Picky Eaters, Joking & Pretending, Engaged Fathers – PediaCast 326

Show Notes

Join Dr Mike in the PediaCast Studio for more News Parents Can Use! This week’s topics include picky eaters, happy kids, joking & pretending, antibiotics & juvenile arthritis, involved fathers and vaccine advocacy. 

Picky Eaters
Happy Kids
Joking & Pretending
Antibiotics & Juvenile Arthritis
Engaged Fathers
Vaccine Advocacy

Juvenile Arthritis – PediaCast 311


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.

Dr. Mike Patrick: Hello, everyone. Welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital on Columbus, Ohio.

It is Episode 326 for August 26, 2015. We're calling this one "Picky Eaters, Choking and Pretending, and Engaged Fathers". I want to welcome everyone to the program.

I have another News Parents Can Use Edition of PediaCast lined up for you this week. We've been gone a couple of weeks, so it's good to be back. Last week, we had a CME podcast that came out. I don't advertise those too often on this program, but PediaCast CME — you can find it over at PediaCastCME — is really aimed at pediatric providers. Providers can listen and get Category 1 CME credit for doing so, free.

This is a particular one that we had last week. I think parents would be interested in this one as well. It's on evidence-based medicine, which it's kind of a buzz word that we like to use. Oh yes, I practice evidence-based medicine, and I think evidence-based medicine is important. In fact, I've said on this program many times that we're all about evidence-based medicine.

So what exactly is that? It doesn't mean that you run with every single research study that comes out because we know that some studies are better than others. Some are more powerful statistically, have more significance, have been reproduced to show that it's really true, maybe more than once.


So, how do you evaluate the literature and decide what you're going to incorporate into your practice and what you're not going to incorporate? And where does past experience, what you've learned in medical school and as a resident, things that you've seen that work and haven't worked and your patient's preferences, how does that all go in together to practice evidence-based medicine, where the science of medicine and the art of medicine are intersecting at that sweet spot?

That's what we're covering on our most recent PediaCast CME program, which again is aimed at providers. But I do think that parents will find this one interesting, because how your doctor handles evidence-based medicine affects the care that your kids get. So, it's an important topic and I think you'll find interesting.

And then, we were gone the week before that because we were on a family vacation. It was a fantastic time. I posted a picture of the family on the beach on the PediaCast Facebook page, so you can take a look at that.

We just returned from North Carolina. My wife's sister is fortunate enough to live on the beach, literally. You step outside and there's the ocean, which is great when the ocean is calm, but I guess not so great if there's a tropical storm or hurricane bearing down. Fortunately, we don't have to worry about that.

We didn't have any up close and personal shark encounters either, which had been a real concern this summer. The beach next door to theirs had two shark attacks. In fact, two teenagers lost limbs this summer. And in the other direction, that beach, there was a shark attack there as well this summer.

So before we went, we're kind of joking around. Well, actually, I wasn't joking around. I was very serious. We laughed nervously as we said it, that we were going to go out to our ankles and that would pretty much be it.

But there hasn't been any shark sightings in about a month. You get down there. The sun is shining, and people are splashing around out there. The water temperature is like 85 degrees, so just perfect. And so we did end up going deeper than we thought we would and riding the waves.


It was fun, no shark encounters, no injuries from sea creatures — except my daughter reached under the water to grab what she thought was a shell, which ended being a blue crab, which pinched her in the finger. Of course, she comes yelling and running out of the water, which, of course, get your blood pressure going a little bit. And everybody's looking around, "Hey, what's going on?" "OK, folks, go back to what you're doing. It's just a crab bite, another crab pinch, and not a shark attack." Although, it did draw blood.

So anyway, it was a great time, and thanks to the Pompeii's for their hospitality. Really appreciated that. Great times had by all, lots of relaxation, game playing, reading, sitting, watching the waves, just plain simple rejuvenation and re -energizing.

Sometimes you need that. More than sometimes, I think you need it regularly, even if it's just a quick afternoon at the library. Reminds me of those old commercials on TV for Calgon. How they would say, "Calgon, take me away." If you remember those or not. Of course, they're the folks who also gave us, "Ancient Chinese secret, huh?"

I know I'm showing my age now. Those of you who are born after the Internet hit it big are scratching your head. You have no clue what I'm talking about. That's all right.

The point is sometimes you need to get away and relax. That's what we did, but I'm back now and we have some great and practical news stories for you this week.

What exactly are we covering? Picky eaters, this is a very common problem, especially with young kids. But sometimes older kids are picky eaters, too. So when is picky eating really a problem, and what should you do about it? When should you worry? Can picky eating ever be a sign of an underlying illness? They're all good questions. We have the answers for you, including some new research that's out on picky eaters.


Then, happy kids — parents want their kids to be happy. When kids are perpetually unhappy, parents tend to worry, especially if there's a concern for depression. But how well are parents able to actually judge the true happiness levels of their kids?

It's an important question because doctors rely on parental reports of child happiness levels to determine if a kid could have depression or not. So how well do parents judge their child or teenager's feelings, we'll take a look at that.

Then, I absolutely love the next story on joking and pretending. Turns out joking and pretending are important, especially in young infants, because they positively affect development. You heard me right, babies and toddler benefit from joking and pretending. We'll explain why and give you some examples.

This story was a relief, by the way, because there is a whole lot of joking and pretending that go on in our house. And, as your kids get older, you do have a tendency to wonder if you raised them right, or did your joking around somehow messed them up. You know what I'm saying? That will be their contention, of course. So stay tuned for that one.

And antibiotics and juvenile arthritis. We've talked about juvenile arthritis in the past. It's an autoimmune disease. It's becoming increasingly apparent that exposure to bacterial microbiomes is important for a normally developing immune system. So what happens when we overuse antibiotics and disrupt those bacterial colonies in the body? Could that somehow contribute to the development of autoimmune diseases, like juvenile arthritis?

We don't have a definitive answer to that question, but we are taking steps in the right direction. The path we are taking suggest that antibiotics might play a role in all this. Of course, antibiotics can also be life-saving, but sometimes they're not. They're definitely overused, we all know that. Parents and providers alike, you've heard it before. So we'll explore this territory in more detail a little bit later in the program.


We're also going to talk about involved or engaged fathers and the role mothers play as gatekeepers — sometimes opening the gate for father involvement and sometimes closing it; sometimes closing it for good reason, and sometimes closing when they don't really need to. So we'll take a closer look at that dynamic.

Then, finally in my Final Word segment at the end of the show. I'll have some advice for pediatric providers out there who counsel parents and families on vaccines. New study suggests a bit of a different approach to improve immunization rates, not because we want to win the struggle but because we truly believe the benefits of vaccines far outweigh the risks. But what's the best way to communicate that message? We'll take a look.

Again, that last story is primarily for the providers in the crowd, but parents, you're more than welcome to stick around and listen in. We're not hiding anything. We don't have a conspiracy of pediatricians behind closed doors, trying to figure out how we can talk those parents into getting vaccines.

It's really just important to us, and we want to be transparent. Sure, we want to figure out better ways to communicate that message because we truly believe that vaccines are beneficial and really harmful in exceedingly rare cases. Certainly, driving every day in your car is more of a risk than getting your child a vaccine.

Before we get started, I do want to remind you that the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, make sure you 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 at PediaCast.org.


Also, we would love to have your questions and your comments on the show. So if you have a question you'd like to ask, if there's a topic you'd like us to talk about or you want to point me in the direction of a news article or journal article, it's easy to get in touch, just head over to PediaCast.org and click on the Contact link.

You can also call the voice line and leave a message that way. The number is 347-404-KIDS, 347-404-5437.

All right, let's take a quick break, and I will be back with news parents can use right after this.


Dr. Mike Patrick: Picky eating among children is a common but burdensome problem that can result in poor nutrition for kids, family conflict and frustrated parents. Although many families see picky eating as a phase, moderate and severe picky eating may be a symptom of a more serious childhood issue such as depression or anxiety. And these are issues that may require intervention.

This, according to a new study from Duke Medicine, which examined over 3,000 children with results published in the August 2015 edition of the journal, Pediatrics.

Researchers found 21% of children between the ages of two and six are selective eaters. Of them, nearly 18% were classified as moderately picky. The remaining children, about 3%, were classified as severely selective, so restrictive in their food intake that it limited their ability to eat with others.

Dr. Nancy Zucker, director of the Duke Center for Eating Disorders, says, "The question for many parents and physicians is: when is picky eating truly a problem? Because the children we're talking about are not just misbehaving kids who refuse to eat their broccoli."

Children with both moderate and severe selective eating habits showed symptoms of anxiety and other mental conditions. The study also found that children with selective eating behaviors were nearly twice as likely to have increased symptoms of generalized anxiety at follow-up intervals during the study.


Dr. Zucker says, "These are children whose eating has become so limited or selective that it's starting to cause problems. Impairment can take many different forms. It can affect the child's health, growth, social functioning, and the parent-child relationship. The child can feel like no one believes them, and parents can feel blamed for the problem."

The study found that both moderate and severe and selective eating were associated with significantly elevated symptoms of depression, social anxiety, and generalized anxiety.

Although, children with moderate picky eating did not show an increased likelihood of a formal psychiatric disease, children with severe selective eating were more than twice as likely to also have a diagnosis of depression.

Children with moderate and severe patterns of selective eating would meet the criteria for an eating disorder called 'avoidant restrictive food intake disorder,' a new diagnosis included in the most recent Diagnostic and Statistical Manual of Mental Disorders, known as the DSM-5.

The findings also suggest that parents are in conflict with their children regularly over food, which does not necessarily result in the child eating and families and their doctors need new tools to address the problem.

Dr. Zucker says, "There's no question that not all children go on to have chronic selective eating in adulthood. But because these children are seeing impairment in their health and well-being now, we need to start developing ways to help these parents and the doctors who care for these families know when and how to intervene."

Dr. Zucker said some children who refused to eat might have heightened senses which can make the smell texture and taste of certain foods overwhelming causing aversion and disgust. Some children may have had a bad experience with a certain food and developed anxiety when trying another new food or being forced to try the offensive food again.


She adds, what's hard for physicians is that they don't really have data to help predict when children will age out of the problem and which children won't. And so, they're trying to do the best they can with limited information and interventions.

Some children may benefit from therapy, which may include demystifying foods that cause anxiety through repeated exposure, but traditional methods may not address children with sensory sensitivities for whom some smells and flavors are too intense and may never be palatable.

Dr. Zucker says new interventions are needed to deal with children who have sensory sensitivity and frequent experiences of palpable disgust. Treatment seemed to be better tailored to a patient's age range.

One benefit to spotting picky eating in young children is that it's a condition parents can easily recognize, and it could be a good tool for identifying who may be at high risk for anxiety and depression.

Dr. Zucker says it's a good way to get high-risk children an intervention, especially if the parents are asking for help.

So lots of picky eaters out there. Definitely, one of the more common complaints that pediatrician hear about, especially in younger kids. I'm sure there are plenty of pediatricians out there who would love to be able to better define degree of picky-eating and to have interventions on hand that they could advise parents that were shown to work.

But keep in mind, this study suggest that only about 20% of all children are truly picky eaters with 18% falling into the category of moderately picky which was not associated with an additional diagnosed mental health disorder, but many of these kids do demonstrate some signs of anxiety.

Now, one has to wonder if the anxiety is really associated with the picky eating or with parental response and family interactions that arise because of the picky eating. I mean, if focus is always on what kid is or isn't eating day after day, meal after meal, it makes sense that we see anxiety creep in on the part of the child, and the parents, and the siblings as well, because the entire family is affected by mealtime struggles and dynamics, right?


Then, there are those 3% of kids who would qualify as severely selective, and these kids in the study are the ones that you really do worry about. They are twice as likely to have an associated diagnosis of depression.

So, the question becomes, how do you know if your child's eating habits are normal or if they're moderately picky or severely selective. We don't really have hard, fast rules that all pediatricians agree upon for these definitions. As it is right now, until we know more, and we have interventions that we know work and we have better definitions, doctors and parents are really forced to just look at the big picture. Is your child healthy and growing? Is he or she getting an adequate variety of nutrients to maintain good health and proper growth? Is mealtime interfering with the quality of your child's life? Is family quality of life taking a hit? And if so, to what degree?

So these are the important questions we have to answer, and we have to separate how much of the problem is intrinsic to the child and how much is related to the family's response. Because if family response is a mitigating factor, that must be brought to light and dealt with if we want the situation to improve. And now, we're talking about family counseling and family interventions, and when we get to that point, it sure is nice to have a feeding center available with adequate time and resources to help these families.

But the question remains, who exactly do you refer? Because if you referred every picky eater to a feeding program — 20% of all kids — you'd quickly overload the system. And really, some families just need reassurance. They need someone to say, "Look, your child's healthy and growing well with what they're eating. Their diet right now is adequate for them in terms of health and growth."


So let's take the focus off of mealtime, give your child some latitude and let's see where this goes on its own. Things often sort themselves out naturally in this way for many families.

A good plan, I think. Again, I don't have any data on this, and the researchers made a good point that no one does. We really don't have good data on what works and what doesn't work, but we do have our past clinical experience. All of us as pediatricians, we worked with families who have these problems. We do start to see what kind of things work and what doesn't work. Even if you're not a principal investigator in a research institute, you do have your collection of patients and your own experience matters, too.

So good plan, I think. It's worked well for many of the families I've counseled over the years. Again, in this case, we're talking about picky eaters who were healthy and growing as expected, not those 3% which we'll get to.

Moms and dads, in this case, you pick what food your kids has access to. You buy the groceries, you prepare the meals, you make the snacks. So you pick which foods they can have, keeping in mind your child's preferences and aversions, because we love our kids and we want them to be happy. We don't want to give in to everything, but at the same time, we don't want to say, "No, you can never have anything you like."

So let the child then pick how much of those foods he or she is going to eat, and sometimes that's going to be none of it. Sometimes, we let them pick when he or she is going to eat. So you give your child some control, but not unfettered access to cookies and cake.

Once we have a plan in place with known expectations and more predictable outcomes, anxiety tends to lift. And when anxiety lifts, a lot of times things sort themselves out naturally.

Now, the investigators of the study fret that we don't have data on these types of interventions, which we'd love to have the data. We'd love to know what works and what doesn't in a little bit of a better way that show where we can look at the numbers. But until we do, pediatricians are going to go with their past experiences. Again, what have you seen that works, what doesn't work.


You get a doctor with a decade or two under his or her belt, and they may not be out there publishing their data, but they certainly do have some sage advice to offer on what you can do to relieve anxiety and keep your picky eater healthy and growing well.

So, I know I'm repeating myself but I think this is really important, and your doctor is going to know and have great insight into which families need referral to a formal feeding program and which ones don't.

You know, in areas of medicine where we lack hard data and published evidence — and there are many areas of medicine like this — that's where the art of medicine really does have a chance to shine, because the art of medicine is still important even when we take evidence-based medicine seriously.

In fact, as I was talking about in the intro to the show, an important element of evidence-based medicine practice, is the evidence a seasoned doctor has seen firsthand? Is she or he cares for young patients and families day in and day out. We don't want to get to the point where we completely discount that experience and rely solely on p-values and confidence intervals, because scientific studies have their own problems including bias and erroneous conclusions. So, there has to be balance.

I think the real value of this research is showing us that only 3% of kids, the seriously selective ones, have an increased risk of formally diagnosed mental health problem such as depression, which is not really a surprise since we know eating problems can be a sign of depression. At the end of the day, this should be reassuring to parents who have picky eaters at home.

Most picky eaters do not suffer health, including mental health or growth problems. Most outgrow their pickiness. There may be some associated anxiety. Family response and interactions may play a role in that anxiety, but there are things we can do to ease those difficulties. While we don't have data on the best interventions quite yet, seasoned pediatrician will likely have some great ideas for you, ones that are likely to work.


For those 3%, the seriously selective who's health or growth may be suffering or whose quality of life, or the family's quality of life is suffering, your pediatrician will know what to do for you, too. Which will probably involve a referral to a community resource that can sit down and spend more time working with you and your family.

So moms and dads, whether you have a moderately picky eater or a seriously selective one, or maybe you don't really know how to best characterize your child, but you have a concern about your child's eating habits — even if it's just a itty bitty tiny concern — your best bet, as always, is to bring up your concern with your child's primary care provider. That's always the best place to start.


Dr. Mike Patrick: Parents' estimation of their children's happiness differ significantly from the child's own assessment of their feelings. This, according to a study from Plymouth University and published in the Journal of Experimental Child Psychology.

Investigators found that parents of 10- and 11-year-olds consistently overestimated their child's happiness, while those with 15- and 16-year-olds were inclined to underestimate happiness.

The study attributes the discrepancies to an "egocentric bias" through which parents rely too heavily on their own feelings in assessing the happiness of the family unit as a whole.

Research on happiness in children has gained considerable attention in recent years. However, the investigators of this study say the potential problems of relying on parental reports to assess the child's happiness had been overlooked.

They go on to say, their study could provide valuable information not only for advancing knowledge about wellbeing but also for improving parent-child relationships and paving the way for carrying out improved interventions.


The study was conducted by Dr. Belen Lopez-Perez, a postdoctoral research fellow in developmental and social psychology at Plymouth University, and Ellie Wilson, a recent student in the program.

They questioned a total of 357 children and adolescents from two different schools in Spain, along with their parents, and their happiness was assessed using a range of self-reporting measures and ratings.

The results showed that parents were inclined to score a child or adolescents' happiness closely in line with their own emotional feelings, whereas in fact there were notable differences in the child's own reports.

In this regard, children and adolescents reported very similar levels of happiness, however parents reported different levels depending on the age of their child. Thus, the study not only showed discrepancies between informants but also a decline in the level of happiness in the parents of adolescents.

Dr. Lopez-Perez says, "Studying informants' discrepancies and the relationship between parents' and children's self-reports on happiness is vital to determine whether parental report is valid. Being unable to read a child or teenager's happiness appropriately may increase misunderstanding between a parent and his or her children, which has been shown to have negative consequences for parent-child relationships.

Furthermore, parents might not be able to provide the appropriate emotional support or attend to their child's needs accurately."

So we gleaned some interesting insights from this study, that parents have a tendency to project their own happiness on to their children which doesn't always measure the true happiness level of the child.

There are take-home points here for both parents and providers. For parents, we must be mindful how our feeling affect the lens through which we see our kids.


I think — although I don't have a study to back me up on this, but until I do, I'll go with this thought — the closer we maintain relationship and communication with our children, I think the better we'd be able to have a true sense of their happiness. I think we're more likely to project out our own happiness on to them, maybe when we don't have as close of a relationship with them. That would be my hypothesis.

Again, this idea wasn't measured at all in this study, but it's a hypothesis I think would be interesting to look into. Because, at least on the surface, it seems like it could be valid, which if it's true gives us more reason to maintain close relationships.

So, there you go, a great study for someone — does the closeness of the parent-child relationship affect how well a parent can judge their child's feelings?

For the providers in the crowd, the take-home point is an important one. We have to realize that parents of pre-teens may have a tendency to overestimate their child's happiness, and parents of teenagers may have a tendency to underestimate their child's happiness. Maybe because the parent is not all that happy, because it's hard parenting some teenagers, saying other things are going on in life as well.

So, important points to consider when we are assessing the mental health of our families.

Parents who joke and pretend with their parents are teaching them important life skills, which in our house is a very reassuring research finding.

This study comes from the University of Sheffield and is published in the journal Cognitive Science.

Investigators found that children as young as 16 months old naturally learn the difference between joking and pretending by picking up on the cues of their parents. It also showed understanding the difference between joking and pretending, allows young children the opportunity to learn, imagine, bond and think in abstract ways.

Researchers from the University of Sheffield's Department of Psychology carried out two studies. The first one involved parents being asked to joke and pretend with their 16- to 20-month-old children using actions. Jokes involved misusing objects like putting food on their heads, and pretend play included activities like washing hands without soap or water.


In the second study, parents of 20- to 24-month-olds were asked to joke and pretend verbally with their toddlers. Pretend play included parents telling their children that a round block was a horse, and jokes included mismatching items like saying that a toy chicken was a hat.

Investigators found parents can offer explicit cues to help distinguish between joke and pretend intentions, and children, even as young as 16 months old, pick up on those cues.

In both studies, parents showed more disbelief and less belief through their language and actions when joking in compared to pretending. In response, their children showed less belief through their actions, and the older children showed less belief through their language.

Dr. Elena Hoicka, from Sheffield's Department of Psychology, says, "The study shows just how important play is to children's development. Parents who pretend and joke with their children offer cues to distinguish the difference between the two and toddlers take advantage of these cues to perform.

"For example, if a parent says something like, "That's not really a hat!" children would realize it was a joke, and not real, and would avoid putting the toy chicken on their head. But if parents were pretending that, for example, a block was a horse, they might repeatedly make the horse gallop, which would encourage children to do the same, and understand that the block really was a horse in their imagination."

Dr. Elena Hoicka adds, "The research reveals the process in which toddlers learn to distinguish joking and pretending. Knowing how to joke is good for maintaining relationships, thinking outside the box, and enjoying life. Pretending helps children to practice new skills and learn new information.

"So parents may feel a bit daft putting a toy chicken on their head, they can at least console themselves with the knowledge that they are helping their children develop important skills for life."


Future research projects include parent surveys on joking and pretending to see how these abilities develop from birth through to three years old.

So there you go, joking and pretending, not only fun but important contributors to learning and imagining, and bonding, and thinking in abstract ways. All good things and good to know.


Dr. Mike Patrick: Taking antibiotics may increase the risk that a child will develop juvenile arthritis. This, according to a study from Rutgers University, the University of Pennsylvania and Nemours A.I. duPont Hospital for Children and recently published in the journal Pediatrics.

Researchers found that children who were prescribed antibiotics had twice the risk of developing juvenile arthritis compared to children the same age who were not prescribed antibiotics. The more courses of antibiotics prescribed, the higher the associated risk, and the risk was strongest within one year of receiving antibiotics.

Between 4,300 and 9,700 children under the age of 16 are diagnosed with juvenile arthritis each year, that's according to the latest Centers for Disease Control and Prevention statistics.

Juvenile arthritis is a form of autoimmune disease and involves chronic inflammation of the joints and eyes that can lead to pain, vision loss, and disability. Genetics only explains why one quarter of children develop arthritis, which means environmental triggers may also play an important role in the onset of the disease.


Previous studies indicate that about a quarter of antibiotics prescribed to children — and half of antibiotics prescribed for acute respiratory infections — are probably not necessary.

Dr. Daniel Horton, lead author of the study and a post-doctoral research fellow working in the Department of Pediatrics at Rutgers Robert Wood Johnson Medical School, says, "Our research suggests another possible reason to avoid antibiotic overuse particularly for infections that would otherwise get better on their own."

Researchers began the study in 2014 because previous investigations showed antibiotics could predispose children to develop other chronic diseases, including inflammatory bowel disease. Disruption of microbial communities in the intestines and elsewhere appears to play a role in inflammatory bowel disease and other autoimmune diseases, including rheumatoid arthritis in adults. Dr. points out that antibiotics are one of the better known disruptors of human microbial communities.

Using The Health Improvement Network (THIN), a database with information on over 11 million people across the United Kingdom, the researchers compared children with newly diagnosed juvenile arthritis with age- and gender-matched control subjects. The database provided researchers with high-quality data on diagnoses and prescriptions for people under general practitioners' care.

Of the roughly 450,000 children studied, 152 were diagnosed with juvenile arthritis. After adjusting for other autoimmune conditions and previous infection, children who received prescriptions for antibiotics had an increased risk of developing juvenile arthritis.

Researchers also found that upper respiratory tract infections treated with antibiotics were more strongly associated with juvenile arthritis than untreated upper respiratory tract infections. Additionally, they noted that antiviral and antifungal drugs were not linked to juvenile arthritis, suggesting that risk for arthritis was specific to antibacterial medications.


Dr. Brian Strom, chancellor of Rutgers Biomedical and Health Sciences and a senior author of the study, says, "This is an extremely important clue about the etiology of this serious and potentially crippling disease. If confirmed, it also provides a means of preventing it."

Viral infections have been suggested as triggers for juvenile arthritis, but multiple studies argue against this hypothesis. According to Dr. Horton, what is more clear is that children with juvenile arthritis have a higher risk of serious infections, in part because the immune system does not protect against infections as well as it should.

So an alternative explanation to our findings is that this abnormal immune system makes children more susceptible to serious infection even before they are diagnosed with arthritis. And under this hypothesis, antibiotics would be a marker for abnormal immunity rather than a direct cause of arthritis.

He adds, "A majority of children get antibiotics, but only about 1 in 1,000 get arthritis. So even if antibiotics do contribute to the development of arthritis, it's clearly not the only factor."

Dr. Horton cautioned that additional research is warranted to confirm these findings and to understand the mechanism that might link antibiotic use and arthritis in children.

So like many research studies in medicine, this one doesn't give us a definitive answer but it does point us in an important direction as we consider autoimmune diseases like juvenile arthritis and try to prevent them.

Take-home points for parents and providers is really the same, and it's a take-home points I've said before, and one you've heard before, not just from me. Antibiotics are great when a child truly needs them, but when you don't really need them, don't use them. Because antibiotics do have their own risks, like the development of resistant bacteria when they're overused.

Another one of those risk might be a role in the development of autoimmune disease but as the authors point out, an alternative explanation is that there's just something going on with the immune system that ends up causing juvenile arthritis. But before the arthritis really kicks in, that something going on with the immune system makes infection more likely, which makes it more likely that kids will get antibiotics.


So the two, the antibiotics and the arthritis are just associated with each other because of the underlying immune dysfunction. It's not that the antibiotics caused the arthritis. But maybe it does, we just don't know yet.

So more to come on that, but interesting stuff.

That's why you have to evaluate these studies that come out and decide how that's going to affect your practice in evidence-based medicine. So, it's also important that the art of medicine and the science of medicine intersect.

If you would like to know more about juvenile arthritis, we did a show on that a few months back, PediaCast 311 with Dr. Charles Spencer. He's the guy on the Sherlock Holmes garb. You might have seen him on our Facebook page. Because pediatric rheumatologist do a lot of investigative work to arrive at a diagnosis, that was his point, which he made in a rather fun and dramatic way.

I'll put a link to that episode, 311, in the Show Notes for this episode, 326, over at PediaCast.org.

For this next story, we're going to talk about engaged fathers. Now, they're not engaged to be married. We're talking about involvement as being a father — engaged, involved.

New mothers take a close look at their personal relationship with their husband or partner when deciding how much they want him engaged or involved in parenting. This is according to research from the Ohio State University and published in the journal Parenting: Science and Practice.

The study found that mothers limited the father's involvement in child-rearing when they perceived their couple relationship to be less stable. Mothers also limited fathers who were less confident in their own ability to raise children.

Dr. Sarah Schoppe-Sullivan, co-author of the study and professor of human sciences at The Ohio State, says, "The bottom line is that new mothers are assessing their partners' suitability to be a parent.

"New mothers are looking at their partner and thinking, "Is he going to be here for the long haul? Does he know what he is doing with children?" because, this assessment by mothers is really what is most critical in gatekeeping among the couples we studied."


'Maternal gatekeeping' is the term researchers use to describe the behaviors and attitudes of mothers that may support or limit father involvement in child-rearing.

Gate-closing behavior includes actions like criticizing the father's parenting, redoing tasks the father has already completed and taking over parental decision-making. Gate-opening behavior includes asking the father's opinion on a parenting issue and arranging activities for the father to do with the child.

Dr. Schoppe-Sullivan, says, "We wanted to find out the characteristics of mothers and their families that may make some mothers more or less likely to act as gatekeepers. Because if we want to increase fathers' involvement in child-rearing, we need to know what may be limiting their participation."

Researchers used data from the New Parents Project, a long-term study co-led by Dr. Schoppe-Sullivan that is investigating how dual-earner couples adjust to becoming parents for the first time. In all, 182 couples participated in this study. All the couples were assessed twice — once during the third trimester of pregnancy and again three months after the baby was born.

Results showed that mothers were more likely to push fathers away from child-rearing at three months if they reported during their third trimester that they had considered divorce or separation, or if they didn't think things were going well with their partner.

Mothers also were more likely to "close the gate" on fathers who reported during the third trimester that they didn't feel confident about their parenting skills, such as the ability to do things like soothe a crying baby.

Mothers who were perfectionists or who were more anxious and depressed were also more likely to limit fathers' child care involvement.


Surprisingly to the researchers, mothers who held more traditional gender attitudes, such as "mothers are instinctively better caretakers than fathers", were not more likely to "close the gate" on fathers than other women. Dr. Schoppe-Sullivan says more research is needed to investigate this finding,

Also, somewhat surprising was that mothers who indicated religion was more important to them than it was to others were more likely to encourage fathers' involvement in child-rearing. The researchers thought that religious views might be linked to gate-closing by mothers because some religions and religious groups have a strong belief in traditional gender roles.

However, ,Dr. Schoppe-Sullivan says this sample of highly educated, mostly high-income couples might be different from typical religious people. In addition, many religious teachings emphasize the importance of family relationships, which may encourage more father involvement.

The study found that women who were particularly confident about their child care skills when they were pregnant were also more likely to discourage fathers' involvement in child care.

Dr. Schoppe-Sullivan says, "There's this social belief that new mothers have a natural instinct to be a parent, even though they don't have any more experience than new fathers. So mothers who are particularly confident are in the position of being seen as the expert parent, while fathers are left to be the apprentice."

She adds, none of these results should be seen as blaming mothers for shutting out fathers — "Gatekeeping is a dynamic process that includes both partners. Part of this is mothers judging fathers. But if the mother has bad feelings about the father's ability or desire to take care of the child, it may be accurate. It might make sense to put up some barriers."

However, she says in some cases, mothers should have more realistic expectations of fathers, and moms need to differentiate between parenting decisions that are dangerous and those that are simply a matter of choice. "There are a lot of things in parenting that don't have to be done in one particular way, such as clothing choices. Moms should give dads the latitude to make some decisions on their own."


Dr. Schoppe-Sullivan says, as a society, we can do more to help new fathers by offering them information and training about parenting and by boosting their self-confidence in their ability to care for children. Gatekeeping can be a barrier to gender equality in relationships and we want to find ways to break down those barriers.

So I think the story speaks for itself. Moms, please open the gate when it's safe to open. And fathers, go ahead, walk right through.


Dr. Mike Patrick: My final word this week is aimed at the pediatric providers in the audience, but parents you're welcome to listen. We're not trying to hide anything here.

It might not be possible to convince someone who believes that vaccines cause autism that they don't. Telling skeptics that their belief is not scientifically supported often backfire, strengthening rather than weakening their anti-vaccine views. But researchers say they have found a way to overcome some of the most entrenched anti-vaccine attitudes — remind the skeptics with words and images why vaccines exist.

The researchers report their findings in the Proceedings of the National Academy of Sciences.

The widespread fear of vaccines got its start in 1998, when The Lancet medical journal published a study of 12 children that claimed to link the measles, mumps and rubella vaccine to a later onset of autism. The study was quickly refuted and eventually retracted and follow-up studies showed a very different answer, but the idea that vaccines might endanger children's health took hold.

Though outbreaks still occur, most young parents have never seen measles, mumps or rubella in their lifetime, thanks in large part to the efficacy of vaccines. Many have, however, heard accounts of children with autism whose behavioral difficulties became evident days, weeks or months after their first vaccinations.


Parents who decline to vaccinate their children often focus on the perceived risks of vaccines. This is according to University of Illinois graduate student Zachary Horne, who conducted the new study with psychology professors, Dr. John Hummel and Dr. Keith Holyoak of the University of California at Los Angeles, and UCLA graduate student Derek Powell.

Mr. Horne says, "Perhaps we need to direct people's attention to the other aspect of the decision." Mom or dad may be focused on the risk of getting the shot, but there's also the risk of not getting the shot, and you or your child could get measles, or mumps, or pertussis.

While measles have previously been eradicated in the US, travelers to other parts of the world sometimes bring these diseases home and infect others — quite often children or adults who have not been vaccinated. In addition to the recent outbreak of measles centered around Disneyland, a 2014 measles outbreak infected 383 people in the Midwest, many of them living in unvaccinated Amish communities in Ohio.

A previous study attempted to moderate people's anti-vaccination views using a variety of approaches, including challenging anti-vaccine fears and sharing science-based information about the dangers of preventable diseases. In that study, these approaches failed.

In the new study, the researchers tested 315 participants' views about a number of potentially controversial subjects, including their attitude towards vaccines and their willingness to vaccinate their children.

Participants were then randomly assigned to one of three groups. The first looked at materials challenging the anti-vaccination point of view.

The second, a "disease risk group," focused on the risks associated with measles, mumps and rubella. Participants read a paragraph written by a mother about her child's infection with measles, saw pictures of a child with measles, a child with mumps and an infant with rubella, and read three short warnings about the importance of vaccinating one's children. This intervention was more in-depth than those in the previous, unsuccessful study.

A third group, serving as controls, read about a subject not associated with vaccines.


Afterwards, participants again completed the vaccine attitude evaluation and answered questions about their past vaccine behaviors and their intention to vaccinate their children in the future.

Mr. Horne says, "We found that directing people's attention to the risks posed by not getting vaccinated, like getting measles, mumps and rubella and the complications associated with those diseases, changed people's attitudes positively towards vaccination — and that was for even the most skeptical participants in the study," He adds, "Actually, the largest effect was for people who were the most skeptical."

"Of course, skeptics are the people with the greatest amount of room to move, so in a sense that finding is unsurprising," But, he says, it's also extremely important, because those are precisely the people you want to move. That's the kind of result we were really looking for."

Mr. Horne said he thinks the study was successful in part because it addressed the primary concern of parents, which is their children's wellbeing.

He says, "People who fear vaccines ultimately do care about the safety of their children, so our manipulation focuses on the safety of their children. So that's not just one calculation in your decision whether to get a vaccination, but now there are two."

So I hope covering this study isn't that too unsightly for the parents in the crowd. As I said in the beginning, nothing to hide here.

I don't necessarily like the author's use of the word 'manipulation' really. I don't see it as manipulation. It's really education. You know, back in the day, moms and dads knew all too well the complications and side effects and terrible things that can happen when a kid is infected with measles, and pertussis and diphtheria and polio. We've really become victims of our own success because parents don't have to experience these diseases anymore.


Now, if herd immunity continues to break down and moms and dads see living examples of these diseases and hear stories of real life tragedy, then the risk-benefit discussion goes in a very different direction, and decisions start swaying the other way.

As doctors, we're trying to prevent that scenario. We don't want to see our children serving as examples. So, we do need to share those pictures and stories from the past, not to manipulate, but to sound a warning and educate on the dangers of these diseases, with the hopes that more children will get vaccinated — which not only protects themselves and their families but also strengthen the broader herd immunity within the community.

That's my two cents anyway, and as it turns out, it's my final word.

I do want to thank all of you for making time out of your day to include PediaCast in it, really do appreciate that.

That's all the time we have. PediaCast is a production of Nationwide Children's Hospital.

Don't forget, you can find PediaCast in all sorts of places. We're in iTunes and most podcasting apps for iPhone and Android, including the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher and TuneIn.

We're also on iHeart Radio, where we not only have this program, we also have PediaBytes, B-Y-T-E-S. They're shorter clips from this show, and they can be weaved together with other content providers to make your own custom talk radio station.

Then, there's the landing site, PediaCast.org. You'll find an archive featuring hundreds of past episodes there. We also have transcripts of each program, in case reading suits your taste, and a handy contact page to ask questions and suggest show topics.

We also have a voice line if you'd rather phone in your question or comment. Our number is 347-404-KIDS, 347-404-5437 if you need the digits.

We're also on Facebook, Twitter, Google Plus and Pinterest with lots of great content you can share with your own online audience.


Of course, we always appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids or those who take care of children, including your child's health care provider. Next time you're in for a sick office visit or a well-check up or a sports physical, or a medicine recheck, whatever the occasion, let them know you found an evidence-based pediatric podcast for moms and dads. We've been around for nearly a decade with lots of great content, deep enough to be helpful, but in language parents can understand.

And, while you have your provider's ear, let them know we have a podcast for them as well, PediaCast CME. It is similar to this program, we do turn up the science a couple of notches. We also include some faculty development topics, so folks who are in academic medicine — whether that be a physician who practices at a university or a large children's hospital, but also a lot of community physicians have medical students and residents rotating through their offices — at PediaCast CME, we do provide some podcast with ideas on how better to educate up and coming doctors.

So make sure you check that out, or at least let your physicians know when you go in for a well check-up. Because, really, we don't have a big advertising budget here. We rely on word of mouth. We increase our audience through organic means, because we want to be useful. We don't want gimmicks and marketing. We want to provide something useful for folks, but it is helpful if you can let your doctors know about it.

So PediaCast CME — by the way, those episodes, we do provide free Category 1 Continuing Medical Education Credit. Here in Ohio, I think it's 50 — I should know, since I have to do it, and I do, I do it — you have to do 50 hours a year of Continuing Medical Education, and this counts towards that.


That's in Ohio. Other states are going to have a little bit of a different requirement. But we do offer free Continuing Medical Education Credit for listeners. If you go to PediaCast CME.org, let your doctor know they can do it all on one webpage. Just go there, you read the Continuing Medical Education information. It's got the Learning Objectives, you can listen to the podcast right from that page. You can take a Post-Test right from that page. And you pass the Post-Test, a certificate of completion gets emailed to you immediately.

So, you can look really smart when you go on to tell your doctor about this because you know all the details. Be sure to let him know.

Also shows in Details, so they can see what exactly what we have to offer in the Details on the CME Credits. It's all available at PediaCastCME.org.

All right, once again, I want to thank all of you for stopping by. I really do appreciate that, and until next time.

By the way, our next show is going to be an Answers to Listeners show. We got a bunch of those lined up for you, so be sure to stay tuned for that. That will be next week.

Until then, 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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