Video Games, Diaper Rash, Baby Bottles – PediaCast 342

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  • Join Dr Mike in the PediaCast Studio for more news parents can use! This week we cover ADHD & school entry age, video games & intellectual ability, and substance abuse prevention in young children. Dr Cherrelle Smith-Ramsey stops by to talk about diaper rash (causes, treatment, prevention), and we answer a listener question about toddler eating and baby bottles.

Topics

  • ADHD & School Entry Age
  • Video Games and Intellectual Ability
  • Substance Abuse Prevention in Young Children
  • Diaper Rash
  • Toddler Eating
  • Baby Bottles

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Transcription

Announcer 1: This is PediaCast.

[Music]

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

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

It is Episode 342 for March 30th, 2016. We're calling this one "Video Games, Diaper Rash, and Baby Bottles". I want to welcome everyone to the program.

Pretty quintessential pediatric program today. I mean, video game, diaper rash, baby bottles, really, can you get more pediatric medicine that that? I'm not sure that you can.

We have another full line-up for you this week. We have news parents can use, an interview with the pediatric expert. That's the diaper rash part, which is a very common condition in babies. I'm sure that every parent out there dealt with at least one diaper rash, probably many more.

Then, we'll end with the question from a mom in Berlin, Germany who has a smallish toddler who is a light eater and she wants to know about packing in the calories while weaning the bottle. So we'll answer her question as well.

Before we get started right here out of the gate — and I mentioned this last week but I really want to remind you again — we're in a temporary studio now for a couple of months with a portable equipment, paper thin walls and a window that looks out on a very busy street that is apt to have fire trucks raising up and down it from time to time, with their sirens blaring.

So, if you hear some odd noises, no need for alarm, it's the sound of progress, because we're going to be moving into a brand new state-of-the-art audio studio soon enough, probably around mid-May. So just bear with me until then and all will be right with the podcasting world once again, at least as far as PediaCast is concerned. There, I said it. Let's move on.

0:02:20

I mentioned toddler eating and growing and baby bottles all coming your way in a bit. Also, the interview segment on diaper rash. It's with another primary care pediatrician at Nationwide Children's — Dr. Cherrelle Smith-Ramsey. That will promise to be an enlightening interview for many of you. We're not only going to cover sort of typical diaper rash but let you know what other kind of rashes occur underneath the diaper, not just the ones that you typically think of as diaper rash or the yeasty ones and the contact or irritant dermatitis rashes.

We'll also talk about infections and things like eczema or atopic dermatitis, psoriasis even. We'll talk about how to differentiate them, what you do about them, how to prevent them, when to call your doctor. Those sorts of nuts-and-bolts things.

What about our news segment? What are we going to cover this week? There's a new study out looking at ADHD and the age at which kids start school. Could it be that some cases of ADHD might simply be immaturity? Maybe in a kid who wasn't quite ready to start school. Would he or she had needed medication if they had simply waited another year before starting school?

It's a reasonable question, and if we have an evidence-based answer, it may help some parents who are deciding whether to enroll little Jimmy in kindergarten this year or wait until next year. So we'll discuss the issue surrounding that.

And then video games, lots of research studies focus on negative aspects of video games. I should mention there are some negative aspects, there's no question. But there are some positive aspects as well, including a project that shows an association between video game playing and intellectual ability and school competency with a positive relationship between the two. Now, there are some caveats to keep in mind. So we'll explore the study and try to interpret what it means and how it could affect possibly your family.

0:04:19

Then, we're going to consider substance abuse prevention, but instead of focusing on middle school and high school kids, we'll tell you about some resources from the National Institute on Drug Abuse which concentrate on prevention efforts in very young children from before birth until just after preschool. So we'll tell you what that's all about. As it turns out, there are some things you can do right from the beginning of a child's life that decrease the risk of drug abuse in that child when he or she becomes a middle school or high school student.

So, that's coming your way as well. Then, following the news, we'll talk diaper rash and then we'll answer our listener question from Berlin, Germany about toddler eating and baby bottles.

Speaking of answering listener questions, I would love to answer yours. It's really easy to get in touch with me. Just head over to PediaCast.org and click on the Contact link.

You can also call the voice line, 347-404-KIDS, 347-404-K-I-D-S if you like to leave your message that way.

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 interview and hands-on physical examination.

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

Let's take a quick break and I will be back with news parents can use and lots, lots more. That's coming up right after this.

[Music]

0:06:18

Attention deficit/hyperactivity disorder, also known as ADHD, is typically diagnosed in childhood and manifests as an inability to sustain attention and control activity levels and impulses. It's also fairly common with the prevalence of 15% in Western countries.

Although the causes of ADHD are still unknown, it appears that the age of a child when he or she enters school may have an effect on the diagnosis of the disorder. This according to a study published in The Journal of Pediatrics.

Dr. Mu-Hong Chen and colleagues from Taipei Hospital and Taiwan examined cohort data from 378, 881 children ages 4 to 17 years of age from 1997 to 2011. They evaluated the prevalence of being given a diagnosis of ADHD and/or prescribed ADHD medication.

Using the Taiwanese annual cut-off birthdate of August 31st for school enrollment, the researchers compared the youngest children in a grade (so those born in August) with the oldest children in a grade ( those born in September) and they assessed whether age was associated with being diagnosed with ADHD and/or being medicated for it.

When looking at the database as a whole, children born in August were more likely to be diagnosed with ADHD and/or receive ADHD medication compared with those born in September. When broken down and analyzed further, researchers noted it was only the preschool or elementary school-aged children who are born in August that had an increased risk of being diagnosed with ADHD and receiving medication.

Teenagers born in August did not have an increased risk of ADHD diagnosis. Researchers say this may imply that increasing age and maturity lessens the impact of birth month on ADHD diagnosis.

0:08:10

Worldwide, the number of children and adolescents diagnosed with ADHD or those receiving a prescription medication for the disorder has increased significantly in recent years. This evidence shows that relative age, which reflects neurocognitive ability, may increase the likelihood of ADHD diagnosis and medication.

Dr. Chen says, "Our findings emphasize the importance of considering the age of a child within a grade when diagnosing ADHD and prescribing medication to treat it."

So this was a very large study. We're talking almost half a million kids that were involved in this. So it's a very strong study in terms of looking at the statistical power of it. Now, it's also from researchers in Taiwan, so you may be thinking well how does this apply then to the United States? Well, it is a valid study as you think about the US or whatever other Western country you're listening from, because Taiwan is a Western society that happens to be in the East with communities and family structures and schools and medical system that's very similar to those found here in the United States. So don't let the fact that the study was done in Taiwan sway your opinion of it.

So what does this finding mean for you, the parent, and for pediatric providers out there taking care of kids. Well, for one, is your child — or the child you're taking care of if you are a provider — does he or she really suffer from ADHD? And the answer for a lot of kids is going to be yes. They really do. Or could it simply be that they're not quite ready for the grade that they're in and would they benefit from moving down a grade rather than being medicated?

Of course, the right answer will depend on the specific child and family. Moving down to a lower grade or failing a grade comes with other things to consider. There's a stigma which is probably more pronounced as the child gets older. There are friend and social group disruptions, the feeling of failure. All of these are possible. Certainly not guaranteed. Other kids would do just fine moving down a grade.

0:10:19

So it really does depend on the child and the family. Some kids do well with the medication, so why disrupt life if life is going well, especially if he or she is tolerating the medication and they are doing better in school with it. And other kids may move down a grade and still need medication, or maybe he or she needs to move two grades which can be even more disruptive. Maybe. Depends on the family, and the child, and the school system.

So lots of complicated options to think through. But here is where I think the study really has the most value for parents and providers. As a pediatrician, and also just out and about as a family and friend, I hear many moms and dads asking the question about kids born near the cut-off date, "Should we go ahead and send little Jimmy to kindergarten or should we wait until next year?" It's a perplexing question that many parents struggle with.

Well, with this study in mind, I would say if you have any doubt about little Jimmy being ready for kindergarten, maybe it's best to give him another year to mature before starting school. It's not a guarantee that he won't end up with an ADHD diagnosis or need medication, but it probably does give little Jimmy a better chance to succeed.

Video games are a favorite activity of children, and many adults as well. In fact, they exist in nearly every American home. There are also many research studies that pertain to video games and when new one of those studies come out, we do try to cover it on PediaCast because they affect so many of you.

Now, it's true that lots of these studies focus on some negative aspect of playing video games, but the study we're talking about today actually focuses on a benefit you should know about. Researchers at Columbia Mailman School of Public Health and colleagues at Paris Descartes University assessed the association between the amount of time spent playing video games and a child's mental health, cognitive ability and social skills.

0:12:12

So what did they find? Well, according to the study, which was recently published in the journal Social Psychiatry and Psychiatric Epidemiology, after adjusting for child age, gender and number of children in the home, researchers found that high video game usage was associated with significantly higher intellectual functioning and higher school competence.

Furthermore, there were no significant associations with any child-reported, parent-reported or teacher-reported mental health problems.

The researchers also found that more video game playing was associated with fewer relationship problems among peers.

So, how often did these kids play video games that we're talking about? Probably not as often as you would think, with only one in five of the children playing more than five hours per week, according to their parents.

Results were based on data from the School Children Mental Health Europe project and included kids who are 6 to 11 years of age. Parents and teachers assessed each child's mental health in a questionnaire and the children themselves responded to questions through an interactive tool. Teachers evaluated academic success.

Factors associated with time spent playing video games include being a boy, being older, and belonging to a medium size family. Having a less educated or single mother decreased time spent playing video games.

Dr. Katherine M. Keyes, study author and assistant professor of Epidemiology at the Mailman School of Public Health says, "Video game playing is often a collaborative leisure time activity for school-aged children. These results indicate that children who frequently play video games may be socially cohesive with peers and integrated into the school community. We caution against over interpretation, however, as setting limits on screen usage remains an important component of parental responsibility as an overall strategy for student success."

0:14:03

OK, so she does make some good points there in the end. And I do want to mention a couple of other confounding factors that could be potentially be in here. So, they did say that they adjusted for the child's age, gender and number of children in the home. I do wonder if they also adjusted for socio-economic status. So you do wonder if folks who come from a lower socio-economic level don't have the resources and support that they need to do as well in school. Maybe they also don't have as much access to video games.

So I think that's one sort of confounding factor that you would also want to adjust for them. And maybe they did. I'm just not sure about that, but that's one thing that kind of comes to mind.

The other thing I found interesting was that the more video game playing that they did, there was fewer relationship problems among peers. That maybe because they're playing video games instead of interacting with their peers and having relationship problems with them. Although, then again, maybe they're all playing video games together.

So, in any case, video game playing is associated with higher intellectual ability and school performance, according to this study. But do keep in mind these were 6- to 11-year-olds that we're talking about. Many of the kids were playing video games with other children. So that is true, not necessarily playing alone. And the majority of the kids were playing video games less than five hours per week.

Researchers also mentioned, and this is important, that those kids with less educated parents and single moms spend less time playing the video games. So I guess that does kind of speak toward socio-economic status there to some degree.

There are probably underlying factors here that contribute to video game playing and academic success. One I mentioned is possibly socio-economic status being tied together, rather than one causing the other. So, I don't think the researchers are saying that you should play more video games because you will do better in school. I think what they're saying is there is that association. There's probably underlying things below the surface that cause both of those things to go up together. I think that was what I was alluding to when we talked about correcting for socio-economic status.

0:16:16

Still, the study does provide some reassurance, at least for parents, that at least in 6- to 11-year-olds playing video games, especially with siblings and friends and moderation, it's not going to rot their brain. It doesn't lower their school performance. It doesn't cause an increase in mental health problems. And, in fact, maybe somewhat beneficial.

It's also fun, which is another important part of life. And, especially when kids and parents play video games together, it's a great bonding experience. Sometimes, depending on the child and the game, a lesson of humility for the parent.

The National Institute on Drug Abuse, which is a part of the National Institutes of Health, has launched an online guide regarding the interventions in early childhood that can help prevent drug use and other unhealthy behaviors.

The guide offers research-based principles that affect a child's self-control and overall mental health, starting during pregnancy through the eighth year of life. It recognizes that while substance use generally begins during the teen years, it has known biological, psychological, social, and environmental roots that begin even before birth.

Dr. Nora Volkow is Director of the National Institute on Drug Abuse. She says, "Thanks to more than three decades of research into what makes a young child able to cope with life's inevitable stresses, we now have unique opportunities to intervene very early in life to prevent substance use disorders." She adds, "We now know that early intervention can set the stage for more positive self-regulation as children prepare for their school years."

The online guide is called Principles of Substance Abuse Prevention for Early Childhood. It addresses the major influences on a child's early development such as lack of school readiness skills, insecure attachment issues, and signs of uncontrolled aggression in childhood behaviors. Special attention is given to a child's most vulnerable periods during sensitive transitions, such as a parents' divorce, moving to a new home, or starting school. There is strong evidence that a stable home environment, adequate nutrition, physical and cognitive stimulation, and supportive parenting, all of these things, can contribute to good developmental outcomes.

0:18:23

The online guide includes two supplemental sections for policymakers and practitioners that go into greater detail on how early childhood interventions are designed and how to select the right strategies for specific needs at the family and community levels. Dr. Volkow says, "This guide is important reading for anyone who has an influence over a child's life, from early development through the transition to elementary school."

The online guide, again, entitled Principles of Substance Abuse Prevention for Early Childhood is the fourth in a series of evidence-based tools produced by the National Institute on Drug Abuse. The other three are called Principles of Drug Addiction Treatment, Principles of Adolescent Substance Use Disorder Treatment, and Principles of Drug Abuse Treatment for Criminal Justice Populations.

The online guide concludes with a list of selected resources with information on research-based early childhood drug use prevention programs.

So this is one thing that I love about free and open access medical education. These are great resources for folks. And, back in the day, this kind of stuff would not be readily available for policy makers, practitioners. They kind of tied up in journals and very difficult to get around.

And then, there was a period of time where, OK, if you subscribe to something and pay money, you can get access to this kind of material. And now, we're really moving into more of an open system of just sharing medical knowledge with each other. And that I think is just such great benefit.

These are great resources for parents, pediatricians, family practice doctors, nurse practitioners, psychiatrists, psychologists, counselors, teachers, coaches, other school officials — you get the picture. Really, anyone who takes care of kids or has influence over a child's life, especially young children, should know the Principles of Substance Abuse Prevention for Early Childhood.

0:20:18

If you're dealing with older kids, sure, those other publications may be important for you as well — Drug Addiction Treatments, Principles of Adolescent Substance Use Disorder Treatment, and then the Criminal Justice one. And certainly, if you're dealing with kids who are in the criminal justice system then, that may be a good one for you to look at as well.

But the main one here I think that we're talking about today anyway, Principles of Substance Abuse Prevention for Early Childhood. So, if you — anyone really — who takes care of kids or has influence over a child's life, again especially young children, really should take a look at this. How can we care for them in such a way that reduces the risk of substance abuse later on and in a way that's rooted in evidence, that the recommendations actually work?

So important stuff and you can find the online guide along with those other resources that I was talking about from the National Institute on Drug Abuse. And I'll put links to all four of those publications in the Show Notes for this episode, Number 342, over at PediaCast.org.

[Music]

Dr. Mike Patrick: Dr. Cherrelle Smith-Ramsey is a primary care pediatrician with the section of Ambulatory Pediatrics at Nationwide Children's Hospital and an assistant professor of Pediatrics at the Ohio State University College of Medicine. She takes care of kids from birth through adolescents in her office practice and also sees children in the Urgent Care setting.

She's here today to talk about a very common problem for babies in pediatric practices and urgent care centers and probably in your home if you have a baby, and that problem is diaper rash.

So let's give a warm PediaCast welcome to Dr. Cherrelle.

0:22:30

Dr. Cherrelle Smith-Ramsey: It's no problem, happy to be here.

Dr. Mike Patrick: So let's just start out with a definition of diaper rash. What kind of signs and symptoms do parents typically see with diaper rash. What's the typical stuff that you would see with that?

Dr. Cherrelle Smith-Ramsey: Kind of the most common thing you'll notice is redness. It can be raised. It can be bumps scattered across the perineum. It can also involve the genitalia as well as the bottom. A lot of different diaper rashes exist out there, and sometimes they can be hard to tell them apart.

Dr. Mike Patrick: Yeah, so it can be in the front or the back. It can be patchy. It can be all red. It can be bumpy, dry, really just something in the diaper area that doesn't look quite right, right?

Dr. Cherrelle Smith-Ramsey: Exactly.

Dr. Mike Patrick: OK. So that's what you see. What about symptoms that the baby may have? Can the baby feel that they have this rash, do you think?

Dr. Cherrelle Smith-Ramsey: Yes, they definitely can. Sometimes, if you notice, "Oh, my goodness, my baby's so fussy, what's going on. So they're being fussy. They may be a little bit more clingy in older kids. You may noticed they're putting their hands down their diapers, or it may be itchy to them, so they may be digging at their bottoms or scratching. So that's something to look out for.

And some diaper rashes can be really painful. So besides being fussy, they may actually cry especially during bowel movements, or they having poop or urine in them, it can also be irritating.

Dr. Mike Patrick: Now, you were talking about older babies who may put their hands down there and start scratching and itching at it, and then that can lead to sort of breakdown of the skin, even on a microscopic levels. So just some micro-abrasions that maybe you don't even notice. But then, that gives opportunity for bacteria that's on the surface of the skin to kind of invade that area and then you can get infection as well.

Dr. Cherrelle Smith-Ramsey: Exactly.

0:24:18

Dr. Mike Patrick: Now, I had said, so anything under the diapers the parents look at and say, "Hey that doesn't look right. Think about diaper rash." But there are some other possibilities that we wouldn't really classify as diaper rash that can happen under the diaper. I kind of alluded to infection. Tell us a little bit more about those things.

Dr. Cherrelle Smith-Ramsey: Yes. So besides infections, there can be other skin disorders that you cans see sometimes in the diaper area, especially if you're looking at a rash that's more scaly per se. If you notice a yellow scale in the diaper, you think more like seborrheae or the same type of dandruff that you see in your scalp, you can also see in the diaper area.

Also, since we're speaking of scales, if the scale may be a little bit more silvery, sometimes you can even see a psoriasis type diaper rash there. Oftentimes though with the psoriatic diaper rash, you won't see the silver in this but you may see if your child has psoriasis in their scalp or on their extremities but kind of just watching and seeing if it doesn't get better with diaper rash treatment. So things like that can kind of push you towards thinking it may be actually skin disorder.

Dr. Mike Patrick: Yeah, absolutely. And then, eczema, I think a lot of parents have heard about eczema . As physicians, we call it atopic dermatitis, same thing. You can see that in a diaper area as well. What does that look like?

Dr. Cherrelle Smith-Ramsey: You can. With a lot of eczema rashes, the skin is dry. You may see brown bumps or papules in the area and it's also one of those rashes that's pretty itchy too as well.

I often don't see a lot of eczema in the diaper area. You may see it more common in the upper thighs which may also be in that region or on their bottoms.

Dr. Mike Patrick: I was just going to say that's one way that helps the doctor differentiate this from just plain diaper rash, this skin disorders. And oftentimes, they are on other areas of the body and not just confined to the diaper area. Whereas, the more traditional diaper rashes are confined to that region.

0:26:18

In terms of infection, what's the difference — these are terms a lot of parents have heard of but maybe don't understand what the difference is — what's the difference between impetigo, cellulitis and an abscess?

Dr. Cherrelle Smith-Ramsey: OK, so impetigo, usually you see a lot on the face, kind of around the perioral region. It can involve the nose. Then, it starts there and kind of spreads out. So, you will also see kind of red papules or bumps in the area. But impetigo oftentimes crusts, and it will be kind of a yellow crusts. Not necessarily the same as the scale but kind of a harder crust on it. Impetigo is also itchy.

Moving toward the cellulitis and abscess, cellulites, those rashes there, usually bright red. There can be some swelling or even some fluctuance in the skin. And it's really more showing a side of infection, like something else is going on besides just a simple diaper rash. Your baby may be having a fever, and again having some fussiness. Then, thinking more of an abscess, there's more of a localized pocket of infection. When you see an abscess often, it's one, it's large, it's painful and it can even drain. It can be a clear fluid, a yellowish or whitish fluid.
So those are kind of some of the things you can use to establish, This is impetigo. This is cellulitis versus an abscess.

Dr. Mike Patrick: And the bottom-line is, if you think your child has a skin infection like that at any place, but we're talking on the diaper area here, you definitely want to let your doctor look at your child. And the treatment is going to be a little bit different depending on which it is. So if it's an impetigo, you might be able to use just a topical antibiotics. Sometimes, you need oral antibiotics with those as well, but topical may do it.

0:28:04

Then, as you get in to the deeper infections like cellulitis and then abscess, then definitely oral antibiotic or draining of it. So you definitely don't want to take care of this on your own at home with some Triple antibiotic from the store. Take your child to your doctor and let them take a peek if you're worried about infection.

You did use the word fluctuance. So that just means kind of like soft bouncy…

Dr. Cherrelle Smith-Ramsey: Right.

Dr. Mike Patrick: Feels like there's maybe some fluid under the skin. Another term doctors use with regard to infection under the skin is induration, which is more of a firmness. And that just let you know that there is more concentrated infections. It maybe not an abscess quite yet but something is developing there.

All right, so how then do you, and I think we've kind of alluded to this, how do doctors tell the difference between diaper rash and other skin problems?

Dr. Cherrelle Smith-Ramsey: I think the biggest thing that we take into consideration is actually finding out more information from the parents. We want to make sure we ask you lots of questions about what type of things your baby is eating. and maybe perhaps what we're seeing is actually a nutritional deficiency. Maybe your baby isn't getting enough zinc or protein. Or better yet, there are some type of deficiency that could be going on.

And sometimes if you're feeding your baby those things, it doesn't necessarily mean that you're causing them to have a deficiency. Sometimes there are enzyme problems that lead to babies not having enough those types of nutrients, and then it manifests on the skin.

So we always want to ask lots of questions. And then, besides what they're eating, is anything run in the family? Do they have any rashes anywhere else? So providing your provider with as much information as you can about the rash when it started, how long it's been there, can be very helpful in us telling apart what's going on, as well as the symptoms that your baby may be having.

Dr. Mike Patrick: So this is one of those things where there's not a big battery of tests that we're going to get or imaging, but really just a good history in physical examination is going to help us differentiate what exactly it is that's going on.

0:30:09

Dr. Cherrelle Smith-Ramsey: Yeah, there are very few rashes that actually need biopsy or something like that to confirm, like, "Oh, OK, this is what we're seeing that's happening in your diaper region." A lot of the diagnosis is strictly clinical, meaning what we see in the office and what you tell us the baby is doing at home or more information about the rash.

Dr. Mike Patrick: Yeah, absolutely.

So, as we narrow it down now, so we've talked about the other things that can be in the diaper area including infection, let's focus in on really more classic diaper rash. And there's kind of two big buckets for diaper rash. What are those?

Dr. Cherrelle Smith-Ramsey: So usually most types of diaper rashes, they either fall into a contact dermatitis or irritant or allergy dermatitis, versus a fungal dermatitis, which is usually a candida which is a type of yeast that loves moist areas.

Dr. Mike Patrick: Yeah, absolutely. So how do you tell those apart, those two things?

Dr. Cherrelle Smith-Ramsey: So focusing more on like contact dermatitis, when you look at your baby's bottom, usually on the rounded or the convex surfaces is where you'll see that particular type of rash. It's usually bright red, and then also kind of a shiny appearance. Again, it's on those rounded areas.

Sometimes, they can also involve parts of the genitalia. It's really just kind of localized, the places that have actually come into contact with the skin. So I think that's important to remember about contact or irritant dermatitis.

When you're looking more at a fungal type diaper rash, those areas, they actually involve the skin folds a little bit more. We call them the intertriginous areas. The rash will be beefy, kind of really bright red. The areas will be very well demarcated. Or you can tell the difference between the rash and where the skin is. And then, you'll also see these little satellite lesions. So you may see a large area of the rash and then you can kind of pinpoint areas of redness that kind of surrounds the area.

0:32:06

Dr. Mike Patrick: Yeah, we call those satellite lesions as you mentioned. So again, like telling diaper rash from other things, it's really based on history and physical. Again here, it's really based on history and physical. But I will say you've described the classic looks to these things. But there's such a big variety of appearance that can occur and you can even see them together often.

And so, it can be difficult to tell, and that's why again, if you have any doubt at all because they're treated differently, then you'd want to take your child to your doctor, have them take a look at the rash and let you know exactly what's going on. Because it does take seeing this over and over and over again to figure out, "Oh, yeah, that's what this is."

Dr. Cherrelle Smith-Ramsey: Exactly. Just like you mentioned before, a lot of times, the baby may present just the contact dermatitis, but you provided the entry way now for a fungus or yeast to get into the skin and once the skin is broken, it can be really hard sometimes. They'd be able to tell, is this a fungal rash? Is this now a super infection? What's happening here?

Dr. Mike Patrick: Yup. Absolutely. Let's focus in on the contact dermatitis. What are some examples? You'd mention sort of mechanical irritation and allergic type reactions. Just give us some examples of each of those categories that are common causes of an irritant or contact dermatitis in the diaper area.

Dr. Cherrelle Smith-Ramsey: The most common thing that's in contact with the bottom in the diaper is going to be urine. It's going to be poop. Diarrhea type of… in the area can definitely cause alone a contact dermatitis. Doesn't have to be anything else going on in the diaper but poop, it could make your baby's skin break out and even have some areas of skin break down if you leave that moisture there in the diaper area.

Other things that can also cause contact dermatitis would be kind of harsh soaps that really got strong fragrance or perfumes in them. Different wipes can cause babies to have a contact dermatitis as well. And, if you're putting really strong smelling baby powder's in the area, they can also cause your baby to have some rashes.

0:34:12

Dr. Mike Patrick: And we want to avoid powders because kids can also breath those in.

Dr. Cherrelle Smith-Ramsey: Right.

Dr. Mike Patrick: So that's a good thing to avoid. I mean, a lot of parents use those in the diaper area to kind of dry things out but maybe creams would be a better option.

Even if they're using disposable diapers, even the diaper brand sometimes, you hear like "Well, they can't use Huggies, they have to use Pampers," or vice-versa. You know, the older child use one, the younger child has to use the other one. Who knows why?

Dr. Cherrelle Smith-Ramsey: Exactly. It may be a dye or something different the dye that they use, "Oh, this turns yellow."

Dr. Mike Patrick: Yeah, right.

Dr. Cherrelle Smith-Ramsey: Then, maybe this in contact with urine.

Dr. Mike Patrick: Yup. Another interesting point I think a lot of parents don't realize, and I think it's important to bring up now, because as we talked about how we treat these rashes, it will make a little bit more sense. But when kids have diarrhea, and so things are moving through the intestine at a fast rate, sometimes the actual digestive enzymes make it out into the diaper area, and those digestive enzymes are meant to break down food but they also break down skin.

Now again, if they just have their regular, normal, day-to-day loose-ish baby stool, this is not a problem, but when they truly have diarrhea and things are moving through fast and those digestive enzymes come out, then they can start to break down the skin. And so it's not only just the stool itself that's the irritant, but the digestive enzymes are adding to the problem as well.

Dr. Cherrelle Smith-Ramsey: Yeah, and the bacteria there that are in stool have a chance to interact with the urine more. Urea is broken down and ammonia's there too, which is another irritant.

Dr. Mike Patrick: Yes, lots of going on there. How do we treat that then? When kids have a contact dermatitis in the diaper region?

0:36:07

Dr. Cherrelle Smith-Ramsey: So again, it's really important to try to do is many diaper changes or get in the moisture off the baby's skin as much as you can.

And besides trying to keep them more dry, making sure that you use some type of zinc oxide-containing barrier cream. Now, it could be Desitin. It could be Boudreaux's Butt Paste. It could be lots of different brands. It could be even be the Equate or whatever your drugstore brand is. As long as you're seeing that component in it, zinc oxide, it can help with these types of diaper rashes. Or even a type of barrier cream.

So, if it's not those particular ones, it can be A+D Ointment. Even petroleum jelly like something that you're providing a barrier.

Dr. Mike Patrick: Absolutely. So whatever it is that's we're trying to keep whatever is causing the irritation, trying to keep it from touching the skin. So it touches the cream instead. So you really want to put it on thick.

Dr. Cherrelle Smith-Ramsey: Yes. Lather it on generously.

Dr. Mike Patrick: So you can't see the skin, right? And whatever the area is that's being irritated. And you do that with every diaper change?

Dr. Cherrelle Smith-Ramsey: Every diaper change.

Dr. Mike Patrick: And you're changing the diapers frequently.

Dr. Cherrelle Smith-Ramsey: Mm-hmm.

Dr. Mike Patrick: Then, you'd mentioned trying to keep the area dry. So do you ever advise parents once they do change the diaper maybe just to leave it off as long as they dare, just to let that area dry out?

Dr. Cherrelle Smith-Ramsey: Exactly.

Dr. Mike Patrick: Before they put the cream on?

Dr. Cherrelle Smith-Ramsey: You're going to be at home. Walk around a little bit. Let things air out. It can always help.

Dr. Mike Patrick: Yeah, absolutely. We talked about the digestive enzymes and that leads us to, when kids do have diarrhea and then they have a bad diaper rash, sometimes doctors will prescribe Aquaphor Maalox. Or in some places, it's called magic butt cream. I mean, literally, I know there's a children's hospital within the state, not ours but another one, that literally if you write a prescription for magic butt cream, you're going to get it.

So the Aquaphor acts a barrier.

Dr. Cherrelle Smith-Ramsey: Exactly.

Dr. Mike Patrick: Maalox is an antacid. I mentioned those digestive enzymes, and they have to be in an acidic environment in order to work. The stomach makes acid for them. And so, if you use an antacid and get rid of the acid component in the stool that inhibits the digestive enzymes from working so they don't break the skin down quite as much. So that's kind of a cool chemistry science-y thing going on when we're talking about treating some kinds of diaper rashes.

0:38:23

Dr. Cherrelle Smith-Ramsey: For sure, usually when I see kiddos and they're coming in to Urgent Care, I'm like, "Oh, maybe mommy's not using enough of her Desitin," and that's what I'm seeing. Sometimes I will add that on and they see a difference.

Dr. Mike Patrick: Now, the zinc oxide kind of works as an anti-inflammatory so it helps to get rid of the redness. Do you ever used steroid creams in the diaper region for these kind of rashes?

Dr. Cherrelle Smith-Ramsey: For areas that are very inflamed. So your baby's very tender to touch. It's really bright red. It just looks like a very severe diaper rash. Sometimes, we will prescribe a very short course or a very mild topical steroid like hydrocortisone cream, but we'll only do it for a few days. We don't want it heavy on a extended two-week course of a steroid cream in the diaper area.

And if you're considering using a steroid cream that you have at home or one that you can buy over the counter, I would definitely want to talk to your physician about that before trying to put that on a diaper rash on your own.

Dr. Mike Patrick: Yeah, absolutely. Because if it's an infectious diaper rash, the steroids also sort of inhibit the immune system and your immune system is trying to fight that infection. Now, sometimes, you do need a steroid with an infection. That's possible. But again, you want your doctor advising on whether you need to do that or not.

Dr. Cherrelle Smith-Ramsey: Yeah, exactly. And long term steroid cremes can cause some thinning of the skin, so we're already trying to keep this area healthy. If I'm making the skin thinner there, it's more easy to break down and you're having a whole lot other problem on your hands.

Dr. Mike Patrick: Then, if they do have itching associated with it, what about Benadryl or antihistamine. Diphenhydramine is the drug name for Benadryl. Those types of medicines, do you ever have kids use those if they're having a lot of itching associated with the rash?

Dr. Cherrelle Smith-Ramsey: Very severe, yeah. You can do couple of doses of Benadryl. But again, I definitely don't want parents to just go over the counter and start giving them Benadryl multiple times a day. It's a very easy medication to overdose on. So again, I will always want to make sure you're listening to your doctor. "Is it OK for me to give Benadryl right now? How many doses should I give? How much should I give my baby?"

0:40:25

Dr. Mike Patrick: They also have products like creams with Benadryl on them. Those aren't so helpful, are they?

Dr. Cherrelle Smith-Ramsey: Not so much so.

Dr. Mike Patrick: Yeah, so if you're not going to do Benadryl, by mouth is the best way to go. But you want to do that in conjunction with advice from your physician, not just running out and doing it on your own. Absolutely.

All right, a lot of these is so individualized to the patient, isn't it? Because depending on the location of the rash, what's causing the rash, where it is. Again, that's why even for something that seems, "Oh, this is simple. Do I really need to see the doctor?" At least if it's a recurrent thing, at least the first few times, you do. And then, if you start to see patterns, then it may be OK to do what's worked in the past and kind of try that again. Does that make sense?

Dr. Cherrelle Smith-Ramsey: Yes.

Dr. Mike Patrick: Yup. Let's talk about actually prevention of the contact dermatitis ones. I think there, we talked about the things that caused it. So you really just want to avoid those.

Dr. Cherrelle Smith-Ramsey: Exactly.

Dr. Mike Patrick: Figure out what causes it and then avoid those things in the future, which is going to be different from kid to kid.

Dr. Cherrelle Smith-Ramsey: Exactly. So prevent that irritation. So is it the diaper? Is it a wipe that you're using? Is it one of your barrier creams that your baby skin just doesn't agree with? Being able to figure out which one of those is causing the rash is the biggest way to stop a contact dermatitis.

Dr. Mike Patrick: Great. Then, the yeasty or candidal fungal type diaper rashes, where does the fungus come from?

Dr. Cherrelle Smith-Ramsey: So fungus lives there. It loves moist areas, again. Usually, there are other bacteria. There are things in the skin that compete with it for growth. So sometimes you may see that after your baby's on an antibiotic or something like that — something that's killing off the normal flora or the normal bacteria that lives on the skin — the fungus can outgrow and really take over in the area. And that's sometimes when you'll see the fungal type rashes.

0:42:19

Dr. Mike Patrick: As proof that there's fungus everywhere, bread gets moldy because there's yeast and fungus in the environment. And as you said, the bacteria kind of keep it in check. And we talked about good bacteria on the skin and if the bacteria weren't there, then the fungus would be going wild in warm environments like under the diaper.

And then, how does thrush relate to that as well? So it's not in the diaper. This is when you get fungus in the mouth. How was that?

Dr. Cherrelle Smith-Ramsey: Right. Again, it goes back to fungus living on skin. If something on the bottle cap or the nipple of the bottle or just like mom's breastfeeding, those fungi can get into areas that are again super moist. And you often see if your baby has a fungal diaper rash, they'll also have thrush, too. So it's very good, you know, look at both areas to see if anything is different there, if it's a rash or if anything's crawling there.

You can even see fungal rashes in other areas where the skin folds or creases. So at the base of the neck, you may see a bright red rash. Or they're teething and they are drooling more, you're like, "Oh, they never have a rash there, but now I see it." So those are other areas to look out for.

Dr. Mike Patrick: Yeah, the inner thighs, the arm pits. Basically, where there's a fold, it's going to be more likely to be a warm moist environment which the fungus likes. And then, if they don't have a lot of bacteria in that area, like baby's mouths. And that's one of the reasons why we want babies to get bacteria in their mouth, so that they don't get thrush as easily.

So how do you treat the yeasty rashes then?

Dr. Cherrelle Smith-Ramsey: So your yeast-type rash, you can't really get these types of treatment over the counter. You just can't walk in to CVS and buy an anti-fungal cream. You can but it may not be prescribed for an infant. I would really want you to see your physician to be treated for a fungal type rash. We use creams that have anti-fungal medications in them.

0:44:16

Lotrim, Nastatin are often the named ones that you'll see on your prescription bottles. And you apply those three to four times a day or almost with every diaper change, to treat the fungal infections there.

One thing I always try to recommend to parents is even though it may say a ten-day course, I try to stress, use this cream until the rash is gone.

Dr. Mike Patrick: Yeah, maybe even a few days after that to keep it from coming back. I think you make a good point that you want to see your doctor, to make sure it really is a fungal infection before you treat it. There are anti-fungal creams out there that are available over the counter.

I think a lot of parents find it if they use the prescription and take it to the pharmacists, they're going to get a generic product. It will work just as well but it's going to be cheaper for them than buying name brand anti-fungal creams over the counter. So you may want to check cost or talk to your doctor about what the best options are there.

What about prevention? Oh, I should mention too — there are also oral medications for fungal infections. Most babies don't need that, but if you have severe case or it just keeps coming back, there are…

Dr. Cherrelle Smith-Ramsey: And the topical creams just aren't cutting it, then sometimes we do consider a course of oral anti-fungal. Or even just like with the contact dermatitis rashes, we may do it again — a very brief course of steroids to try to help.

Dr. Mike Patrick: And then, there's the whole antihistamine, Benadryl kind of thing if they're itching a lot with it, too.

Dr. Cherrelle Smith-Ramsey: Exactly.

Dr. Mike Patrick: But again, talk to your doctor about those things.

So how do you prevent fungal inspections then in the diaper region?

Dr. Cherrelle Smith-Ramsey: Again, it's kind of the same thing. You want to make sure you try to keep those moist areas as dry as possible. And also kind of just being aware if your baby's on an antibiotic, to kind of start preparing, like, "OK, let me start checking their diaper areas a little bit more frequently, changing their diapers more because I already know they're going on antibiotic. So it's something I need to pay a little bit attention to, because they could develop a fungal rash there."

0:46:21

Dr. Mike Patrick: Yup. Absolutely. What advice do you have for parents who are dealing with recurrent diaper rashes? So you have a kid and they just seems they have diaper rash all the time and they get one cleared up, and here comes another one. What should they do?

Dr. Cherrelle Smith-Ramsey: I definitely want parents to understand that it's not a sign of bad parenting if you have a baby that has a recurrent diaper rash over and over and over again. You're trying to use your over-the-counter-cream. It's not getting any better. At that point, you definitely want to reach out to your physician and say, "I'm having a really hard time treating this diaper rash. I like to come in and have you look at it, too."

Definitely, not all simple diaper rashes are simple diaper rashes, and we just need to have a little bit more history and actually look at the rash and see if something else is going on.

Dr. Mike Patrick: So definitely partner with your doctor, have them take a look at it. Sometimes, keeping a log can be helpful, too. What products am I using? What's touching the skin down there? As you said, at the very beginning of this discussion, we want to get all the information that we can. Have all of those little data points in the back of our mind, as we're kind of putting them together to try to figure out what's going on.

So the more information that parents can provide in terms of what they're using, what's going on the skin, how often it's going on may be helpful.

Dr. Cherrelle Smith-Ramsey: For sure.

Dr. Mike Patrick: All right, we really appreciate you stopping by today and talk about diaper rash.

Dr. Cherrelle Smith-Ramsey: That's no problem.

Dr. Mike Patrick: Let's change subject here for a minute. We have done this in the past. It's been a little while. It's been several months since we've talked about family games. So we talked a little bit before we started the interview. What kind of games do you remember playing as a kid that you found particularly fun that maybe parents could find and play with their kids today?

0:48:08

Dr. Cherrelle Smith-Ramsey: I love board games growing up. So even from my young age, and even we weren't playing the games right, we still just love to sit down — me and my brothers and sister — and play. So even starting off with Sorry! or Monopoly. We played a lot of Trivial Pursuit, but I think my all-time favorite as I got a little bit older was Mall Madness. Maybe it fueled some of my shopping addiction now. But Mall Madness was a super fun game.

Dr. Mike Patrick: That sounds great. You mentioned Sorry! We bought a classic version of Sorry!, since it looks like the original Sorry! games look back many decades ago. And that thing has gotten so much play. I was just kind of surprised. I thought it would be one of those, you know, we'd play a few times and it goes away. We play that one a lot.

And then a game that we got for Christmas is called Splendor. Have you heard of that one?

Dr. Cherrelle Smith-Ramsey: No, I haven't.

Dr. Mike Patrick: No? It's kind of a combination of a card game and you're trying to collect jewels as well. And so, once you collected so many jewels… So it goes back to shopping, I guess, although you have nobles and more 1400, 1500s kind of feel to it.

So you're collecting these jewels but the jewels themselves are these tokens. And you know how a lot of games these days, the pieces just feel really cheap. It's just like really thin cardboard. These tokens are like chips in Vegas. They just have a really solid feel to them. They're just something satisfying about playing this game.

And it's just the right mix of strategy versus luck, and I think middle school age school could easily play it. Then you can a play a game in a half an hour.

So Splendor, we got it for Christmas. My family is actually getting a little tired of playing it. Because every time we're going to play a game, like "Hey, I want to play Splendor." So we have to get Sorry! to back out, I guess. Or find Mall Madness.

Dr. Cherrelle Smith-Ramsey: You need to find Mall Madness, yes.

Dr. Mike Patrick: Yeah, I think we do need to do that.

All right, we appreciate you stopping by today.

Dr. Cherrelle Smith-Ramsey: It's no problem. Happy to be here.

0:50:14

[Music]

Dr. Mike Patrick: We have a question today from Megan in Berlin, Germany. Megan says, "Hello, Dr. Mike. Since the beginning, feeding has been an issue for my child. My daughter was born four weeks early and she had a tongue-tied that was corrected in the hospital. We spent five months trying to breastfeed but she never latched. I pumped for several months and then switched to formula.

"She was not a great drinker in the beginning months both breast milk and formula, but with persistence in the later months, she finally started finishing most of her bottles. Then, we began solid foods at six months with porridge, fruit and veggies. She has always been willing to try nibbles of new foods but has never fully taken to eating solids as her real meal. She's now 14 months old and still gets 4 bottles a day.

"After starting daycare last month, where she was eating breakfast and lunch, the socialization seem to help with her interest in food but she still eats very little for her age. So I'm reluctantly still feeding her these bottles and trying to whittle them down carefully in order to pique her appetite, but she has always been so small and I fear her losing too much weight.

"I do not want her on formula. It's so sweet and makes me feel for her teeth and taste pallet but I also fear whole milk is not enough if she's eating like a bird. Should I be courageous and go down to three bottles this month or less? Or, should I follow her lead somewhat and let her wean herself?

"She's not attach to her bottles for comfort like some toddlers are her age. It's more that she needs the calories.

"I should also mention, she drinks water from her cup happily and I brush her teeth daily. We give her finger foods now so she can feed herself, which she likes. She rejected spoonfeeding, and I only minimally try to encourage bites here and there.

"How bad is it for her to drink so many bottles still? Is this abnormal? How much longer is this OK? Please help. I'm very unsure and desperate for any guidance. Thank you — Megan in Berlin."

0:52:35

Well, thanks for the questions, Megan. They're good ones and I'm sure other parents are asking the same ones or have asked in the past or will ask in the future the same questions. Because they are very common. This is a really common situation.

In fact, it's a situation that's not unlike the one my wife and I face with our now 21-year-old daughter. She was 14 months old at that time and a very light eater, just like your daughter, Megan. And she was tiny — just below the fifth percentile but proportional for height and weight and following the slope of the growth chart line. So her growth chart was the same shape as the normal growth chart but she was just hanging on at the fifth percentile. In fact, we used to joke that she was hanging on to the bottom of the growth chart by her fingernails.

Now, I should also tell you that she was otherwise healthy. We did what you should do. We talked to her doctor and together, we came up with a plan. She had a bit of a workup to make sure there was no medical reason for her being such a light eater and of small stature. We checked for thyroid. She was checked for cystic fibrosis. She had some genetic testing and imaging to look at bone age. That sort of thing.

Everything came back completely normal, which was reassuring. We were also reassured by the fact that there are a lot of small people on both my side of the family and my wife's side of the family. So this wasn't exactly unexpected. She's 21 now and about 5'1". She's on the petite side but not abnormally small.

0:54:11

So, it wasn't unexpected but still, like you Megan we wanted to maximize her calories when she did eat. So we talked to her doctor about that as well, and again, came up with a plan together. Now, I know, I'm a pediatrician. But back in those days, I was a pediatric resident, just learning the ropes in my training. And of course, you do lose some perspective when you're the parent, so it was good to have a partnership with our child's doctor in dealing with her eating and growing issues.

So the first thing I would urge you, Megan, is definitely talk through all of these with your child's doctor. Really important thing.

Another point I want to make — because it just came to mind, but it's an important point and I just thought of it– some kids are small because they eat very little. But a lot of kids eat very little because they're programmed genetically to be small. This is an important thing I think to keep in mind.

It's also important to consider the shape of the growth chart. During the toddler years, you'll notice that the slope of the chart really becomes more shallow until the adolescent growth spurt when it shoots up again. So if you look at the shape of the growth chart, from birth through toddlerhood, it's pretty steep.

And then, it shallows. And then, puberty hits and it gets steep again. In other words, older infants and toddler aren't supposed to grow as fast as they did during the first few months of life. And one of the ways that toddlers accomplish the slowdown in growth is to stop ingesting so many calories.

So a child's normal growth is somewhat determined by genetics and normal physiology and these things are partially accomplished through appetite and eating calories — all important things to keep in mind as we consider the individual child.

0:56:03

So Megan, when you say she eats less than kids her age supposed to eat, there is a wide range of what toddlers are supposed to eat. And it really kind of depends on genetics, how big are they programmed to be, and when a doctor is deciding whether this is really a problem or not, they're looking at the shape of the growth chart. They're looking at the health of the child. They're looking at the family history. Lots of data points coming together to help us decide is this really a problem or not a problem at all and just the normal progression of appetite, nutrition and growth for this particular child?

So let's head back to Megan's question. She doesn't want to keep her child on formula. You mentioned the sweetness, Megan. I'm really more concerned with the cost of infant formula. It gets expensive to keep using infant formula during the toddler years. Some of the formula companies make and market toddlers-specific formulas. Kind of next-step formula nutrition. But these are expensive too, and to some degree, it's a way for those formula companies to keep customers longer.

So it's not necessarily the products that you have to use. Other options include just sticking with the whole cow's milk and keeping an eye on her growth during the health supervision checks or well-child checks at 15 months and 18 months of age.

You can also add something to the cow's milk to boost calories if you wanted to. Our doctor back in the day had recommended a product called Carnation Instant Breakfast. And so, we sometimes put that in our milk. Sometimes we use Nestle Quik which is not necessarily the best thing, to be honest and transparent with you. Or half and half dairy creamer added to the milk to boost the caloric content. Some strategies that we used.

Looking back, honestly, I'm not sure that any of that made a big difference at all. She was a small light eater then. She's a small light eater now, 20 years later. But adding something to the milk to boost calories, I don't
know, maybe it just made us feel better. It's something you can talk to your doctor but again, probably not
absolutely not necessary.

0:58:07

It sounds to me like you're doing the right things. You're offering finger foods and fruits and veggies and offering bites here and there, letting her graze throughout the day. And as long as your daughter is small and healthy and doesn't have tons of food aversions or serious control issues, then she's probably just programmed to be small, especially if there are other small folks in your genetic pool. And if your provider, if your child's providers is reassuring you on all of these things, let my v voice be additional reassurance.

On the other hand, if you haven't really gotten to the nitty and gritty of this with your child's doctor, you should. Because there a lot of, again, data points to look at whether this is a really a problem or not. So, that's my two cents anyway, but again, talk to your child's provider.

With regard to the number of bottles and when to wean the bottles, I don't get too dogmatic about this, except to say no bottles or sippy cups with milk or any other beverage other than water overnight. That's the real danger to teeth. Not the bottle itself, but what's inside the bottle at night soaking the teeth without adequate saliva and swallowing to clear the sugar. Bacteria feed on the sugar overnight and serious decay of teeth happen in a hurry.

So good for you, Megan, for brushing your child's teeth. Do that before bed. Nothing but water overnight and then brush teeth again in the morning. That's important.

What about the bottles themselves? Again, I don't get too dogmatic about this. I like what you said, Megan, about letting your daughter wean them on their own. She's not going to go to kindergarten with a bottle in her hand, right? It's not going to happen. She's going to wean off of them in her time.

Some families want their kids off the bottle at 12 months. It's important to them. They want to transition to cups. And that's fine. That's great. Others aren't so concerned about when that happens. Maybe 15 months, maybe 18 months, maybe 2 years old.

Probably by two and a half to three years old, they're off the bottle. Not for any specific reason, just because most two to three-year-olds want to drink from what the rest of the family is drinking from. They want to be like their siblings and their parents, so it just happens naturally. And usually, before age two, but not always.

1:00:25

Again, and we've talked about this before in other aspects of this show, if you try to force something that you don't need to force, you can create more behavioral problems. So, if you try to take it away too soon, simply because often then, the child will cling to it harder than ever simply because you're trying to take it away. You'll probably prevail if you want to, but it's going to give you a headache and some sleepless nights for sure. So, it probably is better just to let things happen naturally on their own.

You know, one of the great things about working with kids and families, they're all different. Some kids are just going to give that bottle up right away and not be a problem and others are going to hang on to it, and you're going to be putting up a fight. It really is better just to let things happen organically and naturally. And each family is going to be different with regard to that.

Evidence-based medicine is important, absolutely. But there's room for common sense here, and also for not sweating the less important stuff too.

So my advice, Megan, with regard to number of bottles, don't worry about weaning. Let her do it on her own. Don't worry about a maximum age. It's going to happen. It really is. With regard to what to give her in the bottle or the cup, talk to your doctor about that, only water overnight.

For most kids, whole cow's milk in her situation is going to be fine. Maybe 2% cow's milk, if there are concerns with obesity. Those choices will be fine for most. But there are some options for packing in some extra calories, but that's a conversation you should have with your doctor as you explore all the facets of your daughter's unique situation.

1:02:12

So hope that helps, Megan. Thanks so much for writing in from Berlin and for sharing the show with other parents in Germany, really appreciate that as well.

Don't forget, if you have a question for me, it's really easy to get in touch. Just head over to PediaCast.org and click on the Contact link. You can also call 347-404-KIDS if you'd like to leave your message that way.

[Music]

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

Also, thanks to Dr. Cherrelle Smith-Ramsey with the Ambulatory Pediatrics here at Nationwide Children's Hospital for sharing her expertise with us on the topic of diaper rash.

By the way, I forgot to mention during the interview and this is kind of important. We have some links for you that may be helpful as you're dealing with diaper rash at home. So if you go to PediaCast.org, look for the Show Notes for Episode 342, you'll find the links there.

One is to a previous PediaCast, number 233 on atopic dermatitis or eczema. That can be helpful because that's another skin condition that lots of babies get under the diaper region but other areas as well.

Also, we have a link to an article on HealthyChildren.org that I think is really good called When Diaper Rash Strikes.

Then, a couple of resources from Nationwide Children's Hospital. We have what we call a Helping Hand, which is a parent handout on diaper dermatitis. Then, we also have a 700 Children's blog post for you called how to combat diaper rash.

1:04:17

And again, I'll put links to all of those resources for you in the Show Notes for Episode 342 at PediaCast.org.

All right, that's all the time we have today. PediaCast is a production of Nationwide Children's Hospital.

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1:06:20

And while you have your providers ear, please tell them that we have a podcast for them as well — PediaCast CME, which stands for Continuing Medical Education. It's similar to this program, we turn the science up a couple of notches and provide free Category 1 CME Credit for listening. Shows and details are available at PediaCastCME.org.

Couple of topics we have coming up on that side of things — Type 2 Diabetes, kind of a nuts-and-bolts approach to that in children and teenagers. And then, we're going to be talking about pediatric hypertension and high blood pressure. That will be coming up in a few episodes as well. So check that out, PediaCastCME.org.

And then, we also have posters, if you like to share the show the old-fashioned way. Those are available under the Resources tab at PediaCast.org.

Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long everybody.

[Music]

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

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