Infant Hearing, Steroids, Head Injuries – PediaCast 045

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Topics

• Infant Hearing Test May Predict Sudden Infant Death Syndrome
• Steroids Don't Help Kids with RSV
• AAP Revises School Transportation Recommendations
• Sports-Related Traumatic Head Injuries
• Improving Heart Health in Kids with Diabetes
• Growth Hormone Adds Height, But Kids Stay Short
• Sun Exposure May Prevent Multiple Sclerosis

Interview

• Erin from Manic Mommies stops by to discuss the upcoming "Escape"

In-depth

• Botulism

Links

• Appendicitis
• The ART of Medicine

Links

• Mattel Toy Recall – Product Information
• AAP Thoughts on School Transportation Safety
• "Head's Up" Toolkit from the CDC
• Manic Mommies Escape
• Dog vs Fun Noodle

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Los Lonely Boys
"Heaven" (mp3)
from "Live At Blue Cat Blues – Dallas Texas"
(Blue Cat Blues Records)

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Transcription

Announcer:  This is PediaCast.

[Music]

Dr. Mike Patrick: Hello, everyone and welcome to this week's edition of the one, the only PediaCast. It's a pediatric broadcast for moms and dads. This is Dr. Mike coming to you from Birdhouse Studio and I'd like to welcome everyone to the program. It is episode number 45. I'm calling it Escape Botulism and Appendicitis. Boy, there's a motley crew of topics for you. Of course, we'll start it out with the News Parents Can Use segment.

This week, infant hearing test may predict sudden infant death syndrome. Two things that seem totally unrelated and yet some say there is a connection. So we'll talk about that. Steroids do not help kids with RSV. I'm sure there's plenty of parents out there whose kids have had RSV. Just think winter time wheezing. And I'm sure a lot of you out there who had kids with RSV, I'm sure they had some steroid medicine. But should we be doing that?

0:01:16

Also the American Academy of Pediatrics revises school transportation recommendations. A couple of weeks ago, we had a research article from Columbus Children's Hospital, which happens to be my alma mater. And the American Academy of Pediatrics has something to say on the next topic. So we'll discuss that.

Kids make up the bulk of sports-related traumatic head injuries. Improving heart health in kids with diabetes. Human growth hormone, it adds height. But you know what? The kids stay short.

And then we'll wrap things up with the news. Sun exposure may prevent the development of multiple sclerosis. Of course, it can increase your risk of skin cancer. We'll talk about that in the News segment.

0:02:02

And then Erin from Manic Mommies is going to join us. I'm very excited and honored to have Erin, from the very popular Manic Mommies show. If you haven't listened to that, you got to check it out. It's a great one. Then our In-Depth segment. Botulism, a very timely topic and appendicitis in research roundup.

Don't forget, if there is something that you'd like us to talk about, if you have an idea, you hear a news story, you got a line-up on the interview of the decade, like if you're working for a presidential campaigning candidate kind of person and you want to get them on PediaCast, you're more than welcome to lend a hand.

But if you have someone or something that you would like us to discuss, just go to the website at pediacast.org. Click on the Contact link. Or you could email pediacast@gmail.com or call the voice line, (347) 404-KIDS, K-I-D-S.

0:03:02

Alright, first off, I do want to say here very quickly that our thoughts and prayers go out to all of those folks in Minnesota who have been affected and will continue to be affected by the bridge collapse there. So here at PediaCast in the Birdhouse Studio, we've been thinking about you and you're definitely in our prayers.

I also like to remind you the Bundlo contest. Remember, Bundlo is the Web 2.0 version of the traditional baby book. You can make a blog, post photographs, the baby journal in terms of first teeth, first time they walked, first words. Just basically like a baby book but the online version so that you can share it immediately with family and friends across the country. And of course, it's all password protected.

We'll have a code word during our interview segment with Erin from the Manic Mommies. So you want to listen for the Code Word of the Week. There was one last week, and there'll be one next week and the week after. So four of them altogether.

0:04:05

Just write down the code words, unscramble them into the phrase I'm looking for and three lucky winners will get lifetime subscriptions to Bundlo, B-U-N-D-L-O dot com. And we thank the folks at Bundlo for providing that for us.

Also PediaCast was nominated in the People's Choice Podcast Awards in the Education category. You can vote every 24 hours for another week or so. I think it's August 11th when they're wrapping up the voting. I think, don't quote me on that, but I think I'm pretty close. So please show your support for PediaCast by voting for us. We really need your help because I did notice that Grammar Girl is in our category, and she's got a great podcast.

And then Tips From the Top Floor, I think it's called. It's a digital photography podcast. And I hear great things about that one as well. Plus they drove like the most traffic to the Podcast Awards site during the nomination phase. So I'm not sure I really have a chance. But I do thank you for nominating me. And by all means, go vote. Maybe we'll pull out the underdog upset, who knows.

0:05:17

Okay, don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. So if you have a concern about your child's health, 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.

And with that in mind, we'll be back with News Parents Can Use right after this short break.

[Music]

0:06:17

Alright. Our News Parents Can Use is brought to you… every time I hear that, it just reminds me of the Tonight Show with Letterman. Okay, I know, I don't have my own band yet. Okay. Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.
I guess before we get into the first news story, I should remind you that Mattel has recalled nearly 1 million toys because of a lead paint hazard. Their very popular children's toys including some Elmo things. And it's actually $30 million worth of toys they're recalling. They're all ones that were made in China and have lead in the paint, so they do post a hazard and you are supposed to return them or get rid of them immediately.

0:07:14

For an entire list of the recalled toys, we have a link in the Show Notes to the official site at Mattel where they have a list of every product that is affected. So just go to pediacast.org, click on the Show Notes and there will be a link for you to Mattel's website.

Alright. Infant hearing test may predict sudden infant death syndrome. One of the greatest medical mysteries of our time may have taken a leap forward in medical understanding with new study results announced by Dr. Daniel Rubens of Children's Hospital and Regional Medical Center in Seattle.

Rubens' study published in the July 2007 edition of Early Human Development found all babies in the Rhode Island study group who died of sudden infant death syndrome, or SIDS, universally shared the same distinctive difference in their newborn hearing test results. This is the first time doctors might be able to identify newborns at risk for SIDS by a simple and affordable test, the routine newborn hearing examination.

0:08:18

In this study, medical records and hearing tests of 31 babies who died from SIDS in Rhode Island were examined and compared to healthy babies. Rhode Island, as it turns out, has a particularly robust database of newborn hearing test data.

The cause of SIDS, known around the world as crib death and cot death, has eluded physicians and grieving parents for centuries, responsible for many previously unexplained deaths of infants usually two to four months old and striking boys more than girls.

SIDS causes tragic sudden death in approximately one in 1,000 newborns worldwide, making it the largest cause of death in young infants. In the United States, more than 3,000 deaths each year are attributed to SIDS.

0:09:04

Death occurs during sleep seemingly with no warning and no previous symptoms. Changes in infant sleep position have been prompted with the Back to Sleep campaign discouraging unattended sleep on the stomach. And parents are also urged to avoid exposing young infants to cigarette smoke as this too is a risk factor for SIDS. The exact cause of SIDS remains a mystery, but a variety of causes have been suggested including disturbances in respiratory control and infant overheating. But today, nothing has proven conclusive.

It is known that the inner ear contains tiny hairs that are involved in both hearing and balance function. Dr. Rubens proposes that tiny hair cells in the inner ear are important also in transmitting information to the brain regarding carbon dioxide levels in the blood. He postulates the injury to these cells will disrupt the respiratory control, playing a critical role in predisposing infants to SIDS.

0:10:03

The SIDS infants in Rubens' study showed a consistent four-point lower score in their standard newborn hearing test across three different sound frequencies in the right ear when compared to the babies that didn't die from SIDS. Additionally, healthy infants typically test stronger in the right ear than when compared to the left. However, in each of the SIDS cases studied, the right ear tested lower than the left, reversing the results seen in healthy babies.

This discovery opens a whole new line of inquiry in the SIDS research, says Dr. Rubens. For the first time, it's now possible that with a simple standard hearing test babies could be identified as at risk for SIDS, allowing preventative measures to be implemented in advance of a tragic event.

Of course I have to interrupt here real quickly. We already sort of universally have parents do what preventative measures we know. And since there's usually no precursor event to SIDS actually occurring, just because you know this, I'm not sure it really helps to prevent it.

0:11:07

But anyway he, Dr. Rubens, does urge further research adding that we must now fully explore all aspects of inner-ear function in SIDS and analyze testing frequencies that are higher than those currently tested by the routine newborn hearing screen.

Previous ground-breaking SIDS research at Seattle's Children Hospital and Regional Medical Center took place during the 1970's when Dr. Bruce Beckwith, one of the first researchers to describe the features of SIDS that distinguishes it from other causes of infant death at the autopsy examination.

Dr. Rubens went on to say, "It has been my great privilege to follow in Dr. Beckwith's footsteps with this new discovery that creates the possibility of if identifying SIDS infants before tragedy strikes…. But can you prevent the tragedy? That's still to be seen.

Each new breakthrough brings us closer to making SIDS a condition of the past. And of course the more we know about something, then the more likely it is that we'll find more help with it down the road.

0:12:07

Okay. Infants suffering from RSV bronchiolitis not helped by steroid medication. The use of steroid medication to treat bronchiollitis, a common lower respiratory tract infection in infants and one most commonly caused by the RSV virus, does not prevent hospitalization or improved respiratory symptoms, according to a study published in the New England Journal of Medicine.

The findings by the Pediatric Emergency Care Applied Research Network resolved controversy from prior research and are expected to help guide treatment for the most common cause of infant hospitalization. The study compared hospitalization rates for 600 children between the ages of two months and 12 months who visited emergency rooms with moderate to severe bronchiolitis.

Patients were treated with either a dose of dexamethasone, a form of steroid medication, or a placebo and evaluated one hour and again at four hours. The hospital admission rate for both groups was identical at nearly 40%. Both groups improved during treatment but the placebo groups did as well as the group treated with active steroid medication.

0:13:15.4

The study was conducted in the emergency department at 20 hospitals across the United States between November and April during a three-year period. Bronchiolitis is most common during the winter months.

"We learned that a commonly-used treatment doesn't work,… said Dr. Howard Cornell, Professor of Pediatrics at the University of Utah and the principal investigator of this study. "Now that we've demonstrated steroids aren't effective in treating bronchiolitis, we can focus our efforts in finding better treatments and better preventative strategies….

Bronchiolitis is the leading cause of hospitalization for infants in the United States and accounts for more than 100,000 admissions each year. Hospital charges associated with the disease exceeds $ 700 million, it's with an M, million dollars annually.

0:14:05
Cornell says the best solution to the problem of bronchiolitis would be to design a vaccine for the RSV virus, which accounts for up to 80% of all bronchiolitis cases. Bronchiolitis infection begins most frequently with a fever, runny nose, coughing and wheezing. Most children recover from the illness in about two weeks. The majority of children hospitalized for bronchiolitis infection are under six months of age. Although many children with bronchiolitis have mild infection and most don't need hospitalization, children born prematurely or who suffer from heart and lung disease are most at-risk for severe bronchiolitis requiring hospitalization and for developing disease complications.
"The study provides solid evidence to guide treatment for this common illness,… said Dr. Joseph Zorc, an emergency physician at the Children's Hospital of Philadelphia. Current recommendations suggest that simple supportive care is the best available treatment for bronchiolitis. This study will help resolve some of the uncertainty for physicians and families and prevent unnecessary side effects.

0:15:08

Both physicians note that steroid medication still plays an important role in other respiratory illnesses of childhood, such as asthma and croup. They point out that the side effects seen with long-term steroid use are not a risk in the short-course treatment used for croup and asthma attacks.

The American Academy of Pediatrics revises school transportation recommendations. This is a follow-up to a story we had two weeks ago on school bus injuries. Each year, 815 students die and 152,250 are injured during regular travel between school and home. That's right, each year, 815 students die traveling between home and school. That just is mind boggling.

A revised American Academy of Pediatrics policy statement entitled School Transportation Safety provides new information and recommendations related to safe transportation of children who walk, ride bikes or travel by car or bus.

0:16:11

During normal school travel hours, an estimated 23.5 million children are transported annually on 457,000 school buses totaling 5.8 billion, this time with a B, student trips and 3.13 billion miles. A national estimate of 17,000 school bus-related injuries each year was determined in a recent study, far more than previous estimates.

The American Academy of Pediatrics recommends that all children travel in age-appropriate and properly-secured child restraint systems in all motor vehicles to ensure the safest ride possible. Despite school buses having a better safety record than passenger vehicles, the AAP's long-standing position has been that new school buses should have safety restraints and that it is reiterated in this statement more specific recommendations.

0:17:04

The AAP encourages parents and pediatricians to work with their school districts to ensure new school buses are equipped with lap and shoulder seatbelts that can also accommodate car safety seats, booster seats and harness systems.

The AAP also advocates for national standards on the selection, training and continued regulation of school bus drivers to ensure optimal driver performance and more importantly, the safety of children. Basic driver requirements include the ability to pass a driving performance test and demonstrate correct use of all occupant-protective systems. They must also pass a written test or an oral test covering driver duties and bus operating procedures, traffic and school bus regulations and transportation of children with special needs. That makes sense.

Teens driving other teens are at a high risk of being involved in a crash, representing 55% of school travel-related fatalities and 51% of injuries. The statement promotes passage and enforcement of graduated-driver licensing laws which have been shown to reduce fatal crashes.

0:18:11
The AAP's statement also supports efforts to make walking and bicycling to school safer. This includes bicycle helmet education and legislation, school zone improvements such as speed limit enforcement and the development of safe routes to school, as well as infrastructure enhancements like bike and walking paths.

Transportation for preschool-aged children, bus passenger safety instructions, specialized restraint systems for children with special needs and environmental issues, well they're treading there, such as reducing toxic emissions are among other issues addressed in the statement. So they're even getting political.

There is a link to the complete American Academy of Pediatrics statement on school transportation safety issues in the Show Notes so you can see all of the recommendations in there. Don't get me wrong, I'm all for reducing toxic emissions. It's just throwing that into the school safety thing seems a little excessive.

0:19:12

Okay. Otherwise, it's a great statement. Don't get me wrong. So go take a look at it. And remember really you, as a parent, have to be the one to promote these things in your school district because you can't trust the school board to do it.

Most sports-related traumatic brain injuries occur in kids. An estimated 135,000 or 65% of all sports-related traumatic brain injuries treated in the United States in emergency departments in the United States occur each year and young people ages five to 18 according to a recent study published in the Centers for Disease Control and Preventions, Morbidity and Mortality weekly report. There's a mouthful.

Approximately 8% or more than 10,000 of these young people require hospital stay. Traumatic brain injuries including concussions are caused by a blow or bump to the head that disrupts the way the brain normally works.

0:20:11

CDC researchers examined data from the National Electronic Injury Surveillance System from 2001 to 2005 and looked at both the overall number of traumatic brain injury-related emergency department visits and the activities that caused them.

The study found that activities associated with traumatic brain injury in kids, the ones that were most associated were bicycling, football, basketball, playground activities and soccer. The study also found that some sports and recreation activities resulted in an even higher percentage of traumatic brain-injury related emergency department visits. Among five to 18 year olds, horseback riding, ice-skating, riding all-terrain vehicles, hockey and sledding were activities with the highest percentage of serious visits.

Researchers say the emergency department visits represent only a small portion of all sports-related brain injuries. It's estimated that there's as many as 3.8 million, with an M, of these injuries occur in the United States each year. Most are considered mild. However, even relatively mild brain injuries can result in health consequences such as impaired thinking, memory problems and emotional or behavioral changes.

0:21:24

"These injuries are very serious and should never be ignored,… said CDC director Dr. Julie Gerberding. Signs and symptoms of concussion can show up right after the injury or it can take days or even weeks to be noticed. Learn the signs and if you believe you see any, see your doctor right away.

Concussions and other brain injuries can occur in any sport. To help coaches, parents and athletes learn the science, symptoms and action steps to take when a concussion is suspected, the CDC has created and is making available a new toolkit called Heads Up: Concussion in Youth Sports. This free toolkit includes essential and easy-to-use information about recognizing and responding to a suspected concussion.

0:22:08

As part of this educational effort, the CDC encourages youth sports program administrators to order and distribute the toolkits to their coaches at the beginning of each sports season. The kit includes fact sheets for coaches, parents and athletes, a poster, clipboard and magnet with concussion facts for coaches and administrators. There's also a quiz for coaches, parents and athletes to test their concussion knowledge.

"Playing a sport is a wonderful way for kids to have fun and be in shape,… said CDC Injury Center Director Dr., uhm, oh boy. Ileana Arias. I'm sorry.
Dr. Arias says, "But there are risks involved in sports and recreational activities, especially when heads get bumped, players collide or get hit by balls and people fall down. We need every coach, parent and athlete from soccer to baseball to tennis and across all age groups to help us recognize and react when a player might have a concussion…. The Heads Up toolkit will help the information get to those who need it most.

0:23:10

And of course as always we'll have a link in the Show Notes at pediacast.org for Episode 45 to the CDC's, what are they calling it, Heads Up Concussion in Youth Sports Toolkit. So make sure you check that out with your teacher. Make sure you let the coaches and administrators at your school know that that resource is available.

And Dr. Arias, my humble apologies for botching up your first name. I'm not a professional newscaster folks, I'm a doctor. Okay. [Laughs] I got that from Star Trek, "I'm a doctor, Jim…. I'm not a Trekkie, but I remember that.

Improving heart health in kids with diabetes. It's never too early to focus on how to maintain good cardiovascular health, especially for people with Type 1 diabetes. A study published in the August issue of Diabetes Care underscores the need for regular physical activity among youth, finding that the more active the child, the better the child's cardiovascular risk profile.

0:24:11

Heart disease is the number one killer of people with diabetes among Type 1 patients as young as 20 to 39 years. The risk of dying from cardio and cerebrovascular events, such as stroke, is five times higher than it is for people who don't have diabetes. Previous studies have shown that the development of artherosclerotic lesions begins in childhood and that 69% of pediatric patients with Type 1 diabetes exhibits one or more cardiovascular risk factors.
A new study by researchers in Germany and Austria, which lifted the physical activity levels and cardiovascular health of more than 23,000 young people between the ages of 3 and 18, found that those who are most physically active were the least likely to be at risk for heart disease. As physical activity levels rose, the study showed risk factors such as high lipid profiles, diastolic blood pressure and blood glucose levels fell.

0:25:09

Specifically as physical activity rose, the percentage of patients with high cholesterol and triglycerides decreased from 41.2% for those with no regular physical activity to 36% for those who are active once or twice a week and down to 34.4% for those who are more active three or more times per week. Regular physical activity was defined as exercising for at least 30 minutes at a time and did not include school sports.

The study found that those who are active at least once or twice per week were also less likely to have high blood pressure than those who didn't exercise at all and it showed that the frequency of regular physical activity was one of the most important influencing factors for hemoglobin A1C. The A1C test measures average blood glucose levels over a period of two to three months and helps a person with diabetes how well they're keeping blood glucose levels under control overall.

0:26:04

A previous study published in the June issue of Diabetes Care found that the more television children with Type 1 diabetes watched, the less they were able to keep blood glucose levels under control. "Clearly, getting off the couch and out of doors where they can be more physically active is good for all kids,… says lead researcher Dr. Antje Herbst of the Department of Pediatrics of the Hospital of Leverkusen in Germany. Sure, I get the Germany guy's name right. [Laughs]

But for children with Type 1 diabetes, the need to stay physically active is even greater due to the increased risk of heart disease. Maintaining a physically active lifestyle is something we need to encourage during childhood so that these kids build a habit they can continue for a lifetime. I'm a doctor, Jim.

Growth hormone injections add height but kids stay short. Growth hormone injections appear to boost height in extremely short healthy children, according to a recent systematic review but height gain appears to peak at about three inches, and those inches are expensive.

0:27:13

"Even after treatment, children with idiopathic short stature, meaning their height does not result from a medical condition, who received growth hormone injections remain relatively short,… said Jackie Bryant, the review's lead author. There is no indication that increases in height will improve a child's quality of life.

Bryant, a senior research fellow at the University of Southampton in England, and colleagues analyzed 10 randomized controlled trials involving growth hormone therapy in 741 children with idiopathic short stature. The studies compared children receiving growth hormone therapy for at least six months to children who did not receive treatment or who received a placebo. Children with idiopathic short stature have heights well below the average for their age and sex, but are physically healthy and have normal laboratory results.

0:28:02

If parents choose treatment, their children undergo years of recombinant human growth hormone injections typically given six to seven times weekly at home. Each half inch in final height gained via human growth hormone therapy costs somewhere between $18,000 and $36,000. Each half inch in final height gain.

The review appeared in the latest issue of the Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical research on the topic.

One of the studies took place in the United States and one in the United States and Chile. The remaining studies occurred in the United Kingdom, Australia, New Zealand, The Netherlands, Italy and Egypt. The current review and update of the previous analysis includes an additional trial conducted since 2003.

0:29:05

Generally, growth hormone injections increased height in these children, review results indicated. In one study, they followed children throughout adolescence. Girls treated with growth hormones reached heights of about three inches taller than an untreated controlled group by near adulthood. In another study, children treated with a growth hormone were 1.4 inches taller than children treated with an inactive placebo. Just 1.4 inches taller.

In addition to gaining more inches overall, children treated with growth hormone also grew faster. In three studies, treated children experienced a significantly greater rate of growth after one year compared to untreated children. Despite these findings, children treated with growth hormone remained short near the lower range of normal when compared to their peers.

"Genetic factors affect growth and final height and parents should be realistic in their expectations about the potential effect of growth hormone," Bryant said.

0:30:01

In addition, despite its potential to increase height, growth hormone therapy can cause earlier onset of puberty which paradoxically shortens the growth period and leads to premature closure of the ends of the long bones which may actually limit final height.

Dr.Steven Dawson a pediatric endocrinologist at the Alfred duPont Hospital for Children in Wilmington, Delaware, praised the review's methods but said that much more research is necessary to evaluate the effectiveness of therapy in these kids.

Many pediatric endocrinologists still do not consider the data and the potential benefits proven well enough to actually treat patients for this indication. A lot of the reasoning behind treating this group of patients has traditionally been that they are socially or psychologically suffering because of their short stature or will later when they reach short final height as adults.

"There's a very scant evidence that the psychological, social and other outcomes are improved by therapy,… Dowshen said. Only one study included in the review addressed psychological issues and found that children receiving growth hormone treatments reported no improvement in quality of life compared to children in the controlled group. These factors, plus the costs of treatment, which is substantial, makes it unclear whether the small expected gain in height justifies such treatment in children who are not ill.

0:31:22

And finally, childhood sun exposure may influence the risk of developing multiple sclerosis. New research has suggested that people who spend more time in the sun as a child are less likely to develop multiple sclerosis. Scientists in California have released the results of a study involving 70 pairs of identical twins in which one twin had multiple sclerosis while the other did not.

They also examined each child's history of sun exposure. The twins were asked how much time they spent outdoors on hot and cold days, how much time they spent getting a tan, going to the beach and taking part in team sports. Sun exposure was gauged according to a sun exposure index. Scientists found a strong connection between a lack of sun exposure and the development of multiple sclerosis and discovered that the twin spending more time in the sun was up to 40% less likely to be diagnosed with multiple sclerosis later in life.

0:32:17

Dr. Laura Bell, Research Communications Officer at the MS Society said,…this interesting study highlights the role of sunlight in multiple sclerosis development and supports findings from previous similar studies….

There are issues involved in accuracy of recall and studies based on self-reporting from participants. However, the authors do point out that their data was collected when sun exposure was not considered to be an important factor in multiple sclerosis development, meaning participants will be less likely to unintentionally bias their activities.

The causes of MS are unknown. However, research suggests that a combination of genetic and environmental factors play a role in its development. If a twin has multiple sclerosis, there is one in three chance that the other twin will also have MS. The reason is not 100 — the reason it's not 100% is because multiple sclerosis development is not due to genetic susceptibility alone.

0:33:14

It is thought exposure to sunlight could bring about protection against autoimmune disease such as multiple sclerosis by any number of mechanisms including the production of Vitamin D in the skin. Dr. Bell went on to say that further studies of the pathways by which sun exposure produces multiple sclerosis risk would be beneficial in determining the factors involved with the development of this disease.

Of course you do have to wonder the kids that are spending more time outdoors and more time exposed to the sun. Are they getting more exercise and is that the protective mechanism? So again as Dr. Bell said, further studies are certainly needed for this.

Okay. So that wraps up our News Parents Can Use segment. We actually have a visitor coming up next. So after we take this quick break, Erin from the Manic Mommies is going to stop by and join us. We are very excited about that. But before that interview, let's take a short break. And we'll be back with Erin.

0:34:13

[Music]

Kristin: This is Kristin.

Erin: And I'm Erin.

Kristin: And the Manic Mommies would like to invite you to join us for our first ever Manic Mommies Escape on November 9, 10 and 11 in Newport, Rhode Island. Join us as we reconnect with old friends, meet new friends, have cocktails, listen to fabulous speakers, go to the spa, mansion tours, our chic boutique, MOM U. The list goes on. So much to do in a fun-filled weekend.

0:35:18

Erin: And it's actually very affordable.

Kristin: It is. And although November may seem like it is ages away, we know from personal experience how fast that calendar is going to get booked up. So make your reservation now or find out more about the trip by visiting our website at manicmommies.com and clicking on the Escape graphic.

Erin: Be the first cool mom on your block to join us. Hope to see you there.

[Music]

Dr. Mike Patrick: Alright. I have the distinct pleasure of being joined by Erin from Manic Mommies. Hi Erin, how are you doing?

Erin: I'm good, Dr. Mike. How are you today?

Dr. Mike Patrick: I am doing great. And I also, I wanted to congratulate you and Kristin on the two years of the show.

0:36:07

Erin: And same to you, delayed. I was going to… we were going to record something for you, but you know we're manic.

Dr. Mike Patrick: Oh.

Erin: We have lots of things we're going to do.

Dr. Mike Patrick: Yeah, you know…

Erin: Did Kristin do it?

0:36:16

Dr. Mike Patrick: Yes, she did.

[Laughter]

Erin: That's so funny because we were just talking about the DivaCast. I don't know if you know the Divas, but when they were celebrating their anniversary, we recorded something and Kristin never sent it to them. So I thought, ugh, it's another one that we let go by. Well, I'm glad to hear that she took care of it.

Dr. Mike Patrick: Yeah she did, she did. She called in on the Skype line and left a nice message so it was pretty nice.

Erin: Excellent.

Dr. Mike Patrick: I was actually listening to your latest Manic Mommies show on my way to work today.

Erin: Oh yeah.

Dr. Mike Patrick: I had to take this opportunity to make a couple of comments.

Erin: Of course.

Dr. Mike Patrick: When, this was Kristin's friend who was getting ready to leave for Prague. You know what I'm talking about.

0:37:02

Erin: Yes.

Dr. Mike Patrick: And they were describing their experience taking all the kids out to dinner. And pretty much, it was a nightmare. And I just have to say, I am so glad that my kids aren't toddlers anymore.

[Laughter]

Erin: Ugh. Isn't that the worse?

Dr. Mike Patrick: I tell you, and of course, being a pediatrician, I love toddlers, don't get me wrong. But it is tough and I mean we're just at the age now, Katy's 13 and Nicholas is 10. And I mean we're just at the age where we can actually go out and enjoy a nice dinner without it being a big fiasco.

Erin: I know. There's so many things that I, I have two as well and I keep saying once I get Brandon potty trained, life will be great because I can get rid of the diaper bag. Just like it's a little hurdle that I feel like once I clear that, there'll be other hurdles. But I just feel like that's one less thing to deal with.

Dr. Mike Patrick: It just, it gets so much better. [Laughs]

Erin: Well, good. Keep telling me that.

0:38:04

Dr. Mike Patrick: Yeah, yeah. Well I mean Katy, Katy's a teenager which now brings a whole new set of problems. But really, she's a good kid. So…

Erin: That's great, that's great.

Dr. Mike Patrick: And then the other thing that I wanted to mention is someone, there was a voicemail about someone whose child had learned all the letters in the alphabet from a video, like a two-year old.

Erin: Yes.

Dr. Mike Patrick: And so she was saying it was sort of silly that the American Academy of Pediatrics comes out with these that kids two and under really shouldn't watch videos. And I just wanted to say for the record that I'm with her.

Erin: Oh, you're with her? Oh, interesting.

Dr. Mike Patrick: I am because, I mean, I don't think two-year olds should sit in front of the TV for hours on end. But I mean if you have a two-year old who did seem to get something out of it, like she said, the research means nothing if she's making an observation that seems to be true. You know what I mean?

Erin: Right, right. No, and I understand that and hear that from… it's interesting because when we were playing that voicemail, Kristin's friend, our guest at the show, was kind of rolling her eyes like, what? You know.

0:39:11

Dr. Mike Patrick: Right, right.

Erin: We were making an argument that TV's a good thing. Every mother has their own opinion… everyone has a different opinion. I mean, that's what I love about Manic Mommies because we're no more of an expert than anyone else.

Dr. Mike Patrick: Right

Erin: But you are an expert. So if you say it's okay because I think a class of my kid don't know.

[Laughter]

Dr. Mike Patrick: I'm not saying hours on end. But there's got to be some moderation. And also, this is going to sort of play in what we're really going to talk about. Part of, I think part of being a good parent is you have to look out for yourself sometimes.

Erin: Right.

Dr. Mike Patrick: And if your child is going to sit there for half an hour or even an hour and watch TV and it's not all day long. We're just talking one show or one DVD. And you can actually get some housework done while they're doing that, then you're going to be less stressed and you're going to be a better parent. And then how does that affect the development of the two-year old?

0:40:05

Erin: Exactly. And then I have to tell you, I can even sense it in myself when it's the end of the day and I'm trying to get dinner ready and… I have put a video on at that point because there's no possible way for me to make a meal when I have two kids hanging on me, mommy do this with me, play with me. Mommy, can you do it? You're like, I'm just trying to get dinner prepared!

Dr. Mike Patrick: Yeah, exactly.

Erin: So I'm, yeah, I'm a huge advocate for it during the dinner preparation hour.

Dr. Mike Patrick: Yeah and sometimes common sense just has to win over cold research findings. [Laughs]

Erin: Right.

Dr. Mike Patrick: I mean obviously, we think research is important but it has its place and it can't control your life either.

Erin: And sometimes just have to do the best that you can do. And as I always say to people in work and in life, it's like sometimes the best you can do may not be the best you can do. But it's just the best you could do given the situation.

0:41:01

Dr. Mike Patrick: Right. So I am with you, I'm with you. And that kind of brings us to the Manic Mommies' escape because it's really all about doing something for yourself which sort of enhances your role as a mom. So you guys have this escape planned for November 9th through the 11th of this year in Newport Rhode Island?

Erin: You're right, you're right. And the sort of idea for the escape came actually last year, last summer. My girlfriends and I went to the Martha's Vineyard. We go every summer on a girl's weekend. And I happen to bumped into some friends on the street that I hadn't seen in a while and it was the mom, the dad and the one-year-old baby. And after making small talk, the mom pulled me aside and said, we are your kids? And I said, oh, this is the girl's weekend. And she looked at me and said, I wish I was with you guys.

0:41:59

And I thought to myself, you know, it is so rare that moms have this experience where they're able to get away from all of the things that they have going on in their lives and just be themselves again. Do the things that you want to do because you want to do them whether that's reading a book or go shopping or get a spa treatment or whatever that might be. So just allow yourself. It's almost like moms don't want to give themselves the permission to do that.

Dr. Mike Patrick: And I see that in the office all the time. I mean, you can just tell the parents really frustrated with the behavior of a toddler or with a baby that cries all the time and might be colicky and you say, when was the last time that you were actually away from the child? And they can't remember. (Laughs)

Erin: Right, right!

Dr. Mike Patrick: And you just have so much renewed energy to be able to deal with babies in toddlerhood if you have a respite here and there.

Erin: It's true and I think especially hard for moms who are at home every day. I mean I get to go, well I work from home and I kind of feel like a fit that delve, but for a lot of moms who work and may be travel for their business, they do get to get away a little bit.

0:43:19

I used to travel, before I had kids, with women who did have kids and they would say I'm not going to dinner, I'm not going to drinks. I'm just going to my room, ordering room service, getting a movie and calling it the night.

Dr. Mike Patrick: Just chill. Just let… enjoy the quiet.

Erin: Yeah. Because that to them was their vacation.

Dr. Mike Patrick: It's something too that as men, we don't… sometimes you have to be hit upside the head to realize it because for me, I leave to go to the office every day and it's hard for me to remember that Karen is here 24/7 dealing with the kids. And we homeschool our kids too.

Erin: Oh my God!

Dr. Mike Patrick: So it's a ton of work.

Erin: I'd love her.

0:43:59

Dr. Mike Patrick: Yeah. It is, it's a ton of work and you don't realize, it is important for them to be able to have their time and her time and quiet time because I certainly get that at the office especially in the summer when it's not nearly as busy as in this winter. There may be some time in between patients when I'm in the office, it's quiet, I can work on some things but this house is usually not very quiet.

Erin: Well and the truth is it's funny, there are some moms in my neighborhood who stay home that I'm friendly with and when I first mentioned the escape, they all were kind of like, that sounds great! And they said, I have to talk to my husband. And another friend of mine said to me, well, I can't go on that. I'm not a manic mommy and I'm like, you're not? And she goes, well, no. I don't work. I'm like, so what? You need it more than anyone.

Dr. Mike Patrick: Right. And it's kind of funny to say well, I don't work because it's a lot of work staying at home and take care of things.

Erin: I think it's more work. Hello? That's why I have a job because I can't do that everyday. But I do think you're right. I see a lot of moms that just friends of mine that I feel like it's really hard to remember what you were like before you had kids. Like what were the things I'd like to do? Where did I go?

0:45:18

Dr. Mike Patrick: It just seem so long ago.

Erin: It really does.

Dr. Mike Patrick: I remember when we first had Katy. I was actually in my intern of my residency. So it was my very first year of residency. And I remember another resident who had a, I think, a two-year old at the time said to me, well, say goodbye to ever sleeping in again. And I was kind of laugh but it's true.

Erin: Oh, my God, yeah. I mean I joked because one time before I had kids, I said to a colleague at work and I said, well, I can't wait until or may be I have had a baby at the time, my first child. And I said, I can't wait to just sleep through the night again. And the mom looked at me and she goes, that's not going to happen for years. Once they're done being babies, they're going to be getting up in the middle of the night to go to the bathroom or they're going to have nightmares or they're going to be… you're never going to sleep through the night again.

0:46:11

Dr: Mike: Oh my. Its one of the great things about podcasts, I think, that like when we were going through that, I mean you might have a couple of people tell you that this is the way it's going to be, but you still get this feeling like it's only you who's going through it. And that's one of the great things about Manic Mommies. I know I'm sure so many women identify with the things that you guys talk about. It's just… must make them, your audience, feel so much better about what they're dealing with.

Erin: I hope so. I mean, that's why we do it. As we often say, it's a labor of love. But yeah, I think being a mom is very isolating. And I think especially in today's society where we live in suburban communities, where we're not out of our houses, walking to the market or something.

0:47:03

We go from our car to wherever it is we are running and it's really hard to meet people and if you're a social person who had a career and was with the people everyday and then you suddenly are home with a small child who doesn't listen or follow instructions or challenges you on a daily basis. It does wear after a while. I mean, let's be honest.

Dr. Mike Patrick: Yes. Yeah, definitely. Well I was looking through the schedule for the escape and boy…

Erin: Because you're going to send Karen, right? [Laughter]

Dr. Mike Patrick: I'm going to try to talk to her into going.

Erin: I think there's a cheap fare on sky bus. Someone wrote in and told us about, don't you have sky bus out where you are?

Dr. Mike Patrick: We do. Yes, we do. Do they fly into Boston?

Erin: Well, no. Someone emailed to me to say that sky bus goes from Ohio to Hartford and from Hartford, you could drive to Newport in no time so.

Dr. Mike Patrick: Oh, okay.

Erin: Yes, have her check that out.

Dr. Mike Patrick: Yeah, I will. They do like $10 fares.

Erin: Yeah, that's crazy!

0:48:06

Dr. Mike Patrick: It makes you a little nervous like how are they paying for oil? Do they oil the planes?

[Laughter]
Erin: I know, I know.

Dr. Mike Patrick: Now looking at the schedule, it seems like there'd be a lot of work putting something together like this.

Erin: It is a lot of work. Shoot me now.

Dr. Mike Patrick: Yeah. [Laughs] So did you and Kristin pretty much on your own come up with a schedule and contact the speakers, I mean get everything wound up?

Erin: Yeah, we did. And actually, I confess that because it was my idea, Kristin said great, put it together. [Laughter] It has been a lot of work on that front. We had to get a travel partner, someone who does this because obviously, we don't book reservations. They pretty much are handling all our negotiations with the hotel and getting the speakers wasn't really as hard as I would have thought. There were a couple of speakers that I was going after that were just completely out of our price range. It's amazing what you can make on the speaking circuit. Did you just hear that? That was my email going on.

0:49:15

Dr. Mike Patrick: No, it might have been mine too.

Erin: Anyway. It has been a lot of work but what we're doing in the MOM U sessions, which is sort of I'm billing it as sort of like speed dating. Where we're going to have a mom at one of several tables and you can kind of open space, you can kind of float in and out of different conversations.

So it won't be like formal presentations. It'll be more like if you want to talk with the parenting coach, you can just sort of dip into that conversation. If you want to talk to a life coach, you can head over to that one. So most of the speakers for that session are people who are going to be on the escape anyway. And I really wanted to feature moms as experts. So that was sort of the thinking behind it.

Dr. Mike Patrick: Yeah, that's a great idea. And then your, I guess, your two headliners that are least in the agenda with Dena Blizzard?

0:50:15

Erin: Dena Blizzard, she was actually an our show. She's the host of the real simple television series on PBS. She's also a standup comic and a mother of three and a former Miss New Jersey. So she's hysterical and I think she'll be great for Friday night sort of kick things off and get people laughing and..

Dr Mike: Great, oh, that's great.

Erin: And then Jane Porter who's the author that's speaking on Sunday who's sort of the other book end. She is a single mom of two boys, very successful author and she has a new book coming out in September. That's actually about a working single mom. The book's called Odd Mom Out. And actually just read over the weekend when I was in the vineyard and it's a great read and I think she'll be fabulous to have as well.

0:51:03

Dr. Mike Patrick: Oh, yeah. I did looking up on her and apparently, in July of this past month, she's the author in the spotlight for the eHarlequin, not that I listen to that [laughs], their debut podcast. But anyway, I mean if people are interested in hearing her talk a little bit before the escape, apparently, the eHarlequin, their debut podcast in just last month featured her.

Erin: Excellent. Yeah, she has written a number of Harlequin romance novels, I think.

Dr. Mike Patrick: And then I did notice that it said keynote speaker to be named. It's that… are you ready to announce the…

Erin: Yes. I wish I could

Dr. Mike Patrick: Break it live on PediaCast. No, I'm just… [laughs]

Erin: I wish I could, Dr. Mike. And it may be keynote speaker never confirmed. No. That's the big hole in my schedule right now and that's causing me great angst. But I can pull things out at the last minute. November is a long way away.

0:52:05

So our biggest concern right now is that we have people who signed up. I mean we've gotten a lot of great response and I think the reality is that moms are busy and November does seem far away so people say, oh yeah, yeah. I'm going to go, I just haven't booked yet. But if I don't have enough people booked early enough, the hotel's going to say to us, we're not going to hold your rooms anymore. So that's the big logistical challenge that I face right now, turning all that support and optimism and theory into action.

Dr. Mike Patrick: So if anyone is listening who had thought about going, this is the time to sign up.

Erin: Exactly! And you'll lock in the best rates because after Labor Day, we're going to have to increase the price slightly, not anything major, but if you book now you might have more money for manicure or a couple of Cosmopolitans.

Dr. Mike Patrick: Now how do people go about signing up?

0:53:06

Erin: If they actually just go to our website, manicmommies.com, there's a big graphic in the upper right-hand corner that says, Come on the Escape. And you just click on there and there's a whole online reservation process. There's also a 1-800 number that people could call if they want to talk to a live human being at the travel company.

And the hotel where we're having it, the Hotel Viking, it's a great hotel, recently refurbished, has a nice spa right on site. It's in the heart of Newport which is a beautiful seaside town, lots of shopping and then the mansion tours are special to Newport. I don't think there's anywhere else where you can go and tour these amazing mansions and one is going to be decorated for Christmas.

It's actually the first day of their Christmas tours on Saturday and the other is going to be Doris Duke's couture fashion collection and it's the last day of that exhibit. So there are two great mansion tours that people can opt into and yeah, lots of fun.

0:54:11

Dr. Mike Patrick: Yeah, that sounds great. It really does. And I think again, as we talked about, I think it's really important for moms to give themselves permission to do something like this to get out of the house. Really.

Erin: I agree.

Dr. Mike Patrick: Yeah. Alright. Well, before we go, we have been doing a promotion with Bundlo. Have you heard of them?

Erin: I haven't heard of them.

Dr. Mike Patrick: It's a Bundlo, B-U-N-D-L-O.com. And it's basically an online baby but. It's sort of like Flickr in that you can put baby pictures of but then it also has a blog for the baby and then a journal as well so that you can keep track of like when did they get their first tooth, when did they take their first steps, and so it's really…

Erin: That's great!

Dr. Mike Patrick: Yeah, and then it's all password-protected and you can email friends and family that you want to have access to it. You can email them their username and password and then they can log on and immediately see anything that you've put up.

0:55:09

So it is… it's neat service and what we're doing on PediaCast is our first four interviews that we're doing, we're giving out a code word. And then at the end of the month, they have to put the code words together into a phrase and unscramble and get the phrase right and three people are going to win lifetime subscriptions to Bundlo.

Erin: Cool.

Dr. Mike Patrick: Yeah. So I thought I would let you tell everyone what the codeword this week is.

Erin: The code word this week is go.

Dr. Mike Patrick: Alright. So go, G-O, go.

Erin: Like go on the Manic Mommies escape.

Dr. Mike Patrick: That is exactly right. Go to their website right now and sign up.

Erin: Exactly.

Dr. Mike Patrick: Well, thanks for thanks for stopping by. Really, really appreciate it.

Erin: Thanks for having us. We really appreciate it. As you know, we're big fans of yours and your show and I hope your listeners will consider coming out and take a little time for themselves.

0:56:11

[Music]

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0:57:02

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0:58:08

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Alright, this is our research… no, it's not. This is our In-Depth segment. And we're going to talk about botulism. Now botulism is a rare but life-threatening, paralyzing syndrome caused by a neurotoxin which is produced by a specific microorganism, in this case, Clostridium botulinum. It's the name of the organism.

Now the syndrome was first described in the 1820s after hundreds of people were afflicted with sausage poisoning in a small south German town. Several decades later, scientists in Belgium demonstrated an association between the paralyzing disorder and a bacterial spore that was isolated from poorly cooked ham.

0:59:13

The microorganism was subsequently named bacillus botulinus. The latter part of the name coming from the Latin word botulis which means sausage. Scientists later renamed the bacterium Clostridium botulinum to reflect the microorganisms correct classification.

Fast-forward, nearly 2 centuries and the organism is still up to no good, causing a string of illness and leading to the recall of tens of thousands of canned goods manufactured by the Castleberry division of Bumblebee Seafoods. Now what about sort of what kind of effect this botulism have across the United States? Well on average, there's 110 cases of botulism each year in the US. 72% of these cases involved infants. Infant botulism is the most commonly reported form of botulism in the world.

1:00:08

Food-borne botulism usually occurs in small outbreaks and usually is involved with home canned foods. So that makes this recent outbreak a little bit unusual in that it was commercial canned foods that were involved. The highest rate of botulism in the United States actually occurs in Alaska. And that comes from the ingestion of fermented fish. So that's the highest rate of food-borne botulism, I should say.

Large outbreak of botulism occurred in Thailand in March 2006. And that one was related to the home-canned bamboo shoots. But altogether, 209 people were affected, 141 required hospitalization and 42 of them had to be put on mechanical ventilators because the muscles of breathing were paralyzed.

Infant botulism was long associated with the ingestion of raw honey. However, widespread public education to avoid honey in infants 12 months and under has done little to affect the incidence of infant botulism in the United States.

1:01:15

So there is some question as to whether that's really a significant thing or not. Although my personal opinion would be still to avoid honey in kids under 12 months just in case.

Cases of infant botulism are highest in Utah, California and Pennsylvania. And these States also have the highest numbers of soil botulinum spore counts. For unclear reasons, most cases involve an infants less than six months old who are breast-fed. Older infants and bottle-fed infants are involved less often.

So what actually causes botulism? Well, the organism is a gram-positive, for all you microbiology nuts out there, to gram-positive, rod-shaped, spore-forming microorganism. It's an obligate anaerobe which just means that that it can reproduce… it can only reproduce naturally in an environment that is low in oxygen.

1:02:10

Spores are easily isolated from the surfaces of unwashed fruits, vegetables and seafood. And spores are also easily found in soil and marine sediment pretty much all over the globe. The spores are heat-resistant. They can easily survive at 100°C or boiling for five or more hours but they are destroyed by heating up to 120°C for five minutes.

Under the right conditions, so the spores really aren't harmful. But under the right conditions and those conditions would be low oxygen, low acid and just the right temperature, the spores germinate into the rod-shaped toxin-making organisms.

Now the toxin that these organisms make is actually one of the most potent poisons known to man. In fact, a minimum lethal dose is thought to be .0003 microgram per kilogram of body weight.

1:03:11

Now if you compare that to cyanide, cyanide, to be deadly, requires 10,000 micrograms per kilogram of body weight. So it takes 10,000 micrograms per kilo to be deadly. But for the botulism toxin, it takes 0.0003 micrograms per kilogram. So it's really, really, really potent. One gram of aerosolized botulinum toxin has the potential to kill 1.5 million people. The toxin has no smell and no taste. Basically, what it does is it enters the nerve cell and it produces an irreversible disruption in the release of the neurotransmitter. So nerves, remember, talk to each other with a chemical that gets released at the end of one nerve and then that chemical goes to the next nerve and that's how a message is transferred from nerve to nerve.

1:04:13

And basically, what the botulism toxin does is it makes it so that in certain nerves, that communication process cannot happen. So the nerve basically, it gets the signal gets stopped in its track because one nerve can't communicate with the next. And it tends to be in the type of nerves that control muscle so that's why paralysis occurs. So your brain tells the muscles to move and that includes the breathing muscles. So it should be the diaphragm underneath the lungs and the intercostals which are between the ribs. So your body, your brain tells those muscles to move but the message can't get to the muscles because of the mechanism of that toxin.

So remember that the disruption too is irreversible so the nerve must make a new facility to make the chemical that gets released and it can take up to six months for the nerves to actually recover completely.

1:05:18

So how do you actually come into contact with this organism or get the toxin? Well, really depends on what kind of botulism that you're talking about. So if it's the food-borne type, you're not really ingesting the organism itself. You're just ingesting food that contains the toxin in it. So one point at food had the organism. The organism made the toxin and now that toxin is in the food. So it's not really an infection as much as a poisoning with the food-acquired botulism.

Now in infant botulism, it's a little bit different. In this case, the infant does ingest the spores, whether that be from honey or whether it's just on mom's skin and from breastfeeding, it gets transferred that way.

1:06:04

But then these spores are in the baby's intestinal tract. And the conditions are just right as we mentioned, low oxygen, the acidity is just right, the temperature's just right. And then basically, these spores turn into the real deal and then those in the bacteria begins to release the toxin. So in infant botulism, it really is an actual infection because now it's not just the toxin that's gone inside the body but the organism is inside the body as well and it's making the toxin.

Now there's also a type of botulism called wound botulism. And this is when basically you have a wound that spore, botulism spores colonize the wound and then they produce and release the toxin. So it's a lot like infant botulism except it's usually an older child or an adult and the infection is in the wound instead of in their intestinal tract but still the botulism organism is making the toxin.

1:07:04

There's also the potential to have the same type of thing as infant botulism in adults. Usually this is going to be an adult or an older child has a weakened immune system. And so basically, they ingest spores, they colonize the adult or older child and then they make the toxin. So they call that enteric which is just a fancy name for the intestinal tract, enteric botulism. But that's just an older kid or an adult who has the same thing going on. And again usually, they have a weakened immune system that allows that to happen.

And then finally, this is one that is a potential issue and that we kind of alluded to. That's inhalation. And that inhalation botulism could occur with bioterrorism if aerosolized toxin was inhaled. So something to think about.

So what happens? What are the signs and symptoms of this disease? Well, classic botulism, you basically have muscle weakness that then leads to paralysis. Usually starts from the face and then goes to the trunk, arms and legs, finally at the very end.

1:08:07

And how much progression and how total the paralysis is really depends on how much toxin is inside the body. It's usually both sides of the body that are involved so if you have weakness on one side, you worry more about something like a stroke or something else causing the paralysis. So this is usually on both sides and pretty equal on one side. Usually, there's not a fever. The exception to that is actually wound botulism. But that's likely from an infection with other bacteria that just happened to be in the wound in addition to the botulism bacteria.

The patient usually is responsive. They have normal brain activity. So they know exactly what's going on, they just have weakness. So usually there's no disruption in terms of mental capacity. And then usually, there's an absence of sensory deficits except maybe blurred vision because they have droopy eyelids and an inability to blink and that could dry out the eyes.

1:09:07

So they might have a little bit of blurred vision. But other than that, their senses are all normal. So the sensory nerves are not affected by botulism. So they can smell and taste and feel, those kinds of things is just fine. It's really more of a muscle issue.

Now in infant botulism, maybe a little bit harder to diagnose especially in the very early stages of the disease. But basically, these kids have feeding difficulties, drooling, irritability. You might have a weak cry, decreased muscle tone where which is how their muscle weakness shows up. So it may be kind of floppy or act like what we call a rag doll.

They can have difficulty with their breathing. Also you might see constipation, urinary retention. They could have blood pressure problems or heart arrhythmias where their heart rhythm is not playing nicely, not doing what it's supposed to do.

1:10:00

The differential diagnosis for botulism, there are a lot of other things that can cause this kind of symptoms where you have weakness. Some of the things to think about as I mentioned, stroke. Polio, the old disease polio that really don't see anymore but you always worry about especially in pockets where parents aren't getting their children immunized. But polio can cause paralysis.

Myasthenia gravis, geon beret syndrome, we're not going to go into these. I think actually in the previous episode, we talked about geon beret. It's been many months ago, but if you search the archives, you'd be able to find that. Heavy metal intoxication and then in young infants, there's a genetic disease called spinal muscle atrophy that can also cause extreme weakness which leads to almost near paralysis.

Now in terms of diagnosing botulism, really, half the battle is remembering to include in the differential diagnosis because this disorder is so rare, a lot of times as a doctor, it's not the very first thing that pops into your head when you have someone who's experiencing muscle weakness.

1:11:07

In infants, it's hard to diagnose because if you try to look for the toxin in their blood, they usually don't have enough of it to give you a positive test. So you can't really do a blood test to look for the toxin because they just don't have enough of it in the blood. It's enough to affect their nerves, but not enough to give you a positive test result.

If you find the organism Clostridium botulinum or the toxin in the babys stool, then that would support the diagnosis but oftentimes, it doesn't grow on the stool. You don't find the toxin. So just because you don't see it in the stool, whether it's the organism or the toxin, then that doesn't necessarily mean that it's not botulism.

But one of the things that does help you to diagnose it in infants is the EMG. Now EMG is electromyography. Basically, what they do is they put tiny needles inserted into muscles or sometimes surface electrodes can be used.

1:12:06

And basically, you look at the pattern of electrical activity of the nerve and the corresponding muscle and botulism usually results in specific EMG electrical patterns. But even early on in the process, those can be… that can be normal too. So I'm not going to get into all the science behind that but just suffice it to say that there is a test that looks at the electrical activity of nerves and muscles that can aid in the diagnosis of infant botulism.

Now for food-borne botulism which is what we were seeing with the recent recalls. That is a little bit different. The serum toxin levels in this case are higher and often, they are detectable. And you could also look for a toxin in the stool and in suspected food items as well. And you oftentimes, you'll be able to find the source of it that way.

Wound botulism, if you isolate Clostridium botulinum from the wound, then that would be diagnostic. And the EMG that we talked about with infant botulism may be helpful in the difficult cases of wound botulism as well.

1:13:13

So how do you treat it? Well, patients generally have to be hospitalized and monitored really closely for respiratory failure. And if respiratory failure starts to occur and progress, then they would have a breathing tube put in and be put on a mechanical ventilator to assist with their breathing.

There is an antitoxin. However, it has to be obtained from the CDC through your state's health department. There may be a bit of a delay in getting it. It's hard to get it. Basically comes in a couple of different forms. One is equine or horse antitoxin. It's only allowed to be used in kids who are older than one year of age.

Basically, what you're doing with this is you take a horse, you inject the horse with not with the toxin, but with a toxoid. So it doesn't actually hurt the horse. And then the horse makes antibodies against the toxoid and then those are collected and given to the person so that then those antibodies will attack the actual toxin and get rid of it a little bit quicker.

1:14:22

The problem is that horse serum is going to have an issue because it has other proteins in it that your immune system can react to. So allergic reaction with horse blood products are can be serious and anaphylaxis, which is where you have really severe hives and wheezing and that in itself, can actually be life-threatening. So you do have to watch out for that. Of course, if they really have bad botulism, they're on the ventilator anyway. But still anaphylaxis can costs blood pressure issues too. So it still can be serious.

Now for infants who are less than a year of age which actually ends up being the majority of cases because most cases of botulism or infant botulism as we mentioned, there is a human-derived immunoglobulin which just means that human-derived antibody.

1:15:14

And basically, it's the same thing. Volunteers except humans, instead of horses, are injected with botulism toxoid which is again a harmless molecule that just looks like the toxin, but it's not active. And then the volunteer's body makes antibodies against it. The serums collected and then that could be given to infants.

Now because it's a human blood products, then there is a slight risk of transferring human diseases along with that. But again, it's a chance, it's a low chance but something to discuss with the doctors. The Department of Defense has a large supply of human-derived antiserum. But it's unavailable for public use. And if you think back to the bioterrorism potential, then you understand why it's important to keep a large supply of it with the Department of Defense.

1:16:05

Now I should mention too, it seems like the human version of the anti-toxin will be so much better than a horse version. Why do we have a horse version? Well, it's because you don't have to pay horses to be injected and then collect the serum. So it does get expensive to have humans do that. I think I said volunteers, but most of the time, they're not actually volunteers. They're paid to do this. Plus you can just get a much, much larger supply of it from horses than you can with humans.

Now the antitoxin actually works best if it's given early in the process. So once the toxin has done its damage and paralysis has ensued, then the antitoxin is not going to be nearly as effective as it would be right after exposure. But the difficult thing with that is it's so hard to diagnose early on. You may not be… by the time you diagnose it, it may be too late for the antitoxin to really help too much.

1:17:04

So if botulism is suspected, it's best to get the ball rolling and go ahead and give the antitoxin sooner rather than later. Just to show you how soon you have to do it, in the Thailand outbreak last year that we talked about earlier in this segment, patients who received antitoxin on day four had significantly reduced duration of having to be on a ventilator compared to those who received it on day six.

So the difference between getting the antitoxin on day four of their disease versus day six made a substantial difference. So yeah, something to think about. Again, it's difficult to diagnose because you don't always think about it and because it's so rare.

What about antibiotics? Well, they're really have been unproven to help in clinical trials. Still, with wound botulism, often they are used. They're no help at all with food-borne botulism because remember, only the toxin is present, not the actual bacteria.

1:18:07

And with infant botulism, you have to avoid antibiotics because the antibiotic would kill the bacteria in the gut, but then the bacteria would decompose and release even larger amounts of toxin. So you really just have to wait for the infant's immune system to kill the botulism organism which it usually does pretty well.

Now in terms of the course of the disease and outcomes, symptoms usually progress for one to three weeks before they peak. And then peak muscle weakness and paralysis usually remain for an additional two to three weeks after that and then slow recovery begins and that can take several months and may involve relapses and remissions.

Patients usually require hospitalization for one to three months with this disease. The mortality rate is low, less than 5% to 8% for adult disease and even lower in infants. The death rate there is less than 1% as long as supportive care is begun in a timely fashion.

1:19:06

So really, the main thing with this, you're weak and it's a long disease process. But as long as you support them from a respiratory standpoint, in other words, you have them on a ventilator because they can't breathe and you watch for complications that can arise from being bedridden for that long and on a ventilator that long. Complications are pretty rare as long as it is diagnosed and taken care of.

Okay, so everything you wanted to know about botulism and probably a little bit more. So that wraps up our In-Depth segment. We still have a research roundup coming up and we'll get to that right after this.

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1:20:14

Alright, moving right along, our research roundup is brought to you in conjunction with research partner, Devon Technologies, creators of robust information retrieval software for the Macintosh platform. You can visit them online at devon-technologies.com.

Pediatric appendicitis. This is a study that comes out of the Children's Hospital of Boston and the Morgan Stanley Children's Hospital of New York. And it was published in the February 2007 edition of the Journal of Academic Emergency Medicine.

So the question before the researchers was they were going to look at classic appendicitis symptoms include pain around the bellybutton which then moves to what we call the right lower quadrant. So the appendix basically if you just divide the abdomen into four quadrants you go below… the bellybutton is basically the intersection of all of those quadrants.

1:21:07

So if you draw line straight across the bellybutton and then straight up and down on the bellybutton, you get your basically four squares. And the right lower quadrant would be below into the right of the bellybutton. So the pain starts around the bellybutton and moves to the right lower part of the abdomen.

Also feeling sick to your stomach, vomiting, fever, lack of an appetite, guarding which is where as soon as you touch that area, they're pushing your hand away. So it's almost an involuntary kind of reflex. Also what we call rebound tenderness which means that you push down and then kind of hold it and then when you've let go, that hurts just as much as when you actually pushed down. That would be rebound tenderness and that makes you think about appendicitis. Also a high white blood cell count also. So that's sort of the classic appendicitis symptoms.

But we do know that kids can have an atypical presentation and so that they don't necessarily have those things that I just mentioned and then that can lead to a delay in diagnosis which then can result in perforation of the intestine where basically there's a rupture and intestinal contents spill into the abdominal cavity.

1:22:18

And that can result in infection complications and a lot of malpractice lawsuits arise because of a delay of diagnosis associated with appendicitis and that can be difficult because if they present an atypical fashion, it may be difficult to diagnose and result in a delay.

So the author is basically wanted to identify the specific components of an atypical appendicitis and what frequency atypical appendicitis occurred. So and it's important really for parents to also know these features because if there is some atypical way that appendicitis can present and you're at home with your child, you want to know what those symptoms are because you don't want to put that off. You want to make sure that you let your doctor know.

1:23:04

So what they did is they did a 20-month data collection period in children who were ages 3 to 21 were enrolled. Now all of these kids had suspected appendicitis as their initial diagnosis and that was determined by a standardized form that was completed by a fellowship-trained pediatric emergency medicine physician and that form was filled out prior to a surgical consult or any diagnostic imaging. So any CT scans or abdominal x-rays, you didn't get the surgeon's opinion.

You basically just do standardized form. If they meet certain criteria, you say, hey, they're a high risk for this being appendicitis. Now they were excluded from the study if they were pregnant, had a history of prior abdominal surgery, if they had chronic medical conditions or if they had the need to have an x-ray done in the previous two weeks.

1:24:00

So any confounding factors out of the ordinary, they were basically thrown out of the study. It's just going to be the kids are who sort of freshly presenting emergency medicine patients with suspected appendicitis.

So if you like at the 15 classic signs of appendicitis, loss of appetite, feeling sick to your stomach, the pain migration that we talked about around the bellybutton and then down to the bottom right of the abdomen, pain duration greater than 48 hours, guarding, gradual onset of the pain, absence of diarrhea, decreased bowel sounds, percussion tenderness, fever, the high white blood cell count. Percussion tenderness is where I kind of bang on the abdomen with a finger, trying to make like an echoing sound and that hurts.

So all of these things, there were 15 signs altogether that were considered the classic sign of appendicitis and then basically, they just determine whether or not each patient actually have those signs and then they determine if they actually had appendicitis or not.

1:25:08

And basically, the rates of occurrence of the 15 classic signs and symptoms were compared to whether or not the patient really had appendicitis or not. So what were the results? Well, 755 patients were looked at and of the 755 patients, 270 of them actually had appendicitis and of them, 17% presented with a ruptured appendix which would suggest that they had a delay in the diagnosis. 12 of the 15 classic symptoms were more common in those who actually had an appendicitis and I guess that's why they're considered classic symptoms. But there were exceptions. For instance, gradual onset of pain, absence of diarrhea and fever were less likely to actually be present.

1:26:00

Some of the classic instance that were frequently absent and just examples fever, there was no fever 83% of the time. There was no rebound pain 52% of the time. The pain didn't migrate like it was supposed to from around the bellybutton to the right lower quadrant 50% of the time. There was no guarding which we talked about 47% of the time. There was no lack of or loss of appetite 40% of the time. And the maximum tenderness in the right lower quadrant was absent 32% of the time.

So 44% of patients with appendicitis were found to have six or more atypical features meaning absence of six or more classic signs. I know it's a little bit confusing, but basically what that means is that the people who actually had appendicitis, 12 out of the 15 classic symptoms were common, but still in a lot of them were absent as often as 50% of the time.

1:27:07

So it really basically, the conclusion here is that appendicitis in children does not always follow a classic pattern. And I think this is important for parents to understand not just in recognizing the signs and symptoms of appendicitis, but look, medicine is not a black and white science and not all kids are going to present the same.

As a doctor, you certainly don't want to miss an appendicitis, but you also don't want to subject kids to unnecessary surgical procedures or unnecessary radiation from unnecessary x-rays. And not only is there radiation risk with x-rays, but also if you get a contrast material, there are certain percentage of kids who are going to have a life-threatening allergic reaction to the contrast that the die that is needed to get good x-ray picture.

1:28:03

So it's tough and you definitely got to cut doctors a little bit of slack here. I mean at the same time, if you're worried about your child and they're not getting better, you don't want to sit wondering if you should call your doctor again or should you just break down and go into the emergency room and by all means, if your kids have abdominal pain and your doctor says, I don't think it's their appendix and they get home and they're doing worse and you're worried about it, by all means, call your doctor. Go to the emergency room because you have to realize the best doctors are going to miss the occasional appendicitis on its initial presentation, it's true.

And why? Because many cases, as this study shows, are atypical. And if a doctor never misses a case of appendicitis in its early stages, then he or she is probably ordering lots of costly and radiation and die-exposing procedures on a lot of kids who only have a stomach virus or constipation. And yes, I did say constipation because a lot of kids with constipation will have abdominal pain that can be every bit as bad as appendicitis pain.

1:29:09

So my point here is not to scare you. I mean most cases of appendicitis are going to get recognized. Most kids who have to get x-ray aren't going to be exposed to radiation to the point that it turns into a leukemia or initializes a brain tumor. Most of them aren't going to have a life-threatening allergic reaction with the die or the contrast material.

My point really is just to say that practicing medicine is not easy and often, the art of doing it, the art of knowing when to do tests, the art of missing as few cases as possible, but the art of not overdoing it is all important. So I mean the art of medicine at times is every bit as important as the science that we so frequently discuss.

Okay. Let's… we're definitely running over here. A lot longer than I thought it was going to be. So once again, I do want to remind you that the information presented in every episode of PediaCast is for educational purposes only. We're not diagnosing medical conditions or formulating treatment plans here.

1:30:12
Also, your use of the audio program is subject to the PediaCast Terms of Use agreement which you can find at pediacast.org. Thanks go out this week, as always, to news partner, Medical News Today; research partner, Devon Technologies; and this week's sponsor, Mariner Software. Website and feed are work of art brought to you by Vladstudio so be sure to check out Vlad's website at vladstudio.com.

Also, of course, thanks to all the listeners out there. Remember, if you would like to add your own two cents, just go to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or use the voice line at (347) 404-KIDS.

The PediaScribe, I always sort of pick out my favorite PediaScribe blog entry from the previous week. You got to see Dog Versus Fun Noodle. It's good for a laugh. There'll be a link in the Show Notes Dog Versus Fun Noodle. It's a video of my wife having fun with the dog. So you got to check that out.

1:31:15

Okay, we're going to leave you with a little bit of music. This week's feature music is brought to you by IODA Promonet and Blue Cat Blues Records. If you like the song, there's a link to download it absolutely free for your personal use as a DRM-free MP3. And if you really like the music and would like to support the artist by purchasing the entire album, there are links for that as well.

So we're going to leave you with Los Lonely Boys. The album is live at Blue Cat Blues in Dallas, Texas and it's their number one Grammy-winning hit, Heaven.

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

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