Dangerous Toys, Sugar Cereal, Pityriasis Rosea – PediaCast 192

Listen as Dr. Mike talks about dangerous toys, daycare boosts immunity, overuse of antibiotics, sugar cereal, Pityriasis Rosea, Osteopathic doctors, and toddler scratching behavior today on PediaCast!


  • Dangerous Toys – Top 10 List
  • Daycare Boosts Immunity
  • Overuse of Antibiotics
  • Sugar Cereal
  • Pityriasis Rosea
  • Osteopathic Doctors
  • Toddler Scratching Behavior



Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike and I'm coming to you from the campus of Nationwide Children's Hospital in beautiful downtown Columbus, Ohio.

It would be a little bit more wonderful if we could get a bit of snow on the ground. We're pretty much 50 degrees and a light rain, just what we've been dealing with for the last couple of days. It's funny because, a year ago, we were living in Florida and we came up to visit a family for the holidays, and we knew at that point that we were going to be moving up here to bring PediaCast to Nationwide Children's.



There was snow on the ground, White Christmas chill in the air. It was great, so we were kind of looking forward to that this year. I feel a little bit like there's been a 'bait and switch' kind of thing with Mother Nature because it's not so lovely now. But we still have a couple weeks before we can have first snow before Christmas, so hopefully we'll get a little snow on the ground. But we'll see. We'll still have a great Christmas regardless.

I appreciate your patience also. We did not have a show last week. I took a vacation week. It was the first time that I've been off, and we haven't had something big to do or somewhere to go or a scouting trip to find a house or a vacation, so it was just basically a stay-at-home week.



It was nice. We got the Christmas tree up, I got a lot of our holiday shopping out of the way, we got the house all set and Christmas plans made. It was a really nice, relaxing break. But just I appreciate you folks waiting for an extra week before we had a show out.

We've got a big one for you today. It is a news and listener edition. In fact, we're calling this one 'Dangerous Toys', good to know for the holidays, 'Sugar Cereal, and Pityriasis Rosea'. It is December 14th, 2011.

Lots in the lineup other than what we mentioned in the title.

Daycare boosts immunity. So if you're sick and tired of your child in daycare being sick and possibly making you tired all the time, there is a little consolation that it does boost their immunity. We're going to look at a research project that showed that.

Also we're going to discuss the overuse of antibiotics, sugar cereal, pityriasis rosea, that comes from a listener question. Also, osteopathy. Osteopaths. What's the difference between MDs and DOs, we're going to discuss that. A listener had a question about the difference there.



A toddler with scratching behavior, like scratching other kids. Why do they do it, how do you stop it, we're going to discuss that as well.

I would like to remind you, if there is a topic that you would like us to talk about, it's easy to get a hold of us here at PediaCast. Just go to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347, 404, K-I-D-S, or 5437 is the numbers.

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

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



All right, with all that in mind, we're going to take a quick break here and we'll be back with News Parents Can Use, right after this.


Mike Patrick: We are back. Today's News Parents Can Use segment is brought to you in conjunction with news partner Medical News Today, the largest independent health and medical news website, and you can visit them online at medicalnewstoday.com.

Boston-based World Against Toys Causing Harm, how's that a name for an organization? World Against Toys Causing Harm. They're in Boston, and they released their annual top 10 list for the most dangerous children's toys, of course just in time for the holiday season.



The group, which issued its first list in 1973, has a long history of raising awareness among Christmas shoppers. So what is on the top 10 dangerous toy list this year? We'll give you a little bit of a sampling.

The first, the sword-fighting Jack Sparrow. Now, I like "Pirates of the Caribbean" and Jack Sparrow just as much as the next guy, but this version comes with a four-and-a-half-inch-long sharp rigid plastic sword. It pokes straight out at you when the pirate is standing at rest, and when activated with a lever, the arm and sword swing upward to jab your opponent. Of course, this combination provides the perfect potential for eye and other impact injuries.

Then, I love this one. Not really. The Z-Curve Bow. It's a high-performance foam bow and arrow set and it's marketed as being able to fly over 125 feet. Again, it's sold as a toy, it's made of foam, yet the package contains the following warning: "Arrows should not be pulled back at more than half-strength," because that's easy for a kid to remember and stick to. "Do not aim at eyes or face, do not aim or shoot at people or animals," even though it's foam, "and anyone within close distance to intended target should be alerted prior to firing."



Now, I don't know about you, but if they have to tell you it flies at 125 feet, don't pull it back more than half-strength, and make sure people get away, it doesn't really sound like a toy anymore. I mean, I'm thinking this is a weapon. Seriously. "Do not pull back more than half-strength." What kid is going to listen to that?

Next up, the Fold & Go Trampoline. I can't make this stuff up. Really. I mean, I couldn't make it up any funnier. The Fold & Go Trampoline. Now we all know trampolines are dangerous, right? Even when they're sturdy and only one child jumps at a time and safety nets are in place, we still see injuries. Trust me, we do all the time. So the idea of a trampoline that folds and goes, there's really nothing about that combination that can be good, folks.



World Against Toys Causing Harm reminds parents that there were at least 28 toy recalls in the United States during 2011 with 3.8 million individual toys affected, and 250,000 U.S. children seek treatment in hospital emergency departments each year for toy-related injuries.

Pay attention to recalls, but don't wait for recalls, and don't wait for your child to get hurt. Do a little research before you shop. Think about what you're buying. We all have to use a little common sense here. Really, if a toy bow and arrow has to warn your child to only pull back at half-strength, maybe it's not such a great idea for a toy. You know what I'm saying?

We'll put a link to the entire top 10 list of the most dangerous toys for 2011 in the show notes over at pediacast.org.



Now here's something we've previously discussed on PediaCast, and now there's a study to back us up. I've mentioned before that one advantage of daycare is that daycare kids get sick all the time.

Now, I know you're asking how exactly is that an advantage. Well, our immune system makes antibodies with each illness, so the next time that particular bacteria or virus comes along, you have antibodies that are there ready to fight it off quickly.

While daycare kids get exposed to lots of microbes, bacteria and viruses, in the daycare and they seem to get sick all the time, they are also building up immunity with each of those infections and can expect to get sick less often a little bit later on once they start school.

The kids who don't go to daycare, so those who stay at home, they avoid lots of illness during the first few years of life, but once they start school, bam, they are susceptible to all those same germs and tend to get sick more often. That's been our hypothesis, anyway, based on observation that makes sense.



Well, now, researchers at Charles Sturt University in Australia are showing it to be true. The team has completed a prospective longitudinal study of 10,000 Australian kids and they found that those who attended daycare were more likely to have frequent illnesses such as viral upper respiratory inspections, ear infections, and throat infections when compared to their stay-at-home counterparts.

But once all those kids hit school age, then it's time for those who had stayed home to suffer. Since the stay-at-home children had not built up as much antibody protection, they got sick more often once school got rolling.

Research team leader Dr. Linda Harrison presented the findings last month at the Growing Up in Australia Conference in Melbourne and offered the results as a consolation to parents whose daycare kids seem to get sick all the time.

Now, that's not to say that daycare is better. We're just making an observation of the way the world works and our body works. Certainly, there's advantages to kids staying home, if that's possible. A lot of times, in these times and economy, that's not possible. So we're not making a judgment here in saying one way's right, one way's wrong but just, again, making an observation about how things work.



All right. Speaking of getting sick, you've probably experienced this scenario: Your kiddo has a stuffy nose, a cough and a fever, you take them to the doctor, and she tells you the illness is caused by a virus. Antibiotics won't work, you just have to treat the symptoms and wait it out. Your doctor's assessment and recommendation hits the mark, and kudos to your doctor for getting it right.

Unfortunately, many doctors aren't getting it right to the tune of 10 million unnecessary antibiotic prescriptions each year in the United States. That's the findings of researchers at the University of Utah in Salt Lake City, as reported in the journal "Pediatrics".

Researchers looked at a nationally representative sample of 65,000 out-patient visits by kids under the age of 18 from 2006 through 2008. They looked at each child's diagnosis and treatment plan, including documentation of prescribed medications, and they found that doctors prescribed an antibiotic for one in every five patient visits.



Most of the time, the antibiotics were warranted because the child's infections were bacterial in nature, things like pneumonia, urinary tract infections, strep throat, sialitis, but in nearly 25% of cases, when doctors prescribed an antibiotic, there was no documented bacterial infection.

In these cases, physicians used the antibiotics to treat viral upper respiratory infections, bronchitis, the flu, asthma and allergies. Study leader Dr. Adam Hersh says that translates to more than 10 million antibiotic prescriptions each year that likely won't do any good but might cause harm.

So why are doctors doing this? Well, one reason, according to Dr. Hersh, is the diagnosis isn't always certain and doctors want to prescribe something to be on the safe side.

Another troubling revelation is that half of the prescriptions were for broad-spectrum antibiotics. These wipe out lots of helpful as well as harmful bacteria and can lead to other health problems and the creation of resistant bacteria, which are difficult to kill later on.



Dr. Hersh advises parents to ask the doctor how sure he is of the diagnosis. If he's not certain, parents could ask if it's OK to wait a couple of days with close follow-up to see if things might get better on their own.

OK, I have to add a couple of my own thoughts to this one. Realistically, most parents aren't going to ask if they can wait a couple of days to see if things get better. In many, many cases they already waited a few days. That's why they came to see the doctor. So if the doctor suggests an antibiotic, they're typically relieved, because that's why they came in the first place. They wanted an antibiotic.

So let's not put the ownership of this one on the parents. It's not up to the parents to say, 'Could we wait a little longer? Even though I came in, could we wait even longer?' The blame really goes squarely on us doctors.

Often, it's easier to write a prescription and move on to the next patient than taking the time to provide an explanation, and sometimes arguing with a parent about the lack of need for an antibiotic. I think that happens just as often as doctors writing prescriptions to be on the safe side.



I'll also say this. The data from the study comes from 2006 to 2008. This may be a bit anecdotal on my part, but I really sense a shift in the last two to three years compared to even five years ago. I really think parents are more receptive to the reality of a viral diagnosis with asymptomatic care and tincture of time as the only treatment plan. I think parents really are starting to get it. So it's time for us doctors to start getting it, too.

Parents wishing to give their kids a good start to the day have good reason to be concerned about the amount of sugar in children's breakfast cereals, says the Environmental Working Group in a recent review of 84 popular brands sold in the United States.

According to their analysis, the worst offender is Kellogg's Honey Smacks, which is made up of nearly 56% sugar by weight. In fact, a one-cup serving of Kellogg's Honey Smacks contains 20 grams of sugar, which is more than you'll find in a Hostess Twinkie.



Another 44 cereals, including the popular Cap'n Crunch and Honey Nut Cheerios, contain more sugar in a one-cup serving than the three teaspoons of sugar found in three Chips Ahoy chocolate chip cookies.

Environmental Working Group's Senior Vice-President of Research Jane Houlihan said, "As a mom of two, I was stunned to discover just how much sugar comes in a box of children's cereal." She said the bottom line message of their report is most parents would never serve dessert for breakfast, but many children's cereals have just as much sugar or more.

So who are the worst offenders? Well, based on percentage of sugar by weight, the Environmental Working Group analysis lists the 10 worst children's cereals as, I feel like I need a drum roll here. Have you noticed, this is our list of episodes, which I think is appropriate before the holidays.

OK, number 10, Kellogg's Fruit Loops, the original formulation. They have a new formulation out there now with a little more fiber in it, so I think that brings the sugar down a little, but the original formulation, which was just plain old Fruit Loops like a year ago, 41.4% sugar by weight.



Number nine, Quaker Oats Cap'n Crunch Crunch Berries, 42.3%. Number eight, Kellogg's Apple Jacks, 42.9% sugar by weight. Number seven, Kellogg's Smores, if you've got 'smores' in the name, you probably can assume there's going to be a lot of sugar, 43.3%. Number six, Quaker Oats O's, 44.4%.

Number five, Quaker Oats Cap'n Crunch Original, 44.4%. Number four, Quaker Oats Cap'n Crunch OOPS! All Berries, 46.9%. I've never heard of that one, OOPS! All Berries, Cap'n Crunch. Number three, Kellogg's Fruit Loops with Marshmallow, 48.3% sugar by weight. Number two, Post Golden Crisp, 51.9% sugar by weight.



And finally, the worst cereal in terms of how much sugar is there, Kellogg's Honey Smacks. I think it's funny. You and I both know, that used to be Sugar Smacks, right? This cereal used to be called Sugar Smacks. They changed the name to, I don't know, it looks like they're trying to trick you. 'OK, we're not Sugar Smacks anymore, we're Honey Smacks.' But they have 55.6% sugar by weight, which is 20 grams of sugar.

Only one in four of the cereals reviewed met the government's recommended guidelines of no more than 26% added sugar by weight. The guideline comes from the Federal Interagency Working Group on Food Marketed to Children, which proposed standards to Congress to curb marketing of children's food with too much sugar, salt, and fat as a response to the growing obesity crisis.

The Environmental Working Group would like to see the guideline even less than 26%. Of course, it's just a guideline, since without legislative support the allowable level of sugar is unenforceable.



Actually, it is enforceable. It may not be enforceable at the product level, but for us parents, it is enforceable, because we make choices of what we're going to buy our kids. We can choose, we can enforce in our own homes what sugars are going to be there.

Again, my whole thing with this boils down to moderation. If your kids really, really, really like Sugar Smacks and you give them a bowl of Sugar Smacks once a month, twice a month maybe, is that really going to be a problem? In my opinion, no. But when they're eating Sugar Smacks or the equivalent amount of sugar everyday, every morning, day in and day out, then it's a problem.

So, again, I think moderation is key, but again, there are people who disagree with me on that.



One of them is New York nutrition professor Marion Nestle. Great name for a nutrition professor, don't you think? New York University Nutrition Professor Marion Nestle. She says that cereal companies spend a fortune convincing parents that kids should have cereal for breakfast and that sugar cereals are fun and that all kids like them.

Cereal makers invest tens of millions of dollars advertising brands at the top of the worst for sugar list. Why? Because children want them, parents buy them, and fortunes are made. Nestle says no public health agency has anywhere near the education budget equivalent to that spent on a single cereal. She adds kids should not be eating sugar for breakfast, they should be eating real food.

Health expert Dr. Andrew Weil remembers, when he went to medical school in the 1960s, the view was that sugar was a fairly harmless food that gave empty calories but no vitamins or minerals or fiber. But according to Weil, 50 years of nutrition research has confirmed that sugar is actually the single most health-destructive component of the standard American diet. The fact that a child's breakfast cereal is 56% sugar by weight, and many others not far behind that, should be cause for national outrage.



Research shows that, compared to kids who eat breakfast with less sugar, kids who eat high-sugar breakfast have a harder time in school. They experience higher levels of frustration and find it more difficult to work independently. Also, by lunch time they are hungrier, have less energy, find it harder to pay attention and concentrate, and they make more mistakes.

OK, so that is really good information. If those things are true, then we do want to have our kids have less sugars at the breakfast table.

Also, the rate of childhood obesity has tripled in the U.S. in the last three decades to the point where now, according to the Centers for Disease Control and Prevention, one in five children is obese. And with the rate of Type 2 diabetes in children also riding rapidly, Dr. Weil says we may well be facing the unprecedented scenario that the children of today will have shorter lifespans than their parents.



If you want to buy cereal for your children but not sure how to choose the right one, then you do well to pay more attention to the back of the box than the front. Dr. Nestle recommends that you look for cereals with a short ingredients list, although added vitamins and minerals are OK. You want a cereal that's high in fiber and cereals with little or no added sugar.

Added sugars, by the way, include honey. I think that's what happened with the Sugar Smack to Honey Smack change. But honey is still an added sugar. Molasses, fruit juice concentrates, brown sugar, corn sweetener, sucrose, lactose, glucose, high-fructose corn syrup, and malt syrup. Nestle says one of the best and easiest breakfasts that you can make for your child is fresh fruit with high-fiber, low-sugar cereal.

Of course, keep in mind, fruit contains sugar. I did a little research on that, too. A serving of strawberries is your best bet. It only has seven grams of sugar. That's about six medium-sized strawberries, seven grams of sugar, a serving of pineapple, which is a few rings, like three rings, nine grams of sugar. Banana has 17 grams of sugar, an apple 23 grams, and an orange also about 23 grams of sugar.



So if they're really saying that sugar causes decreased concentration at school and all these problems, you don't want too much sugar. The fruit has it, too.

For an even more nutritious breakfast, take out the cereal and put in homemade oatmeal. We've been eating this steel-cut oatmeal at home, and boy it is good, but maybe still a hard sell for kids. Although those dried cherries in it kind of sweeten it up a little bit. Of course, again you're adding some sugar.

If you'd like to read the Environmental Working Group's report in its entirety, which includes lists of the best cereals as well, and the not quite as good but still good-tasting alternatives list of those, we'll put a link to it in the show notes over at pediacast.org. So head over to pediacast.org, show notes for Episode 192, and we'll have a link over to their entire report and all their lists.



All right. That concludes our News Parents Can Use. We're going to be back to answer some of your questions right after this.


Mike Patrick: All right, first up in our listeners' segment. A quick reminder: if you have a question or a comment, go head over to pediacast.org, click on the Contact button, and you can get a hold of us and ask your own question.



This comes from Maria in Paint Lick, Kentucky. Maria says, "I've been a loyal listener for years now and love the new show format and interviews. As both a mom and a paramedic, I love learning from your podcast, not only for my kids but for all the kids I encounter at work as well."

"Recently, my four-year-old was diagnosed with pytiriasis rosea. I searched the website and listened to Podcast 52 on rashes, but it was not mentioned. I was wondering if you could do a brief overview of this rash, including differential diagnosis type information."

"Thanks for being such a great resource. Maria in Paint Lick, Kentucky."

Maria, I went through the archives as well, and lo and behold, we have never covered pytiriasis rosea on PediaCast.

It's a fun rash to cover. It has some unique properties and often goes sort of misdiagnosed at first, but then once it really expresses itself, then most doctors who see folks with skin issues is able to recognize it and diagnose it for you.



It's got a big name, but it's not too serious. A lot of conditions have the medical name and then a common name. For instance, an ear infection, the medical name is otitis media or acute otitis media, then there is serious otitis media. Oftentimes there is a more complex medical name and then the name that we use when we talk to patients and moms and dads. For pytiriasis rosea, that's it. What you hear and see is what you get. There is no other common name for it.

So what does this rash look like? Well, let's start with the description. It often begins with what we call a 'herald patch'. A herald patch, it looks a little bit like ringworm. It's a large oval patch that can be anywhere from one to three inches in diameter, kind of oval-shaped, usually on the trunk. It didn't always have to be, but most commonly that's where you're going to find it. It sort of has a crinkly, scaly look to it.



Oftentimes it is mistaken for ringworm, so initially, when it starts, some people will get prescribed an anti-fungal medicine or recommend that they buy one over the counter, and it doesn't help because it's nor really ringworm.

And then what happens is, seven to 14 days later, smaller versions of this herald patch, much smaller, they're like less than an inch in diameter, sort of one to two centimeters, start to develop on the trunk, and sometimes they'll go to the extremities as well, rarely to the face. It's mostly on the trunk that you're going to see this.

At that point, the people who thought it was ringworm and they've been treating it, now looks like it's spreading, but it's not really. It's how this rash is expressed. So you end up with the smaller ovoid crinkly- to scaly-looking.



They don't have the raised borders that you oftentimes see with ringworm. Also with ringworm, oftentimes then the center part of it, once it progresses, will start to clear, and that doesn't happen with these.

Also, this small ovoid rash that developed the seven to 14 days after the herald patch has oftentimes a distinctive pattern, especially if you look on the back, and it kind of follows skin lines or skin folds into what we call a Christmas tree pattern. It's just sort of a cascading pattern of these ovoid spots that follows the skin lines. We call that a Christmas tree pattern.

Sometimes it's itchy, but when it is itchy it's not like poison-ivy itchy. It's just mildly itchy. Although it can be still a nuisance.

Now here's the thing: the rash lasts for a really long time. A lot of rashes you see, they last a week. Boy, two weeks is getting out there for a rash, right? Well, this one can last one to two months is pretty typical. So four to eight weeks that this rash lasts, and as long as three months is possible. You just have to wait it out and then it finally goes away.



So what causes it? Well, we don't know for sure. We think it's probably an immune response to a viral infection. In fact, 70% of cases of the rash are preceded by a mild viral upper respiratory infection.

There has been some question if perhaps human herpes virus 6 or human herpes virus 7 might be implicated in this. However, it's hard to know because a lot of people have viral upper respiratory infections. So 70% of people who had this rash had a cold before the rash broke out. Well, a lot of people have colds, so is it a coincidence or is it a significant association? The verdict on that is still out.

It's one of those things, too, where not a lot of research is done, because a lot of research is really driven by how you are going to treat something. So when a disease process is more of a nuisance and it's not life-threatening, it really doesn't even decrease your quality of life that much, do you really need to spend a lot of money to figure it out more?



So that's some of the reason why. If we wanted to know more about this, we probably could figure it out; there just isn't the interest and the money to do so.

We think maybe there is a connection with human herpes virus 6 or 7, but again, we're not sure.

The rash itself is not contagious. Now, if it is associated with a preceding viral infection, then that would be contagious. But then just because one person goes on to have pytiriasis rosea expressed as a rash and association with that viral infection doesn't mean that the person who catches the virus from Person A, they may not have the rash associated with it.



It's not really contagious, although, again, if you had two people whose immune system would be prone to making this rash when they had the infection, then the upper respiratory infection, you could pass that on, and then that Person B could get their own version of pytiriasis rosea. It's possible. But in general, the rash itself is not itchy. You're not going to touch it and then catch it.

Now, in terms of differential diagnosis, as I mentioned, oftentimes in the beginning stages it can be mistaken for ringworm. That's pretty common.

It's always the second or third doctor who seems like the smart doctor, but they have the advantage of, 'OK, now I see all these little spots, they form a Christmas pattern, they don't have raised borders, there's no central clearing, they had a little cold a week before the rash started, and there was this herald patch.' It's going to be easier for that doctor to make the diagnosis based on the clinical scenario than it is for the doctor who's seeing you where you kind of forgot that you had the cold and it just looks like one patch. So oftentimes the second or third doctor seems smarter because they finally figure it out, but they have the advantage of the entire history.



Other differential diagnosis. Nummular eczema. Dry skin condition can cause spots that look sort of similar, although the distribution usually is more on the extremities and on the face, so it's a little bit different. But you could say that one looks like it.

Also, contact dermatitis. But, again, if you had a history of having your skin in contact with something that had an allergic reaction to, contact dermatitis could look that way as well. But again, when you look at the whole scenario and progression, once those littler spots start to develop, then you know for sure what it is.

So what do you do for it? Well, there are some things that may help the rash resolve a little bit faster, but again, do you really need to do that? Some would suggest antiviral medication such as Acyclovir could possibly shorten it by a week or two. Maybe there is that association. There have been some people who have tried Acyclovir and it seemed that the recipients of the Acyclovir had a shorter course. But there haven't been any well-done large studies that really looked to see if that works.



Also, UV light or sun exposure also appears to help it resolve a little bit faster. But again, we're not talking about these things making it go away in a few days. We're talking, instead of it lasting eight weeks, it only lasts six weeks if you use the medicine. These things aren't really all that helpful.

Plus, these treatments can cause more trouble than they are helpful. Acyclovir folks can have allergic reactions, there can be side effects to any medication, and of course UV light, too much exposure can cause sunburn and over longer periods of time can increase your risk for skin cancer. So again, is treatment really necessary?

The biggest symptom is mild itching. Many people with so mild, they don't really need anything for it at all, just a little moisturizing cream in the spot where it's itching, and leave it alone and things get better.



If the itch is bothersome, over-the-counter antihistamine medicines like Benadryl are helpful, especially at nighttime when you're lying there trying to fall asleep and it seems like it's itchier then. So over-the-counter antihistamines are sometimes used. If it's more severe of an itch, topical steroids can be used like hydrocortisone cream or oral steroids like prednisone if it's really itchy.

But again, there's long-term issues with those as well. Fortunately, it's mild itchiness and most people really don't need anything other than reassurance that this is going to go away. But it's kind of an interesting rash.

Prevention, there is no prevention for it other than if it is associated with a virus, trying to avoid getting the virus, and that's kind of difficult to do.

So hope that helps. Thanks for the question, Maria.

We're going to move on to another question, and this one actually is someone who called in using the Skype line. Let's go and listen to what they have to say.



Listener: Hi, Dr. Mike. This is Katherine calling from Wiesbaden, Germany. I really enjoy listening to your show over here in Germany. I have three kids, seven, five, and almost 18 months. It's really interesting to hear American perspective on a lot of things, for example fluoride. Here in Germany, the big discussion is always, should you add fluoride to Vitamin D, vitamins that they give in the first year of life, or should you leave out the fluoride and just give it as part of the toothpaste.

My question I have for you is osteopathy. I've never really heard much of it in the U.S. when I lived there. I moved here about 10 years ago. Here in Germany, the question came about my five-year-old. He's a kindergartener, which here in Germany, by the way, kindergarten is for three- to six-year-olds, a mixed group. She says my five-year-old, he just turned five in October, she's noticed some tension when he gets really excited, or when he gets frustrated or upset about something, he has tension in his jaw area, his fists and his shoulders.



She recommended, and also a neighbor recommended, to see an osteopathist. I think that's what you call them. I was just wondering what your take is on that, maybe a medical history or what exactly we can expect from an osteopathist, and if you've heard of any success rates or what exactly they do and how it works. From what I understand, it comes from the traditional Chinese medicine. Just be curious to see what your medical take on it is.

Keep up the great work. I'm going to put up some signs here in the local kindergarten and pediatrician's. Most people here do speak English, so I think that's great what you do. Thanks very much! Bye-bye.



Mike Patrick: All right. Well, thank you to Katherine in Wiesbaden, Germany for taking the time out to call the Skype line. For those of you out there who would like to get a hold of us that way, 347-404-KIDS is the way that you go to leave a message.

So your first question regarding fluoride, and I think we probably just crossed paths on this one, but back in PediaCast 189, which was not that long ago, Dr. Elizabeth Gosnell, a pediatric dentist here at Nationwide Children's Hospital, joined us and we did talk a little bit about fluoride. Probably you hadn't heard that one yet when you'd written in, and maybe you have now, and if you haven't, then head on over to PediaCast 189 by going to pediacast.org. We'll put a link to that in the show notes, too, so if you're at the site for 192, you can click on over to 189 pretty easily.

OK, so what is osteopathy? Well, you know what I'm going to do is go through a brief history of osteopathy in the United States. I think that in Germany kind of mirrors that and it does have some associations with Chinese medicine. But let's go back to the beginning here real quick.



I'm not an expert on this, but I did do a little research and there are some things, some conceptions that I had which perhaps to some degree were misconceptions that I corrected in doing research over the years on this. There are listeners out there who have much more knowledge of this than I do and I'm sure will correct me if any of this is wrong, and then we'll pass the information on to you. But I suspect that history of osteopathy in Germany kind of mirrors the history of it here in the United States.

So here is the deal. Especially in the Midwest, I think it's more pronounced here because it got started in the central part of the United States, and there aren't as many schools and then folks who practice osteopathy on the coasts.



But back in the day, there were doctors of medicine who went to medical school, and that type of medical school was called an allopathic medical school. The degree that they got was an MD, so a medical doctor. You go to the college of medicine after you've gone to a university and you get a Doctor of Medicine degree and you're an MD, and that's an allopathic medical school. Osteopathists or doctors of osteopathic medicine, their degree is a DO, so Doctor of Osteopathic medicine. So MD versus DO.

Back in the 1800s, medicine in the U.S.A. was pretty crude. We bled people with leeches and cutting. We were just beginning to understand the human body. But the idea of a scientific method was in its infancy and we often knew just enough to be dangerous and not always helpful.



There was a guy by the name of Andrew Taylor Still. This is in the late 1800s. He was pretty disgruntled by the state of medicine and he felt that there wasn't enough emphasis on prevention, nutrition, holistic approach. He saw these patients suffering and the techniques and things that people were doing weren't helping, and he just wondered, is there a better way of dealing with the human body?

I guess it does harken back to Chinese medicine as well. It's just that whole holistic approach, nutrition, prevention, 'Let's look at the whole body and just try to find a better way of explaining things and to see what works,' because everyone in the end wanted the patient to get better. This guy just took a more naturalistic approach. He started his own medical school in Kirksville, Missouri, which was something easier to do in those days than it would be today.



But science was still important to him. He really wanted to understand the human body, but he also acknowledged that there was a lot that we didn't know, and he thought, rather than experimenting with potentially harmful medications and surgical procedures, he would rather at that point focus on prevention, nutrition, and also manipulation of the skeletal system, especially the spine, much like modern-day chiropractors would do.

And this is really where the term came from, 'osteo'. Osteo, Latin word, we think of when we talk about bones. So we have 'ortho' and 'osteo' are words that deal with bones. This is where that word 'osteopathic' comes from.

On the other hand, he didn't really want to eliminate science. If a procedure or medication could be proven to work, he wanted to use those as well.



Other doctors with similar philosophies started to open up their own osteopathic medical schools, and the schools began churning out doctors. So at that point we started to have sort of a competing system of now MDs and DOs, so allopathic medical schools and osteopathic medical schools.

Now, the allopathic schools came around and did begin to embrace more of a scientific method, it became more of a mature method, and they began to look also at prevention and nutrition. But they never really locked on to the osteo-manipulation component of things, and I think the reason, and this is my opinion, is that from the allopathic viewpoint, something had to set them apart.

Allopathic schools were affiliated with big-name, established universities like Harvard, Yale, Case Western Reserve University. The osteopathic schools tended to be rural and the Ivy League sort of frowned down on them.



The bone manipulation and the skeletal system part of it was kind of looked at as, 'Well, that's their thing.' It became kind of a class system in the early days. People who wanted to be doctors, you had to come from well-known families or you had to have the financial means to do it, and those who didn't have those things had a better chance of getting into an osteopathic school than an allopathic medical school.

So the allopaths sort of considered the osteopaths to be second-rate, like 'You're not good enough to get into our school, so you're going to go there,' and the osteopaths criticized the altopaths as ignoring the natural and holistic aspects of treatment. So it was kind of a war between the two.

Now, as medicine matured, the states wanted to license physicians, and it has come to be now that whether you go to an allopathic medical school and get an MD degree or an osteopathic medical school and get a DO degree, you have to have the same curriculum, you have to pass the same exams, you have to be licensed, so there really is not much of a difference between the two today.



In fact, osteopathic medical schools now are affiliated with bigger universities, and there's really little difference. And, really, most of them don't even do much of the bone manipulation, holistic-type treatments like they used to. In fact, I've talked to lots of DOs who are like, 'Yeah, I had one quick class on that, but no one really does it.'

That doesn't mean that there's no benefit in those things, by the way. I mean, there's not a lot of research to prove that some of those techniques work, but I think there is becoming more of that as you look into more traditional medicines, especially when it relates to things like stress and your kiddo having the jaw issue and finding ways to deal with their stress.



So someone who is trained in osteopathy, they still have a sound scientific basis, at least here in the United States, and I can't comment for sure on the licensing requirements and training requirements of osteopaths in Germany, but here in the United States, you know you're getting a sound doctor. They had to go to a medical school, had to pass the same boards to be certified, get the same knowledge base, but they may be the personality type who are going to look into things a little bit more naturalistic, holistic, to get at the whole person.

So I hope that helps your understanding, Katherine. I, again, don't know a lot about osteopathy in Germany other than what I can look at on the internet, which I'm sure you've looked at as well, so I don't really have any insight into that system, but that's kind of the story here in the United States. So I hope that helps.

OK, finally we have Susanna in Toledo, Ohio, a little closer to home than Wiesbaden, Germany.



Susanna says, "Hi, Dr. Mike. I love listening to your show and I appreciate the great education that you provide for parents. But now I have a question of my own."

"For about the past six or seven months, my 26-month-old has exhibited strange behavior: she scratches others. I've noticed a pattern, too. Sometimes it's because she's bored, other times because she's over-stimulated, and still other times when she's overly excited or upset. It seems to happen much less frequently when she is on a one-on-one situation, but since she attends daycare, that is not always feasible."

"I've also tried to prevent under- or over-stimulating situations, but that's not always possible. I'm completely clueless as to how to address this behavior, and it seems everyone I talk to is baffled and just as clueless as I am."

"I mentioned it to her pediatrician and she just reassured me that it's normal. While it's comforting to know she'll eventually grow out of it, what can I do about it now? Her daycare is getting frustrated by the behavior, and frankly, so am I. I've tried verbally correcting her and also doing timeouts, but none of the above seem to really make a difference. Timeout seemed to cause more distress and upset. Any advice would be greatly appreciated. Thanks, Frustrated in Toledo."



All right, Frustrated, also known as Susanna. Thanks for the question.

All of us, whether we want to admit it or not, has a degree of egocentricity in us. Right? I mean, we all have an idea of what we want and we figure out ways to get what we want. And if we can't get what we want, we at least want to try to break the competition. Let me just give you a couple examples from a lot of people's adult everyday existence.

Let's say I want pizza for dinner and the rest of my family doesn't. Now, my son Will, he loves pizza, so he'll go for the pizza, but everyone else in my family, they're going to resist. They're like, 'Really? Do we have to have pizza again?'



So I'm going to go first to my son and say, 'Hey, you want to get some pizza tonight? We'll see if Mom and your sister will go for it.' Then you tell your wife and your daughter, 'Hey, we haven't had pizza in a long time.' Now, my daughter loves Asian food, but the last two times we ate out, it was at an Asian restaurant. So I'm going to use that argument. 'The two of you don't want pizza, but look, we had Asian the last two times. OK, fine, we're not going to have pizza, but we're not going to have Asian, either. We're going to do something else.'

Again, it's this 'I want my way, I don't want you to get your way,' and it's just one of those, you can look into faith-based systems and why are we like that at our core, but we're egocentric, and in the adult world, mental manipulation is the game we play to express our egocentricity that we want what we want. The same goes for picking a movie. We're going to all go see a movie, 'I want to see this one,' 'I want to see that one.' How can I leverage, how can I get my way, how can I, 'No, I don't want to see the cartoon,' or a TV show or what board game we're going to play.



So I think that Frustrated's two-year-old hasn't developed the fine art of manipulation that teenagers and adults have, so her egocentricity is expressed as scratching.

And it often gets her what she wants when polite ways aren't working. If there's a toy she wants and another kid's not giving her the toy, scratch the kid, get the toy. And if it doesn't get her what she wants, at least it causes some problem for the competition in the form of a little pain, a little bleeding, a little frustration, a little attention.

For another kid, it's not scratching, it's expressed as a temper tantrum. They're going to have that tantrum and get what they want. For another, it's vomiting. We see that a lot. Kids are going to get a shot, they start getting upset, they cough, they gag, the next thing you know they're puking, their parents are, 'Oh, let's not do the shots today. Let's hold off another day.' For another kid, destroying property is the way they act out and try to get their way.



So my point is, Frustrated, your child has the same issue that we all have. It's that same issue and it just shows up as scratching rather than something else. To be honest, you can get rid of the scratching behavior. But in all reality, it will likely be replaced with another strategy, but hopefully one that's more socially acceptable and doesn't cause as much frustration on the preschool.

So what do you do? Well, a few things. Definitely keep her nails trimmed so that she doesn't have daggers when the scratching behavior does come out. And then the biggest thing is to anticipate her needs and frustrations fairly. Like you said, the over-stimulation, what you're really doing there is you're trying to anticipate her needs, keep her happy so that she doesn't have to resort to the scratching. So you're already doing that. That's great.



Distraction oftentimes will work. If she has in her mind that she wants to do one thing, and instead of getting her to the point where she's going to scratch, distract her. 'No, there's another toy over here.' So you distract them from what they were getting frustrated about, and that's a technique that often works.

But it's a technique that requires supervision. It requires people at the daycare who are in tune with what's going on with every kid, so part of the daycare's problem with your kiddo scratching maybe that they just don't have enough adult supervision to anticipate those kind of needs and to redirect and to keep kids from getting to the point where they're using those kind of techniques to get their way.

So in that case, you may need to find a different preschool or a different daycare that can appropriately monitor that so it doesn't get to that point. I mean, it's not so much of the daycare letting her scratch, it's the daycare not paying enough attention to her needs that she gets to the point where she has to resort to that behavior.



The other thing is, never let it work. Once she scratched, 'You're not getting what you did the scratching for. I don't care how frustrated you get over it.' You can't let it work.

And that goes true with whatever way a kid is working out. Unless it's me trying to do the mental manipulation to get pizza for dinner, then you've got to let it work, right? [Laughter] But it's the same kind of thing. You don't want to positively reinforce a socially unacceptable means of getting your way.

Once you let it work, then it's ingrained, 'Hey, I'm just going to keep doing it. The scratching eventually works. I'm going to keep doing it.' So once she's done the scratching, you can't let that work. She can't get her way.

I think timeouts are still appropriate. She can get frustrated and decompensate, but you have to say that scratching is not appropriate. And if you're going to institute timeouts for scratching, you have to be consistent with it. Those timeouts should happen at home, at daycare, wherever she is. Whenever scratching happens, boom, she gets a timeout.



And the fact that the timeout does cause her distress is a good thing because it means she doesn't want to be distressed, so hopefully at some point it clicks in her mind that, 'Hey, if I scratch, I'm going to get a timeout. I don't like timeouts.' So the fact that she's distressed during it lets you know she doesn't like it. That's good, too.

But the thing with that is you have to be consistent. They have to be able to do timeouts at the daycare if she scratches. Otherwise, she's going to keep doing it because she knows 'I won't get a timeout there, so I'm going to keep using it because it works.' And you can't blame her for that.

Again, you can get rid of the scratching behavior, but more than likely she'll figure out a different technique of getting what she wants. And that's just because that's how we're programmed. I mean, that's how people are programmed.

There's hope, though. The hope, and again, we're getting into faith-based kind of stuff, but when you start putting other people first, then they're more likely to start putting you first, which I guess is just another technique of getting your way.



Again my example is, my wife and daughter really love Asian and they know I love pizza. It means more to them when I say, 'Hey, you know what? Let's not do pizza even though we haven't done pizza. Let's do Asian again tonight because I love you. Let's do it.' It's more likely that they're going to come back and say, 'You know what, let's do pizza. We've had Asian the last few nights. Let's do pizza tonight.'

I mean, when you start putting other people and their needs before your own, it's more likely that then they'll also start putting your needs before their own, and then suddenly your needs get met. Again, I know we're getting dangerously close to religion with that kind of philosophy, but that's another thing, too, just modelling.

And that's what you're doing when we're saying anticipate what's making her frustrated. You're saying, 'You know what, I'm going to figure out what her needs are and try to meet those needs before she gets frustrated. I'm going to put her first.'



Anyway, there is hope, Frustrated, and not just for your two-year-old daughter but for all of us. Wow, we could even tackle philosophy here on PediaCast.

All right, we are going to take a quick break. Normally, we go to a little musical interlude here and then we come back and we wrap up this show. When we come back, I have something really important I want to talk to you about. So if you're prone to thinking, 'Oh, the music's going to play and then he's just going to say hey, goodbye, folks,' please don't. Come back after the break, because there's something important that I want to talk to you about.

We will be back right after this.




Mike Patrick: All right. It has been a big year of change in 2011 at PediaCast. We brought the show here to Nationwide Children's Hospital. We've really been playing with the format quite a bit. We've had more interviews, still trying to get the News Parents Can Use and answer your questions. Our next show we have a research roundup planned, which we haven't done in a while, and then we're going to kick off 2012. We've got more interviews. We've got one on sickle cell anemia coming up and others as well.

But one thing that I want to do is really acknowledge the fact that the folks here at Nationwide Children's have allowed us to build a studio on the campus and to have access to all of their specialists. We really appreciate it. And this is completely free, of course, for you guys.



There are folks out there who at the end of the year give money because of tax implications, so it's a good time of the year to give. We have a campaign going on here at Nationwide Children's called Every Gift Matters.

Nationwide Children's is currently the fourth largest children's hospital in the United States and we have a new patient tower that is going to be opening in June of 2012, and when that happens, this hospital will be the second largest children's hospital in the United States of America.

We're also the fourth busiest children's hospital in the U.S.A. when you look at volume of patients that are seen, and in the foreseeable future, that's going to be going up. It's also in the top five of NIH-supported grants. There's a lot of research that goes on here. So it's a big center.



In the world of medicine, pediatric reimbursements are less than what they are in the adult world. So in order to take care of all these kids, and we take care of kids regardless of their ability to pay, we do rely on a lot of contributions. So we have a campaign going on called Every Gift Matters, and there will be a link in the show notes to help you get there. It's basically nationwidechildrens.org/giving.

You can say, how much do you give? Well, this is really cool. There's some tangibles here that you can think about.

For instance, $10, if you give a $10-gift, that pays for a pair of pajamas. Now, why would a kid in a hospital need a pair of pajamas? Well, these are fun pajamas for a pajama closet that kids with cancer, who are here for an extended stay, you don't want them to have to wear a gown when they're here for a long time. You want them to feel at home. So having pajamas that they can wear that are cool and fun and that then they can take home with them, it's their pajamas. It's not just, there goes the linen cart, you get a new gown the next day. These are your pajamas, and you get to go home with them. So $10 buys a pair of pajamas.



Twenty-five dollars will buy a five-pack of diapers for premature babies, because we use 31,000 diapers every year here at Nationwide Children's. So a $25-donation does that. Fifty dollars will buy 17 new books for the Reach Out and Read program. Here at Nationwide Children's, age-appropriate books are handed out at well child visits. So $50 will help buy 17 book to be given out for our Reach Out and Read program.

A hundred dollars will buy a wagon. There are wagons available at every entrance of the hospital, and that's how kids are transported around the hospital here at Nationwide Children's. Parents can pick up a wagon, put their kids in, or whatever supplies that they have, and cart them around at the hospital. If a patient's up on the floor and they have to go to x-ray, if it's possible, they'll take them down in a wagon. When they get discharged and going out to their car, instead of a wheelchair, they'll use a wagon in kids who are medically stable enough to go by that route of transportation.



And the kids love it. I mean, it's really, really cool. But we need more wagons, especially as we're opening up a new tower, 12 stories. Each floor is as big as a football field, so it's a huge, massive building and we need more wagons to get kids around.

Two-hundred and fifty dollars pays for a last chemo family celebration. When a kid who has cancer has chemotherapy, their last chemo, they get a celebration, a party, and $250 will pay for a family celebration for their kid's last chemo. Two-hundred and fifty dollars will also buy a snuggle wrap for premature babies. They basically get snuggled in this thing to keep them warm and cuddled in their isolette. So $250 will do that.



Five hundred dollars will buy one-month supply of celebration chest toys. Kids in the Cancer Clinic, when they have procedures done like bone marrow biopsies or they have to have a peripheral IV line done, any procedure that they have, afterward they get to go to the celebration toy chest and pick out a toy. So $500 will pay for a one-month supply of celebration chest toys for kids in the Cancer Clinic.

A thousand dollars will sponsor a summer camp scholarship for medically safe camp experiences. We have a diabetes camp, asthma camp. It's kids with chronic diseases who have some special medical needs that they can still experience a summer camp atmosphere. Lots of fun. I've served personally as camp doctor at these before. A $1,000 will fund a scholarship so that a kid can participate in summer camp even though they may have diabetes or asthma.



A thousand dollars will also pay for a teen patient entertainment system with a flat-screen TV, a PlayStation 2, and an assortment of games. So as they are building the new hospital, they are going to have special rooms that are really meant for teenagers with an entertainment system in the private room. So $1,000 will help fund that.

Also, $5,000 will supply the surgery toy room for one month. Kids who have surgery here for whatever the reason, after post-op they go to an ocean room that's full of toys and they get to pick out a free toy. So $5,000 will supply one month of the toy room.

These are just some tangible examples of what your money can do, and if you go to nationwidechildrens.org/giving, that's one way. Or you can go to pediacast.org in the show notes for this episode, which is 192, and there will be a link to Every Gift Matters, and that's how you can give.



So please consider doing that if you're looking for tax break and you need to give some money for the year and you're looking for a good place to do it.

Even though this is a children's hospital that's in Central Ohio, we do treat people and see people from wherever. No one is denied access to this hospital regardless of a patient's ability to pay and regardless of where they're from. If they show up here, we take care of them. So we need your help in doing that. We'd just appreciate it.

And we really don't ask for much from you from this show. We put it together, we put it out there. So if you want to give back a little bit, this is one way that you can do it.

The other thing I wanted to talk to you about is your comments. What are we doing well? What could we do better?



Obviously, this show can't be what everybody wants. I mean, you can't have a show where one person wants it to be all interviews and each show lasts 20 minutes, and another one's only the news and listeners and one's an hour-long show. You can't have both of those things.

So we're trying to do a little bit of everything and trying to please everyone. We do want to know what you think. It doesn't mean that we can make it happen, but your comments and suggestions are all listened to. Every comment that comes in through pediacast.org's contact page or at pediacast@gmail.com or on the Skype line, every single one of those I personally read and look at.

Also, we do have more of a blog at our website now, so if you go to pediacast.org, each of the show notes, if you have comments that you would like to make, we can start building a community of listeners there. So if you have comments, if there's a topic we talked about and you have a personal story relating to that particular thing, feel free to go to pediacast.org and comment.



We're also on Facebook and Twitter. Just do a search for PediaCast in either of those places and you'll find us.

And of course we're on iTunes. If you have not left an iTunes review, those are extremely helpful. It doesn't take you long at all to do it, literally 30 seconds. But the reviews on iTunes are really important. For a lot of you, that's how you found us; you read the reviews, thought you'd like to give it a try. So if you could add a review to iTunes, that would be helpful as well.

And then we also have our PediaCast flyers. If you go to the Resource tab at pediacast.org, there's a PDF that you can download. Those are great for bulletin boards, at your daycares, at nurseries, church nurseries, the YMCA gyms, and your doctor's offices. So make sure you let your doctor know about PediaCast so they can help spread the word to other of their patients as well. We talk about that quite often.



So all of these things are ways that you can get involved in the program. We really, really want to try to build this community. That's sort of my goal for 2012. We have a pretty big audience, but there's not a lot of sense of community online with Facebook and at the website. So I'd just encourage you to jump on board and be part of the PediaCast community. We really, really appreciate that.

All right. I am not sure if there will be another show before the end of the year or not. I'm working on one. I think it's going to be an interesting one. We're doing a research roundup, I had mentioned that, on basketball. We've got three different research projects on high school and college basketball in terms of injuries and that sort of thing. So we're going to have kind of a basketball research roundup coming up in the next episode.

But again, I'm not sure if that's going to end up being before the end of this year or the first part of January. We'll see how things go as we're trying to make our plans here at PediaCast.



Again, I appreciate all of you taking the time to make us a part of your day. I know our outros usually don't last this long, but I just had some important things to pass on to you.

One last time I want to remind you, if there is a topic that you'd like to talk to us about or a suggestion or a question, just go to pediacast.org, click on the Contact link. You can also email pediacast@gmail.com, and again that voice line number is 347-404-KIDS, 347-404-5437.

And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!


Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

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