Bug Spray, Power Lines, Potty Training – PediaCast 176

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Topics

• Food Mascots
• Bug Spray
• Hormones in Milk
• Electromagnetic Radiation
• Gastroesophageal Reflux
• Potty Training

Transcript

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, a pediatric podcast for moms and dads and grandmas and grandpas, aunts and uncles, pediatricians, family doctors, medical students, residents. Anyone who's interested in knowing about child health, we are here for you. And it's episode 176. Dr. Mike coming to you from Nationwide Children's Hospital. And Bug Spray, Power Lines, Potty Training.

Now with a title that diverse you can bet it's a listener episode so we're going to take some of your questions and get those answered for you. Before we get started with that, I tell you there is a lot of construction going on at Nationwide Children's Hospital. We are in the process of building a brand new hospital tower and a new research building as well. Lots of improvements around the grounds – an underground parking garage and lots more.

So it's really kind of cool seeing all these take shape. And when it's all said and done, Nationwide Children's Hospital will be the second largest children's hospital in the country. So that's pretty exciting stuff.

Now of course how big you are and how many beds you have does not necessarily mean how great you are. And I think that the specialist that we've had dropped by the studio here so far really speaks toward the breath and the talent that we have here at Nationwide Children's.

I've been excited to share some of that with you. I know we've had a whole string of interview shows and we have lots more planned. In fact, we have interviews scheduled now well into the Winter or at least late Fall or early Winter. And we're so excited about that. But I don't want to do that at the expense of answering your questions and still getting out news parents can use, so we still have those shows lined up and in fact, this is one of them.

02:29

Today what we are going to talk about? Well we got lots of cool stuff on the agenda. We have some feedback on our whole food mascot debate that we had talked about, so we're going to share that with you. Also bug spray. Apparently, in some areas, West Nile virus has been found this Summer as in previous summers in the mosquito population. And so in the news they are kind of scaring folks about that. But parents want to know should they use insect repellant and what about DEET, is it safe for kids. It seems like we address this issue about once every summer and we haven't done it yet this Summer, so now's the time.

Also hormones in cow's milk. Is that bad for your child? We'll also kind of touch on antibiotics in milk as well. Or should you stick with organic milk? So we're going to talk about that.

Power lines and cell phones. Do electromagnetic fields give you an increase risk of cancer? And then there's another study out that suggests that maybe asthma could be related to electromagnetic field. So we're going to discuss that.

And then we have parent questions on reflux, infant reflux and spitting up and fussiness with reflux and potty training as well. So lots coming your way.

I want to remind you if there is a topic you would like to hear us talk about, it's easy to get a hold of me, just go to pediacast.org, you can click on the Contact link there. Or you can email pediacast@gmail.com. If you go that route make sure you let us know where you're from because on the Contact page there's a space for that so everybody fills out your location, but when you email we don't get that so please make sure you let us know where you're writing from if you get a hold of us through email. Because everybody likes to know, hey, where's the audience, where people are hanging out, because it typically is around the world with our audience and so it's kind of fun to see where everybody comes from.

And then you can also call the Skype line 347-404-KIDS. That's 347-404-5437.

Before we get started, I also have to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you 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.

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

04:56

All right. First stop is Gem from Colorado and Gem, G-E-M, says, "Hi Dr. Mike. I have a very conflicted feeling regarding whether or not I think the government should regulate cartoon characters on food marketed to our children. I agree that in the end it's the parents' responsibility regarding what a child eats. I suspect that many PediaCast listeners are fairly educated parents. However, this is not true of all the United States. It's really startling when you run in to people who don't understand basic nutrition fact labeling. I once had a woman stopped me in the dairy aisle, she gave me two cartons of yogurt and asked me which one had more protein. I did a quick glance and they both had exactly the same amount. Figuring there was a trick somewhere, I double checked, but the serving sizes were also the same. I told her they were identical, she nodded and told me her doctor had instructed her to grab some high-protein yogurt for her son but she couldn't figure out which one was higher. Sadly, I was too startled to point her toward the Greek yogurt. If a parent can't tell the difference between a healthy cereal and an unhealthy one, I can imagine they might cave in to their child's desire for the one with the cartoon character. I know it sounds silly but that doesn't mean it won't happen. Maybe we'd have better luck requiring high fat and high sugar kids items to contain warning labels that state 'this is not a health food'. Imagine the uproar that would cause. Gem."

I don't know, Gem, I think you're on to something there. Personally, I think I would prefer seeing a rating scale on all food with regards to health, not just kid's food, any food. Is that particular food as it relates to your health, is it an A, a B, a C, a D or an F and you can have formal guidelines based on the content of the food. And at the end of your shopping trip it's OK to have a couple of Ds and Fs in the cart but you should make up for it with lots of As and Bs. And maybe you could color code this based on the food group. Again in the checkout line, you have lots of different colored letters and more As and Bs than you do Ds and Fs.

06:59

So if a parent wants to and they can read the nutrition label, great. But if they're not interested that's OK too. The grade will let you know in general how well balanced and good that particular food is for your child's diet and for your diet as well.

You could put it up in the corner of the box, a little white square with a colored letter. And of course it has to be an expert panel with no lobbying intimidation to decide what the criteria are for an A, a B, a C, a D or an F. It could be done in relation to other food in that category like of all the cereals, which ones are the A cereals, the B cereals, C, D and Fs.

Now again, the no lobbying would be important because for instance if high fructose corn syrup gets a ding, you don't want the corn growers intimidating the panel. You know what I'm saying? Again, I've talked about this before, but to me it seems very un-American to murder Toucan Sam and Snap, Crackle and Pop. But if they deserve a C or a D give them a C or a D and encourage the cereal manufacturers to tweak the product to boost it to get a better grade.

I know it won't taste the same but we'll get use to it. I mean lots of products taste different these days. When I was a kid soda had sugar and if you try a Pepsi Throwback it tastes different now than it used to.

And I remember when McDonald's French fries were like the bomb! And literally, it was like a bomb going off in your coronary arteries as well. But I mean they used to use a different oil; they salted them more, of course you can still add a little more salt. But they were different that they are today because of pressures to make them more healthy.

So things change and we adapt. And what's with parents letting their kids intimidate their shopping? Train them from a young age that the food's grade is better than the mascot. And this is where sarcasm and a little bit of cynicism come in, which by the way is very American.

For your kid, from a very a young age, hey, look, Lucky the Leprechaun he gets a D, what a loser? That would be my plan, which is probably why the government is not asking me.

9:09

All right. Let's move on. Annika here in Columbus says, "Hi, Dr. Mike. I live in Columbus. And the news has been talking about local mosquitoes carrying West Nile virus. I have an almost three-year old boy. What types of bug repellant should I use? Is DEET safe for kids? And should I send him to daycare with a bottle of bug repellant. Thanks. – Annika. P.S. Love the shorter show format. The long shows are like drinking from a fire hose. Much better that or attention with the shorter format."

It's a nice visual, Annika, and thanks for your feedback and your question as well. So the short answer is the benefit of DEET definitely outweighs the risk. And to understand why let's look at both the risks and the benefits and like I said we do this about every summer. But I think it's a good discussion to have.

Before we talk about risks and benefits of DEET, before we do that, first off your bug repellant should have DEET in it. There are some other chemicals that work as well but instead of doing a whole big long list, just remember that one word, DEET, that's what you want.

Ones that don't have DEET in it or some of the other good chemicals they just don't work that well. But we're going to focus on DEET with this one. And it's interesting how this works. So first let's say what is DEET?

Well the chemical name is Diethyl-meta-toluamide and it's a chemical that was developed by the U.S. Army to protect soldiers from insects in jungle warfare. How it works, human sweat and breath contain the chemical 1-octen-3-ol and insects are attracted to this chemical which is how the insect finds you. And DEET blocks the insect's ability to sense the presence of 1-octen-3-ol so you basically become invisible to the insect.

Some insects and most notably mosquitoes will still be able to find you even if you used DEET and that's because these insects are also attracted to carbon dioxide, which we all breathe out. But it appears that carbon dioxide only brings mosquitoes to you it doesn't make them want to bite you. Only the presence of 1-octen-3-ol makes the mosquito want to suck your blood.

So with DEET around mosquitoes may find you but they are less likely to bite. Interestingly, that's how DEET works. But let's talk about what kind of risks does DEET have, because OK, it works great and it's kind of interesting how it works but that's no good if it's going to cause you harm.

11:47

So let's talk about the potential harm from DEET. And this is really at the heart of Annika's question, is it safe to use bug spray/insect repellant that has DEET on kids? Well DEET does appear to have some toxic effects on the central nervous system. And I say appears because there've not been any formal studies looking at toxicity, only case reports. So the EPA maintains a registry of DEET associated adverse effects and it has close to 50 reports of seizures following DEET use and four of these cases led to death.

Remember these are case reports. We don't know if the DEET caused those seizures or if DEET use and the seizures were just a coincidence and timing. That's still a possibility. But let's say for the sake of argument, that DEET did cause the seizures in those cases.

In that case, let's put the number of DEET-related seizures into perspective. With an estimated 30% of the U.S. population regularly using products with DEET in the summer time, that gives a seizure rate of one case per 100 million users. So you're much more likely to be in a deadly car crash for instance, than you are having a seizure from DEET. Maybe it does cause some neurotoxicity but it's a pretty rare occurrence, if it does. And we really don't know for sure if it does.

13:15

On the flip side, what are the benefits of using DEET? Well as it turns out insects can carry some nasty diseases. And we'll name a few and since we have a global audience here at PediaCast we'll includes ones inside and outside the United States.

So mosquitoes, of course, can carry malaria, West Nile virus as Annika pointed out, yellow fever, dengue fever, viral encephalitis. Ticks can carry Lyme disease, rocky mountain spotted fever and typhoid. And fleas can carry plague, to name just a few.

So repelling insects can be an important task and that can prevent disease and can save lives from those diseases and we know that DEET does a very good job of doing this. It boils down like so many things do to a risk versus benefit analysis, which is basically what I've done here for you.

And the consensus on DEET and including from the Centers for Disease Control and the American Academy of Pediatrics is that the benefit of using DEET-containing products outweighs the risk in adults and children older than two months.

14:17

Now, why should you not use DEET in kids less than two months? It's a good question and I don't have a good answer. It's arbitrary. Have there been more seizures and deaths associated with DEET use in kids less than two months? No.

Do we know for sure that DEET has any toxic effects humans at all? No. But I'm certainly not going to go against the explicit advice from the CDC and the AAP. So don't use DEET on kids less than two months. If there are biting bugs around just keep them inside. Got it? Good.

All right. Since there is this question mark on toxicity, there are some additional caveats here concerning DEET use both in kids and adults over the age of two months. Because there is a small possibility, let's use it but let's also minimize any effect it might have on you beyond what's necessary.

So DEET is absorbed through your skin so you don't want to apply it under your clothes. And actually, let's talk about clothes for a minute. Clothes are a great barrier between insects and your skin. So if you know that you're going to have significant exposure, wear long pants and long sleeves, tuck your pants into your socks, wear wide brim hat, wear a shirt with a collar that's unfolded and up around your neck and then spray the DEET on top of your clothes and on the little bit of skin that's exposed, use it there as well directly on the skin. But try to cover yourself with clothes as much as possible.

Should you do this every time you go out? Of course not. But if you are anticipating significant exposure like you're going to go out at dusk and take a hike in a heavily wooded area next to a lake, then you might want to think about increasing your clothes coverage. But on the other hand, if it's in the middle of the day and you're outside playing at the playground, you don't need to dress like that because the exposure is not going to be nearly as great.

16:05

You also want to avoid using DEET on the hands of young kids because their hands go in their mouth. And don't apply the DEET to a broken down skin or areas where you have sores. Also after you go inside wash the DEET off your skin with soap and water and put the clothes in the laundry and don't go to bed with DEET on your skin.

So let DEET do its job and then get it off your skin when you no longer need it, just in case. So Annika, again the consensus is that the benefit of DEET outweighs the risk, but because there may be a small risk you should use the DEET with those caveats that I mentioned.

Also, other things to think about, DEET concentrations of 30% is about as high as you want to go. Higher than 30% does not provide any additional benefit but it could have a higher risk for toxic effect, that's possible.

Also don't use a combination product containing DEET and sunscreen and the reason is because sunscreen should be reapplied often but the DEET should be used sparingly. So you want to stay away from combo products.

All right. Annika, so there is your answer. Thanks for the question and we'll move on.

17:13

Next up we have Lindsay in Houston and Lindsay says, "Hi. What is the current recommendation on young children, especially girls, drinking organic versus non-organic milk. I know many people have concerns about hormones given to the dairy cows. Thanks. Have a great day. – Lindsay."

All right, Lindsay. Well thanks for your question. Really not going to be a big difference here between boys and girls. So the kind of hormone that is in cow's milk is going to be a growth hormone which pretty much has the same effect on boys and girls.

So it's not a sex type hormone. Really there's not going to be a big difference between its effect on male versus female. Now there are no studies that I have come across demonstrating that there is a definite problem from hormones given to dairy cows in humans.

And there are also no studies that I've come across showing that they're absolutely positively safe without any problems at all. In fact, there are really no good studies on this subject at all. And since we don't have any guiding studies let's just use a little science knowledge and sort of common sense to answer the question.

First, what hormone is given to dairy cows and why is it given? Well again, I mentioned the hormone is a growth hormone, it's actually called recombinant bovine growth hormone. As it turns out about 25%, it's actually about 22%, so right about a quarter of commercial dairies give this to their cows.

And why do they do it? Well it helps the cows produce more milk. It's easy to think OK, this quarter of the dairies that do it they're being selfish, right? They want their cows to make more milk so that they can sell more milk per cow and make more money.

It seems like well maybe these dairies are doing this at the detriment of our children's health just so they can be greedy. On the other hand, in this economy and with overhead cost being high, there may be some farming operations that without that extra boost in productivity they may be closer to the point of folding and not being able to make milk at all and then we have decreased milk supply.

19:30

I'm not saying that that's absolutely true. I'm just saying let's be sensitive to that fact. Obviously, if the hormone is definitely causing a problem that's an issue. But if it really is safe then their increased productivity may be warranted.

Now as it turns out, Japan, Canada, Australia and many countries in Europe have banned the use of these hormones because of concerns for human health. Of course, what they don't tell you is exactly what they're concerned about. They just said they have concerns. The public has concerns. And they don't want panic so they say we're not going to use hormones in cows to help them produce more milk because we have concerns.

Well here in the U.S. we like to spell out exactly what those concerns may be and then study to see if it's true. Well you can't do a study if you don't know what concerns you're looking for, so really no studies have done and no ban is in place.

Now we do know that human growth hormone is fairly safe in kids. In fact, it's used for some kids with growth delays. We also know that there's a small risk of some types of cancer with human growth hormone. But remember those kids are also getting an injection of it directly into their body of relatively a much higher amount of the growth hormone than what you're getting exposed to in milk.

So the question then is there an increased cancer risk in kids that drink milk. That's kind of a hard study to do since we want all kids to have milk. I guess you could do a group of kids with organic milk with not hormones and another group with it and then follow them prospectively and see if there's an increased cancer risk. But that's not been done. And the establishment at this point still believes that this is a pretty low risk. And exactly why that is we'll get to in a minute.

21:20

Now you may say what about obesity. I've heard this a lot, the hormones in milk are making are kids too fat and that's the reason that we have childhood obesity. That's not it. First of all, I remember it's cow growth hormone which is not the same as human growth hormone. They are different. Maybe they have some similar effects but it's not the same thing.

And human growth hormone may help you grow taller but it doesn't make you obese. It may increase your muscle mass and make your bones longer but it really doesn't increase fat. Now I supposed if a kid was part cow then cow growth hormone might help them grow taller or give them more muscle mass but again this is not what's making our kids fat.

Increased caloric intake and decreased exercise is what's making our kids fat. But let's say for a minute that there is a valid concern for human exposure to bovine growth hormone? The fact is, that kids actually aren't exposed to that much even if the milk they drink has bovine growth hormone in it. That's right. There really is no significant exposure and this is really I think the key reason why this hasn't been studied and here in the U.S. has not been looked as really a major problem.

And to understand why there's really not a significant exposure even if the milk has the growth hormone in it let's look at the signs of it to understand why. How is bovine growth hormone given to cows? It's given by injection. How is human growth hormone given to humans? It's given by injection. It's not given orally. And the reason it's not given orally is because growth hormone is a large and fragile protein that gets denatured in the stomach as a result of acid exposure.

So growth hormone goes into the stomach but that's not what comes out to be absorbed into the body in the intestine. What comes out is a different protein that's been denature and inactivated by stomach acid and also by enzymes that break apart proteins and the strings of amino acids.

23:28

So intact bovine growth hormone probably very little of it actually makes its way out of the stomach and into an area that can be absorbed by the intestine. And that's why growth hormones are given orally because it's not effective. It just gets broken apart and denatured.

Now what about the pasteurization process? When you pasteurize the milk does that destroy the bovine growth hormone? Well as it turns out that does not. So pasteurization is a process of heating milk to kill bacteria and it's not hot enough to affect the bovine growth hormone.

So fear mongers will point out, oh, that growth hormone is still in there, pasteurization does not inactivate it. No, but your child's stomach does. That's why I think it's not that big of a concern and why it's not really been studied here in the United States.

OK. I kind of made light of the exposure risk and the affect risk, but there is another concern which in my opinion is actually a little bit more valid. Cows who get bovine growth hormone do have a higher incidence of mastitis or other infection and this results in more antibiotic use in these cows. And those antibiotics also make their way into the milk and survive the pasteurization process and they also survive your child's stomach acid.

So does the antibiotic that could be in the milk, does this affect your child's health and does it play a role in the development of bacterial resistance to antibiotics. Maybe. The verdict is really still out on that one.

So the bottom line here should Lindsay use organic milk for her kids. And I would say it's really up to you, Lindsay. I'm not sure that there's really a right or wrong answer to this one. You can make an educated decision and hopefully the information that we've provide here on PediaCast can help you with that process.

25:15

Organic milk is more expensive but you're often supporting a family farm when you buy it and you are eliminating hormone and antibiotic exposure to your kids. We don't know that it's harmful but you certainly aren't going wrong by avoiding those things.

But there are also families out there that can afford organic milk while others don't have access to it. So should they be afraid of giving their kids milk because of possible hormones and antibiotics?

We have to remember milk is a great source of iron, protein and fats and it's important for the developing bodies of young kids. And I'd say that its benefit outweighs the risk even with the presence of hormones and antibiotics on board. So there you have it.

I also want to point out that, again, only 22% of commercial dairies use these hormones. If you always go to the same grocery store and you always get the same brand of milk, maybe worthwhile for you just to find out from that dairy, hey, do you use it or do you not. And choose a different grocery store or a different brand.

It doesn't have to be organic because obviously if 22% are using it, 78% are not and certainly 78% of dairy farms out there are not what we would classify as organic. Just something to keep in mind. You just may need to do a little bit of research but it might not have to come in the glass bottle from a family farm. Organic, still do not have hormones and antibiotics in it. You just may need to do a little bit of research to figure that out.

26:44

All right. Let's move on to Ericka in Portland, Connecticut. Ericka says, "News outlets recently reported there appears to be no link between cell phone use and increase risk of brain tumors. But an online group that I receive notices from questions the interpretation of the data. Wondering if you can shed light on this. My children are rapidly approaching the age where they believe they need cell phones. Thanks for your help."

So the issue here, Ericka, is electromagnetic radiation and you get that from exposure from power lines, cell phones, microwave ovens. And some think that these may be implicated in leukemias, solid brain tumors and more recently, asthma.

Several studies have looked at this and none have provided statistically significant results. Although there was a recent one which showed increased exposure led to an increased incidents of asthma and this relationship was statistically significant.

But there's a problem. And the problem with that study is that they were not studying asthma. So they weren't looking to see if electromagnetic radiation from power lines, microwaves, cell phones, etc., the question before the researchers was not does this lead to asthma.

The questions before the researchers was does that lead to spontaneous abortion in pregnant women or a miscarriage? And that association was not found to be statistically significant. But in the course of analyzing their data and looking at asthma between the two groups they did find that the group with greater exposure had greater incidents of asthma and so they said that there was a statistically significant relationship between electromagnetic radiation exposure and asthma.

28:29

But the problem is if asthma is not what you're looking for you're not necessarily specifically controlling for other risk factors for asthma between the two groups. In other words, did they make sure that both groups were the same – the experimental group and the control group – were they the same with regards to asthma risk factors? Did each of those two groups have the same degree of family history of asthma? Did they have more viral upper respiratory infections? Did they have parents who smoked?

So they weren't looking in asthma specifically so they weren't trying to make the two groups as similar as possible with regards to asthma because they were actually looking at spontaneous abortion. So really you can't say that this means anything. You would have to reproduce that study and make sure you get all the co-factors for asthma out so that the two groups are equal with regards to all the asthma co-factors except for electromagnetic radiation. That would need to be done.

And I suspect, this is just my personal opinion that if you did that and you strictly controlled for asthma that you probably would not get a statistically significant difference between those two groups. But again that's my opinion.

We don't really have a mechanism of action and I think this is where a lot of the skepticism comes from. The number one, we don't really have any studies that would have shown there to be an association with electromagnetic radiation and any disease process with any kind of reliability.

And then we also don't really understand why that would cause issues at all. We don't have a mechanism of action to sort of go after. Another issue that we have with these electromagnetic radiation studies is that exposure doesn't just come from power lines and microwaves and cell phones. It also comes from hair dryers, coffee grinders, washing machines, blenders, mixers, shredders, cars, your household wiring.

So a well done project would require a prospective study where you take a large group of people and eliminate electromagnetic exposure completely for many years because we don't know how much exposure would cause these things.

So you really want a group of people with no electromagnetic exposure for years and then follow them with another group that has a controlled amount and see if there's a difference in cancers and such. But it's a little difficult to find control subjects (1) willing to do that, you'd have to travel to Amish country and they generally aren't keen on participating in this sort of thing, because you would have to ask someone who's willing to stay away from all technology and motors in order to stay away from these electromagnetic fields.

31:12

The other thing is that then if you stay away from those things, what other things are you staying away from which could be the real cause? Because there are so many variables associated with having these machines with what your life is like and what your house is like and what your daily living is that could be confounding factors that it just so happens that if you have more technology you have more x, y or z and that's why you have increased risk of these things.

So we don't know. And it's going to be very difficult to find out for sure and I don't foresee that happening any time in the future, in a foreseeable future, I should say. So what's my advice to Ericka?

I think the benefit of cell phones, used in moderation, for kids to stay connected with family and friends and as a safety rope when they're out and about so you can get hold of their parents quickly, I think that those benefits of a cell phone used appropriately and in moderation, not up till three in the morning texting your friends every night, but used appropriately, the benefit of cell phones outweighs any know risk. And that's the case probably well into the foreseeable future.

32:20

All right. Ashley, she wrote in by Gmail so I'm not sure where Ashley is. But Ashley wherever you are, we're going to answer your question. "Dr. Mike, I have a question about my daughter. She's almost four months old and since the age of two weeks she has always thrown up after eating or she usually cries until she throws up. I have tried whatever the doctors told me including changing formula but she won't drink soy. She yells and yells and refuses it. Is there anything you can suggest, any insight is helpful. Thanks a bunch – Ashley. P.S. I'm an avid listener."

Thanks for the question, Ashley, I appreciate you asking. Basically, you have a vomiting, fussy four-month old and a vomiting, fussy four-month old always needs to see their doctor because there are some serious and potentially life threatening disease processes which can cause these symptoms.

And examples include bowel obstruction, there are metabolic disorders that can do it, infections can do it. So a fussy, vomiting four-month old you got to see your doctor. Now, the good news is that most four-month old babies who are fussy and spit up with no other symptoms, no fever, rashes, that sort of thing, most of them don't have any of these terrible things I just mentioned.

Most of them end up that the diagnosis is that they're suffering from gastroesophageal reflux disease or GERD. Again, before you settle on that as the diagnosis you want to see your doctor who can usually tell the difference between these things with a good history and physical; sometimes additional testing such as imaging or PH probes might be needed to tell for sure, but most of the time that's not necessary.

So let's say you see your doc and they say the problem is gastroesophageal reflux disease, so what exactly is this and what do you do? That's what we're going to talk about. Well, let's look at it this way, the stomach has two valves, right? There's a valve on top and there's a valve on the bottom. So between the esophagus and the stomach there's a valve and between the stomach and the small intestine there's another valve.

34:20

Your baby drinks, whether that be breast milk or formula, and fills up the stomach. The stomach churns and the acid and some enzymes mix together start breaking it down and now the stomach wants to get rid of the volume of formula or milk that's in there.

So it squeezes and what's supposed to happen is the valve on top of the stomach is supposed to stay close and the valve on the bottom of the stomach is supposed to open so that when the stomach squeezes the food inside goes in the correct direction.

Well in babies with gastroesophageal reflux disease the valve that's on top of the stomach is a little bit loose so that when the stomach squeezes it basically pops open and now the one on the bottom opens as well but most of the contents of the stomach go through the bottom but some of it comes back up because there's pressure generated in that valve opened.

I also want to remind you that there's always liquid in the stomach waiting on the food. So the stomach has a pool of mucous and juices and acid and enzymes that's waiting for the baby to eat. So when a bunch comes up, remember a lot of what comes up was already down there, so if a baby takes say two ounces and they throw up two ounces it doesn't mean that everything they just drink came up because there was probably already a couple of ounces down there waiting on them. So just keep that in mind.

OK. So what do you do about this? Well the good news is it usually over time corrects itself. So as babies get older that valve on top of the stomach tends to mature and it stops popping open. Now when does that happen? Usually like nine to twelve months and sometimes it lasts longer than that, sometimes it goes away sooner than that. But nine to twelve months is pretty typical.

36:07

So what do you do? Well you wait. You wait until the valve fixes itself. Now there's a couple of issues where you don't necessarily want to wait and we can kind of break this down into two basic problems with this. One us pain. You have stomach acid that now is coming up into the esophagus and that can cause heartburn.

For some babies they don't seem to be bothered by this. So you don't necessarily have to do anything for it if they seem to be happy and they're not fussy. But if you have a baby who is fussy with their spit ups and they're crying after a meal, they're distraught about this and it's causing them discomfort, then these are kids that you can do something for them in conjunction with your doctor.

And things that are possible are antacids, Zantac and proton-pump inhibitors, things like Prevacid and Prilosec. Usually Zantac is what we settle on. It works better than antacids. It's not likely to cause any electrolyte disturbance like too much antacid possibly could cause, although that's pretty a little risk. And it's not as expensive as the proton-pump inhibitors like Prilosec and Prevacid. And so it's generic, it's safe, it's been used over a long period of time in babies. And so Zantac is usually, or ranitidine, is usually the drug of choice for this that your doctor will prescribe.

So what it does is it only decreases the amount of stomach acid. So your baby still spits up but they don't get the heartburn and the fussiness associated with it. So if your baby is spitting up and fussy all the time and your doctor decides that it is gastroesophageal reflux and they haven't started Zantac you can ask him about that.

Now what about the spitting up itself? Do we need to make the spitting up itself go away? Well you can but there are consequences to that. The question becomes do you need to. I think first, if you need to, if your baby's losing weight then you need to. If your baby is choking and aspirating on what comes up then you need to.

If your baby has breathing problems, wheezing cough that you suspect is because of the spitting up or they're not able to gain weight because of the spitting up, then you want to help him out and make that spitting up go away.

Otherwise, if they're happy, they're breathing fine, no cough, no wheezing, they're not fussy, they're growing well, they're a happy spitter, then as an instructor once told me it's a laundry problem, not a baby problem and you just wait it out.

Now let's say though that it is a baby problem and you are losing weight or you're having choking spells or aspiration, wheezing, that sort of thing, then there are things that you can do. And those range from thickening the feedings to using medicines that help the stomach to empty faster and there are some surgeries that can be used in extreme cases as well. But most kids don't need that. Most kids just need the Zantac, if anything, and that's about it.

So I hope that helps, Ashley. Again it's important to see your doctor first to make sure that gastroesophageal reflux is the real problem and that there's not something else going on. But most likely that will be the real problem because gastroesophageal reflux is a very common disorder.

39:25

OK. I know we're running a little bit longer here but I'm trying to get caught up on some of your questions. And like I said I have a bunch more that I didn't get to so we're going to try to get to those next time.

Last one up here is Crystal in Dubuque, Iowa and Crystal has a potty training question. She says, "First, I'd like to take a moment and thank you for your podcast. I love listening to it on my way to work and it has helped me over the last couple of years. I do have a question regarding potty training my three-year old son. He is pretty good about urinating in the toilet with little prompting. My problem is getting him to defecate in the toilet. He has only done it twice and says he doesn't know when he has to go. Do you have any tips that could help? I'm getting frustrated because we have been trying to get him trained for the last couple of months and he's required to be self sufficient with the bathroom to start in the three-year old preschool, otherwise they'll put him in with the two-year olds until he is trained. Thanks again. – Crystal."

Well Crystal, thank you for your question. First, let me say it is possible that your three-year old might not be ready. So he's ready for the pee but he's not ready for the poop. For those kids the problem is that they just don't have the sense of when they need to go and they don't have the muscle control to be able to hold when they do have to go and so the next thing they know they're pooping in the pants. And so that's possible.

Now how do you tell whether it's just they don't want to do it or they can't do it? And I have found that this works, if you try just taking away their diaper. Take it away. They go, not pull-ups, they go on regular underwear. And you tell him now if you poop, you're going to make a mess in your underwear and that's going to be a problem, but if you feel like you have to poop you let me know and I'll put the diaper on you.

You don't have to go in the toilet because we want to eliminate being afraid of sitting on the toilet as a possible cause here. You're just going to say hey, you let me know when you got to go, we'll put the diaper on, you poop, we'll change it but you're a big boy put your underwear back on.

41:29

And kids who can't do it often times this will work. Even though you think no, this is not going to work, you just have to try it. You just got to trust me and try it and you'll find that it does work. If it doesn't work and they really do poop in their underwear and then they're distraught about it and you can tell, they wanted to let you know and they just couldn't then that might be your kid is not quite ready yet.

And there are some three-year old boys who aren't quite ready yet. On the other hand, if that's working out and you put him in underwear and he lets you know, hey, I got to poop, I want the diaper on, you put on the diaper, he goes, you change him, you put the big boy underwear back on, now you're dealing with a kid that could but they don't want to.

And in this situation this is where bribing comes in really handy. I mean, you just have to use a great reward to get them over that fear of using the toilet. Maybe just being in with the three-year olds is going to be enough of a motivation. Like you want to be with the little two-year old babies or do you want to be with the big boys doing fun stuff?

Sometimes, that's enough to make them want to be successful. Other times you got to go out and take him to like a toy store and buy him not an expensive toy, buy him something inexpensive that will motivate him, take it home and say when you go in the big potty then you can have this.

I know it seems to me they'll have their little temper tantrum but don't give in because they're going to poop soon and just let him know, you poop in that big boy potty you'd get the toy. So that can be successful.

Then what happens if you get a kid who only goes when they get a toy? Then you can come up with a sticker chart, every time you go on the big potty you get a sticker, get five stickers then we'll buy you something little, it doesn't have to be expensive. You can play cake kids with little inexpensive things.

So that's just an idea for you and Crystal I hope that helps.

43:24

All right. I want to thank all of you for tuning in and being a part of PediaCast. We really appreciate it. I have to tell you we have not had any new iTunes reviews since early June, which is a long time. And I would just ask that if you found us through iTunes probably one of the reasons that you took a chance and took a listen is because of the reviews that you saw in iTunes.

And I would just ask that you just take, literally it takes less than five minutes of your time just to write out a quick review. And news reviews on iTunes just help us to be a little bit higher on the ratings and get noticed a little bit more and also to just let parents know hey, this is a cool thing and there are other parents recently who have listened and got something out of the show.

Again, I don't go into this detail with most of our shows. Yeah, I mention hey, iTunes reviews. But if you could just give a little back, not much, we're not asking for much and that is just to go to iTunes and jot down a quick review in the iTunes store that would be oh so helpful, especially if you came to us through iTunes in the first place.

Blogs, Facebook, Tweets, we do have a Facebook page. If you have not liked us, just go to Facebook and search PediaCast. We also have Twitter feed so you can go look for us @PediaCast there as well and it's all great.

45:02

And I also am pretty active in the Nationwide Children's Hospital Facebook page and also in their Twitter feeds, so you'll see me comment here and there in those places as well. So even if you're not in Columbus that's fine, make it one big happy family, just go over to Nationwide Children's Hospital and like our Facebook or our Twitter.

But we're still doing the Miracles at Play thing. I think we're up to like 75,000 likes right now. The basic gist is this, there's a company here in Central Ohio that's going to give the hospital $100,000 if they can get 100,000 sign ups on Facebook, Twitter and with email.

And so we're just trying to get up to 100,000 so we can get the full amount. We're not pretty far with 75,000 and I'm fans with lots of different children's hospital, so I like to be in the know on what's happening out there in pediatric world.

And I can tell you, I think we probably have the largest fan base of any children's hospital probably in the world. That's pretty exciting. We really try to have lots of different pediatric information there for you. It's not just us telling you all about our hospital. We really have lots of great tips and tricks for moms and dads and latest research findings from all over the place. So make sure that you check us out again in Facebook and Twitter.

46:21

And then finally, please tell your doctor about PediaCast next time you go in for a well check-up or a sick visit. Just say hey, there's this cool podcast that's evidence-based and answers listener questions, covers news, interviews pediatric specialists and I think you need to know about it. Because I think your doctor will probably enjoy listening because a lot of this stuff, our last show was on factor V Leiden. I didn't know anything about factor V Leiden before I researched it for the show.

It's just not one of those things that you really retain. So it's a nice refresher and even though it's aimed at parents we still have enough good stuff here for doctors as well. And in the future, well while I got your ear, we are kind of putting together this idea of a PediaCast pro which is really aimed at clinicians, doctors, nurses, EMTs, that sort of thing. Hopefully with CME credit. So that's kind of in the pipeline and in the workings right now, just a little something to keep in the back of your mind. So hopefully that will be something coming up in the future.

47:34

All right. So how do you get a hold of us one more time, pediacast.org, you can click on the Contact link. Also email pediacast@gmail.com. If you do that make sure you let us know where you're from. Or you can call the voice line, 347-404-KIDS. That's 347-404-5437.

And even though I mentioned that we still have a little bit of backlog on listener questions, don't let that keep you from writing in, because I'm trying to get a good diversity of questions for each show from each age group, from babies up to teenagers, like one from reflux to cell phone use and everything in between. So write in even though we have a backup of questions yours may still be the one that I pick.

All right. So until next time, this is Dr. Mike of course saying stay safe, stay healthy and stay involved with your kids.

So long everybody!

[Music]

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