Scabies, Laughing Gas, Spinach Popsicles – PediaCast 327

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Join Dr Mike in the PediaCast Studio for more Answers to Listener Questions. This week’s topics include scabies, emotional support during a hospital stay, painful swallowing, nitrous oxide for dental procedures, spinach popsicles & food safety, and back-to-school headaches.

TOPICS

  • Scabies
  • Emotional Support
  • Hospital Stay
  • Painful Swallowing
  • Laughing Gas
  • Dentist Office
  • Spinach Popsicles
  • Food Safety
  • Back-to-School Headaches

LINKS

Transcription

Announcer 1: This is PediaCast.

[Music]

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 on Columbus Ohio. It is Episode 327 for September 2nd, 2015. We're calling this one "Scabies, Laughing Gas, and Spinach Popsicles".

I want to welcome everyone to the program.

So I have another Answers to Listener Questions episode for you lined up this week. You had to figure that out, with the Spinach Popsicles in the title. It's got to be answers to listener questions, right?

And I love it when you guy ask questions, really I do. We do have some interesting ones this week. I'll get to a quick rundown of the entire line-up in a moment. You got a little hint from the title but there's more, lots more.

Before we run through that complete list of topics though, I did want to let you know, the question bank is getting low. So I pulled out quite a few of them for this episode, and we really do need to fill it back up. So if you have a question for me, now would be a super time to ask. And I'll do my best to get it on the show with an answer, just like we're going to do with these great topics today.

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, 347-404-KIDS, 347-404-5437. You can leave a message that way. Or head to the website, PediaCast.org, click on the Contact link. I do read each and every one of those that come through and we'll try to get your question on the show and get an answer for you.

All right, so what are we talking about this week? What are the great and interesting topics that I've alluded to? First up, scabies. We have a listener write in wanting to know, how easy is it to pass scabies from one person to another? Can you get it from being in the same car with the person who has it? Along those same lines, the next person getting into the car, can they get scabies?

0:02:32

So good questions, and of course, I'll take the topic a bit further because even though our discussion will probably make you itch — in fact, I guarantee it — it is an interesting problem, scabies, and a pretty common one. It's one that I haven't really talked about much on this program in the past.

So we're going to cover scabies pretty extensively. What causes it? How do you get it — including answers to our listeners car questions. What symptoms result? How do you treat it? So stick around for more information than you probably ever wanted to know. But if your family is dealing with scabies, it's exactly the information you want to know on scabies.

Then, pediatric hospital stays are tough. Not only for the sick or injured child, but also for the parents, and the sibling, really the entire family. There's lots of worry and information to process. There's lost sleep, and you can move from being mentally taxed to completely exhausted pretty quickly. So we had listener write in wanting to know what resource are available to provide support, especially emotional support for families who find themselves in the hospital 24/7 with an admitted child.

We'll do a quick survey of the resources available here at Nationwide Children's because they parallel the resources at many children's hospitals, but more importantly, we'll talk about ways to find and connect with the right people and services in your neck of the woods regardless of where that may be. Who do you ask and how do you find them? We'll talk about that.

0:04:05

Then, painful swallowing. A lot of things can cause it. There is a 14-year-old niece out there who's been dealing with painful and difficult swallowing for several months. Her aunt is a listener and is concerned, so we'll explore possible cause of painful and/or difficult swallowing and the tests and procedures that might be involved in finding an answer and a solution when this problem occurs.

Now, as always, we aren't trying to diagnose the problem for this particular patient or suggest what workup this particular 14-year-old niece should get, because we don't know the full story and we aren't privy to the physical examination. That's the way it should be, but we can talk about painful swallowing in general along with possible causes and typical tests and procedures.

Then, laughing gas in the dentist office, also known as nitrous oxide. We have a listener who's taking her child to a new dentist, and they keep offering sedation by gas for fairly routine dental procedures like filling cavities. She wants to know if nitrous oxide is really necessary. Is it safe? Very reasonable questions, ones that will allow us to revisit a familiar friend, our risk-benefit meter. So, stick around for that.

Then, spinach popsicles and food safety — we have a listener who wants to freeze spinach into popsicles and feed it to her kids. It's a noble approach, but apparently — and I had to look this up, it's true — there are plenty of veggie popsicle recipes floating around the Internet. Who knew? But will they work? Will kids actually eat them? I guess that's the big question.

I won't be able to answer that question because it's going to differ from one home to another, one kid to another, one family to another. I can predict the answer on that question for my home, and it involves crunch up faces and rolled eyes, I'm sure of that.

Of course, my kids are straddling the teenage and young adult years, so we sort of missed our chance on fooling them into eating a spinach popsicle. But hey, maybe spinach popsicles will work for you.

0:06:09

The real question then becomes, are they safe? We'll step through the answer to that. But more importantly, I'll direct you to a fantastic resource that will allow you to research and answer these sorts of questions confidently on your own.

Now, not that I don't want to answer food safety questions here. I love answering your questions regardless of the topic. But there are lot of variations when food safety questions arise. What about carrots? Are sprouts any different? What if I want to serve them raw versus cooked versus frozen? What's the best way to clean vegetables and store them long-term?

So as you can imagine, there are hundreds of combinations we could think of. So where do you go when you have a food safety question. I'll direct you to a great resource, and then we'll explore actually using it as we answer the spinach-popsicle question.

So lots coming your way this week as we answer listener questions. As I mentioned before, maybe you have a question of your own. I would love to answer it here on the show.

Now, I do want to point out if you have an urgent or important question, be sure to ask your doctor. If your doctor's answer ever conflicts with information you hear on this show, go with the person in the exam room actually seeing your child, not the guy behind the microphone, OK?

There are lots of nuances to practicing medicine. It's every bit an art as it is a science with so many factors and variables to consider, not to mention an important thing like the physical examination. So ask your doctor first, especially if the question is urgent or important. The purpose of this show really is to explore deeper, to go beyond the five-minute answer your doctor can provide in the exam room, because the waiting room is full and there are lots of other kids to see, not because your doctor doesn't want to spend more time with you.

So urgent, important questions, ask your doctor the whys and hows and tell me mores, those we can handle just fine. It's easy to get in touch. Again, just head to PediaCast.org and click on the Contact link or call the voice line, 347-404-5437. That's 347-404-KIDS.

0:08:13

I forgot to mention, at the end of the program, stick around for a final word on back-to-school headaches. Headaches in kids increase as the school year kicks back in. We'll explore why, what you can do about them, and when you should worry. So also stay tune for that discussion at the end of today's program.

All right, let's move forward, and as we do I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, 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.

All right, let's take a quick break and I will be back to answer your question right after this.

[Music]

Dr. Mike Patrick: Our first question today comes from Belinda in Saint Mary's, Ohio, "Could you tell us about scabies? Can I catch them by being in the same car? Could the next person getting in my car catch them? Thanks in advance for your answer."

Well, thanks for the question Belinda. Scabies is actually a fairly common problem we see in kids. It's caused by a tiny mite called sarcoptes scabiei, and this tiny mite burrows into the skin of human and causes an itchy rash.

0:10:06

Now, I said tiny. How tiny are we talking? A third to a half of a millimeter. Now, millimeters, you'll recall, are those really tiny close together lines on the metric side of your ruler. So the mite that causes scabies are really really small. They're not quite microscopic like viruses and bacteria, but they're still very difficult to see with the naked eye.

So here's how it works. Male and female mites get together on the skin surface, either from another infected individual — so you can catch it sort of skin to skin — or from the eggs that had been deposited into the skin (and more on this to come). Then, the hatchlings, the little mites that come out of those eggs come up to the surface of the skin and the males and females get together there.

So you kind of get it from yourself, if you're already infected, or you can get it from the skin of another person who's infected.

So the males and females like to meet up and mate in warm protected areas on the surface of the skin. So, places where the skin folds and meets other skin is a popular destination, so places like between the fingers and the toes or on the armpits or axilla or in the inguinal or groin region. Really, they can happen any place on the skin, but in the skin folds, sort of in warm protected areas is where it is more likely to occur.

So the male fertilizes the female and then dies — great life. The female mite, after being fertilized, burrows into the skin and digs a little tunnel under the surface of the skin and travels about two millimeters each day in a straight lines. As it goes, the mite lays two to three eggs at a time. Its total lifetime egg-laying as it travels is about 10 to 25 eggs over 1 to 2 months, and then the female dies.

0:12:10

So they don't live long. I mean, the males really have a brief life, and the females still just live a month or two. But it's long enough. So the eggs hatch into males and females which then tunnel back to the surface, mate and the cycle repeats. Until, the immune system kills all the mites which can take a really, really long time and is not always completely successful or until the mites are killed by medical treatment.

The itchy rash of scabies is actually caused by an allergic reaction. In fact, it's a delayed Type 4 hypersensitivity reaction, for those of you who like the fine details. The allergic reaction is a response to the mite themselves, their feces and the eggs they are laying. So your body has an allergic reaction.

The rash does have a characteristic appearance with a fine red bumps and short linear components. That's actually where you're seeing the mite as it travels. The inflammation follows its travelling and that's where you see sort of a linear component to these red bumps.

You especially see the rash in the areas I mentioned, where you have the skin folds in protected areas, but really it can occur anywhere that there is skin. The rash tends to be extremely itchy. In fact, just mentioning scabies and the rash might make many people itch, including me as I describe it and probably many of you as you listen.

So that's the process and the rash. With regard to transmission, it is pretty contagious when skin-to-skin contact occurs with an infected individual. And I should point out too, since the rash is caused by an allergic reaction some people aren't as allergic as others. So you can have some folks with seemingly asymptomatic infestation of these scabies mite without much of a rash or an itch, and they can pass the mites on to others, just the same as those whose skin looks pretty bad. Which is why we typically treat everybody in the home even if they don't have a rash, once scabies has been diagnosed, because it is fairly common for some folks just not to have much of an allergic reaction to the mites and just have an asymptomatic infestation.

0:14:35

That's important to remember because if one person still has the mites on their skin, even without symptoms, they can pass it on to others in the house and the rash keeps coming back even for those who have been treated, but they keep getting it again from the person without symptoms.

Those lucky few who don't get much of a rash, they can spread it at school too in a very silent fashion, which is why scabies in the community can be pretty difficult to completely stamp out.

OK, so let's go back to Belinda's question — what about in the car? Can scabies be transmitted from person to person without skin-to-skin contact? In other words, can the mites fall off the skin and then get on you and then you get scabies? They can, but here's the good news –the mites can only live on objects away from the skin for 24 to 36 hours. So if you let the car sit for a couple of days, you should be fine.

Also, they don't transmit from objects as easily as let's say headlights does. So even if you do come into contact with one of the mites on an object, you'd have to come into contact with both the male and female in order for the male to fertilize the female and perpetuate the cycle on your skin. So, it's not an automatic thing. It's very contagious skin to skin, but getting it from object is not quite as easy but it's possible. Once the mite has been away from the skin for 24 to 36 hours, then you're in good shape.

0:16:07

So let's talk treatment and expectations of treatment because that's important too, and then we'll round things up by talking about prevention.

First, you want to make sure it really is scabies and not something else before you treat this. In other words, you want the right diagnosis, so you really do need to see a doctor for this.

Second, you want to kill the mites, and the most common way to do this is with a topical product. The most common one used is a medication containing 5% permethrin, has a tradename of Elimite — just pretty clever, "eliminate the mite" Elimite. It's 5% permethrin –is the generic — which works just as well.

Typically, you apply the lotion from stem to stern. You basically want to cover all the skin and you do this before bedtime. You sleep with the lotion on about 8 to 14 hours and then wash it up with soap and water in the morning. We usually treat everybody in the home including infants, even folks without symptoms for reasons that I already mentioned. Since the failure rate of one treatment is 10 to 20%, we usually have you repeat the process in one to two weeks.

Then, after you wash the lotion off in the morning, you wash all the bedclothes and sheets in the laundry, vacuum carpets and furniture and the inside of the car if you like. Then, anything that can't be laundered or easily vacuum such as stuffed animals and pillows, you can place those items in a plastic bag in a couple of days while you wait for any remaining live mites to die. Or you just live them alone, and they will die in one to two days.

There are other treatment options. The permethrin lotion is probably the most common. But as I mentioned before, this isn't a 100% do-it-yourself-at-home project. You want to get your doctor involved and follow his or her instructions.

0:18:06

OK, number three, after getting the right diagnosis and killing the mites, then you want to ease the itch. You can do that with the help of oral antihistamines like diphenhydramine or Benadryl is the tradename. Also, 1% hydrocortisone cream that can help the itch on the rash.

Now, quick note on the hydrocortisone cream. It's a steroid, and this is one of the reasons that correct diagnosis is important. If you mistake the rash for something else, like eczema or atopic dermatitis or just an allergic reaction to something on the surface of the skin and you use hydrocortisone cream without killing the mites, then the scabies and the itchy rash have the potential to spread like wildfire across the body and can also develop a very atypical appearance.

Even though the immune system isn't so great at eliminating the mites, it does do a pretty good job of keeping them in check. So when you use a steroid cream you suppress the immune system and the mites have a field day. It's not a pretty picture.

So if you see a doctor for an itchy rash, always tell them what you've used before including hydrocortisone cream.

One final caveat and it's an important one, when you kill the mites, the rash does not go away immediately. Now, it shouldn't spread much anymore but what's there is there because, remember, you're having an allergic reaction to the presence of the mites whether they're dead or alive, and also an allergic reaction to the eggs and the feces which is still going to be in the skin.

So the rash stays until the dead mites and eggs and feces gets sloughed off as all skin eventually does. So as you make new skin, the infested skin falls off and the new uninfested skin takes its place. But this can take several weeks.

So that's what I meant by managing treatment expectations. It's important for parents to know the rash is not going to go away overnight. It's going to take awhile. In fact, it can take a few weeks before it gets better.

0:20:06

So that scabies in a nutshell, Belinda and as always, thanks for the question.

[Music]

Dr. Mike Patrick: Next up we have an anonymous question, "Our daughter has a condition that requires frequent surgeries and hospital stays. We've had many, many great nurses and doctors, but I still feel uncertain about what the roles are of hospital staff when a child is involved. I do not expect them to babysit my child, but what type of emotional support can be expected? What can we do facilitate better care? If this question seems vague, that is because I feel lost about what kind of help to ask for, for my child and myself. I just know we leave the hospital exhausted."

Well, thanks for the question. It is definitely a terrific one. First, let me say feeling exhausted when you leave the hospital is normal. Hospital stay is stressful. There is always the unknown, even when you've been there before. You're not at home. You're not in your normal usual comfortable space. Your child is stressed and restless and often afraid and dealing with discomfort. You aren't sleeping well. And to some extent, you can't make it completely better. So I think it's important to understand our exhaustion and validate it.

Now that said, there are many, many resources you can draw upon during a hospital stay. So let me share some of those that come to mind, and I'm especially going to be talking about hospitals that are geared towards children. So, children's hospitals or pediatric floors in a larger hospital setting.

0:22:15

I'm probably going to leave out some important resources. I'm going to apologize for that upfront. It's not intentional. There are so many possibilities, and they're certainly going to vary from place to place.

The first place I would start is just with your medical team. You have physicians and nurses and patient care assistance. When we break down the physicians, you have attending physicians, fellows, maybe nurse practitioners. There may be physician assistants, fellows, residents, medical students.

So your medical team is a large group of people, and they're likely going to be able to help you identify what resources are available in your area. They can also kind of probe what issues and problems you're having or what concerns you have and maybe able to direct you to the resources that are most likely to prove helpful. So your medical team is a definitely a great place to start.

The second thing I would consider is asking to talk with a social worker who specializes in whatever area of the hospital that your child and your family is dealing with. Social workers are really trained to match needs and resources, and they do a stellar job of this. They can also help manage expectations of the available resources.

Child life specialists are fantastic. I would encourage you to listen to PediaCast 290 for more details on their job description. Many hospitals also have activities for siblings that you may want to look into utilizing. Also music therapists are great with kids and can help with stress and taking the load off a little bit, and you can listen to PediaCast 310 for details on what music therapists do.

I'll put links to all the things that I'm talking about in the Show Notes for this episode, 327, over at PediaCast.org.

You may need to talk to a psychologist or other mental health counselor. Pastoral care is another great department to tap into regardless of your faith background. They aren't there to sway you in the direction of a particular region but rather to support your family spiritually right where you are.

0:24:34

So there is my short list. Your medical team, social work, child life, music therapy, psychology, pastoral care. I'm sure I'm leaving someone very important out, and I'm sorry about that.

Two other points I do want to leave you with. One, it is OK to need and ask for help. The help that you need is something that it's hard for people sometimes to get past the pride, "I can do this. I'm going to be a wall for my child. We're going to get through this together." While it's good to be strong for your kids, there's no doubt about that, but sometimes that attitude becomes a wall that does not allow you to reach out to the help that really will be beneficial.

So I think, the first thing is to just recognize that it is okay to need help and to ask for help and to put your hand out.

And the support people that I mentioned, they are passionate about helping you. That's why they get up in the morning. So please don't b afraid to reach your hand out and let them grab it. It really is OK to be at the receiving end. There will come a day and time and situation where you will be the helping hand, but for now, in the hospital, for your sake, your child's sake, your family's sake, push down that wall, reach out and ask for help.

The other point, sometimes, you aren't going to like the help and support that grabs your hand. Personalities can clash. Those who serve have their own pressures and stresses, and sometimes help doesn't really feel like help at all. I'm sure there are many of you out there who know exactly what I'm talking about.

0:26:15

So if the hand who grab yours doesn't really seem to be helping — and I'm not placing blame here — sometimes it just doesn't work, and there's issues on both sides of the fence, and when that happens, it's also OK to let go, and reach out for another hand. Find someone you are comfortable working with, someone who connects with you, your child and your family. So don't let a bad experience keep you from connecting with others in the future. I hope that makes sense.

Also, just because personalities clash doesn't mean that person who you clashed with isn't going to go on to really be a super help to other families who may have a little bit of a different personality. We're all a little different and connect with people in different ways.

So reach out for help. If the help's not working, let go, reach out for other help.

I think also this question is a wake-up call for those of us who take care of kids and families. Our jobs are not easy, and there often aren't enough of us. The hours are long and hard. The bureaucracy and red tape can be taxing and the spent emotional energy can be overwhelming. We sometimes need a hand to hold on to for our own well-being and sanity. And yet, here we are, we can't ignore our calling to be compassionate and empathetic to our patients and families and to keep on serving even when the road is rough and uphill.

That's why we chose our professions in the first place. Sometimes, I think we forget that. So let this anonymous question be a reminder that hospital visits are exhausting. I don't think we can fix that completely, but we sure can help each other out along the way.

Next up, we have a question from Courtney in Charlotte, North Carolina, "Hi, Dr. Mike. Love your show. I'm not yet a mother but as an aunt and pharmacist, I find your podcast very informative. I have a question about a symptom my 14-year-old niece has been experiencing for over six months which is painful swallowing. She visited an ENT and was prescribed omeprazole, 20 mg once daily. She was told to return one month later for follow up. If the symptoms hadn't resolved with a month course of omeprazole, they would perform an endoscopy.

0:28:25

"The trial did nothing to relieve her symptoms but unfortunately, they have not scheduled the follow-up appointment. They try to gather whether or not it could be related to anxiety. My niece doesn't think this is a contributing factor but didn't seem to rule it out either.

"I was wondering if you had any insights or thoughts behind painful or trouble swallowing. Thank you – Courtney."

Well, thanks for the question, Courtney. So there are several things that can result in painful and/or difficult swallowing. One of those things is acid reflux or GERD, which stands for gastroesophageal reflux disease, G-E-R-D. This occurs when the valve that sits between the bottom of the esophagus, and the top of the stomach is loose and allow stomach acid to leap up into the esophagus which can cause burning and inflammation.

That's what your ENT doc was thinking because as a pharmacist, Courtney, you know omeprazole decreases stomach acid production. So the ENT was hoping this would work, but it didn't, so his next suggestion is an endoscopy which involves sedation and a tube with the camera to go down the esophagus and take a look.

So what is it looking for? Well, even with the omeprazole on board, there could still inflammation and/or ulcers from the stomach acid. There could be inflammation even in the upper airway from the stomach acid if it's coming up far enough. A month may not have been long enough for the symptoms to have resolved completely or the dose of the omeprazole might not be enough for the job.

A PH study may also be helpful in determining if stomach acid remains the issue even if the endoscopy is normal. PH study just looks at the PH in the esophagus especially over a long period of time, to see if there are spikes when stomach acid is entering into the esophagus.

0:30:15

With the endoscopy, he'll also be looking for foreign bodies, like a swallowed chicken bone for example, or anatomical or structure problems that might be blocking the way. Esophageal muscle spasms can also cause this, although endoscopy might not reveal a muscle spasm. You might need to swallow study with contrast or esophageal manometry which measures the pressure generated as you swallow.

Certain infections can cause painful and/or difficulty swallowing including pharyngitis, infections in the back of the throat, gingivitis or gum infections, dental infections, thrush, just a fungal infection in the mouth.

The esophagus itself can have an infection with things like herpes simplex virus, cytomegalovirus, fungal infections, HIV. These are all possibilities. Esophageal cancers sometimes occur, another reason to take a look and get a biopsy if anything looks amiss.

Finally, difficult swallowing can be a component of a mental health issue, including anxiety, like you mentioned. Although, an undiagnosed medical condition resulting in chronic swallowing difficulty, that can also lead to a mental health problem.

So it's kind of like, which came first, the chicken or the egg, that you have to try to figure out. Is the chronic swallowing causing a mental health problem? Or is the mental health problem causing chronic swallowing difficulty?

The important point here is the mental health connection is really a diagnosis of exclusion. You want to make sure none of the other organic medical possibilities exist first before you settle on mental health being the cause of difficult or painful swallowing.

Finally, seeing the ENT doctor's a great start but if you aren't getting to the bottom of it, a visit to a GI specialist or a gastroenterologist may also be helpful. And if nobody can find any organic medical cause, as you mentioned, seeing a mental health provider may also be helpful.

0:32:14

And this may be helpful even if a cause is found. If it is then whatever the disease processes that's causing it, depending on how fast you can fix that, you may still have depression or anxiety related to the difficult swallowing. So even if the medical condition came first and then lead to a mental health complication, you still may want to see a mental health provider for that. Just, it's not necessarily your first stop but it definitely is a part of the picture, if that makes sense.

Also, eating disorders come to mind. Does it really hurt, or does she just not want to eat? Or is she bingeing and purging which can cause its own set of problems including acid issues and difficulty swallowing? What is her weight doing? How is her body self image?

And as I think about these sorts of things, it really is a good idea that her regular doctor is on in this too. Sometimes, you need a set of eyes on the big picture, on the family picture rather than focused in on one specific organ system, not the subspecialist only focused in on the system. They look at the family as whole too, but nothing can replace the relationship and knowledge of your family that your regular doctor has who can really provide insight. So both sets of eyes are important.

Six months of this must be pretty frustrating, Courtney. Hopefully, these comments are somewhat helpful and your niece's doctor get to the root of the problem quickly. Thank for writing in.

[Music]

0:34:16

Dr. Mike Patrick: We have another question from Sarah in Bluffton, South Carolina — "I was looking for your opinion on nitrous oxide on pediatric dental patients. We recently moved and when taking my youngest, who's six years old, to a new dentist, I was shocked to find that he needed a tooth pulled. It was abscessed and he had two cavities. I agreed to the nitrous oxide for the tooth pulling. At this practice, you buy your own 'nose' and keep it for future use."

So there, she's just talking about the little gadget that goes on the nose that will deliver that laughing gas to the child. So you keep that 'nose' for future use.

Sarah goes on to say, "It didn't seem to help. My son screamed the entire procedure, and even though the dentist predicted it would be an easy extraction, it was not. A few weeks later, we went back to fill one of the cavities. I was surprised they expected to use nitrous oxide for the filling. I certainly have never been offered it for any of my fillings. Apparently, they used it all the time for procedures. I declined because it did nothing to calm him down the first time, and it was just a filling.

"But again, it was a bad experience for my son. I don't blame the dentist for this. I think my son is sensitive to the pressure he feels on his teeth. Tomorrow, he has his second filling and I know they're going to offer it again. Is this a trend to offer this to pediatric patients? Is it OK to have multiple exposures as a child within a few months?

"Thanks, Dr. Mike. By the way, my oldest son has no tooth issues at his checkup. I do try to make sure that we all take care of our teeth."

Well, thanks for the question, Sarah. First, let me address the differences between your two kids. Poor dental hygiene, lack of fluoride, going to bed with a milk bottle or a formula bottle — these things can all lead to dental decay and tooth problems, but sometimes, it just boils down to genetics. And despite your best effort, problems occur.

0:36:11

My wife and I experienced that with our children, too. My daughter had tons of cavities as a child and my son had none. Same diet, same hygiene standards, but different kids and different experiences. So that's to be expected, and nobody should fault you for your younger son's cavity experience.

OK, so let's turn our attention to nitrous oxide, better known as laughing gas. Nitrous oxide is a colorless gas with a faint sweet smell. It's pretty safe, but we all know safety is not a 100%, so we always have to pull out our benefit-risk meter.

Now, lots of pediatric dentists use nitrous oxide. They're comfortable using it because they have lots of experience using it. They're set up in their office for emergencies with the right equipment and regular training, and they practice handling emergencies, so everybody is comfortable when one occurs.

So, in that environment, in a practice where it's used routinely, and the staff is prepared, and when you have a child who is very anxious and may be out of control who may otherwise pose a hazard to himself and the dental staff, in that situation, in my mind, the benefits outweigh the risks.

What are the risk by the way? Well, the biggest is going to be too deep of sedation which can cause respiratory depression. So your child gets so relaxed that they stop breathing. But this is minimized with experience and patient monitoring. Vomiting and aspiration are a concern, but that's minimized by not eating a heavy meal prior to the procedure and being ready with suction, which a dentist usually have on hand anyway, right?

Headaches may also follow procedures where nitrous oxide are used.

So those are the biggest risks. On the other hand though, if your child is not anxious and not posing a danger to himself or others, is it absolutely necessary? Probably not. But you really do have to take each case on its own merit and walk through the risk and benefits with moms and dads. That's what you would expect your dentist to do before the procedure and help you with informed consent.

0:38:21

Now, as it turns out, the American Academy of Pediatric Dentistry has a fantastic article that steps through the risks and the benefits in an evidence-based way that I think is readily understandable even to non-science types. It's called Guideline on Use of Nitrous Oxide for Pediatric Dental Patients. I'll put a link to it in the Show Notes.

So the next question Sarah, why did the nitrous oxide not work for your child? My best guess — and it is a guess, since I'm sitting in a sound studio in Ohio and you and your child saw a dentist in South Carolina — but my best guess is that your child is screaming and hollering through his mouth. And that's where the air was coming and going, through the mouth, and the nitrous oxide was being delivered to the nose.

So if air exchange is happening at the mouth level, he's not really breathing through his nose where the drug is hopefully being delivered. So the trick is, calming your child and getting him to breathe through his or her nose right from the onset before the procedure takes place. This may be a difficult task, especially if they had a bad experience in that environment before, but if you can get the induction in order before you start, get them calm and breathing through their nose before invading their mouth with little instruments, that's often the key.

Now, I'm not a dentist, but that's just some keen observation here. That really is the key because once the gas is on board and working, they will hopefully keep breathing through their nose throughout the procedure. Once, the unbridled screaming starts, the gas just isn't going to be delivered anymore.

You might want to practice at home, having your child practice breathing through it before you get to the office. Maybe your child needs to know that a reward is going to follow the experience, something he or she knows and loves and can look forward to after the experience is over, that may be helpful as well.

0:40:24

With regard to long term safety and recurrent use of nitrous oxide, I'm not aware of any well done study showing any significant consequences. You'll find anecdotal reports and stories on the Internet. Everyone wants something to blame their child's behavior on or developmental and mental health concerns. You know what I'm talking about.

I have the seen the blame placed on nitrous oxide for some of these things. But I haven't seen anything that validates that concern with evidence in any way. Again, it comes down to risk versus benefit which is something your pediatric dentist should be willing to walk you through, which you can better understand with the article I referred to from the American Academy of Pediatric Dentistry. Again, I'll put that link in the Show Notes for this episode, 327, over at PediaCast.org.

Hope that helps, Sarah, and as always, thanks for the question.

Lorie in Chicago has a question for me, "Hi, Dr. Mike. Thanks for your great evidence-based podcast. I have a food safety question. In an effort to feed my daughter healthier snacks, I've started making homemade popsicles by blending together Greek yogurt, bananas, fresh spinach and frozen berries, and then freezing the mixture in popsicle molds. There are lots of great online recipes for popsicles with greens in them, but I'm wondering if it is safe to freeze the fresh spinach since it hasn't been cooked at all first.

"Also, is there a good website that I should go to for these types of food safety related questions. Thanks, Lorie."

Well, thanks for the question, Lorie in Chicago. First, let me comment on raw spinach. Spinach is a leafy plant that is in close contact with the soil. So a dangerous microbes including E. coli and botulism are a concern, especially if the produce is not handled and prepared properly or if your child is very young or her immune system is not functioning normally.

0:42:22

So there are concerns, and for more on the botulism concern, be sure to listen to PediaCast 258, and I'll put a link to that in the Show Notes as we covered that pretty extensively there. Also, on a blog post I wrote for 700 Children's and I'll put a link on the Show Notes for that as well over at PediaCast.org for this episode, 327.

Now, most kids are going to be fine with raw spinach. You'll find plenty of parents who are willing to tell you so. They feed it to their kids and have never had a problem, and they're eager to share their recipes online, so it must be okay, right? And it usually will be all right until it's not, because there is a risk and you should know what it is and how to minimize it, which is really what's at the heart of your question, Lorie.
So how do you find out the risk and how you can minimize them?

Before I get there, I do want to say a word about freezing food and popsicles, which is a great idea by the way, if your child will eat them. I might have to try that for my own vegetable ingestion, kind of like a smoothie but an alternative. What I want to say is this, there is a difference between freezing something for long-term storage and freezing it overnight for consumption as a popsicle in the next day or two.

We're talking about the latter here. Freezing and eating soon after. For that the rules are really going to be the same as preparing and eating something immediately. Long-term storage may be a different beast. So let's stick as we're talking about this, which is the quick freeze and eating the popsicle soon after for this particular discussion.

Freezing by the way does not kill botulism spores. If they go into the freezer, they're going to come out of the freezer, they're going to come out of the freezer. So any food you want to freeze and eat as a popsicle really should be ready for consumption before it goes into the freezer and then eaten sooner than later.

0:44:13

OK, so how do you safely handle and prepare any food prior to consumption? Well, I do have a fantastic resource for you, and I'll put a link to it in the Show Notes for this episode, 327, over at PediaCast.org so you can find it easily.

That resource is FoodSafety.gov. Yes, it really is that simple. FoodSafety.gov. What you can do is go there and search for spinach on their site, and you're going to get relevant articles from the FDA, the USDA and the CDC. So it really is a great catch-all for evidence-based food safety information from multiple branches of the government — the Food and Drug Administration, the United States Department of Agriculture, and the Centers for Disease Control and Prevention.

Unfortunately, when I do this, when I go to Food Safety.gov and do a search for spinach, I don't get an obvious result that tells me immediately how to best handle and prepare raw spinach prior to consumption, which is what I want to know before I make it into a popsicle. I get lots of other great information on dangers and recalls but I'm not told how to safely handle and prepare.

So, first off, I do think the site needs a little bit of a better search engine, but all is not lost because with a little bit more digging, I can go to the top of the page, and I find as one of the choices across the top as something that says "Keep Food Safe." So if I click Keep Food Safe, and then one of the dropdown is "Select by Type of Food". And then, I can select fresh fruit, vegetables and juices in the left sidebar.

So, Keep Food Safe, then I'm going to select which type of food, and then I'm going to find their article on vegetables. And now, I get a list of tips including Tips for Fresh Produce Safety. So I click that and then I find Buying Tips, Storage Tips, and Preparation Tips, and now, I'm getting somewhere.

0:46:18

I couldn't do a simple search, although I did get some interesting articles that way. But if I'm really looking for how to prepare spinach safely, then, I'm going to have to go through the menu system, but it only was like three or four clicks. So we really are getting there, and one of the things that I get is this set of instructions, and again, this is coming from FoodSafety.gov.

For vegetables, begin with clean hands. Wash your hand for 20 seconds with warm water and soap before and after preparing fresh produce. I want to cut away any damaged or bruised areas of fresh fruits and vegetables. Produce that looks rotten should be discarded. All produce should be thoroughly washed before eating. Wash fruits and vegetables under running water just before eating, cutting or cooking, and in this case, I'll add freezing briefly to make a popsicle to eat the next day.

Many pre-cut bagged produce items like lettuce are pre-washed. If the package indicates that the contents have been pre-washed, you can use the produce without further washing. So that's good to know. Even if you plan to peel the produce before eating, it is still important to wash it first.

Washing fruits and vegetable with soap or detergent or using commercial produce washes is not recommended. So in another words, all you really need to do is run it under clean water.

Scrub firm produce such as melons and cucumbers with a clean produce brush and dry produce with a clean cloth towel or paper towel may further reduce bacteria that may be present.

So this is extremely helpful, I learned that I want to wash the spinach really well but only with running water and then dry it with a clean cloth towel or paper towel, and that's going to minimize my exposure to microbes/

And then, under storage tips, I'm told, store perishable fruit and vegetables like strawberries, lettuce, herbs and mushrooms, and I'll include spinach in there. That's like the same category as lettuce in a clean refrigerator at a temperature of 40 degrees or below. And refrigerate all produce that's purchased pre-cut or peeled.

0:48:28

So, there is a risk of bacterial contamination with spinach, including botulism spores. It's not unfortunately a 100% absolutely positively safe. Is anything really? But I can minimize the risk by following these instructions, as long as my child is not very young. In this case, old enough to sit up and hold a popsicle in his or her own hand as they eat it and enjoy it is going to be old enough, and they have a normal well functioning immune system. Then, in my mind, and you have to decide for you and your family, then the benefit of veggie consumption outweighs that risk.

The risk is not zero, but it's low especially if I'm feeding healthy children who aren't young infants and I'm following these safety instructions.

I hope that makes sense, Lorie. To be even more useful, the site we've been exploring together, FoodSafety.gov, also gives me a link to a produce-safety article from the FDA which gives me much of the same information but it does adds some specific further warnings about sprouts including onion sprouts, alfalfa, clover, radish, and mung bean sprouts. The FDA article makes the point that sprouts need a warm, humid environment to sprout and grow, conditions which many bacteria including salmonella, E. coli, listeria also like, so they have a particular risk when eaten raw.
Rinsing under running water is not enough. Sprouts really need to be cooked first. I'll let you read more on that for yourself. The point here really is not to spoon-feed you with all the safety information but rather to show you what's out there, and how to use it confidently to answer these kinds of questions for yourself.

So, definitely check out FoodSafety.gov. It really is a gem and highly recommended. Hope that helps, Lorie. Really appreciate you taking the time to write in.

0:50:18

Don't forget, you can do the same. It's really easy. Just head over to PediaCast.org. Click on the Contact link and ask your question. We'll try to get in answered here on the podcast. You can also call the voice line, 347-404-KIDS, 347-404-K-I-D-S. If you have a question, you can call in, ask the question. We'll also try to get that on the show.

[Music]

Dr. Mike Patrick: Findings from physicians here at Nationwide Children's Hospital demonstrate that headaches increase in the Fall in children. It's a trend that may be due to back-to-school changes and stress, routines and sleep. And although, it may be difficult for parents to decipher a real headache from a child just wanting to hold on to summer a little longer and avoid going back to school, there are a variety of other common triggers including poor hydration and prolonged screen time that could contribute to a child's discomfort.

Dr. Ann Pakalnis, a professor of pediatrics and neurology at the Ohio State University and pediatric headache specialist at Nationwide Children's, says, "When we saw many of our families and patients in clinic, the families will report that their child or teenager's headaches would increase during the school year. So, we decided to go back and look at emergency department visits for that time period and see if there were more visits at certain times of the year."

0:52:03

The research, conducted by Dr. Pakalnis and fellow neurologist, Dr. Geoffrey Heyer, is rooted in a retrospective analysis of about 1,300 emergency department visits from 2010 to 2014. Results concluded that when monthly emergency department visits are grouped seasonally, there is an increase in headaches in the Fall in children ages 5 to 18 years old.

Dr. Pakalnis says, "We see a lot of headaches in young boys, from five to nine years of age, and in boys they tend to get better in later adolescence. In teenage girls, migraine oftentimes make their first presentation around the time of puberty and unfortunately tend to persist into adulthood."

The two types of primary headaches seen most often by physicians are tension-type headaches and migraines. While migraines are less common in children, they are far more severe in regard to the pain that children experience. Migraines are generally associated with nausea and vomiting, and sensitivity to light, sound and possibly smell.

Tension-type headaches on the other hand tend to feel more like tightening around the head, and children can continue with their normal day despite the discomfort.

The increase in Fall headaches may be attributed to a number of factors, including academic stressors, schedule changes and an increase in extracurricular activity. Other common headache triggers include lack of adequate sleep, skipping meals, poor hydration, too much caffeine, lack of exercise and prolonged electronic screen time.

These results support previous research done by Dr. Pakalnis by confirming that lifestyle issues are important in managing headaches and migraines, and minimizing stressors would decrease headache and migraine frequency.

Another headache specialist at Nationwide Children's, Dr. Howard Jacobs, says, "Your brain is like your cell phone. If you don't plug your cell phone in, it doesn't have energy, it doesn't work well. If you don't plug your brain in by providing energy, it doesn't work well and that causes headaches."

According to Dr. Jacobs, headaches can often be prevented by eating three meals a day, getting enough sleep at night without napping during the day, drinking enough liquids, and working to remove the stresses in a child's life. Pain medications such as acetaminophen, ibuprofen or naproxen can also be helpful, but they can make headaches worse if taken too often. Parents should work with their child's doctor to manage and prevent headaches.

0:54:25

Dr. Jacobs adds, "A sudden, severe headache or a change in the headache sensation from previous, what we call 'first or worst' headaches should be evaluated. Another good rule of thumb is that if the headaches are interfering with the child's normal routine, then it is time to get them evaluated. So therapy can be instituted to return your child's life to normal."

So headaches, they are common in children. They are more common as school gets back in session. There are some things you can do about them, as we've mentioned here. But if they're severe or changing in quality from previous headaches or recurring often despite changes in lifestyle or medication use or interfering with the quality of your child's life in any way, be sure to see your doctor. And that's my final word.

Also, the good folks at Nationwide Children's have produced a video where you can learn more and share the info on back-to-school headaches. I'll put a link to it in the Show Notes for this episode, 327, over at PediaCast.org.

All right, that's all the time we have today. I do want to thank each and every one of you for taking time out of your day to make PediaCast a part of it. I really do appreciate that.

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. With regard to iTunes, we're in the Kids and Family Section of their podcast directory. We're also in the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher, and TuneIn.

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

0:56:04

Then, there's the landing site, PediaCast.org, where you'll find an archive featuring hundreds of past episodes, 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. That 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, co-workers, anyone with kids or those who take care of children, including your child's healthcare provider. Next time you're in for a sick office visit or a well-check up or 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 providers' ear, let them know we have a podcast for them as well, PediaCast CME. Similar to this program, we turn the science up a couple of notches and provide free Category 1 Continuing Medical Education Credit for listening. Shows and details are available at PediaCastCME.org.

Thank 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.

[Music]

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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