact they expose your child to large doses of ionizing radiation.

17:15

Now, if you're an ER doc, especially if you're an adult ER doc and you don't want to miss a skull fracture or a brain bleed or an appendicitis in the kid, I mean do that and you're the next feeding frenzy for the friendly neighborhood lawyers. So you get the scan, you rule out the badness, you discharge the child. But that scenario is happening with decreasing frequency in pediatric emergency departments as we begin to understand who ultimately suffer for haphazard use of CAT scans.

So we're going back, hopefully, to using our clinical skills and expectantly observing the children with whom we have a low index of suspicion for having skull fractures and brain bleeds and appendicitis. And we're looking for alternatives like evaluating the appendix with ultrasound when the equipment and expertise for doing so are available.

Could we get too lax and have some kids fall through the cracks? Yes, it's possible. So this is a balancing game we play. We want to do no harm, we don't want to harm now and we don't want them to be harmed years from now. And certainly, many, many kids really do need CAT scans but at the same time there are many kids who currently get them that didn't really need them.

Dr. Larson says radiologists, ordering clinicians and CT equipment manufacturers need to partner together to improve outcomes, but really he forgot about an important partner and that's you, the parent. You may actually be the voice of reason to the ER doc when you simply ask, hey, does the risk versus benefit play out here? If they give you a compelling reason for the scan, I say go for it. But you just might be surprised at the number of doctors who say, you know what, let's hold off and just watch little Suzy or Jimmy for a few hours and see how their symptoms play out before we order the CAT scan.

And yes that means tying up a room for observation, it might mean slowing the flow through the department, it might mean having to argue in admission to the insurance company, but you know what, it's high time that we stop letting administrators and insurance companies and lawyers dictate how we practice medicine. OK. Now maybe we don't say those words all the time, but I guarantee you that there are thousands of doctors out there thinking them.

19:21

All right. Moving from CAT scans to walking on water. This story is about a dangerous new past-time – water-walking balls. They look like giant hamster toys, you get inside, they seal you in and off you go walking on the water. They are all the rage at resorts hotels and athletic clubs, but once inside you'll discover something very disturbing – there's no way out. Your only hope of rescue is someone on the outside opening the ball for you, which means that the risk of injury or even death if there is an accident or emergency is unacceptably high. And that's some warning from the U.S. Consumer Product Safety Commission.

The large transparent floating spheres have recently come out of the water with many venues allowing guests to walk and roll across the grass or ice and concrete. They become popular at shopping malls, amusement parks, sporting events, county fairs and carnivals and children love them. You can even buy one for your family. But please don't.

The authors of a new Consumer Product Safety Commission report explained that individuals with breathing problems, heart or lung disease and other pre-existing medical conditions can have seriously worsening symptoms when inside one of these balls. Some states are now refusing to provide permits while others are banning them altogether. The report mentions an incident in which a child was unresponsive and in need of emergency medical treatment while inside one of these products.

Another child used the ball on a shallow above ground swimming pool, the ball fell out of it onto hard ground and the child suffered a fracture. The Consumer Product Safety Commission warns the following risks are associate with these water and ground-walking balls: suffocation, the ball is air-tight as the person inside breathes oxygen levels drop and carbon dioxide rises, within many minutes air quality can start to pose a serious danger; drowning, if the ball is on water and has a leak or puncture it can fill up with water and there's no way for the person to get out without outside help; impact injury, the balls have no padding and if they collide with each other or had a stationary object or roll on into the street, well you can imagine it's a whole lot of bad news.

The Consumer Product Safety Commission is attempting to educate state officials across the country not to issue permits or allow the sale of walking balls in their state because they believe there is no safe way of using them.

So I'd say that story pretty much speaks for itself. Let's take a break and we're going to answer your questions right after this.

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22:32

All right. First up on our Listeners Segment is Leslie from South Carolina. She says, "I can't find the search function for past episodes. My husband wants to hear specific information for himself instead of listening to me, but I have no idea what episode it was." Thanks for noticing and bringing this issue to everyone's attention, Leslie. This is actually a bit of a sore spot for me. We had a search page at pediacast.org and we dropped it with the latest build of the site because I really wasn't happy with the way it was working. And we are building a new and improved search capability but it's not quite ready for prime time.

So in the mean time, how can you find what you want? Well, in a couple of ways, there is a tag cloud on the Show Notes page. So if you go to the Show Notes and in the left hand margin there, the left side bar, there is a tag cloud so you can look up topics that way. The only issue there is the tag cloud only goes back about 25 episodes, so we still need to go back into the archive and put the right tags for the episodes. But that's one way you can get some of our more recent shows.

The other way is just to do a Google search. If you type PediaCast and then your search term or do your search term and type pediacast.org and it'll get you there. You'll be able to find out. And onsite search will be returning soon, so keep your eyes open for that.

23:58

All right. Moving on the Jenny and her location is her BlackBerry, I think she just didn't want to say where she was from. And this is the steamy one here that I alluded to in the intro. Jenny says, "Dr. Mike, in a recent episode you stated that breastfeeding was safe for HIV-positive women as long as they are on medication. As an OB and NICU nurse, I was horrified to hear this advice. We never allow positive moms to breastfeed and even women on meds can have measurable viral loads. Can you please explain this or provide your sources? I have never heard this before. Thanks, Jenny B.

Well, thanks for taking the time to write and voice your concern, Jenny. I think horrified is a bit strong but I do understand your concern. Let me start just by putting your question into context. This was in episode 157 and during our Research Round-Up we examined the study that looked into Google's ability to provide accurate answers to medical questions. And the study looked at five specific questions that parents might google and then looked at the top search results to see what categories of sites had the highest percentage of accuracy.

Incidentally, they found that government sites were the most accurate with giving 100% of the time correct answers, followed by educational sites, corporate sites, interest group and individual websites, which were right about 80% of the time and then the new sites and sponsored sites were the least accurate. But we won't go into the details of that study again. If you're interested, just check out PediaCast #157.

25:35

OK. So one of the five questions that the researchers asked Google was should HIV-positive women breastfeed? And when all the results were examined only 35% of them gave what they considered to be the correct answer. And according to the researchers the correct answer was no, HIV-positive women should not breastfeed.

Now, my focus on this study was the Google issue and specifically how well does the search engine provide accurate answers to medical questions. And at the very end of my analysis of the study, I just gave a quick run down of the correct answers and I mentioned that HIV positive women could breastfeed if they were on antiretroviral drugs and this is the comment that horrified Jenny. And many of you may be asking yourself, wait a minute, he just said that the researchers wanted Google to say no, HIV positive women shouldn't breastfeed but now he says they can if they're on antiretroviral drugs.

OK. So let me explain. The Google study was published in April of 2010 and at that time the commonly accepted answer really even worldwide was no, HIV positive women should not breastfeed. But since the Google study was published, another study came to light two months later in June 2010 and it was a study that was published in the New England Journal of Medicine and it concluded that the risk of transmission of HIV through breast milk is significantly reduced if women take antiretroviral medication or if the infant is taking a drug called Viramune throughout the breastfeeding period.

Now let's take a step back. The risk of HIV transmission is reduced according to the study, it's not eliminated. So why do it? Why would an HIV-positive woman take that chance and breastfeed? Why? And here's where my issue came in. I was really speaking on a global level and not at the United States of America. And I think what you to remember when we go back to risk versus benefit is that in many countries of the world and in fact, for probably a majority of the world's population, you could argue, commercially prepared infant formula is not available or is substandard. And this is particularly a problem in Africa, which is you know has a very high percentage of HIV-positive mothers.

28:02

Many women in Africa are afraid to breastfeed for fear of transmitting HIV to their infants so they use powdered formula instead. Well unfortunately, there's not a lot of it available, there aren't quality standards or regulations placed on the powder. And the shady companies out to make a quick buck market their product to consumers. These baby formulas are not the same as infant formulas we know in the West. They don't always provide the right mix of fats, proteins, vitamins and electrolytes. Some powders are distributed without directions and many, many mothers are illiterate and can't read what the directions say anyway.

And here's the biggest problem of all, the formula is often reconstituted with contaminated water. It's also often over-diluted because the people are poor and they need to make the powder last longer. And then they use that same contaminated water to wash their bottles, if they have bottles. So actually the death toll from malnutrition, infection and diarrhea causing dehydration is higher than the transmission rate of HIV from mother to infant when mother is on antiretroviral drug.

29:11

So we look again at the risk versus benefit, if you significantly reduce a breastfeeding mother's chance of transmitting HIV by using antiretroviral drugs then the risk of breastfeeding is that better than the alternative. Well, the World Health Organization believes that it is and they released a bulletin recently that states "Breast is best even for HIV-positive mothers". And in that bulletin they backed up their advice with several well-done studies by respected institutions that show the transmission rate of HIV from mothers to babies when using certain HIV drugs can be as low as 1.8% which is far below the mortality rate of kids who succumb to infant formula problems such as disease and dehydration.

OK. So now at least in my mind two more question are raised. What is the availability of antiretroviral drugs in Africa? I mean, if they don't have clean safe water are they really going to have fancy drugs? And the answer to that question is yes, they do have access to those drugs and not clean water, just a bit ironic. But through the tremendous effort of UNICEF and the World Health Organization about 80% of HIV-infected people in Africa have access to antiretroviral medications and their goal is 100% coverage in the next couple of years with the desire to halt and actually reverse the spread of HIV by 2015

Now, as for drinking water, nearly 1 billion people that's half the population of the entire African continent do not have access to clean safe water. So what does this all mean to you the listener. Well, for those of us blessed to be born in the developed world quality infant formula and clean safe water is readily available, the risk of HIV transmission from formula is 0%, which is less than 1.8% from breast milk of HIV-positive mothers taking antiretroviral drugs.

So when you look at risk versus benefit, Jenny's patients on the OB floor and then the NICU, sure, infant formula is the way to go. But not everyone lives in Jenny's world. And for millions and millions of babies whose lives are far different from our own, breast milk really is best even if your mom is infected with HIV as long as the mom is on the right medication.

31:33

So why didn't I run through this whole thought process in episode 157? Because we were talking about Google and I know I have to watch myself when I make statements and sometimes they do need more explanation and I do see how my comment could be misleading since the bulk of my listeners are in the developed world and for that I apologize.

All right. Jenny, you wanted me to explain and provide sources. I think I've done a fine job of explaining, so all that's left are the sources, so you can check out the Show Notes, there's a link to the World Health Organization's bulletin on HIV and breastfeeding. And I also have a link to the research study in the New England Journal of Medicine showing a reduction of HIV transmission for breastfed mothers on the right medication. I also have a link to the CDC's current stance on breastfeeding and HIV. And I also have a link to the American Academy of Pediatrics Policy Statement on breastfeeding and the use of human milk, which does touch upon the HIV question.

But keep in mind that was last revised in 2005, so it doesn't necessarily include the most up-to-date information. OK. So just to recap, women who have HIV should not breastfeed if they have access to quality formula and clean safe water. But if you are listening to this podcast in Africa, which we do have listeners in Africa, if you're listening in Africa and you do not have clean safe water and you do not have access to quality formula that you're using correctly, then you want to make sure that you're on antiretroviral medications, which help kill the virus that causes HIV and then breastfeeding may be the better way to go. So just all these things to think about.

33:22

Let's move on. Tammy in Indiana says, "Hello! I'm so glad you're back. I found your podcast just when you stopped production previously and I was overjoyed when iTunes showed a new show again. My daughter is three and needs to have a tooth removed. She bumped it over a year ago which killed the nerve. It was not infected at the time so we were advised to leave it be. Well, now it is infected and it needs to come out. A few things are troubling me, she will be sedated for a short time, her appointment will around six in the morning and we are not allowed to be with her when she is put under or when she is waking up a few minutes later. My dentist recommends talking about it as little as possible. My daughter is very inquisitive and I know she'll have questions. Do you have any advice for making this as smooth and untraumatizing as possible? Thank you. – Tammy from Indiana."

Thanks for your question, Tammy. First, let me say I disagree in principle with your dentist's approach to family presence. In general, parents want to be with their kids as much as possible even during procedures. And when my daughter had tooth pulled at around the same age, our pediatric dentist allowed us to be with her actually throughout the entire procedure – when she went out, when the tooth was pulled and when she woke up.

Now, I realized some parents don't want to be there and that's fine. But if moms and dads want to be with their kids outside the sterile and rigorously controlled confines of an actual operating room, personally, I think they should be allowed. Now having said that, even though I disagree with your dentist on principle, I respect his policy and if he is otherwise a good and trusting dentist this wouldn't necessarily be a deal breaker for me.

So what do you do with regard to preparing your child? Well, I wouldn't bring it up unless she does. And so I think your dentist's advice on talking to her about it as little as possible is good advice. That morning you can bring it up when she wants to know where you're going, but I wouldn't stoke the fire without it being necessary to do so.

Now, if she does ask, I would be truthful. I wouldn't necessarily offer more information beyond what she requests and if she's a very smart cookie and she figures out where you're going in a few days and she pointblank asks, hey, are you going to be with me the entire time? Then what would I do, well, I wouldn't lie. You can say I'll be right down the hall, only doctors and dentists are allowed in the back. But I would stress that they're nice; they're going to take good care of you; they're going to help your tooth not hurt anymore.

I mean, all the reassurances that you can pour on her, I would pour on her, but I wouldn't lie because then you break a very important trust. And it's a trust that I think is worth more than avoiding a brief stint of anxiety. So, while I would avoid the topic as much as possible, I would still answer any questions that she asked honestly, but with lots of reassurance. So I hope that helps, Tammy.

36:17

Lindsay in Houston says, "Hi, Dr. Mike. I wasn't able to find a tag for sunscreen in your Show Notes and I've got a question about that." OK. Thanks Lindsay for pointing out that the tag system doesn't always work. "It takes a good amount of time to slather three kids up with sunscreen and it's time for the Splash Pads to open down here in Houston." And thanks for pointing that out too. It's not quite warm enough here in Ohio but in Houston you're enjoying the pools. Lovely. "In the past year, I've applied a thick coat of Banana Boat cream to my kids before we left the house but I have to admit I've wondered about the spray sunscreen. It would be so much faster. I suspect many pediatricians would answer the best sunscreen is the kind you'll use and I understand that. But for a long day at the Splash Pad or at the beach, I want to use what's truly best. Is the spray-on kind as effective as something you rub into the skin? Do the manufacturers have to compromise something in order to get it into spray form? And don't sunscreens protect both UVA and UVB rays while others don't protect against both? Anyway, just looking for a shortcut if the shortcut is of equal quality to the original. I'm a little skeptical that it could be but thought it was worth asking. Thanks Dr. Mike." – Lindsay

Thank you Lindsay. I disagree on your assumption of what many pediatricians would say. I think all pediatricians would agree with what you are saying that the best sunscreen is one that works and prevents burns and skin cancer. It's not the one that you'll use, it's the one that works and I think most pediatricians would agree with that because it's no good to use a substandard product where your kids going to get burnt anyway and you have a false sense of security.

So the question becomes are spray sunscreens as effective as their rub-in lotion counterparts. I was excited about researching this question. I was hopeful that I'd find randomized controlled prospective study, this sort of thing – you take 1,500 kids, let's say between the ages of eight and twelve, you have them be active, play outside in the sun, those kinds of kids. Kids who are going to be out in the sun and you take an equal number of boys and girls and we'll them all fair skin Caucasian for this study to minimize the variable of skin pigmentation and we'll randomize those kids into three groups.

38:56

Group one gets a standardized application of a rub it in sunscreen lotion with an SPF of 50. Group two gets a standardized of spray it on sunscreen with the same SPF and group three, our control, gets no sunscreen at all. Now we're going to bake all those kids under a midday sun with no access to water because we don't want to introduce the variable of water taking off the sunscreen. We'll check the kids for evidence of sunburn every 30 minutes. Oh wait, you might not see the sunburn right away. So we'll have to leave them all in the sun, still no water on the skin for a specified period of time, let's say three hours. Then we'll wait six more hours for the skin damage to show up and then we'll check all the kids for burns and see how many in each group have no burns, how many in each group have first-degree burns and how many in each group blistered with second-degree burns and finally we'll see if there is a statistically significant difference between the three groups. Does that sound good?

Now, would you enroll your child in that study? Of course not. And herein lies some of the difficulty of pediatric research. I mean, you might find some college students willing to participate in that sort of a study for some extra spending cash. But no parent in their right mind is going to stand for it and if they do stand for it, that they do stand for the fact that their child could be randomized to the no-protection control group, then I think Child Protective Services would probably get involved sooner rather than later.

So as it turns out there are no studies in kids or adults, for that matter, looking at the effectiveness of lotions versus spray-on sunscreen. And retrospective studies in this case aren't really going to be all that useful either. I mean, sure you can take kids with sunburn who present for medical care and say hey, what kind of sunscreen had you used? But you'd have to find a way to reliably rely on their memory to tell you how much they applied; what technique they used; how much time did they spend in the water; how much sun exposure had they had on the days preceding the burn and so on and so on and so on.

40:58

So, have I beat this into the ground enough? It's a difficult thing to study. Here's what we do know, UVA and UVB exposure is dangerous and we do talk about this in PediaCast #127 and I'll put a link to that in the Show Notes. Again our tags begin with episode 135 or so. We do need to go back and tag this stuff in the archive, I know, and we need a better search option, I know. Listen folks, it takes time to put these shows together. And at least we have new content now week after week, right?

OK. So where was I? UVA and UVB, yes, you want to protect against both and the higher the SPF the better. And again SPF stands for sun protection factor and it's a number that tells you how many times longer it takes for your skin to burn with the product applied compared to the length of time without the product. And again, the poor people who were involved in this research study.

So if it normally takes your skin 10 minutes to burn, it would take 20 minutes to burn if you use an SPF of 2. It would take 100 minutes to burn if you use an SPF of 10; 200 minutes if you use an SPF of 20 and 500 minutes if you use an SPF of 50. Now this assumes correct coverage, you use enough of it on all the exposed skin and its durability, how old does it stay on and if you don't put enough on or the product comes off because of swimming, sweating, your clothes coming on and off, then you aren't going to get the full length of protection.

42:27

So what type of application ensures that enough goes on and that all areas get covered? Well, I think it could be accomplished with both lotion and the spray, but if you're going to use the spray you need to use a lot of it so that you get the proper amount on the skin and you need to rub it in to be sure that all areas get covered.

Now, the label, if you look at these spray-on sunscreen, the label says, "Apply generously and evenly to all exposed areas." Now how do you apply a spray generously and evenly? Of course you also need to reapply it as needed after towel drying, swimming, perspiring, rigorous activity, that sort of thing. But how do you apply an even and generous amount when you first put it on and with each reapplication what's difficult. And if you're doing it right it's probably going to take you just as long and be just as messy as lotion because you need to put a lot of it on and you need to rub it in.

So my vote is just stick with the lotion. And in the end, Lindsay, you knew that was going to be the answer, didn't you? You were hoping for the shortcut but you knew there wasn't really a shortcut coming. Thanks for the question though. We always appreciate it.

43:41

And finally, we have Heather in Munster, Indiana. She says, "I have a three-year old son who has gotten what I can only describe as a head freeze a few times after consuming ice cream and other really cold items. I usually try to make sure he's consuming cold items slowly but as he gets older I can't watch him all the time. When it happens, he goes limp and his eyes rolls back in his head. He seems disoriented afterward. Fortunately, he has not gotten hurt but I am not sure if I should be more concerned and bring it to the attention of his doctor or just continue to use caution with cold items. His father also has issues with head freeze but his twin brother and I do not."

Thanks for writing in, Heather. First, absolutely, you should bring this to the attention of your doctor. In fact, any time you're concerned about anything, you should talk to your doctor in person, in the exam room with the history and physical. We don't practice medicine here. And really in a case like this I would have a bunch more questions for you that I'd want to know and I would definitely want to take a look and listen to your son to figure out what's going on because your eyes rolling back in your head and passing out and becoming limp and then seeming disoriented afterward is not the kind of head freeze that we have in our family.

Now, that's not to say that it's something serious and life threatening, it may not be. But it is something though that I think you do want to see your doctor about. So I can't give you medical advice on what's causing your son to do this. But what we can do is talk about a couple of cold-related phenomena, not to say these are whether affecting your son but they are possible results of eating something cold. And not to say they're the results of your particular child, Heather, but your question reminds me of a couple interesting things to talk about, let's put it that way.

45:34

We've all experienced what we in our family like to call an ice cream headache. We don't call the head freeze, I know some people do. Ice cream headache in our house. You take a big bite of something cold and you get a stabbing sensation in the middle of your face, which goes away a few minutes after you swallowed the cold food. Now, some in our family think they've figured out a trick. They press their thumbs up on the roof of their mouth and the headache seems to go away faster.

I'm not convinced that it actually works. In fact, I'd like to see a randomized controlled prospective study on the hypothesis, but that's another discussion altogether, one we already had earlier today about studies. Now, you'll notice Heather that our ice cream headaches again, don't really sound like your child's symptoms. It's just a brief stabbing faceache that last about 20 seconds or so. There's no eyes rolling back or passing out.

So what causes an ice cream headache? Well, here we do have some published research, thanks to the British Medical Journal and Scientific American. And here's what we know happens – very cold food such as ice cream and Popsicles have the ability to change the temperature of the roof of the mouth, also known as the palate, and this area is innervated by the 5th cranial nerve known as the trigeminal nerve.

So there's a nerve that is responsible for sensing the temperature of the roof of your mouth and that nerve is called the trigeminal nerve. Now, in response to this rapid change in temperature, becoming very cold, the trigeminal nerve sends a flurry of electrical impulses to the brain. But the brain interprets those signals as coming from other structures that are served by that same nerve mainly the skin of the face, eyelids and forehead. So this nerve just starts rapidly sending impulses and the brain thinks that you have a horrific face and head injury because of all the activity that's coming in from the trigeminal nerve.

47:36

So that's what the brain thinks that you just had horrible trauma to your face and because that's what your brain thinks that's what you feel and it's a phenomenon called referred pain. This is also why you have arm numbness and tingling when you have a heart attack. There's nothing wrong with your arm, your brain is just getting impulses from the heart but its impulses that doesn't typically get from the heart but it is impulses that typically gets from your arm, so your brain interprets it as coming from your arm and you feel numbness and tingling in your arm which is really associated with a heart attack.

It's also why inflamed throats when you have strep throat it can cause your ear to hurt, even though the doctor looks in your ears and they're fine. And it's why sometimes with the ear infections we look in the ear and they have an infection but they came in complaining of a sore throat. They may have mucous and draining or a virus that's also infecting their throat, but sometimes there's nothing but an ear infection or even a swimmer's ear and they can have some throat pain associated with that. And again it's referred pain. The brain is having some trouble figuring out where the impulses are coming from and so interprets it as coming from some place different and so you feel pain in that some place different place.

Now, after a few seconds the roof of the mouth warms, the trigeminal nerve stops firing and the pain goes away. So I suppose that pressing the roof of your mouth with your thumbs might warm you palate faster and make the pain resolve more quickly. It's possible. Don't tell my family because it's kind of fun to tease them about how silly they look with their thumbs in their mouth.

49:12

OK. So what about Heather's son? Eyes rolling back and passing out from the cold. Well, there are many things that can cause those kinds of symptoms ranging from seizures to heart problems and brain problems. Now, I wouldn't think that those things would only be brought on by cold but kids don't always follow rule books so you definitely want to talk to your doctor about it. Now having said that there is another nerve that when stimulated can produce those symptoms that Heather is describing and that is cranial nerve number 10, also known as the vagus nerve, not Vegas as in casino town, but vagus, v-a-g-u-s. And a certain stimuli cause this nerve to fire in a particular way that gets the attention of the brain stem and the brain stem responds by activating the parasympathetic nervous system and deactivating the sympathetic nervous system.

Now, that's a lot of medical jargon but the bottom line is this, when the vagus nerve fires in a certain way, your heart rate drops and the force of heart contractions lessen so that overall blood flow is reduced and in addition, smooth muscle in blood vessels relax and the blood vessels dilate. So what happens then if you have a decrease on heart rate, a decrease in how forceful your heart pumps and a decrease in smooth muscles tension in the blood vessels? Those three things are going to act together to decrease your blood pressure and then blood flow to the brain is reduced, which means that oxygen delivery to the brain is reduced and that results on you getting faint, perhaps dizzy and passing out. And this is what we call a vasovagal episode.

50:55

Fortunately, these are short lived and are rarely dangerous but they can be confused with other serious and even life threatening conditions. So that's vasovagal episodes are not something you want to diagnose yourself at based on the information you heard on a podcast. That's not a good idea. So see your doctor, Heather. Let him ask more questions and take a look and listen and give you his opinion.

But going on vasovagal episodes, what sort of stimulation can cause these? Well, the list is a long one – prolonged standing, especially if you're overheated, this is the reason the choirboys sometimes go down to the ground; sudden onset of extreme emotion like passing out when you get great news or bad news; stressful situations like public speaking, seeing a spider, the site of blood; abdominal strain or bearing down and this is why some people pass out and fall off the toilet, it does happen; intense laughter can cause these and that's why the phrase 'he died of laughter' or 'that killed me' comes in; severe pain or trauma can make you pass out and these are all vasovagal-mediated episodes of unconsciousness.

And here is an interesting one, cold exposure of 10-degree Celsius or below to the central face. The vagus nerve isn't in the business of sensory perception on the face, that's the domain, as we mentioned before, of the trigeminal nerve. So if you touch the central face with your finger you just activated your trigeminal nerve and actually if you touch your central face with something cold you still feel that with the trigeminal nerve.

But the vagus nerve is also stimulate when cold touches the central face and that results in an interesting thing called the mammalian diving reflex, which is a vasovagal-mediated thing. This is a reflex that allows aquatic mammals to stay underwater for long periods of time by slowing down their heart rate and actually constricting the peripheral blood vessels, so those in the extremities and closer to the surface, so that blood is diverted to the heart and brain. So oxygen is conserved because muscles in skin isn't using the oxygen so there's more oxygen available for the heart and the brain while the animal is underwater.

And in aquatic animals these peripheral areas account for 30% of oxygen use, so by cutting them off the brain and heart can survive longer without the lungs bringing in a fresh supply of oxygen. Now, humans aren't as efficient. The diving reflex in humans typically yields less than a 10% drop on oxygen use which isn't too helpful to the brain and heart. The exception though is young children who have a stronger mammalian diving reflex and they can sometimes divert a much higher percentage of oxygen to the heart and brain, which is why some children survive prolong periods of submersion in icy water. Not all young kids, of course, but some, which is why you hear stories of some kids surviving prolong cold water submersion.

54:00

OK. So it's interesting stuff, to me anyway. Here's another interesting fact, the vasovagal response can be medically helpful at times. Sometimes kids have a condition called SVT or supraventricular tachycardia where their heart is beating way too fast like over 200 beats per minute. And again, don't try this at home, but one of the ways that doctors can get a child out of SVT is by putting an ice bag on their face. And by putting an ice bag on their face, they elicit the mammalian diving reflex, which is vasovagal-mediated and remember one of the things it does is drop your heart rate and so you can take someone out of SVT by inducing a vasovagal response.

All right. Enough of the medical trivia. Bottom line here, Heather, be sure to take your son and let your doctor examine him to be sure there's not something more going on, that's important.

All right. Lots of great comments and questions today. Remember if you'd like to add to the show, it's an easy thing to do, just go to the Contact page at pediacast.org. You can also email pediacast@gmail.com or call our voice line and leave a message at 347-404-KIDS.

We're going to take a quick break and we'll be back with our Research Round-Up, right after this.

55:47

All right. We are back with our Research Round-Up and we're going to talk about treatment of acute otitis media in children under the age of two and this comes out of the University of Pittsburgh and was published in the New England Journal of Medicine just this past January 2011.

The question before the researchers, does antibiotic treatment for otitis media improve signs and symptoms in children who are 6 months to 23 months of age? They used a randomized double-blind study to look at this.

Now let me give you a little bit of background, many physicians have sort of established a 'watch and wait' philosophy in the treatment of acute otitis media, especially in children over the age of two, because many of these ear infections are viral-mediated, they're caused by viruses, so the antibiotic is not going to help anyway and ones that are bacterial are often self-limiting, meaning they go away on their own without needing antibiotics to treat. And also overtreatment with antibiotics contributes to the rise of drug-resistant organisms.

So the focus on these older kids is really more on pain control and reserving antibiotic use for complicated and what we'd call refractory cases that just aren't going away or really toxic-looking kids, high fevers and vomiting and you're worried about it becoming a blood infection. Now, could this same philosophy apply to infants 6 months to 23 months of age?

57:12

So what the researchers did they recruited children from 2006-2009 and all the participating children had received two doses of pneumococcal conjugate vaccine. That's important because the pneumococcal vaccine kills strep pneumonia or the organism and strep pneumonia is a common cause of otitis media or ear infections in children. If you're doing a study and you divided them randomly into two groups, but as it turns out one group they all had the pneumococcal vaccine and the other group didn't, then you're going to introduce a variable that's in addition to the variable that you're testing.

In this case, they wanted to make sure that all participating children had received two doses of the vaccine so that wasn't a complicating variable in the outcome of the study. What was required the diagnosis of acute otitis media for all of these kids was a score of three or greater on the acute otitis media severity of symptoms scale, onset of symptoms in the past 48 hours, presence of a middle ear effusion (fluid behind the eardrum) and a bulging eardrum with pain on exam and/or marked erythema, which means redness.

These kids had to have a bulging eardrum that was red or painful, fluid behind it, these symptoms had to have started in the past 48 hours and the symptoms had to be severe enough to warrant a three or greater on the acute otitis media severity of symptoms scale. I love saying that. Excluded children, these are the children they said no, you can't be a part of our study, comorbidity that means they had another acute or chronic illness along with the ear infection; allergy to amoxicillin – because that's the drug they're going to use or the drug they're going to use contains amoxicillin; antibiotic use of any kind during the previous four days; or a perforated tympanic membrane, so if their eardrum had a little hole in it and fluid and puss was leaking out, which many of you parents know what I'm talking about; those kids were excluded from the study.

59:24

So they enrolled 1,385 children (Great number! Good, good sample size.) and they randomly assigned them to one of two groups – treatment versus no treatment. The treatment group was treated with amoxicillin-clavulanate, which is Augmentin, is the brand name of that drug. Most people get the generic form now but I just mentioned the drug name because most parents have heard of Augmentin. So this is the drug they used to treat. They used a standardized dose of 90mg/kg per day based on the amoxicillin content and divided that up into two doses each day for 10 days.

The no treatment group received a placebo with a similar appearance and taste using the same volume, dosing schedule and length of treatment time. So it's really difficult for parents to know whether they were in the test group or in the control group.

By the way, I just want to mention, really I want to give kudos to the parents who participated in this study. I mean, you have a nine-month old, let's say, who has an ear infection and you're agreeing to the possibility that your child will not be treated even when the standard of care is to treat a child of that age with the known ear infection. So kudos to the parents who did this. It's not to harm your child, the sunscreen thing yeah, no kudos there. But this one the shout out to the parents.

OK. So what did they do? They assessed symptoms by phone each day until the first follow-up visit and then they assess symptoms in person during each follow-up visit, thereafter. And ear examinations were performed at each follow-up visit.

So when did these visits take place? Well, the first one was on day four or five of therapy on the antibiotic. The second follow-up visit was at the end of therapy on day 10 through 12, one of those days. And finally, they had a long-term follow-up on somewhere between day 21 and 25. And at each visit, each child was labeled as a clinical success or a clinical failure.

61:31

They were considered to be failure at the four to five-day follow-up if they had lack of substantial symptom improvement and/or worsening exam. So if the eardrum was looking worse at four or five days then that was a failure and if they weren't substantially getting better in terms of their symptoms then that was a failure.

Failure at the 10 to 12-day follow-up was defined by lack of complete resolution of all symptoms and any abnormality on the ear exam, except for the persistence of a little fluid behind the eardrum. So if they had a persistent middle ear effusion but it's not bulging, it's not red and there are no symptoms then that was still considered to be success. But if they had any symptoms at all or if there is anything other than a little fluid behind the eardrum then it was a failure at the 10 to 12-day mark.

OK. So what did they find? Resolution of symptoms by day 2 in the treatment group – 35%; in the placebo group – 28%, which was not statistically significant. Resolution of symptoms by day 4 in the treatment group – 61%; in the placebo group – 54%, not statistically significant. Resolution of symptoms by day 7, 80% in the treatment group, 74% in the placebo group, again not statistically significant.

62:55

Persistence of abnormalities on the ear exam at the four to five-day follow-up, treatment group – 4%; placebo group – 23%, so this was statistically significant. So the symptoms were still there but the ear looked better at the four to five-day follow-up.

Persistence at the 10 to 12-day follow-up, persistence of an abnormal-looking exam, treatment group – 16%; placebo group – 51%, which again was statistically significant. Other observations, one child in the placebo group developed mastoititis, which is a bone infection that can be a complication of acute otitis media. And adverse drug effect such as bellyache, vomiting, diarrhea, allergic reactions were of course increased in the treatment group when compared to the placebo group.

So the authors concluded that in children 6 to 23 months of age with acute otitis media, treatment with amoxicillin-clavulanate for 10 days reduced the burden of symptoms and the persistence of otoscopic signs of acute infection. For the authors to conclude that, they said treatment reduced the burden of symptoms and yes it did, the burden of symptoms when you look at day 2 the treatment group was 35%, the placebo group 28%; day 4, 61% versus 54%; day 7, treatment group 80% had resolved; 74%.

64:22

So a higher percentage of the treatment group did have resolution of symptoms, but those differences were not statistically significant, meaning that those changes in percentages when you compare treatment group to placebo group could have just happened by chance.

I'm not really happy with the authors for their conclusion because their conclusion is not statistically significant. Now when you look at the ear exam then there is a statistically significant difference. So the ones who had the antibiotic their ear really did look better. So what does this all mean to you, the parent?

Well, a couple observations are in order. The first is, again, even though the authors tout a reduced burden of symptoms in their conclusion, this reduction in symptoms was not statistically significant. So the take home here in my opinion is that even when an antibiotic is used and there is evidence that the ear infection was there and it got better, your child's symptoms may persist even though the antibiotic is working. I think that's the real take home here. It's not the fact that the antibiotic didn't help the symptoms, it's the fact the antibiotic did help the disease but your child may still have symptoms even though the antibiotic is working.

And just to look at the numbers at the four to five-day follow-up 96% of the kids in the treatment group had an improved exam but 39% of them still had symptoms. So at four or five days out if your child still has symptoms it doesn't mean the antibiotic is not working. And how many people go back to the doctor at day 4 to 5 and say hey, it's not working; my kid's still is fussy and pulling on the ear and won't eat and is vomiting once a day.

So that doesn't necessarily mean antibiotic failure just because the symptoms are still there. So I think that's the take home. Then we always talk about risk versus benefit. What's the risk of not using an antibiotic in this age group? Well only one child developed mastoititis. So 1 child of 692 that's 0.1%, which is really low risk and no other complications were noted.

66:24

So bottom line for me and my practice of medicine, if I see a child in the 6 to 23-month range with a definite otitis media, it still makes sense to me to treat with an antibiotic because there's a statistically significant difference in the resolution of ear findings when you compare treatment versus non-treatment. And kids in that age group are at risk for recurrent otitis media, so when you find it you want to get rid of it.

However, if you aren't sure if a child has acute otitis media and I'll circle back around to that in a minute, but if you're not sure then watching and waiting may not be a bad idea in this age group since 74% of them have resolution of symptoms and 50% have resolution of exam findings without antibiotic treatment.

So that sort of how this study would impact my practice of medicine. As you know, when I'm sure, treat. If I'm not quite sure if it's an otitis media then maybe hold off in that age group. Now, what do I mean by saying if your doctor isn't sure if it's an ear infection? When I say if I'm not really sure if it's an ear infection, how can a pediatrician not be sure if your child has an ear infection?

Well here is a little secret, diagnosing ear infections in this age is not always an easy thing. Just ask any medical student about his percentage rate of having an attending agree with his exam findings when he looks in ears. Ear canals at this age are often very small, narrow, long, wax-filled. When you try to remove the wax in can cause bleeding and when babies cry and are upset, which is usually the case when they come in with an ear infection, their cheeks turn red and their eardrums turn red too just from their crying. And any pediatrician out there would agree with me that we aren't always 100% sure.

And in the past, when we're not 100% sure we have erred on the side of treating rather than not treating the kids in this age group. So I think more of us now are heading in the other direction in treating only when we know for sure it's an ear infection and doing more of a wait and see approach in the kids we're not quite sure.

68:27

What about kids less than six months of age? That's a different issue with a different set of problems and a different risk for not treating, which we won't go into now for lack of time. There is a link in the Show Notes to the research paper at PubMed. The actual research paper was called "Treatment of Acute Otitis Media in Children Under 2 Years of Age". So if you're interested in seeing the actual study, head over to pediacast.org and we'll have a link for you in the Show Notes.

All right. That wraps up our Research Round-Up and we are going to come back and wrap up the rest of the show, right after this.

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69:40

All right. Thanks go out to Nationwide Children's Hospital for being a large, large part of this program. In fact, this program is a part of Nationwide Children's Hospital. Also, Medical News Today, Vlad over at VladStudio who helps us out with our artwork, Wizard Media and of course listeners like you.

I want to remind you iTunes reviews, this is not self-promotion here folks. I mean how many of you found PediaCast because someone before you had taken the time five minutes to write a nice review? And we have only had a handful of reviews in the last couple of months. So if you have not written a review on iTunes, I would just encourage you to take five minutes of your time and do that. Again, it's not just self-promotion. Our mission really is to put a source of evidence-based pediatric medicine into the hands of parents and broken down into a way that they can understand. And that's really important to all of us here at Nationwide Children's.

We want parents to make educated decisions and educated decisions are based on evidence. And where do we get that evidence? From research, we really try to pick apart things and make decisions not based on stories or what we think might be happening, but what is the best way to practice based on the evidence that's out there. And we really want parents to become more in-tune and I think so many times parents just look at doctors as being in this ivory tower and they know all. But we don't know all and we're trying to figure it out and as more information becomes available we change how we practice. So we just want parents to be cognizant of that and to be educated.

71:25

Anyway, again it's not self-promotion. It's just we want everyone to know about PediaCast and be able to benefit from it if it's something that interests them. And of course pediatric medicine should interest you if you have children or you work with children or you like children.

So anyway, iTunes reviews are helpful. Also give us a shout out in Twitter, blogs, Facebook. We're on Facebook and Twitter now. I really do need to do more with those. We do have a blog at pediacast.org which I need to update. So we'll get to that. There are just too many things to do.

And the other thing too and I've mentioned this, I don't know if anyone's taken me up on this, but when you go in for well child checks and sick visits, just mention PediaCast to your doctor and let them know pediacast.org is the place to find and maybe they'll help spread the news amongst their patients as well.

Of course really important is your participation in the program. We just love getting the comments and the questions even when they are steamy, when you're upset or you don't like something I've said, hey, let me know that too; pediacast.org, you can click the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. 347-404-5437.

Thanks for taking the time out. I know that it's an over hour-long show and there are so many different things that you could spend that hour doing. I just want you to know that I really do appreciate you taking the time to spend an hour with the rest of us. So until next time, this is Dr. Mike saying stay safe, stay healthy and of course stay involved with your kids. So long everybody!

[Music]

Walking Balls, Spray-On Sunscreen, Head Freeze – PediaCast 159

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

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from BirdHouse Studios, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone and welcome to PediaCast. It is episode 159, 1-5-9 for April 13th 2011. And we're calling this one Walking Balls, Spray-On Sunscreen and Head Freeze. Have you seen these walking balls? Do you know what I'm talking about? These giant bubbles, just a big transparent sphere and you can climb inside and you can actually walk on water with them. I mean it sounds fun, but the big question is are they safe? And the answer to that may surprise you. Well actually since I'm doing it as a teaser it probably won't surprise you now. But anyway that's coming up in just a few minutes along with lots of other topics.

First, I want to say though, spring is really here. Just in the last couple of days the trees have bloomed and so even up here in the middle portion of the Midwest, I won't say upper Midwest but we're within a couple hours drive to Canada, so we are pretty north. And I know it's been warm for a while in the southern part of the country where I used to live and I know that because we've been getting people writing in warm weather type questions and in fact we're going to cover one of them in this episode about spray-on sunscreen. So I know that you're going to the beaches and you're going to the pools, it's not quite that warm here in Ohio yet. But I'm adjusting. We're from here originally so we're, I guess used to it. But I tell you it doesn't take being in Florida long, just a few years, and you get spoiled because spring comes so soon, so early.

02:27

They do have a winter though. So for those of you who kind of rolling your eyes and saying what do you mean? It's spring all the time, all winter-long. Yeah, it can get cold and for long periods of time, but we're not here to talk about the weather of Florida. We're here to talk about pediatric issues and we have a big line-up for you today. In the news section, we're going to talk about vaccine safety and in particular, who do parents trust when it comes to giving information about vaccines. I think this is an important news story not just for parents but for doctors too, because there's some reassurance with this story. So we'll get to that.

Also pediatric CAT scans. Are we doing too many of them and are they dangerous or are they helpful? How do you decide? So that's coming up. And then of course water walking balls, we'll discuss those. Breastfeeding and HIV, we have a clarification to make and that's coming up here in the Listeners' segment.

Also dental procedures and sedation questions and family presence. Should you be there when your child is having a dental procedure done? What if the doctor kicks you out and says you have to wait in the waiting room, how do you handle that?

And then sunscreen spray-on, is it better, worse, no difference than lotion? Head freeze. When you take a big bite of ice cream and you get that instant headache, someone wants to know what causes it and we're going to get in to the details – the science behind head freeze. Only here on PediaCast folks.

And then finally, we're going to round things up with a Research Round-Up on ear infection treatment in kids who are less than two years old. For a while now we've doing sort of the wait and see approach to ear infections, especially in older kids. You know, they have a little earache but aren't toxic. They don't have a high fever and vomiting and you go in to see your doctor and they say, you know it looks like a there's a little bit of an ear infection but why don't we just watch and wait? The question becomes what about in a six-month old, can you watch and wait in kids six months to 23 months of age? And there's a new research out that may help doctors decide what to do in that situation. So we'll cover that, I should say, in the Research Round-Up later on in the program.

04:44

Don't forget if you would like to get a hold of us here for a comment or a question or you just have some steam to get off your chest, it's easy to get a hold of us at pediacast.org, just go to the Contact link and you can write in. And I say that, you think who's writing in, who have steam to release and we did have one this week and we'll get to that when we get to the Listeners segment.

Also you can email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-5437. Before we go any further, I 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 a specific individual. 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 and you can find at pediacast.org.

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

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06:21

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 medicalnewstoday.com.

Most parents get their information about immunizations from their child's doctor, but many also turn to public health officials, other parents, friends and family members and even celebrities as sources of vaccine information – so say the results of a national survey conducted by University of Michigan researchers and published in the journal Pediatrics. The objective of the study was to determine how much parents trust different sources of information in regard to vaccines and to determine what distribution methods would be most effective for those attempting to present evidence-based information about immunizations.

"We know parents get information about childhood vaccines from many sources," says Dr. Gary Freed, M.D., chief of the Division of General Pediatrics and director of the Child Health Evaluation and Research (CHEAR) Unit. "But the source trusted most by parents for vaccine-safety-related information is their child's doctor, which is consistent with the results of several previous studies."

The Michigan researchers surveyed 1,552 parents with children all under the age of 18 asking them to rate their degree of trust in various sources of vaccine information as 'a lot,' 'some' or 'none.'

Seventy-six percent of parents reported trusting their child's doctor 'a lot', which I think that's kind of funny. That means that a quarter of parents don't trust their child's doctor a lot. OK, maybe we need to fix that. You probably want to find a doctor who you trust a lot.

Twenty-six percent said that they trusted other healthcare providers 'a lot'. Twenty-three percent said they trusted government experts/officials. Only 23% trusted the government a lot. I think that says something as well. And only 2% said they trusted celebrities a lot. OK. That's good. I have faith again in parents that only 2% of them trust celebrities a lot with pediatric health information.

In the I trust them 'some' category, 67% of parents have some faith in family and friends; 65% have some fait in the information presented by parents who believe their own child was harmed by a vaccine and 24% have some faith in celebrity opinions.

08:46

The study found mothers were more likely than fathers to put 'some' or 'a lot' of trust in vaccine safety information provided by parents who claimed their child was injured by vaccines, celebrities, television shows, and magazines or news articles. So moms are more likely than dads to put 'some' or 'a lot' from information sources other than their child's doctor.

Trust also varied by race and ethnicity: white and Hispanic parents were more likely than black parents to trust family and friends 'a lot' or 'some,' and Hispanic parents were more likely than white or black parents to trust celebrities 'a lot' or 'some' for vaccine-safety information.

In fact, 40% of Hispanic parents placed a lot or some trust in celebrities. It's unclear from this study whether such celebrities are in the Spanish-language entertainment or in the mainstream English-language medium.

Dr. Freed says, "Those who design public health efforts to provide evidence-based information must recognize different strategies may be required to reach all groups of parents."

So here I say the American Academy of Pediatrics just needs a few celebrities and particularly Spanish-speaking celebrities on their side to get the message out and I think they need to look into that.

"Even if only a fraction of parents receive, believe, and act on misinformation about vaccine safety provided by these different sources, a child's health and the population's health may suffer because of vaccine preventable illness."

Take home here for parents, if you trust what your child's doctor is saying about vaccines you're in good company. And if you don't trust what your doctor is saying about vaccines, why are you still seeing that doctor? The take home for doctors who see kids and I think this is really important, rest in the fact that the overwhelming majority of parents trust what you are saying.

Too many doctors out there, in my opinion, are giving in to parents who want to follow the advice of the Jenny McCarthys of the world. They're letting parents design their own customized immunizations schedules because of irrational fears perpetuated by anecdotal accounts and poorly designed research. The vast body of evidence-based medicines supports the current immunization schedule and there is a history and precedent for changes in the schedule when problems do become evident.

No one's trying to hide the fact that immunizations are dangerous in some way or another. Here is a really cool thing for doctors out there, parents trust what you have to say. Sure you have to spend more time in the examination room defending your stance, but remember your stance is based on evidence and not anecdotal reports, emotions or poorly designed and later recanted studies. So please stand strong and be of advocate for your patient's health.

11:36

All right. Computerized Axial Tomography, also known as CAT scans, those examinations of children in hospital emergency departments increased substantially from 1995 to 2008. That's according to a new study to be published in an upcoming issue of the journal Radiology.

Researchers said the findings underscore the need for collaboration among medical professionals to ensure that pediatric CAT scans are appropriately ordered, performed and interpreted. The study's lead author, Dr. David Larson, M.D. said, " We need to think creatively about how radiologists, ordering clinicians and CT manufacturers can partner together to ensure all children are scanned only when it's appropriate and with appropriate techniques."

Advancements in CT technology like helical scanning have made it a vital tool for upper diagnostic evaluation of children in the emergency department. Decreased scan times are especially helpful in eliminating the need for sedation in many pediatric cases. However, the relatively higher radiation doses associated with these CAT scans compared to most other imaging exams have raised concerns over an increase in risk associated with ionizing radiation.

A child's organs are more sensitive to the effects of radiation than those of an adult and they have a longer remaining life expectancy in which cancer may potentially form. In addition to current prevalence of CT, make it more likely children will receive a higher cumulative lifetime dose of medically related radiation than those who are currently adults.

13:07

To study utilization trends in children, Dr. Larson and colleagues analyzed National Hospital Ambulatory Medical Care Survey data from 1995-2008. The number of pediatric emergency department visits that included a CT examination increased five-fold over the study period from roughly 330,000 to 1.65 million with a compound annual growth rate of 14.3%. The leading medical conditions among those receiving CT scans include head injuries, abdominal pain and headache.

The rate of imaging for abdominal pain increased the most owing to improvements in the technology. "We found abdominal CT imaging went from almost never being used in 1995 to being used in 15-21% of all radiology visits in the last four years of the study," Dr. Larson said. In 1995, abdominal CT took much longer, the resolution was not as good and the research hadn't been done to support it.

By 2008, helical scanning had helped make CT very useful for abdominal imaging. It's widely available, it's fast and there are a lot of great reasons to do it, but it does carry a higher radiation dose. Dr. Larson pointed out that abdominal CT's effective dose of radiation is up to seven times that of a head CT, which means kids aren't only getting more scans, they're also getting much bigger doses of radiation each time they slide into the machine.

Non-pediatric focused emergency departments made up 89.4% of emergency department visits associated with CAT scans in children and increased from 316,000 annual examinations to 1.4 million per year over the study period. Dr. Larson noted most of the radiologists who oversaw and interpreted these studies were adult radiologists not subspecialty-trained in pediatric radiology.

He says, "The performance of CT scans in children requires special oversight, especially in regards to the selection of size-based CT scan parameters and sedation techniques. It's important to consistently tailor CAT scanning to the body size of the pediatric patient."

15:13

OK. So what's the bottom line here? Well, there are several bottom lines really. First, kids are getting many, many, many more CAT scans in emergency departments across the country than they used to. And in many cases, each exam results in bigger doses of radiation than the scans of the past. Not because the machines let out more, it's just the type of scans that we're doing, abdominal and the helical ones, they do have more of a radiation exposure associated with them.

These newer scans look better, they're easier to interpret and they provide more reliable information, but the cost of that information is a lot more radiation exposure for our kids. So how would that affect cancer rate as today's kids grow up? And time will tell. Does that mean parents and doctors should avoid CT scan in kids? Of course not. There are many instances when a CAT scan can save a child's life or improve the quality of life by revealing the unknown. But, as is so common in medicine as well as in other areas of our lives, we have to looks at risk versus benefit. Is the benefit of information worth the risk of radiation exposure and that's something that has to be decided on a case by case basis.

And I think that this is also a big take home for parents. If you find yourself talking to a physician who is recommending that your child has a CT scan, simply ask the doctor if the benefit of the scan is worth the risk of radiation and they will take a step back if you ask them that. Seriously, if the doctor is saying hey, I think we need a CAT scan, don't argue with them. Just say hey, is the benefit of the scan worth the risk of radiation and it very well may be. And if it is your doctor should be able to educate you on his thought process.

Unfortunately, many doctors don't give it much thought. I mean, CAT scans are easy to order and they are chockful of information. They can rule out skull fractures and brain bleeds if your child has a head injury. They can rule out appendicitis, they can find tumors and masses. They're great except for the fact they expose your child to large doses of ionizing radiation.

17:15

Now, if you're an ER doc, especially if you're an adult ER doc and you don't want to miss a skull fracture or a brain bleed or an appendicitis in the kid, I mean do that and you're the next feeding frenzy for the friendly neighborhood lawyers. So you get the scan, you rule out the badness, you discharge the child. But that scenario is happening with decreasing frequency in pediatric emergency departments as we begin to understand who ultimately suffer for haphazard use of CAT scans.

So we're going back, hopefully, to using our clinical skills and expectantly observing the children with whom we have a low index of suspicion for having skull fractures and brain bleeds and appendicitis. And we're looking for alternatives like evaluating the appendix with ultrasound when the equipment and expertise for doing so are available.

Could we get too lax and have some kids fall through the cracks? Yes, it's possible. So this is a balancing game we play. We want to do no harm, we don't want to harm now and we don't want them to be harmed years from now. And certainly, many, many kids really do need CAT scans but at the same time there are many kids who currently get them that didn't really need them.

Dr. Larson says radiologists, ordering clinicians and CT equipment manufacturers need to partner together to improve outcomes, but really he forgot about an important partner and that's you, the parent. You may actually be the voice of reason to the ER doc when you simply ask, hey, does the risk versus benefit play out here? If they give you a compelling reason for the scan, I say go for it. But you just might be surprised at the number of doctors who say, you know what, let's hold off and just watch little Suzy or Jimmy for a few hours and see how their symptoms play out before we order the CAT scan.

And yes that means tying up a room for observation, it might mean slowing the flow through the department, it might mean having to argue in admission to the insurance company, but you know what, it's high time that we stop letting administrators and insurance companies and lawyers dictate how we practice medicine. OK. Now maybe we don't say those words all the time, but I guarantee you that there are thousands of doctors out there thinking them.

19:21

All right. Moving from CAT scans to walking on water. This story is about a dangerous new past-time – water-walking balls. They look like giant hamster toys, you get inside, they seal you in and off you go walking on the water. They are all the rage at resorts hotels and athletic clubs, but once inside you'll discover something very disturbing – there's no way out. Your only hope of rescue is someone on the outside opening the ball for you, which means that the risk of injury or even death if there is an accident or emergency is unacceptably high. And that's some warning from the U.S. Consumer Product Safety Commission.

The large transparent floating spheres have recently come out of the water with many venues allowing guests to walk and roll across the grass or ice and concrete. They become popular at shopping malls, amusement parks, sporting events, county fairs and carnivals and children love them. You can even buy one for your family. But please don't.

The authors of a new Consumer Product Safety Commission report explained that individuals with breathing problems, heart or lung disease and other pre-existing medical conditions can have seriously worsening symptoms when inside one of these balls. Some states are now refusing to provide permits while others are banning them altogether. The report mentions an incident in which a child was unresponsive and in need of emergency medical treatment while inside one of these products.

Another child used the ball on a shallow above ground swimming pool, the ball fell out of it onto hard ground and the child suffered a fracture. The Consumer Product Safety Commission warns the following risks are associate with these water and ground-walking balls: suffocation, the ball is air-tight as the person inside breathes oxygen levels drop and carbon dioxide rises, within many minutes air quality can start to pose a serious danger; drowning, if the ball is on water and has a leak or puncture it can fill up with water and there's no way for the person to get out without outside help; impact injury, the balls have no padding and if they collide with each other or had a stationary object or roll on into the street, well you can imagine it's a whole lot of bad news.

The Consumer Product Safety Commission is attempting to educate state officials across the country not to issue permits or allow the sale of walking balls in their state because they believe there is no safe way of using them.

So I'd say that story pretty much speaks for itself. Let's take a break and we're going to answer your questions right after this.

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22:32

All right. First up on our Listeners Segment is Leslie from South Carolina. She says, "I can't find the search function for past episodes. My husband wants to hear specific information for himself instead of listening to me, but I have no idea what episode it was." Thanks for noticing and bringing this issue to everyone's attention, Leslie. This is actually a bit of a sore spot for me. We had a search page at pediacast.org and we dropped it with the latest build of the site because I really wasn't happy with the way it was working. And we are building a new and improved search capability but it's not quite ready for prime time.

So in the mean time, how can you find what you want? Well, in a couple of ways, there is a tag cloud on the Show Notes page. So if you go to the Show Notes and in the left hand margin there, the left side bar, there is a tag cloud so you can look up topics that way. The only issue there is the tag cloud only goes back about 25 episodes, so we still need to go back into the archive and put the right tags for the episodes. But that's one way you can get some of our more recent shows.

The other way is just to do a Google search. If you type PediaCast and then your search term or do your search term and type pediacast.org and it'll get you there. You'll be able to find out. And onsite search will be returning soon, so keep your eyes open for that.

23:58

All right. Moving on the Jenny and her location is her BlackBerry, I think she just didn't want to say where she was from. And this is the steamy one here that I alluded to in the intro. Jenny says, "Dr. Mike, in a recent episode you stated that breastfeeding was safe for HIV-positive women as long as they are on medication. As an OB and NICU nurse, I was horrified to hear this advice. We never allow positive moms to breastfeed and even women on meds can have measurable viral loads. Can you please explain this or provide your sources? I have never heard this before. Thanks, Jenny B.

Well, thanks for taking the time to write and voice your concern, Jenny. I think horrified is a bit strong but I do understand your concern. Let me start just by putting your question into context. This was in episode 157 and during our Research Round-Up we examined the study that looked into Google's ability to provide accurate answers to medical questions. And the study looked at five specific questions that parents might google and then looked at the top search results to see what categories of sites had the highest percentage of accuracy.

Incidentally, they found that government sites were the most accurate with giving 100% of the time correct answers, followed by educational sites, corporate sites, interest group and individual websites, which were right about 80% of the time and then the new sites and sponsored sites were the least accurate. But we won't go into the details of that study again. If you're interested, just check out PediaCast #157.

25:35

OK. So one of the five questions that the researchers asked Google was should HIV-positive women breastfeed? And when all the results were examined only 35% of them gave what they considered to be the correct answer. And according to the researchers the correct answer was no, HIV-positive women should not breastfeed.

Now, my focus on this study was the Google issue and specifically how well does the search engine provide accurate answers to medical questions. And at the very end of my analysis of the study, I just gave a quick run down of the correct answers and I mentioned that HIV positive women could breastfeed if they were on antiretroviral drugs and this is the comment that horrified Jenny. And many of you may be asking yourself, wait a minute, he just said that the researchers wanted Google to say no, HIV positive women shouldn't breastfeed but now he says they can if they're on antiretroviral drugs.

OK. So let me explain. The Google study was published in April of 2010 and at that time the commonly accepted answer really even worldwide was no, HIV positive women should not breastfeed. But since the Google study was published, another study came to light two months later in June 2010 and it was a study that was published in the New England Journal of Medicine and it concluded that the risk of transmission of HIV through breast milk is significantly reduced if women take antiretroviral medication or if the infant is taking a drug called Viramune throughout the breastfeeding period.

Now let's take a step back. The risk of HIV transmission is reduced according to the study, it's not eliminated. So why do it? Why would an HIV-positive woman take that chance and breastfeed? Why? And here's where my issue came in. I was really speaking on a global level and not at the United States of America. And I think what you to remember when we go back to risk versus benefit is that in many countries of the world and in fact, for probably a majority of the world's population, you could argue, commercially prepared infant formula is not available or is substandard. And this is particularly a problem in Africa, which is you know has a very high percentage of HIV-positive mothers.

28:02

Many women in Africa are afraid to breastfeed for fear of transmitting HIV to their infants so they use powdered formula instead. Well unfortunately, there's not a lot of it available, there aren't quality standards or regulations placed on the powder. And the shady companies out to make a quick buck market their product to consumers. These baby formulas are not the same as infant formulas we know in the West. They don't always provide the right mix of fats, proteins, vitamins and electrolytes. Some powders are distributed without directions and many, many mothers are illiterate and can't read what the directions say anyway.

And here's the biggest problem of all, the formula is often reconstituted with contaminated water. It's also often over-diluted because the people are poor and they need to make the powder last longer. And then they use that same contaminated water to wash their bottles, if they have bottles. So actually the death toll from malnutrition, infection and diarrhea causing dehydration is higher than the transmission rate of HIV from mother to infant when mother is on antiretroviral drug.

29:11

So we look again at the risk versus benefit, if you significantly reduce a breastfeeding mother's chance of transmitting HIV by using antiretroviral drugs then the risk of breastfeeding is that better than the alternative. Well, the World Health Organization believes that it is and they released a bulletin recently that states "Breast is best even for HIV-positive mothers". And in that bulletin they backed up their advice with several well-done studies by respected institutions that show the transmission rate of HIV from mothers to babies when using certain HIV drugs can be as low as 1.8% which is far below the mortality rate of kids who succumb to infant formula problems such as disease and dehydration.

OK. So now at least in my mind two more question are raised. What is the availability of antiretroviral drugs in Africa? I mean, if they don't have clean safe water are they really going to have fancy drugs? And the answer to that question is yes, they do have access to those drugs and not clean water, just a bit ironic. But through the tremendous effort of UNICEF and the World Health Organization about 80% of HIV-infected people in Africa have access to antiretroviral medications and their goal is 100% coverage in the next couple of years with the desire to halt and actually reverse the spread of HIV by 2015

Now, as for drinking water, nearly 1 billion people that's half the population of the entire African continent do not have access to clean safe water. So what does this all mean to you the listener. Well, for those of us blessed to be born in the developed world quality infant formula and clean safe water is readily available, the risk of HIV transmission from formula is 0%, which is less than 1.8% from breast milk of HIV-positive mothers taking antiretroviral drugs.

So when you look at risk versus benefit, Jenny's patients on the OB floor and then the NICU, sure, infant formula is the way to go. But not everyone lives in Jenny's world. And for millions and millions of babies whose lives are far different from our own, breast milk really is best even if your mom is infected with HIV as long as the mom is on the right medication.

31:33

So why didn't I run through this whole thought process in episode 157? Because we were talking about Google and I know I have to watch myself when I make statements and sometimes they do need more explanation and I do see how my comment could be misleading since the bulk of my listeners are in the developed world and for that I apologize.

All right. Jenny, you wanted me to explain and provide sources. I think I've done a fine job of explaining, so all that's left are the sources, so you can check out the Show Notes, there's a link to the World Health Organization's bulletin on HIV and breastfeeding. And I also have a link to the research study in the New England Journal of Medicine showing a reduction of HIV transmission for breastfed mothers on the right medication. I also have a link to the CDC's current stance on breastfeeding and HIV. And I also have a link to the American Academy of Pediatrics Policy Statement on breastfeeding and the use of human milk, which does touch upon the HIV question.

But keep in mind that was last revised in 2005, so it doesn't necessarily include the most up-to-date information. OK. So just to recap, women who have HIV should not breastfeed if they have access to quality formula and clean safe water. But if you are listening to this podcast in Africa, which we do have listeners in Africa, if you're listening in Africa and you do not have clean safe water and you do not have access to quality formula that you're using correctly, then you want to make sure that you're on antiretroviral medications, which help kill the virus that causes HIV and then breastfeeding may be the better way to go. So just all these things to think about.

33:22

Let's move on. Tammy in Indiana says, "Hello! I'm so glad you're back. I found your podcast just when you stopped production previously and I was overjoyed when iTunes showed a new show again. My daughter is three and needs to have a tooth removed. She bumped it over a year ago which killed the nerve. It was not infected at the time so we were advised to leave it be. Well, now it is infected and it needs to come out. A few things are troubling me, she will be sedated for a short time, her appointment will around six in the morning and we are not allowed to be with her when she is put under or when she is waking up a few minutes later. My dentist recommends talking about it as little as possible. My daughter is very inquisitive and I know she'll have questions. Do you have any advice for making this as smooth and untraumatizing as possible? Thank you. – Tammy from Indiana."

Thanks for your question, Tammy. First, let me say I disagree in principle with your dentist's approach to family presence. In general, parents want to be with their kids as much as possible even during procedures. And when my daughter had tooth pulled at around the same age, our pediatric dentist allowed us to be with her actually throughout the entire procedure – when she went out, when the tooth was pulled and when she woke up.

Now, I realized some parents don't want to be there and that's fine. But if moms and dads want to be with their kids outside the sterile and rigorously controlled confines of an actual operating room, personally, I think they should be allowed. Now having said that, even though I disagree with your dentist on principle, I respect his policy and if he is otherwise a good and trusting dentist this wouldn't necessarily be a deal breaker for me.

So what do you do with regard to preparing your child? Well, I wouldn't bring it up unless she does. And so I think your dentist's advice on talking to her about it as little as possible is good advice. That morning you can bring it up when she wants to know where you're going, but I wouldn't stoke the fire without it being necessary to do so.

Now, if she does ask, I would be truthful. I wouldn't necessarily offer more information beyond what she requests and if she's a very smart cookie and she figures out where you're going in a few days and she pointblank asks, hey, are you going to be with me the entire time? Then what would I do, well, I wouldn't lie. You can say I'll be right down the hall, only doctors and dentists are allowed in the back. But I would stress that they're nice; they're going to take good care of you; they're going to help your tooth not hurt anymore.

I mean, all the reassurances that you can pour on her, I would pour on her, but I wouldn't lie because then you break a very important trust. And it's a trust that I think is worth more than avoiding a brief stint of anxiety. So, while I would avoid the topic as much as possible, I would still answer any questions that she asked honestly, but with lots of reassurance. So I hope that helps, Tammy.

36:17

Lindsay in Houston says, "Hi, Dr. Mike. I wasn't able to find a tag for sunscreen in your Show Notes and I've got a question about that." OK. Thanks Lindsay for pointing out that the tag system doesn't always work. "It takes a good amount of time to slather three kids up with sunscreen and it's time for the Splash Pads to open down here in Houston." And thanks for pointing that out too. It's not quite warm enough here in Ohio but in Houston you're enjoying the pools. Lovely. "In the past year, I've applied a thick coat of Banana Boat cream to my kids before we left the house but I have to admit I've wondered about the spray sunscreen. It would be so much faster. I suspect many pediatricians would answer the best sunscreen is the kind you'll use and I understand that. But for a long day at the Splash Pad or at the beach, I want to use what's truly best. Is the spray-on kind as effective as something you rub into the skin? Do the manufacturers have to compromise something in order to get it into spray form? And don't sunscreens protect both UVA and UVB rays while others don't protect against both? Anyway, just looking for a shortcut if the shortcut is of equal quality to the original. I'm a little skeptical that it could be but thought it was worth asking. Thanks Dr. Mike." – Lindsay

Thank you Lindsay. I disagree on your assumption of what many pediatricians would say. I think all pediatricians would agree with what you are saying that the best sunscreen is one that works and prevents burns and skin cancer. It's not the one that you'll use, it's the one that works and I think most pediatricians would agree with that because it's no good to use a substandard product where your kids going to get burnt anyway and you have a false sense of security.

So the question becomes are spray sunscreens as effective as their rub-in lotion counterparts. I was excited about researching this question. I was hopeful that I'd find randomized controlled prospective study, this sort of thing – you take 1,500 kids, let's say between the ages of eight and twelve, you have them be active, play outside in the sun, those kinds of kids. Kids who are going to be out in the sun and you take an equal number of boys and girls and we'll them all fair skin Caucasian for this study to minimize the variable of skin pigmentation and we'll randomize those kids into three groups.

38:56

Group one gets a standardized application of a rub it in sunscreen lotion with an SPF of 50. Group two gets a standardized of spray it on sunscreen with the same SPF and group three, our control, gets no sunscreen at all. Now we're going to bake all those kids under a midday sun with no access to water because we don't want to introduce the variable of water taking off the sunscreen. We'll check the kids for evidence of sunburn every 30 minutes. Oh wait, you might not see the sunburn right away. So we'll have to leave them all in the sun, still no water on the skin for a specified period of time, let's say three hours. Then we'll wait six more hours for the skin damage to show up and then we'll check all the kids for burns and see how many in each group have no burns, how many in each group have first-degree burns and how many in each group blistered with second-degree burns and finally we'll see if there is a statistically significant difference between the three groups. Does that sound good?

Now, would you enroll your child in that study? Of course not. And herein lies some of the difficulty of pediatric research. I mean, you might find some college students willing to participate in that sort of a study for some extra spending cash. But no parent in their right mind is going to stand for it and if they do stand for it, that they do stand for the fact that their child could be randomized to the no-protection control group, then I think Child Protective Services would probably get involved sooner rather than later.

So as it turns out there are no studies in kids or adults, for that matter, looking at the effectiveness of lotions versus spray-on sunscreen. And retrospective studies in this case aren't really going to be all that useful either. I mean, sure you can take kids with sunburn who present for medical care and say hey, what kind of sunscreen had you used? But you'd have to find a way to reliably rely on their memory to tell you how much they applied; what technique they used; how much time did they spend in the water; how much sun exposure had they had on the days preceding the burn and so on and so on and so on.

40:58

So, have I beat this into the ground enough? It's a difficult thing to study. Here's what we do know, UVA and UVB exposure is dangerous and we do talk about this in PediaCast #127 and I'll put a link to that in the Show Notes. Again our tags begin with episode 135 or so. We do need to go back and tag this stuff in the archive, I know, and we need a better search option, I know. Listen folks, it takes time to put these shows together. And at least we have new content now week after week, right?

OK. So where was I? UVA and UVB, yes, you want to protect against both and the higher the SPF the better. And again SPF stands for sun protection factor and it's a number that tells you how many times longer it takes for your skin to burn with the product applied compared to the length of time without the product. And again, the poor people who were involved in this research study.

So if it normally takes your skin 10 minutes to burn, it would take 20 minutes to burn if you use an SPF of 2. It would take 100 minutes to burn if you use an SPF of 10; 200 minutes if you use an SPF of 20 and 500 minutes if you use an SPF of 50. Now this assumes correct coverage, you use enough of it on all the exposed skin and its durability, how old does it stay on and if you don't put enough on or the product comes off because of swimming, sweating, your clothes coming on and off, then you aren't going to get the full length of protection.

42:27

So what type of application ensures that enough goes on and that all areas get covered? Well, I think it could be accomplished with both lotion and the spray, but if you're going to use the spray you need to use a lot of it so that you get the proper amount on the skin and you need to rub it in to be sure that all areas get covered.

Now, the label, if you look at these spray-on sunscreen, the label says, "Apply generously and evenly to all exposed areas." Now how do you apply a spray generously and evenly? Of course you also need to reapply it as needed after towel drying, swimming, perspiring, rigorous activity, that sort of thing. But how do you apply an even and generous amount when you first put it on and with each reapplication what's difficult. And if you're doing it right it's probably going to take you just as long and be just as messy as lotion because you need to put a lot of it on and you need to rub it in.

So my vote is just stick with the lotion. And in the end, Lindsay, you knew that was going to be the answer, didn't you? You were hoping for the shortcut but you knew there wasn't really a shortcut coming. Thanks for the question though. We always appreciate it.

43:41

And finally, we have Heather in Munster, Indiana. She says, "I have a three-year old son who has gotten what I can only describe as a head freeze a few times after consuming ice cream and other really cold items. I usually try to make sure he's consuming cold items slowly but as he gets older I can't watch him all the time. When it happens, he goes limp and his eyes rolls back in his head. He seems disoriented afterward. Fortunately, he has not gotten hurt but I am not sure if I should be more concerned and bring it to the attention of his doctor or just continue to use caution with cold items. His father also has issues with head freeze but his twin brother and I do not."

Thanks for writing in, Heather. First, absolutely, you should bring this to the attention of your doctor. In fact, any time you're concerned about anything, you should talk to your doctor in person, in the exam room with the history and physical. We don't practice medicine here. And really in a case like this I would have a bunch more questions for you that I'd want to know and I would definitely want to take a look and listen to your son to figure out what's going on because your eyes rolling back in your head and passing out and becoming limp and then seeming disoriented afterward is not the kind of head freeze that we have in our family.

Now, that's not to say that it's something serious and life threatening, it may not be. But it is something though that I think you do want to see your doctor about. So I can't give you medical advice on what's causing your son to do this. But what we can do is talk about a couple of cold-related phenomena, not to say these are whether affecting your son but they are possible results of eating something cold. And not to say they're the results of your particular child, Heather, but your question reminds me of a couple interesting things to talk about, let's put it that way.

45:34

We've all experienced what we in our family like to call an ice cream headache. We don't call the head freeze, I know some people do. Ice cream headache in our house. You take a big bite of something cold and you get a stabbing sensation in the middle of your face, which goes away a few minutes after you swallowed the cold food. Now, some in our family think they've figured out a trick. They press their thumbs up on the roof of their mouth and the headache seems to go away faster.

I'm not convinced that it actually works. In fact, I'd like to see a randomized controlled prospective study on the hypothesis, but that's another discussion altogether, one we already had earlier today about studies. Now, you'll notice Heather that our ice cream headaches again, don't really sound like your child's symptoms. It's just a brief stabbing faceache that last about 20 seconds or so. There's no eyes rolling back or passing out.

So what causes an ice cream headache? Well, here we do have some published research, thanks to the British Medical Journal and Scientific American. And here's what we know happens – very cold food such as ice cream and Popsicles have the ability to change the temperature of the roof of the mouth, also known as the palate, and this area is innervated by the 5th cranial nerve known as the trigeminal nerve.

So there's a nerve that is responsible for sensing the temperature of the roof of your mouth and that nerve is called the trigeminal nerve. Now, in response to this rapid change in temperature, becoming very cold, the trigeminal nerve sends a flurry of electrical impulses to the brain. But the brain interprets those signals as coming from other structures that are served by that same nerve mainly the skin of the face, eyelids and forehead. So this nerve just starts rapidly sending impulses and the brain thinks that you have a horrific face and head injury because of all the activity that's coming in from the trigeminal nerve.

47:36

So that's what the brain thinks that you just had horrible trauma to your face and because that's what your brain thinks that's what you feel and it's a phenomenon called referred pain. This is also why you have arm numbness and tingling when you have a heart attack. There's nothing wrong with your arm, your brain is just getting impulses from the heart but its impulses that doesn't typically get from the heart but it is impulses that typically gets from your arm, so your brain interprets it as coming from your arm and you feel numbness and tingling in your arm which is really associated with a heart attack.

It's also why inflamed throats when you have strep throat it can cause your ear to hurt, even though the doctor looks in your ears and they're fine. And it's why sometimes with the ear infections we look in the ear and they have an infection but they came in complaining of a sore throat. They may have mucous and draining or a virus that's also infecting their throat, but sometimes there's nothing but an ear infection or even a swimmer's ear and they can have some throat pain associated with that. And again it's referred pain. The brain is having some trouble figuring out where the impulses are coming from and so interprets it as coming from some place different and so you feel pain in that some place different place.

Now, after a few seconds the roof of the mouth warms, the trigeminal nerve stops firing and the pain goes away. So I suppose that pressing the roof of your mouth with your thumbs might warm you palate faster and make the pain resolve more quickly. It's possible. Don't tell my family because it's kind of fun to tease them about how silly they look with their thumbs in their mouth.

49:12

OK. So what about Heather's son? Eyes rolling back and passing out from the cold. Well, there are many things that can cause those kinds of symptoms ranging from seizures to heart problems and brain problems. Now, I wouldn't think that those things would only be brought on by cold but kids don't always follow rule books so you definitely want to talk to your doctor about it. Now having said that there is another nerve that when stimulated can produce those symptoms that Heather is describing and that is cranial nerve number 10, also known as the vagus nerve, not Vegas as in casino town, but vagus, v-a-g-u-s. And a certain stimuli cause this nerve to fire in a particular way that gets the attention of the brain stem and the brain stem responds by activating the parasympathetic nervous system and deactivating the sympathetic nervous system.

Now, that's a lot of medical jargon but the bottom line is this, when the vagus nerve fires in a certain way, your heart rate drops and the force of heart contractions lessen so that overall blood flow is reduced and in addition, smooth muscle in blood vessels relax and the blood vessels dilate. So what happens then if you have a decrease on heart rate, a decrease in how forceful your heart pumps and a decrease in smooth muscles tension in the blood vessels? Those three things are going to act together to decrease your blood pressure and then blood flow to the brain is reduced, which means that oxygen delivery to the brain is reduced and that results on you getting faint, perhaps dizzy and passing out. And this is what we call a vasovagal episode.

50:55

Fortunately, these are short lived and are rarely dangerous but they can be confused with other serious and even life threatening conditions. So that's vasovagal episodes are not something you want to diagnose yourself at based on the information you heard on a podcast. That's not a good idea. So see your doctor, Heather. Let him ask more questions and take a look and listen and give you his opinion.

But going on vasovagal episodes, what sort of stimulation can cause these? Well, the list is a long one – prolonged standing, especially if you're overheated, this is the reason the choirboys sometimes go down to the ground; sudden onset of extreme emotion like passing out when you get great news or bad news; stressful situations like public speaking, seeing a spider, the site of blood; abdominal strain or bearing down and this is why some people pass out and fall off the toilet, it does happen; intense laughter can cause these and that's why the phrase 'he died of laughter' or 'that killed me' comes in; severe pain or trauma can make you pass out and these are all vasovagal-mediated episodes of unconsciousness.

And here is an interesting one, cold exposure of 10-degree Celsius or below to the central face. The vagus nerve isn't in the business of sensory perception on the face, that's the domain, as we mentioned before, of the trigeminal nerve. So if you touch the central face with your finger you just activated your trigeminal nerve and actually if you touch your central face with something cold you still feel that with the trigeminal nerve.

But the vagus nerve is also stimulate when cold touches the central face and that results in an interesting thing called the mammalian diving reflex, which is a vasovagal-mediated thing. This is a reflex that allows aquatic mammals to stay underwater for long periods of time by slowing down their heart rate and actually constricting the peripheral blood vessels, so those in the extremities and closer to the surface, so that blood is diverted to the heart and brain. So oxygen is conserved because muscles in skin isn't using the oxygen so there's more oxygen available for the heart and the brain while the animal is underwater.

And in aquatic animals these peripheral areas account for 30% of oxygen use, so by cutting them off the brain and heart can survive longer without the lungs bringing in a fresh supply of oxygen. Now, humans aren't as efficient. The diving reflex in humans typically yields less than a 10% drop on oxygen use which isn't too helpful to the brain and heart. The exception though is young children who have a stronger mammalian diving reflex and they can sometimes divert a much higher percentage of oxygen to the heart and brain, which is why some children survive prolong periods of submersion in icy water. Not all young kids, of course, but some, which is why you hear stories of some kids surviving prolong cold water submersion.

54:00

OK. So it's interesting stuff, to me anyway. Here's another interesting fact, the vasovagal response can be medically helpful at times. Sometimes kids have a condition called SVT or supraventricular tachycardia where their heart is beating way too fast like over 200 beats per minute. And again, don't try this at home, but one of the ways that doctors can get a child out of SVT is by putting an ice bag on their face. And by putting an ice bag on their face, they elicit the mammalian diving reflex, which is vasovagal-mediated and remember one of the things it does is drop your heart rate and so you can take someone out of SVT by inducing a vasovagal response.

All right. Enough of the medical trivia. Bottom line here, Heather, be sure to take your son and let your doctor examine him to be sure there's not something more going on, that's important.

All right. Lots of great comments and questions today. Remember if you'd like to add to the show, it's an easy thing to do, just go to the Contact page at pediacast.org. You can also email pediacast@gmail.com or call our voice line and leave a message at 347-404-KIDS.

We're going to take a quick break and we'll be back with our Research Round-Up, right after this.

55:47

All right. We are back with our Research Round-Up and we're going to talk about treatment of acute otitis media in children under the age of two and this comes out of the University of Pittsburgh and was published in the New England Journal of Medicine just this past January 2011.

The question before the researchers, does antibiotic treatment for otitis media improve signs and symptoms in children who are 6 months to 23 months of age? They used a randomized double-blind study to look at this.

Now let me give you a little bit of background, many physicians have sort of established a 'watch and wait' philosophy in the treatment of acute otitis media, especially in children over the age of two, because many of these ear infections are viral-mediated, they're caused by viruses, so the antibiotic is not going to help anyway and ones that are bacterial are often self-limiting, meaning they go away on their own without needing antibiotics to treat. And also overtreatment with antibiotics contributes to the rise of drug-resistant organisms.

So the focus on these older kids is really more on pain control and reserving antibiotic use for complicated and what we'd call refractory cases that just aren't going away or really toxic-looking kids, high fevers and vomiting and you're worried about it becoming a blood infection. Now, could this same philosophy apply to infants 6 months to 23 months of age?

57:12

So what the researchers did they recruited children from 2006-2009 and all the participating children had received two doses of pneumococcal conjugate vaccine. That's important because the pneumococcal vaccine kills strep pneumonia or the organism and strep pneumonia is a common cause of otitis media or ear infections in children. If you're doing a study and you divided them randomly into two groups, but as it turns out one group they all had the pneumococcal vaccine and the other group didn't, then you're going to introduce a variable that's in addition to the variable that you're testing.

In this case, they wanted to make sure that all participating children had received two doses of the vaccine so that wasn't a complicating variable in the outcome of the study. What was required the diagnosis of acute otitis media for all of these kids was a score of three or greater on the acute otitis media severity of symptoms scale, onset of symptoms in the past 48 hours, presence of a middle ear effusion (fluid behind the eardrum) and a bulging eardrum with pain on exam and/or marked erythema, which means redness.

These kids had to have a bulging eardrum that was red or painful, fluid behind it, these symptoms had to have started in the past 48 hours and the symptoms had to be severe enough to warrant a three or greater on the acute otitis media severity of symptoms scale. I love saying that. Excluded children, these are the children they said no, you can't be a part of our study, comorbidity that means they had another acute or chronic illness along with the ear infection; allergy to amoxicillin – because that's the drug they're going to use or the drug they're going to use contains amoxicillin; antibiotic use of any kind during the previous four days; or a perforated tympanic membrane, so if their eardrum had a little hole in it and fluid and puss was leaking out, which many of you parents know what I'm talking about; those kids were excluded from the study.

59:24

So they enrolled 1,385 children (Great number! Good, good sample size.) and they randomly assigned them to one of two groups – treatment versus no treatment. The treatment group was treated with amoxicillin-clavulanate, which is Augmentin, is the brand name of that drug. Most people get the generic form now but I just mentioned the drug name because most parents have heard of Augmentin. So this is the drug they used to treat. They used a standardized dose of 90mg/kg per day based on the amoxicillin content and divided that up into two doses each day for 10 days.

The no treatment group received a placebo with a similar appearance and taste using the same volume, dosing schedule and length of treatment time. So it's really difficult for parents to know whether they were in the test group or in the control group.

By the way, I just want to mention, really I want to give kudos to the parents who participated in this study. I mean, you have a nine-month old, let's say, who has an ear infection and you're agreeing to the possibility that your child will not be treated even when the standard of care is to treat a child of that age with the known ear infection. So kudos to the parents who did this. It's not to harm your child, the sunscreen thing yeah, no kudos there. But this one the shout out to the parents.

OK. So what did they do? They assessed symptoms by phone each day until the first follow-up visit and then they assess symptoms in person during each follow-up visit, thereafter. And ear examinations were performed at each follow-up visit.

So when did these visits take place? Well, the first one was on day four or five of therapy on the antibiotic. The second follow-up visit was at the end of therapy on day 10 through 12, one of those days. And finally, they had a long-term follow-up on somewhere between day 21 and 25. And at each visit, each child was labeled as a clinical success or a clinical failure.

61:31

They were considered to be failure at the four to five-day follow-up if they had lack of substantial symptom improvement and/or worsening exam. So if the eardrum was looking worse at four or five days then that was a failure and if they weren't substantially getting better in terms of their symptoms then that was a failure.

Failure at the 10 to 12-day follow-up was defined by lack of complete resolution of all symptoms and any abnormality on the ear exam, except for the persistence of a little fluid behind the eardrum. So if they had a persistent middle ear effusion but it's not bulging, it's not red and there are no symptoms then that was still considered to be success. But if they had any symptoms at all or if there is anything other than a little fluid behind the eardrum then it was a failure at the 10 to 12-day mark.

OK. So what did they find? Resolution of symptoms by day 2 in the treatment group – 35%; in the placebo group – 28%, which was not statistically significant. Resolution of symptoms by day 4 in the treatment group – 61%; in the placebo group – 54%, not statistically significant. Resolution of symptoms by day 7, 80% in the treatment group, 74% in the placebo group, again not statistically significant.

62:55

Persistence of abnormalities on the ear exam at the four to five-day follow-up, treatment group – 4%; placebo group – 23%, so this was statistically significant. So the symptoms were still there but the ear looked better at the four to five-day follow-up.

Persistence at the 10 to 12-day follow-up, persistence of an abnormal-looking exam, treatment group – 16%; placebo group – 51%, which again was statistically significant. Other observations, one child in the placebo group developed mastoititis, which is a bone infection that can be a complication of acute otitis media. And adverse drug effect such as bellyache, vomiting, diarrhea, allergic reactions were of course increased in the treatment group when compared to the placebo group.

So the authors concluded that in children 6 to 23 months of age with acute otitis media, treatment with amoxicillin-clavulanate for 10 days reduced the burden of symptoms and the persistence of otoscopic signs of acute infection. For the authors to conclude that, they said treatment reduced the burden of symptoms and yes it did, the burden of symptoms when you look at day 2 the treatment group was 35%, the placebo group 28%; day 4, 61% versus 54%; day 7, treatment group 80% had resolved; 74%.

64:22

So a higher percentage of the treatment group did have resolution of symptoms, but those differences were not statistically significant, meaning that those changes in percentages when you compare treatment group to placebo group could have just happened by chance.

I'm not really happy with the authors for their conclusion because their conclusion is not statistically significant. Now when you look at the ear exam then there is a statistically significant difference. So the ones who had the antibiotic their ear really did look better. So what does this all mean to you, the parent?

Well, a couple observations are in order. The first is, again, even though the authors tout a reduced burden of symptoms in their conclusion, this reduction in symptoms was not statistically significant. So the take home here in my opinion is that even when an antibiotic is used and there is evidence that the ear infection was there and it got better, your child's symptoms may persist even though the antibiotic is working. I think that's the real take home here. It's not the fact that the antibiotic didn't help the symptoms, it's the fact the antibiotic did help the disease but your child may still have symptoms even though the antibiotic is working.

And just to look at the numbers at the four to five-day follow-up 96% of the kids in the treatment group had an improved exam but 39% of them still had symptoms. So at four or five days out if your child still has symptoms it doesn't mean the antibiotic is not working. And how many people go back to the doctor at day 4 to 5 and say hey, it's not working; my kid's still is fussy and pulling on the ear and won't eat and is vomiting once a day.

So that doesn't necessarily mean antibiotic failure just because the symptoms are still there. So I think that's the take home. Then we always talk about risk versus benefit. What's the risk of not using an antibiotic in this age group? Well only one child developed mastoititis. So 1 child of 692 that's 0.1%, which is really low risk and no other complications were noted.

66:24

So bottom line for me and my practice of medicine, if I see a child in the 6 to 23-month range with a definite otitis media, it still makes sense to me to treat with an antibiotic because there's a statistically significant difference in the resolution of ear findings when you compare treatment versus non-treatment. And kids in that age group are at risk for recurrent otitis media, so when you find it you want to get rid of it.

However, if you aren't sure if a child has acute otitis media and I'll circle back around to that in a minute, but if you're not sure then watching and waiting may not be a bad idea in this age group since 74% of them have resolution of symptoms and 50% have resolution of exam findings without antibiotic treatment.

So that sort of how this study would impact my practice of medicine. As you know, when I'm sure, treat. If I'm not quite sure if it's an otitis media then maybe hold off in that age group. Now, what do I mean by saying if your doctor isn't sure if it's an ear infection? When I say if I'm not really sure if it's an ear infection, how can a pediatrician not be sure if your child has an ear infection?

Well here is a little secret, diagnosing ear infections in this age is not always an easy thing. Just ask any medical student about his percentage rate of having an attending agree with his exam findings when he looks in ears. Ear canals at this age are often very small, narrow, long, wax-filled. When you try to remove the wax in can cause bleeding and when babies cry and are upset, which is usually the case when they come in with an ear infection, their cheeks turn red and their eardrums turn red too just from their crying. And any pediatrician out there would agree with me that we aren't always 100% sure.

And in the past, when we're not 100% sure we have erred on the side of treating rather than not treating the kids in this age group. So I think more of us now are heading in the other direction in treating only when we know for sure it's an ear infection and doing more of a wait and see approach in the kids we're not quite sure.

68:27

What about kids less than six months of age? That's a different issue with a different set of problems and a different risk for not treating, which we won't go into now for lack of time. There is a link in the Show Notes to the research paper at PubMed. The actual research paper was called "Treatment of Acute Otitis Media in Children Under 2 Years of Age". So if you're interested in seeing the actual study, head over to pediacast.org and we'll have a link for you in the Show Notes.

All right. That wraps up our Research Round-Up and we are going to come back and wrap up the rest of the show, right after this.

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69:40

All right. Thanks go out to Nationwide Children's Hospital for being a large, large part of this program. In fact, this program is a part of Nationwide Children's Hospital. Also, Medical News Today, Vlad over at VladStudio who helps us out with our artwork, Wizard Media and of course listeners like you.

I want to remind you iTunes reviews, this is not self-promotion here folks. I mean how many of you found PediaCast because someone before you had taken the time five minutes to write a nice review? And we have only had a handful of reviews in the last couple of months. So if you have not written a review on iTunes, I would just encourage you to take five minutes of your time and do that. Again, it's not just self-promotion. Our mission really is to put a source of evidence-based pediatric medicine into the hands of parents and broken down into a way that they can understand. And that's really important to all of us here at Nationwide Children's.

We want parents to make educated decisions and educated decisions are based on evidence. And where do we get that evidence? From research, we really try to pick apart things and make decisions not based on stories or what we think might be happening, but what is the best way to practice based on the evidence that's out there. And we really want parents to become more in-tune and I think so many times parents just look at doctors as being in this ivory tower and they know all. But we don't know all and we're trying to figure it out and as more information becomes available we change how we practice. So we just want parents to be cognizant of that and to be educated.

71:25

Anyway, again it's not self-promotion. It's just we want everyone to know about PediaCast and be able to benefit from it if it's something that interests them. And of course pediatric medicine should interest you if you have children or you work with children or you like children.

So anyway, iTunes reviews are helpful. Also give us a shout out in Twitter, blogs, Facebook. We're on Facebook and Twitter now. I really do need to do more with those. We do have a blog at pediacast.org which I need to update. So we'll get to that. There are just too many things to do.

And the other thing too and I've mentioned this, I don't know if anyone's taken me up on this, but when you go in for well child checks and sick visits, just mention PediaCast to your doctor and let them know pediacast.org is the place to find and maybe they'll help spread the news amongst their patients as well.

Of course really important is your participation in the program. We just love getting the comments and the questions even when they are steamy, when you're upset or you don't like something I've said, hey, let me know that too; pediacast.org, you can click the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. 347-404-5437.

Thanks for taking the time out. I know that it's an over hour-long show and there are so many different things that you could spend that hour doing. I just want you to know that I really do appreciate you taking the time to spend an hour with the rest of us. So until next time, this is Dr. Mike saying stay safe, stay healthy and of course stay involved with your kids. So long everybody!

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