Sleep Problems, Montessori, Mumps – PediaCast 284

Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include newborn sleep spots, baby sleep problems, toddler sleep problems, misshapen toes, Montessori education, Canadian referrals, and sore nipples with puberty. All this plus everything you need to know about the recent mumps outbreak in Central Ohio!


  • Newborn Sleep Spots

  • Baby Sleep Problems

  • Toddler Sleep Problems

  • Misshapen Toes

  • Montessori Education

  • Canadian Referral

  • Puberty & Sore Nipples

  • Mumps Outbreak!



Announcer 1: This is PediaCast.


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

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It's April 16, 2014 episode 284. We're calling this one Sleep Problems, Montessori, and Mumps. I want to welcome everyone to the show, we have an Answers to Listener Questions edition of the program lined up for you this week. And I'll get to a complete rundown of the questions in a moment but first we are in the midst of a mumps outbreak in Central Ohio with well over 100 cases of the vaccine preventable disease reported and many more expected to occur.



First we do have answers to your questions this week so let's run down the list for you real quick. First up we have a question from a mom in Chicago who appreciated our recent talk on safe sleep for babies but she has some specific questions about play yards, bassinets, and cribs. So we'll entertain her questions and provide some answers. Then having established the ABC's of safe sleep, what about babies who won't sleep, the ones who cry when it's bed time, or when you put them down to a nap, or to sleep for the night? We've talked about ways to deal with this in the past but a mom in Manila has a specific problem and we'll see if we can help her as well as many of you who are dealing with similar issues. Then we're going to move up the age ladder to toddlers, what about toddlers who won't stay in bed? We have a mom in Sydney, Australia that has tried everything and her two year old is still causing trouble at night. We'll see if we can provide some assistance for her. And then misshapen toes, you've all seen them, some of you have them. 


Toes that cross, or are longer, or shorter or ones that seem to grow from a common stalk, what causes this? And do you need to do anything about it? Then we're going to talk a bit about the Montessori style of education. I get it, I'm a doctor, I'm not a teacher but pediatricians get asked about education all the time in the examination room. So I won't shy away from it here, just to understand my background is medicine, not education. On the other hand my wife and I had been very involved in the education of our kids and I do teach medical students, and residents, and parents, and children both in the clinical setting and here on PediaCast so maybe I am qualified. Stick around, we'll see how that goes. Then we have a mom in Canada with a child who has a complex medical problem. She's running into lots of red tape with a Canadian health care system and ones are referral to the United States. So we're going to hear her story and see if we can help point her in the right direction.


I also received a question from a 14 year old girl. We don't get many questions from children and teens on PediaCast but I love answering questions from young patients, so this one really makes me happy. If your child or teen has question, fire away on the contact page over at So this particular teenager has a question about sore nipples coming alongside puberty. Is this normal? What can you do about them? Turns out it's a common problems and not just for girls sometimes for boys too, and we'll give that question some thought coming up. And then at the end of the show we'll wrap things up with an expanded final word on the recent mumps outbreak in Central Ohio. We'll do the who, what, when, where, why, how of mumps and get you caught up to speed on that. So that's all coming your way. Couple of quick reminders, the 700 Children's blog, it's at It's a great blog, definitely check it out. Some recent topics planning family vacations with an extra guest, hemophilia, so if you have that blood disorder. Some tips on planning vacations. And why is that your baby gaining weight, and when should you worry?


And then third one, what are seizure clusters? So be sure to check out, our hospital's blog. Don't forget, if you have a question, or a comment, or you want to point us in the direction of a new story or journal article it's easy to get in touch, just head to and click on the contact link. Also 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. If you have a concern about your child's health, be sure to call your doctor and arrange a face to face interviews 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 Alright with that in mind let's take a quick break and we will be back with answers to your questions right after this.



Dr. Mike Patrick: First up we have Katie in Chicago, Katie says, "Hi Dr. Mike I'm a first time mom expecting a baby boy in June, 2014 and your show has been overwhelmingly helpful in allaying my anxieties about this new adventure. I'm curious about your thoughts on new born sleep spots. My husband and I are moving around the time the baby is due. Husband is beginning a medical residency so we decided not to order a crib until we're settled in our new home. In the meantime we plan on having the baby sleep in a fisher price rocking play sleeper. I've read the incline is good for babies with reflux and its portability and compact size is appealing." 


"After for the research however I'm no longer certain of our decision. Is the incline safe for the new born sleep cycle, or a flat surface bassinet a better option? We received the pack and play with the bassinet included but I'm worried that this bassinet will be uncomfortable for the baby since the pack and play seems to be an on the go product not necessarily for sustained long term use. Is the bassinet included with a play yard safe, or is a standalone bassinet a better safer option? In short I want our baby to sleep in the safest spot possible but I also don't want so many sleep spot items floating around the house, i.e one in our bedroom, one in the living room, one in the baby's room, one for on the go. Perhaps the safest option is just to order the crib ahead of time and have the baby sleep there from day one. Thank you for any insight you have on this topic, Katie." Well thank you for the question Katie, I really appreciate you writing in. The best role I can play here is that of a sounding board and I'll explain why that is in a moment. 


I do think your line of thinking is on track and in the end I think you've probably reach the right conclusion that the safest thing that you can do is to order the crib ahead of time and have your baby use it from day one. Now why do think this is the right conclusion? Well as I mentioned my number one reason is the safety factor. Back in episode 281, the bulk of the show was on infantile spasms but at the end of the program for my final word we covered safe sleep for babies and if you miss that segment I don't think it's worth going back for a listen. Again episode 281 at the end of the program. The bottom line, the ABC's of safe sleep, I'll recap those for you here. A stands for alone, it's fine to keep your baby close when you're sleeping but share the room, not your bed and keep pillows, blankets, bumper pads, stuffed animals, toys and other soft bedding materials out of your baby's sleep area. B stands for on the back, you want to place your baby back down, face up each and every time he or she sleeps. 


Sleeping on the back does not increase your baby's chances of choking and sleep positioning products such as wedges claim to keep your baby safe but in fact they are dangerous and not recommended. And then C stand for in a crib, you want to use a firm sleep surface covered by a tightly fitted sheet and a safety approved crib bassinet or portable play yard every time your baby sleeps. Couches, chairs, and beds are too soft, they can trap your baby between cushions and bodies and they are dangerous places for infants to sleep. So those are the rules. So the question becomes, and you'll notice that C stands for crib but we did mention bassinets and portable play yards. So how do bassinets and play yards come into play in your decision making process? How do those fit in with the rules and with convenience? Well that's going to depend on the character of the particular product we're talking about and since I don't have any of them in front of me to touch and inspect I'll leave the final word of that evaluation in your hands. 


If they offer a firm sleeping surface without a bunch of padding then you're probably OK. The problem is that the devices you're considering, the Fisher Price rocking play sleeper and the pack and play bassinet insert, my own personal opinion based on the pictures that I've seen, I'm not really sure they fit that description. They sure does seem to be a lot of padding in those devices, but again that's based on what I'm seeing on the pictures. They're kind of a small area that your baby's in and you can imagine a baby kind of twisting their body around a little bit and potentially get in their face in the padding. SO check it out, see what it looks like and what your guts telling you when you see it in person and you can touch it and feel it. You know, is this something that could be a hazard to your baby? Even though those are things that are on the market out there and marketed as things for your baby doesn't necessarily mean it's a 100% safe. 


So again you want that flat, firm sleeping surface without a bunch of padding. Now those devices may be fine for a supervised nap. You know when you're in a room and you're keeping your eye on your kid I don't feel as confident regarding their safety for unsupervised sleep night after night. But again pictures maybe a bit different than examining and touching the actual product, so ultimately you should decide. Now what about a standalone bassinet, or just using a portable play yard without the bassinet insert. Those options I think are more likely to offer a firm safe sleeping surface, but again you need ti inspect before you buy and use them. Crib on the other hand, that's the gold standard. For a firm yet comfortable place for baby to sleep and as long as it's a new crib model it's likely going to meet all current safety recommendations. So that's where I stand on safety, like you Katie I think a crib is the safest choice right out of the gate. Bit a dedicated bassinet or portable play yard with a firm sleeping surface without padding or any objects in there, it would probably be OK too but you have to make the judgement for yourself. 


So now we have the factor and that's the safety angle. Now we have to factor in convenience, and here Katie it didn't give me as much to go on. Some of the issues I see are how far are you moving? How many nights would your baby be away from the crib during the move? If you're going to need a portable solution anyway because you're going to be spending some nights on the road getting to your new place then getting it now before the move makes some sense and plan on crib shopping once you're settled in. On the other hand how difficult really is it to move a crib? I mean you probably have beds, couches and other furniture to move anyway right? So the addition of the crib really be a big deal? My guess is no but you might need a portable solution anyway while your goods are in transit. Now I know I'm not really being much help here and that's why I said I really going to be more of a sounding board. The reason for that is this, there isn't necessarily a right or wrong answer.


As long as you follow the safe sleep rules every time your baby sleeps regardless of the device that you decide to use and ultimately that decision is yours. You just want to make sure that you're following those ABC's, that your child's alone as they sleep. I don't mean alone in the room but alone in the sleeping spot. On their back and see his crib but the important part of crib is providing a firm, flat sleeping surface. By the way my daughter who is now 19 years old, she was born in July during my first month of my pediatric residency. I know your husband's getting ready to start his residency so I know first-hand that you guys certainly have some fun and busy times ahead. I hope that helps Katie and again thank you for the question. Next up is Madhavi in Manila, Madhavi says, "Hi Dr. Mike I'm a new listener to your show. I have a question about my seven month old baby girl. She cries a lot before going to sleep whether it's a day time nap or at night." 


"Even if we pick her up she still cries though sometimes it helps. We notice cues that she's getting sleepy such as rubbing her eyes, yawning, and pulling her ears and we try getting her into bed in time but it doesn't always help and she still cries. Why did this happen, and can you suggest something to help her? Thank you." Well thank you for the question. So Madhavi there could be several reasons that your seven month old baby cries before going to sleep. And the most common of these reasons is that there appears to be no good reason, you never find a reason and one day your baby stops doing it. We don't know why she's doing it, we don't why she stopped doing it but we sure are glad that this isn't happening anymore. There are some reasons that are actual reasons which means there's a chance that you might be able her if the reason that she's crying is for a helpable reason.


So first let's think about medical reasons that could cause a baby to cry when they lay down to sleep. Some babies have acid reflux and when they lie down flat as in for a nap they get fuzzy because they're experiencing symptoms of heart burn. These babies usually have other symptoms of reflux as well like lots of spinning up, sometimes a chronic cough or wheezing. And there are medications we can give to alleviate these symptoms and helps stop the crying so it may be worth a visit to your doctor to see if gastroesophageal reflux is the problem. But truth be told chances are the crying is not from reflux and these medications won't help if the crying is not from reflux. But it may be worth a shot especially if your baby seems to be in pain and cries every time she lies down flat. If your doctor decides to start some anti-acid type medications and that medicine doesn't seem to be working most doctors would then advice you to stop using it. No need to give your child a medicine that's not doing anything. Another possibility is your baby could be over tired. 


I have girls in my life, namely my wife and my daughter and it's not just girls that this happens to but just the ones in my life happened to be girls who get emotional when they're sleep deprived. Tears come more readily. And if this is the case routine is going to be really important for your baby. Don't let her get over tired, don't wait until she's rubbing her eyes, and yawning, and pulling her ears. Get her down for a nap or for the night before she reaches that point. This may be helped by sticking to a nap time and bed time routine. Naps and bed time should happen on schedule each and every day for babies who have this issue. Yet another possibility, your baby doesn't mean to be alone. She wants to be with you and when you pick her up things get better. But the crying doesn't always stop completely because once she gets worked up it's difficult for her to settle down. The best fix for that is don' pick her up. Let her cry and start learning to soothe herself to sleep. 


It may make for few rough days but she'll get the hang of it. So I think that's a good plan, see you doctor first to rule out any medical issues, like reflux for example. keep to a schedule routine day in and day out and let nap and sleep time be nap and sleep time, don't interrupt it by picking her up, let her cry and soothe herself to sleep which will be crazy for a few days but then like magic almost always gets better. So I hope that helps Madhavi and as always thank you for the question. Next up is Jessica in Sydney, Australia. Jessica says, "Hi Dr. Mike I love your show and appreciate your interesting and insightful advice. My question relates to toddler sleeping problems. I have a two and a half year old son who had previously had no sleeping issues. He went to sleep easily almost every night even though we never had a set routine or schedule. All of a sudden though, in the past two or so months all that has changed. We put him to bed at about eight which is more less when he's always gone to bed but he refuses to go to sleep. Staying up sometimes until 10 or later at night." 


"His behavior ranges from screaming and crying when we first put him to bed, to lying in bed quietly with his eyes open but he still just won't fall asleep. I've tried sitting in his room with him but not interacting. Shutting him in his room and ignoring the fact that he's awake and just letting him play quietly until he falls asleep but nothing seems to work, he just stays up. I should stay too that he insist on his light being on, if we turn it off he just turns it back on and we take the light bulb out, we've done it twice now and then he screams and works himself up into such a state he throws up. I'm at my wicks end, I know it's not good for him to go to bed so late but he seems to refuse to do anything different. Is this normal toddler behavior that he will grow out of or a case of insomnia, or just us not approaching it correctly? Thank you, Jess." Well thank you for the question Jess, I really appreciate you writing in. Before we start down this path I do want to point out one thing you said here at the end.


You said, "I know it's not good for him to go bed so late," that's not necessarily true. Toddlers need certain number of hours and it varies of sleep per night, but what time that sleep starts, and what time that sleep stops is as important as how much that they spend in sleep. When we put kids to bed at 8:00 it really is for us, not for them and it's a valid reason. Parents need some adult time in the evening when their kid's in bed and there's nothing wrong with that. But I just want to point out that there's not anything necessarily unhealthy with the kid who stays up till midnight. If they're then sleeping until 10:00 the next morning, that's fine. It doesn't fit with most families and your patterns but it's not necessarily unhealthy, so I just want to point that out5 first. Now the rest of this we're going to approach from the fact that yeah, you do want your kid in bed at 8:00 because you need some time to yourselves and the house being quiet.


Toddlers sleep problems like this are absolutely common and they often take some trial and error to find the right solution and what works for one family may not work for another. Now as it turns out we had an identical problem with my daughter when she was two and a half years old and we settled on a pretty creative solution but it took some trial and error and I'll describe that solution in a moment. But I do want to give you some initial thoughts first. First, is your child napping, and if so what time and for how long? Is he getting too much sleep at nap time? And is nap time too close to bed time? Things to think about. Also are you wearing him out in the early evening, lots of physical activity, let's say after dinner because a worn out toddler is more likely to become a sleepy toddler. And then follow all that physical activity with a gradually soothing bedtime routine.


So what does that look like? Well you know rough housing a bit, then you engage in some creative play rest the legs, gets the heart rate down, and maybe a soothing bath, pajamas and some reading time with mom or dad but limit place on the reading time. OK you can pick two books, that's it. That way he's worn out and knows bed time is coming. Now with regard to the light, you could try a dimmer bulb, something with less wattage or lumens depending on what kind of bulb you're using. You could install a dimmer switch, that way the light is still there but not quite as stimulating, although my guess is he'd figure out the dimmer switch pretty fast. Maybe he'd find a cute night light to be an acceptable substitute so that the lights just not quite as bright. SO these little tricks have helped many a toddler but then there are the difficult kids like my daughter when she was his age and none of these things work, they just want to be up and we don't want them to be up because we need some adult time. So what we end up doing after much trial and error is we device the game and we found her currency. SO what does that look like? 


Well she really liked these little Polly pocket play sets and we had found one for a really good price that actually had a several little play houses in the one set. I think it ended up being that there were 8-10 of these little houses, and so what we did we said, "Hey you know this first night you're going to get one, you get a house to play with. Just one, you can pick whichever one you want and you can play with it quietly in your room but here's what we're going to do, we're going to put a chart on your door and you are allowed to come out of your room twice. So if you need another drink of water, you need another hug, you want to go potty again, you know you just went. You are allowed to leave your room twice and each time you leave your room we're going to put a little X on that day on the chart. Now in the morning if there's only two x's on the chart you're going to put a sticker on there. If you have three X's, no sticker OK? But you can try again the next night to only have one or two X's and then you get your sticker."


And then what we did was that, "OK, once you've earn one sticker you get another one of those play houses, so now the next night you got two of them that you can play with. Now we're going to make it harder, we're going to say after you've got those two, now you've got to earn three stickers. So you have to have three nights where you only bothered us twice and you're allowed to play in your room and then fall asleep in your bed when you fall asleep, as long as we keep the light dim." So in over the course of time you start to develop a habit of her playing quietly in her room and then putting herself to bed. And that really seem to work pretty well and what you'll find actually is if you really do a good job of wearing them out in doing that routine that they aren't up till midnight playing and they might be the first couple of nights because it's exciting and this is something new. But overtime you do notice that they do kind of put themselves to bed then a little bit earlier. 


Now what happens when you run out of all the Polly pocket houses in doing one every three days? Well you know a lot of times then you have developed that routine and sometimes it's just the sticker is enough and at that point maybe you just buy some really cool stickers and you know the next morning, you know keep doing it, they're not earning anything anymore other than they got to pick one sticker each day and they can pick from all of them and which one do you want to pick and you know, "I like these three." Well you do a day but you know earn another one tomorrow night, you know that kind of thing. So it turned out to be expensive and certainly we use stickers in the Polly pocket houses. You use whatever is going to engage your child so that's why I say you've really got to device a game, make up your own rules, and device what currency in order to make that happen. So that works for us, your millage on that may vary. I hope that helps Jess, thank you for the question. If you find it different creative solution, be sure to write back in and share it with the rest of us. Alright next up is Suzanne in New Hampshire. 


Suzanne says, "Thank you Dr. Mike for your great podcast, great topics and great information. My questions has to do with my three year old son, his middle toes overlap his second toes on both feet. Is this normal? Should I worry? Should I send him to a specialist? His shoes fit well, I always buy him new shoes when he grows out of them. I think my nine month old daughter is starting to get the same thing. I remember when my son was a baby, his toes looked like my daughters toe look now. Is this some sort of hereditary thing? My grandmother did have a pinkie that turned in. Thank you so much and thank you again for a wonderful podcast. Well thank you for the question Suzanne, unfortunately I can't address your son's toes specifically since I can't see and examine his feet and we don't practice medicine here. So if you're concern with his toes definitely take him and have his doctor take a look. Now having said that I can say generally that many toe deformities including any cases of overlapping toes can have a genetic basis. 


And when you see an identical toe deformity on both feet and among many members of the same family then you probably are dealing with a genetic cause. You can also have sporadic toe deformity meaning it probably has a genetic basis but the culprit genes were passed on from one generation to another, rather they mutated on their own sort of one of abnormality so to speak. Another possibility is a developmental toe deformity and in this case the deformity isn't programmed to occur but rather happens is the baby is developing inside the womb. Maybe the toes are squeezed up against the side of the uterus for a prolonged period or surrounded by the amniotic sack in an abnormal way. Now these usually aren't going to be overlapping toes, there's going to be different types of toe deformities but there are the possibility of some toe deformities, having a developmental basis to them. Now is your son's case Suzanne, given that it is the same on both feet and given that your daughter's toes are starting to do the same thing, and given that people aren't always transparent enough to share their abnormal toes at a family reunion.


Given all these factors I would say a genetic basis is very likely but again bounce it of your doctor and take his word not mine since he's the one examining your child's feet and I have to keep the PediaCast lawyers happy. So here's the bottom line regardless of the cause, the bottom line is this, are the abnormal toes causing pain, or a functional problem, or a significant cosmetic issue that is interfering with your child's quality of life, or has the potential to do so down the road? If the answer to these questions is no, there's not any pain, he doesn't have any trouble with the shoes, he jumps, and runs, and plays like any other kid his age, and he doesn't really care that his toes overlap fact he only notice it that when you point it out. If that's the case then doing nothing is probably better than starting down the path that could ultimately cause harm through anesthesia or a surgical procedure complication.


Which are unlikely but can happen and you really need to fix something that's not really broken. On the other hand if there is pain, or problem with function, or you think there's a potential for a significant cosmetic issue down the road, then you may want to see a specialist. So as with so many other things it really boils down to risk versus benefit. If there's a problem it may be worth the risk to fix it. If there's not a problem, let's not create one. And that's something that you have to really decide, you and your doctor decide together. Let's say there is a problem, who do you see for a toe abnormality? Well that depends. Getting an x-ray may help determine if bones are involved with the problem, if they are then a pediatric orthopedic surgeon might be the right way to go. If bones aren't involved, the deformity might fall under the expertise of a general pediatric surgeon. 


It also depends on what resources are available i your community. A podiatrist who sees kids with foot and toe deformities might be the right person in some communities. At the end of the day have your doctor take a look. Most cases of overlapping toes don't create any problems and don't require any kind of intervention but your situation could be different so be sure to have your doctor take a look. So I hope that help Suzanne and thank you again for writing in. Next up we have Jen in Fremont, California. Jen says, " Dear Dr. Mike our so Kye has been an interact beneficiary of your show because thanks to you he's being raised by more educated parents. Now that he's two and a half and about ready for pre-school we have been shopping around the neighborhood. There's several private facilities touting Montessori curriculum and a couple of them are even AMI certified. We have done some research on the main ideas of Maria Montessori but still aren't sure of its merit.


Alternatively there are schools in the area with more emphasis on academics with what seems like the traditional way of classroom teaching. I realize that you home schooled your children, something we wish we could do but still we'd highly value your opinion about a Montessori education. Thank you so much." Well thank you for the question Jen. The educators in the crowd are all cringing right now, "Oh no a doctor's going to answer an educational question." Yes I am because look folks, like it or not parents ask these kinds of questions to their child's doctor all the time and I would answer in the examination room, and I'll answer here. So first a quick overview of Montessori. For those of you who may have heard of it but you're not quite sure what it is all about. Maria Montessori was an Italian physician and educator, kind of like me except that exchange the Italian heritage for more of an Irish background. She lived from 1870 to 1952 and her philosophy was this, "create a classroom with kids of all ages." 


"Let them pick and choose what they want to learn and how they want to learn it, and let them learn from each other in the process." So teachers are more like guides and there is controlled chaos in the classroom. Now despite the chaos there is structure and modern accredited Montessori programs are careful to graduate kids with a broad based of experience who are ready to embark on the next step of their education. Sounds like a marketing line. I did not look at any marketing materials for Montessori, that's what it's about. And I think this really shines in the elementary school years. Most Montessori programs stop around sixth grade although you can find some middle school and high school programs here and there. There aren't very many of them, most of them are going to be elementary school, and then there're some pre-school programs around as well. Now truth be told many graduate level educational program are actually beginning to take sort of a similar approach. AT the Ohio State University College of Medicine for example, a new curriculum begin two years ago which really allows much more flexibility on how individuals learn and you could choose among different ways of interacting with the same content.


It may be attending the traditional lecture, it could be watching a web cast, it could be listening to podcast. SO there's different ways depending on if you're more of a visual learner or an auditory learner, and also are you a big picture person or let's get right in and explore the minutia. Now you're going to have learnt the details at some point but for some people seeing bigger pictures and the way things relate to one another helps to get that down first and then study the details. Other people would rather study the details first and then see how they all fit together. SO it really depends on your learning style and there are ways of testing your own individual learning style to see what might be the best way to go. So we know that kids and college students all have different sorts of learning styles and there is a good case to be made for a flexible education that allows you to kind of pick and choose.


It's proven itself overtime. Now is there a guarantee of success? No, your child still has to participate and dig into the available opportunities and there's going to be a whole lot of kids out there that the best for them is a structured classroom, that the controlled chaos is actually destructing and they're not going to learn as well. So you really have to know your own kid to know which is going to be best. Now I will say this, in your case Jen we're talking about a two and a half year old and at two and a half years I think most day-cares and pre-schools are already filled with controlled chaos. It didn't have to be Montessori and some of that chaos is more controlled than others. I'm not sure you're going to get the same bang for your buck as get with the school age curriculum, you know what I'm saying? I mean if the cause is on par with other programs in your area, or you really like the location, or the staff, or the facilities then my impression, it's fine. But if you're going out of your way, or paying lots of money for the Montessori name during the pre-school years, I'm not so much sold on it. 


Two and three year olds need to play. They just need to burn off energy in a safe supervised environment, great. But what about the multi age classroom, that's fine but most two and three year olds are independent players anyway. There's not a lot of cooperative play t two, maybe a little more at three, definitely a lot more at four but your son's at the age where he's going to be doing his own thing anyway and he could care less what the age of the other kids are. You'll probably get more out of the fact that it's a multi aged classroom than he will, just saying. So that's my two cents for what they're worth, coming from a medical, not an educational professional disclaimer. And from someone who home schooled his kids although in all transparency, with our kids it was more of an online educational experience. We didn't really teach, we let the online teaching professionals do that with the K12 curriculum and most recently with the George Washington University online high school, how's that for a shout out.


And yes my kids are socially well adjusted, they have friends, they have their corks but don't we all? My daughter received a nice scholarship at a private liberal arts university, she's there and nearly a straight A student. I'm not being defensive about home schooling, maybe I'm a little bit. But more than that I'm just a proud dad, and proud of my son as well. I hope that helps Jen and as always thank you for the question. Next up Nicole in Saskatchewan, Canada. "I love your show and listen all the time. I love being medically informed as a parent. I have a very medically complex two year old girl, she's many diagnoses tracheomalacia, aberrant subclavian artery, developmental delay, hypotonia, and nose speech. Her biggest problem was breathing issues from birth and hypotonia. That I was told for a long time, it's just benign laryngomalacia, and tracheomalacia. They have tested her for everything under the sun, the only markers they have found are alpha succinctP2 protein in her blood and some urine organic acids showing possible succinct semialdehyde dehydrogenase deficiency.


We are repeating this test but our local doctors seem to be at a lost with her. My question is can you tell me what you think the leading children's hospital is so I could possibly be referred out of Canada for these types of matters. This is a very frustratingly slow process in Canada, you have to be referred everywhere and referrals can take months or years just to get an appointment. Our medical system is very red taped oriented and every genetic test has to be approved by our province before going ahead. I feel like my two year old is falling between the cracks of the system. Many metabolic disorders need to be diagnosed early to prevent permanent damage, please help." 


I hear your frustration Nicole and believe me I wish I could fly up there and bring you and your family back with me to Nationwide Children's Hospital and pay for the whole thing because we most certainly are a leading children's hospital 9and we have an excellent metabolic program, but I can't do that. I don't have those kinds of resources or that sort of pole, I'm just a podcasting primary care doctor. But you are most certainly welcome to use the link on the show notes, episode 284 at and click on the one that says "Connect now with a pediatric specialist from Nationwide Children's Hospital" and tell them your story right there and that's going to put you in touch with our welcome center and they may be able to help you out with the process of getting started. Now having said that, this program is not a great big giant advertisement for Nationwide Children's Hospital. We want to put great advice and information in the hands of parents everywhere. And there are plenty of excellent US children's hospitals that are a little bit closer to your home in Saskatchewan. Seattle Children's would be a good option.


Children's Hospital Colorado in Denver is another. But look, if you're travelling from Saskatchewan to either of those, you surely must be flying and if you're flying why not come to Columbus, Ohio. To be fair other leading hospitals in the United States include Children's Hospital Philadelphia also known as CHOP, Boston Children's, Cincinnati Children's, Texas Children's Hospital in Houston, Children's Hospital at Los Angeles, St. Louis Children's, Lurie Children's in Chicago, and John Hopkins in Baltimore. But truth be told, of all of those excellent children's hospitals I really do believe the best is Nationwide Children's Hospital here in Columbus, Ohio. You can't go wrong coming here, if you can find the way and the means, and again the best place to start is reaching out to our welcome center by going to the show notes for this episode 284 and clicking on the "connect now with a pediatric specialist" link. 


And that goes for everyone else out there too, we'd love to see you here. And if you do stop by shoot me a note through the contact page at and we'll see if we can do a little meet and greet. So I hope that helps Nicole and please write back and let me know how your family is doing. Don't make me come up there and get you, because I would if I could. Next up we have Beth in Ashville, North Carolina. Beth says, "Hi, I'm a 14 year old girl and I'm really embarrassed about this but I need a medical opinion. I heard some parent talking about your show and you sound like a good doctor so I thought I'd ask you. I've been having a lot of pain in my breast. I recently just started puberty and they're just sore, they're really hard and painful around the nipples like there's a mass underneath them. Is this normal? Is there anything I can do that would help with the pain?" Well thank you from writing in Beth, it's an excellent question and it's one many teenage girls and teenage boys for that matter ask. 


The breast tissue under the nipples in girls and boys is sensitive to the hormones of puberty, and this tissue we called breast buds response to these hormones and they wake up so to speak and start growing, at the same time the rest of your body is waking up and starts changing. Now in boys this is a brief process but it's startling, and very often a cause for concern. The good news for boys it usually doesn't last very long. Many teenage boys do come in to see the doctor for this because they're afraid it could be cancer or just as bad in the minds of the adolescent boys they might be growing breast which of course isn't the case at all but it's definitely unsettling for these kids. If boys are particularly worried, or particularly uncomfortable, or if there's any discharge or bleeding from the breast, or any other concerning symptoms that go along with it then a trip to see the doctor's definitely warranted and may boys do make that trip because they're concern about this and most are found to have found normal changes of puberty and they're simply re-assured.


But again any question, there is nothing wrong at all, we'd go and see a doctor for this and the doctor saying it's normal. Don't feel bad about that, that's why we're here, we want to be able to reassure you that it's normal. What about the girls? They too often worry about breast cancer and it's usually not breast, it's usually not the case but again and especially if there's a family history of breast cancer at a young age, it's worth a trip to the doctor to verify that this is normal. For girls the tenderness may last longer and you may find it waxes and wanes with he menstrual cycle over the course of a few months or even a few years. And some women have tender breast during their cycle on and off for a long time. So what can you do about it? Well again, see your doctor because we don't give up medical advice for specific people here, you want your doctor to verify that this is simply a normal part of puberty.


And if that's the case they would usually recommend a short course of non-steroidal anti-inflammatory drugs like Ibuprofen which is marketed as Motrin and Advil to treat these symptoms if they're really bothering you, just treat it as needed. So breast bud swelling and tenderness underneath the nipples sometimes more on one side than the other, sometimes only on one side, it's common on girls and boys especially at the onset of puberty but sometimes it last longer than that. Any discreet lumps or dimpling of the skin, or discoloration, or redness of the skin around or distant from the nipple, or bleeding, or drainage from the nipple, or any other concerns that you have should be checked out by your doctor and if he or she finds a normal response to puberty which is the case the vast majority of the time, then symptomatic treatment most commonly with Ibuprofen and reassurance is generally all that's needed. So thank you so much for writing in Beth I really do appreciate the question.


For those of you out there thinking, "Hey, I'd like him to answer my question," let me know what it is and if your child or a teenager has a question either have them write it or you write it, I would love to answer more questions from kids and teenagers. And it's really easy to get in touch with me, just head over to and click on the contact link and write away. I read each and every one of those that come through. Alright let's take a quick break, we do have a mumps outbreak going on here in Central Ohio and we're going to talk more about that right after this.



Dr. Mike Patrick: Alright we are back. As of this recording and this show is for April 16, 2014. As of now we are in the midst of a mumps outbreak in Central Ohio with well over 100 reported cases of the vaccine preventable disease. It started with college students on the campus of the Ohio State University but has spread into the Columbus community, Franklin County and surrounding counties. So what is mumps? What causes it? How it's spread? Why is it a problem? What complications can it create? And why are people getting it including those who have been vaccinated? Let's take a look, first off mumps is caused from a virus, so this is a viral infection and it primarily infects one or both parotid glands and these are the salivary or spit glands that are located below and in front of your ears, right at the angle of your jaw overlying that area. It was common in the United States until mumps vaccination became routine which was in the late 1940's to early 1950's.


The incubation period for mumps is two to three weeks, so it's a pretty long incubation period from the time you're exposed till the time symptoms start. Two to three weeks but a range of 12-25 days have been reported. You're contagious before the symptoms appear by about two days and you have no symptoms, you have it, you're spreading it that's one of the reasons that this does spread so easily because for a couple of days you're spreading it and you don't even know you have it. It spreads easily by way of saliva droplets. So basically little droplets of your spit have the virus in it and that's how it's spread. And those can be spread from coughing, sneezing, sharing drinks that sort of thing. Now what about symptoms? Well a large number of people, in fact one third of all people with the mumps never develop any symptoms at all but they have the virus and they can spread the disease and they're usually contagious for about a week despite the fact that they have no symptoms at all. 


That's another reason why this spreads like crazy in an outbreak situation. For the two thirds of people who do have symptoms we generally fever, headache, weakness, fatigue, loss of appetite, and those one or both swollen parotid glands which again are the salivary or spit glands located below and in front of the ears overlying the angle of the jaw. And with those being swollen it does cause painful chewing and painful swallowing. Now there are other things that can cause these kinds of symptoms including other viruses other than the mumps virus, it's rare but it can happen. And the bacterial infections from mouth bacteria that go up the little duct that the spit get released and into the gland so you can get a bacterial infection of the parotid gland as well. But in an outbreak situation like we have here we're going to assume that everyone who has swollen parotid glands that it's mumps. It's mumps until proven otherwise in an outbreak situation. 


So how do you diagnose mumps? How do you tell if it's mumps for sure or if it's another virus or bacteria that are doing it? Well in this section I'm really talking to the doctors and other clinicians out there. You want to touch base with your local health department or the infectious disease guru at your nearest children's hospital. The advice may defer on how to work this up from place to place. The current advice here from our infectious disease specialist and our health department as of early April, 2014 is that getting IGG and IGM, again this is aimed at the clinicians out there, getting immunoglobulin levels is not helpful. So IGG is most likely going to reflect immunization status, not current disease and IGM may not yet be positive in an acute infection situation. 


So IGG and IGM are not really going to be that helpful in diagnosing it. What's going to be more helpful is oral swab where you swab the buccal mucosa and you swab that and you also take blood work and you send both of those for a viral culture and mumps PCR. Again this is the clinicians out there I'm talking to. Now that is current advice here early April, 2014 Central Ohio mumps outbreak that's the recommendation from the Franklin County Health Department. Most hospital labs do not perform these tests, so you you're not going to want to send in to a hospital, again you're going to want to touch base and utilize your local health department, they'll tell you what test they're recommending and should give you instructions on how and where to send the testing to be done. So that's the work up and how you tell if it's measles versus something else. Now how do we treat measles? 


Well it's a viral infection so there's no medicine that we can give to make it go away faster, all we can really offer is supportive care. So rest and fluids, medicine to help with aches, and pains, and fever and want to make sure that they stay hydrated. The symptoms usually last about two weeks and you're contagious as I mentioned before from about two days before the symptoms began until five to seven days after the symptoms appear. So generally once the symptoms start we advise that you stay home for a week. And you're most contagious during those couple of days just before the symptoms appear. Now what about complications? The parotid salivary glands aren't the only possible sights of infection swelling, inflammation. Now these are going to be less common but they can happen. You can have inflammation or swelling in the testicles which we call orchitis, or in the ovaries which is ovaritis. 


That primarily happens to kids who have already passed through puberty or in the midst of puberty. It may affect one or both testicles or ovaries, they can be painful for several weeks and it's rare but they can lead to sterility down the road so that you're unable to conceive children, now again that's rare. I don't everyone thinking, oh these mumps, you're going to be sterile because it's rare that you have testicles or ovaries swollen and then if you do have that, it's even more rare that it can lead to sterility but it can. We can also see a redness and pain of the breast which we call mastitis, you can have swelling and inflammation of the pancreas that causes pancreatitis which results in abdominal pain, vomiting, and dehydration. Now we're going to get a little more serious, it can cause encephalitis, so the virus can infect the brain and this may result in permanent neurological problems and it may be life threatening. 


It's rare, that rarely happens but it can happen, it's not rare when it's your kid that it happens to. We can also see meningitis, the membranes and fluids surrounding the brain and spinal cord. This is usually not life threatening like encephalitis, but it does cause severe head ache, neck stiffness, vomiting, dehydration. It's not as dangerous as like a bacterial meningitis, this would be a viral meningitis which is really uncomfortable and nuisance but generally not life threatening. It can also cause hearing loss. Now hearing loss when it happens, it's rare but when it happens it's usually permanent and it can occur in one or both ears. Now it's about one in every 20,000 cases of mumps is going to result in permanent hearing loss. Now that doesn't mean that you need 20,000 cases before you're going to see one kid with hearing loss. It could happen to the first kid who gets mumps and then you don't have another on for 20,000. 


And of course when you're talking about a population, you could have five n one outbreak and none in another outbreak and the average still ends up being one in 20,000. And again if it's your kid that has permanent hearing loss for mumps, if they're that one those numbers don't mean anything at all because it happens to your kid. Mumps during early pregnancy may lead to miscarriage of the fetus. Given these types of complications, and given how easily the virus spreads immunization was developed in the late 1040's and that is our primary method of preventing mumps is the mumps vaccine. It's given as a component of the MMR vaccine which is mumps, measles, and rubella and the first doses given at 12-15 months of age, and the second dose is given at four to six years of age. So about the time they're entering kindergarten or any time after this if only one dose has been given. 


So you want two doses of the MMR vaccine to be protected against the mumps. Now is everyone who gets two doses protected? The answer is no, two doses results in an 80-90% zero conversion rate. Now what does mean? It means if you get two doses of the MMR vaccine there's an 8-90% chance that you're going to be protected against the mumps because your body has responded to the immunization and made the antibodies. But that means 10-20% of people who get the MMR are unprotected so they don't form an immune response so they did not zero convert. Now does that mean that you shouldn't get it? No, because traditionally people who don't zero convert, these people are protected by what we consider this concept of herd immunity. And what means is, OK so I got the shots and it didn't result in me being protected.


But all the other kids in my classroom that I'm exposed to, they did zero convert, they're protected against the mumps and so I'm surrounded by people who aren't going to get it and give it to me. So that's where this concept of herd immunity comes in and it's really work well for us over many years until we start to have parents who don't give their kids immunizations because of an imaginary fear of things like autism which certainly not been proven. I would say in fact that lots of research studies have proven the opposite that the MMR is not related to autism. But because of this fear that's out there and that spread so easily by the internet and miss-information. We have parents making decision not to give their kids MMR that's not only living their child unprotected it's also putting your child at risk because now that's one less kid that they have as a buffer around them that is protecting them from getting the disease because of the unvaccinated kids get it and your child is one of those that got the vaccine but didn't zero convert, they're going to get it from the kid who we wish had had the vaccine to protect your child.


So we're starting to lose our herd immunity and that's why we're seeing more and more outbreaks of vaccine preventable diseases. Now I do want to point out even if your child did zero convert, there is still chance they could get the mumps following vaccination even though they did make antibodies against the mumps. In those situations it's usually a milder form of the disease, doesn't last as long, isn't a severe, and has fewer complications associated with it. So you do have immunity, your anti-bodies are working but rather than immediately stopping the mumps virus, the mumps virus gets a little strong hold and then your immune system kicks in and gets rid of it quicker than if you weren't protected at all. So vaccine is really our primary way of preventing mumps.


Covering your mouth and nose when you're coughing and sneeze also helps prevent spread and of course hand washing is king, it's really important especially if you're in an outbreak situation, it's important all the time to wash your hand frequently especially after you touch your mouth or face and use soap and water or an antiseptic hand gel. For more information about the current mumps outbreak from the Franklin County Ohio Health Department, just head over to and go to the show notes for episode 284 and I'll have a link there with all the up to date current information for the outbreak at the Franklin County Health Department. Another cool link that I'll put there for you, it's from the council on foreign relations. It's a pretty cool map of the world that shows recent vaccine preventable outbreaks and you can filter the map by disease. You can look for measles, mumps rubella, polio, and whooping cough. You'll see that there's a lot of recent outbreaks in the United States particularly of measles and pertussis or whooping cough. 


You can zoom in on the map to get outbreak information like where it started, how many cases, that kind of thing. So you nerdier parents out there like me be sure to check it out it's a really cool map and again it's in the show notes for this episode 284 over at So mumps and other vaccine preventable diseases are still around and as long as we have parents to declining to get their children immunized we're going to see more and more outbreaks of these things which puts all of our kids including those who are up to date with their vaccines at risk. And that's my final word. I want to thank all of you for taking time out to your day to make PediaCast a part of it. That does wrap up our time together. PediaCast is a production of Nationwide Children's Hospital. Don't forget PediaCast and our single topic, short format program PediaBytes are both available on iHeart Radio Talk which you'll find on the web at and the iHeart Radio app for mobile devices.


our show archive which includes over 250 programs as well as our show notes, transcriptions, terms of use and contact page are available at our landing site which is We're also on iTunes under the kids and family section of their podcast directory. And you'll also find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Podbay and most other podcasting apps for iPhone and android. We're also on Facebook, Twitter, Google Plus, and Pinterest and of course we really appreciate you connecting with us there and then sharing, re-tweeting, re-penning all of our post so you can tell your own online audience about our little show. We also appreciate you talking us up with your family, friends, neighbors, and co-workers, anyone with kids or anyone who takes care of children and as always be sure to tell your child's doctor about the program. We do have we do have posters available under the resources tab at And until next time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids. So long everybody.



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

d as always be sure to tell your child's doctor about the program.  We do have we do have posters available under the resources tab at  And until next time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids.  So long everybody.



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


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