Potty Training, Sports Drinks, Hearing Loss – PediaCast 365

Show Notes


  • This week we answer YOUR questions. Topics include distracted drivers, early potty training, Tdap for adults, homemade sports drinks, ADHD behavior and conductive hearing loss. We hope you can join us!


  • Distracted Drivers
  • Early Potty Training
  • Tdap for Adults
  • Homemade Sports Drinks
  • ADHD Behavior
  • Conductive Hearing loss



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, and 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. We're in Columbus, Ohio.  

It is Episode 365 for January 11th, 2017. We're calling this one "Potty Training, Sports Drinks, and Hearing Loss." I want to welcome everyone to the program.  

It's going to get some taking used to say 2017 instead of 2016. In fact, on my script here, I wrote 2016. But I caught it. It's 2017. And it's January, which means it's the time of the year that I usually get a cold and I have one now. So it's why my voice sounds a little different. And if there's a few coughing episodes in the course of the program, I'll try to edit out as many of those as I can. But if I miss one or two, please forgive me but we'll try to make it through. It's that time of the year, you know. When you're seeing sick kids, just the hazard of the job, you sometimes get sick yourself. 

But the show must go on. And I have a lot of great contents for you. We have an Answers to Listener Questions edition of the show for you this week. And I love preparing and producing these segments because PediaCast really is about you, the audience. And I love talking about what you want me to talk about. 

And of course, if one listener has a question, plenty more have that same question or a similar one. So we really are I think being most helpful in addressing what's on the mind of the audience when we do these Answers to Listener Questions shows. Plus, I don't have to come up with the topics. You do that for me. So it does make my job a little bit easier. 


Now, you may be asking yourself, how do I get my question on the show? It doesn't have to be a question that pertain… It can really be any sort of question or comment. So, it might be something that's going on in your house right now, maybe a disease process or something with your child that you have a question about. 

Maybe it's just something that you heard in the news. It's not really affecting your house but you think it could in the future. Or it affects someone you know. Or you're just generally interested in it and it's a pediatric topic. Feel free to ask away. 

And it doesn't have to be medical. Pediatricians ask a lot of parenting questions. And so, I'm happy to answer those in the best way that I can as well. 

And of course all of our answers are researched and evidence-based to the best of our ability. 

So if you do have a question or a comment, it's easy to get in touch. Just head over to PediaCast.org and click on the Contact link. At the top of the page, you'll see Contact Dr. Mike. Just fill that out, send it in. I do read each and every one of those that come through. And just like all of our other listeners who wrote in and ask questions that we're answering today, we'll try to get your question in on a future show. Hopefully, in the near future. 

All right, we're going to talk about the entire line-up because most of you know that we cover more topics that I mention in the show's title. So potty training, sports drinks, and hearing loss, we do have some other topics. I'll get to those in just a minute. 

First though, you're probably aware that distractive driving is a prevalent safety hazard for everyone. But did you know it's especially true for drivers in their first several years behind the wheel? This is according to a new study from the Center for Injury Research and Policy at the Research Institute here at Nationwide Children's Hospital, which shows that universal handheld phone bans — so when a government body bans the use of handheld phones universally for all drivers — that may be effective at reducing handheld phone use particularly among young drivers. 


And this was a study recently published in the Annals of Epidemiology. They examined data for young drivers handheld cell phone use across the country from 2008 through 2013 and compared it to state legislation regarding cell phone use while driving. 

Nationally, over the six-year period, young drivers in states with a universal handheld phone ban were 58% less likely to have a phone conversation while driving compared to those in states without a ban. And this effect increased the longer the law was in effect.
Dr. Motao Zhu, the study's lead author and principal investigator in the Center for Injury Research and Policy at Nationwide Children's Hospital, says, "We know traffic crashes are the leading cause of death for young adults between 15 and 24 years of age, and distraction is a key factor in many of these crashes. Our study shows that handheld phone bans work. We encourage all states to implement universal bans on handheld phone use while driving to help keep everyone safer while they're on the roads." 

The investigative team recommends a universal ban because it is easier to enforce than a ban based on age, and everyone benefits from roadways with fewer distracted drivers.
Data for the study was obtained from the National Occupant Protection Use Survey, which uses roadside-observed handheld phone conversation at stop signs or traffic lights in cities across the United States. The study also looked at state legislation regarding cell phone use while driving.

So my first comment with this study, I bet you didn't know that someone was watching you at stop signs and traffic lights to see if you're using a handheld phone. So if you see a guy with a clipboard making tally marks at the intersection, now you know what's going on. 


I can just see that. Not really. I'm sure it's much more subtle than a guy with a clipboard. But you know there's that chance someone's watching you and keeping track of this. 


Second, keep in mind that we're talking about holding the phone and using it while you drive. So conversations by Bluetooth and In-car, hands free, where you have the microphone and speaker, but you still have both hands on the wheel, those are OK. So you can still call the office and let them know you're going to be late. You can call home and get the shopping list that you need on your way home from work. Maybe your kids got home from school and they need something for you to pick up on the way and you're checking in with them. You can do that. The idea here is just don't fiddle with the phone while you're driving. Don't take your eye off the road. 

Third, even if your state doesn't have a ban, don't fiddle with your phone while you drive. Be a good role model for all kids, but even at a young age, impress upon them that you don't handle the phone while you drive, period. So don't do it yourself and let them know how you feel about it consistently and at a very young age. That way, when it's their turn to drive, they'll have a healthy respect for the danger and just becomes second nature to them. No, you don't use a phone while you drive. You don't do it. 

And that's something you can do right now to help protect your kids in the future, by being that role model and talking about it even when they're really young.

But I do understand the author's point here about having the ban. I'm not just saying that because they're from our host institution. Our laws that ban divers from fiddling with their phones while they operate their motor vehicle sure seems like a good idea to me. Hands on the wheel, eye on the road, attention to the crazy drivers around you. That habit has saved many a life. 


All right, so what else are we talking about today besides distracted drivers? Again, this is a line-up that you created. Early potty training. why are some children ready to potty train earlier than others. Why are there differences based on culture and even time periods, as we hear about stories of kids being potty trained much earlier in past centuries. 

So we'll consider that question and give you some hints on how to potty train earlier, but also to talk about do you really want to do that? What are some of the risks of early potty training, in addition to the benefits. So that's coming your way as we think about potty training and why some kids do it earlier than others. 

And then, a Tdap vaccine. How often should adults get it to protect babies in their care? And what about pregnant moms, what are the recommendations for them? 

Then, we'll turn our attention to sports drinks. We have a great episode a few months back on sports nutrition but we failed to share a recipe for homemade sports drinks. We talked about it but we didn't tell you to make them yourself at home. And a listener complained about that omission, so we plan to correct that this week by sharing a homemade sports drink recipe with you, one that's tried and true. Lots of kids like drinking it, so I think you'll find that helpful. 

And then, ADHD and oppositional behavior, what are some of helpful tips on engaging kids with ADHD and oppositional defiant behavior? We've covered ADHD and oppositional behavior in previous shows. And I'll point you in the direction of our previous work on that. But I also want to share some insight on engaging these kids in a helpful and positive way because sometimes that little extra step along with the right diagnosis, the right medication, the right counselor, the right classroom, all these things are important. But sometimes, how the parent engages, that can make or break the rest of the plan. So we'll walk through that. 

Finally, a listener has a question about conductive hearing loss — what is it, what causes it, how is it treated? So stick around for that discussion coming up near the end of the program. 


All right, one more time, if you have a question or comment, now is the time to ask because we did get caught up with this one on a lot of our questions. The question bank is empty. We need more questions and comments from you. So, if you have something that you've been wanting to ask, now will be a great time to do it. Just head over to PediaCast.org and click on the Contact link and we'll try to get your question or your comment on the program. 

Also, I want to remind you, 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, 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 at PediaCast.org. 

Let's take a quick break. And, I will be back to answer your questions. It's coming up right after this. 


Dr. Mike Patrick: We have a question from Julia in New Zealand. Julia says, "Hello, Dr. Mike. I recently discovered your podcast and had been listening to several episodes per day. I especially enjoyed the episode on the origins of the vaccine war. I have always been a supporter of fully vaccinating but mostly relied on my intuition rather than any data. It's great to know the full story especially when talking to other moms. 


"My question today is slightly outside of the medical realm but I am very curious nonetheless. I have a six-month-old baby and we're using disposable diapers. My parents keep saying that in their day, potty training started at six months and babies often went diaper-free by 12 months. 

"Nowadays, though, it's not unusual to see a two-year-old in diapers. Why is there such a big difference in the perceived abilities of modern kids compared to kids born in the 1980s? And what about the generations before diapers such as the late 19th century? How did they potty train? Thank you. Julia." 

Well, thanks for the question, Julia. It's a great one. And I'm sure that other parents in lots of different places, it's a question that comes to their mind as well. There is great variation among potty training times — you know, when kids do it — as we compare one child to another, one culture to another, and even one time period to another. 

And I covered a pediatric news story back in 2013, Episode 244 in fact, about infants being successfully potty trained in Vietnam. And I want to consider the details of that story again because I think it really sheds light on the mechanism of how early potty training takes place, which in turn gives us an idea of exactly why there is so much variation as we consider one child to another, one culture to another, and even one time period to another. 

So, you've probably heard that babies and toddlers aren't ready to be potty trained until the nerves and muscles that control bladder and vowel habits have matured and are ready for voluntary use. In other words, the parts have to be ready and willing to open and close. Or, in muscle and nerve terms, they have to be ready to contract and relax when the child wills them to do so. And no matter how hard you try, potty training won't happen successfully and consistently until these things have matured. 


And, traditionally, we have considered the child's age as the limiting step in when these things are ready to work on demand. However, Dr. Anna-Lena Hellstrom — she's a pediatric urologist and researcher from Sweden — she published the story from Vietnam which we'll get to in a moment in the Journal of Pediatric Urology. She proposes that maturation of these nerves and muscles, so they're ready for voluntary control, is not so much a function of the child's age, but rather a function of consistent and effective potty training. 

In other words, when you start the training, whatever the age it is, the nerves and muscles mature. And that theory would explain why we have such great variation time from one kid to another, one culture to another and one time period to another. As we compare these things, we find that parents start potty training at different times. And babies and toddlers gain the ability when parents start potty training.

As an example of her theory in action, she points to Vietnam. So let's take a look at what has been observed there. Mothers in Vietnam provide constant attention to their babies, right from birth. Because of this, they're able to catch them in the act of peeing or pooping. Each time they catch them in the act, especially of peeing, right really from the beginning, the mother makes a distinctive whistling noise. So, it doesn't take long for the baby to figure out that that sound is associated with going potty. 

By three months of age, many babies will consistently urinate on command when mom makes the whistling noise. And by nine months of age, they're so good at doing this that the mom is able to get rid of the diapers at least in terms of urine. Now, passing stool does take a little longer. But again, mom pays constant attention and she can tell when the baby's about to pass a bowel movement. And she prepares where the baby is going to poop and then takes care of it. 


So it can happen early today in 2017 at least in the Vietnamese culture. But the key really is constant attention and anticipation. And that's where things are a bit different in Western culture even compared to the 1980s. Most parents simply don’t have time for constant and consistent attention and anticipation. 

We're distracted, we work. We entrust a good portion of baby and toddler awake time to babysitters and daycare workers who really aren't set up to provide constant one-on-one attention. We're distracted with activities of older sibling and with our own activities and hobbies and mobile devices, and televisions, sporting events. We can't find time to eat together as a family on a regular basis. At least, that's true for many of us. 

So potty training happens when we get around to it. And when we get around to it is later today than it has been in previous time periods. But here's the thing. It's OK. It happens when it happens. They get potty trained. 

And other research tells us that the earlier that kids are potty trained the more likely that they will hold their bladders and bowels longer than they should, because they're busy and want to kid just like we are and want to keep playing rather than taking the time out to use the restroom. We know that prolonged bladder holding is associated with an increased incidence of urinary tract infections, and prolonged bowel holding is associated with an increased incidence of constipation. 


So we have good reasons not to rush things. Just because you can't potty train sooner doesn't mean that you should. And when you look at the Vietnamese model, do you in the life you live now have time and opportunity for that plan? Maybe in the 1980s, some folks, but really today, not so much — at least if you live like most Americans, or in your case, Julia, like most New Zealanders. Because I get the feeling that your culture is probably a whole lot like ours. 

With regard to the pre-diaper era, I'm not sure there ever was a pre-diaper era. As long as there'd been clothes, I imagine there had been some form of diaper. Maybe not as we picture them today. They may have not been as absorbent, probably not disposable, unless you're really wealthy. 

Cleaning them was likely fairly large choir, but mothers tended to stay home with their kids. So they had the opportunity to clean up those things. But they also had the opportunity to potty train earlier and they did. 

Hope that answers your question, Julia. As always, thanks so much for writing in. 

Our next question is from Amber in Irvine, California. "Hi, Dr. Mike. I've been a long-time fan of your podcast. I listen to your episodes during my commute to and from work. And I truly appreciate the time you take to provide such a valuable resource to parents. 

"I'm currently pregnant with my first child. My OB-Gyn has told me that my husband (who received the Tdap a little over two years ago) and my father-in-law (who received it about nine years ago) both need to get the shot again since they will be around the baby. However, my father-in-law's doctor says he only need the shot once every ten years. And my mother-in-law's pharmacist told her that immunization is good for life.

In doing my own research, the CDC website mentions that one lifetime dose of Tdap should be given to adults with a tetanus booster given every ten years. However, the CDC also mentions that only about three or four out of ten people are fully vaccinated four years after getting Tdap. 

If the effectiveness of the whooping cough vaccine decreases each year, is it recommended that adults who have previously had the shot get another one if they are going to be caring for a baby?  Are there any risks associated with getting the shot again and are the possible benefits worth going through the hassle of getting another dose of the vaccine? Thanks again for all you do. Best, Amber. 


Thanks for the question, Amber. You guys always have great ones. And this is another really good question. So the current recommendation from the CDC is one Tdap which is tetanus, diphtheria, and pertussis. So it protects against whooping cough or pertussis. So the current recommendation from the CDC is one Tdap for adults who have not had one and then a tetanus booster every ten years following that. Or sooner if you have an injury requiring an early tetanus booster. 

The exception to this is pregnant women who should receive a Tdap with each pregnancy. And these are the recommendations as of right now, January 2017. They could change. And the thought being that receiving a Tdap with each pregnancy in the third trimester will stimulate mom to make antibodies against pertussis — some of which cross the placenta, go into the baby's body, and provides some pertussis protection for the baby in the first couple of months of life until they begin getting their own immunizations. 

And then, once they get their own shot for pertussis, the DTaP which is a little different — still diphtheria, tetanus and pertussis, but the formulation, the amount of the things in it on the proportions are a little bit different — that starts at two months of age. So it just kind of bridges that gap from birth to age two months with some antibodies that mom produces, that cross the placenta, and go into the baby's body. And that's why it's recommended that moms get a Tdap vaccine in the third trimester of every pregnancy.


So those are the current official recommendations and they're based on lots of considerations. Yes, immunity wanes over time. But we also have to consider vaccine availability and cost. So as we kind of look through a public health lens, what plan, what overreaching plan for communities protects the most babies in the most efficient and cost-effective way. 

Now, with regard to the safety of giving Tdap more often, that's not really been studied t the population level. However, women are getting it or should be with each pregnancy even when those pregnancies are spaced fairly close together and there are surveillance systems in place to watch for adverse reactions and other potential problems. 

So the bottom-line, it's probably safe to get extra Tdaps. But is it really necessary and do we have the supplies and the money involved in vaccinating everyone with a Tdap on a more frequent basis? And how do you measure or how much baby care do you have to give before you qualify? It can become very confusing. And even if we did that, would it really decrease the incidents of infant pertussis? Or is what we're doing right now adequate? 

So those are the sorts of questions and balancing acts that public health officials have to ask themselves as they're formulating policy that affects entire communities. I'm inclined to heed the official recommendations but with a watchful eye for updates which could happen. And if updates take place as long as they're based on sound evidence, which they usually are, then you're going to take that balance of individual  and community interest in mind and follow those updates if and when they take effect. 


But for now, I would go with the current recommendation of one Tdap during adulthood followed by a regular tetanus booster ever ten years. Unless you're pregnant, in which case again, you should get a Tdap booster during the third trimester of each and every pregnancy. 

And I'll put a link in the Show Notes for this episode, 365, to the CDC webpage where you can find that pregnancy recommendation. 

By the way, like me, it sounds like your father-in-law's doctor is following the same recommendations that I would follow, because those recommendations are based on evidence and by public health officials who again are balancing lots of differing interests. 

With regard to your mother-in-law's pharmacist, it's unlikely that immunity from Tdap last for life. Evidence says that immunity does wane. The question is how fast does it wane? When will boosters be needed? And is waning immunity from Tdap responsible for the rise in infant pertussis? Or is the bigger problem not getting enough adults to complete that one dose of Tdap and also the issue of unimmunized infants in the community? All questions that our public health officials have to answer as we look to them for the most up-to-date evidence based recommendations. 

So hope that helps answer your question, Amber. As always, thanks for writing in. Really do appreciate it. 

My next question comes from Sarah in New Albany, Ohio. Little closer to home. Sarah says "Hello. I recently listen to you sports nutrition podcast, number 325. And Dr. Mike and his guest talked about making your own sports drink. Was there a recipe posted somewhere? If not, could you by chance share a good one? 

"I've looked online but I want to make sure it's reputable. By the way, that was a really great topic. Thanks so much. As the mom of a young athlete, aged seven, I'm really concerned about the ingredients in Gatorade, so I really value your feedback. Thanks again. Sarah." 


Well, thanks for the question, Sarah. As it turns out, PediaCast episode number 325 on sports nutrition, that was one of our most popular episodes of all time. It was a good one with our resident sports nutrition expert and dietician Jessica Buschmann. So, if you have student athletes at home, I think that one really is a must-listen-to episode. So be sure to check it out. 

We talked about snacks, best ways to start the day, what do you eat on days when you're going to compete, how do you rehydrate, all those sorts of things. What does a balanced diet look like, how many calories do you need, how do you know if you're not getting enough calories? So be sure to check it out, especially if you have student athletes at home — PediaCast episode number 325 on sports nutrition. 

So let's address Sarah's question. First, did we share a sports drink recipe in that episode? No, we did not share a recipe. But after receiving your question, Sarah, I contacted Jessica and she did provide me with her favorite one. And I'll put a link to it on the Show Notes for this episode, 365, over at PediaCast.org. 

It comes from a highly recommended book by Nancy Clark called the Sports Nutrition Guidebook. And I'll put a link to the book in the Show Notes as well. Again, just head over to PediaCast.org and click on Shows & Notes and then find the notes for Episode 365. We'll put the link there so you can find it easily. 

It's a pretty simple recipe. It uses sugar salt and water, along with some orange juice and lemon juice. Now, remember, in many many cases, plain water is fine for hydration. But if your child's very active and working up a considerable sweat over 20 minutes or more, then you do want to think about replacing sugar and electrolytes in addition to water. So electrolytes meaning salts, sodium, chloride potassium, that sort of thing. And that's where sports drinks come in. 


Now, you mentioned Gatorade, Sarah. And of course, there are many, many more commercial products out there other than Gatorade. There's lots of sports drinks. And at least, in terms of the big names that you've heard of, I don't think there's a lot of concern about the ingredients. 

I mean, I would pass by the ones offering additional nutrients or an energy boost. If there's something on the label that they say, "Hey, this is a wonder… This is going to make you perform better," that's probably not the case. You just want the ones that are basically a little flavored water with some sugar and electrolytes in it. And simple Gatorade and many others offer that. 

So it's not the ingredients so much, Sarah, at least in the major brands and the mainstream sports drinks, not the ones with added energy boost. You definitely want to avoid those. But the ingredients in let's say just your standard Gatorade, not so much a concern and not really the reason that you would want to make your sports drink. 

Really, I think, in my mind, it's the cost. You're paying for the brand and the convenience when water sugar and salt are pretty cheap and easy to make, although you do want the right proportions and that's where the recipe comes in. And again, I'll share that in the links, in the form of a link, in the Show Notes for this episode, 365, over at PediaCast.org. The orange juice and the lemon juice they just make it more fun and a little more tasty. 

So hope that helps, Sarah. Thanks so much for writing in. And thanks, too, for giving the opportunity to tell more moms and dads about 
 Episode 325. Definitely a good one on Sports Nutrition for those of you with student athletes in the house. 



Dr. Mike Patrick: My next question comes from Yael in Israel, "Hello, Dr. Mike. I'm a nurse and a mother of two and had been listening to your shows for years. I have a six-and-a-half-year-old with ADHD and I suspect oppositional behavior disorder. Do you have any tips on how to raise a happy, healthy, and adjusted kid who has both ADHD and oppositional behavior?

"At school, he takes Ritalin LA 30 milligrams. I try to have patience but it is really hard. Also, what type of parenting school do you recommend following? I also have a two-and-a-half-year daughter. I have so many questions but we'll start with this one. Thank you very much."

Well, thanks for writing in, Yael. We have quite a few listeners in Israel, And I always appreciate your contributions to the program as I do from folks from all over the place. 

So first let's talk about ADHD and oppositional behavior. And the first thing I want to share is that we've already done some podcasts on these things that are really great resources for you. And they go much deeper into ADHD and oppositional behavior than I have time to cover today. 

So the first resource that I would point you toward is PediaCast episode number 246. "All About ADHD", that's the title. My guess was Dr. Becky Baum. She is a developmental and behavioral pediatrician at Nationwide Children's Hospital. In fact, newly named Chief of that division at our hospital. So really great resource. We talked all about ADHD nuts-and-bolts — what is it, how do you diagnose it, how do you treat it, what are the long-term outlook, what does that look like? How do you get the school on board and how you treat it at home? 
So really, just all around great deep content on ADHD. And again, that's Episode 246. And I'll put a link to the Show Notes for this episode, 365.

Then, the second resource I would direct you to is one of our CME episodes which stands for Continuing Medical Education, PediaCast CME Episode 6. And those are available at PediaCastCME.org. The title of the that was "ADHD, Oppositional Defiant, and Aggression".


Now, our Continuing Medical Education episodes, they're for healthcare providers. We turn the science up a couple of notches. We offer Category 1 Continuing Medical Education Credit. But I think interested parents would benefit from listening to this as well. If you have a kid at home like you do, Yael, with ADHD and oppositional defiant tendencies or behavior, I really think you'd get a lot out of this. 

Even though we turned the science up, there may be some sciencey things that you don't quite understand, but I still think that you would leave from listening to that episode with a better understanding of the problems and how they're treated. My guest for that one was Dr. Kristina Jiner. She's a child and adolescent psychiatrist here at Nationwide Children's Hospital. 

So you're getting the pediatrician perspective with the "All About ADHD" episode, PediaCast 246, and the child psychiatry perspective with the PediaCast CME Episode 6. So tons of information between those two podcasts. I really do think it would be right up your alley, Yael. So look for links again in the Show Notes for this Episode 365 over at PediaCast.org. 

So you asked for tips on raising a happy, healthy, and well-adjusted kid with ADHD and oppositional issues. Now, you'll find lots of tips in the podcasts that I mentioned, but let me add some thoughts here. 

First, you want to make sure you have their correct diagnosis. So an ongoing relationship with the health care provider is essential. So you want to make sure it really is ADHD and oppositional defiant behavior. 


Second, you want to realize that medicine alone is not going to solve your problem. But, likewise, avoiding medication when it's warranted also won't help solve your child's problem. So the right medicine can be very helpful, things like Ritalin LA, like your child is taking, Yael. But you do have to look at the bigger picture. Your child's environment, his or her support system. Counseling can be very helpful and often, family counseling can be most helpful as we think about complex and intertwined relationship in the home. 

So it really is a combination of medicine when it's needed, counseling very often with a mental health provider, and the marriage of those two, the medication and the counseling, really seem to be the best way to move forward with this. And maybe then, you can wean the medicine and get him off of it at some point. But oftentimes, both medicine and counseling are required long term. 

You also want to make sure your child is getting good nutrition and adequate sleep. Both of those things are very important. And you want to make sure that they don't have a vision or hearing problem, that they're reading, and literacy skills are where they're ought to be for their age. You want to identify any learning disorders that they may have, all important considerations, and making your child is in an educational setting in which he or she can excel. 

So it's really a partnership. And not only a partnership between your child and you as the parent and the pediatric or/and mental health provider but also the school system and the teacher. Really, everybody has to come together with your child's best interest in mind. 

And then, third, as much as your child's behavior can be frustrating — and I do hear the frustration in your written voice, Yael — in the midst of that frustration, find something that you and your child can celebrate together. What is he or she really good at, what do they really love to do? And in the midst of those frustrations and problems, it's important to also identify joy and success, find success, create success. What's an activity you can do together, one that your child loves, one that allows your child to be him or herself and provides a sense of accomplishment? 


That goes a long way to promoting confidence and self-esteem while feeling loved and supported. And that's important for every kid but how much more important for the child who has trouble at school or always seems to be in trouble. 

And then, fourth, you want to set clear boundaries and expectations. But you want to make sure that those boundaries and expectations are reasonable and doable, and help your child reach them. Follow through on consequences but be reasonable in your expectations, too. 
Give him every opportunity to succeed. 

In the beginning, small tasks and responsibilities, but then lavish them with praise when they pass the test. And if they don't pass the test, if you give them small tasks and responsibilities, also support and love him when they fail with their second chances. Sure follow through on those consequences but keep them reasonable. 

And then, as they do succeed in small tasks and responsibilities, little baby steps, then slowly increase what is expected. Don't expect to change the world from the beginning. Give them a chance to slowly learn and grow. 

Now, I know, I'm being a bit mysterious with all of this. I'm not exactly providing concrete examples, but each kid and family is different. And as you think about things like family counseling, the counselor is really going to get an idea of what the culture of your home is like, what the culture of the child's school is like and can really come up with more concrete examples that are right for your family and your situation. 


You know the in behavior that you want for your child. So how do you get there? Step by step. Expectations and consequences are needed for sure, but realism and tiny steps in the right direction with love and support along the way, that's all required too. 

And at the end of the day, you really do want to walk this journey with professionals who will also love and support your child, ones who will listen to your frustrations and provide helpful advice molded to your family's needs and unique circumstances. 

So talk to your child's doctor and his or her teacher and mental health counselor. That's going to be the most helpful. And you want to find the right medication, the right classroom, the right home environment. It's a total package. There are no shortcuts. But as your child grows and matures, and slowly becomes the adult you want them to be, the effort is certainly worth the result. 

So listen to those podcasts, Yael. Good place to start, PediaCast Episode 246, "All About ADHD", PediaCast CME Episode 6, "ADHD,  Oppositional Defiant and Aggression." You'll find all sorts of useful information there. And, again, I'll put links in the Show Notes for this Episode 365 so you can find them easily. 

But in the midst of your frustration, Yael, find some fun stuff to do together with your son. Something that's fun for both of you and that he can succeed at, and let him know you love him despite the adversity he finds himself up against. 

So hope that helps, Yael, and as always, thanks for writing in. 

My next question comes from Beth in Seattle, Washington. Beth says, "Hi, Dr. Mike. I've been listening to your podcasts since my first pregnancy. Now, my kids are six and four. And you've already helped me out with a couple of questions. I'm hoping you have time for one more. 

"Over the past couple of months, I began to suspect my older son had developed hearing problems. His pediatrician conducted a hearing exam and told us that it was abnormal. She confirmed that he has fluid behind his eardrum and said that she suspected conductive hearing loss. We have an appointment to see an ear, nose, and throat specialist soon, but I was wondering if you could go over the potential causes and treatments for conductive hearing loss so I can be prepared for our appointment. Thank you very much, Beth."


Well, thanks for the question, Beth. And thanks for your continued participation in the program. We don't have a one-question limit on PediaCast. If you have a question, ask and I'll try to get it on the show, even if there are multiple questions over long periods of time. That's fine. 

So conductive hearing loss, it's a common problem for kids and we can contrast a conductive hearing loss with what we call a sensoral neural hearing loss. And sometimes, kids have a combination of these things. 

So let's first just define what each one of those things is. Now, remember in order to experience the sense of hearing, first, sound waves travel through the air, reach our ear. The sound waves travel down the ear canal to the tympanic membrane, also known as the ear drum. And then, the vibration of those sounds causes the ear drum to vibrate. 

Then, that vibration is transferred along three tiny bones within the middle ear. These bones are known as the malleus, incas, and the stapes. They take those vibrations to the inner ear where they interact with the cochlea and it's here that physical vibrations are converted into electrical impulses which travel by way of the auditory nerve to the brain. And then, that in the brain is where hearing is actually experienced. 

So if there's a problem in this pathway involving the physical vibrations, we call it conductive hearing loss. And if there's a problem with the transition of physical vibrations to electrical impulses, or the travel of the electrical impulses to the brain, or the brain's experience of those impulses, then we would call that a sensory neural problem. 

So more the nerves, it's the sense itself, sensory  neural as opposed to conductive or transmission of the physical wave. So that's the difference between the two types of hearing loss, as we consider sound traveling from the ear to the brain.


So what sort of things could cause a conductive hearing loss? Well, to figure that out, we just have to trace the pathway and think about potential problems. So, in the ear canal, we could have too much ear wax, especially if it's a really thick, solid, compacted ear wax. Foreign bodies in the ear canal — paper beads, crayon bits, whatever else kids stick in their ears — if you have a foreign body in there, that can interfere with the transmission of sound waves. 

Then, we move on the ear drum or the tympanic membrane, if you have a hole in your ear drum or ruptured tympanic membrane which can result from frequent ear infections or barotrauma. You know, if you dive down deep, the water pressure could cause barotrauma. So anything that disrupts the tympanic membrane or the ear drums that doesn't give a nice vibration, that can affect your hearing. 

And then, remember, from the ear drum, it moves on to those three little bones in the middle ear space. So if you have fluid in that space which is the issue that you've described, Beth, the fluid can come from an ear infection. You could have had an ear infection and you just have chronic fluid left over from the ear infection that may have been or even in the distant past. So you can have an acute ear infection 
or an ear infection right now or past ear infections with fluids that's been left behind. And we call that chronic serous otitis, meaning just chronic fluid behind the ear drum.


You can also get a tumor in the middle ear space, things like cholesteatomas. And you could get problems with those three little bones we talked about — scar tissue from recurrent infections, sclerosis, arthritis where they meet. So you can have bone problems. 

And these are going to be the most common issues. Really, that's probably where you're finding yourself now, Beth, because of the fact that your doctor mentioned it's a conductive hearing loss and there is fluid behind the ear drums. That's probably the issue you're dealing with, but these other things I mentioned can also cause conductive hearing loss. 

So what do you do for it? Exactly what you and your family are doing, Beth. You see an ear, nose and throat doctor, preferably one who sees lots of kids. And they'll be able to take a look and identify the exact nature of the problem, to just verify that it really is just fluid behind the ear drums and there's not something else going on. 

They'll likely refer you to an audiologist. So someone who is an expert in hearing test. So the one that you had in your pediatrician's office is really a screening exam. So now, you want a formal hearing test, one that's a little more sophisticated. A lot of ear, nose, and throat doctors actually have an audiologist right there in their office with a sound booth, or they'll refer you to one. And that will better define the exact character and degree of your child's conductive hearing loss. 

What do you do in the end? Well, it depends on the nature of the problem and consideration of the character and degree of your child's hearing loss. So let's go through our possible problem list again and just consider treatment for each one. 

So if you have ton of ear wax in there, you got to get it out. And your pediatrician can help you out with that or the ear, nose, and throat doctor can. If you have you have a foreign body in the ear canal — again, things like paper beads, crayon bits, whatever your child put in there — you want those to be removed. Again, that can be done by your pediatrician or by an ear, nose, and throat doctor. 


Ear drum, if you have a rupture or a hole in the ear drum, again, that can result from ear infections and barotrauma. There are several methods to repair damaged ear drums that really goes beyond the scope of this podcast. In fact, I'm thinking we have to get an ear, nose, and throat doctor sometime this year to talk about that. 

My son has had three ear drums surgeries. So I do have some connections with ear, nose, and throat docs who perform these kinds of surgeries. But there are several methods that you can do to repair ruptured ear drum or one with the chronic hole in it. But it usually requires surgery. 

And then, the middle ear space, if there's a tumor or cholesteatoma, those generally need to be removed. They can be quite distractive if they're allowed to grow. If you have fluid in the middle ear space, either from an acute infection or from chronic infections — and so you have just this fluid that's staying around for a long period of time — it really depends on how long the fluid's been there along with the character and degree of the hearing loss. 

So if you have an acute infection and conductive hearing loss, first you treat with antibiotics. And if it goes away, and if the fluid goes away, the hearing loss gets better and you don't have to do anything for it. If you have a recurrent infections that are happening over and over and over and your kid just has this chronic fluid that's not going away, then you can consider putting ear tubes in to drain that fluid. And that will generally result in resolution of the hearing problem unless there was more damage to those little bones that we talked about. 

So if it's just a little bit of fluid that's not been there long and it's mild hearing loss, your child doesn't have any speech issues, you might just want to wait that out and see if it gets better on its own and be able to just accept that there's going to be some mild hearing loss until this resolves itself. 

On the other hand, if it's long lived fluid and significant hearing loss or even mild hearing loss over longer period of time, and then they start to have some speech issues that you think might be because they're not hearing quite well enough, then you would consider draining it and putting in ear tubes. 


So, again, this is where you really want a doctor face to face looking at your kid, talking to you about risks and benefits to figure out exactly what you want to do for your child's unique situation. If there's problems with those bones that we talked about — scar tissues, sclerosis, arthritis where they meet — again, depends on the scope of the hearing loss. If it's mild, your child may be able to live with it or they might need hearing aids for it if it's more severe. 

Prosthetic bones are another option that can actually replace those bones. But again, you want to talk to the ear, nose, and throat doctor about that. As always, you want to walk this path with your child's pediatric provider and the appropriate consultants like the ear, nose, and throat doc and the audiologist as you consider risks and benefits and figure out together the best course of action for your child's unique situation. 

And it sounds like that's exactly what you're doing, Beth. So kudos to you. Hope that helps and as always, thanks so much for writing in. 

Don't forget, if you would like to have a question answered on the program, it's a really easy thing to do. Just head over to PediaCast.org. Click on the Contact link at the top of the page. I think it says "Contact Dr. Mike". Just click on that. You can write out a message and send. I do read each and every one of those that come through. And I'd love to hear your questions and your comments and we'll try to get those on the program. Really helps to make this an interactive experience when we get lots of listener questions. 

So there's no silly questions. Please ask away. Ask anything that you like and we'll try to get it on the program. Because even it seems silly but it really is a question you have, there's probably hundreds of moms and dads out there who have the same question. So that makes it not silly anymore because there is no silly question. We want everyone to have good information and well educated. 

So ask away. Again, just head over to PediaCast.org and click on the Contact link. 



Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.

Don't forget, you can find us in all sorts of places. We're not only on the website. So, of course, PediaCast.org, you have the archive to all of our past programs, all of our Show Notes, our transcripts, our terms of use, our contact page. It's really the landing site. 

But you can also find the podcasts in iTunes, in the podcast section of iTunes. We're also in Google Play, along with all their other podcasts. We're on iHeart Radio. Just search for PediaCast. Also Stitcher and TuneIn and most mobile podcasting apps. If you do have a podcast app that does not have PediaCast in it, let me know and I'll do my best to get our show added to their line-up. 

We're also on social media — Facebook, Twitter, Google+ and Pinterest — so be sure to follow us and like us and share and retweet and all those things so we can help build the audience and get more moms and dads connected with evidence-based trustworthy parenting and pediatric information. 

Also, it really helps us out if you tell others about the program — you know, your family, friends, neighbors, co-workers, baby sitters, day care workers, grandparents, anyone who takes care of kids or who has kids. And of course, be sure to tell your child's doctor about the program so they can share the show with their other patients and families. 

Also, while you have your doctor's ear, let him know we have a podcast for them as well, called PediaCast CME, the CME stands for Continuing Medical Education. It's available at PediaCastCME.org.  Also on iTunes and Google Play and iHeart Radio all those other places. It is similar to this program, but we turned up the science a couple of notches and offer free Category 1 — and free, I mentioned free, tell them that — Category 1 Continuing Medical Education Credit. Shows and details are available at the landing site, which again is PediaCastCME.org. 


Thanks again for stopping by, 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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