Sensory Processing, Potty Training, Nail Fungus – PediaCast 238

Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include sensory processing disorders, tic disorders, potty training, chronic abdominal pain, GERD, nail fungus, and hemoglobin A1C screening for kids. It’s another info-packed show this week… Don’t miss it!


  • Sensory Processing Disorders

  • Sensory Integration Therapy

  • Tic Disorders

  • Potty Training

  • Chronic Abdominal Pain

  • Gastroesophageal reflux (GERD)

  • Nail Fungus

  • Hemoglobin A1C Screening for Kids



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, a pediatric podcast for moms and dads. It's episode 238 for January 16th 2013. I almost said 2012. It's one of those things that just takes a little time getting used to it. In fact, I even end the script I actually wrote 2012 that's why I almost said it. But we'll get the hang of the new year.

It is 2013, January 16th, episode 238 of PediaCast. We're calling this one Sensory Processing, Potty Training and Nail Fungus.

I'd like to welcome everyone to the show today. We're going to get into the content rather quickly because we have lots to cover. I do want to remind you though the purpose of PediaCast, in fact, the initial vision was to answer your questions in a way in which your doctor maybe couldn't in the examination room because of time limitation.

So instead of the three-minute-why-your-child-keeps-getting-ear infections-talk, some parents would rather have the ten-minute version with lots of details but still presented in a way that moms and dads can understand without necessarily having a medical degree.


And in the past year, back in 2012, I do think we got a little bit off track with the bigger emphasis, in my opinion, on interviews and news stories, which they're great things, they're important things, but I don't think we answered quite as many questions from moms and dads last year as I would have liked.

So my goal this year is to have more episodes devoted to listener questions because if one parent out there is asking a question we can all be sure that lots more parents have the same question. So I want to focus more on you, the listener, and what's on your mind.

But to do that I do need your participation so think up some good questions about your kids and send them my way. It's an easy thing to do and I'll get you the details on how to send me a question in just a couple of minutes.

And I would like to take the time to thank everyone in the past who has sent in questions. We try to get to as many of them as we could. And I still have a collection of them from last year that we didn't get to, so I'm going to pick some of those and some of the new ones that come along and get those answered for you.

OK and I'll tell you how in a minute. But first, what are we talking about today? And we do have a listener show coming your way. So what do you, the parent, want to know?


Well in this episode we're going to talk about sensory processing disorders and sensory integration therapy. Big words but ones that you may have vaguely heard of, especially as relates to children with autism or in the autism spectrum. So we're going to talk about sensory processing disorders and sensory integration therapy.

Also tick disorders, potty training – always some good questions about potty training, so we'll get you to the details on that. Chronic abdominal pain, so bellyaches that last for a long time and sort of flowing out of that conversation we're going to talk about gastroesophageal reflux, also known as GERD.

Also got a question on nail fungus, which is maybe more common than parents would like to think, we're going to talk about that. And hemoglobin A1c screening for kids, a little discussion on that that's coming your way as well.

So if you do have a topic that you would like us to talk about or a question for the program and as I mentioned we're going to try to have more listener shows this year, just head over to and click on the Contact link.

You can also email or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S. And to give you an idea of what that sounds like one of our listener questions today does come from the Skype line, so that's another way that you can get your message to me just call in and leave it on the voice line.

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 do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

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

All right. With all that in mind, we're going to take a quick break and we'll be back to answer your questions, right after this.



All right. We are back and as I mentioned we're going to go to the Skype line for our first question, so let's do that now.

Hi, Dr. Mike! This is Rebecca in Tennessee. I just enjoyed listening to the Poison Control line jingle at the beginning of PediaCast number… Oh! I don't know what number it was now. But I thought downloaded a rogue podcast. It was great. Thanks! I'm calling about my one-year old daughter. At 10 1/2 months she has not made any motor development progress since her sixth month appointment and she's my third child and so I was getting concerned. She can sit up alone if we set her down sitting up and she can roll both ways but that was all. So our pediatrician referred us to a physiatrist at a local children's hospital in Knoxville and they promptly diagnosed her with a sensory processing or integration delay. So we're doing physical therapy. It was so hard to find any information about her specific delay because everything for sensory processing is the five main senses and for her it's only spatially in how she perceive things dealing to her, in particular, white bearing on her hands and on her legs as well. Muscularly she was totally normal. All other developmental areas are normal or above "average" for her age. If you could speak to this, give some information that would be great. Thanks! Have a great holiday season!


All right. Well thanks for the call and the question, Rebecca in Tennessee. Let's just kind of sum this up. Rebecca has a one-year old daughter and she has a pause in motor development between six months and about ten and a half months of age. So she's sitting up, she's rolling both ways but she's not moving longitudinally. And I do want to point out that not crawling is common, but most 10 1/2-month olds are getting from point A to point B in some fashion.

So parents want kids to crawl, but from the kid's point of view they just want to get there and they're going to do so in a manner that just comes most naturally to them or that's easiest for them. And for some kids that's crawling, but for lots of other kids it's kind of scooting or rolling. But the point is there's something off in the distance that they want to get to and they are able to get there most of the time at 10 1/2 months.

But in the case of Rebecca's daughter, she's not doing that quite yet. So your pediatrician referred you to a physical medicine physician at a children's hospital and they determined that her neuromuscular examination was normal other than this motor or movement delay. And so they diagnosed your daughter with a sensory integration or a sensory processing delay.

Physical therapist is now working with your daughter and I assume she's coming along well since you didn't mention any further concerns. So the question is what is sensory integration or processing delay. What causes it? What are the signs and symptoms of it? How does one diagnose it? What's the treatment? What's the long-term outlook?

OK. I added a few questions for you, Rebecca, but I'm pretty sure these line up with what you want to know.


So here's the deal, the reason that you're having trouble finding information on sensory processing problems is that we don't really understand them. We aren't sure they exist. It's kind of controversial.

When a child's development or behavior falls outside of what's normal we like to have a label. Why is my child different than other kids his or her age? What's causing it? What do we call it? And that push for a label sometimes causes labels to be made simply for the sake of having a label without fully understanding what's going on.

Now in children with autism we know that they interact with people and their environment in a way that is different from other kids. They see normally, they hear normally, they have normal motor and sensory exams, but they may respond differently when their senses are stimulated.

And this is what has come to be called a "sensory integration" or a "processing problem". So what does that look like at the cellular or tissue level? What's the pathophysiology of what's going on?

And unfortunately we don't know. It's likely that this is just a component of their overall central nervous system dysfunction which resides along that autism spectrum. But we really don't understand that completely.


So what do you do about it? Well there are many number of sensory integration techniques that physical and occupational therapist use to help these kids respond to sensory stimulation in a more socially appropriate manner.

Now, does this really fix the so-called problem or is it really just behavior modification to get socially acceptable responses to sensory input. And so someone question whether it really does anything at all.

There are studies showing it improves behavior, but there are also studies showing that sensory integration therapy has no effect at all. So I take kind of a practical approach here. If your child's having troubling behaviors, particularly if he or she has an autism spectrum disorder and if these problems or troubling behavior are in response to sensory input then it certainly doesn't hurt to try sensory integration therapy.

And if it works, great. And there are a lot of parents out there who have had success with it. On the other hand, there are a lot of parents who haven't seen a lick of success. So if you're trying sensory integration therapy with your child but it doesn't seem to be making a difference and especially if you're showing out lots of money for the treatments, then you may want to talk to your doctor about a different approach.

Now having said all of that, you probably have the impression that I'm talking about this in the context of a much older child than Rebecca's one-year old. And that's because I am because sensory integration and processing problems are a label generally used for toddlers and school-age kids with autism or problems along the autism spectrum.

Does that mean I think Rebecca's daughter has autism? No. Well she might depending on how her development continues to progress and the early intervention and physical and occupational therapy is definitely a good idea for babies with developmental delays.


On the other hand, there are tons and tons and tons of otherwise normal babies whose development is delayed simply because they are programmed to develop more slowly. So there's not really a disease. They just develop slower but the end result is still normal development.

And pediatricians see these kids every day. It's sort of like the constitutional growth delay we talked about in a previous episode of PediaCast. So development is slow but then it ramps up and you're off to the races with no problem at all and development catches up with everybody else.

Now for Rebecca, she has two children so it's easy to compare what the other kids did at a particular age and may compare a sense and get worried. If Rebecca's other kids also had developmental delay followed up by catch up and normalcy, then really you have less of reason to be worried.

But this is often the case where one kid out of the three develops more slowly. And by the way, it usually is younger siblings who do this. Why? They don't always have a reason to get from point A to point B, because their older siblings bring them the toys or the food or the screen, the iPad or whatever, so the baby doesn't have to work as hard to get what they want and instead of getting to the object the older siblings bring the object to the baby.

And we see that in language too where younger children or younger siblings tend to develop language more slowly than older ones and again it's because the older kids talk for them. So how do you know if this is really a problem or if it's normal?

Well of course time will tell as you move down the path if development catches up then hey, it wasn't a problem. You can also look at your extended family. Are there other kids with autism or are there other kids who started development slowly and then caught up to normal? It's no guarantee, of course, but finding family trends does help in predicting.


And otherwise, normal neurological exam is also good news. But at the end of the day you just have to wait and see where development takes you. I think you did and are doing all the right things, Rebecca, sharing your concern with your doctor, seeing physical medicine, working with the physical therapist.

Even if the underlying issue is slow but ultimately normal development, these interventions aren't going to hurt anything. And if it doesn't turn out to be autism or another problem, which is less likely but possible, then you have a terrific early start in dealing with it.

With regard to the diagnosis of sensory integration delay in the "spatial realm" for a 12-month old, it's just a label. It's just something to call it. We can't unwrap the brain and point to a processing problem. We don't even know where to look because everything other than the activation and coordination of behavior that we want to see is working properly.

Do these babies really have a problem processing sensory input or is the part of the brain that must do the processing just not done cooking yet, still developing? And if that's the case, if the brain is still developing just slower than your neighbor's kid's brain, is that really a problem?

It's frustrating, Rebecca, I get that, but nobody said being a parent was frustration-free. I hope that helps at least a little bit and thanks for the question.


All right. We are going to move on to Patty in Ripley, West Virginia. Patty says, "Dr. Mike, I am so glad I found your site tonight. My eight-year old grandson spent a weekend with me and I observed for the first time him making constant soft noises when not talking. For instance, when he sits and watches TV you would almost think he is humming or singing a song under his breath, but there is no pattern of sounds like singing music. Tonight I asked him if he knew why he was making sounds and he said it feels like my throat wants to make those noises. He didn't seem to be upset but it sure puzzled me. Of course I questioned him in a non-alarmed manner and I planned to ask his mom tomorrow if she has noticed this. He's a very bright boy who makes straight As and is involved with lots of sports. He is deaf in his right ear and has some speech problems that haven't been treated in school although his mother has repeatedly asked for some speech therapy. I'm very worried about him. He has my heart and he's a really special little boy, very handsome too. Thanks in advance for any advice you can give. Signed, Grammy Patty."

All right. Well Grammy Patty from Ripley, West Virginia, I appreciate you writing in. So this may or may not be a problem. As pediatricians we get asked these kinds of questions often – why is my kid or my grandkid, in this case, doing A, B or C, X, Y, Z, whatever behavior it is? Why are they doing this?

And in this case it's making soft noises. Now I'm encouraged that you just noticed it, so it's not something he does every minute of the day for months on end, right? He was doing it last night and you noticed it for the first time. And likely if you just forget about it and don't remind him of it, the behavior will go away.

On the other hand, if this is something he does all the time and you know it's certainly possible that this is the first time but it's the first time of a length of time that he's going to do this. So right now it's sort of undeclared. Is this just a transitory thing or is this going to become a problem? And again, time is going to let you know about that.


And if it is something he does all the time and especially if it's interfering with his daily living or is accompanied by other signs and symptoms then should definitely talk to your doctor about it. There's a lot of possibilities here. Being deaf in one ear may play a role depending on the cause of his deafness. Maybe the noise is making a loud and again I'm assuming that this is something that he's going to do for a while.

Again, if it just happened last night I wouldn't get concerned about it. But if this is something he's doing all the time, being deaf in one ear could play a role. Again, depending on the cause of the deafness maybe the noise allows him to pick up some bone vibrations on that side and that's a cool, newly discovered thing that he can do.

Let's get really personal here. I can click my tongue on the roof of my mouth in such a way that it makes a snapping sound that I can hear in the center of my head. Now don't ask me how I discovered this skill.

I do it now and then for fun. OK, fine. I can snap my tongue and make this weird popping noise in the middle of my head. Now, if I do it 10 times a day, OK, that's a bit eccentric. But if I click my tongue during meetings and while recording my show, OK, now that's a problem. So that's what I mean by is it affecting your daily living.

By the way, feeling the urge to make a noise and then doing it over and over that falls within the realm of a tick disorder. Doing it one night at granny's house doesn't qualify. But if it becomes repetitive and troublesome, especially if it starts to interfere with your daily life or kids are making fun of you then it does become a problem and a tick disorder.

Back in July, we covered tick disorders in considerable details. So if you want to know more about these, check out PediaCast #219, 2-1-9, and I'll put a link in the Show Notes so you can find it easily.

Other reasons for frequent clearing of the throat or making funny throat noises include, but is not limited to, throat infections, which cause irritation like viruses or strep throat. I've seen a few kids along the way who basically they started to clear in their throat and the parents bring them in; you look back there it's red and inflamed; you do a strep test, it's positive. They weren't really complaining of a sore throat but they were making some funny noises.

Allergic rhinitis or allergies with mucus stringing down the throat, tonsil stones, tumors and cysts and acid reflux. The list goes on. So again, if this is persistent thing make sure you have your doctor take a peek.


OK. And we have a somewhat sort of similar question from Kim in Brownsville, Texas. Kim says, "My seven-year old started blinking often about a year and a half ago. My pediatrician told us to ignore it and that it'll go away. It did after about two months. Even as he was falling asleep his forehead would be going up and down over and over. About the same time the next year it started again and it's still going strong and now includes eye rolling and it really freaks me out. At this year's seven-year check-up at the end of February, he failed his eyesight screening and did need glasses. I told the ophthalmologist about the eye tick and he wants to see him again in a couple of weeks. Can you talk about tick disorders in children and what do you think? Worried. Love your podcast. Been listening since my son was about 18 weeks old. Thanks for coming back."

Well thanks for your continued support, Kim in Brownsville, Texas. I really appreciate it. So again, all about ticks PediaCast episode 219, check it out and we'll put a link in the Show Notes. I do want to make one important point, ticks are voluntary. Meaning a child consciously initiates them.

So if your child's making funny movements with his eyes and forehead as he's trying to fall asleep, but he's still awake, that's one thing. But if your child is making these movements after he falls asleep that's something different.

Now of course eye movements can also be normal when you sleep, we talked about rapid eye movement being a cycle of sleep or REM, R-E-M, sleep. But if there's more movement than that then it could be a concern.

So Kim, definitely follow-up with your ophthalmologist as scheduled and talk with your regular doctor about it as well. If there's anything concerning about your child's exam or abnormal movements are involuntary, not initiated by an awake child, then your kid should probably see a pediatric neurologist.

But again, talk to your regular doctor, see the ophthalmologist back as you have scheduled, those all sound like great ideas.


All right. Next up, we're going to shift gears and talk about potty training. This is from Ariel in Phoenix. "Hello, Dr. Mike! I've been listening for the past two years and your show has been a great source of information for my wife and me. We've been working with our 27-month old daughter for a few months with potty training. For the most part, it is pretty much at her discretion whether or not she wants to sit on the potty, but we have done our best to incentivize her efforts by offering stickers and treats when she does go to the bathroom and the potty. Lately, we can see her fighting the urge to go number two, but when we ask her if she needs to go to the potty, she says "no" emphatically "I don't have to." What is more concerning is often times she will not go on her diaper either and continues to fight the urge. Other times she frequently asked to sit on the potty but doesn't go to the bathroom despite saying she went poo-poo and is excited. How can we get her to relax and not fight the urge to go to the bathroom when it does come? We tried making trips to the potty pleasant experiences always and I've never made her feel bad for going in her diaper. Any advice would be appreciated. Thanks."

Well thanks for the question, Ariel in Phoenix. I appreciate you writing in. First, let me say 27 months is a bit on the early side for poop control. Now some kids can do it fine, but other kids may not be ready to relax the sphincter muscle on demand. The wiring just isn't ready yet.

And again this comes in to the whole development thing that some kids progressed at a different rate than others. And so in this case, kids at 27 months who are controlling their poop are the exception. So most kids at 27 months aren't quite ready to do that yet.

And for these kids we can often see cases were it sometimes works and sometimes it doesn't. So you get the impression that they can do it but they won't do it, which leads to frustration. So sometimes you just need to give up trying. Wait a few months, try again and then all is well with the world.


Other times kids are developmentally ready and again these kids tend to be older than 27 months, but they're stubborn. You can understand why. Two and three-year olds don't have much say or control in their lives. When and where they poop is one thing they can control and you can't.

So ha-ha on you and there's nothing you can do about it. And for these kids it's also better just to give up trying. Forget about it for a few months and reintroduce the concept down the road. Often these kids will reintroduce the concept on their own because as soon as going in the right place at the right time isn't important to you anymore, then it's suddenly very important to them. It's funny how that works.

So in your case, Ariel, it sounds more like a developmental issue though than a stubborn issue just based on age and by your description of the problem, because it sounds like she wants to do it, she just can't quite yet.

I do want to mention a couple of other things that can confound this all a bit, constipation can make having regular bowel movements difficult, especially if they have large painful bowel movements. Sometimes kids will start to hold it back because it hurts to poop. And so then because they hold it back they get even more constipated, you just got this vicious cycle – the painful bowel movements lead to holding, which can worsen the constipation.

So if you think constipation could be playing a role, talk to your doctor because there are ways to loosen the stool. But your child needs to be seen before starting that sort of thing on your own. There are also neurological diseases that can make it difficult for children to relax the anal sphincter – things like Hirschsprung's disease, which I don't think we've actually covered on PediaCast, but should sometime in the future.

These things aren't common but they're possibilities, so it's always a good idea to have a doctor take a look but at the end of the day, Ariel, the most likely scenario is that your 27-month old daughter just isn't quite there developmentally.

You just have to give her more time and patience. It sounds like she's trying to please you. She's motivated; she wants your approval and the awards or rewards. So if you decide to back off the potty training for a while, pick another behavior to work on, give her another game to play with stickers and treats and other rewards.

So thanks for the question, Ariel. They are always appreciated.


Next up, we have Jane in Alexandria, Virginia. Jane says, "Hi, Dr. Mike! I'm a big fan of your show, though I'm sorry to say that my 21-month old is not such a fan. While she would love to face forward in her car seat, I plan to keep her facing backward at least until age two, specifically because of a statistic you mentioned on your show. You said children under the age of two are 75% less likely to die or be severely injured in a road accident if they are riding in a rear facing seat and I appreciate the good advice you provide."

I appreciate you reminding our listeners of the statistic, Jane, which by the way came from a study in the Peer Review Journal Injury Prevention.

Jane goes on to say, "My question for you is regarding my five-year old daughter. She experienced stomach discomfort for about three months every time she ate. Her bowel movements were normal and the same discomfort resulted regardless of the contents of the meal. She was put on Zantac for a month and the symptoms went away. She still occasionally has the same stomach discomfort. She is believed to have an ulcer, functional abdominal syndrome or some other disorder. I would love to know more about these types of abdominal conditions in kids. Thanks – Jane in Alexandria, Virginia."

So Jane, first let me say thanks for writing in. We always appreciate that. And as we're trying to do more listener shows for the new year I appreciate it even more and would encourage others to write in with their questions as well.

So Jane, abdominal pain in kids that is relatively mild and lasts for several months and is predictable with regard to when it happens is a different animal than sudden onset of severe abdominal pain. Severe abdominal pain is always a medical emergency.

And you should always have your child seen right away to rule out things like appendicitis, bowel obstruction, intussusception, twisted testicles or twisted ovaries, something called malrotation of the intestine. And the list goes on with bad things that can be life threatening.


Now with that said, the differential diagnosis for mild, predictable abdominal pain that lasts for several months is it's not a list of things that are life threatening for the most part. But the possibilities of what can cause mild, predictable abdominal pain that lasts for several months, the possibilities is still quite large.

And often you make the diagnosis by trying some treatment under a doctor's guidance and that doctor is not me, so you want to see your regular doctor for this. So you try some treatment and if a particular therapy works reliably, then you have your answer without needing an invasive or expensive workup.

So let me just give you an example, you have a kid with mild abdominal pain that seems to be more around meal time and it's there for several months and you try Zantac and the symptoms go away and then you stop the Zantac and the symptoms gradually return, then the diagnosis is most likely acid reflux.

And you didn't need exposure to radiation or a pH probe down the gullet to figure it out. Another example, let's say you have similar abdominal pain and you try a lactose-free diet and the symptoms go away and then you reintroduce lactose and the discomfort returns. Well guess what, you're probably lactose intolerant. You didn't need to do a big work-up to figure it out.

If you try a stool softener and even in kids we've talked about before in this program, even if you have regular soft bowel movements, too much stool in the intestine can lead to discomfort for some kids. And so even if they're pooping regularly every day, you need to get more out in order to empty the intestine of the poop that's in there and make the discomfort go away.

And so constipation is not always hard infrequent bowel movements. It can just be too much stool load in the intestine and getting it out helps the symptoms go away. So if you have a kid like that and you try a stool softener and the symptoms go away, but then you stop the stool softener and the symptoms eventually return then you're probably dealing with constipation.


And sometimes none of these treatments work and then fine we do a bigger work-up and sometimes your child often makes their way to see a GI specialist as well. And if the GI specialist does big work-up and finds nothing wrong, then they label the condition functional abdominal pain.

We used to call it irritable bowel syndrome, but irritable bowel syndrome still sounds like something is wrong. So most docs have settled on calling it functional abdominal pain, which basically means we believe you that your belly hurts. We don't know why.

One possibility is a gastric motility disorder, which we talked about in great detail back in PediaCast 179 and we'll put a link to that one in the Show Notes for you too, if you're interested in gastric motility disorder.

Or maybe that your child is just more in tune with their abdominal signals and the concentrating on them too much which results in the perception of discomfort. For example, if right now you concentrate all your thinking on your right big toe, it starts to feel funny. You can even make it start to kind of hurt.

And there has actually been some good research done on biofeedback techniques and hypnosis for this kind of problem and we talked about that in great detail in episode 229 of PediaCast with a research project on biofeedback techniques and hypnosis for functional abdominal pain. And I'll put a link to episode 229 in the Show Notes for you as well.

So the bottom line here, lots and lots of things can cause abdominal pain. Some are life threatening, especially when you have sudden onset of severe abdominal pain, but most of them are not life threatening.


Chronic abdominal pain, though it's usually not life threatening, can often be life changing. OK? I mean, it's a pain in the rump. Well not the rump, you know the other side and a little bit higher, but you know what I'm talking about.

You want to get to the bottom of the problem and you want it to go away. And the best way to do that is to see your doctor. And I want to mention this too, don't get frustrated with your doctor if he or she wants you to try something and it doesn't work.

A lot of this is trial and error. Find out what works before embarking on an invasive and expensive work-up, because if there's a particular therapy that works then you can backtrack and say, 'Oh! We know what the problem is.' But if nothing is working then it's time to go digging for an answer.

So I hope that helps, Jane. In your daughter's case, it sounds like the Zantac worked and I'm wondering if you had stopped the Zantac prior to the symptoms returning. And if so, it just confirms your doctor's suspicions, especially if we starting the Zantac makes the symptoms go away.

Ulcers are very unusual at this age and usually require an expensive scope procedure to diagnose. But acid reflux or GERD is not uncommon and it usually results from a loose sphincter, the muscle, between the bottom in the esophagus and the top of the stomach. Acid escapes through it, the lining of the esophagus is not designed for chronic stomach acid exposure and it becomes inflamed and irritated.

And when a child eats, food passes over this irritated area aggravating it and your stomach acid produces more acid in response to the food and starts churning, which causes more acid to leak through that loose sphincter or valve.

Now Zantac doesn't tighten the valve but it does reduce the acid, so stomach juice that flows through it is less irritating and overtime the inflammation gets better and the symptoms get better.


What about the sphincter? Well it may tighten and your child outgrows the problem. It can wax and wane, getting worse with the ingestion of certain substances like caffeine or it may become a chronic problem requiring the use of Zantac for a very long time.

Also, I'll mention when you the inflammation there sometimes that and of itself can make that muscle looser which then again you get that circular problem – the looser that muscle is, the more likely that as stomach acid goes up into the esophagus the more irritating that is and the looser that valve becomes.

And if you get rid of the irritating acid you get rid of the inflammation, then that valve may tighten up on its own, so you don't need the Zantac anymore. Sometimes simple antacids work. Sometimes you need stronger medication like what we call proton pump inhibitors, things like Prilosec or Prevacid, to name two of them.

Speaking of drug names, to be fair there are other options other than Zantac in the same drug category and those are H2 receptor antagonists, things like Pepcid and Tagamet. We don't endorse any specific drugs here on PediaCast. Sometimes we use brand names just because that's what clicks with you.

You've heard of Zantac before. But there are others in that category that work just as well and the generic is fine also. So again, I only mention specific drug names on this show just because you've heard of them and I want to use terms that you understand.

Rarely surgery is required for extreme reflux. For instance, when we see stomach contents frequently coming all the way up the esophagus and entering the lungs and causing pneumonia, but again that's not typical.

So that's gastroesophageal reflux in a nutshell, Jane. I'm not saying that that's what your child has. That's between you and your doctor. But I wanted to concentrate on it since your child was taking Zantac.

So I hope that helps. Just an overview of abdominal pain and sort of how doctors approach that and so are the differences between bad, severe, sudden onset abdominal pain versus the lingering stuff that last for months.

So I hope that helps, Jane, and again thank you very much for writing in. I really appreciate that.


All right. We are going to move on. Our next question comes from Nathalie in Vermont. And Nathalie says, "Dear Dr. Mike, I love your show. Huge fan. Tell lots of parents to tune in. We appreciate that. Up here in Vermont we all drive a lot. My daughter's now three. When she was one, her primary doctor and I noticed nail fungus. He said that she'd outgrow it. He has since left the practice and at her two-year appointment it's still there. That doctor has now also left the practice. And at her three-year appointment I pointed it out again to a third doctor. It's not any better. It's actually kind of grows that her big toe is yellowish and thick. It's not progressed to what an adult nail fungus can get to, but it's definitely out of the ordinary. I keep putting off saying she'll outgrow it and obviously now she has not outgrown it. Do you recommend I push this further and visit with some type of specialist or just let it go. Also wage, do you recommend an A1c if the parent, me, is concerned about a predisposition of diabetes. I have a predisposition and have been on meds since pregnancy. I think my condition was around much longer but it was never diagnosed. I want to be sure that if she has a predisposition we address it with her diet now. Thanks again for all your wonderful factual insights and straight forwardness. We're lucky to have you to navigate this confusing path of parenting. Sincerely, Nathalie of Vermont."

So thanks to you, Nathalie, for writing in. I always appreciate that as I've mentioned. So we have two issues here, nail fungus, also the medical term for that is, you'll love this, is onychomycosis, and it is a bit unusual for a young kid to have a problem with it. If your child had lots of other infections like frequent pneumonia or recurrent thrush in the mouth, it would cause concern about the possibility of an immune system problem.

But an isolated finding, so persistent nail fungus in an otherwise healthy kid is less concerning. Now the problem with treating nail fungus is that it's difficult to deliver the medicine to the fungus. Topical medicine doesn't penetrate the nail very well, so very little of it gets to where the organism is living. And as a result since very little of the medicine is getting to the organism you have to apply it for a very long time.


There are also medications that you can give by mouth, which work better than the topical ones, but they still have to be used for a relatively long time. Sometimes for months and these can have significant risks associated with them including liver problems, blood cell issues and severe allergic reactions.

It is true that in kids nail fungus may just spontaneously resolve. The body's immune system may take care of it. So it it's stable and it only involves one nail, you can make a case for the risk of the oral medication outweighing their benefit.

But three years is a long time to have this nail fungus. How long is too long? That's really up to each parent and the child. If it's not causing any discomfort, no one's making fun of the kid maybe worthwhile just to leave it because the risk of the medicines you feel that they're too great.

Here's what I would do if I saw your kid, not your kid but a similar story. So if I were practicing and I saw a kid who had nail fungus for a year and we're trying to decide should we treat this or just still just let it be? What would I do?

And again, I'm not giving you a medical advice on your child. I'm just saying in that situation I'd probably send them to see a pediatric dermatologist just to get their opinion. They may say, yeah, leave it alone for a little bit longer. But then you and your doctor will have some reassurance that you're taking the right course.

On the other hand, the dermatologist may have some treatment options and can take the time to sit down and explore benefits and risks in detail before you decide on a course of action. So that's what I would do.


On to your second question, screening hemoglobin A1c in kids with a family history of type 2 diabetes. You say you want to do this so you'll know if diet changes are necessary. Let me say this, if you think dietary change is necessary because you have a family history of type 2 diabetes, then dietary changes are necessary regardless of the A1c reading.

Kids tend to grow up continuing the diet that you provide in childhood. So don't wait for the A1c to be abnormal. Institute healthy eating now. Make healthy choices the status quo. Establish that pattern while you still can.

In terms of screening, we don't have guidelines on that specifically. We do have some lipid screening guidelines and it seems reasonable to me to check an A1c along with the lipid panel, not necessarily every year, but a time or two during childhood, especially if there's a family history.

Now if there's a family history of other children having type 2 diabetes, then I would make that A1c screening definitely something that maybe you do every year or every other year. So you do have to kind of look at that.

Or if your child's growth pattern is concerning for metabolic syndrome, then that's the kid that you're going to also test a little bit more frequently. And again, this is something best discussed with your doctor who knows your situation and your child's vital signs and growth profile and your child's physical examination. All those things really are important in deciding what you're going to do.

But if you're wanting the hemoglobin A1c to guide your meal choices, don't wait. Make those changes now. Thanks for listening, Nathalie. Thanks for writing in. Again, we always appreciate your questions.


I would like to remind you if you have a question of your own we're going to make a commitment to getting to more of those in 2013. And it's easy to get a hold of me, just head over to and click on the Contact link.

You can also email or call the voice line at 347-404-KIDS. That's 347-404- K-I-D-S.

All right. We're going to take a quick break and I'll be back with the final word and again, we're playing a little bit more meat into our final words this year. So stick around. I'll have more for you, right after this.



All right. We are back with a final word. This week's final word stems from Nathalie's question and this idea of diet. I guess it's not a further answer to her question but it got me thinking about this.

We all know there's an obesity problem in this country. OK. We know that. Let's just take that fact and set it aside here for a minute. We also know that with the coming changes in our healthcare system that we have opened up more access. So more people are going to have health insurance than have had in the past, which is a fantastic thing.

Obviously, we want people to have good medical care. But we also have to realize that with that improved access comes increased healthcare cost. And the cost of providing healthcare in this country is going to get worse.

When we look at the obesity problem and we combine that with increased access and we combine that with increased cost, we could have a very real fiscal problem in this country. We already have a very real fiscal problem, but it can get worse. And in fact, it probably will get worse.

And so my final thought today is just really taking a look at what doctors and parents can do with the health of our kids, which then corresponds to the health of our country, which then corresponds to the fiscal position that we're in, because we want to decrease that cost of healthcare and be healthier and have healthier kids.

So what is the doctor's role and what is the parent's role? Well, we really need, I think, to train doctors with some common sense who aren't necessarily ordering invasive and expensive tests for no other purpose than protecting themselves from lawyers looking over their shoulders and parents demanding work-ups that make no sense.


I kind of alluded to this, too, when we talked about abdominal pain in kids and trying some things and seeing what works and making a diagnosis based on what works for that individual child. And again, that kind of goes to let's not do the big, huge, expensive workup right out of the gate.

Let's use some common sense. Let's use our clinical skills more. Let's rely on technology a little less. Let's rely on it when we need to, but we don't need to with every single case. And if we do rely on technology and invasive tests and labs the cost just gets to be staggering.

So I think that's the job of the doctor with the coming changes in our healthcare system is use that technology when you need to. Absolutely. But you don't always need to. And hopefully, we're training doctors to have some common sense and rely on our clinical skills and critical thinking about how we're going to approach things.

So what about you the parent? What is your job in saving the physical health of our country and ultimately the fiscal health of our country as well? And this is where Nathalie's question really got me thinking about this with the diet.

We have a childhood obesity problem. We know that overweight kids become overweight adults. Let's just say it for what it is, they become fat adults. And fat adults have all sorts of very expensive and life changing health problems that cost lots of money and shorten your life. So by changing your child's diet now, you can help prevent that.

Your child will have the potential to live longer. They're going to have a healthier life and you'll save the country a boatload of money in the process. And you'll save your child a boatload of headache and suffering down in the road in the process as well.


So how do you do that? How do you change your child's diet? Well, a very child it can be difficult because they can be stubborn. But how do you go about changing your child's diet? There's a number of things you can do.

Eat together as a family. Model good food choices in your own life. Eliminate after-dinner-TV-watching-snacking. Encourage physical activity over screen time. Offer a balance healthy diet. Get all the food groups in there.

Cut back on the fat. Push more the veggies. Choose healthy snacks over chips. Choose water over soda. And do it now while you still can. It's common sense but many of us and myself included, I am not on a soapbox here at all.

I need to exercise more. I need to watch what I'm eating more. I need to encourage my children to snack less just like you do. We're not always making the smart choice. We make the easy choice. So I think we need to start making not just the easy choice but the smart choice as really where we need to go.

So change your diet, get more exercise for yourself, for your kids and for the health of our country. And that's my final word.


All right. I want to thank all of you listeners out there for making PediaCast a part of your day. We really appreciate it. I do want to remind you iTunes reviews are helpful if you've not taken a few moments to write an iTunes review for PediaCast we would definitely appreciate you doing so. It really helps us to spread the word.

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And then also be sure to tell your family, friends, neighbors, co-workers and your child's doctor about PediaCast. We do have posters available under the Resources tab over at

One last time, best way to get in touch if you have a topic idea or a specific question for the program, just go to and click on the Contact link. You can also email or call the voice line at 347-404-KIDS. That's 347-404- K-I-D-S.

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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