Developmental Dysplasia of the Hip – PediaCast 230

Dr Kevin Klingele joins Dr Mike in the PediaCast Studio to discuss developmental dysplasia of the hip. From screening examinations and ultrasounds to Pavlik harnesses and surgical interventions, we cover the nuts and bolts of this common condition.

Topics

  • PediaCast on Pinterest!

  • Seasonal Flu Resources

  • Developmental Dysplasia of the Hip

Guest

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

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

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus. I like to welcome everyone to the program. It is episode 230, for October 24th 2012. And we're calling this one Developmental Dysplasia of the Hip.

Now I know that sounds a little bit complicated, but it's actually something that a lot of parents deal with. You may just not have heard it called that before. And we'll get to exactly what developmental dysplasia of the hip is in just a couple of minutes.

01:04

First, a couple of housekeeping items for you. I want to remind you that we are now on Pinterest. I know lots of moms and dads are on that social network, Pinterest. We have two boards over there, an Episodes board and I would just encourage you to please check that out and repin your favorite episodes and share those.

And then we also have a board that I'm really excited about called Our News Parents Can Use board and it's going to have different stories on it than you hear on the podcast. Just some examples for you, there are new warnings on Simply Thick, which is an infant formula thickening agent. We also have the latest research on the "cry it out" or Ferber Method for getting your baby to sleep.

We also have one on the psychological impact of pacifier use; the pediatrician's role in helping families with adopted children; the relationship between video games and motor vehicle accidents for teenage drivers; and the effect (I love this one!) on teenagers if they're tasered by a law enforcement. So lots of goodies on our Pinterest News Parents Can Use board and again it is information you won't find in the podcast, so be sure to check that out.

One more item for your consideration, flu season, it will soon be upon us and if you and your kids have not had the flu shot now is the time. We aren't doing an episode this year dedicated to influenza but we did one last year and the information is still up to date and relevant. The latest flu show is episode 184 and it featured an interview with Dr. Dennis Cunningham, an infectious disease specialist here at Nationwide Children's Hospital. And to help you find that show I'll put a link to it in the Show Notes over at pediacast.org for this show, again episode 230.

Also, Nationwide Children's has a large influenza resource page with tons of helpful information about the disease and the shot. You'll find articles, helpful tips and Q&A, video segments, so if you want to be flu smart be sure to check that out and again we'll put a link in the Show Notes so you can find it easily.

03:04

One more interesting place to find influenza material and it's a place you may not have considered, Hannah over at fulltimenanny.com has put together a list of 30 Blogs with Good Information on Seasonal Flu. Now if you are a nanny or you need a nanny or you want to become a nanny, fulltimenanny.com is chock-full of great information for you, so be sure to check that out.

And in particular, dive into Hannah's 30 Blogs with Good Information on Seasonal Flu. And I perused the blog posts you'll find there and I can say they are evidence-based and Dr. Mike approved. So head over to the Show Notes at pediacast.org and you'll find links to fulltimenanny.com and 30 Blogs with Good Information on the Seasonal Flu for you.

All right. I know this episode is just getting started and I'm throwing links at you left and right. So what do we have lined up for you today? Well, it's a topic that affects many parents with newborn infants at home. In fact, some studies show that to one degree or another, this is an issue that affects 1 in every 60 babies.

So here's a scenario, you take your new infant in for his/her well check-up exam. The first one at two weeks of age and your baby's doctor takes the newborn's hips for a spin. Your doctor pauses, maybe rotates the hips around again and then tells you that one or both of your baby's hips seems a little loose or he tells you that he feels a click or a clunk in the hip and he has you maybe come back in a couple of weeks to recheck it and if the problem persists, he orders an ultrasound.

Now many of you out there I know are not in your heads, you've been through this and in most cases the ultrasound is not concerning, the hip looseness goes away on its own and it's a done deal. But sometimes, the ultrasound is not normal and the hip problem does not correct itself or the problems was so severe at that first exam, your doctor wants to send you to a pediatric orthopedic specialist right away.

What then? That's what we're talking about today. It's called developmental dysplasia of the hip and to help me talk about it we have a great studio guest lined up for you. Dr. Kevin Klingele, MD, is the Interim Chief of Orthopedic Surgery here at Nationwide Children's Hospital.

But before we get to him, I'd like to remind you if there's a topic that you'd like us to talk about it's easy to get a hold of me, just head over to pediacast.org, click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, be sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

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

05:05

All right. Let's turn our full attention to our studio guest this week. Dr. Kevin Klingele, MD, is the Interim Chief of Orthopedics and the Surgical Director for Sports Medicine at Nationwide Children's Hospital. He's also an Assistant Professor of Orthopedics at The Ohio State University College of Medicine. Dr. Klingele received his medical degree from Ohio State, completed an orthopedic residency at Indiana University and wrapped up his training with a fellowship in Pediatric Orthopedic Surgery at Boston Children's Hospital.

He's back in Columbus at Nationwide Children's and it's with a warm PediaCast welcome that we say hello to Dr. Klingele. Thanks for joining us!

Dr. Kevin Klingele: Thanks for having me.

Dr. Mike Patrick: We really appreciate you stopping by. Let's kind of just start with the definition. How would you define developmental dysplasia of the hip?

Dr. Kevin Klingele: Well, developmental dysplasia is really a spectrum of hip disorders that present at different forms depending on the age of presentation at the different age of the patient. Most commonly, this is going to refer to those kids that you just mentioned who present at birth or very early thereafter with their pediatrician with an unstable hip, meaning a ball on socket joint can pop in and out or is out and pops in and to find this on exam.

But that spectrum ranges from those children who have an unstable hip to a young adult or adult who has a very mild flat knee or shallowness of the cup of the hip, which can lead to early arthritis in the hip.

Dr. Mike Patrick: Sure. I know sometimes this goes by some other names and just a few of those – congenital hip dysplasia, hip dysplasia, acetabular dysplasia, developmental dislocation of the hip, congenital dislocation of the hip, hip dislocation and I just mentioned those because parents out there may have heard it called something different. But they're all the same thing that we're talking about.

Dr. Kevin Klingele: Same spectrum of disorder. Same general but in a whole wide variance and how it presents.

07:40

Dr. Mike Patrick: Sure. Who gets this? Is it more common, let's say males versus females, that's a good place to start.

Dr. Kevin Klingele: Yes. We talk about four big risk factors in our world, being first-born females with a family history, whether they've had a grandmother, mother who've been treated or untreated for hip dysplasia and breech presentation. And so breech babies is often the most common risk factor we talk about.

The frank breech are the real kids that have the increasing sense or risk factors from breech. The single and double breech, which often a family is not going to know, but those only carry really a 1% to 2% chance, we think of increased hip dysplasia.

It's the frank breeches with the knee extended in uro that's the real high-risk factor from the breech presentation. So those are the four big risk factors we talk about. But again, we see geographic variation, we see racial variation. It's much higher in Native Americans, European descents. It's rare to see in African-American children. Twin gestation and various genetic disorders carry higher risk factor for it.

Dr. Mike Patrick: Sure. Do you see a difference between right side versus left side?

Dr. Kevin Klingele: More commonly the left.

Dr. Mike Patrick: That's interesting.

Dr. Kevin Klingele: Often thought to be due to the way the baby often lays in uro, so the left hip is usually tucked on the safe of the mother and crosses over the mid-line, so you get a little bit of what we term abduction force on that left side, typically.

09:13

Dr. Mike Patrick: And just a reminder for parents, breech is when babies are kind of bottom first. Normally, we like to see the head come out first, but if their position so that their bottom is closest to coming out that's what the definition of breech is.

And then I did see that this instability rate in the hip when babies are firstborn. Some studies say it's as frequent as 1 in 60, but by one week of age it falls to about 1 in 240, so that speaks to there's kind of some natural looseness to the hips that you can see.

Dr. Kevin Klingele: Right. Many children are going to be born with unstable hips thought to be related to the maternal hormones that are still floating around the child's bloodstream and those will stabilized in the first one to two weeks and are really normal hips.

Dr. Mike Patrick: Yeah. So the thought is the female hormones are going to help mom have a baby and so her hips need to be a little bit looser to get a baby out through the birth canal and so those babies could affect the baby's hips, make them loose but then that should fix itself quickly.

Dr. Kevin Klingele: Very quickly.

Dr. Mike Patrick: Yeah. So when it doesn't fix itself, so now we do have the situation of the development dysplasia of the hip, what causes that?

Dr. Kevin Klingele: There's no single cause noted. Ligament is thought to be a big risk factor and that's why you'll see it in various genetic disorders when kids can be looser than others. Positioning, we mentioned the breech presentation, postnatal positioning, swaddling has always been discussed as a risk factor, having kid's legs crossed or tucking them under is always thought to be a risk factor for this.

Again, we see it higher in twins and higher in firstborns thought, again, to be due to the intra-uro positioning. So they're packed tight and so you see kids who have what we term packing disorders who have wry necks or torticollis, who have club feet, all because they don't have enough space as so firstborn females or twins that will cause the hip to be a little bit tighter packed.

Dr. Mike Patrick: Sure.

11:09

Dr. Kevin Klingele: But again, there's no single cause we know. There is a genetic factor that we're still not quite sure on because it can run in families.

Dr. Mike Patrick: Yeah. So there's a hormonal contribution, kind of a mechanical contribution and genetics play a role too. Interesting. So what early signs and symptoms are associated with this? So a parent who is concerned that their baby might have developmental dysplasia of the hip, how would they know that that's going on?

Dr. Kevin Klingele: They probably won't. There's really no clinical symptoms related. The kids will not hurt, even a child who has a hip that's out of socket, a child that has a hip that comes in and out of socket will not have pain associated with it. And so that's the hard part. It's a very difficult thing to sometimes pick up. It's a very hard thing for the pediatrician to identify sometimes on a physical exam. And so we rely, in the United States, on this clinical screening program where the child is evaluated at birth or right after, at a week, in a month, by their pediatricians with the hip exam you mentioned to try to determine if there's instability in the hip. But again, it won't hurt the child.

And a newborn or a one to two-month old child clinical exam is where the only signs and symptoms you'll find. And what we'll see on those exams is you'll feel a clunk, often times with the ball will come in and out of the socket and you'll feel the clunk when you rotate the hips. That sometimes is very hard to feel on a child that's awake kicking or crying in the office.

Dr. Mike Patrick: Yeah. Yeah.

Dr. Kevin Klingele: When they get a little bit older and some of the six-month old, nine-month old children who may have this that wasn't identified early, then you start seeing signs that they may not be able to bring their legs out as far or it may look like the skinfolds are a little bit different when you look at their thighs or their inner thighs the skinfolds may be a little bit off when you compare it to the other side.

And that is usually typically related to a little bit of shortening of the limb. So if the hips are out of socket and the ball rides up a little bit because it's not perfectly in socket that essentially produces a shorter limb, which can be very subtle but that's often what you'll see very early.

13:21

Dr. Mike Patrick: Sure. So it's the more severe cases that are a little bit easier to diagnose right from the get-go, but the subtler ones can still cause problems down the road but it may be longer before it gets diagnosed.

Dr. Kevin Klingele: Unfortunately, yes, because it is a hard thing to identify.

Dr. Mike Patrick: Yeah. Are there other problems that can cause similar signs and symptoms? In other words, if you had a kid who had a click or clunk in the hip or the skinfolds don't line up or one leg looks a little longer than the other, is there a differential diagnosis involved here?

Dr. Kevin Klingele: Yes, but it's rare. I mean, the skinfolds, the differing skinfolds, most kids will have if you look at them and it means nothing. It's just the way they're built. But if it's anything that produces a mild leg length discrepancy, there are various genetic disorders or very rare disorders in children where you can get a shorter femur bone or thigh bone. But in the many kids that present with clicks in their hips that are benign clicks. Really the majority of children that present to us in referral or the pediatricians with the hip click at an early age have normal hips, they just have normal joint clicks and pops.

Dr. Mike Patrick: Sure. And it's just things rubbing against one another, the ligaments, tendons, bone. Gotcha! So they have the screening and the pediatrician identifies there's a problem with the hip, how do you diagnose whether that's a normal hip or there really is developmental dysplasia?

14:47

Dr. Kevin Klingele: So again, we, in America, tend to rely on the clinical screening exams, so it's a physical exam finding. And if we have any suspicion or if we have a child who has significant risk factors or family history, then we can go on to what you mentioned earlier, the hip ultrasound, which in any child under six months of age, a hip ultrasound is the diagnostic tool of choice.

Remember, in a kid that's under six months much of the hip joint is still cartilage in that bone, so you can't see it really on a plain X-ray. So we rely on hip ultrasound to give us good measurements and ideas where the hip is positioned and those are done both statically and dynamically. We'll get a static view of the hip where it sits but the hip will also be taken through a range emotion under ultrasound to see and judge its stability.

Dr. Mike Patrick: Sure.

Dr. Kevin Klingele: And so that becomes the main diagnostic tool other than the physical exam at a very young age.

Dr. Mike Patrick: You mentioned you examined them and then depending on the clinical scenario, the history and your exam maybe you'll get an ultrasound. So if a pediatrician in their office and we have a lot of primary care doctors who listen to the program, if they feel a click, should they automatically order an ultrasound or would it be better to refer them to orthopedic surgery, let you do the exam and decide if an ultrasound is needed?

Dr. Kevin Klingele: I think if you're comfortable with your exam and I think if you have a quiet, happy child per se, that is letting you examine them and you feel that you feel a click but not the clunk that once you feel you know what you're feeling, it's OK to watch them. If you have a child that you think has significant risk factors and you want to do more of a clinical screening and you have a normal exam where you feel to be a normal exam, the key with those children is to wait till then get 68 years old before an ultrasound is obtained because we will get quite a few false positives the earlier the ultrasound's done.

Even in a normal hip you can get what we term 'physiologic immaturity', so the hip will still look a little bit shallow in a two-week old but it's actually a normal hip and you repeat an ultrasound six weeks later and it's a normal ultrasound.

So I would say, if there's a question of the exam or you feel the Ortolani-Barlow exam that we mentioned with the hip popping in and out then an immediate referral is a good thing. If there's really no clinical evidence that you feel the hip truly unstable or if you want to check what you question then I'll wait till six weeks.

Dr. Mike Patrick: And do an ultrasound when they're 68 weeks.

Dr. Kevin Klingele: Right. Right.

17:21

Dr. Mike Patrick: And probably the ultrasound ought to be done at a facility that's used to doing ultrasounds on hips in babies. So you want a radiologist who's this is what they do, so your community hospital may not be the best place to get that done. You may need to travel to a pediatric facility to have it done.

Dr. Kevin Klingele: Without a doubt.

Dr. Mike Patrick: So let's say you have a kid, they have the ultrasound done and it's confirmed they do have developmental dysplasia of the hip, how do you go about treating that?

Dr. Kevin Klingele: In the newborn up to about six months, nine months often of age, those children if they have unstable hips we place them what we term 'Pavlik harness', which is just a brace per se that's strapped on to the child, often times full time, which causes the hips to be flexed up and fall outward. And then that keeps the hip really directed towards the socket or reduce the ball into the socket, really 85%-90% of the time, and hold it there until the hip forms around it and stabilizes on its own.

It's a very easy thing to place on a child. The child doesn't seem to have a problem with it and it can be a little bit of a nuisance for the family, but it's the early best form of treatment with again 85%-90% depending on excellent results on stabilizing the hip.

When the child gets a little bit older, if they present older or if they're in that small group that does not stabilize with the harness, then those children are often taken to an operating room, place on an anesthetic, the hip pop in place while they're asleep and place in what we term 'spica cast', which is more of a body cast in common vernacular, that holds the hip in place. They may have to stay on for a good six to twelve weeks often.

You get into that spectrum and then you have children who have hips that are out of socket and won't go in, which is rare, or have hips that have failed the close reduction or the Pavlik and the casting, those children will have to undergo what we term an 'open reduction' where we'll actually have to make an incision on the front of the hip to allow us to put the hip back in socket, stabilize it and then place a cast.

19:28

Dr. Mike Patrick: Is hip replacement something that has to happen, not obviously in the infant age range, but if you have this and it continues to be an issue and a problem and you have severe arthritis, could this lead to needing a hip replacement earlier than you otherwise would?

Dr. Kevin Klingele: Really that's what we're trying to avoid. That's the whole real effect of underlying hip dysplasia. And so many would say that residual hip dysplasia into adulthood is one of the, if not the leading cause of arthritis in the hip and subsequent hip replacement in an older patient.

And so we always tell parents the hip development and the growth relies on having a socket developed together. And so you need the ball in the socket for them to grow and develop normally. Even with that, these children are followed through childhood and what I always tell the parents, once you have dysplastic hip, you always have a dysplastic hip, because even if in the best terms and the best of stability, these children may present at 16 years or when they're mature with still some very mild residual what we term 'dysplasia' or a little bit uncovering of the ball that may lead to arthritis down the road.

Dr. Mike Patrick: Sure.

Dr. Kevin Klingele: The whole goal of treatment is to prevent that long-term.

Dr. Mike Patrick: Yeah. If you don't get it treated and so let's say you have someone who doesn't present until they're older, teenager or an adult, what kind of complications do you see developing from untreated dysplastic hip?

21:01

Dr. Kevin Klingele: Well really the degenerative joint disease is the big issue and early hip pain and arthritis is the end result. If you have a child who has one hip that is out of socket and not in socket that is not treated that child will have a limb length discrepancy of significance.

You can have an abnormal gate. In the older child if both hips are out they will present with what we term a 'waddling gait' or a real wide-based gait. We will get a little bit of sway back and a little hyperlordosis or their back will bend back a little bit more, so they can get a gait abnormality.

But again, this won't hurt, these children don't hurt, they still walk at a normal age, they're still normal functioning children. It's just the end result what we're trying to prevent as an adult.

Dr. Mike Patrick: And then there are nerves and blood vessels that run through the hip, too. Is there any concern for damage to those is if the hip's popping in and out?

Dr. Kevin Klingele: Really the main complication of this is not only failure to achieve reduction and a stable hip. That's really the big complication or worry. And that can be for various factors. Some hips just won't do it; sometimes it can be compliant with keeping the harness on.

The other thing we really worry about is what we term 'avascular necrosis'. You mentioned blood supply, avascular necrosis is where the blood supply at some point during treatment is temporarily loss to the hip sock or the hip ball and so the growth can be affected. You can get destruction of the ball, of the ball in socket related to avascular necrosis.

That can be very mild and subtle. It may not present or show at least till the kid's older or it can present very early and there's really no way to alter that or change that in the midst of treatment. It's very rare and each subsequent treatment other than we've talked about earlier that risk goes up a little bit each time every time you heal more invasive to the hip. It's a very rare thing but that's the main real complication we worry about.

Dr. Mike Patrick: Yeah. Are there any complications from the treatment itself? So let's say that Palvik harness, are there disadvantages to using that? And I only mentioned this because a lot of parents these days Google symptoms or they have a kid with a disorder they're going to Google it. And one of the things that's out there is that the Pavlik harness could be associated with avascular necrosis, but then in my mind, as a physician, I have to say or is it just that the kids that are bad are in a Pavlik harness, it's used pretty much universally and so was the avascular necrosis really from their disease and not from the harness?

23:36

Dr. Kevin Klingele: It's rare but it can. There's a term that we use called 'Pavlik disease', which again is very extremely rare. It's a pretty benign thing to place on child, but if it's placed on a child and the hip's not fully reduced and it's not picked up it can cause worsening problems.

If it really has to be held on tight or if it's strapped on too tight then you get too much pressure in the hip and you can get avascular necrosis. So it has to be applied appropriately. It has to be managed appropriately and compliant.

Dr. Mike Patrick: Yeah. And this is why even if you're out in a rural area, primary care doctor probably shouldn't feel the hips are loose and then order a Pavlik harness. This is really something that you need to see a pediatric orthopedic specialist for and followed along to make sure you're doing it the right way.

Dr. Kevin Klingele: Really because it does have to be placed in a certain way. It has to be held in a certain way. The straps placed and tightened in a certain position to be safe.

Dr. Mike Patrick: Now, you mentioned sort of once you have dysplastic hip you always have a dysplastic hip. What really is the long term outlook for these folks? What's typical? Do you usually see lots of problems down the road or is it pretty much a done deal?

Dr. Kevin Klingele: Well there is no real so called cure for it, because once you're there you're there. But the earlier it's treated the better the prognosis. And so the quicker you can get a hip in the socket it's going to grow together, the ball and socket is going to grow together. And the higher the chance that when you're mature and done growing, at least rated graphically and mechanically and atomically, the hip will be more normal than if it's treated later on.

And so the end result if you have a hip that is nice and deep and stable and meets all the rated graphic criteria we think when you're mature, then we would think that hip will last you a lifetime without really any increased risk of arthritis.

Some of the hips they have a very mild amount of shallowness or a hip that may still be a little bit what we term 'sub-blocks' or out of the socket a little bit. Those are the hips that get in trouble when they're young adults. It comes in when they're 30 with arthritically painful hip. That's what we worry about.

25:52

Dr. Mike Patrick: And those are the ones that are more difficult to diagnose when they're young. If you do have an adult who presents, they're thinking, "Wow! Why didn't my doctor catch this when I was little?" But sometimes those can be difficult to catch.

Dr. Kevin Klingele: Very difficult to catch. And again, we're being much more aggressive and have much better surgical options for the young adults and the teenagers now they have a little bit of residual dysplasia. And so we're doing surgical intervention on these children and adolescents now that we weren't doing in the past that is now showing that we can salvage their hip and give them a pretty normal hip for their life if we catch it and still follow…

Dr. Mike Patrick: Sure. Is there any way to prevent this from happening in the first place? Anything that expectant mothers may be able to do?

Dr. Kevin Klingele: I don't think there's really any prevention. Again, the key is going to be early diagnosis. But there's nothing from a mother's standpoint that they can do to prevent this. If there is a family history of this, like I always tell my patient's mothers and fathers that if there's a family history of hip dysplasia, whether somebody in the family had a very early hip replacement for some reason or the mother was treated in a brace or a cast at a young age for hip dysplasia, I would suggest that they always talk to their pediatrician about that and really make sure that they're aware of that.

And so when they have subsequent children or any children with a family history that each of those next subsequent kids are screened with an ultrasound, regardless. And so early diagnosis is really the key to prevention per se.

Dr. Mike Patrick: And it's something that if it went away easily parents may kind of forget about it and not tell their kids that they had this issue. So moms and dads who are listening right now, if you went through this when your child was a baby and when they're teenager now, bring it up again and just say, "Hey, when you have a baby, this is something you need to think about."

We really appreciate you stopping by and talking about developmental dysplasia of the hip. The Orthopedic Center here at Nationwide Children's Hospital and I know I'm a little biased but it's one of the best in the country.

For those of you in Central Ohio, we have here on the main campus and out in Westerville, too, right?

28:07

Dr. Kevin Klingele: As well in Dublin.

Dr. Mike Patrick: In Dublin, too.

Dr. Kevin Klingele: Yes.

Dr. Mike Patrick: So lots of locations where you can see a pediatric orthopedic specialist and I know that there's a little bit of a fight out there in the sports medicine worlds for high school athletes. And I just want to say that even though it's a children's hospital this is a great place for teenagers to come, right?

Dr. Kevin Klingele: Correct.

[Laughter]

Dr. Mike Patrick: OK.

Dr. Kevin Klingele: I'm as biased as well, but yes.

Dr. Mike Patrick: Yes. And if you head over to our website we have all the information you need about the orthopedic clinic location, directions, contact information, referral resources, all that. It's nationwidechildrens.org/orthopedics and of course we'll have a link in the Show Notes.

I'll also have a link to the brand new health library at the Nationwide Children's Hospital website and I have a link to the article on developmental dysplasia of the hip. Also, as I mentioned earlier on the show, we're on Pinterest now and there'll be a link to our Pinterest page so you can follow that.

And then the influenza and flu vaccine show, which was episode 184 and the influenza resources here at Nationwide Children's. The fulltimenanny.com blog and 30 Blogs with Good Information on Seasonal Flu, as I mentioned in the introduction. All of those links in the Show Notes for you today.

All right. So Dr. Klingele, before you leave and I kind of have a habit of doing this the last few interviews I've done, but Christmas season is coming up before we know it and one of the things that we talk about here is doing things as a family.

So we've been asking folks what their favorite board game or family game, from your childhood or for when you get together with relatives now or your kids. What do you think? What should parents buy if they don't have it? Board game-wise.

29:49

Dr. Kevin Klingele: I'm going to go with Uno. The card game Uno.

Dr. Mike Patrick: Oh yeah. I love Uno. I haven't played that in a while. That's a good classic one.

Dr. Kevin Klingele: Good classic game.

Dr. Mike Patrick: And then you can kind of make up your own house rules with that one, too. All right. Again, we appreciate you stopping by. We really do appreciate the time you spent here.

iTunes reviews are helpful, so if you have not reviewed the podcast on iTunes, we'd encourage you to do so. As our links on you webpages and mentions in your blogs, on Facebook, in your Tweets and on Google+ and on Pinterest now, too.

You can swing by the Show Notes at pediacast.org to add your comments on today's show. And of course, we also appreciate you telling your family, friends and neighbors about the program. And don't forget to tell your doctor about the show when you go in for your next well check-up or sick office visit. It's a great way that you can help us spread the word about the program.

And we also have posters you can download and hang up wherever moms and dads hang-out. And you can find them under the Resources tab at pediacast.org. Once again, if you have a topic you'd like us to discuss, just head over to pediacast.org, click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404- K-I-D-S.

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

[Music]

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

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