Topics

• Hand Sanitizer Abuse

• Baby Bottle, Pacifier and Sippy Cup Dangers

• A New Use for an Old Antibiotic

• Math Skills and Medication Errors

• Cell Phones and Driving (an update)

• Aspirin and Reye’s Syndrome

• Grey Hair

• Artificial Sweeteners

Links

• Feeding Your Kids (45-day healthy eating program)

• Teens Getting Drunk on Liquid Hand Sanitizer

• Baby Bottle, Pacifier and Sippy Cup Dangers

• Penicillin Antibiotic May Improve Motility Disorders

• Parents’ Poor Math Skills Lead to Medication Errors

• Cell Phones and Driving: Don’t Even Think About It!

Announcer 1: This is PediaCast.

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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 from the good folks at Nationwide Children's Hospital in Columbus, Ohio. This is Dr. Mike and it is episode 211, 2-1-1, for May 17th 2012. We're calling this one Hand Gel Abuse, Reye's Syndrome and Artificial Sweeteners.

Now, most of you will recognize that this is a news and listener episode of the program and of course we'll cover lots more topics than just those three. They're kind of a highlights there and we'll get to the full lineup in just a couple of moments.

01:07

We are in full swing here into a preparing for the opening of a new hospital on June 20th and as it turns out this is the Nation's largest pediatric expansion ever in the history of the United States. I mean, this is huge. So our new hospital is going to open on June 20th and when you look at all the new facilities that are going into this expansion project you were adding 2.1 million square feet to our existing facilities, so this is huge.

The new hospital tower, itself, is 12 stories tall and each floor is the size of a football field. I mean, it's colossal. And in fact, during our orientation they showed us the center elevators, they're calling that the 50-yard line because of the fact that each floor is 100 yards. So it's huge and to learn our way around it and how the facilities work, there's lots of really cool stuff for patients.

I mean, you hate to see a kid have to be hospitalized. You just hate it. And as a parent, you hate it and as medical professionals we don't like to see kids sick but sometimes they do have to spend a night in the hospital and I'm telling you if your kid has to spend in the hospital this is the place to do it because it's really cool. Lots of neat stuff and as you can imagine, we have to train everyone to know where things are and so there were lots of orientation stuff going on, lots of buzz, lots of excitement to get us ready for June 20th.

And one of the things, the emergency department is actually doubling in size and of course that's were I do some of my clinical time and we're doubling up to 70 beds in the emergency department, so a huge ER. And you know, when there's an emergency you don't want to be trying to figure out where things are located so we actually have scavenger hunts that are going on with the staff actually has to get a list of things and go find them fast. So just to get everybody on board or where things are located. It's exciting, really lot of buzz around this place over the new hospital opening and as we get closer to June 20th I'll share more of it with you.

03:20

Another cool thing that we have going on here at Nationwide Children's is a joint product and project from the Center for Healthy Weight and Nutrition here at Nationwide Children's and also the Pediatric Comprehensive Weight Management Center at the C.S. Mott Children's Hospital. Now, they're affiliated with the University of Michigan and of course here we house the Department of Pediatrics for the Ohio State University.

So here we have an Ohio State Michigan joint project, so we can work together with the State of North, just want to point that out. So this is a pretty cool project called Feeding Your Kids, it's a free 45-day text and email based program. So you basically sign up for it and for the next 45 days, you can either get them everyday or you can spread it out to 90 days and get it every other day. And you get text messages and email messages each day of the program that address the real life challenges of feeding today's kids and teenagers. And it's written from a parent's perspective aimed at other moms and dads and caregivers and really just dealing with feeding issues and toddlers up all the way through teenagers.

04:36

So it helps you make small changes overtime that add up to big results. So to sign up for that or to find out more information, there'll be a link in the Show Notes over at pediacast.org. Basically, you go to nationwidechildrens.org\feeding-your-kids or an easier way just go to pediacast.org look at the Show Notes for episode 211 and we'll have a link for you at that point so you can sign up for it.

OK. So what is the full lineup of today's show, hand sanitizer abuse, teens are getting drunk on hand sanitizer. So we're going to let the parents out there know exactly what kids are doing so you can be one step ahead of them.

A baby bottle, pacifier and sippy cup dangers, now we're not talking about plastic or the BPA content, which we're talked about before on this show. We're talking about trauma, so kids running around with the bottles, pacifiers and sippy cups in their mouths or holding on to them and exactly how many kids are injured because they are mobile with these things in their hand or in their mouth, we're going to talk about that.

Also a new use for an old antibiotic. Math skills and medication errors. The numbers are going to surprise you here just how many kids have a medication error because of poor math skills, so we're going to discuss that.

Also cell phones in driving, we've talked about this one before but there's a new study out and we'll have an update for you on the dangers of cell phone in driving. In this case, it's not even the act of using your cell phone when you drive, it's actually just anticipating that you're going to get a phone call or a text message can lead to more accidents. So we're going to talk about that.

06:21

Also Reye's syndrome, this comes from a listener question. You've probably been to the doctor before and your doctor's made a point of saying don't use aspirin for your kids at all, unless directed by a physician because they have something like Kawasaki disease; just don't use aspirin, use Tylenol or ibuprofen instead. So why is it that parents shouldn't give their kids aspirin? Well, the reason is Reye's syndrome, we're going to talk about exactly what that is, how we discovered it, when the recommendation not to use aspirin came along. Because a lot of parents out there that are my age remember taking the little orange chewable baby aspirin. It was like if you were sick it was a given you're going to get one these things and they tasted pretty yummy. So why don't we do that anymore? And we're going to talk about that.

Also, gray hair, why some kids have it? Is it a problem? Is it a concern if your child is getting gray hair as a child? We're going to discuss that and then finally we'll wrap up with artificial sweeteners. This one also coming from a listener who used the Skype line. What's with all the new artificial sweeteners including the new ones from the Stevia plant, which are reported as natural artificial sweeteners, although if it's natural should we really call it artificial? I'm not quite sure about that. So anyway, we're going to talk about aspartame and saccharin and sucralose and the new Stevia plant products and that's all coming up toward the end of the program.

I want to remind you if there's a topic you' d like us to discuss just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, 347-404-K-I-D-S. So if you have a question or a topic suggestion please be sure to let us know.

I also 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. If you do have a concern about your child's health, make 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. And with all that mind, we will be back and cover News Parents Can Use, right after this.

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09:04

Our News Parents Can Use is brought to you by in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.

Los Angeles emergency departments are reporting a growing number of teen coming in drunk after drinking cheap liquid hand sanitizer. The hand sanitizers which contain over 60% ethyl alcohol and can make 120 proof liquid are becoming an increasingly popular route for getting drunk. According to the Los Angeles Times, six teens have been reportedly taken to emergency rooms in the San Fernando Valley and treated for alcohol poisoning after drinking the hand sanitizers. In some cases, salt was used to separate the alcohol so that it could be drunk straight like a shot. Learning how to distill this sanitizer's not difficult if you know how to look things up online.

Public health officials in the San Fernando Valley have been describing these cases as a possible trend nationally. A dangerous trend. And Dr. Cyrus Rangan, director of the Bureau of Toxicology and Environmental Assessment at the Los Angeles Department of Public Health told the L.A. Times, "All it takes is just a few swallows and you have a drunk teenager. There is no question that it is dangerous. And it's kind of scary the extent they'll go to distill the hand sanitizer in order to get a shot of what amounts to hard liquor."

Dr. Rangan is worried this behavior could turn into a national problem since hand sanitizers are readily available and relatively cheap, certainly within the budget of most teenagers. Intentional hand sanitizer consumption appears to be a new trend with virtually no cases reported in past years. Accidental ingestion by younger children is another hand sanitizer hazard but one that can be lessened by keeping the bottles away from little hands and using foam versions in the home rather than gel because it's more difficult to consume large volumes of the foam, unless of course they get the cap off.

Incidentally, it's also more difficult to distill foam sanitizers so this may be the better option to stock in your home if you're worried about teenage temptation. Dr. Rangan stresses the importance of parental awareness of just how much alcohol these products contain and you shouldn't overlook the small travel bottles either because even these contain enough alcohol to be dangerous.

11:18

So, it's one those things with something good you always have the potential for issues associated with it. I can remember and I'm sure a lot of healthcare providers out there my age or older will tell you that before hand sanitizers really came onto the scene and became an accepted substitution of using soap and water that when we had to wash with soap and water before and after every patient, especially in the winter time up in the north where it was dry outside, I mean, washing your hands with soap and water between every patient just would tear up your hands. Just dry them out, crack, you get little bleeding, it's not great although it's great for preventing the spread of an infection.

But when the alcohol based hand sanitizers came on to the market, it's really made a huge difference. And it doesn't dry out my hands even nearly as much, so you know, we gel as we go into a room, we gel when we come out of a room, so our hands are sanitized in between patients. And it's really made a big difference and so it's a great thing but when there's a great OK what's the downside and apparently this is one of the downsides.

So we talked about so-called synthetic marijuana a few weeks ago and how teens were lead that it's only incense. Well here's another potential hazard and unfortunately it's one you really can see catching on and I think we're going to hear more about this in the coming months. I did a quick Google search to see for myself exactly how easy it is to distill hand sanitizer gel to make pure 120 proof ethyl alcohol and let me just say it is remarkably easy.

Purell has began adding a chemical that provides a bitter unpleasant taste which remains even in the distilled product in an effort to eliminate abuse, but there are plenty of brands out there to choose from and some folks may not find the taste to be an obstacle, especially after you've had a couple of drinks, if you know what I'm saying. So parents be pro-active, know what your kids are doing, stay one step ahead of them and we're trying to be helpful in that regard here on our little program.

13:30

All right. Let's move to some news from my own backyard, a new study by researchers in the Center for Biobehavioral Health and the Center for Injury Research and Policy here at Nationwide Children's Hospital, exam in pediatric injuries associated with baby bottles, pacifiers and sippy cups. Researchers found that from 1991 to 2010 an estimated 45,398 children younger than three years of age were treated in U.S. emergency departments for injuries related to the use of these products.

This works out to an average of 2,270 injuries each year or one child treated in a hospital emergency department every four hours for injuries from these products. The study released online this week and slated for publication in the June 2012 print issue of Pediatrics, found that baby bottles accounted for 66% of injuries, followed by pacifiers at 20% and sippy cups at 14%. Body regions most commonly injured were the mouth – 71%; and head, face or neck – 20%. Most injuries were the result of falls while using the product – 86% – which suggest that children were walking or running with the products in their mouth at the time of the injury. "Two-thirds of injuries examined in our study were the one-year-old children who are just learning to walk and more prone to falls," said the study's co-author, Dr. Sarah Keim, PhD, MA, MS. "Having children sit down while drinking from baby bottles or sippy cups can help reduce the occurrence of these injuries."

Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that children be transitioned to regular, lidless cups at 12 months of age. The AAP also suggests parents try limiting pacifier use after six months of age because they might increase the risk of ear infections.

"These are products that almost everyone uses," noted study co-author, Lara McKenzie, PhD. "Educating parents and caregivers about the importance of transitioning their children away from these products at the ages recommended by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry could prevent up to 80% of the injuries related to baby bottles, pacifiers and sippy cups."

This is the first study to use a nationally representative sample to examine injuries associated with bottles, pacifiers and sippy cups that were treated in U.S. emergency departments. Data for this study were obtained from the National Electronic Injury Surveillance System, which is operated by the U.S. Consumer Product Safety Commission. This surveillance system provides information on consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the country.

15:59

So, I think the take-home here really is there's nothing magical or a design flaw with pacifiers, bottles and sippy cups. I mean, these just happen to be the things that 12-month olds are carrying and have in their mouths. So I really think the take-home here is that your kids, when they're learning to walk, when they're young, they really shouldn't have anything in their mouth and probably shouldn't have anything in their hand either when they're walking, cruising, crawling, toddling.

Basically, if they're in motion, their mouth and their hands really ought to be empty, I mean, that's my take-home for you and then interpret it as you will. It's not that the pacifier or the baby bottle or the sippy cup is inherently dangerous. It's just that's the object that most of them have and so regardless of what it is, keep their mouths clear, keep their hands empty when they're toddling around.

Another interesting study from my home institution concerns an antibiotic and I'm sure most of you will recognize amoxicillin combined clavulanic acid, better known as Augmentin as the brand name, but a lot of docs just call it Augmentin so I'm going to use that term. But this time around we are not using it to kill bacteria. As it turns out this common antibiotic may improve small bowel function in children experiencing motility disturbances, that's according to a study that will appear in the June print edition of the Journal of Pediatric Gastroenterology and Nutrition.

Augmentin is most commonly prescribed to treat or prevent infections caused by a bacteria, however, it is also been reported to increase small bowel motility in healthy individuals and has been used to treat bacterial overgrowth in patients with chronic diarrhea. Upper gastrointestinal symptoms such as nausea, vomiting, abdominal pain or early satiety, that means getting full fast, and abdominal distension are common in children despite the advances in the technology for diagnosing motility disorders there continues to be a lack of medications available for the treatment of upper gastrointestinal tract motor function.

18:03

"There is a significant for new drugs to treat upper gastrointestinal symptoms in children," said Dr. Carlo Di Lorenzo, MD, chief of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s and one of the study authors. “Currently used drugs are often only available on a restricted basis, have significant side effects or aren’t effective enough on the small and large intestine.”

To examine whether amoxicillin-clavulanate might serve as a new option for treating upper gastrointestinal tract motor function, investigators at Nationwide Children’s examined 20 patients who were scheduled to undergo antroduodenal manometry testing. So this is a testing movement and pressure in the small intestine. After catheter placement, the team monitored each child’s motility during fasting for at least three hours. The children then received one dose of Augmentin enterally, that means by mouth or through a feeding tube, either one hour before ingestion of a meal or one hour after the meal and then had motility monitored for one hour following.

The study showed Augmentin triggered groups of propagated contractions within the small intestine, similar to those observed during the duodenal phase III of the interdigestive motility process; or another way of putting it, following Augmentin, the small bowel moved food better. This response occurred in most of the study participants during the first 10-20 minutes and was most evident when Augmentin was given before the meal.

"Inducing a preprandial duodenal phase III may accelerate small bowel transit, influence the gut microbiome and play a role in preventing the development of small bowel bacterial overgrowth," said Dr. Di Lorenzo. Translation, the Augmentin may kill bad bacteria, promote healthy growth of food intestinal microorganisms and improve the forward flow of the stuff you've eaten.

Dr. Di Lorenzo says that Augmentin may be most effective in patients with alterations of duodenal phase III, chronic symptoms of intestinal pseudo-obstruction and those fed directly into the small bowel with gastrojejunal or nasojejunal feeding tubes. Boy, he is making me work today!

So it's most likely in help of one of the things Augmentin improves was broken in the first place and it's more likely to work in children fed with feeding tubes. Although Augmentin seems to mainly affect the small bowel, the mechanisms by which it works are not clear. Dr. Di Lorenzo also says that possible downsides of using amoxicillin-clavulanate as a prokinetic agent and this include the induction of bacterial resistance, especially from gram negative bacteria such as E.coli and Klebsiella and it may also cause Clostridium difficile induced colitis.

Still, he says further investigation of Augmentin’s long-term benefits in gastrointestinal clinical situations is worthwhile. And he says, "The scarcity of currently available therapeutic options may justify the use of Augmentin in selected patients with severe forms of small bowel dysmotility in whom other interventions have not been effective."

20:53

So this news story probably isn't of great interest to many of you, other that my seemingly amusing use of big words, but for others of you and you know who you are, it's very interesting and it's something you might want to discuss with your child's GI specialist at some point in the future if your kiddo is suffering from intestinal motility problems.

Also, I want to point out and just to be fair because if it we're coming from any other institution I would mention this and so if it's coming from my home institution I want to mention it as well. The study size is only 20 patients, so obviously there's going a need to be larger studies done with an increased sample and a well-done prospective study with the control group and then an experimental group to really see if this is an evidence based type of recommendation before it becomes a recommendation for everyone to use. But it's something on the horizon and there seems to be more and more kids being diagnosed with GI motility disorder, so I thought you'd be interested in hearing about it.

21:57

All right. Let's move on to one of my daughters least favorite subjects and that is math. Many parents cringe when their child asks for help with their math homework. Yeah, I've been there, especially when it's coming close to calculus, yeah, I've been there.

Our new research shows that poor math skills can cause another difficulty for caregivers and that is measuring the right amount of medicine. In fact, parents with math skills at the third grade level or below were five times more likely to measure the wrong dose of medication for their child that those with skills at the sixth grade level or higher. That's according to a study recently presents at the Pediatric Academic Societies annual meeting in Boston.

"Parents face many challenges as they seek to administer medications to their children in a safe and effective manner," said study co-author Dr. H. Shonna Yin, MD, MS, FAAP, assistant professor of pediatrics at New York University School of Medicine and Bellevue Hospital Center. She goes on to say, "Dosing liquid medications correctly can be especially confusing, as parents may need to understand numerical concepts such as how to convert between different units of measurement, like milliliters, teaspoons and tablespoons. Parents must also accurately use dosing cups, droppers and syringes, many of which vary in their measurement markings and the volumes that they hold."

Studies have shown that people with low reading skills are more likely to make mistakes in measuring the correct amount of medicine. Little research, however, had focused on whether low math skills contribute to dosing errors.

In this study, researchers looked at the relationship between both reading and math skills and medication dosing errors. Participants included 289 parents of children younger than 8 years of age who were prescribed a short course of liquid medication after being seen in a pediatric emergency department. Caregivers spoke either English or Spanish and were the primary person responsible for administering the medication. Caregivers were given three tests to assess their reading and math skills. Researchers also watched parents as they measured out a dose of the medication that had been prescribed for their child.

The study results revealed that nearly one in three parents had low reading skills, while 83% of parents had poor numeracy skills with 27% had skills at the third grade level or below. Observations showed 41% of parents made a dosing error.

24:12

I seriously need to pause and say that again, 41% of parents made a dosing error. That's crazy. I mean, that's just crazy. Parents' math scores, in particular, were associated with measuring mistakes, with parents who scored below the third grade level on math test having almost a five times increased odds of making a dosing error.

Dr. Yin concludes by saying, "Our study found that many parents have poor numeracy skills, placing them at a high risk for making dosing errors. These findings point to a need to examine whether strategies that specifically address parent math skills can help reduce medication errors in children. In addition, recognition of the importance of addressing math skills may be helpful for health care providers as they seek to improve their communication of medication instructions. For example, having providers review and give parents pictures of dosing instruments filled to the correct amount for that prescription may be beneficial."

So this is really important information for clinicians and I'm going to say, it's not just the doctors who are failing here, it's also the pharmacists, because we write out a prescription, this is how much we want the patient to give and granted we should have tools, pictures, the syringes, the cups, whatever, to make it quite clear exactly what we're giving. But ultimately, it is the pharmacist who says I'm going to dispense the medicine and I have provided any teaching that the parent needs. And so I really have to say that the pharmacists are also to blame if we're going to put blame somewhere on this, if parents aren't giving the right amount of medicine.

I mean, really it should be clear, hey, this is the cup, this is dropper, this is syringe that you're going to use, here's the line. I don't know if we need special droppers with the line marked in a different color for that particular medicine then it's an added issue because they're going to use that dropper for something else down the road and it's not necessarily the right dose for that one, I understand that.

So it's not perfect and I'm not placing all the blame on the pharmacist, don't get me wrong here. But I think all of us need to really look at this and figure out what we can do to make things better, because 41% of parents making dosing errors is just unacceptable. It's easy to whip out a prescription or just say hey, give them some Tylenol or Motrin as needed, but I guess we really need to do more than that. I need to do more than that. I think most of the doctors and nurses listening right now need to do more of that and I think pharmacists need to do more of that.

So I guess the next question is how do we improve this at the level of the medical visit and the pharmacy visit? Dr. Yin gave us some ideas but I'm sure some of you have others and be sure to share them and you can do that on the Show Notes blog over at pediacast.org for episode 211.

27:00

It's well known that using a cell phone while driving can lead to motor vehicle crashes and new research, this one also presented at the Pediatric Academic Societies annual meeting in Boston, shows that even anticipating calls or messages may distract drivers and increase the risk of a crash.

Dr. Jennifer M. Whitehill, PhD, a postdoctoral fellow at Harborview Injury Prevention and Research Center at the University of Washington, and her colleagues sought to determine whether compulsive cell phone use is associated with motor vehicle crashes.

They enlisted undergraduate students to complete the Cell Phone Overuse Scale (CPOS), a 24-item instrument that assesses four aspects of problematic cell phone use: 1) frequent anticipation of calls/messages; 2) interference with normal activities, impacting friends/family, we've all either seen that or been a part of that, someone's trying to talk to you and you're clicking away with your thumbs; 3) a strong emotional reaction to the cell phone and 4) recognizing problem use.

The 384 students also took an online anonymous survey that included questions about driving history, prior crashes while operating a vehicle, and items assessing risky behaviors and a psychological profile.

Another one of the study's author, Dr. Beth E. Ebel, MD, MSc, MPH, FAAP, says, "Young drivers continue to use cell phones in the car, despite the known risk of crash. We were interested to explore how cell phone use contributes to distracted driving and to begin to understand the relationship between the driver and the phone."

Results showed that for each 1 point increase on the Cell Phone Overuse Scale, there was an approximately a 1% increase in the number of previous motor vehicle crashes. And of the four dimensions of compulsive cell phone use, a higher level of call anticipation was most significantly associated with prior crashes.

Dr. Whitehill says, "We know it's important to prevent young drivers from taking their hands off the wheel and eyes off the road to use a cell phone. This study suggests that even thinking about cell phone calls and messages may be an additional source of distraction that could contribute to crashes."

So, I guess when it comes to using cell phones while you're driving the old adage proves true, "Don't even think about it." And on that note we conclude this week's News Parents Can Use. We're going to come back and answer your questions right after this.

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29:51

All right. Welcome back to the program. It is time for our Answers to Listener Questions segment and you will recall a few shows ago, I put out a call for more listener questions because we are running a little low in the listener question piggy bank and of course you guys came through in large numbers and we are definitely reloaded. We won't get through all of them in this particular show but if you wrote in please be patient because we do have more News and Listeners shows, it's coming your way very soon and we are going to get to a lot of those.

If you haven't written and then you do have a question, please still write in, because if you have a great one that I think is really going to impact the audience and make a difference for people, we'll get to it. So please continue to send your questions in. But I did want to put out a thank you because I asked for more questions and you guys definitely responded.

All right. First up, we have Meg in Sewanee, Tennessee and Meg says, "Hi, Dr. Mike. Love your show. I'm a pre-med student and I'm planning on going into pediatrics and I just love listening to your podcast. I wanted to know if you could do a segment on Reye's syndrome and aspirin. I grew up referring to any pain reliever or anti-inflammatory drug as aspirin. And whenever I told my doctor I took aspirin even when I really meant ibuprofen or Tylenol they always got very stern with me. I know that taking aspirin can cause Reye's syndrome and I wondered if you could explain what that is and how aspirin causes it. I also want to know why it is so much more dangerous for kids. Thanks."

31:25

Thanks for your question, Meg. And I would encourage you that you're a pre-med student thinking about going into pediatrics and I would definitely encourage you to do it. This is absolutely a rewarding field, whether you're going to primary care pediatrics or then you go on to choose a sub-specialty within pediatrics, I really love it. And I certainly do not regret going into pediatrics in the least and I would encourage you to do that.

And when you're looking for a great medical school, I would say hey, take a look at Ohio State, they've got a really cool curriculum out there. It's really unique and integrates the basic sciences and the clinical sciences and so definitely check them out, even if you're from Tennessee. And when you're looking for a Pediatric Residency Program, there's no place better, in my humble opinion, than the Nationwide Children's Hospital.

OK. So, this is advice about aspirin that many parents have heard, don't give your kids aspirin; use Tylenol or ibuprofen instead and in general it is absolutely good advice. Now, there may be cases when a physician instructs a parent to give their child aspirin, for example, a pediatric cardiologist may tell you to do that if they suspect that your kid is suffering from Kawasaki disease and back in episode 203 we talked about Kawasaki disease. But these situations are rare and really we only use aspirin in kids if the benefits of using it clearly outweigh the risk. Certainly, giving your kids aspirin is not something you should do on your own, only with directions from and supervision by a physician.

So what's up with this risk? Isn't there a product out there called baby aspirin? The orange-flavored chewables that many of us remember taking as kids, made popular by such brands as Bayer and St. Joseph and either you loved them or you hated them. And those of you in your late 30s and 40s know what I'm talking about. I used to call them googoos as a young child, I don't know why and I'm kind of embarrassed that I just told you that actually.

33:32

But you know, when I was sick and mom was getting out the bottle, I'd say googoo, probably because I thought they were yummy and I was trying to say good, good. I mean, it was definitely tasty in my opinion, orange-flavored candy-like medicine, which of course is a Poison Center's nightmare. You've got pills that are chewable and taste good. All right, but I digress.

The orange-flavored chewables are still out there but they are not called baby aspirin anymore because they aren't for routine uses in babies or children or teenagers, they're only for adult use now. So again, what exactly is the risk? Well, as Meg mentioned, the risk is something called Reye's syndrome so let's talk about it.

Back in the early 1960s, a physician by the name of Dr. R. Douglas Reye, that's why it's called Reye's syndrome, published a study in The Lancet Medical Journal that first described a seemingly new set of unexplained symptoms. So what happened? Well, the symptoms went like this — these kids had this syndrome that became, called Reye's syndrome, first they would have high fever, vomiting and sometimes a rash would be present, then they would progress into liver inflammation; they would have then get some mild liver dysfunction and some brain inflammation or encephalitis, which would cause behavioral changes and confusion.

This would then turn into what he called stage three where they would have worsening brain and liver inflammation. The liver would still be mild problems but it became bad news for the brain because the brain you remember it's enclosed in a hard skull, it doesn't have a lot of space to expand and so it the brain swells you get increase pressure on the brain and that causes cerebral edema, swelling of the brain that chokes off its own blood supply and so the brain is swelling the pressure, itself, cuts off return of blood, which causes even more swelling. So it's basically a vicious cycle of more and more swelling and then that leads to loss of consciousness and ultimately coma and then death.

35:44

And then stage four, we would see worsening brain and liver inflammation and now at this point the liver problem is beginning to get worse and you'd also get some kidney inflammation at this point. And then deepening unconsciousness or coma and then finally, stage five, which would happen rapidly is that now you'd have seizures, respiratory arrest, your liver and kidneys are in failure and you'd get a high ammonia level and then finally death.

Now, if you go back to stage one, high fever, vomiting and a rash, a lot of kids had that. So this was a common viral presentation but so why was it that some kids would just have the high fever, vomiting, rash and then get better but other kids would progress down this pathway to Reye's syndrome and at that time no one really knew why this would happen to some kids but most kids it wouldn't happen with.

And most kids, by the way, in the 1960s who had this progression ended up dying. And ultimately, it really did progress all the way to death. And while Dr. Reye outlined the progression of symptoms which defined the syndrome, still nobody really knew what caused it or how they could prevent it. I just seemed to happen at random to some kids with no clear way to predict who would get it and who wouldn't. And in fact, it took them about 20 years to determine that the culprit was a combination of a viral infection treated with aspirin.

So why did it take so long to figure this out? Well, tons of kids had viral infections and tons of kids took baby aspirin but only a few cases of Reye's syndrome popped up here and there. So it wasn't one of those things where oh yeah, every kid who had a virus and they took aspirin this happened to them. It was sporadic and so no one really looked at aspirin as being part of the cause because so many kids took aspirin and most kids who had a fever and vomiting and might get a rash did not go into Reye's syndrome.

37:37

So what really led to identifying the association was when Tylenol and ibuprofen entered the market. So kids treated with these products they did notice now where much less likely to develop Reye's syndrome compared to those who are taking aspirin. So now that Tylenol and ibuprofen are an option, now you can start to say, hey, wait a minute, kids who take Tylenol and ibuprofen this is not happening, it's only in the kids, even though it's sporadic and not all kids taking aspirin get it, it's always in the aspirin kids. So now we've got to look could aspirin be an issue?

We also got better at identifying viruses and we began to see that kids with chickenpox and influenza-like viruses were also more common to get Reye's syndrome. So if it was a kid who took aspirin and they had chickenpox or an influenza-like virus, those were much more likely to then go down that Reye's syndrome, cascade to those stages and then ultimately ended up dying.

By the early 1980s, the association was pretty clear and the warnings began to appear on aspirin bottles saying that it was not safe to give kids aspirin if they had a current viral infection. It wasn't an outright ban at that point. Doctors didn't say don't do it, it was just if your kid has a viral infection you might not want to use aspirin; go with the Tylenol or with ibuprofen instead. But it still wasn't like really you had to do this. And the reason for that is because there was a lot of push back and the use of aspirin in kids was very popular and most families would say, hey, my grandparents had aspirin, my parents had aspirin, I had aspirin as a kid, I'm going to give my kids aspirin because this is all nonsense.

So it appeared to be safe and it really took a while for parents to switch over to using Tylenol and ibuprofen instead of aspirin and so it wasn't an overnight ban kind of thing. Moms still used it for pain, but then it became more and more acceptable, OK, if you kid's in pain use the aspirin, if they have an illness with the fever don't use the aspirin. And especially, if they have chickenpox, don't use the aspirin.

39:48

So slowly, over the next 10 years or so, through the 1980s, it became more and more on topic of just stop using the aspirin, stop using the aspirin. So as this sort of caught on with the family and with practitioners out there, it really became more OK, now we're going to actually put a label on the aspirin saying don't do this and the messaging from the medical community became more consistently, don't do it.

But that was a process and it really did take some time to get to the point where we were saying, "no aspirin for kids and taking baby aspirin off the shelves as something that's marketed toward giving to children." Now, even though we had this association and we really knew that it was a true and the recommendation came out not to give the aspirin, we still didn't really know the mechanism. So what pathological process was at play?

And in terms of absolute certainty, we still don't know exactly, even today, what's happening. But we do have a pretty good idea and it took some time for this to happen too. It took a very long time for us to kind of get to the point where, in fact, when I was in medical school, it was we don't know. We don't know, we just don't do it but we don't know what the mechanism is. But here in the last five to ten years we do have a pretty good theory and that theory is that some people are born with an inherited condition known as a fatty acid oxidation disorder. And this means that they're either missing or they have a defective enzyme in their cells which makes it difficult to break down fatty acids.

41:33

And under normal conditions when you just have a few fatty acids that need to be broken down, there are alternate pathways that can do that, so pathways that don't involve their missing or defective enzyme. So on a normal circumstance it's really not a big deal because whenever they're missing or defective enzyme is they have other enzymes that can do the job. They're not necessarily the enzyme of choice but they can break down fatty acids.

However, under the stress of illness and particularly with chickenpox and influenza-like viruses, more fatty acids are produced as a by-product of having the infection and fighting the infection. And so now, you have a big load of fatty acids that you need to break down and you have a missing or a defective enzyme to do that and so the alternate pathway can't keep up. And then what we think is that aspirin actually blocks that alternate pathway, so that now not only do you have a big build-up of fatty acids and a defective enzyme for breaking them down but now with the aspirin you have basically eliminated the alternate pathway. And so you're going to get a build-up of these fatty acids that your body can't handle and your body has to do something with them.

And that's why it happens sporadically because if you were born fine, without an enzyme problem to begin with, it wasn't an issue. You can use the aspirin to break down the alternate pathway but your primary pathway still works fine and so it's not going to be a problem. It's just these folks who are born with this issue who would have a problem when they got the virus or they had the aspirin. And because it didn't really show up as an issue until they have the viral illness and had the aspirin, you couldn't really identify which people would have this issue and which wouldn't.

43:26

And so, ultimately, you get a massive build-up of fatty acids in the blood and in an effort to get rid of them the body starts storing them. And guess where, in the brain and in the liver and the kidneys. And these organs don't like them being there and so inflammation and swelling and dysfunction result which finally lead to liver failure, kidney failure, brain failure and death. So, if this is the case at this point, why not test everyone for fatty acid oxidation disorders and only have those people avoid aspirin?

Well, testing everyone of course would be expensive and there are accepted alternatives to aspirin now like Tylenol and ibuprofen, which don't block fatty acid metabolism. Now, if you have a family history of someone with the Reye's syndrome that could be a reason for testing of you could also just make doubly sure that you're avoiding aspirin. Actually, there have been cases of Reye's syndrome in the absence of a known fatty acid oxidation disorder, so there may be other enzymes and pathways that we don't know about which means a negative screening test for a fatty acid oxidation disorder could give you a false sense of security if there are other mechanisms that could lead down that Reye's syndrome pathway that we just don't know about yet.

So there you have it, many people today are walking around with undiagnosed, generally mild, metabolic disorders but when you give them a severe viral infection or you add aspirin on top of that, bam!, they could start down that Reye's syndrome pathway. And that, Meg, is the story behind Reye's syndrome. I hope that was helpful for you.

And by the way, Meg, I mentioned that we have a great residency program, we do have a show coming up down the road this summer where we're going to have the director of our Pediatric Residency Program and one of our first year residents come into the studio and talk a little bit about what goes into training a pediatrician and I think you'll find that show particularly interesting. So look for that, Meg, in the coming weeks.

45:25

All right, let's move on to Lisa in Southern California and Lisa says, "Dear Dr. Mike, I love listening to your show and I have a question for you. My five-year-old son has had a third gray hair. Now I have some, I'm in my late 30s, my husband used to have quite a few gray hairs when he was in his 20s but has less of them now, which we kind of explain with his current sedentary lifestyle." So he sits on the couch and the gray goes away. All right. I'm sorry. Lisa goes on to say, "My son is out in the sun a lot and swims at least once a week, although indoors. He's also a picky eater except for red meat, he does eat those and he's a smart kid. Is this a fluke or should I be concerned? Thanks, Lisa."

Well thanks for the question, Lisa. First, smartness is not associated with gray hair and neither is lack of physical activity, otherwise we'd have millions of gray haired kids out there because there is a lot of kids who are smart and there's a lot kids who lack in the physical activity department. What actually causes gray hair is a decreased amount of a pigment called melanin, they get incorporated into the hair as it's made in the hair follicle. So then the question becomes what causes a decrease in the pigment melanin as hair is getting made?

Well, the most common reason is just normal aging, they just happens. But what about when it happens early? Well there are genetic patterns of early graying, meaning this phenomenon tends to run in families and is nothing to worry about. So if a mom and dad both had some gray hairs early and grandparents had gray hairs early and now your child has some gray hairs early it's a family pattern, it's probably nothing to worry about.

Then having said that, there are some disease processes that can result in the emergence of gray hair but the good news is they're not common. In fact, they're pretty rare, but it's still possible and some examples of those include a condition called alopecia areata, which we have talked about on this show before. It's an inherited auto-immune disorder, so your immune system attacks the hair follicle and that results in hair loss and it can also result in some pigment changes because of what the immune system is doing and hair can initially grow back kind of gray in this order after it's fallen out.

But eventually, there usually is recovery of the original color. So with alopecia areata, often times you'll have hair that falls out in patches and then those patches come back gray but then the color comes back. So it's not really what you're describing. It's not a strand here and there. It's a pretty particular pattern that's fairly easy to recognize on the part of your doctor, he should be able to recognize that.

48:13

Some other diseases that can cause some gray hair and usually it's not just one gray hair here and there, so this is going to be more in patches, widespread kind of graying and the things that can do that include vitamin B12 deficiency, abnormal thyroid function, pigment disorder known is vitiligo, some neural diseases like tuberous sclerosis and neurofibromatosis and Wallenberg's syndrome, these are all things that can cause the emergence of gray hair.

Usually not like one strand at a time or here and there sporadic, but more patchy, full graying that can happen. But these things are rare and it's far more likely, Lisa, that your child is simply following the family pattern. Still it's worth to mention to your doctor the next time you're in for a check. I hope that helps and as always thanks for the question.

All right. Finally, up in our Listeners segment, we are going to head over to the Skype line.

Rebecca: Hi, Dr. Mike. This is Rebecca from Kingsley Center Academy. I was just listening to episode 200 and I have heard some of that baby-led weaning in the past and I thought it was interesting, but I just wanted to ask you to address one part of the study about the puree that you give to infants. You noted that it was sweetened puree and combinations like lasagna was what the parents were feeding those babies. Wouldn't it be important to consider the fact that some parents are doing 100% fruit or vegetable purees to start with? These are things that are not sweetened and also maybe if your cooking helps fully and feeding your baby the things that you're cooking so you know what's in it, wouldn't it not make a difference? Also, I was curious about some of the non-sugar all-natural sweeteners that are available now like Truvia and ones from the Stevia plant, not sure if I'm saying that right or not. What do you think about those and if there's any research available to share how safe all of these are. Are they really better for you than sugar, they don't use any fake sweeteners like aspartame or NeutraSweet, those things at our home? But I just want to know your thoughts on it. Thanks again for making PediaCast. Have a great day!

50:49

Dr. Mike Patrick: All right. So, Rebecca near Chattanooga, Tennessee, apparently it's our Tennessee show, we have Meg and Rebecca from Tennessee today. It's a great state; we just had a family vacation out in the Smokies recently which I'd talk about on the show. So, a little loving to Tennessee here with Meg and Rebecca. So Rebecca has some comments concerning baby lead weaning and there are points that are well-taken, Rebecca. Lots of parents are pureeing food from the kitchen in their natural form and with great success, so I think those are definitely good points.

What about artificial sweeteners and in particular newer ones from the Stevia plant would seem appealing because they're labeled "natural". Are they safe and are they better than sugar? So let's first talk about sugar, itself. As a sweetener, sugar has a pretty good safety record. I mean, it's safe to say that sugar has been used for an extremely long time. And it taste great, in fact, it's our gold standard when we want to sweeten something. When we're looking at sweeteners we say, hey, how does that relate to sugar because sugar is kind of our basis for understanding what sweetness is because it's been used for such a long time and it's such a part of pretty much every culture in the world, probably since the beginning of time.

So if you do use something different you're going to compare the taste to sugar. So why not just use sugar? Well, the problem with sugar of course is that it's full of calories. One teaspoon of table sugar contains close to 20 calories, so in a can of regular soda it has the equivalent of seven teaspoons of sugar, so you got 140 calories and that adds up if you are consuming lots of things with sugar in them.

52:34

Well, back in the 1960s, people began to realize that they didn't look so great in their swimsuits if the drank a lot of soda and the soda companies didn't want to lose sales so the race was on to find a low calorie sweetener. So it was really the cola wars that sort of stimulated the discovery of artificial sweeteners in the first place. Tab was one of the first diet colas on the market made by the Coca-Cola Company and it was originally sweetened with cyclamates and saccharin.

Well, cyclamates didn't last long. There was a 1969 study that linked it to bladder cancer in rats and the FDA was still reeling from the whole thalidomide debacle where there were birth defects associated with the drug that they had too quickly approved for use. And so when the study in the late 60s came out that cyclamates were related to bladder cancer in rats, it was like the FDA we're not going there again, let's just ban its use.

And so then, diet colas became just sweetened with saccharin, saccharin alone. And that really saccharin at that point became king of the artificial sweetener. Studies initially found that this also could cause bladder cancer in rats and so there was a little bit of the FDA saying, oh, should we ban this, should we ban this. But then what they found was that number one, it took a huge amount of saccharine to cause bladder cancer in rats, way more than people are being exposed to even if they drink a lot of diet cola; and the other thing is that the mechanism by which saccharin was found the cause of bladder cancer in rats appeared to not be a mechanism in humans. So humans, they didn't have the mechanism in place to even do this.

54:23

So you can imagine the soda industry lobbyist just going nuts about this and saccharin did win a stay of execution. But the FDA did insist on putting a warning label on any product containing saccharin, which of course had a tendency to decrease sales. Now, as it turns out saccharin has been shown to be safe for human consumption in multiple well-done studies since that time and the FDA has removed it from its list of potentially harmful substances; warning labels are no longer required.

But the image damage was done and the soda industry had trouble selling their diet sodas that contain saccharin and so the race was on to find another low cal sweetener with a safer brand image. Incidentally, saccharin also has a bitter aftertaste which sort of defeats the whole sweetening deal. It tastes sweet, oh bitter, oh sweet, no now it's bitter. So it wasn't the ideal artificial sweetener.

So what came next was aspartame and aspartame like saccharin is not a natural occurring chemical, that's made in a lab, just like saccharin was. So that's bad rep number one, people don't like that. I mean, never mind that sugar is as much a chemical as any other substance, including artificial sweeteners. It's a chemical, it's got atoms, you can draw the chemical equation of what it looks like. It's a chemical but the fact goes if said chemical occurs in nature I'm going to trust it more. Of course, this doesn't mean all-naturally occurring chemicals are safe, right?

I mean, here's a list of naturally occurring chemicals for you, cyclopeptides, monomethylhydrazine, muscarine, coprine and ibotenic acid and these are all naturally occurring ingredients of poisonous mushrooms. So I know I kind of digress here a little bit, it seems to be a theme for this show but just because something occurs naturally doesn't mean that it's safe. And just because something is made in a lab doesn't necessarily mean it's dangerous but we do have those ideas in our mind, I understand that.

56:33

So back to aspartame, it's actually still going strong, Equal and NutraSweet are both made of aspartame. The FDA considers it safe. There are anecdotal tales of side effects, my wife swears she gets a migraine whenever she drinks something with lots aspartame in it, but no studies have shown a significant problem. And aspartame is widely used today, but again, it is artificial because it's made in lab.

Well then sucralose comes along and sucralose as their slogan goes made from sugar so it taste like sugar, still made in a lab, not naturally occurring. Basically what they do is three chloride molecules replaced three hydroxil groups on the chemical sucrose. So it taste very much like sugar without an aftertaste associated with it but the addition of this chloride atoms actually makes sucralose an organochloride. So if you look at the sucralose molecule, and this is Splenda by the way, Splenda is the sucralose name brand, and if you look at the molecule, itself, once you replaced the hydroxil groups of sucrose with these chlorides, you have a molecule known as an organochloride. And organochlorides are used to make such things as vinyl, solvents and pesticides.

58:01

Now, that does not mean that sucralose can be used in making vinyl, solvents or pesticides but here comes the bad press, hey, this is an organochloride; pesticides are made of organochlorides, not made of sucralose but you get the bad press in there and the buzz on the Internet and we can't use this. Now the FDA has deemed sucralose safe and acceptable but you know, again, the bad press and blogs are out there that hey, your soda's being sweetened with a component of pesticide.

But there's another big problem that sucralose has and that is that it is patented in the United States by one company and marketed as Splenda. So the Cola companies can't use it unless they buy it which they don't want to do. So now the Cola companies want to develop and patent, because that was such a good idea, their own artificial sweetener which they don't have to buy, which then they can claim is the best.

And in the process of doing this in walks the Stevia plant with its low calorie, naturally-occurring sweet chemical component called rebaudio-side A or Reb A, that's the chemical name. Well, the soda companies, they were all over this. And they each have been coming up with their own proprietary patented way of extracting Reb A from the Stevia plant to use in its commercial product. That way, they have their own product, they don't have to buy it from someone else and it comes from a plant so they can say this is naturally-occurring sweetener, not an artificial sweetener. So this is like a win-win kind of discovery for the cola companies.

59:37

For Coca-Cola, their product that they have from this is called Truvia and for Pepsi Cola, it's called PureVia, got to love this. The FDA says purified Reb A is safe and it is approved for use in the U.S. so it is starting to show up all over the place. So Coca-Cola can market Truvia, which then other companies can buy it to use it as a naturally-occurring alternative to sugar, might be a better way to put it.

However, there is one controversy that remains; the FDA did deny approval for another Stevia plant-derived product in the 1990s because it was linked to cancers and infertility at lab animals. But that was a different substance. It was a different component of the Stevia plant. It wasn't Reb A and Reb A the FDA says is safe. So, there you have it, a short history on the artificial sweetener and the cola wars.

So the question then becomes should you use this for your kids? I really can't answer that, I mean, the FDA says it's safe, it's showing up everywhere. It's probably safe. Time is going to let us know for sure. What I do know this though, sugar has been around for a long, long, long, long, long, long time and if you really want to sweeten something and yet limit calories in a healthy way, my suggestion would be to eat a well-balanced diet, including lots of fruits and vegetables and when it comes to artificial or naturally-occurring sweeteners, one work seems wise and that word would be moderation.

All right. I hope that helps, Rebecca and as always thanks for calling and thanks for using the Skype line.

61:17

I want to remind you that if there is a topic you'd like us to talk about or you have a question for us on the show, even though I did get a lot of questions recently, please send them in, I read every question. And if you have a great one we'll put it on the show. You just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or again call the voice line at 347-404-KIDS. 347-404-K-I-D-S. And we will be back to wrap up the show, right after this.

All right. We are back to wrap up the show and I want to thank all of you for taking part in PediaCast and for making us a part of your week. We really do appreciate that. And also I want to remind you that again, I've been kind of pushing that we just got a lot of questions but I love hearing from you. And if you do have a question or comment, please don't hesitate to write in or call the Skype line, we'd really appreciate it.

Also, I want to mention one more time, Feeding Your Kids, the joint project between Nationwide Children's Hospital and our Center for Healthy Weight and Nutrition and the C.S. Mott Children's Hospital of the University of Michigan and their Pediatric Comprehensive Weight Management Center, it's a free 45-day text and email based program with lots of helpful hands written from a parent's perspective aimed at parents and caregivers of how to improve the nutrition and ease of feeding your toddlers through your teenagers to help you make small changes overtime that can add up to big results.

63:12

So head on over to nationwidechildrens.org\feeding-your-kids or an easier way just head over to pediacast.org, click on the Show Notes for episode 211 and we'll have link for you to that. So make sure you check that out. It's a really cool and free program that you can use.

Also, I want to remind you if you have not written a review on iTunes, we'd really appreciate you doing so. iTunes reviews help get us in front of more moms and dads' eyes and so just the more reviews that we get, the more they highlight PediaCast in the iTunes store and the more people who see it and find out that it exists, so we really appreciate you doing that.

Also, be sure to join our community by liking PediaCast on Facebook, following us on Twitter and tweeting with hashtag #pediacast. You can also hang out with us oven on Google+, we're there as well. And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show.

64:14

We'll also appreciate you telling your family, friends and neighbors about PediaCast and don't forget to talk us up with your child's doctor at your next well check-up or your sick office visit. Just let them know hey, we got this great podcast we found that deals with evidence-based pediatric topics, it's great for parents, it's great for clinicians as well, hey doc, you might even learn a thing or two on the latest research in pediatrics if you take a listen to the program.

And we do have posters you can download and hang up. You can find them under the Resources tab at pediacast.org. All right. One more time on the contact information, pediacast.org, Contact link, pediacast@gmail.com or 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.

Topic

• Summer Safety

Guest

• Dr Sarah Denny
  Section of Emergency Medicine
  Nationwide Children’s Hospital

Links

• Emergency Services at Nationwide Children’s Hospital

• Center for Injury Research and Policy – Nationwide Children’s

• Seattle Mama Doc Blog

• American Red Cross

• US Consumer Product Safety Commission 1999 Helmet Standards

• US Consumer Product Safety Commission – Which Helmet for Which Activity?

• Snell Memorial Foundation

• Snell – Current Helmet Safety Standards

• Consumer Reports Bike Helmet Ratings

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!

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 the campus of Nationwide Children's Hospital.

And as always we are in Columbus, Ohio. It's Episode 210, 2-1-0, May 9th, 2012. And we're calling this one 'Summer Safety', this is of course part two of a two part series. Last week we covered pre-hospital emergency care.

01:00

We sort of talked about -if you didn't listen to that program, you might want to run back and check that one out. We talked about when do you call 911, when do you call your doctor? When do you go to an urgent care?

When do you go to the emergency department and sort of what to expect if you utilize those services or have to go to those places. Today we're going to sort of pick up and actually take a step back and talk about injury prevention, so what you can do to avoid needing emergency care for your children in the first place.

And as it turns out prevention of fatal injuries is an an area where we make great strides in recent years. The CDC reports the childhood death rate from unintentional injuries dropped nearly 30% between 2000 and 2009.

So, that's really huge, I mean, when you think about the number of kids who are out there living today, and you think of the death rate dropping 30% from 2000-2009, there's a lot of kids out there who would have died if injury prevention had not shown up as a priority on our national radar.

02:05

Now, I realized some of our success has been better emergency and critical care measures that's keeping injured children alive, I get that. But we also have much improved safety awareness and new safety standards for things like seatbelts, car seats, bicycle helmets, playground equipment, trampolines, swimming pools.

You name it we're trying our best to raise awareness and make it safer. And as much as we sort of poke fun at how things have changed since we were kids, I can't tell you how many conversations I've had with other moms and dads where they say, "Oh do you remember how we had this big metal slides, they're like 20 foot tall and there was concrete underneath it and we kind of make fun of that.

But the reality is, that because we've made those changes, many kids are alive today because of safety and injury awareness and prevention. Of course we still have work to do, the number of preventable childhood injury is not zero.

03:02

And even though we have seen fantastic improvement these statistics don't mean much if you're one of the 10,000 or so families who this very summer will lose a child to a preventable injury. Here at PediaCast we don't want your child to be a statistic, we want you to have a safe and happy summer, and that's the reason for our summer safety show.

We have a great studio guest joining us on the discussion Dr. Sarah Denny, she is here. She is physician with the section of emergency medicine and the Center for Injury Research and Policy here at Nationwide Children's Hospital. Before we get to her I want to remind you if there's a topic that you like us to talk about or you have a show idea, just head over to PediaCast.org, click on the contact link.

You can also email PediaCast@gmail.com, we love to hear from you. We also have a voice line 347-404-KIDS, that 347-404-K-I-D-S, and you can just leave your name, where you're from, and the question or comment that you have for the program. Also want to remind you the information presented in every episode of PediaCast is for general education purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals.

04:08

So as always, if you have a concern about your child's health, make 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 over at PediaCast.org.

All right. Let's start out attention to our studio guest Dr. Sarah Denny, is physician with the section of Emergency Medicine at Nationwide Children's Hospital, and an assistant professor of pediatrics at the Ohio State University College of Medicine. She's also an affiliated faculty member with the Center for Injury Research and Policy at the Research Institute here at Nationwide Children's.

Her interest include Pediatric injury treatment and prevention which makes here a great studio guest for our big summer safety show. So, welcome to PediaCast Dr.Denny.

Sarah Denny: Thanks, Dr. Mike. I'm happy to be here.

Mike Patrick: We are glad that you're hear joining us. And you are from Central Ohio originally? And then you actually went to Seattle Children's Hospital for your Pediatric residency?

05:06

Sarah Denny:I did.

Mike Patrick: So, what do you think of the Pacific Northwest?

Sarah Denny: I love it. You know, we miss it very much. We made wonderful friends while we were there.

Mike Patrick: Yeah.

Sarah Denny: But came back for family and it was a valid choice.

Mike Patrick: Sure. I've never been, and we actually have some extended family that lived up there, and they've always offered, "Hey, anytime you want to come up", and it just never been in the cards to do it. But you know, you see pictures and just look so beautiful up there.

Sarah Denny: Yeah. We're heading back in about two weeks, or actually about a month to go back and visit.

Mike Patrick: Sure.

Sarah Denny: So looking forward to it.

Mike Patrick: So many of my listeners are kind of avid social media folks, and there is a pediatrician mommy blogger in Seattle, Dr. Wendy Sue Swanson better known as "Seattle Momma Doc". So when you were in Seattle, did you ran into her?

Sarah Denny: I did. Dr. Swanson and I did residency together. She was a year older than I was. So I know her very well and I am follower of her blog.

06:03

She's got two little kids, the same age as mine, and so she's a mom, she's a doctor, and she gets what we're all going through with our parenting.

Mike Patrick: And is she as nice as she comes across in her blog?

Sarah Denny: Absolutely.

[Laughter]

Mike Patrick: She seems like a great person and she's actually recorded a bit for us on PediaCast a couple of years ago with one of our blog post. And so she actually has been on PediaCast, although not in the studio as a guest. But for those of you who haven't heard of Seattle Momma Doc, we'll put a link in the show notes over at PediaCast.org so you can find her blog. So pediatrician and mommy blogger, and pretty much social media rockstar really.

Sarah Denny: Absolutely.

[Laughter]

Mike Patrick: All right. So let's move on to summer safety. Kids like to move fast in the summer, you know, bicycle, roller blades, skateboards, now this zip sticks which we see a lot of injuries with those. What are some of the common injury associated with these activities?

Sarah Denny: Well, we always have here minor injuries associated with these kind of things. Your scrapes, cuts, bruises, sprains.

07:05

But then we also see a significant number of more serious injuries like broken bones, head injuries. And unfortunately even sometimes stuff.

Mike Patrick: Yeah. You know, when kids go out there, and of course we encourage them to be active, and when they go out in the summer and their riding their bikes, and roller blading, you don't think about them getting hurt and having to take them to the emergency room, and yet that happens everyday.

Sarah Denny: Absolutely. It sure does.

Mike Patrick: Yeah. So I think some injury prevention tips are really important. What are some ways that parents can prevent injuries when kids are doing these things?

Sarah Denny: I think you know, some of the most important things are supervising your children and really just across all kinds of activities. Knowing what is developmentally appropriate for your child and what their skill level is, is really important. You know, when I was in Seattle they did a study just on kids crossing the street, and they realized that parents greatly overestimated their child's ability to make good decisions for crossing the street.

08:03

So knowing what your child is capable of doing and keeping them within that safe comfort zone. A great example of this is ATV's. We're seeing an increased numbers in the sales of ATV's, so we're also seeing an increase number in childhood injuries and fatalities related to ATV's.

This is because ATV's are built for adults not for children, and kids aren't developmentally able to control that kind of vehicle. So you put a child who's not developmentally able to control a vehicle on a vehicle not made for children. And then they'll put a helmet on them and unfortunately we see a lot of significant brain injury and fatalities around ATV's.

Mike Patrick: Yeah. Absolutely. When talking about the supervision issue in kids who you trying to get them make good decisions. I think one thing parents sometimes forget is you may have a kid who really seems like they're mature. And they do make good decisions in a perfect environment. But when they're doing these activities, they're distracted.

09:00

And so, it's easy even if it's a kid who usually makes good decisions, if they're distracted and they're excited, and the adrenaline is going, it's easy for snap impulse bad decisions to happen even in the kid who you would not expect it.

Sarah Denny: That's absolutely right. And you know, you may have a child you know, for example my oldest is five, and he's really good athlete, and he thinks he's really able to do everything, and he asks for skateboard for Christmas, and we got him one.

And then I realized that he's not developmentally ready to be on the skateboard. So the AEP has some rough guidelines about things like scooters and skateboards, and they really say if your child is less than eight, they should be supervised by an adult when they're on a scooter. And really kids five and under shouldn't be on a skateboard, they just don't have the balance and coordination to safely be able to handle that kind of equipment.

Mike Patrick: And you know, part of it, do kids see other kids on TV doing fancy things and then they want, they think, hey that kid can do it, I can do it too. But what they don't realize is the kid on TV or in a competition that they're seeing didn't start to how doing that, so they had to work up to it and train, and get muscle memory on how to do things. And so I can't imagine

10:07

And so I mean, I can't imagine just called doing the gymnastic move that you see in the Olympics. I mean, you have to work up to that. And the same thing is true with the tricks and things that we see on bikes and skateboards and things.

Sarah Denny: That's exactly true. You know, making sure that a chile knows how to work the piece of equipment and then do they practice it and realize what their own skill level is before they try going out and doing all the crazy stunts they see on TV.

Mike Patrick: Right. Apart from helmets, because we're going to get to that and talk specifically about head injuries. What kind of protective gear except for helmets, what are the protective gear do kids need when they're doing these activities?

Sarah Denny:So, wrist guards, knee pads, elbow pads, sometimes kids like to wear the little gloves to kind of protect their hands if they fall on and outstretch hand. And then just making sure your equipment is in good working order, you want to make sure that something has breaks, the breaks are working, you want to make sure the tires are tight.

11:05

Mike Patrick: Yeah.

Sarah Denny:And that the piece of equipment is in good shape before you let your child use it.

Mike Patrick: Yeah. I have done this myself, and I have to you know, not be upset of myself, but sometimes we make fun of it and say you know, we're wrapping our kids in bubble wrap these days because we're protecting them so much. But then on the other end you know, when it's your kid and they have an injury, and you could have prevented it by using appropriate gear, then you feel bad about it.

Sarah Denny:You're right. And you know, you were saying the statistics about the decreased number of injuries and deaths related to injury is dropping which is great, but unintentional injury is still the leading cause of death in children. And it's unfortunate because it is so preventable.

Mike Patrick: Yup. So risk guards particularly if there's a risk for falling on an outstretched arms, so bicycle, roller blades, skateboards, I mean anything where you could fall and put your arm out, that's going to help prevent a forearm fracture.

12:01

Sarah Denny: Right.

Mike Patrick: And we see a lot of forearm fracture.

Sarah Denny: We sure do.

Mike Patrick: Head injuries are kind of in a special category, why is that?

Sarah Denny: Well, you know, if someone falls and breaks their wrist or gets a cut, it's not too hard to fix that, we put them in a cast or we stitch them up. But when they injure their head, there's not a lot we can do and you can get significant long term or permanent side effects from that kind of injury. They can cause long term effects with thinking, emotions, attention, memory, and what we call executive function. That's kind of your ability to interpret the situation, regulate your own behavior. And kids unfortunately are at increased risk of permanent damage because they have -they get recurrent head injuries.

Mike Patrick: Yeah. If there's one take home from this show that I wish parents would hear, I mean, of course all of this information that we're going to through is important, but I think making your kids wear helmets every single time and modeling that behavior by wearing a helmet yourself when you're doing this activities is just is huge.

13:06

Sarah Denny: I could not agree with you more. We know that kids look to their parents and their peers as their biggest influence on whether or not they were at home. And we also know that 75% of bicycle related fatalities in kids could have been prevented if the kid had just been wearing a helmet. So, it's such a small piece of equipment and such a small intervention that could save so many lives.

Mike Patrick: Yeah. It's one of those places where I think parents need to take a stand, and even if their kids say you know, "Johnny next door is not wearing a helmet", no you're wearing a helmet, I mean it's really you got to bleed a lot down on this one.

Sarah Denny: I know. And you know, sometimes people in my neighborhood I think they come a little silly because I have my little one year old on his little scooter bike wearing a helmet. But I feel like the earlier you can get that as part of their natural routine if I'm getting on my bike, I'm putting on my helmet, then the easier it gets and you don't have to have those battles when they get a little bit older.

Mike Patrick: And if those parents could see what you see in the emergency department, I mean you see kids who their parents meant well and they get hurt and they get severely injured, and it just breaks your heart because you know it could have been prevented.

14:11

Sarah Denny: Right. And these traumatic brain injuries can be life altering, it can really take a significant toll on not only the patient, but the family as well.

Mike Patrick: Yup. Now so what type of helmet? How do parents go about picking a helmet for these kind of activities. So, we're talking bikes in lower speed movement, you know, so bikes, skateboards, roller blades, what kind of helmet do they need?

Sarah Denny: OK. Well, when you think about falls off a bike, you're usually falling forward so the area that's most likely to get injured is the front or the side of the head. So, a bicycle helmet would be ideal for riding. Again like you said, we're talking about non motorized vehicles here.

So, a true bicycle helmet is what you would want if you're riding a bike. But when you're looking at scooters, roller blades, the rip sticks, any of those kinds of things, you could hit any part of your head.

15:00

So, a multi support helmet goes down lower in the back and so that can be used in really anything including bicycling and gives you a little bit better protection on the back of your head that a bicycle helmet does not cover.

Mike Patrick: Sure.

Sarah Denny: They also make toddler helmets for the littler ones and those also go down back further there down lower on the head.

Mike Patrick: Great. Now, well we're going to get to sort of safety standards with helmets and how to pick a helmet. I think we should make a point that some helmets are for specific things. So you know, like a batting helmet for instance.

Yeah, its got padding, but it's not as snug of a fit, you know so that if you were to fall while you're moving fast, it might fall off your head and not protect you. So, it is important you know don't just throw whatever helmet if your kid plays lacrosse you probably don't want their lacrosse helmet whether doing these other activities.

Sarah Denny: Right. That's absolutely true. And the other thing with the multi support helmet, you don't want to forget I know we're in the middle of summer break, you don't want to think, forget about things like skiing, sledding, even ice skating those are all definitely areas where you can get a head injury.

16:11

Mike Patrick: Yup.

Sarah Denny: And helmet could be protective.

Mike Patrick: Yeah. Absolutely. Again, we don't recommend kids being on motorized things.

Sarah Denny: Absolutely not.

Mike Patrick: But if you're a parent that is going to do that anyway, and again not to give anyone permission, but we want people to be safe. These kind of helmets are not for high velocity stuff?

Sarah Denny: No.

Mike Patrick: I mean, you need like a motorcycle helmet.

Sarah Denny: That's true. And again strongly, strongly, strongly do not recommend children under 16 to be on something motorized like an ATV, but yes a bicycle helmet.

Mike Patrick: We're talking about 18 year olds?

Sarah Denny: Right. Exactly 18 year olds, while a bicycle helmet is better than nothing at all. They really need to have kind of a higher impact sort of helmet like a motorcycle helmet.

17:01

Mike Patrick: Yeah. So, where can parents find inappropriate helmet?

Sarah Denny: Well fortunately bicycle helmets are now readily available almost anywhere. Any kind of sporting goods store would have it, as well as kind of the big box stores like Babies "R" Us, Toys "R" Us, Walmart, Target. But I also can recognize it because it can sometimes be an issue, and so there's a lot of community groups that provide helmet free of charge or at a reduced rate.

Every county in Ohio has a safe kids department and they all have helmets. You could always contact your local police station and see if they have some available. And then just keep an eye out for community events, there's a lot of bike rodeos that go on across the state. A lot of organizations come and provide helmets to children who don't have them.

Mike Patrick: There's also some -there's a government agency the U.S. Consumer Product Safety Commission and they have standards that they've come up with in terms of which activities and which helmet is the best one, and then it will give a certification number.

18:06

And there is a website that we're going to put in the show notes where parents can find that, so they can look at what activity they're going to be involved in and then find the helmet that has the right safety standards. Safety standards have changed over the years.

Sarah Denny: This is true, right. So, if you have a helmet that's made before 1999, it's time to get rid of that one and purchase a new one because this safety standards have changed. And getting rid of it really means throwing it in the garbage, don't turn,sell it to the garage sale or give it away because we really want to keep all the helmets out there to be safe. Also if helmet has gotten dented, has gotten cracked, then it's time to get rid of it, and also helmets that don't fit, need to be replaced as well.

Mike Patrick: So, this is something that parent should check probably a couple of times during -I mean, in terms of fit because kids grow rapidly.

19:01

You know during the summer time. This is definitely the beginning of the season, but sometime in the middle probably too.

Sarah Denny: Absolutely.

Mike Patrick: And then there's the Snell Memorial Foundation we see Snell stickers on helmets. What's with that?

Sarah Denny: They regulate more of the multi sport kind of helmets and so they provide standards for the multi sport helmets.

Mike Patrick: Yeah. I'm always interested in -I'm kind of a history buff, and so you hear something like Snell. How did that get started? So I had to research this, and I don't know if you're -and I didn't know this until I researched it for the show.

But Snell was named after Pete William Snell who was an auto -a popular sports car racer back in the 1950's. And he wasn't wearing a helmet, had a bad accident, had a head injury and died in 1956. And he had a good friend who was a physician, Dr. George Snively.

20:01

And a group of sports enthusiasts and some scientists, and physicians got together and established this in his honor. And so that's how we have the Snell standards now.

Sarah Denny: Oh, there you go.

Mike Patrick: So, I mean that's one of them too, and we'll put a link to the show notes, because you can go to Snell's website and again you can put your activity and it will tell you which kind of helmet you need and with certification criteria, and then you can make sure whatever helmet you're getting is appropriate for that. What kind of price are we looking at if you had to go out and buy appropriate one on your own.

Sarah Denny: Yeah. I mean, they can range, you can spend as little as $10.00, and you can go all the way up to for bike helmets, you know, 45.50, the sometimes the multi sport helmets can run you a little bit more.

Mike Patrick: Yeah.

Sarah Denny: But you can get them inexpensively.

Mike Patrick: And so the more expensive ones are -as long as it meets whatever safety standard by the Consumer Product Safety folks or Snell, you can -even if it's a cheaper one, you can feel comfortable that it meets what you need?

21:06

Sarah Denny: Absolutely. So, you want to look for that sticker certification for me to consider Consumer Product Safety Commission or from Snell on the outside packaging.

Mike Patrick: OK. Yup. And again we'll have links to both of those places in the show notes so people can find exactly what they're looking for. So, the more expensive ones are -you're just paying for cosmetics at that point?

Sarah Denny: Absolutely.

Mike Patrick: Which should maybe important to a lot of kids.

Sarah Denny: And you know, we'll talk a little bit more about that when we get to picking out a helmet.

Mike Patrick: Yup. I also want to mention this, it will be in the show notes as well. And this is a subscription site, but everybody has heard of consumer reports and they have done their own independent testing of bike helmets and so we'll put a link to their site too and just to be helpful to folks. So, how do parents then check proper fit you know, when they're picking a helmet. How do they know that it fits right?

Sarah Denny: OK. That's a great question. First of all, you should bring your child with you when you go to pick a helmet for your child so that they can pick out the helmet.

22:03

They are going to be much more likely to wear their helmet if they like it. So, number one, the child should pick it out, and then you need to try it on the child and it should be snug on their head, but not too tight. And then when they're actually wearing their helmet, the helmet should be on their head straight.

So, you want to put one finger above the eyebrow, there should no more than one or two finger widths between the eyebrow and the top of the helmet. The helmet shouldn't be tipped forward or as I see a lot of children in my neighborhood, it should not be tipped back. That does not give you adequate protection, so you want it straight across the head, and then the straps around the ear should make a V or a Y going around each side of the ear.

And then the chin strap needs to be buckled, the helmet's not going to work well if it's not buckled on. And you should only be able to get one or two fingers between the chin and the straps. So, it should be snug, but obviously not choking the child.

Mike Patrick: Choking.

Sarah Denny: Exactly.

Mike Patrick: And I think probably folks that work in bike stores are usually pretty safety kind. I mean, I can't say that for -I'm sure there's some folks who aren't, but I mean as a group.

23:08

Sarah Denny: Right.

Mike Patrick: Would probably be trustworthy in terms of hopefully letting you take the helmet out of the box and trying it on.

Sarah Denny: Right.

Mike Patrick: You know what I mean really making sure it's a good fit before you leave the store.

Sarah Denny: Absolutely.

Mike Patrick: And if you can't, certainly your local fire station, there's probably someone there that would be more than willing to double check it to make sure that the helmet is right of you didn't feel comfortable with it.

Sarah Denny: That's right. And if you do have some kind of in your community around biking and bike safety, there's many people there who are able to fit helmets.

Mike Patrick: And one of the things that I've noticed a lot of safety stuff here lately is things come with expiration dates like car seats for instance. Now, come with an expiration date that you shouldn't use after that. Do bike helmets expire?

Sarah Denny: They don't you know. We kind of touch on reasons to replace your helmet one; if it is made before 1999, and then the other things would be dents, cracks, obvious malfunctions in the equipment and then helmets that don't fit anymore.

24:06

Mike Patrick: And as you said, garage sales is not a good place to get a helmet because you don't know how old it is.

Sarah Denny: Right.

Mike Patrick: Or if it was involved in an accident.

Sarah Denny: Absolutely. So garage sales, secondhand stores are not a place where you want to buy any kind of safety equipment like a bike helmet or car seat.

Mike Patrick: Plus as we've talked about before never share what touches the hair, so that's another reason.

Sarah Denny: Right.

Mike Patrick: Let's actually change gears. Anything else on helmets that we didn't cover that is important?

Sarah Denny: I just wanted to just mention, if a child is in a bicycle accident, and you look at the helmet and you don't see any kind of obvious signs, the helmet really does still need to be replaced because you cannot tell if the protective function of the helmet is still intact. So if the child is in a bike accident throw that helmet away and get a new one because you just want to be on the safe side.

Mike Patrick: Yup. Because the foam stuff in the inside maybe collapsed, and you would know it because the plastic shell still looks OK, but it's not going to protect their heads.

25:02

Sarah Denny: Exactly.

Mike Patrick: All right. Let's change gears and talk about swimming. What dangers lurk around residential and community pools?

Sarah Denny: Well, the obvious danger that unfortunately we started seeing a lot of this time of the year is drownings. Drowning is the leading cause of death in children from ages on to four, and like I said we started seeing a lot of increase in this time of the year with drownings, but really it's something to be mindful of all year round.

Little kids should not be left alone near any standing water, this means bath tubs, toilets, buckets of water, anything where they could drown. And then other causes of injury around pools this time of the year that are really significant would be the head and neck injuries related to diving into pools that are too shallow for diving.

Mike Patrick: And kids like to run.

Sarah Denny: Right.

Mike Patrick: So you don't want then to run on the pool decks and when we see cuts and scrapes, and broken bones from that too.

Sarah Denny: Right.

Mike Patrick: It's kind of a slippery surface and don't want them to run. We talked about over confidence and how important supervision is, and of course those are things that are really important around the pool too.

26:04

Sarah Denny: That's right. I mean, supervision is absolutely the most important thing you can do, and adult supervision we shouldn't have a seven year old watching the two year old at the pool, that's just a recipe for disaster.

Mike Patrick: Even sometimes the 14 year old watching the kids.

Sarah Denny: Right. They get caught up in texting or whatever, and it's just not a good idea.

Mike Patrick: Yeah. So, what are some ways that parents can prevent pool related injuries and drowning.

Sarah Denny: Right. So, supervision as we already said, and then having their children take swimming lessons. Really studies have shown us that kids who have some kind of history of swimming are much less likely to drown. Things for community pools, pools should have four sided fences which is really important.

And that's a law, but we're starting to see a large number of these inflatable pools. And the law doesn't cover those, but it's really important that even if although the law doesn't cover it the people enclosed those kind of pools because that's a danger for children to wander into the yard.

27:04

If the fences have gates, they should be self closing and self locking. So, if somehow the gate gets opened, and it closes and doesn't stand a jar inviting little guests. Rescue equipment should be kept at the poolside in case there is an emergency.

And parents, caregivers, people who own a pool should know CPR, so that if something happens they know how to intervene and try and help someone who is in trouble.

Mike Patrick: Absolutely. We have talked about this on PediaCast several times. It's so important that parents take a CPR class. And the show notes for the last show, so that would be 209, we did have a link to the American Red Cross. And I'll try to remember to put it in this one as well. So you know, you can find out where your local places where you could get CPR training because that is so important.

Sarah Denny: Yes, I agree.

Mike Patrick: And the other thing too is a lot of kids and some parents will be in tune with this and some won't, but their kids have physical and health limits that could make swimming not safe.

28:01

So, if they have a seizure disorder that's not well controlled, swimming is probably not the best idea. If they even have a well controlled seizure disorder, they probably got to be in the pool with a friend or someone who is very responsible and would know what to do if they started to have a seizure.

We see a lot of kids with ADHD and they have impulse issues and I mean they need, you know of course want to keep a close eye on everybody, but those kids need a little extra attention.

Sarah Denny: That's true. And you know, I take my kids to pool this summer and I just find constant reminding them about safety issues, how to keep themselves safe and just watching them carefully is really the best thing you can do even if there's a lifeguard on duty, they're watching a lot of kids, you know at the same time. So, you really need to be watching your children even though there's a lifeguard on duty.

Mike Patrick: Speaking of lifeguards, I got a great story for you. We had a pool once upon a time in ground pool, and when my daughter for her fifth birthday party, we're going to have a bunch of kids over for our pool party for five year olds.

29:02

So, the parents are going to be there and you know, being a pediatrician we're pretty in tuned safety and my kids will attest to that. So, we decided it would be a good idea to have a lifeguard at the pool party at our home, so that way you know someone was watching the pool, that was their job.

And if parents were socializing they could at least feel a little comfortable that someone, their whole job was watching the pool and we thought a lifeguard would be a good idea. And I had a co-worker who knew a kid who is a certified lifeguard, who is an older teenager. And I think the deal was for $50 bucks they would watch the pool for two or three hours. So, this was 10 years ago or more.

And so this was pretty good, and we thought, my wife and I thought, if he did well and nobody got hurt we'd surprise him and give him 75 bucks. But the deal was for 50, but if he did a good job we're going to tip him and 75 bucks.

Sarah Denny: That's great. Can I lifeguard at your next pool party?

30:01

Mike Patrick: Well, before the party, my wife's going to be upset, but I remember her saying, "Let's just give him the 50 bucks, OK, 75 is a little generous, let's just do the 50 bucks." So the kids arrived, the lifeguard had just gotten there as the kids are getting there.

And he's still in his sweats, he hasn't even down to his trunks yet. And my son who we actually him Mr. Safety because I mean, they won't jump on trampolines, I guess it was just horror stories at home.

And for some reason my son, who at that time was two just jumps in the pool with the other kids and he didn't have floaties on, it was very weird for him. And he just jumps in the pool, goes underwater, lifeguard still in his sweats, jumps in the pool, saves my son. And so we ended up giving him a 100 bucks.

[Laughter]

Sarah Denny: I was going to ask how much he ended up.

Mike Patrick: Yeah. We're not skimping on this guy.

[Laughter]

31:00

Sarah Denny: That's right. Well, you know your story brings out a good point about floaties, that actually those are not life saving devices, and so if kids want to wear them just to play around, that's one thing, but don't put them on your child and hopes that that's going to keep them afloat.

Mike Patrick: Yeah. Absolutely. And the other thing too is then our kids did take swimming lessons, but even if your kids take swimming lessons and they're doing great, they're getting a little stickers and going up to the next class, to the next class, even though that is important, and there's less chance for drowning, by doing that parents still shouldn't have overconfidence because when their kid suddenly struggle, they may forget their skills.

Sarah Denny: That's absolutely true. Having swimming lessons is great, but it does never replace adult supervision.

Mike Patrick: Yup. What about playgrounds, I kind of joked in the introduction about the 20 foot tall metal slides with concrete which is not an exaggeration, that's really was -that's what we had.

Sarah Denny: I know. Absolutely.

Mike Patrick: And they were hot. Do you remember that? They were like baking in the sun.

Sarah Denny: That's right. We're actually going to talk about that in just a second.

[Laughter]

32:01

Mike Patrick: So, what about the playgrounds?

Sarah Denny: Well, since you brought up this cement thing, you know, obviously we want playgrounds to have a soft surface, so molds or that new rubberized material and is much better than the concrete that we've all encountered at some point in our childhood.

You know some of the dangers at the playground would include falls. Also pedestrian safety, we got a lot of kids running around, worry about our kids running out in the road. Dog bites which is not something that you might think of, but you know, people are walking their dogs or may or may not be on a leash and you have a lot of small kids.

So, we've seen several dog bites that takes place at parks. And then other children modeling risky behavior, you talked about kids seeing older kids on TV doing this and that, and the same things happens at parks, kids doing stunts that five year old probably is not able to do, but things that looks neat so give it a try.

Mike Patrick: Yeah. Absolutely. And strangers.

Sarah Denny: Right.

Mike Patrick: Got to watch out for them too.

33:01

And how can parents prevent playground injuries? What some things that they should be on the lookout for?

Sarah Denny: Well, we talked a lot about bike helmets and bike helmets absolutely are essential if you're going to the park and your kids running their bike, they need to put the bike helmet on. But when they get to the park, they need to take the bike helmet off.

So, you know, bike helmets, straps can be strangulation risk as well as anything whether tying, jump ropes, leashes, anything to equipment, that's just not a good idea that's all present strangling risks to kids. Other things keeping their shoes on, you never know what's going to be on the ground or especially if there's mould on the ground, they can get a lot of splinter, so keeping shoes on.

The parents needs to just take a look at the equipment making sure it's in good repair, there's nothing sharp poking out, the swings are secure, that sort of thing. And then as we've been talking about really during this entire interview adult supervision and then making sure that a child is playing on a piece of equipment that they are developmentally and at an appropriate skill level to manage that piece of equipment.

34:00

Mike Patrick: You see a lot of parents chatting it up with other parents, and are reading their emails, or texting and really they just have their eyes off of their kids for a significant amount of time when they're at playgrounds, and that's not good.

Sarah Denny: I know. You know, and it's hard you get caught up in a conversation and then all of a sudden you know, you realize your kids are doing something they shouldn't be doing. So, yeah it is important t have your priority is keeping your child safe at the park.

Mike Patrick: Yeah. I mean it's tough because as a parent you know, I mean a lot of times you re isolated during the day and so you know, having other adults to talk to is important you just have to be you know, talk where you're looking.

Sarah Denny: Absolutely, yeah. It's easy to say you know, realize your kids are similar ages and you start talking about preschools and this and that, and right you just got to keep one eye on the child as you are chatting.

Mike Patrick: Yup. And play with your kids.

Sarah Denny: Right.

Mike Patrick: I love playing on the playground.

[Laughter]

35:00

Mike Patrick: And then we talked about how play equipment is different that it used to be, you know a long time ago. But there are in some states there are laws that they have to change to new safety standards. But we have an international audience, and there maybe places that still have unsafe slides that are 20 feet tall. And so, parents should avoid those places.

Sarah Denny: That's true. And even on the new parks and playgrounds that we have that are up the code, there are still areas that are very high up where for example uphold might be. And for a five year old that's fine, but if you have a two year old or an infant, crawling around up there, they don't understand that there's a drop off there.

So, you know just being really vigilant especially when the children are higher up. And even this plastic swing or plastic slides that they have in the parks, still get hot in the sun and can burn the skin. So, you just want to be careful especially now that the temperature are starting to warm up that you're checking for those kinds of things as well.

Mike Patrick: Yup. If my kids had to tell you their biggest pet peeve with regard to safety, it would be that we have not let them have a trampoline.

[Laughter]

36:09

Sarah Denny: I'm right there with you. For the longest time I tried to keep my kids off the monkey bars too because we see so many broken arms with monkey bars, but I've lost that battle.

Mike Patrick: Yup. But you're still going strong on the trampoline?

Sarah Denny: Oh, yeah absolutely.

Mike Patrick: We did go to one of those indoor places you know, that wasn't very crowded and they have like a huge trampoline area, do you know what I'm talking about? So you don't have the frames and you can't fall off of it. And we went in a time when it wasn't crazy busy and of course my wife and I were there with them and making you know, they weren't doing flips and getting crazy. But I did find out it is a good exercise.

Sarah Denny: Did you get on it?

Mike Patrick: Yeah. And like I was winded and I don't even want to tell you how long it took.

Sarah Denny: We had my son's birthday party at a place where again against my bad adjustment, there were trampolines, so I was a nervous wrecked the whole time.

37:01

But before anyone got there I got on the trampoline and it was pretty fun I have to say.

Mike Patrick: Yeah. Yeah.

Sarah Denny: I was winded too.

Mike Patrick: This is what happen when you get two pediatricians and they were like, "No we're not doing the trampoline", but you know, it was kind of fun.

Sarah Denny: But when the kids showed up.

Mike Patrick: Right. Right exactly. And you know, i probably see as many trampoline injuries that are just caused from two kids being on the trampoline and they run into one another or jump on an arm. I mean, obviously you think about hitting the frame, falling off of it, you know getting injured that way, but really it's one person kind of thing here.

Sarah Denny: Right. So you know, I have always just in my experience, as you said we see so many trampoline injuries and a lot of them are broke bones, and that kind of thing. You do see some of them more severe head and neck injuries, but broken bones are the most significant. And I always have felt like it's often when there's multiple people on the trampoline.

Mike Patrick: Yes.

Sarah Denny: So, I had that theory, but I decided to actually research it.

Mike Patrick: OK.

Sarah Denny: And what I found a group at Salt Lake City Children's Hospital looked at trampoline related injuries. And what they found were that a significant number, actually the majority of the kids that were injured were having multiple children on a trampoline at one time.

38:11

And typically it was the youngest person of the group that got injured. So, people I think get a false sense of security with those nets around the trampoline, but really those have nothing to do with kids getting hurt.

Mike Patrick: Yeah.

Sarah Denny: I mean the majority of injuries aren't from kids falling off trampoline, it's they get double bounced the wrong way, or they get landed on, or something that results in a bone injury.

Mike Patrick: Yup. Yup. I want to stress, and we see everyday.

Sarah Denny: I know.

Mike Patrick: I mean when it's warm outside, It's just everyday.

Sarah Denny: Every time I see one, I think as long as there's trampolines I will always have a job.

[Laughter]

Mike Patrick: This is true. This is true. So, we're not -we're kind of winning the trampoline battle in our own homes, but any drive through a suburban neighborhood and you see trampolines right and left. So, we're not winning the battle of making parents get rid of trampolines.

Sarah Denny: Right.

39:02

Mike Patrick: So what the parents who have trampoline, our first advice would be, get rid of them don't buy them.

Sarah Denny: Right.

Mike Patrick: But if you have them what can parents -other than one kid at a time, what other safety?

Sarah Denny: Really I think that's the biggest one, you know the American Academy of Pediatrics recommends no trampoline, but as you said we're not winning that battle.

Mike Patrick: Yeah.

Sarah Denny: So, I think the biggest rule is one child at a time is the most important thing, and then supervision. Again we keep going back to that.

Mike Patrick: Absolutely. The other thing too is kids want to do more than they think they should and flips, and it's not a good idea. There's too much of a head and neck injury risk with flips.

Sarah Denny: This is true.

Mike Patrick: I do not recommend this at all. We had a neighbor back, this is 10 years ago when we lived or we had our pool. And this kid actually ended up to be an army ranger. But he used to put the trampoline next to the pool, and all that did you imagine, I'll leave that to your imagination exactly what happened.

40:02

I mean, I would cringe, you know, like I don't even want to know this is next door.

[Laughter]

Sarah Denny: Oh that's a disaster.

Mike Patrick: Yeah it was bad. And you know, but he's an army ranger now, he shoots a gun. Actually he shoots a gun back then too.

Sarah Denny: Thankfully he survives. Sometimes I wonder how we all survived childhood.

Mike Patrick: Yes. Yes.

Sarah Denny: But thankfully he made it through.

Mike Patrick: Yeah. And we don't recommend that. All right. so we're pretty scaring parents here. We see kids with severe injuries in playgrounds, or on swimming pools, and trampolines or riding your bike. But it is important for kids to be outside and active in the summer. Talk a little bit about why that's important.

Sarah Denny: Sure. Well, you know when you think about your childhood you have so many memories from being on summer break and all the fun thing you do. We want to get kids out, get exercise, enjoy nature, and kids are out of school. So, it's a nice time for families to spend time together and kids to hang out with the kids in their neighborhood and do some different kind of things.

But as you know from working in the emergency department, summers is the time when we see the most number of injuries because kids are kind of doing things that maybe they shouldn't necessarily be doing.

41:06

So we want kids to have fun, and we want kids to be healthy and get exercise, but we want them to do it in a safe way.

Mike Patrick: Yup. What are your most important, if you had the most important take home tips on the safety stuff for the summer. What's the top five kind of thing?

Sarah Denny: OK. Well, I kind of thought of a few things that we had already talked about. Obviously supervise your kids, keep an eye on them, be vigilant and kind of think ahead about you know what dangers could be in this activity and how we can prevent them. And then simple things like don't forget to put sunscreen on your children ages six months and older.

Mike Patrick: Oh yeah.

Sarah Denny: Keep your kids well hydrated, don't have them out doing heavy exertion during the hottest parts of the day. The other thing that we really start seeing a lot of injuries related to this time of the year is lawn mowers. Kids should not be anywhere near lawn mowers. We don't want them to get run over by lawn mowers, we don't want them to get any kind of eye or head injury from something getting flown out from lawn mowers.

42:00

And then they have no business riding on a lawn mower. We see a significant number of injuries where you know, the parent thinks that it's just kind of fun to have their kids sit on their lap at.

Mike Patrick: The toddler. They got the toddler with one arm. Yeah.

Sarah Denny: You know you see funny and all kinds of badness can come to out of that, it's just not a good idea. And then I've seen especially when I was on Seattle, a lot of burns related to fire pits, and camp fires, it's really fun to have a bonfire, roast marshmallows that kind of thing, but you want to keep kids at a safe distance.

And once you put the fire out, you want the child to understand that although the fire is out, those ashes and what not can still be hot. So, you know, fire safety is important. And then one of the big ones during the summer especially around fourth of July is eye injuries. So, you can get a significant numbers of eye injuries related to fireworks around the fourth of July.

Kids shouldn't be setting off fireworks, they're wonderful to enjoy, but at one of those big community settings where professionals are putting them off.

43:00

Mike Patrick: Yeah.

Sarah Denny: Even sparklers, get hotter than 1800 degrees which is hot enough to melt golds. So, putting those in a hand of a seven year old too don't have a lot of impulse control, it's just a recipe for disaster.

Mike Patrick: Absolutely. And they don't have a lot of coordination either.

Sarah Denny: Right. And they don't realize how hot they can be, they probably just have no idea how dangerous those can be with the eyes.

Mike Patrick: Yeah absolutely. Again, my children would just roll their eyes at this. I was trying to think ahead like, "OK, what's the worst case scenario that could happen here and how am I going to prevent that from happening?

And it's funny because even as teenagers you know, we'll be crossing the street and I was like, "Hold on, hold on", and they were like, " Dad, we're not going to run in front of traffic", but they're just something you know, innate that just has to sort of think of, OK what's the worst case scenario, and I have to actually voice it and say it and it annoys my children.

44:00

Sarah Denny: I'm in the same way, and I convince my kids we'll be in therapy for years because I am so safety conscious, just you know because you do see the worst and like we say like injury prevention is the vaccine against this long term injuries. And so we just want to prevent as much as we can so that kids can live long, healthy, happy lives. And they can go out and have fun, do the things they want to do, but just do it in a safe way.

Mike Patrick: And really I was just floored when I saw that statistic, the 30% decrease in accidental deaths from 2000 to 2009. As I was researching for the show, I came across that statistic and that just floored me, I mean, that is just really impressive.

Sarah Denny: Yeah. I mean.

Mike Patrick: We still have work to do.

Sarah Denny: Absolutely.

Mike Patrick: But these efforts are paying off in getting this information out there.

Sarah Denny: That's right.

Mike Patrick: Well, we really appreciate you stopping by. Again we'll have lots of links in the show notes for you. I'll try to remember to add the American Red Cross, if it's not there though in show 209, I know it's there for sure.

45:04

We'll have a link to emergency services here at Nationwide Children's Hospital also the Center for Injury Research, and Policy. Seattle Momma Doc, and U.S. Consumer Product Safety Commission, The Snell Memorial Foundation, Consumer Reports, all those links will be at PediaCast.org for you.

Before we let you go, one of the things we always ask all of our guests here on PediaCast is for your favorite family game. We just like to encourage families to do stuff together that doesn't necessarily involve everybody just staring at the screen and not communication with one another. So, just in your home, what is a favorite game?

Sarah Denny: Well, my kids are pretty little.

Mike Patrick: Yeah.

Sarah Denny: So I have five, three, and one. So board games especially on a one year old just not happening. So, there's two games we like to play in out house. My boys are really into dinosaurs, so I say a dinosaur name and then they have to walk around the house acting like that dinosaur.

46:00

Mike Patrick: Oh, that is cool.

Sarah Denny: That's one. And then one we do in the car because we don't watch DVD or TV in the car. We take turns thinking of an animal and then other people have to ask questions about what animal it is.

Mike Patrick: Kind of like a 20 questions kind of thing.

Sarah Denny: Exactly, but related to animals. So, yeah we're big on dinosaurs and animals in the house. But there's a really.

Mike Patrick: Yeah.

Sarah Denny: Those are the things we do because like I said my kids don't really at the board I mentioned.

Mike Patrick: Yeah. And I want to encourage just right now, I want to put a call up there, a call to action for dads to get involved with doing these kinds of stuff too. I mean, I don't know, moms I think do those kind of creative, interactive spur of the moment kind of games. There's just there's a natural innate ability to do that. And I think a lot of dads aren't comfortable doing those things. And I just want to put a call out there that "Dads, when you run around making dinosaur noises, and I mean you make an impression on your kids.

Sarah Denny: Right.

Mike Patrick: And it creates a bond in a relationship between you and your kids that's very important.

47:01

Sarah Denny: It's true.

Mike Patrick: I got to get off my sofa on that.

Sarah Denny: Well you know what and the thing is too, it's about you know if you're filling the time then the kids aren't bickering, and yelling, and you can teach them things and they don't even realize they're learning. So, it's fun.

Mike Patrick: Absolutely. Absolutely. Well, we really appreciate you stopping by and been a great guest, and we just love having you here.

Sarah Denny: Well, thanks for having me.

Mike Patrick: Want to remind everyone that iTunes reviews are helpful as our links on your webpage and mentions in your blogs, on Facebook, in your tweets, and on Google+. Be sure to join our community by liking PediaCast on Facebook, following us on Twitter, tweeting with # hashtag PediaCast, and hanging out with us on Google+.

And be sure to swing by the show notes at PediaCast.org, add your comments on today's show. We also appreciate you telling your family and friends, and neighbors about PediaCast.

And don't forget to talk us up with your child's doctor at your next check up or sick office visit. We also have posters that you can download, ad hang up wherever moms and dads hang out.

48:00

And you can find them under the resources tab at PediaCast.org. One more time the links to get a hold of us PediaCast.org, just go to the contact link up on the top of the page. And you can get in touch with us very easily. I read everything that comes through. So, of you put a comment or question there, I would definitely see it.

You can also email pediacast@gmail.com, or call the voice line at 347-404-K-I-D-S, again 347-404-KIDS. 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.

Topic

• Pre-Hospital Emergency Care

Guests

• Dr Dan Cohen
  Section of Emergency Medicine
  Nationwide Children’s Hospital

• Chief Steve Shaner
  Division of Fire
  Grandview Heights, Ohio

Links

• Emergency Services at Nationwide Children’s Hospital

• Division of Fire – Grandview Heights, Ohio

• American Red Cross

• EMSC National Resource Center

• Pediatric Emergency Care Applied Research Network (PECARN)

• EMSC-GFWC Pediatric Jump Kit Bag Initiative

• Oconomowoc Junior Women’s Club – Pediatric Jump Kit Bags

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 and not just for moms and dads, we're getting a growing number of clinicians, so pediatricians and family doctors and nurses and nurse practitioners and medical students who are listening to the show. So I'd like to welcome all of you on board as well. It is episode 2-0-9, 209 for May 2nd 2012 and we’re calling this one Prehospital Emergency Care.

And you'd notice I've been kind of talking this show up. The last episode I mentioned that we're going to embark on a two-week journey on emergency care and summer safety, so I'm really excited about these two shows because I think it's one of those things where we can make a difference in some people's lives. So, moms and dads, I'd like to think we do that every week here on PediaCast, but in particular, it's really important for all moms and dads because even though you don't want to think about it, each day in the United States more than 100,000 parents seek emergency medical services for their children

01:38

And the question on most moms and dads' mind before this happens is what would you do if your child has an emergency, do you call your doctor? Do you throw your child on the car and drive to the nearest emergency room even if it's at an adult facility or do you drive a little farther to get to a pediatric hospital? When you should you visit an urgent care facility and what about this nurse practitioner in a box grocery store clinics that seem to be popping up everywhere, should you use those?

When do you call 911? And if you do call 911, how long will it take for someone to arrive? Will the responding team be prepared for pediatric emergencies and what type of treatment can these folks start in the field? Will they have the right equipment? Where will they take your child? And of course the question everybody wants to know and asks is can moms and dads ride along in the ambulance?

Also, what kind of research is being done to improve the prehospital emergency care of children? How do the results of this research end up in the hands of first responders? And how do emergency services personnel use new findings to guide their approach?

02:44

So we have lots of interesting stuff to consider today. And next week we're going to kind of build on that and talk about summer safety and preventing an emergency. Dr. Sarah Denny, MD is going to stop by and talk to us about that next week.

But today, our focus is on what to do when there is an emergency. And to help me out with the discussion we have two fantastic studio guests with us, Dr. Daniel Cohen, MD is a physician with the Section of Emergency Medicine here at Nationwide Children's Hospital and Chief Steve Shaner is the man in charge of Fire and Emergency Services for the City of Grandview Heights here on Ohio.

But before we get to our guest, I'd like to remind you if there's a topic that you would like us to talk about on PediaCast or if you have a question for us, it's easy to get in touch, just go to pediacast.org and click on the Contact link. Actually, we even have pediacast.com now, so if you accidentally do pediacast.com it doesn't take you to go daddy anymore, it actually gets you to our site. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

I also need to remind you that 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. If you do have a concern about your child's health, make 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 over at pediacast.org.

04:16

All right. Without further ado let's turn our attention to our studio guests, Dr. Daniel Cohen, MD is an attending physician and director of research for the Section of Emergency Medicine here at Nationwide Children's Hospital. He's also an associate professor of Clinical Pediatrics at the Ohio State University College of Medicine. So welcome to PediaCast, Dr. Cohen.

Dr. Daniel Cohen: Thank you for having me, Dr. Mike.

Dr. Mike Patrick: Absolutely. And we also have Chief Steve Shaner with us in the studio today. Chief Shaner is in charge of Fire and Emergency Medical Services for the beautiful city of Grandview Heights right here in Central Ohio. I'd like to welcome you to the program as well.

Chief Steve Shaner: Thank you for inviting me.

Dr. Mike Patrick: I really appreciate both of you stopping by. And Dr. Cohen and I also go way back, I remember working with you when I was a medical student, all those years ago, so it's great to be back here at Nationwide Children's and working with you again.

Dr. Daniel Cohen: Likewise.

Dr. Mike Patrick: So in Grandview, my wife and I love going to stops and hanging out. It's really a beautiful town.

Chief Steve Shaner: It's a nice little destination and we welcome anyone to visit or perhaps move there.

Dr. Mike Patrick: Yeah. Absolutely. So let's start with you, Dr. Cohen. What should parents do when they're facing a medical emergency? So, I mean, you're kind of in the parents' position and your kid is having an emergency, what would you do?

Dr. Daniel Cohen: So, I have a few of my own stories as a parent and emergencies happen to all of us. I think the essential take home message is that we all need to be prepared, because we need to be prepared before the emergency has happened. So as an example, now I have two teenage daughters and they both took babysitting training and they took CPR and I would suggest that everybody needs to take CPR and help them to be able to provide that.

So I think being prepared before an emergency happens is really critical.

Dr. Mike Patrick: Yup.

Dr. Daniel Cohen: And maybe we can talk a little more about that. The other essential question to address is what is an emergency? So, I think sometimes it's really clear, your child is struggling to breathe, you see your child that fell off of playground equipment and there is a bone sticking out in the wrong direction, that's clearly an emergency…

Dr. Mike Patrick: Yeah. Pretty obvious.

Dr. Daniel Cohen: But sometimes it's a little bit hard to know which kind of gets back to the issue of preparation. So, if you have a plan under different circumstances, then you can be prepared. So an example of having a plan is knowing who to call. One important phone number would be that for the Poison Center and there's one number you probably have covered Poison Center…

Dr. Mike Patrick: Yeah. 1-800-222-1222.

[Laughter]

06:50

Dr. Daniel Cohen: There's a little jingle. It's on a magnet on my fridge. Yeah. That's the right set of phone numbers which is really, really important; including your neighbors, your doctors, your local urgent care center, potentially and knowing where you might want to go, that's part of preparation.

Dr. Mike Patrick: Yeah. I always tell parents even if it doesn't end up that it is an emergency if in your mind you think it might be an emergency, you're probably better off treating it as if that's what it is. And then if when all said and done you have to say, oh, I overreacted, but if in your heart you thought this could be an emergency or crossed your mind that it could be, then you're better off being wrong about that rather than being wrong the other way and sort of denying that it's really serious.

Dr. Daniel Cohen: I think it gets back to training again. Knowing some basic first aid is really important. In the emergency department, we see families who have brought their kids in by car that probably should have called 911.

Dr. Mike Patrick: Yeah.

Dr. Daniel Cohen: And then we see people coming in by 911 and Chief Shaner can address this as well as I can, that probably shouldn't have been brought in by 911.

Dr. Mike Patrick: Yeah. Who could have seen their doctor the next day.

[Laughter]

Dr. Daniel Cohen: That is exactly correct. There are a couple of really great websites that really go through the issues of preparation and one of which is the American Red Cross. And what they point out is get a kit, make a plan, be informed. I think those are really essential things for parents to do.

08:16

Dr. Mike Patrick: Yeah. Absolutely. And we'll put a link to their site in the Show Notes too, so folks can find it pretty easily. What about calling their doctor? I mean, should that cross their mind in this whole scheme of things?

Dr. Daniel Cohen: Absolutely. I think that's essential know when to call your doctor but at the doctor's visits when you're getting to know your pediatrician go with through with them, what would be an appropriate phone call for them to handle and when should they call 911. And most pediatricians' offices cover this.

Dr. Mike Patrick: Yeah. Yeah. And they're happy to talk with you about it if you want. We're seeing urgent care centers pop up all over the place and in communities and some of them are pediatric specific, some of them aren't, some run by family practice folks who have some pediatrics experience. Do you recommend parents use urgent care centers and wonder what kind of circumstance should they take them there instead of calling 911 or calling their doctor?

Dr. Daniel Cohen: That's a great question.

[Laughter]

Dr. Mike Patrick: And it doesn't have an easy answer, really, it doesn't.

Dr. Daniel Cohen: I think that certain times and certain, especially injuries would probably be best served in urgent care centers. But it really depends on what resources you have locally.

Dr. Mike Patrick: Yeah.

Dr. Daniel Cohen: And there's a spectrum between very minor injuries and very major injuries, very minor illnesses and major illnesses. And that's sort of where the judgment call comes.

Dr. Mike Patrick: Yeah. Yup.

Dr. Daniel Cohen: So if you have your child and they're having serious difficulty breathing and that is an emergency.

Dr. Mike Patrick: Yeah. That's a call 911 kind of thing. I look at urgent care centers and correct me if I'm wrong about this, it's kind of an extension of your doctor's office, so if there's something going on in the evening and your doctor's office is closed or it's something that your doctor doesn't feel comfortable dealing with like lacerations or the possibility of a fracture, your doctor probably doesn't have X-ray facilities on hand, but it's not a life or death situation, but you do need urgent care now, then that's probably the best.

So it's not a life threatening kind of emergency but it's something that's your doctor's office is closed or it's something that they can't handle because they don't have the right X-rays, that sort of thing.

10:32

Dr. Daniel Cohen: I think it's in a large part, logistic and it's more intended for minor injuries and minor illnesses. And again, it can be addressed when you call in. It's really meant to be there when your pediatrician or your family doctor is not available. Because as a pediatrician first, we support having at home and I think that's the right place to go first.

Dr. Mike Patrick: Absolutely. And you know if you call your end again it's one of those things, I'm not calling 911 but maybe I should call my doctor and get some advice on whether is this something that I can wait to see you tomorrow or do I need to go the urgent care now, those kind of things.

So let's turn our attention to true emergencies. So now you are calling 911, you do have the bones sticking out or your child's not breathing, you've started CPR, you learned that from the Red Cross, or there's an AAD device on hand and you can use that.

Let's say that you do call 911, Chief Shaner, what can a parent expect when they call 911?

Chief Steve Shaner: Well, I'll kind of walk you through a typical call. So if a parent dials 911, technologically, here's what happens, the call goes to what's called a Public Safety Answering Point, some people refer to them as PSAPs, the call's then answered and usually they'll say 911, what's your emergency. If you say I have an injured child, they'll say hold on, we'll transfer you over to the EMS or EMS fire dispatcher and that's usually done seamlessly, electronically.

So they'll switch you over and then someone will come on and ask you about the emergency. One thing that's commonly confused is sometimes people will say, well, they kept me on the line for three or four minutes. The people that are answering those calls are usually EMS trained dispatchers and they will give pre-arrival instructions. They will also give medical care advice such as first aid advice, how to do CPR, they can actually talk you through hands only CPR, they can do a lot of things on the phone while they're simultaneously dispatching the run.

So people could actually be on the way while they're talking to you. So it's a little misconception there that folks think all they did was talk to me when they're actually multitasking. They're sending someone at the same time.

12:54

Dr. Mike Patrick: Yeah. So they don't actually have to talk to someone to send, I mean they can type it out and that gets something dispatched?

Chief Steve Shaner: Yes. They can just type it out, push the button and it automatically goes to the system. Now, every system is different.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: In the United States, primarily, we use the E911 system. In many countries they have better systems, they have worse systems, it's all over the place.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: But in general, when you make a 911 call or a call to an emergency system, it's answered and the care system is activated upon your call.

Dr. Mike Patrick: Now when you say E911, is that the enhanced, so if you have a cell phone it's going to figure out where you are or if you have Internet phone at home it's able to get it…

Chief Steve Shaner: The E911 system is pretty well adapted these days. There's a new system, it's called the NG911, which is Next Generation, which will actually be able to text and you'll be able to do a lot of different modes of electronics to get the desired response that you need.

Dr. Mike Patrick: Yeah. Sure. So a parent calls 911, the dispatcher kind of walks him through what they need to do, dispatches the personnel and then what happens when they arrive?

Chief Steve Shaner: When the EMTs arrive, or at least in the United States and most other developed countries, the EMS arrives, the EMS folks are trained, the EMS responders, there are three different levels, actually four different levels of responders, there's a first responder or what they call the emergency medical responder; there are EMTs, which is a higher level of care than a first responder; intermediate EMTs or advanced EMTs, depending upon where your are what they're called and then the paramedics.

14:42

So everyone has a, there's a different level of response and in some areas that level of response is coordinated with that information that's collected from the EMS dispatcher. So, that's all depended upon who gets there is depended upon how your system works.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: Once the folks arrive, they do pretty much, they're all taught to do the same thing and that's do a scene survey. So they'll get out of their vehicle or they'll stop in their vehicle and make sure everything is safe before they get out, because it doesn't do them any good to get injured while they're trying to go provide care for your child. So they have to make sure that they're safe as well. It advances the time much faster if they don't get hurt themselves.

So, you might see them, you wonder why they're just sitting there for a couple of seconds, they're just making sure everything is safe for them before they get out of the vehicle or before they approach the scene. Once they do that, they'll come in and they'll do what's usually referred to as a primary survey or a life threat survey. And what they're going to make sure that there's no immediate threat to that child's life such as a breathing problem, a bleeding problem or an airway problem and once they get through that or if they can't get through that because there is a problem then they'll usually start talking to the parents a little more and start interacting with them and deciding what's best to do for the child at this point.

16:16

Dr. Mike Patrick: So they could decide that the kid just needs a Band-Aid, they're at the scene, or this is something you could see your doctor tomorrow or we're going to take you to the hospital.

Chief Steve Shaner: That's correct. And once they make that initial assessment, some folks call it a doorway assessment, you can tell when something's wrong just by opening the door and you look at them so, once they make that initial assessment then they'll start talking to the parents and if there's no immediate threat to life, they'll start looking for other things, such as just complaints of pain, discomfort, their inability to ambulate or something like that.

So they'll start to scale it down. So they start with the worst things first and then scale it down from there. And it may very well be that it is just something that requires minor care or emergent care.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: And they kind of will go from there, they'll just start talking to parents and say, you know, we really think this is something that's serious and we need to transport them to the hospital or in some cases, we think this is not necessarily something that's life threatening, it's something that probably could be handled with your doctor or it could be handled at one of the urgent cares.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: So, they'll kind of form an interactive discussion there about what's going on but for the most part, if it is a true emergency there is a little less dialogue and a little more action.

Dr. Mike Patrick: Yeah.

17:44

Chief Steve Shaner: And they kind of get the ball rolling. Now in Ohio and in most other states, all the EMTs follow are written protocols and those protocols are put together with emergency physicians or advisory boards as to what to do. Occasionally, as with any level of medicine, not everything's always in the book.

Dr. Mike Patrick: Yes!

Chief Steve Shaner: So we do have the luxury here and most places have that ability to actually place a call to one of the physicians or what we call medical control physicians and we can discuss the case and decide what the best thing to do.

Dr. Mike Patrick: When there's really an emergency it's kind of easier because you know what you need to do, you need to get them to the hospital, you need to call medical control if there's something that's outside of your protocol. What about when you really don't think that it's a life threatening or even needs urgent attention and the parents are very adamant that they want their child transported to the hospital? Do you run in to that?

Chief Steve Shaner: Yeah, we do. The system in our area here, we usually have an EMS coordinator that can come and discuss that with that parents but as you talked about earlier on in the discussion, an emergency is many times in the eye of the beholder. So if we are positive that it's not an emergency, we'll take a few extra steps to try to steer the patient the correct way but many times it's that fine line area where they could go to the emergency department, they could go to the hospital where there's an urgent care in the hospital that's just as effective as going to an urgent care in the neighborhood, maybe a little less convenient for the parents, but if that's what they want to do then we'll make some accommodations and see if we can do that.

19:36

Dr. Mike Patrick: Yeah. It's kind of a tight road because on one hand there are some parents who know their kids and know they had this situation before and even though it seems like they look good now, they have in the past deteriorated rapidly so sometimes you have to listen to the parent on that.

But on the other hand, if it's not that kind of situation you want to avoid utilizing your resource because if you're transporting someone to the hospital who doesn't necessarily need it and then there's another person who does need it, then your crew is not available for the person who really did need it so I guess everybody has this sort, you look at each others perspective, so to speak.

Chief Steve Shaner: They do and it's truly a discussion that needs to take place at the time and there are times where things aren't what they appear to be then you look at the child, they look fine and the parent says, but I know my child and they do not look right and that's usually good enough for all of us.

Dr. Mike Patrick: Yes.

Chief Steve Shaner: And as first responders we know that when they say this is just not right, that they…

Dr. Mike Patrick: Yeah. You pay attention to that.

Chief Steve Shaner: No one knows their children better than the parents.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: Or the caregivers.

Dr. Mike Patrick: Yeah. Absolutely. Let's say you decide that they do need to be transported somewhere and they need more than an urgent care facility, how do you make the decision on whether to go to the nearest emergency room or to a pediatric hospital?

20:57

Chief Steve Shaner: Those are usually pre-made decisions on our written protocols and in our area here we have pretty elaborate system of pre-written protocols as to what to do in certain cases, for cases of trauma or for cases where it need specialized care, we'll certainly go to a pediatric center depending upon what their ages are, we go to a pediatric center by default. And so those are pretty much pre-made.

If someone is an extremist and we're having trouble getting signs of basic life we go do have the options to go to a local emergency department where the child can be resuscitated and then transported inter-hospitally after that.

Dr. Mike Patrick: Can parents ride along?

Chief Steve Shaner: Well that's a great question, as Dan would say.

[Laughter]

Chief Steve Shaner: In our area here and in general, I'll speak generally, parents are not only encouraged but in some cases required to go along with their children. And I don't say parents to be exclusive because this could include caregivers who again know their children very well.

Dr. Mike Patrick: Yeah.

Chief Steve Shaner: Not only do the EMS and first responders depend on knowledge from the parents, so do the physicians and nursing staff at the hospitals depend a lot upon the knowledge of parents so they want them there to get the information from them.

Dr. Mike Patrick: Yeah.

22:29

Chief Steve Shaner: So, in general, we make every accommodation that we can to make sure that they come. Sometimes it's not possible for them to ride along with us, sometimes it is. Sometimes they need to bring their own transportation but in general, it's great if they can accompany them in some fashion. Whether they follow us in or whether they drive by themselves or however, it's usually not only a nice thing but it's almost a necessity.

Dr. Mike Patrick: Yeah. And I think that Nationwide Children's and the Columbus community, in general, has really been trailblazers in the whole parent-centered model. I mean, really, parents are welcomed during resuscitations and then the trauma room, I mean, we really want parents to be there and be involved right from the beginning and that's not the case in all places. I think it's gaining momentum throughout the country but it's not necessarily everywhere.

Is there a charge for parents to utilized emergency services?

23:30

Chief Steve Shaner: Again, I'm speaking in generality, in most cases yes, there is some sort of a charge for that. In some cases though, no, there's not.

Dr. Mike Patrick: Kind of depends on the model in the community?

Chief Steve Shaner: Depends on the model in the community, yes. Some folks use strictly a third service or a private EMS response and in those cases they're almost always be supported, some folks use a mix, which are pre-supported as well as tax base supported and some are strictly tax-based supported and they don't have a fee.

Dr. Mike Patrick: You may not know the answer to this, does insurance usually cover that, if there was a fee to the parent, is that something that insurance would typically cover?

Chief Steve Shaner: Yeah. In most cases they do.

Dr. Mike Patrick: OK. And then let me ask you this, what specific pediatric training do providers typically get?

Chief Steve Shaner: Each level that I spoke about, the four levels, they all get some sort of pediatric training in their basic training depending upon the level, the hours increase as you increase in your medical knowledge. Now, the continuing education once you are certified at that level also requires certain specific amounts of pediatric continuing education.

Dr. Mike Patrick: Sure.

Chief Steve Shaner: And that, if you do the math, it equals out to about 14% of the requirement. So if you're required to do 92 hours worth of continuing education in three years then about 14% of that is pediatric focused. There are several specialty courses that, again, this is speaking in general, because everybody is different in what they require, but in this area most responders are certified in different specialty courses such as Pediatric Advanced Life Support, such as ITLS Pediatric courses and there the APLS courses, different courses that are available. And usually most places have participated in one of those programs, some all of them, depending upon how long they've been in the field.

25:43

Dr. Mike Patrick: Yeah. Dr. Cohen, this is not something that's required, the PALS or Pediatric Advanced Life Support or APLS, I mean is that something, it's voluntary, correct?

Dr. Daniel Cohen: In general, it's voluntary. However, the medical directors that are in charge of the EMS programs can require that their folks that work under their guidance have that knowledge.

Dr. Mike Patrick: So, Dr. Cohen, you think that that's something that pretty much all responders should have?

Dr. Daniel Cohen: Yes. I think that 14% seems very robust. The plentitude of pediatric transports ranges depending on your region from 10-14%, sometimes a little bit lower. And of those runs, the minority really require advance life saving skills. So this is a low frequency but very high stakes situation. So I think applying in the extra training is really critical. We always say that children are not small adults, so their anatomy is different, their physiology is different and when kids get sick they can get sick very quickly after having commutative for a long time.

27:04

Dr. Mike Patrick: So they look good and then boom, they're not good.

Chief Steve Shaner: There's fall off the edge of the cliff. And I think having EMS providers recognized and being able to respond preferably earlier requires a significant training and it's great that people invest that way.

Dr. Mike Patrick: Yeah. And the fact that there once like you said, low frequency, I mean if it's only 15% it's even more, for the adult patients you're getting your experience on the job. I mean, you're seeing adult patients, those 75-80% or more of adult patients, so you're practicing those skills everyday and if you're only seeing 15% children then you certainly want that extra training every year so that you are brushed up on your skills and feel a little more comfortable when it does happen.

Dr. Daniel Cohen: And clearly, the adult life saving that EMS providers do much more frequently can be applied to children as well.

Chief Steve Shaner: Yeah.

Dr. Mike Patrick: Now, in this having people on board who are trained specifically, have some specific pediatric training, obviously you want some pediatric specific equipment onboard as well. Can you talk a little bit about that?

28:14

Chief Steve Shaner: So as we mentioned briefly, kids come at a variety of sizes and shapes and we see children ranging from a couple of pounds to 300 or 400 lbs. and that really can provide a challenge to EMS providers to just in terms of the array of equipment that they need and just keeping things organized.

So there is a length-based system that people use and a color coded system so people know the right equipment and the right dosing to guide them in their resuscitation if they need to.

Dr. Mike Patrick: Yeah. So that's kind of a cool thing. So you're talking about the Broselow and basically it looks like a birthday card folded up and then you unfold it and put it at the top of the kid's head and then down to the bottom of their feet and then whatever color that lands on then you have all your drug doses and your tube sizes and things like that.

Chief Steve Shaner: Exactly.

Dr. Mike Patrick: Yeah. Because in an emergency you don't want to be doing complicated calculations in your mind, how much does the kid weigh and then do a little algebra to figure out what size tube you need, so that is a nice resource. And I'm sure that's something that you guys carry on your squads.

Chief Steve Shaner: Yes. It sounds like a simple thing to just make a list of what you think you'll need but actually I did a little research on this and I know that a friend of ours, colleague of Dr. Cohen's and mine, Dr. Andy Fixerbon, a portion of this panel, but I guess I didn't realize that it had so much involvement by so many organizations but the American College of Surgeons, the American College of Physicians, the National Association of EMS Physicians, the EMSC Group and American Academy of Pediatrics all got together and made up a list of what they think that EMS transport vehicle should carry.

And that's a lot of groups to get together and to come up with something and they did that, so that's quite an accomplishment and that has been adopted by our organization and most of the area squads around here or you mentioned that's do have that equipment available. So that's quite…

[Crosstalk]

30:35

Dr. Mike Patrick: So we're talking different size, masks and IV tubing and the tracheal tubes and the blades and scopes that you have to use to put those breathing tubes down; different size backboards, C-collars, I mean, all of the stuff starts to add up cost wise, also consider that they expire, like the plastic tubes and things, so a lot of those then get thrown out. How does that kind of expense to have all that equipment in different sizes? Who pays for that?

Chief Steve Shaner: If it's a fee-based service, most fee-based companies have to absorb that cost. It's the cost of doing business. So the equipment does expire in some case as you said and fortunately there are better and better equipment being developed all the time. And everyone tries to stay current with the appropriate equipment so it's that extra added cost but it's for the population that has the most to gain from it. So it's a worthy investment on our part.

Dr. Mike Patrick: So when you do charge it's not like a flat rate? It's what equipment did you use, how much time did it take, I mean, it's a…

Chief Steve Shaner: Yeah. Depending upon the level of care provided. If it's something that's advanced life support run there is a little bit higher charge for that, but as far as the basic cost it's about all the same.

Dr. Mike Patrick: Yeah. There's a cool program in Wisconsin called the Pediatric Jump Kit Bag Initiative. Can you talk a little bit about that? It's kind of a cool thing. There was a group of women I believe, right?

32:20

Dr. Daniel Cohen: Yes. It started out as a grassroots movement and they partnered with the federal program that Chief Shaner mentioned briefly, EMSC, to provide jump kits or go kits for the EMS units throughout their state. And if you go to one of their websites you can see a map of how it flourished from just a few counties to all across Wisconsin and they've virtually covered the entire state.

And it's really to help local groups provide the right equipment for their own children in their counties and their communities. It was really quite a partnership.

Dr. Mike Patrick: Yeah. And this was just a group of senior citizen women who saw a need and thought we're going to organize and fund raise and try to make this a reality and then they were able to get that equipment into the hands of providers throughout Wisconsin. I'll put a link in the Show Notes to their site as well because there may be some folks listening right now, they say, in our state I'd like to start something like that and so it'll be some encouragement and kind of a model for them.

33:21

Dr. Daniel Cohen: I would say and Chief Shaner covered this just little bit, one of the things we say is all EMS is local and I think that people in their community should really know what their resources are. That's part of being prepared.

Dr. Mike Patrick: Yes.

Dr. Daniel Cohen: And then getting involved if they can to advocate for their community.

Dr. Mike Patrick: Yup. So when you talk about EMSC, which is Emergency Medical Services for Children, Chief Shaner, what exactly is that?

Chief Steve Shaner: EMSC is a multi-faceted organization. EMSC is a federal program actually. It is funded by the Department of Health and Human Services, the Health Resources and Service Administration or what it is referred to as HRSA in many cases, and they have a couple of main goals. Those main goals are basically to ensure that the state-of-the-art emergency medical care is provided to all ill and injured children regardless of their age.

Their second major goal is to ensure that pediatric services are well integrated into the EMS system and to make sure that the entire spectrum of EMS from prevention all the way through any possible illness or injury or acute care and rehabilitation is provided and make sure that it's seamless network there for children.

EMSCs in pretty much all states and U.S. territories they all usually have a main office and that main office is in charge of that specific area or state and pretty much all the activities of that office are taken care of by that state. They're kind of a go between the federal program and the local level of liaison if you will.

35:10

Dr. Mike Patrick: Yeah. So is that an act of Congress that actually created EMSC as I understand it and so it's actually part of the Maternal and Child Health Bureau with the Health Resources and Service Administration of the U.S. Department of Health and Human Services. So I mean this is an official body and really their goal is to try to improve pediatric emergency care across the country and so they have these standards and guidelines and things that individual emergency services bodies can look to try to be compliant with.

How can a parent find out if their local emergency medical services is compliant with the recommendations of EMSC?

Chief Steve Shaner: Well again as Dr. Cohen stated, the EMS resources are mainly local. So the best thing to do if you have a question of any type is to contact your local EMS system and ask them are you folks all trained up as far as your local or regional, whatever it is, EMSC guidelines and have a conversation with them and ask them have they implemented any plans and they will be better educated about the process.

36:27

Dr. Mike Patrick: Sure. So this is something parents out there can really be active and say hey, I want kids in my community to be safer, I'm going to contact the EMS and say hey, are you compliant with EMSC and if not, why not and what can the community do to help you get there.

Chief Steve Shaner: Absolutely.

Dr. Mike Patrick: Yup. Let's talk a little bit about research and improving prehospital emergency care. And I think that the EMSC is involved with that too, aren't they? They have a research arm?

Dr. Daniel Cohen: Yeah. So, EMSCs, one of their objectives is to provide state-of-the-art care to children across the spectrum for emergencies and part of that is to help fund research and they fund Pediatric Emergency Care Applied Research Network, we call it PECARN and that's one of the major arms of the work of EMSC.

In medicine, in general, there are a lot of acronyms and abbreviations and combine that with the federal program we have tons short terms, short abbreviations like PECARN and EMS.

Dr. Mike Patrick: Yeah. It's like a language of its own.

[Laughter]

Dr. Daniel Cohen: It totally is.

37:33

Dr. Mike Patrick: What are some of the goals of research in pediatric emergency medicine? Like why do you research?

Dr. Daniel Cohen: That is a fundamentally excellent question. Much of what we've done in prehospital care, really in the past, has not been evidence-based. And fortunately, moving forward, we're providing more and more research to provide the evidence to do the right thing. A great example I can give you was hot off the presses, it was a study called the RAMPART, another abbreviation and maybe some people watched television a long time ago that might ring a bell?

[Laughter]

Dr. Mike Patrick: That might have been longer ago than I can remember.

Dr. Daniel Cohen: I think Chief Shaner will like this.

Chief Steve Shaner: I am well versed in RAMPART.

Dr. Daniel Cohen: And the RAMPART study looks at these of two types of medications, valium-like drugs or benzodiazepine drugs, for the treatment of seizures and it's just hot off the presses from the New Internal Medicine. And it showed one being as or potentially more effective for the use of seizures and its medication is given in the muscles.

The reason that this is potentially fantastic, an example of light's important, is that in pediatric EMS seizures for us are the number one run for a serious problem. And if we can find evidence to support the right thing to do for seizures, that's a great example of how funding research really can change practice.

39:11

Dr. Mike Patrick: Right. So if we can prove with evidence that one way of doing something is better than another then we can give recommendations to the emergency services folks and say hey, this is really what you should be doing based on the study and that's the sort of thing that EMSC is funding.

The other issue with research and I think we don't talk about quite as much but I think is also important is cost effectiveness. I mean, when you look at the state of the economy today and the recession, are there ways that we can still have great care but can do it in a more cost effective manner. Is that common to the mind of the researchers when they're doing these things?

Dr. Daniel Cohen: Ahmm…

Dr. Mike Patrick: Not always.

[Laughter]

Dr. Daniel Cohen: Yeah. I can think of another study that we're doing through PECARN that addresses somewhat the cost effectiveness but not just in terms of financial cost but exposure cost — the use of CT scanning in minor head injuries. CAT scanning is frequently done in minor head injuries and there's been a recent publication from PECARN looking at a set of rules to try decide who should get a CAT scan and who not.

Clearly there's a cost of those CAT scans and not just financial cost but the radiation exposure cost, I think your listeners and me as a parent care greatly about.

40:27

Dr. Mike Patrick: Oh, yeah. We talked about that before.

Dr. Daniel Cohen: And one of the studies that we're doing right now through PECARN is trying to embed these decision rules into an electronic medical record in the emergency department to provide feedback to the providers as to whether or not a CAT scan would be indicated based on these rules.

So we're in the middle of this research and yes there could be cost utilization component to it but more fundamentally we're trying to get it doing the right thing and to minimizing risk and maximizing…

Dr. Mike Patrick: Yeah. Yeah. Don't do radiation exposure, I mean do it if you have to do it but if you don't, why expose them to the radiation and the cost. Absolutely. With PECARN itself, so Pediatric Emergency Care Applied Research Network, as I understand it, it's divided into six nodes. So we have children's hospitals actually pooling their resources and working together?

Dr. Daniel Cohen: Yes. So there are six nodes spread around the country from coast to coast and within each node there are three institutions. So there are 18 institutions participating from coast to coast.

Dr. Mike Patrick: So what node are we a part of here at Nationwide Children's?

Dr. Daniel Cohen: Again, these are more acronyms for you, Dr. Mike…

[Laughter]

Ours is GLEMSCARN, which is the Great Lakes node.

Dr. Mike Patrick: OK. So it's Nationwide Children's and what other two hospitals are involved with that?

Dr. Daniel Cohen: Ann Arbor in University of Michigan and Detroit Children's Hospital as well.

42:01

Dr. Mike Patrick: All right. And we are the best node, right?

[Laughter]

I'm just teasing. It's like rah, rah, root for your team kind of thing.

Dr. Daniel Cohen: It is a very collaborative group across the country and that's one of the fun parts about working together and move the feet forward.

Dr. Mike Patrick: Yeah. Absolutely. And sharing knowledge and actually that really kind of nicely goes into the next question. Once these pediatric emergency medicine research studies have evidence-based findings, how do we get those findings into the hands of first responders so they can start to change what they're doing based on the latest evidence?

Dr. Daniel Cohen: Chief Shaner mentioned this earlier, EMS providers function virtually the whole time based on their protocols. I think that effect change on the ground would mean changing their protocols. So working through the medical directors, working through the groups that inform the protocols is the way to get there.

But as fundamentally important, engaging the community in the conversation about research because doing EMS research is really difficult and it needs to be very collaborative. And I think we have a lot of educational moments including Dr. Mike's show right now, but also through the times that we teach our EMS providers and we go to continuing education is a great opportunity to disseminate knowledge.

43:28

Dr. Mike Patrick: Sure. I think when you talk about EMS research being difficult and if you put yourself in the parent's mind too, you can really understand that. I mean, when your kid's having an emergency, your focus is on their care right now and so when someone says, can they be a part of a study it's like, no, I just want you to help my kid. And so it really kind of takes a special person to not only be caring for them but then also looking forward to how can we learn from this and communicating that with the parent to get them onboard with helping out.

And I would just put a plea out there for parents that if you're in the position that your child's having an emergency and someone does approach you about having them be a part of a research study, no one's is going to, I would hope, of course I can't speak for every researcher out there, but I would hope it's not something that's going to put your kid's life in danger, but it could help us, help other kids in the future and parents should consider being a part of that.

Dr. Daniel Cohen: Yes. And I would say that the bar is being set for inform, consent and safety is extremely high and this issues related to inform-consent are much higher than in clinical care as it should be.

Dr. Mike Patrick: And Chief Shaner, in your experience, have you seen these studies change what you do?

Chief Steve Shaner: Absolutely. The good part about the system, at least in our area, is even though we've function primarily from written protocols, the interaction between the EMS physicians and our EMS services is very high. We have a great group of EMS physicians in this area as well as I can say in most of the Great Lakes area, because I've been to a lot of places, but we have a good interaction with EMS physicians and that's what gets the word down to the local provider is we're constantly working on those written protocols.

45:33

We have a lot of interaction between the physicians and the folks in charge of running the protocols and based upon that interaction we're always looking for how to better our system and they always draw from Index Research Journals on what's the current thoughts. And the fortunate part about having a huge research facility here in Columbus, Ohio is that we can contact them pretty much anytime we need to and ask them what's the right thing to do.

Dr. Mike Patrick: You have this relationship because you're here in Central Ohio and Nationwide Children's is really involved in pediatric emergency medicine research. But what about folks in Guernsey County, it's a small department, how do they make sure that they're keeping up to date?

Chief Steve Shaner: That's the other fortunate piece about EMSC and about the State of Ohio, how it's organized in the regional system so that those people have basically the same access as we do, even though we're only a mile or so from Children's Hospital, the folks that are 50-60 miles away have the same access. They can get the same direction that we do.

46:46

Dr. Mike Patrick: Great. And we will put a link in the Show Notes over at pediacast.org to EMSC so that parents can go and look if there are in their area of local EMS is not kind of glued in to what EMSC is doing. They'd be able to find their website and get that information and kind of get plugged into the system so they can get the latest findings into their hands as well.

So Dr. Cohen, let's talk briefly about emergency services here at Nationwide Children's Hospital. We have a brand new hospital that is opening on June 28th and we're really excited about the emergency room.

Dr. Daniel Cohen: Oh! It's really exciting. I was fortunate to be part of the design team. It was a really great experience going on the country and seeing how other pediatric emergency departments and generally emergency departments are organized. And we're really, really very fortunate because we have a lot of community support here for our facility and we have a very diverse population.

I know that may not be the perception across the country about Columbus, Ohio but we have a very diverse population.

Dr. Mike Patrick: Yeah. Absolutely.

Dr. Daniel Cohen: And we're very regionalized as Chief Shaner said. That's one of the benefits of Central Ohio and Ohio in general that it really helps lead to the different tiers of care for children. So it's a pretty exciting time here for us.

48:09

Dr. Mike Patrick: Yeah. Absolutely. And the new emergency department, I'm really excited about it. I've toured in it three times now. It's amazing. Really, it's an amazing space. And for those of you who aren't aware, here at Nationwide Children's we have the largest campus expansion in the history of the country going on right now. And there's this huge beautiful tower that going to be opening and it's just really going to be a great resource for the community here in Columbus.

And, when we talk to specialists here, a lot of folks do travel in the Columbus for second opinions or because there isn't a specialist on a certain thing in their area, even though it's a little self-promotion here and we are a national and global podcast, I still like to kind of put our hospital out there because it's a really cool place.

All right. If you check out the Show Notes, we have lots of links for you in this particular episode, emergency services at Nationwide Children's, the Division of Fire for Grandview Heights, Ohio, the EMSC National Resource Center, PECARN, the Red Cross, the Jump Kit Bag Initiative. I mean, lots of stuff that you can use as a resource. So I encourage you to check out the Show Notes for this particular episode.

49:24

And of course we really appreciate both of you stopping by the studio. Before you leave, there's one other thing that we ask all of our guests, one of my passions if for families to do fun things together. They don't necessarily involve screen time, computers and T.V.

And so one of the things that we like to do in our house is play family games, board games, card games, those kind of things. And so we just ask each of our guest what's your favorite family game?

Dr. Daniel Cohen: Our favorite family game right now is Bananagrams.

Dr. Mike Patrick: Oh yeah. So you have the banana-shaped bag with the letters in it?

Dr. Daniel Cohen: Yes.

50:00

Dr. Mike Patrick: Yeah. Very cool. And what about you, Chief Shaner?

Chief Steve Shaner: Well, I have to say we don't have a lot of time for games in our house. It's usually transportation from one sport or activity to another is our game. So I guess we don't have a favorite.

Dr. Mike Patrick: Are you on Facebook or no?

Dr. Daniel Cohen: Yes.

Dr. Mike Patrick: Have you done the words with friends?

Dr. Daniel Cohen: I have not. I have not.

Dr. Mike Patrick: But you've seen it around?

Dr. Daniel Cohen: But I know it's a nationally popular thing.

Dr. Mike Patrick: I did it for a while and I had to stop. I had just deleted it off my phone because it was just taking up too much time.

Dr. Daniel Cohen: Absolutely.

Dr. Mike Patrick: All right. Well thanks again to Dr. Daniel Cohen and Chief Steve Shaner. I appreciate both of you stopping by.

Dr. Daniel Cohen: Thank you.

Chief Steve Shaner: Thanks for the invitation.

Dr. Mike Patrick: Yeah. Absolutely. And of course I want to thank all of you out there for listening to the program. We really appreciate it. Don't forget our next episode we're going to kind of continue this sort of conversation. Dr. Sarah Denny, MD is going to be stopping by, we're going to talk about summer safety. So we have tips on keeping you kids safe this summer. We're going to talk about bike safety, how to pick out the right helmet and to make sure your helmet fits; safety around swimming pools, playgrounds, trampolines, just how you can avoid needing prehospital emergency care.

51:10

I also want to remind you that iTunes reviews are helpful as our links on your webpages and mentions in your blogs, on Facebook and your tweets and on Google+. And be sure to join our community by liking PediaCast on Facebook, following us on Twitter and tweeting with hashtag #pediacast and also hanging out with us over on Google+.

And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show. Also we appreciate you telling your family, friends and neighbors about the program and don't forget to talk us up with your child's doctor at your next well check-up or sick office visit.

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. One more time, to contact us if you have a topic suggestion or a question, just head over to pediacast.org, click Contact or you can email pediacast@gmail.com or call the voice line at 347-404-KIDS.

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.

Guest

• Dr Laura Martin
  Pediatric Hematologist / Oncologist
  Nationwide Children’s Hospital

Topic

• Cancer Survivorship

Links

• Hematology, Oncology, and BMT at Nationwide Children’s Hospital

• Survivorship Care at Nationwide Children’s Hospital

• Survivorship Info from the National Cancer Institute

• Ohio Department of Insurance

• Patient Advocate Foundation

• Needy Meds

• Rx Assist

• Rx Hope

• Partnership for Prescription Assistance

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!

Mike Patrick: Hello everyone, and welcome once again to PediaCast, a pediatric podcast from the good folks here at Nationwide Children's Hospital in Columbus. It is episode 208, 2-0-8 for April 25th 2012. And we're calling this one cancer survivorship.

Now I realize, childhood cancer is a pretty heavy topic, and it's one we haven't previously dealt with here on PediaCast, but we're going to change that today. And I also know some of you out there in the audience yourself have either battled childhood cancer or you've lived through it as a parent, or maybe have relatives or friends who have made the journey.

01:12

Or maybe you just feared that your child would get cancer and you wonder how your family would react and cope. Or perhaps your child is a cancer survivor and you want to know what sort of long term follow-up care they need during the rest of their childhood and throughout their adult live.

Well today we are joined by Dr. Laura Martin, a pediatric cancer doctor here at Nationwide Children's Hospital to discuss an important topic related to childhood cancer -and that is survivorship. But before we get to Dr. Martin, I want to remind you if there's a topic that you would like us to talk about or you have a question for us, it's easy to get a hold of me.

Just head over to PediaCast.org, and you can 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.

02:00

I just want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

So as always if you have a concern about your child's health be sure to call your doctor and arrange a face to face interview and hands on physical examination. Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at PediaCast.org. All right.

So, without further ado, let's turn our attention to our studio guest, Dr. Laura Martin is a physician with the section of hematology, oncology, and bone marrow transplant here at Nationwide Children's. And she's an assistant professor of pediatrics at the Ohio State University College of Medicine.

Her clinical interest include treating children with cancer with a special interest in cancer survivorship which is it turns out is what we're discussing today. So, welcome to PediaCast Dr. Martin.

Laura Martin: Thank you very much.

Mike Patrick: Appreciate you stopping by. Why don't we just start out with a definition. What exactly is meant by the term cancer survivorship?

03:00

Laura Martin: I think the term cancer survivorship is an emerging field in sort of reflects a new look at what our hopes and expectations are for people who have begun and completed their cancer journey as far as treatment. And the focus being on wellness beyond the end of that treatment.

Mike Patrick: Great. So this is kind of the time when the acute treatment is over, and the sort of into the remission stage, and then what kind of follow up and care do they need the rest of their lives beyond that.

Laura Martin: That's right. What the focus really being on what do we need to be looking for and doing for them to optimize their health for many, many years beyond.

Mike Patrick: Sure. We hear the term remission a lot, so I supposed that these are kids who are in remission from their cancer. What really is meant by that term?

Laura Martin: I think it can be a little sticky to get caught up with the term remission because being cancer free is probably a better way to describe that important landmark for all our different cancer diagnosis.

04:03

Mike Patrick: Sure.

Laura Martin: Remission has traditionally referred kind of semantically more to leukemia or lymphoma, and means you've reached a point where the doctor's really can't find any evidence of that cancer anymore.

We don't typically use that term for solid tumor, but the intent and the meaning is really the same. When someone is in remission, they're just technically no evidence of their cancer.

That doesn't always mean their completely finish with their treatment,it depends on the diagnosis. But it's a step along the way to reaching what we would call -of being cured of your cancer and starting your survivorship path.

Mike Patrick: I think another term we ought to define, sort of up front that we hear a lot in cancer care and that is -what is a survival rate? So people talk about what's the five years survival rate. What is that term? What does that mean?

Laura Martin: Five and 10 years survival rates in those can get dissected down into overall survival or disease free survival that is really more from the research world and statistical analysis of patients.

05:12

What we try to emphasize the parents is the only statistic that matters for them and to us really is how their child does, but we can give parents some expectations and understanding of the severity of their child's disease.

The expected prognosis and our expectation for how hard it's going to be to cure or get rid of that cancer based on large studies that tell us five year survival rates, and 10 years survival rate etcetera.

So, when you look back and say, hundreds of patients like your child were treated with this disease using this therapy, at five years this many patients were still surviving. Sometimes that's a helpful discussion to have, and sometimes that information is not as helpful depending on how rare the disease is.

06:01

Mike Patrick: Because each individual kid's survival rate is either going to be a 100% or zero%. And so sometimes the statistics can be a little misleading and sometimes gives parents false hope, and sometimes give more anxiety, you know, that they would otherwise need.

Laura Martin: That's right. So when using those statistics we really treat -do try to tell parents that this is a gauge, it's not an absolute, and it can help things.

Mike Patrick: Is cancer ever cured? I mean someone ever free from their cancer and they really don't need any follow up and it's a done deal.

Laura Martin: Absolutely. And I think that's the good news especially in our field of pediatric oncology, we're happy to say that overall to use a statistic, we really are curing approximately 80% of childhood cancers now if we would get all comers. It's very, very different than in the early 1960s and '70s.

Mike Patrick: That was going to be my next question is just how has cancer survivorship changed over the years and obviously it has changed for the better in a very real and great way?

07:03

What factors do you think have contributed to that change?

Laura Martin: I think one of the largest ones really has been organized large clinical trial. We belong to a consortium that's now called the Children's Oncology Group, you'll hear our practitioners fondly use the acronym COG, or C.O.G.

And that arose out of some smaller consortium that have now united, but the paradigm of many centers across our country and now across the world treating large groups in cooperative trials of patients has given us the opportunity to really define and refine therapies that have been most effective. So, without doing that research in an organized and collaborative way, I'm not sure we would have made those strides.

Mike Patrick: Yeah.

Laura Martin: And certainly along the same time over decades, medical care in general has improved. Significant improvements in how we treat the complications of cancer of infectious risks, bleeding risks.

08:06

Just general health of the intensive care issues for a patients kidneys and heart, and lungs. Those have all improved as well. But I think the big jumps that we've seen in cure rates, in long term survival rates really have to be attributed to the cooperative efforts and clinical research trial.

Mike Patrick: And really just the trials and then the collaboration and then the dissemination of what you've learned from it across the network.

Laura Martin: That's right.

Mike Patrick: Do you think too that we're getting earlier diagnoses and maybe more specific diagnoses, does that help?

Laura Martin: Certainly more specific diagnosis and I think that earlier education and awareness across the board helps. Recognition that some cancers arise as a congenital predisposition and have a link to some genetic syndromes has been something that we've learned a lot about in the past several decades.

09:01

And that continues to emerge as well as the fact that the whole advent of molecular and Cytogenetic studies that we know are a large part of pediatric cancers has given us a lot of power to predict who's going to be harder to cure and to tailor therapies to do better with those more challenging diagnosis.

Mike Patrick: Sure. Once you mentioned that you're up to about 80% if you look at all commerce being cancer free then. What does the relapse rate really depend on? What makes the difference between the 80% and the 20%, is it the type of cancer that they have or is it just an individual's response to treatment?

Laura Martin: A lot of factors can go on to that equation. We know that what we know now is that certain cancers are biologically more aggressive than others.

10:00

And what we also know is what we have available in our armamentarium of treatments for that. We also know that certain patients are more or less resilient or have other unrelated, underlying problems. And when you put those all together the combination of the treatment of patient receives diagnosis they have and their ability to tolerate that treatment all factor into that equation.

Mike Patrick: Sure.

Laura Martin: Sometimes patients aren't able to get adequate treatments and sometimes the diagnosis happens very late or it's not managed optimally in the beginning. So, those things can factor in as well.

Mike Patrick: Sure. And I would suspect that it can be difficult than to always predict who's going to be in that so called 20% where their cancer may come back or they may get a new or different whether truly related or not cancer.

Laura Martin: That's true

Mike Patrick: And so this is why the survivorship program is so important to sort of catch those kids who might have a recurrence of cancer, a new cancer to identify them as quickly as possible.

11:04

Laura Martin: That's true. Probably even more of the emphasis for the survivorship clinic though is on the late effect from therapy that we've given them. It's probably important to point out that entry into the survivorship program here and at many centers, it's getting more streamline across the country.

Usually it doesn't happen the day you finish therapy, so there's a little bit of a window after therapy is completed. Sometimes a couple of years where close monitoring happens for just the kind of thing you're mentioning to make sure that cancer isn't going to come back that there's no obvious sign of it sort of rebounding after chemotherapy.

Mike Patrick: Yup.

Laura Martin: And then once you're in that stable phase, we make the transition to survivorship for the focus really isn't so much on is the cancer going to come back, but what has your body sustained in response to those treatment and what do we need to do to make you as healthy as possible for your future.

Mike Patrick: Sure. What are some of the long term sort of toxic effects of cancer treatment that you're -that folks can experience?

12:04

Laura Martin: Unfortunately we don't have perfect therapies and I wish I could say that in 2012, we have magic bullets to take care of the cancer we want to get rid of.

So, virtually every aspect of a patient's body is subject to side effects, but the big ones that have largest impact for us are probably neuro-cognitive or learning and brain function types of side effects that come chemotherapy and radiation. Specific side effects on the heart, cardiovascular health is a major one for some of the chemotherapy medicines that we use, and the chronologic issues.

So families care a lot about this because they can affect not only a child's growth, but their long term fertility. And their endocrine function, there can be problems such as diabetes, being overweight. Virtually every aspect of your endocrine system and all the hormones that our bodies normally make can be all upset by chemotherapy.

13:06

Mike Patrick: Sure.

Laura Martin: Bone health and growth, skin, eyes, and everything.

Mike Patrick: Yup. So, when you have chemotherapy or radiation your goal is to destroy those cancer cells, but your normal cells are also at risk to being destroyed or modified and having problems associate with them so that's how that occurs.

Laura Martin: That's right. The majority of our cancer therapy is still are really directed at rapidly growing cells because that's a feature of cancer cells that makes them susceptible to treatment. But unfortunately we have a lot of rapidly growing cells in our body so that happens as well. And then what we didn't know initially when these things were being designed is that sometimes 10, 20, 30 years later, there can be side effects that emerged that are directly related those therapies.

Mike Patrick: And maybe we didn't know about those side effects when we first started to use the therapy.

Laura Martin: That's right.

14:00

Mike Patrick: We talked about the recurrence of the original cancer that that's a fairly unusual thing to happen. What about the risk of unrelated new cancers in this patient population? Is that a concern?

Laura Martin: Overall that number if you look far out now and we haven't looked, obviously we haven't studied every single patient, but again the field of this research is emerging most people quoting anywhere from 8% to 10%. For most patients it's still very low risk, but in their lifetime there's a risk and you are that number for cancer survivors to have a second cancer. I can't say it's completely unrelated because we don't know for sure that it is, but that is part of our emphasis in screening in the long term survivorship clinic.

Mike Patrick: Is there a difference between chemotherapy and radiation with regard to -because we hear radiation can cause cancer. Is that something that you see? Is radiation more likely to than result in an unrelated cancer down the road or not really?

15:00

Laura Martin: I think it depends on the chemotherapy agent you're talking about. There are a few that are unfortunately still notorious for having that as a risk.

Mike Patrick: In addition to the radiation?

Laura Martin: Radiation does stand out though, still as an effective treatment, but unfortunately leaving a lot of side effects in its way. So, there's an effort worldwide really to try to come up with newer therapies that could replace radiation, or limit dozes of radiation because it really does cause a lot of problems.

Mike Patrick: So we've talked about recurrence of cancer and the toxic effects of cancer, and so these are things that why would someone would need a survivorship program. But really cancer survivors also have a lot of long term psychological and social effects of surviving their cancer, talk about that a little bit.

Laura Martin: So, all of our patient, I mean they are on treatment, had the advantage of our multi disciplinary team that includes psychology and social work, and psychiatry if it's needed child health sort of developmental specialist from many different angles and that need doesn't end when they finish their therapy.

16:05

And as most of us can appreciate any family going through a cancer journey develops needs regarding that. So, siblings of patients, parents of patients, and as the family extends out those needs continue as well.

So, those are well known and still being studied as problems for cancer survivors and it's clear that everything from issues with transition back into normal life whether it be school depending on the age of the child or venturing into the workforce, reasoning physical activity, just having self esteem issues if there has been major surgeries that we required to treat the cancer.

Some of those can be disfiguring or debilitating, we try to limit that, but still it's a very life changing event no matter how you slice it.

17:02

And then the quote "New normal" that patients come back to have many challenges, so we need to try to address those for them in all those different levels.

Mike Patrick: I think it's important too that parents realize -I mean, acknowledge that these anxieties and problems are there so that they do get the help that they need because there is thinking that okay, that cancer is gone you know, now let's just get back into regular life. But it's not that easy and, but you have to recognize it and sort of -and acknowledge that's true in order to get the help that you need.

Laura Martin: That's right.

Mike Patrick: In addition to the social and psychological aspects, there's also a big financial toll that goes along with surviving cancer as well. And I always do a little bit of prep work for these interviews, and one of the things that I came across I thought was really helpful, was just the whole -how important it is not to let your health insurance lapse.

And even though now we have some healthcare reforms in place that sort of bar pre-existing conditions, but we don't know how long that's going to last and whether that gets overturned.

18:08

And so I mean this are all the full financial aspect of it, but still an important thing that the parents go through.

Laura Martin: It is, it's huge. And we rely very heavily on the expertise of our social workers to help parents and patients navigate those challenges. I know there are efforts ongoing even now as we speak in Congress to try to help with that for this population, but it's not a perfect fix yet.

Mike Patrick: Yeah. And I am going to put some -you know we're not going to get into a lot of detail with this. I did come across some pretty good resources that I wanted to put in the show notes. If you live in Ohio, the Ohio Department of Insurance, their website has some helpful information in terms of covering and keeping your insurance up to date in pre-existing conditions and all that sort of thing.

Also the Patient Advocate Foundation , and of course you know wherever you're located, your hospital, and hematology -oncology social workers are good sources of help in trying to navigate that.

19:06

But it's not something you want to -I mean, you got to be proactive in figuring that out and keeping your insurance up to date. And then there's also a lot of these things drug wise get expensive and how do parents deal with that? I mean, just in terms of the therapy, the drugs, and maybe their insurance doesn't cover something.

Laura Martin: Again I often rely and defer to my social worker.

Mike Patrick: Sure.

Laura Martin: Colleagues because that is a huge problem and we can do our best as physicians, but you know there are resources out there, some of them come from nonprofit organizations that are targeted for specific cancer diagnosis which is a wonderful help, but those are limited.

And so, as you're saying being proactive in getting as much of that information as possible is probably the best route about that. But it can be a huge challenge to say the least for families.

20:05

Mike Patrick: Yup.

Laura Martin: And I wish we were able to take that off their plate completely, but are still..

Mike Patrick: And especially with the economy the way that it is it seems like those kind of resources are drying up. But there are some that again in researching this I came across Needy Meds, RX Assist, RX Hope partnership for prescription assistance.

And I'm going to put links on the show note to all of those things so that folks can -I mean, it's certainly not a guarantee that they'll find help there, but it may be something that they would not otherwise find.

There's also especially in really young kids have cancer, as they get older -I mean, when you're really little you may not really understand how serious the situation is. And so as they get older then they sort of discover how serious it really was and how close they came maybe to not surviving.

And then those obviously are also fear and concerns, and anxieties that really need some time, some professional help to help them get through that. And that parents need to..

21:05

Laura Martin: Take advantage of that.

Mike Patrick: Yeah. And sort of be proactive with getting them the help they need even though they're cancer free. How does cancer survivorship affects family planning and cancer risk in offspring?

Laura Martin: It's a great question, and an area that's actively still being researched. We make efforts at that time of cancer diagnosis to help preserve patient's fertility and again that's a very patient to patient specific kind of challenge depending on their age and the treatment they're going to require, and the diagnosis they have.

But we've gotten better at that in our field over the past several years. Those options are discussed, but at that time that a patient is really more in their survivorship phase of treatment. Fertility is something that we can help patients navigate with specialists.

22:00

There are actually in the Columbus area as well. People that specialize in post oncologic kind of fertility issues for family planning and she's about offspring. Happily we know that most cancers, most pediatric cancers are not something that a parent is going to pass on to their child if they are fortunate.

Enough to be a survivor and go on to have their children of their own. The risk to that child is really very small for a patient that received a lot of radiation or heavy dozes of chemotherapy.

Some recent studies have shown that one of the biggest risks is having babies born at low birth weight and prematurely. But now with the higher incidents of cancer, there is one caveat to that and that there is a subset of patients whose cancers really arise out of what we believe is more of a familial cancer syndrome or cancer predisposition syndrome, and that's a separate issue.

We take advantage of having a genetics councilor in our cancer survivorship clinic to help families tease out whether that's a concern or a risk for them.

23:05

Mike Patrick: Sure.

Laura Martin: Because that's not something that was really appreciated probably fully even 10 years ago. So, that's been a better approach.

Mike Patrick: In terms with the family planning, girls of course you're kind of born with all the eggs that you have and so they're susceptible to the cancer treating agents. But with boys, sperm is made kind of on the go. Is there a problem with sperm counts in terms of fertility ad boys who have had chemotherapy and radiation?

Laura Martin: There can be and it depends again on not just the chemotherapy, but the total dose of that chemotherapy and whether or not they had radiation and where that happened. So, strategies to try to optimize fertility include everything for boys.

Sperm donation and banking before their therapy starts and for girls we don't were it for just sort of out the cusp and this is not the field of my expertise, but those that focus on this are really at the cusp of starting to make it viable to actually freeze eggs and have them be usable later on.

24:11

Right now what we can do is for those patients receiving radiation that would affect the ovaries, there can be a surgical procedure ahead of time to move those ovaries behind some of those organs within your abdomen to shield them and in general are you know, radiation therapy techniques have improved over several decades again to limit side scatter and toxicity direct to those organs.

Mike Patrick: Sure. Let's kind of move on to -you have a child who has survived cancer, they're cancer free, they're going to start now with their survivorship program.

Talk a little bit about just how does that go along then, what sort of you know, how often do they have to be seen? What kind of test and studies do you do? What sort of goes into follow up with cancer survivorship?

25:02

Laura Martin: OK. Patients usually enter into this stream of our survivorship clinic when they're approximately five years out from their diagnosis or two years off of therapy or both.

And we've started doing that a little bit earlier than was traditionally done to optimize care because it really does seem to help with the many issues families and patients have. Those visits happen just yearly, so it's just a once a year visit, but it's a very involved visit. We have a comprehensive clinic for most of these patients, that happens once a week.

And when the patients come they get a variety of testing done in the morning that can sometimes include radiologic studies like a CAT Scan or an echo cardiogram pulmonary function test, lab studies, those sorts of things.

And then the clinic that starts in the afternoon offers to patient visits not only with myself, and then there's practitioner, but with the psychologist, the social worker, the nutritionist, someone from dentistry, our genetics councilor, school liaison.

26:13

And in turn each of those practitioners meets with the family in the patient to address whatever issues they might have and offer whatever services they can. So, we talk a lot with patients on those days because it is a big investment of time.

But we encourage them to keep that on their calendar for once a year visit because it really is the only time we're seeing them now. And we are as part of the children's oncology group updated every two years with recommendations for screening that's specific to certain diagnosis.

And certain treatments that includes everything from what age was a child diagnose and what cumulative dose they receive of this drug or that radiation to best be screening for problems that we are just even still learning about as you mention.

27:00

Mike Patrick: And that that kind of gets us to the treatment summary and so I guess this is kind of a card with all that vital information so that if they moved and went to a new city and so now they're going to a different survivorship program from where they were originally treated, they would have all that information,that's an important thing.

Laura Martin: It is an important thing, and I think the value of that is still being appreciated. Many of our patients as you mentioned are treated when they're really not the one in charge. And their parents got all the education and all the information.

And so, with our patients -as soon as they're able to sort of participate more in that discussion we spend a lot of time educating them. And one of the things we focus on is this is your treatment summary, did you know that you received all these medications and this treatment, and why?

And And this is what you need to worry about for years ongoing. So, we like them to have that as you mentioned whether it's our survivorship clinic or another one as part of their lifelong healthcare.

28:01

Mike Patrick: Sure.

Laura Martin: Because any physician taking care of them will need to know those things as well.

Mike Patrick: You talked about once a year, but I would imagine if they're seeing a psychologist or the dentist, or nutritionist and there's other things, so that the big medical screening is once a year, but they may still need more frequent follow up depending on those multi disciplinary.

Laura Martin: That's right and worry, or happy, and able to see them as often as possible. If things are relatively problem free, that once a year visit can take care of it. But for a lot of our patients we're still seeing them when they're a pediatric patient, and they're going through growth like all pediatric patients in developmental stages and transitions.

So, if something comes up they can come in more often than not. There's also a nurse practitioner run clinic that happens weekly for those of our patients that it's clear they really don't need all those other facets they become to a couple of those, or they just need to come for one facet of that. So, there's many different ways.

29:00

Mike Patrick: To go recheck or those kinds of things.

Laura Martin: Exactly.

Mike Patrick: Now, so you start that five years out from the end of your initial treatment, but this is a lifelong thing. At some point I would imagine, you stop seeing them? Being a pediatric hematologist oncologist, I mean, talk a little bit about the transition from pediatric care to adult care for these folks?

Laura Martin: This transition in terms of the care is a challenge and a relatively new field so at our program we, at this point are still seeing patients indefinitely. So, we have many patients in middle age and older that still comes to us.

We are trying to work with options to perfect the transition system,so that's high on my list of priorities. but what we do right now to accommodate those concerns is we have a pretty substantial basis of physicians that we refer to that are comfortable taking on these patients.

30:06

What's clear, this occurs differently anywhere you look in the country right now. And not many places have it perfected, there are a few very large centers that have tried different models.

And what is clear is that someone becomes an adult as a cancer survivor, their best option for limiting their late effects is that they be as informed as possible as their own health advocate. And that they have in their back pocket a primary care physician that's going to be paying attention to their general health.

And some connection with the survivorship clinic whether it is you know things are so simplified that all they need is a summary of their treatment or that they are established with a clinic as well.

So, at this point we're still exploring ways to optimize that transition. But right now we can offer patients a referral base for anything that we can if address typically.

31:05

Mike Patrick: There's becoming more and more adult centers that have survivorship programs, is their focus mainly on adults cancers, and then the follow up for that or do they see adults who had pediatric cancers or I guess it's probably a mix bag.

Laura Martin: The focus really is on adult cancers, and I think that's the challenge because adult cancer doctors are experts in adult cancers and pediatric cancer doctors are experts in pediatric cancers.

And primary care physicians often have a level of discomfort with both of those, either of those. And so, the sort of three way approach I was mentioning right now is sort of the recommendation for survivors to best optimize their health because there really isn't a perfect model in place.

I'm hoping that that would be something that is seen to have enough values that we can be developing programs like that for patients.

32:02

Mike Patrick: Sure. What's your advice for folks who moved away from big city, so let's say you know their job takes them to a county that's hundreds and hundreds of miles from a large tertiary care center. The follow up care is so important for them, what do you suggest for those folks?

Laura Martin: We've tried to help patients in a variety of situations with that. Navigate with that same problem here,and so a lot of our college students, college aged students that moved away from Columbus we schedule their once a year visit with us even if they're far a field from here for their studies during the summer break.

We also offer a one time consultation for any patient even if they weren't treated here to come and sort of review and discuss their treatment summaries, they can get us their medical records, we can provide that service for them even though they weren't our patient initially.

And I think most survivorship clinics that are established across the country, most pediatric survivorship clinics would tend to offer that as well.

33:05

They don't have to be living in a big metropolitan area to be able to get that care because as long as they've had that pulled together by a team that has expertise, it can happen in pieces or at different times.

Mike Patrick: And this is one of those things too where for the most part unless something is found. We're talking once a year.

Laura Martin: Right.

Mike Patrick: And there's you know pediatric facilities all across the country and so you may have to drive two or three hours, but it's once a year and it's really worthwhile in order to make sure that you have this long term follow up.

Laura Martin: And I think that's why we try to see the families as far as being worth that long day is in one stop or sort of trying to address any issues you might have. Recognizing that this affects every aspect of your life.

And even if we can't fix it that day we can educate and inform patients and empower them as much possible to advocate and get the services they need.

34:05

Mike Patrick: That you talked about the one time consult kind of thing. So, if let's say someone had leukemia and now as an adult they're living in Columbus. So, you would see him just the one time or see him once a year or how?

Laura Martin: If they are an adult already we probably -if they are an adult survivor of a pediatric cancer, we've done that a couple of time where we would meet with them and go over their treatments and recreate a treatment summary and go over there if it's not something they have.

Those patients in the past haven't chosen to then come visit our clinic yearly, but that's certainly an option as well. For those people that really just want to have that all summed up and sort of know what their risks are and what kind of treatment they should be receiving we provided that as sort of a consultation kind of thing.

Mike Patrick: Sure. And then that something let's say they needed an echo cardiogram every how ever many years. I mean that's something then that you put that sort of summary and what's recommended they could take back to their primary doctor and then they could order those things. gotcha.

35:11

Laura Martin: That's right. And I think the recommendation we give to people to remain connected with a survivorship clinic whether it's our or someone else's is just the fact that this is an area of ongoing research and we're still actively learning. So, as I mentioned every two years those screening recommendations are changing and we want patients to have the advantage of being abreast of all those as well.

Mike Patrick: Right. And I would encourage people I'm sure there's folks listening who are in this exact situation and maybe you haven't even thought of about it and you think back and oh yeah, my child did have a childhood cancer and they're not in a survivorship program right now. It's easy to make a phone call to our survivorship program and get plugged in.

Laura Martin: That's right.

Mike Patrick: And we'll put a link in the show notes, the survivorship clinics and so that they know how to get in contact with you here at Nationwide Children's.

36:02

And of course as I've mentioned before in the show we see folks from all over the country, so if you don't have the survivorship program near you and you want to take a little vacation trip to Columbus, we have a great zoo, and lots of stuff to do here in Central Ohio. Well we really appreciate you stopping by and taking time out of your schedule to talk about these things.

Laura Martin: It's my pleasure thanks so much.

Mike Patrick: Again in the show notes we'll put a links to the survivorship clinic here at Nationwide Children's Hospital. I also have some links to survivorship information from the National Cancer Institute and the Ohio Department of Insurance as I mentioned in the Patient Advocate Foundation.

And then Needy Meds, RX Assist, RX Hope, and partnership for prescription assistance so just check out the show notes at pediacast.org if you are interested in learning more about those things. Before you take off Dr. Martin, there's one other thing we ask all of our guest here on PediaCast.

One of my passions is for families to do some fun things together that don't necessarily involve TV screens. And so I think family game time is kind of -has always been sort of fun time in our house. So, we're just kind of making a list of different games and activities that are out there.

37:08

So, just from your own experience what's a good family game for people?

Laura Martin: We're big on Charades, it's not a board game.

Mike Patrick: Oh yeah.

Laura Martin: But my children are into drama.

Mike Patrick: Oh sure, yes. Do you use pre made cards or does each person just sort of pick what they're going to do and do it?

Laura Martin: We have a few from other games actually like Trivia games and things like that. But my kids usually like to make up the topics from and we go from there.

Mike Patrick: Oh that sounds like a lot of fun. We've done that more than a few times in our house too. So I love that. All right. Well, once again thanks to our studio guest Dr. Laura Martin for stopping by. I also want to thank all of you for being a part of the program, we really appreciate you making PediaCast a part of your day.

Some exciting news coming up, our next episode, actually our next two episodes are going to focus on summer safety kind of stuff. 209 is the next one, we're going to talk about pre-hospital emergency care.

38:03

And then episode 210 is going to be a summer safety extravaganza. We're going to talk about bicycle safety, making sure helmets fit right, and choosing the correct helmet. Swimming pool safety, playground, trampoline safety all these kinds of things. so, you definitely don't want to miss the next two episodes where we talk about emergency care and safety issues.

Of course these are topics that are near and dear to my heart being a physician with the section of emergency medicine here at Nationwide Children's. But it's a good time of the year to talk about these things. I also want to remind you iTunes reviews are helpful. If you have not reviewed us on iTunes, please take the time to do so.

It really only takes a couple of minutes and a lot of people find this program and give it a try based on reviews on iTunes. So, I would appreciate that. Also links on your web pages and mentions in your blogs, on Facebook, in your tweets, and on Google+.

Also be sure to join our community by liking PediaCast on Facebook. You can follow us on Twitter, or tweet with the hash tag #Pediacast and we're also on Google+ if you want to hang out with us there.

39:05

Be sure to swing by the show notes at PediaCast.org to add your comments on today's show. And we also appreciate you telling your family friends and neighbors about the program.

And don't forget to talk us up with your child's doctor at your next well check up or sick office visit. We have a new poster, I've mentioned before that we had one, we actually have two options now. So if you head over to PediaCast.org and click on the resources tab, there's a couple of posters that you can download, printout and hang up wherever moms and dads hang out.

I also want to remind you that if there's a topic that you would like us to talk about or you have a question for the program, just go to PediaCast.org and click on the contact link.

You can also email pediacast@gmail.com, or call the voice line at 347-404-KIDS, again 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.

Topics

• Concierge Medicine
• Inhaled Steroid Use for Asthmatics
• Rehydration Therapy in the Emergency Department
• MRSA – Risk Factors for Household Transmission
• Whhoping Cough – A New Strain Coming to Town?

Links

• Is Paying for ‘Concierge’ Health Care Worth It? (Wall Street Journal)

• Intermittent Budesonide in Young Children With Recurrent Wheezing (PubMed)

• Rapid Intravenous Rehydration in Gastroenteritis (PubMed)

• MRSA: Risk Factors for Household Transmission (PubMed)

• New Strain Of Whooping Cough Causing Concern

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 from the folks at Nationwide Children's Hospital in Columbus, Ohio. I'd like to welcome everyone to the program. It's episode 2-0-7, 207 for April 18th, 2012 and we’re calling this one Concierge Medicine, Research Round-Up and Whooping Cough.

Research round-up, those of you who are regular listeners of the program know that once a quarter or so we take some time to sort of dissect some research articles and we're going to do that today. In fact, the topics are ones I think that a lot of parents will be interested in. Asthma, lots of you out there have kids who have reactive airway disease and have intermittent wheezing, so we do have a research study on the treatment of asthma in kids; also a lot of folks, especially this time of year, are dealing with vomiting and diarrhea illnesses and sometimes your kids get dehydrated and end up in the emergency department needing IV fluids.

So we're going to discuss a new study on IV fluids and kids with dehydration in emergency departments. Then finally in our research round-up, we're going to look at the study that talks about the transmission of MRSA in the home. MRSA of course being Methicillin-resistant Staphylococcus aureus, so it's a bacterial skin infection you get abscesses and I know lots of moms and dads know exactly what I'm talking about, because these infections are common and they sometimes will spread from one family member to another in the household; and so you're sort of constantly dealing with someone who has one of these infections.

02:17

So we're going to talk on a research article that looks at transmission of MRSA in the home and what you can do based on the results of this study to lessen your risk of getting MRSA from a family member at home.

Before we get started with the show though, a recent article in the Wall Street Journal and I'll open a link in the Show Notes for you, deals with concierge medicine. Basically, this is where a doctor takes on a relatively short panel of high income patients and the doctor charges a retainer fee directly to the family rather than taking health insurance. And it's kind of a pay once, at least once a year, get everything included kind of thing.

Sort of as an example of this, there are some doctors that charge up to $25,000 that's not only retainer fee, but it also is all-inclusive. So, for $25,000 a year, this is your doctor, you can go in whenever you want, there's not going to be a long wait in the waiting room and it's going to include not only your health maintenance exams but sick office visits. Anything that the doctor has direct control over the cost, so laboratory, simple laboratory things, simple x-rays, urinalysis, EKGs, that kind of thing. Anything your doctor can do in the office would be covered for this $25,000 a year.

And some of them have a poor man's special. So, for like $1,500, so much cheaper, you get the retainer, so this is just going to be your doctor, they're not going to be seeing lots of patients so you can get in easily to see them; and it includes one preventative care exam, sort of well check-up, so to speak, but sick office visits, any labs, x-rays, EKGs, urinalysis, those kind of things cost extra. So your $1,500 gets your health maintenance exam and gets you access to this concierge doctor.

04:17

So why would you pony up that kind of money? Well, you get to see the doctor when you want, on your terms, you don't have to wait. You actually going to see a doctor in the office, you don't see a nurse practitioner or a physician assistant or some other physician extender. And here's the key, the doctor has the time to spend a significant time with you in the exam room, explaining things, answering questions, so they're not in and out in 5-10 minutes.

So this sounds good in theory. I mean, the product certainly sounds good. It's a description of a primary care office back a few decades ago. And it would certainly make primary care more palatable for doctors who now have thousands of patients in their practice and are force to see, you know, upwards of 30-40 patients a day just to make ends meet.

But then the question sort of became in my mind as I read this article, how many doctors are actually doing this? This is just in New York City, in LA and Miami where they have these kinds of things or is this becoming a more of a common set-up. And you might be surprised to know that the numbers are increasing quite a bit. In fact, the American Academy of Private Physicians, which is a group representing these so called concierge docs, they say that 4,000 doctors across the country are offering these kind of services and the number is growing by another 1,000 doctors every year and it does include pediatricians in the ranks of these.

05:50

So this got me thinking are we heading toward a two-tiered system of medicine in this country where those who can afford it see private doctors in plush clinics with little wait time, in and out, quickly but at the same time when you're in the doctor being able to spend significant time with you and answering your questions; while those who can't afford this are forced into crowded clinics, staffed primarily by physician extenders, nurse practitioners and physician assistants.

So it gives you something definitely to think about. I'm certainly not advocating this kind of system, but look, if you're fresh out of medical school and you want to go into primary care and you have $200,000 of medical school loans to pay back and you want to work 40 hours a week instead of 60 or 80 and you want to see 15 patients a day instead of 30-40 so you can go home unfrazzled and spend quality time with your family and if you don't have to fight and argue with the "I don't have a clue because I don't have a background in medicine insurance company decision makers," are you going to pass up this kind of gig, especially if it becomes more common place.

06:58

So look out America, this could be the future of primary care. Again, something definitely to think about. Now, if you're thinking about jumping on the bandwagon as a patient of a so-called concierge doctor, there are some questions you might want to ask your perspective physician and you can find those questions in the Wall Street Journal article I eluded to and as always, we'll have a link to the story for you over the Show Notes at pediacast.org.

All right. So, we have a research round-up coming your way. We're going to talk about inhaled steroid use in asthma patients, is this something that should be done daily or is it better to use inhaled steroid intermittently, we're going to discuss that. Also IV fluid rehydration in the emergency department, a couple of different ways you can go with how you rehydrate kids and we'll discuss that. And then as I mentioned, MRSA risk factors associated with household transmission and what you can do to stop the spread.

And then we're going to wrap things up after our research round-up with the new story about whooping cough. There may be a new strain of whooping cough or pertosis coming to town and your vaccinated children might not be protected against it. So we're going to discuss that.

08:08

I want to remind you if there's a topic you'd like us to talk about or if you have a question for us here at PediaCast, it's easy to get a hold of me. Just go to pediacast.org and 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 treatment7 plans for specific individuals. If you have a concern about your child's health, make 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 over at pediacast.org.

All right, with all that in mind, stick around for our research round-up, it's coming your way right after this.

[Music]

09:27

All right. We are back and we're going to cover a research round-up now. For those of you who have not heard one of our research round-ups in the past, basically we just take three recent research studies and we kind of break them down, analyze it and then talk about what it means for you, the parent.

And the first one is on intermittent Beudesonide in young with recurrent wheezing. OK. So let's break that up. Let's break that down a little bit, make it a bit understandable. Beudesonide is an inhaled steroid medicine used as a maintenance therapy for kids with asthma. So it's something that they generally use every day and it helps to prevent asthma flare-up, so to speak. Also known as Pulmicort, that's one of the brand names of this particular chemical. So if you've heard of Pulmicort before, you know someone who's taking it or your own kid is taking it, that's what we're talking about.

So this particular study is going to look at to see if intermittent use rather than daily use would be a better thing and this actually comes from multiple institutions across the country. It was published in the New England Journal of Medicine last November. And with all of these articles we will in the Show Notes over at pediacast.org the Show Notes for episode 2-0-7 we will have links to these articles on PubMed. So if you want to see the articles for yourself, there'll be a way for you to do that.

10:49

OK. For this one, the question before the researchers was among preschool age children with recurrent wheezing is intermittent Beudesonide inhalation suspension or Pulmicort superior to daily use in reducing exacerbations. So what they do here, well children 12-53 months of age, so one year to 4 1/2 years of age where looked at in this study and there were some guidelines for which kids that they could use.

Each child had to have had at least four episodes of wheezing in the previous year, they also had to have a positive value on the Modified Asthma Prediction Index. So that just spent that they had to have certain criteria that made each child likely to have future problems with their asthma. And then at least one of their four exacerbations in the previous year where their flare-ups had to require oral steroids, so Prednisolone or Orapred, or it had to involve an emergency room visit or hospitalization for the asthma flare-ups.

So these are kids with pretty bad asthma. These kids had to have at least four episodes of flare-ups in the past that required either a trip to the ER or hospitalization or the prescription of an oral steroid.

12:06

All together 278 children were enrolled and of those 213 or 77% completed the study. So once they enrolled these kids, they randomized them into two groups. Group one would get a daily low dose regimen of inhaled Beudesonide solution, so this is the control group. This is what generally is already done. They would get 0.5 mg every day.

So for those of you who have kids with asthma who are young and so they are not using an inhaler, they're using a nebulizer, that's what we're talking about here. They would have the Pulmicort nebulized and it is the 0.5 mg dose. It also comes in a 0.25 mg that sometimes is used, but the standard dose that most kids get is of low dose Beudesonide is 0.5 mg respule given once a day. So that's what group one, the control group, did in the study.

The experimental group would use intermittent high doses of inhaled Beudesonide and what they would basically do with this is early on during a respiratory illness, so as soon as the kid got a little sniffle, the parents would start this. So they didn't do it every day but as soon as the kid showed signs of a viral illness, they would start using their inhaled steroid. But they wouldn't use the 0.5 mg once a day; they would use 1 mg twice a day. So they're actually using four times as much, but intermittently.

13:39

So, much higher doses but only when the kids start to show sign that they have a respiratory illness. OK. So they randomized them into these two groups, the daily low dose and the intermittent high dose, and then following randomization they did look at the two groups to make sure that the clinical and demographic characteristics of the two groups were similar, because they didn't want any confounding variables to be in play, so they made sure that the overall severity of the kids' asthma, their social economic levels, how well that they were adherent to their therapy, those kind of things was equal between the two groups.

And then they did a one year prospective study. So they took both of these groups and said, OK, we're going to watch you moving forward for a year. And the primary outcome for this study is what is the frequency of exacerbations or flare-ups as defined by the number of physician consultations for acute wheezing resulting in a course of oral steroids. So, as we move forward with each of these groups we want to know how many time a year does each kid have to go in and see a doctor for an asthma flare-up and that flare-up was bad enough that they were prescribed an oral steroid for the flare-up.

14:54

Now secondary outcomes, so the other outcomes that were just observed along with the study, the number of episode-free days, so these are the number of days that the kid did not have any asthma symptoms and in the case of the experimental group the number of days that they didn't have any respiratory symptoms at all. So these are the number of days they were not using their inhaled Beudesonide.

Also the time it took to get to the first and second exacerbations from the go time, how long did it for them to have that first flare-up, the frequency of albuterol use, the rate of treatment failure, the rate of wheezing-related health care utilization, quality of life measures and change in height over the study period. That's one of the things that parents say we're concerned about if a kid is on an inhaled steroid everyday could it affect their growth. So they wanted to see if there was any growth difference between using it every day and using intermittently.

15:55

OK. So what did they find?

Well, the primary outcome, so the frequency of flare-ups, in the daily low dose control group there were 0.97 exacerbations per patient a year. So if you took the total number and divided it by the total number of patients over that year, the average is 0.97. So each kid had about one major flare-up of their asthma during the course of that year in the control group, the daily low dose group.

In the intermittent high dose or experimental group, that number was 0.95, some say 0.97, it was 0.95 exacerbations per patient a year. So again, each kid in the intermittent high dose experimental group also had about one significant flare-up of their asthma during the course of that year.

So, this of course is not statistically significant so there was no difference between the two groups. So no difference in terms of frequency of exacerbations between daily low dose and intermittent high dose inhaled Beudesonide.

17:05

OK. What about the secondary outcomes?

The number of episode-free days was 78% for both groups, no difference at all; 78% of the time they were symptom-free, 22% of the time they were dealing with upper respiratory symptoms or wheezing and in the intermittent group that's the amount of time that they were using their inhaled steroid. There was no significant difference in time to first and second exacerbations, how long it took to get to that first flare-up, no difference there.

Frequency of albuterol use, 6% of days the kids used albuterol and 6% of all days of the year for the intermittent group and 5% for the daily group. So again, pretty similar there, no significant difference in terms of frequency of albuterol use.

What about the rate of treatment failure? No significant difference there. The rate of wheezing-related health care utilization, there were 2.4 visits per year per child to their doctor that was unscheduled because of their asthma for both groups. So these kids in both groups on average they'd go to their doctor 2 1/2 times a year for wheezing and one of those times they would end up on an oral steroid and there was a time they wouldn't.

Then again we're just talking averages and the important thing here though is no difference between the two groups. With regard the quality of life measures and change in height over the study period, again no significant differences between the two groups.

So, the authors conclude that a daily low dose regimen of Beudesonide inhaled is not superior to an intermittent high dose regimen.

So the two regimens are pretty much the same. Some discussion points here, most of you out there who have kids with asthma who are on a daily inhaled steroid, that's what you do. I mean, that's still really the standard of care, at least here in the United States to do daily inhaled steroid, not the intermittent high dose as was described here.

19:07

So why talk about this, especially since we didn't get a statistically significant result, what's the big deal?

Well, some parents would say the daily group, at least on the surface it would seem, the daily group has a much higher steroid exposure over the course of the year and the intermittent group, since they only use the steroid when they need it, they have a lower total steroid exposure. And so from a parent's standpoint maybe I'd rather do the intermittent type so that my kid doesn't get as much steroid.

So at first look, you'd think that will be the case, but it's really not as true as you'd think, does the intermittent group really have less steroid exposure. And the authors didn't make a point of this but I do think it's the question on most parents' mind, in this intermittent group, was their steroid exposure less?

Let's look at this. If you take the intermittent group on 22% of days they use their high dose Beudesonide, so they were fine 78% of the time but 22% of the time when they started to have the runny nose and congestion, they started their inhaled steroid. If you calculate that out, 22%, that's about 80 days and on those 80 days, remember the kids are getting four times of the dose compared to the daily dose with the low dose group. So instead of getting 0.5 mg once a day, they're getting 1 mg twice a day. So four times the amount at 80 days that equals the equivalent steroid exposure of 320 days versus 365 days for the daily low dose group

So really, over the course of a year the intermittent group only has 45 less days of exposure. Now you might say, yeah, but that adds up over years of use, I mean it's only 45 days in one year but what if my kid's taken an inhaled steroid for 20 years, then what?

21:06

Well before you hop on that bandwagon, you should also know that daily inhaled steroids already have a very low total body exposure profile. So when you compare inhaled steroids to oral steroids, we're basically by using inhaled steroids trying to prevent the number of acute flare-ups that require oral steroids, and the reason for that is because a five-day course of oral steroids is about the same as two years of low dose daily inhaled steroid in terms of total body exposure.

So when you inhaled the steroid, the amount of steroid that gets to the whole body it would take two years of being on a daily low dose inhaled steroid to get the same amount of total steroid exposure on your whole body as it does in the five-day course of oral steroids.

And the studies have consistently shown that in large well-done studies that daily inhaled steroids are at low doses are safe and effective. So, do we argue that we need to make this change from daily to intermittent based on that kids are going to get less steroid exposure? Maybe, but it's a weak argument.

22:18

How about cost?

And again this was not addressed by the research team and I think it should have been. In fact, I think this would have been a more convincing argument for changing the standard of care. Again, I did a little research, myself, and if you take 30 days of once daily low dose Beudesonide, what's the cost of that? So what's the monthly cost of a kid in the control group, so sort of what's the standard of care right now?

Well, that's about $50. So inhaled Beudesonide costs about $50. Now I know not all parents are paying for it, their insurance may be paying for it, but someone is paying for it. So, there's still a burden of healthcare cost here and it's about $50 for 30 days. So in a year it's about $600 a year. Now, if we compare that to the intermittent group, remember about 80 days of use but using four times as much during those 80 days, if you do the math that comes out to about $533 per year. So that's a saving of about $67 per year.

But again, over a lifetime of use that's going to add up and when you consider the very, very large number of people who use daily inhaled steroids and that you consider that over the course of all of their lifetimes, that figure is definitely going to add up. Unlike total body steroid exposure, which really isn't much even when you add it up, the money does add up and it adds up on a very real way. And when you consider our overall healthcare cost burden these days, I do think that's significant.

So I think future studies really need to consider cost as one of their secondary outcomes, because cost does matter more than total steroid exposure, in my opinion.

All right. What about efficacy? Since the two groups are so similar, the next question in your mind might be are inhaled steroids doing anything at all? I mean, maybe the groups are similar because inhaled steroids are ineffective to begin with. So why didn't the authors include a placebo group to see if the placebo kids did have a higher exacerbation or flare-up rate?

But, previously well-done and large prospective studies have shown that daily low dose inhaled steroids are effective at reducing asthma exacerbations. And remember, asthma flare-ups can be deadly and the authors didn't want to put the kids at unnecessary risk by adding a placebo arm to the study because this is really already been shown to be effective in very well-done studies.

24:45

There have actually been those who criticized this study for not including a placebo group, but I'm with the authors on this one. As I already mentioned there's already plea of evidence out there to support the safety and efficacy of inhaled steroids. So in the end, daily low dose inhaled steroids is still the standard of care for the maintenance and prevention of exacerbations or flare-ups in children with asthma.

And I'll caution parents out there who are listening, don't change from daily low dose inhaled steroid to intermittent high dose treatment on your own. Talk to your doctor, let them make the call along with you in collaboration, but I wouldn't expect your doctor to be supportive of this change. Again, asthma exacerbations can kill children and we know that daily low dose inhaled steroids prevent deadly exacerbations.

And one study of 200 some kids isn't going to turn the ship on daily inhaled steroid use. So we'll keep our eyes on the journals and if larger study shows similar results and if the cost advantage is pointed out, we'll let you know. I think if those things happen, if further studies do show, larger well-done studies show similar results and the cost comes more to the forefront here, then the folks who make recommendations and guidelines might be swayed to change their mind on this one.

26:02

In the mean time, stick with what you're doing and as always when it comes to making healthcare decisions for your child make sure you talk to your doctor. One final point and I'd be remissed if I didn't take this opportunity to stress something really important here, daily inhaled steroids and the intermittent higher dose inhaled steroids do help. But the most important immediate treatment for anyone having an asthma exacerbation is the bronco dilator, not the steroids.

So it's important to know which medicines your child has and you need to know the names of those medicines and their functions. Your rescue medicine is always a bronco dilator, something like albuterol or Proventol or Xopenex. And I see too many parents when I worked in the ED who don't know the difference between their child's maintenance treatment and the rescue treatment. It's called rescue for a reason, so make sure you know which medicines your kids are taking and when to give each one.

OK. So let's move on. The next study, this one is a particular interest to me since I do see kids in the emergency department. I hate to be self-indulgent here, but I think it would be of an interest t many of you as well since this is another aspect of medicine that many parents face every day. And this one deals with the IV fluids.

I'm sorry there's not an individual parent out there who faces this everyday but as a parent this is something that you do face from time to time in a very real way and that's when your kid has vomiting and diarrhea and end up dehydrated and you take them into the emergency department because you think they might need IV fluids. So that's what this one is going to deal with.

27:34

This comes out of the hospital for sick children in Toronto and was published in the British Medical Journal also last November. And again, as with the other studies we'll have a link to this particular article in PubMed if you head over to pediacast.org, click on the Show Notes for episode 207.

OK. So the question before the researchers among children with dehydration treated in an emergency department does rapid intravenous rehydration compared to standard rehydration improve the clinical outcome at two hours or reduce the length of stay in the emergency department?

So what they did here is they look it from December 2006 to April 2010 children who are three months of age to 11 years of age and they all had gastroenteritis, so a stomach virus, that was causing vomiting and diarrhea and so the kids were dehydrated. And the way that they defined dehydration, they used a validated dehydration scale and they used parameters that we use to measure clinical dehydration, things like heart rate, what are the mucous membranes like, are they moist, are they dry, are they tacky, also skin trigger, capillary refill.

They also used an electrolyte panel and glucose to determine eligibility and then based on these things they decided whether a kid could be included in the study or not. Some of the exclusion criterions include underlying chronic illness, history of bilious or bloody vomiting with this illness, suspected surgical conditions, low blood pressure or hypotension, severe electrolyte disturbances when they got the blood work or low blood sugar or too high blood sugar.

29:13

And the reasons are that those kids need a specifically tailored work-up and management. So these aren't your standard kid with a stomach bug that gets dehydrated that comes into the ER. So anything more complicated than that it was not for this study.

Now, all of the kids that they identified as being eligible, the first thing they did is just they tried some oral rehydration therapy, although not with medication. They just have them sipped on some fluids see if they could hold it down. If they were able to hold it down they'd let them keep sip in and try to rehydrate them orally. But if they failed oral rehydration, so they started to drink but they continue to vomit or they weren't drinking enough to change their clinical state so that they weren't dehydrated anymore, then they were entered into the study.

Once they were entered, they were divided into two groups — the control and an experimental group. In this case, the control group would get standard rehydration, we'll talk about what that is in a minute and the experimental group would get rapid rehydration to see if that would make a difference in terms of how fast they were able to get rehydrated and how long they had to stay in the emergency department.

OK. So the standard rehydration group would get a fluid bowl list, a standard fluid bowl list of 20 cc/kg of normal saline over an hour. And then subsequent fluid was given per protocol and that protocol basically just looked at the kid's age and weight and would determine what their maintenance fluids ought to be. So they would give them a big bowl of 20 cc/kg and then slower IV fluid infusion right after that based on the kid's age and there's pretty standard on how we go about doing that. So that would be the standard rehydration group.

30:58

The rapid rehydration group would get 60 cc/kl of normal saline over an hour and then subsequent fluids according to that same protocol. So in other words, what we're doing here is just saying and so I've given him 20 cc/kl and then a slower rate, let's give them more up front. Let's give them 60 cc/kl, so bigger volume and see if can get them rehydrated faster by doing that.

And the primary outcome is was the child successfully rehydrated at the two-hour mark and then secondary outcomes, what is the time until discharge, what is the hospitalization rate and what is the prolonged treatment rate and prolonged treatment was considered in emergency department stay of greater than six hours or admission to the hospital following their ED stay; or if within 72 hours of discharge they bounced back and got admitted to the hospital, that was also considered a prolonged treatment.

All right. So 226 children were enrolled and like our last study we talked about the baseline characteristics were similar for the two groups, so there was good randomization so we don't have a lot of confounding type variables. For both groups, 60% of the kids were mildly dehydrated per their dehydration score and 40% were moderate to severe dehydration and that was equal for both groups.

32:21

All right. So what did they find? Well, one-third of all children in both groups were well-hydrated at the two-hour mark, but two-thirds of them did take longer than two hours; but it's in equal number on both groups. And there was no statistically significant difference between the two groups with regard to hydration status four hours time until discharge, hospitalization rate or prolonged treatment rate.

So the authors conclude that rapid intravenous rehydration has no advantage over standard intravenous rehydration among children requiring IV fluids because of uncomplicated gastroenteritis and dehydration.

So again, sort of the point here and again I apologize for being a bit self-indulgent and I know this going to be more interesting to the clinicians out there than to the parents, but the point here is that rapid rehydration, if you give the more fluid at the front-end even though it seems like you might rehydrate faster and get them out of the emergency room faster, it really and according to this study does not appear to be the case.

Now that leads into an interesting point, we have two studies that we're talked about today that fail to show statistically significant findings. And you might be saying what's up with this, why do you even bring these studies up?

Well, keep in mind every investigator brings bias to the table, then they have a hypothesis, they think they know what might happen based on their own knowledge and experience and they set out to prove a point. They think they have a better idea and they want statistically significant results to prove their hypothesis, right?

Well these two studies are different. Rather than trying to prove a new idea is a great idea, these investigators are coming in with the hypothesis that maybe a new idea isn't all that great. If it's not broken why fix it? Just because an idea is new doesn't mean it's better. Is the new idea of intermittent inhaled steroids really better than the daily low dose standard? And in this one, is the new idea of rapid rehydration really better than the tried and true standard rehydration?

34:26

In both of these studies, the investigators' sort of worldview was they didn't think that these new things really were better ideas. So that was their bias. So these guys were looking for statistically insignificant results. That's what they wanted, to prove their point that these new things really aren't better. And that's exactly what they got.

So sometimes, statistical insignificance is a good thing. So if you hear, ahh, that article wasn't statistically significant, well maybe if you really look at the study because maybe the fact it was not statistically significant is actually significant. OK.

As with the previous study too, I'd be remised if I didn't point something out here. Not all kids failed their oral rehydration and because of a drug called Ondansetron or Zofran is the brand name of Ondansetron there is a medicine that helps to take away nausea. And so a lot of times now in the emergency department we'll give kids a dose of this medicine that really just sort of magically makes the nausea feeling go away and kids are able to tolerate oral hydration much better.

And so one criticism of this study is that they didn't use Zofran and so the kids that failed oral rehydration, could they've had a better shot of being able to be successfully orally rehydrated if they've had this medicine. So the study didn't use that. And I will say this, since we've started Zofran in a wide spread fashion, lots of kids have been able to avoid getting IV fluids and that's a good thing because IVs cause some pain, cause anxiety, there's the risk of over hydrating, there's the risk of creating electrolyte disturbances through over hydrating or using improper fluids.

36:33

So, being able to rehydrate orally is a good thing and the authors of this study didn't really point that out. But I wanted to point out to you that if you do have a kid with vomiting and diarrhea just because we're been talking about IV rehydration, chances are when you do go in they'll get a dose of Zofran and be able to orally rehydrate.

Now, of course Zofran is not without its own consequences. Headache and diarrhea are common side effects of Zofran. Diarrhea is not necessarily good thing when you already have vomiting and diarrhea. And so as with all things medicine, we have to look at the benefit versus the risk or the benefit versus the side effect profile and that's why it's important to talk to your doctor about these things because they'll have some insight based on their own knowledge and past experiences.

All right. Let's move on to our final study in this week's research round-up and this one is from investigators in Minnesota and the Centers for Disease Control and Prevention. It was published in the Journal of Pediatric Infectious Diseases also last November 2011. And as always, we'll put a link to the article in PubMed and you can find that at pediacast.org in the Show Notes for show 207.

37:47

All right. So the question before the researchers for this one is among households with children previously infected with MRSA or Methicillin-resistant Staphylococcus aureus, what risk factors were associated with MRSA colonization months later in the same patient or household contacts compared to those households without MRSA colonization?

So in other words, if a kid has MRSA, what sort of risk factors make it more likely that they will continue to be colonized with MRSA and at risk for future infection and what risk factors are associated with other people in the household becoming colonized from the bacteria?

So, patients were initially identified based on culture results at 12 Minnesota hospital laboratories. So there were 12 hospitals involved, if they got a positive MRSA in a kid then the person was deemed, at least, and identified for this study. Then they looked at some exclusion criteria, so if the kid was in the hospital for their MRSA infection, as long as they'd only been in the hospital for 48 hours or less, that was great, that was fine.

But if they had been in the hospital for a longer period of time than 48 hours prior to the diagnosis of the skin infection then they weren't eligible. And the reason for this is we're looking at community acquired MRSA. We don't want to know about MRSA that you might have caught while you're in the hospital because that's a different bug all together.

39:18

They also were excluded if they had previously been hospitalized in the past year or if they've had surgery. Dialysis patients were excluded, residents of long-term care facilities at any point during the past year were excluded, as were patients with entholic catheters, percutaneous medical devices, so any tube through the skin, G-tubes, that sort of thing, they were not eligible for this.

So basically, we want healthy kids who don't have chronic illnesses, they have not been in long-term facilities or hospitalized or have surgeries. They're not at risk for being colonize with MRSA. They're healthy kids as we were talking about here, with skin infections, abscesses from MRSA, that's what we were looking at.

So, when a patient was deemed eligible, the parents were contacted, asked to participate and then a study team after the child had recovered a study team would go to the child's home to interview all the household contacts and obtain nasal swabs on all of the household contacts to culture them to see if they had colonization or MRSA growing in their noses. And then they would look at some behaviors, hygiene behaviors, to see if there were any risk factors that might make it more likely that household contacts would become colonized after a kid came back home who had a MRSA infection.

So they identified 784 potentially eligible children but then when they read them out with their eligibility, their exclusion criteria, only 30% met eligibility requirements. So now they're down to 236 participants. Of those 236, there were 818 household contacts that were identified and 87% of them agreed to participate, so they had 712 household contacts all together. 77% of the households had complete household member enrollment. So, pretty good recruitment and response out there.

41:15

In terms of timing of the home visit after the infection was resolved, the range was 16 to 178 days after the onset of the child's infection with the median of 69 days. So, on average, it was a couple months after the infection that researchers went out to see what was going on in the home.

So what did they find? Well, 25% of case patients, so the kid with the original patients, 25% at the follow-up visit had nasal colonization with generic staph aureus and 13% with MRSA, with Methicillin-resistant Staphylococcus aureus, so one that's more difficult to treat. And the 29% of household contacts had nasal colonization with regular staph, 12% with MRSA. So, 12-13% of all of the kids with the MRSA to begin with and the same amount, 12-13% of their household contacts all had MRSA colonization at the follow-up; 25% of households had at least one colonized household contact and 9% of households had more than one colonized household contact.

This is interesting. Is it the same MRSA or is it a new case of MRSA? So in other words, did the kid really take it home and spread it or is this just the kid went to school and caught it from someone else. So what they did is they actually genetically identified the MRSA in the initial culture and then compared the genetics of the new swabs when they did the follow-up visit to see is it likely that the MRSA is really the same MRSA or could it be different.

43:02

76% of MRSA isolates in the case patients were genetically related to the original infection and 87% of the MRSA isolates in household contacts were genetically related to the original infection. So, the vast majority of this it really was the same MRSA even though the kid had been treated it's still in the nose colonized ready to cause another acute skin infection in the future and that's the one that had been spread to the household contacts.

So, what about the risk factors for a nasal colonization in the household contacts, that's what we want to know about, because if there are some things that you can do, if there's a kid in the house with a MRSA infection they get treated, they come back into the house, what can you do to keep from getting colonized yourself?

So risk factors were eczema or a dry, cracked skin and particularly on the hands, so there was definitely a higher risk if you had eczema. So that means if there's a case of MRSA in the house and you have eczema, make sure you're using lots of your moisturizing cream and keeping your eczema under good control, because that was definitely a risk factor for getting colonized yourself.

Also, assisting the case patient, the kid with the original infection, when they get home assisting them with bathing or showering was a risk factor. Also sharing a wash cloth and sharing balms, lotions and ointments with the case patient, so with the kid that was originally infected. So, you don't want to assist them with bathing or showering, although you may have to, depending on the age of the child. But just no, that's a risk factor. And sharing a wash cloth is a no-no and sharing balms, lotions and ointments.

44:45

Factors that decrease colonization with the use of antibacterial soap in the household and that held true for the case patient and the household contact. So, if you regularly use antibacterial soap in the home, there was less chance that it would then spread once the kid got home after treatment.

So, the authors conclude that following community-acquired MRSA infection in a child substantial portion of household members are colonized with the MRSA and modifiable behaviors, such as the sharing of personal items may contribute to MRSA transmission within the household.

So there you have it and you've heard it said, never share what touches your hair, but I tell you when it comes to balms, lotions, ointments and wash cloths, never touch again what touches the skin; at least of those things were previously touched or used by someone with a recent MRSA infection. Sorry folks, I couldn't resist that one.

All right. Let's take a quick break and we'll be back and wrap up the show right after this.

[Music]

46:20

All right. We are back and as I mentioned in the introduction to the program today, we're going to talk about a new strain of whooping cough that's being seen in Australia. And it's in Australia where a prolong pertussis epidemic has entered a disturbing phase with the study showing a new strain capable of evading the current vaccine. And it is maybe responsible for the sharp rise in the number of whooping cough cases doctors are seeing down under.

A team of Australian scientists led by the University of New South Wales believe this emerging new genotype called prn2-ptxP3 of the Bordetella pertussis bacterium maybe evading the protective effects of the current A-cellular vaccine and increasing the incidents of this potentially fatal respiratory illness. That's according to a study published in the Journal of Infectious Diseases.

Scientists have discovered the genotype in other countries suggesting it has the potential to spark epidemics around the globe and they say should be monitored closely. Dr. Ruiting Lan, an Associate Professor at the University of New South Wales School of Biotechnology and Biomolecular Sciences and one of the study authors, says this prolong whooping cough epidemic in Australia began in 2008 and has been predominantly caused by this new genotype of Bordetella pertussis.

The genotype was responsible for 31% of cases in the 10 years before the epidemic and that's now jumped to 84% a nearly three-fold increase, indicating it has gained a selective advantage under the current vaccine protocol. The current immunization is still the best way to reduce transmission of the disease in reduced cases but it appears to be less effective against this new strain and immunity wanes more rapidly.

48:07

He says, "We need to look at changes to the vaccine itself or increase the number of boosters.” Last year nearly 38,000 cases of life-threatening disease were reported in Australia, despite Australians having a relatively high vaccination rate.

The authors point out the increase in the number of whooping cough cases may be partly due to recent improvements in diagnostic tests, which means that mild or atypical cases in older children or adults are now more likely to be correctly identified. But, this has not explain the marked increase in hospital admissions, especially of very young children who are not yet fully immunized and in whom the diagnosis is much easier and the disease is more severe.

The team's findings suggest that while the current vaccine remains effective against most forms of whooping cough, its use could be contributing to the emergence of new and potentially more dangerous strains. Acellular pertussis vaccine introduced worldwide in the 1990s replaced whole-cell vaccine (WCV), due to concern with whole-cell’s side-effects.

Dr. Lan says, “The whole cell vaccine contained hundreds of antigens, which gave broad protection against many strains of Bordetella pertussis, but the acellular vaccine only contains three to five antigens. If the acellular vaccine (ACV) is less effective against these new strains, we need to ask what other strategies can be used to combat the epidemic, which is ongoing."

There has been growing concern among public health officials about the rising incidence of whooping cough in Australia. The death rate for babies under the age of six months who have pertussis infection is one in every 200 babies infected and adults and adolescents won the risk of passing the disease to these young infants.

So those certainly been more news related to this story, especially if the Australian strain of whooping cough becomes an international traveler on a larger scale and this will keep tabs on the wires and you'll be the first to know of any warnings or changes in vaccine recommendations coming out from the CDC or the American Academy of Pediatrics.

50:08

I do want to pause real quick. Some of you might be reeling a little bit. We used a lot of science terms in that story. So whooping cough, you've heard of whooping cough, it's something that babies get vaccinated against and the medical name for whooping cough is pertussis and the bacteria that causes pertussis or whooping cough is the Bordetella pertussis, a bacterium.

Now, it used to be, really not that long ago, back in the 80s and early 90s and prior to that, that the DTP vaccine that kids got it would have diphtheria, tetanus and pertussis. And the pertussis, basically was the bacteria that was killed and that's why it was called whole-cell pertussis because they would just take the pertussis, the bacteria, and kill it and put that in the vaccine.

So it couldn't infect you but the whole cell was there and cells, a bacterial cell has lots of proteins that are antigens on the outside of the cell and it's these that your body's immune system says hey, this isn't suppose to be here, I'm going to make an antibody against it, so when the real pertussis bacteria that's living comes along, you have antibodies against those proteins that'll attack the cell and kill it and keep you from getting infected; that's how it works.

Well, the problem with the whole-cell vaccine is that it contains some chemicals, one of which was cyclic AMP that had the effect of causing a high fever and it also makes kids just fell miserable, I mean you'd be achy and just feel bad for a few days. And you can have this high fever that lasted for a few days too and the high fever was high enough with the rapid of enough change in body temperature that it could bring on a feberal seizure.

And of course, that freaks moms and dads out even though feberal seizures aren't particularly dangerous but you don't want to see your kids having suddenly a high fever and they're sneezing and right after they got their vaccine, even though the outcome is fine, they're fine, they're protected now but it's stressful and traumatic for the family

52:22

And so what they've discovered is that since it was the contents inside the cell that cause this problem, what we could do instead is just take some of those proteins that are on the outside of the bacteria cell wall and put that, or the cell membrane I should say, we're not plants, and put those in the vaccine so your body would still make antibodies against these proteins but you didn't have to have the whole dead pertussis cell inside of the vaccine.

And we found that this really cut down on those side effects with the fever and feberal seizures and such. So, we came out with an Acellular, meaning the whole cell's not there just the proteins, Acellular pertussis vaccine. Well the problem is you just pick a handful of those proteins, three to five of them, and those are the only ones that you are going to be protected against. But if a new strain of pertussis comes along that doesn't have those particular proteins but has been naturally selected to have other proteins on the cell membrane, it can evade the vaccine, because the proteins that you made the antibodies against aren't on that cell membrane of this particular strain.

So, as the bacteria sort of evades this, the vaccine may have to have antigens or proteins added to it, of course that means that teenagers and adults who have not had the newer vaccine might have to get boosters with this new pertussis component in it, in order to protect babies from getting whooping cough.

53:59

It's easy for all of us to forget that back in my grandmother's day, I mean kids died all the time, right and left, if you had a family you had nine kids so that six of them would live,. I mean, really, kids died very frequently back in the early decades of the 20th century. Polio was rampant, measles was rampant.

That's just a part of life that kids died and I think we forget that and we've just grown accustomed to what life is like post-vaccines and then because of bad information out there about vaccine possible complications and is it associated with autism and other things; people are scared and don't want to get their kids vaccinated. But we forget that these disease that we vaccinate against killed kids.

And as we get larger populations that aren't vaccinated this becomes a threat again as we're seeing. In this particular case, it's not so much a problem with people not being vaccinated, it's because of the side effects of the vaccine, people didn't want it. So we come out with a newer, kinder, gentler vaccine that doesn't cause the same types of side effects in order to get people to actually get their kids vaccinated and so that's coming back to bite us a little bit.

So like I said we'll keep an eye on the story and let you know if there's any new vaccine or new advice coming out from the Centers Disease Control and Prevention or the American Academy of Pediatrics.

55:41

All right. Well that puts this episode of PediaCast in the proverbial can. I'd like to thank all of you for taking time out of your day, to listening and participating with the program. I want to remind you iTunes reviews are definitely helpful to us. So if you have not done that before it really doesn't take much of your time. Just head over to iTunes and write a little review for us, that would be most helpful in helping us recruit more moms and dads to the audience.

Also links on your webpages and mentions in your blogs, on Facebook and your tweets and on Google+, all of those things are helpful to create more buzz about the program and get more moms and dads participating. Also be sure to join our community by liking PediaCast on Facebook, following us on Twitter, tweeting with hashtag #pediacast and hanging out with us over on Google+.

Also, be sure to swing by the Show Notes and add your comments to the topic at hand. If you have a comment about any of the topics we've talked about on the program, on the Show Notes page is the place to get your voice heard as well. You can also spread the word by telling your doctor about PediaCast at your next well check-up of sick office visit. And don't forget we have a flier for you to download and hang-up wherever moms and dads hang-out and it's located under the Resources tab at pediacast.org.

56:55

One more time, if you head to pediacast.org, click on the Contact link, that's the way to put in a topic suggestion or ask your question and you can email pediacast@gmail.com or call the voice line at 347-404-KIDS, 347-404-K-I-D-S. If you email us or use the voice line, make sure you let us know your name and where you're from. If you go to the Contact link at pediacast.org you have to put those things in in order to submit but a lot of times people email or call in and forget to mention where they're from and it's something we'd like to know.

All right. That wraps things up for this time 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.

Topics

• The Cinnamon Challenge
• Synthetic Marijuana
• Passive Smoke Exposure
• Comparing Diets for Obese Children
• Nitric Oxide Therapy for Preemies
• Dangers of Driveway Sealcoat
• Tiny Tim’s Diagnosis

Links

• Synthetic Marijuana Usage Alarms American Pediatricians
• Passive Smoking In Childhood Increases Risk Of COPD In Adulthood
• Comparing Diets For Weight Management In Obese Children
• Comparing Diets – Full Article
• Diet Resources from Center for Healthy Weight and Nutrition (Nationwide Children’s)
• Inhaled Nitric Oxide Still Given To Preemies Despite Lack of Standards
• Mounting Evidence Against Popular Pavement Sealcoat
• Tiny Tim's Near Fatal Illness Likely Due To Environmental Factors

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 podcasts for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio, I might add. And I'd like to welcome everyone to the program, both our regular listeners and our new listeners, alike.

If you're new to the program, welcome, sit back and take a listen. We have lots of information coming your way. This is episode 206, 2-0-6 for April 5th, 2012. Synthetic Marijuana, Driveway Sealcoat and Tiny Tim.

Now, you may be asking yourself how in the world do at least two of these topics pertain to the world of pediatric medicine. And they do relate and we'll get to exactly the hows and the whys in just a few minutes. This is a news edition of the program and we will get to the whole rundown of exactly what we're going to talk about in just a few minutes.

But before we do that, I wanted to remind you that PediaCast is on Facebook and Twitter. So if you haven't stopped by our Facebook page and liked us there, please consider doing so. We try to keep it up to-date. We let you know you what program is coming out just to remind you when a new show is available and have a description of exactly what we're going to be talking about.

And then there's other breaking pediatric news comes up, we include that. And then just some fun thoughts along the way, too. So if you are not a part of our Facebook page make sure you check us out. Facebook PediaCast, just search for PediaCast and it'll be easy to find us.

02:09

We're on Twitter, as well, and we do a few tweets a day and let you know what topics again are coming up and just some thoughts and breaking news, those kind of things. So if you don't follow us on Twitter, please make sure you do.

Also, if you want to help us create a little bit of a buzz in social media, that will be most helpful. Just use hashtag #PediaCast, that's the hashtag we use, so you may want to subscribe to that one. And if you're doing a post about us, just put a little hashtag #PediaCast and then we would appreciate it. You can help with our social media buzz.

Also on Google+ so you can check us out if that's where you are. I haven't gotten into the Pinterest thing yet. I'm not quite sure that PediaCast fits there, but who knows, if you feel strongly the other way, message me and try to convince me. And maybe we'll join the Pinterest world, as well. Although I don't see that one being as likely in the future. Maybe, who knows? I don't know, it's a little lady-like, isn't it?

03:14

OK. Speaking of buzz, you may have heard that there is new movie out, what's been out for a couple of weeks now. Hunger Games. And I wanted to weigh in on it because it is a little controversial.

When you look at just the basic description, it's that there's an arena, although it's not like a Roman gladiator arena. I mean, this is big multi-acre arena with hills and valleys and lakes and streams, so it's a whole geographic area. But still it's an arena and they basically put a bunch of teenagers in here and make them fight out to the death, so that there's only one left.

So when you say it like that, it doesn't sound like it's something that really I would want to expose my kids to. But actually, you have to kind of place that into its context. And I'm not sure that I would've really given it a chance except that few months ago, my daughter, she's a teenager and an avid reader, I might add, and she had gotten a hold of the Hunger Games books and read through it and really loved it. And just before the movie came out, she wanted to read the first one, the Hunger Games, to our family.

And we don't do this very often, I wish we did it more often and I would encourage folks with kids at home. This is really a great thing to do a book out loud as a family. You kind of gather round the living room hang out on the couches and people can take turns reading. And it's just kind of a fun thing to do together as a family.

I'm not setting on my pedestal telling you this because we don't do it very often. But we did for the Hunger Games and it kind of limit itself to it because there were fairly short chapters, so we would do one or two chapters a night; or if the action really got going, which usually did, we do three.

05:09

So when you put this whole teenagers killing each other into the context of the story, then it's not quite as bad because you understand that the society where these people are coming from, that it's actually retribution for a rebellion that had happened 70 some years ago. And there are actually a lot of learning points and talking points in the story. There's substitution, there's sacrifice, there's fear, there are things that are unfair.

It's really, when you just say sort of clinically, that it's about these teenagers all trying to kill each other, it doesn't sound so good. But for mature, older teenagers and adults, I really enjoyed it. I'm not used to doing movie reviews here, but I've been asked about it a lot, from a pediatrician and a dad's standpoint; like, hey, is it this something that kids should be seeing?

I would definitely caution you if you have younger kids from seeing this. But if you have, like I said, older, mature teenagers, especially when you look at the story in the context of where it's coming from, it's not so bad and we enjoyed it. We went out and did the midnight run, its first night out.

So, I'd encourage you to check that out if you have wondered about it and thought, ooh, that sounds a little violent. I would have thought so too but I did end up enjoying it.

06:37

All right. Before we get started, one more thing I wanted to tell you about, I'm just going to weigh in on this. I'm kind of late to the game with this one. But it's still important and I thought you'd be interested in my thoughts on this, as well, because it does concern pediatric medicine.

And that is the cinnamon challenge. Now, this is not something that's new. It's been circulating around since 2001. But it has had a recent resurgence and in fact there are 30,000 videos on YouTube that are tagged with the keywords cinnamon challenge.

Basically, what this is, if you haven't heard, if you've, I don't know, put under a log or something, folks, teenagers, adults, alike, usually younger adults, take a tablespoon of cinnamon and put it in their mouth and try to get it down in 60 seconds; and no water. They're not allowed to drink any water and they record this on video and then upload it to YouTube so that you can see the results.

And if you've seen any of these videos, you're probably thinking ahhh, these people are faking it, they're dramatic, this isn't really what happens. But as it turns out that's not the case. What this cinnamon does is it dries out the mouth because all of your spit is absorbed by the cinnamon. And if you do an entire tablespoon of it, there's too much cinnamon to absorb all of your spit. So what happens is your mouth becomes instantly dry as a bone.

08:12

And as it turns out this stimulates a severe reflexive coughing, so you just start coughing, coughing and you can't help it. It's a reflex cough, you can't stop yourself. And you'll see in these videos, it's exactly what happens. And then there's still dry cinnamon in your mouth and so that dry cinnamon as you cough comes out in a great big cloud, a big puff of cinnamon. And the person is left gasping for air and that this is supposed to be funny.

And for a lot of people the cinnamon that they do get down is irritating to the stomach and it causes vomiting and so in some of these videos they go as far as to show the person vomiting, as well. But there are some really serious risks associated with this, for one, you can choke, you can get a big wad of the wet cinnamon that can include the airway and so you can literally choke on the cinnamon. If you vomit and you're coughing and gagging, you can aspirate so that some of your stomach contents go down in the lungs and can cause an inflammation and infection.

09:21

But the most serious thing that, these are all serious things, but the one that is more likely to happen and can be a problem is that puff of cinnamon cloud, then you're coughing and so in the process of coughing you take deep breaths in and you can actually inhale the cinnamon powder down into your lungs and then that can cause wheezing, it can turn into an asthma attack, especially if you're prone to asthma, you have reactive airway disease. But even if you don't have that, it can cause airway inflammation and you can also get infection associated with that.

And there was actually a high school freshman just recently in Michigan who did this and inhaled the cinnamon powder and he ended up in an Intensive Care Unit on a ventilator with a collapsed lung and a serious infection. He survived but he was very, very sick.

Recently some celebrities and sports stars and even politicians have joined the Cinnamon Club by posting YouTube videos of themselves taking the challenge. Just as an example, Illinois Governor Pat Quinn did it. What is it with Illinois governors? NBA players, Jovial McGee and Nick Young. Great role modeling there guys.

I mean, seriously, this is dangerous and lots of kids are only doing it because they're being pressured and bullied into doing it by their peers. So, moms and dads you can and should put a stop to this. It's dangerous. Talk to your kids about it. Don't tolerate it. Look, you should know what your kids are doing, even on YouTube. It's important.

10:56

Speaking of bullying, there's a bullying movie that's coming out very soon and we'll watch. I'll make sure I take that one in and let you know my thoughts on it as well. Apparently and initially, it's sort of a docu-drama about kids being bullied and because of the real-life language that often times occurs in bullying situations, the Motion Picture Rating Association gave the film a Rated R and so the folks who really need to see this movie, the parents, along with their kids so they can generate discussions and say, hey, is this happening to you at school; how do we deal with this; let's open our eyes and see what this bullying problem really is; aren't going to go see if it's Rated R.

And so the movie company decided to take the rating to release it as an unrated film, which has gotten push back from some theaters. So there's a little bit of controversy there as well. But once it comes out, we'll talk about that one a little bit more because bullying is definitely a pediatric topic.

11:57

All right. Speaking of pediatric topics, what are we going to talk about today? We have lots coming your way. Synthetic marijuana, things like Blaze, Spice, K2, what's going on with that? They're not only common and easy to get a hold of, there are dangers associated with this as well.

Also, passive smoke exposure. Can childhood exposure lead to adult disease? So, secondhand smoke as a kid, you never smoked, but could you develop lung disease as an adult? There's a new study with some interesting information along those lines.

Also, comparing diets for obese children. Are some diet plans more effective than others and perhaps easier to follow that other? Also nitric oxide therapy for premature babies. This sounds, you know, like we're getting into a little deep into science with that one, but there are lots of parents out there who spend many days and nights in Neonatal Intensive Care Units (NICU) throughout this country. And some you, the babies, get nitric oxide and some don't, depending on where you live.

There's not really a good standardization of when and when it should not be used. So someone in the northeast may have a relative in Colorado, they had babies who were about the same, in terms of prematurity, one gets nitric oxide, the other one doesn't and they kind of compare notes and it's like, hey, should my baby have gotten that; or the other one could say, why did my baby get that.

So we're going to discuss the nitric oxide issue. I deluded to that back when Dr. McClead visited. So we are going to get to that in this particular episode.

13:34

Also, the dangers of pavement or driveway sealcoat, the type of sealcoat that you use may make a difference and it could be affecting your family's health. And then we'll wrap thing up with Tiny Tim, what was wrong with him? Well, a doctor from Le Bonheur Children's Hospital just might have an answer.

I also want to remind you if there's a topic you'd like us to talk about, you can head over to pediacast.org, click on the Contact link or you can 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 treatments plans for specific individuals. So if you do have a concern about your child's health, make 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 and where can find that, of course over at pediacast.org.

All right. Let's take a quick break and we will be back with the News Parents Can Use, right after this.

[Music]

15:09

Our News Parents Can Use is brought to you by in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.

A growing number of adolescent children and young adults are consuming synthetic types of marijuana, commonly known as Blaze, Spice and K2. And these drugs are sending many users to emergency departments. That's according to researchers from the Children's National Medical Center in Washington, D.C. as reported in the journal Pediatrics. The author say, "Dealers make these synthetic cannabinoids in illegal laboratories and sell them to convenient stores and gas stations where teens and adults purchase them."

Like their natural counterparts, the smoke of synthetic marijuana is inhaled causing euphoric and psychoactive effects on the users. However, there are other effects associated with these drugs, some of which may be specially dangerous. Then adults and young patients, teens and adults, throughout the United States have arrived at emergency rooms with not only restlessness and agitation, but also diaphoresis, just heavy sweating, catatonia, we all know what a catatonic state is, extreme agitation and the inability to speak.

From 2010-2011, the American Association of Poison Control Centers received 4,500 telephone calls related to synthetic cannabinoid poisoning. The Author say, "The effects of intoxication are short lived, however, healthcare professionals are becoming increasingly concerned about the potential long-term effects of regular synthetic cannabinoid usage."

They also warned that synthetic marijuana does not contain what the dealers claim. According to the package, these products are "a mixture of traditional medicinal herbs". They claim the user will experience mild or relaxing effects, similar to those experienced from marijuana but from natural ingredients.

16:59

I hate to burst their bubble, but marijuana is pretty natural. Laboratory tests in several countries have found these herbal claims to be false. In fact, the labs are unable to identify any of the herbs named in the ingredient list, instead they typically find an unknown plant material sprayed with an unknown toxic chemical.

One of the chemicals has been identified as Tocoferol, which is actually a form of vitamin E, but investigators suspect other chemicals, not yet identified, are also sprayed on the plant material and these unknown chemicals are responsible for the marijuana-like euphoria and the toxic effects.

Since exact nature of the toxins are still unknown, which in drug screenings are negative, which has increased the popularity of theses substances with young users. And, since the identity of the offending chemicals has not been identified, governments are having a difficult time controlling sale and use of the products.

So this is troubling news, really. We aren't sure exactly toxic chemicals yet are sprayed on these pouches of unknown, but certainly not what stated on the label, plant material. We do know the chemicals cause a marijuana-like euphoria, but they also cause the sweating, disorientation, agitation, aggressiveness and sometimes an inability to speak.

So these are obvious signs the chemicals are having unwanted toxic effects on the brain and of course you got to wonder what's the long-term consequences of exposure to this stuff and we just don't know. So parents be on the look out, don't let your kids pass it off as incense. Don't buy that story. Blaze, Spice, K2, these are just some of the names, they aren't incense and they aren't harmless.

18:48

All right, moving on, a new study published in the journal Respirology, reveals that children who are exposed to passive smoke have almost doubled the risk of developing Chronic Obstructive Pulmonary Disease or COPD in adulthood compared with non-exposed children, that's according to researchers at Haukeland University Hospital in Bergen, Norway.

Investigators examined 433 non-smoking adult patients with COPD and 325 non-smoking and healthy adult control subjects. So these are folks who did not smoke in adulthood, their only exposure was secondhand smoke as kids. They found that regular exposure to passive smoke while growing up almost doubled the risk for COPD in adulthood. Gender differences also existed with a stronger associated noted for women. And passive smoking exposure during childhood was a much stronger factor than passive smoke exposure as adults.

Researchers say, "There were results suggest that long-term burden of COPD could be reduced if children were not exposed to cigarette smoke."

And the added factor is affecting early life development of lung function to have important long-term consequences in adult life. So moms and dads, here's another reason to keep your kids away from cigarette smoke, as if you needed another reason.

20:02

All right. A new study of three diets for obese children showed that all diets are effective in managing weight but the reduced glycemic low diet, one that accounts for how many carbs are in the food and how much each gram of carbohydrates raises blood glucose levels, may be most promising.

The Cincinnati Children's Hospital Medical Center's study of low carb reduced glycemic load and portion control diets with obese children is published online in the journal of Pediatrics. The study shows that children have more difficulty following a strict low carb diet, particularly long-term, since children adhered best to a reduced glycemic load diet, this diet may represent the most promising approach for pediatric weight management, according to Dr. Shelley Kirk, PhD, RD, LD lead author of the study.

Dr. Kirk says, "This is the first long-term randomized clinical trial that compared the effectiveness and the safety of these three diets using a family-based behavioral approach for younger obese children. All three diet groups had significant improvement in weight status, another health measures, and showed no adverse effects. Since all three diets were effective, practitioners can offer any one of these approaches for helping obese children achieve a healthier weight.

The study included 7-10-year olds who were instructed to follow their assigned diets for 12 months. During the first three months, they received weekly dietary counseling and every other week group exercise sessions. They continued their assigned diet on their own for the following nine months. Their height, weight, body fat and several other clinical measures were taken at the beginning of the study and again after three, six and 12 months. Clinical measures included cardiovascular risk factors, such as blood pressure, cholesterol, triglycerides and insulin.

Of the 102 children enrolled, 85 completed the year-long study. After three months, children on each diet showed improvements in body mass index and percent body fat and these changes were maintained at 12 months. Children in all three groups were successful in maintaining a reduced caloric intake even in the final nine months of the study, which were without the guidance or counseling from the research staff.

Dr. Kirk says, "This raises the possibility that an intensive initial intervention for any of these diets can lead to long-term successful weight management."

22:12

You know what, I've heard this kind of thing before. It's like three months is sort of a magic number for behavioral change and this is known in the counseling world as well. Really with just about anything. So if and this study kind of backs that up as well, that if you can change a behavior for three months then you're doing pretty well.

When you think about like New Year's resolutions and how long we keep those, even though we're really committed, sometimes you joke around, but when you seriously make a New Year's resolution and then fail, about a time you were really serious about it. I mean, when you started out, you really wanted to make that change and you just didn't stick with it.

But again, if you can make it out to three months then you have a really good shot at more long term success and even though that wasn't the point of this particular study and they didn't have another group where they didn't do the intervention for three months, that would have been an interesting study.

Let's do this dietary intervention that's pretty intensive and involved and do it for three months. Let's do another one where you only did that for one month and another one maybe for two months and then at 12 months see where all three groups are and just see if that three months is magic.

Yeah, I think that'd be an interesting study. OK. So you're probably wondering what are the details of the three diets that were used in this study and it will get a little monotonous if I went through all of these different diets. But I'll tell what I will do for you, in the Show Notes, we'll have a link to the full text of this particular article and we did find a site that has this article for free so you don't have to pony up any money to subscribe and get it, because a lot of them we do put links to the abstracts but you have to subscribe if you want to see the full text. But in this particular case, we do have a link for you that has the full text of the article and it has all the details about the diets right there.

So just head over to pediacast.org, click on the Show Notes for episode 2-0-6, which is this one, and you will find the link to sciencedirect.com and they do have this particular article published with the full text.

24:27

I'm also going to put a link on the Show Notes to the Parents Resource page for the Center for Healthy Weight and Nutrition here at Nationwide Children's Hospital where you'll find loads of great articles relating to, you guessed it, healthy weight and nutrition. They really do have some great stuff there, so you can head over to the Show Notes at pediacast.org, episode 2-0-6 and we'll have that link for you to the Center for Healthy Weight and Nutrition here at Nationwide Children's Hospital.

All right. Moving on, many parents including many of you listening to the show right now, have had premature babies and you spent long days and equally long nights in the Neonatal Intensive Care Unit (NICU). Here's a story that may soon affect the care of these babies, many premature infants throughout the United States continue to receive inhaled nitric oxide during their NICU stay despite the lack of evidence to support its use.

Whether or not a preemie will receive nitric oxide treatment, when and for how long, varies greatly throughout the country as its use in premature infants appears to be unstandardized. These are the findings of a Nationwide Children's Hospital study appearing in the journal Pediatrics.

Inhaled nitric oxide is a selective pulmonary laser dilator approved for use in term and near term infants with hypoxic respiratory failure. And it has been a hypothesized that nitric oxide might help prevent complications of prematurity in infants born less than 34 weeks gestation. However, the National Institutes of Health and the Agency for Healthcare Research and Quality have concluded there is no evidence to support the routine use of nitric oxide in preterm infants who require respiratory support.

"Despite years of data unable to support its off label use, nitric oxide treatment in preterm infants remains common in U.S. children's hospital NICUs," so it says Neonatologist, Dr. Michael Stinger, PhD, lead author of the study. Dr. Stinger goes on to say, "It's important to determine how nitric oxide is being used in this patient population as we may need to implement evidence-based standards of care."

To help characterized variation in recent practice, Nationwide Children's faculty and members of the Ohio Perinatal Research Network performed a retrospective study using the Child Health Corporation of America's pediatric health information database. The study population included over 22,000 premature infants born less than 34 weeks gestation who are admitted to Neonatal Intensive Care Units in 37 U.S. children's hospitals during a 3 1/2-year period.

26:49

The findings revealed that the use of inhaled nitric oxide in premature infants was variable even when controlling for demographic characteristics in disease. There was substantial variation in the age of initiation of nitric oxide treatment and the average number of days of use. Hospitals that used nitric oxide in more patients also used nitric oxide for longer durations and a higher volume NICUs used less nitric oxide and had lower mortality rates than lower volume NICUs.

Northeastern hospitals reported less use of nitric oxide and infants who received nitric oxide were less likely to survive suggesting the gases used in infants already at a high risk of death. "Overall, we found that there is a pervasive lack of standardization in nitric oxide across NICUs," said Dr. Stinger. Adherence to National Institutes of Health consensus guidelines may decrease variation in its use.

Since this study's data are observational, investigators cannot be certain whether or not premature infants benefited from nitric oxide use and Dr. Stinger says, "The findings suggest the use of nitric oxide in extremely low birth weight infants with the most severe forms of respiratory failure did not improve mortality rates." According to Dr. Stinger, "It is clear that there is a need for adherence to and further development of evidence-based protocols to standardize care in order to avoid unnecessary and costly treatment."

28:12

So again you recall a couple episodes back during our Children's on Quality Mashup, Dr. Rick McClead, Medical Director of Quality here at Nationwide Children's, and if you haven't listened to that particular show I'd encourage you to go back.

Even though we're calling it the children's on quality mashup and we did talk about each other's shows, we also sort of interviewed each other and talked a lot about we got involved in podcasting and I think you'll find that interesting. I kind of go back and talk about my days as a 10-year old working as a DJ in a skating rink, so you may want to go back and check out that show if you have not already done so.

OK. So why is this particular study important for moms and dads? And not just moms and dads with premature babies, it really just kind of affects everyone and I'll tell you why here in a minute.

Here's a deal with this particular nitric oxide thing. Nitric Oxide is a gas and it's mixed with oxygen and sometimes given to extremely premature babies who are on ventilators and why, well this gas is known to dilate or widen the openings of blood vessels in the lungs. So the thought is if you increase blood flow through the lungs you might be able to increase oxygenation and maybe these extremely premature babies would improve faster with fewer complications.

Well, the problems is nitric oxide is expensive, fine if it works we'll pay the price. But data is showing that it positively affects outcome in extremely premature babies is lacking. So I bring this up to something parents should be aware of because the underlying issue is cost versus benefit. And the concept is not unique to the newborn intensive care unit. It's happening in other sub-specialties of pediatrics, it's happening at primary care offices and it's happening in the adult medical world.

We can't keep spending and spending and spending, especially on medications, treatments and procedures that aren't effective. And if we, as medical professional don't recognize this and if we don't consider cost as well as benefit in our decision-making process, there's going to come a time when non-medical professionals will step in and make those decisions for us. It's happening in Europe, it's happening across our norther border and it's coming to the USA if we don't get our act together.

30:26

All right. Let's move out of the hospital and on to your driveway. But first, a parking lot at the edge of the University of New Hampshire campus has contributed important research on an emerging concern for the environment and human health.

The research detailed in a recent feature article in the journal Environmental Science and Technology, has found that one type of pavement sealcoat common on driveways and parking lots throughout the nation has significant health and ecosystem implications.

Dr. Alison Watts, Research Assistant Professor of Civil Engineering at UNH, is a co-author of the article, Coal-Tar-Based Pavement Sealcoat and PAHs: Implications for the Environment, Human Health and Stormwater Management.

Sealcoat is a black surface applied over asphalt pavements. It's marketed as improving appearance and enhancing pavement longevity. It's made of either an asphalt emulsion or a refined coal-tar-pitch emulsion. Although the two sealcoats are similar in appearance and cost, concentrations of PAHs or polycyclic aromatic hydrocarbons, a group of organic compounds known to be detrimental to human and ecosystem health, are about 1000 times higher in coal-tar-based sealcoats than those based in asphalt.

Conducting side-by-side studies of coal-tar-based sealcoated and non-sealcoated parking lots at UNH's west edge lot, Watts, a researcher with the UNH Stomwater Center, found the soil at the edge of the sealcoat lot contained orders of magnitude higher concentrations of PAHs compared to soil at the edge of the non-sealcoated lot. More specifically, there were several hundred parts per million PAHs from the sealcoated lot versus less than 10 parts per million from the lot without sealcoating.

What's more, soil samples taken three years after the initial application of sealcoat remained high in PAHs. The problem may be even more pronounced in New England, PAHs move into the environment as the sealcoat wears off, a process that snow piles seem to accelerate. Dr. Watts says, "We think it's likely we have a severe problem here in the Northeast because the sealcoat wears off more rapidly."

The journal article discusses the potential human health effects of coal-tar-based sealcoat, which is associated with elevated concentrations of PAHs and house dust, soil, air, water and sediment. This cites a recent study that found children living at homes adjacent to pavement with coal-tar-based sealcoats were likely exposed to about 14-fold higher doses of PAHs than those living adjacent to unsealed pavement.

32:54

Studies at the Columbia Center for Children's Health have found that PAHs at homes can contribute to delays in cognitive development, asthma and other respiratory symptoms. They are also associated with obesity, metabolic disorders and an increase in a child's cancer risk.

Unlike many complex environmental issues, however, this one has as relatively painless fix – avoid coal-tar-based sealcoats and favor asphalt-based ones or no sealcoat at all. Dr. Watts says, "Consumers generally can't tell the difference and voluntary shifts in the market are making that choice easier." She notes that retailers, Home Depot and Lowe's, no longer sell coal-tar-based sealcoat and several commercial sealcoaters use only asphalt-based products.

The corrects of this issue is in its fairly simple choice we can make that will be beneficial to the environment and the human health without significant impact to the users.

Moving beyond, the Stormwater Center's test parking lots, Watt's will next study the effect of coal-tar-based sealcoats in raising the PAHs concentrations in the sediment of New Hampshire's Great Bay. "PAHs are increasing in Great Bay's sediments and in fact in sediments across the country," she says.

While there are other sources of PAHs in the Great Bay — including old gas plants, car exhaust and woodstove smoke — she wonders if sealcoat may be the culprit.

34:11

So, I don't know about your neighborhood, but in ours a fresh coat of driveway sealcoat is a springtime ritual and that this spring we'll be sure that we use an asphalt-based product, instead of coal-tar. And it does make me wonder what we've used in the past because I really have no idea. I mean, a company drives by and says, "Hey! You want your driveway sealcoated?" And it's the same guy who did three of our neighbors', like yeah, sure you can do it; you got a good price for me?

I have no idea what he has put on my driveway. So this year we're going to ask him though, is it coal-tar-based or asphalt-based. If it's coal-tar keep moving.

All right. We're going to take a quick break. When we come back, we will diagnose Tiny Tim and we'll still wrap up the show, right after this.

[Music]

35:24

All right. We are back. So you may be wondering what exactly was wrong with Tiny Tim. Well, Le Bonheur Professor, Dr. Russell Chesney, M.D. believes he knows what ailed the young iconic character from Charles Dicken's "A Christmas Carol." Based on detailed descriptions of the boy's symptoms and the living conditions of 18th century London, Dr. Chesney hypothesizes that Tiny suffered from a combination of rickets and tuberculosis (TB). His findings were published in the Archives of Pediatrics and Adolescent Medicine.

Dr. Chesney noted during the time the novel was written, 60 percent of children in London had rickets and nearly 50 percent displayed signs of TB. He says this is due to crowded living conditions, poor diets and filth and low exposure to sunlight. Burning coal and particles from an Indonesian volcanic eruption contributed to London's blackened skies for many years.

Both rickets and TB can be improved and indeed cured through increased exposure to Vitamin D, which can be obtained through exposure to sunlight and a balanced diet.

As the Ghost of Christmas Present showed Ebenezer Scrooge, Tiny Tim’s condition would be fatal without a different course for the boy. According to Dr. Chesney’s research, Scrooge's new-found generosity to Bob Cratchit and his family could have helped Tiny Tim by ensuring an improved diet, facilitating more sunlight exposure and providing cod liver oil (a common supplement of the day known to be high in Vitamin D).

So, there you go. Modern medicine has diagnosed Tiny Tim despite the fact he was a fictional character, with the rickets and tuberculosis. And indeed, a generous Scrooge could have a been the boy's savior.

37:02

All right. So that puts a wrap on this week's show. I would like to thank everyone for listening, for taking time out of your day to make PediaCast a part of it. We know you have lots of choices where to get your healthcare information when it pertains to pediatric topics. We appreciate you stopping by PediaCast.

I want to let you know there is not going to be a show next week. We're going to skip a week because we're taking a little family trip to the rolling hills of Tennessee. Actually it's not really the rolling hills, it's more like the mountains of Tennessee. We're going to be in the Gatlinburg area, doing some hiking, doing some ziplining, kind of hang it out with the bears but not getting too close to him.

So it's just kind of a nice family vacation in the woods. We're really excited about that. So that's coming up, that'll be next week and that's why there won't be a program next week. But we'll be back in two weeks and in the meantime, get your questions in, we've actually, I've kind of dialed back the interviews a little bit this year compared to last year. Just a little, based on your guides as feedback.

So we have been getting to a more news and listener type programs. We have a research round-up also planned here in the near future. But we're getting a little bit low in the question bank. So, if you have a question, if you've had a question you've kind of put of writing or calling the voice line and you thought, well, so many people write in, they'll never get to mine; that may not be the case because we do need some questions.

Like I said, we're getting a little low in the tank. So if you have a question for us or topic idea, write and there's a good chance that we will get to it in the program. How do you get a hold of us, over at pediacast.org, just click 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.

38:53

Also, I want to remind you if you email us or use the voice line, make sure you let us know your name and where you're from, because we always want to know those things. Also be sure to tell your doctor about PediaCast, probably the most important way that you can spread the word about the show. The next time you go in to see your doctor for a well child check or a sick office office, either one, just say hey, we know about this great evidence-based podcast that's aimed at parents, that answers lots of questions without giving medical advice.

And you ought to tell the other patients about it. We do have a flier to help facilitate that. You can go to the Resources tab at pediacast.org, click on the Resources tab and we do have a flier that you can download that points folks in the direction of our show.

And I'd also like to point out, yeah, OK, we're affiliated with Nationwide Children's Hospital, we are just so glad about that. It's just the excellent resource for us to be able to get to do interviews and to support the program, but don't let that discourage if you live in other parts of the country from telling people about the show, because it's about the information, it's about the community, more than it is about one particular hospital.

40:05

I mean, we're proud of it. We think it's the best pediatric hospital in the country but not everybody can live right next to it and so we're really just trying to spread the love here a little bit, around the, not just the whole country but around the world as well.

All right. Again, thanks for taking time to be a part of the show. Remember off next week, back in two weeks. And until then, 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.

Topics

Womb Sounds and Preemies
Stair-Related Injuries
Academic Success and Fear of Failure
Father’s Role in Academic Success
High Dose ADHD Meds
Labial Adhesions
Sleep Walking
Meningitis
Healthy Snacks

Links

Sounds From Mother Improve Health of Pre-Term Babies
Stair-Related Injuries: Common and Preventable
Reducing Academic Pressure and the Fear of Failure
Academic Success Linked to How Parents Play with Toddlers
Higher Doses of ADHD Drug May Cause Academic Problems
Kawasaki Disease – PediaCast 203
Night Terrors – PediaCast 188
SnackWise – Nutrition Rating System
Child Nutrition and Reauthorization Act – Local Wellness Policy

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 to PediaCast, a pediatric podcast for moms and dads. And we're coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is episode 205 for March 28th, 2012 and we’re calling this one Academic Success, Sleepwalking and Healthy Snacks.

Now, most of you who are familiar with the show know we cover lots more than just the three topics other than the title and we're going to get to exactly what we're going to talk about in detail here in just a minute.

First and I know it's kind of superficial when you talk about the weather, like if you strike up a conversation with a stranger, you're on public transportation or you're waiting in a doctor's office, you're in an elevator, it's easy enough to say, hey, what's going on with the weather.

And so I try not to talk about superficial things on the show, but this spring has been so crazy that I can't help but mention it. And most of you also know we lived in Florida for a while and this March has been like March in Florida. I mean, you didn't have to go to Florida for spring break; you could just have your spring break right here on Ohio. So temperatures in the mid 80s on some days, rock 'n' rollin' with the thunderstorms.

It's been pretty crazy. And I've one in the past that kind of roll my eyes at the whole global warming climate change kind of thing. And of course I understand that weather varies, but it's been pretty warm and makes me a little nervous about the summer that's coming up. So we'll see, maybe all things will average out and we'll have a cool summer. But I don't know, I'm not going to count on it.

02:25

All right. Also I want to mention to you, we have lots of opportunities for community involvement here on PediaCast. Of course we do have some social media outlets that we are a part of. So we're on Facebook, we're on Twitter, also take part in Google+, so if you are in all of those things as well, make sure you add us in your circle of friends.

You can like us on Facebook, add us to your Twitter feed and join our circle in Google+. So we have all those things available to you. And another way that you can become involved in the program is to go to the Show Notes and make a comment. So if there's a topic in a particular show that is interesting to you, you can just head on over to the Show Notes at pediacast.org and if you have a comment or a question or want some advice from other listeners, you can comment in the Show Notes so we can kind of have a community there at pediacast.org as well.

And of course, the biggest way to get involved is to ask a question on the show. If you go to our Contact Page at pediacast.org you can as a question and we answer those on the program or if you have a topic idea or you want to point us in the direction of a new story, you can use the Contact Page for those things as well.

And then this is something that I typically mention at the end of the show, but, you know, once a quarter, so I like to put it up front so everybody gets a chance to hear it. We don't have a big marketing budget here at PediaCast and we're still trying to get the word out to moms and dads out there across the country and around the world who may be haven't heard about the program. And then there are some things that you the listener can do to help us out. Of course we don't charge anything for the program. It's important to us that we keep it free and accessible for everyone, but one thing that you can do to help us out is just help spread the word.

iTunes reviews are very helpful. If you found us through iTunes and used those reviews to help make your decision to listen to PediaCast, you know how important iTunes reviews are. And we are in need of new ones, so if you head over to iTunes and just want to take a couple of minutes out of your time to write a review for us, we'd really appreciate that.

04:39

You can help us out is to tell your doctor. So the next time you take your child in for a well checkup or a sick visit, either one, just mention the program. Let them know that it's evidence-based and that we cover lots of topics and answer questions in detail. But we don't hand out medical advice for specific people. It's all about education. Just kind of point them in the direction of pediacast.org.

And we also have fliers available on the website. If you go to the Resource tab at pediacast.org you can find the PediaCast flier, that's something that you can download, print out and put on that bulletin boards, exam room walls, church, nurseries, the YMCA kid's room, you know, all those kind of places. So think about that.

And of course telling your Facebook friends and Twitter followers and Google+ peeps about the show, that's always helpful too.

By the way, on the Show Notes pages, we also have a convenient way for you to share each individual show on Facebook or Twitter or Google+. So if there's a particular show you want to tell your friends about, you can just go to the Show Notes page for that particular show and share us that way as well.

05:50

We also need some likes on the landing page of pediacast.org, also the Contact Page and the Listen Now Page, which is where the PediaCast player exists. Again we're just trying to drum up more, you know, get it in front of more eyes so that more moms and dads know about the program.

So those are just some little ways that you can help us spread the word through the Internet and social media and your own community.

For those of you who are listening for the first time, I know that we don't usually self-promote in this much detail at the beginning of every episode. But it'd been a while since we did that and I just wanted to remind everyone that we really count on you to help introduce the show to new folks.

All right. So what are talking about today? I kind of a little bit of a hint in the introduction with Academic Success, Sleepwalking and Healthy Snacks. We're also going to look at a research article that looked at womb sounds, actually artificial womb sounds, piped into the incubators of preterm babies to see if that could help them progress and do well and get out of the NICU a little bit faster. So what's the effect of piped in womb sounds for preterm babies, we're going to talk about that.

Also a study that came out in Nationwide Children's Hospital here regarding stair-related injuries. We're going to talk about the numbers and also some practical tips on how you can prevent stair-related injuries in your own home.

07:20

As I mentioned, we're going to focus a little bit on academic success. One of the things that we found through one research study that can have a determining role on how well your child does is how much do they fear failure. So you might be surprised about this, when parents really put a stress on their kids to really succeed academically, their kids can develop a fear of failure and is this helpful for their academic studies or can this actually make things worse. So we'll talk about that.

Also, what is the father's role in academic success? Can dad make a difference that perhaps mom can't? And what about single moms? And what's the role of the father in academic success?

Also, a higher dose ADHD medicines, you know, when they don't seem to be working anymore and as kids are getting bigger and growing, sometimes we increase the doses of ADHD medicines, is that helpful or could it actually cause some harm? So high dose ADHD medicine and their role in academic success is also coming up on the program in just a little while.

And then we're going to get to some of your questions. This week they deal with a labial adhesions, as with little girls whose labia is adherent. We'll talk about that. Also sleepwalking and infant meningitis and then we'll round up the show with a topic on snacks, healthy snacks. How can you figure out which snacks are healthy for your kids and which ones aren't? I mean, I understand it's easy to say hey, grab an apple, grab a banana and have some fruit or a little bowl of nuts.

But what about actual snack foods in vending machines? That's what we're going to focus on, like the Doritos and Chili Cheese Fritos and all those kind of potato chips are just the things that you find in vending machines and also at school during the school lunch program, they always have a display with some snacks there that you can choose from. And of course in your pantry at home, what are healthy snacks, which ones should you have more often, less often and almost never. We're going to talk about those things, coming up.

09:28

Again, if you have a topic idea or a question for us on PediaCast just head on over to pediacast.org and you can 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. If you have a concern about your child's health, make 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 and you can find over at pediacast.org.

All right, with all that in mind, we're going to take a quick break and we will be back with the News Parents Can Use right after this.

[Music]

10:48

Our News Parents Can Use is brought to you in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.

We start today's news segment in the newborn nursery when babies are born prematurely they are thrust into a hospital environment that will highly successful at saving live is not exactly the same as the mother's womb. And while Neonatal Intensive Care Unit is equipped with highly-skilled caregivers and incubators that regulate temperature and humidity, Dr. Arnir Lahav, Director of the Neonatal Research Lab at Brigham and Women's Hospital, says, "Something is missing – the sounds that a baby would hear inside the womb."

New research conducted by Dr. Lahav and his colleagues links exposure to an audio recording of mom's heartbeat along with her voice to lower incidence of cardiorespiratory events in preterm infants. This research is published online in the Journal of Maternal Fetal and Neonatal Medicine.

Dr. Lahav says, "Our finding show there may be a window of opportunity to improve the physiological health of these babies born prematurely using non-pharmacological treatments, such as auditory stimulation. Because they are underdeveloped, preterm infants experience high rates of adverse lung and heart events including apnea, which is a pause in breathing that last longer than 20 seconds, and bradycardia, the medical term for periods of significantly slow heart rate."

12:14

Researchers sought to determine whether an auditory intervention could affect the rates of these unwanted cardiorespiratory events. To conduct the study, Lahav enrolled 14 extremely premature infants, born between 26 and 32 weeks gestation who were admitted to the Neonatal Intensive Care Unit at Brigham and Women's Hospital.

The infants were assigned to receive an auditory intervention of maternal sound stimulation four times per day throughout their NICU hospitalization. Each infant received a personalized maternal sound stimulation, in other words, a soundtrack consisted of the voice and heartbeat of each baby's mother. The recordings were played inside each infant's incubator through a specialized micro-audio system developed in Dr. Lahav's lab.

Overall, researchers found cardiorespiratory events occurred at a much lower frequency when the infants were exposed to maternal sound stimulation compared in neonates exposed to routine hospital noise. And this difference was statistically significant for infants who are 33 weeks of gestation or older. Our findings are promising and showing that exposure to maternal sounds stimulation could help preterm infants in the short term by reducing cardiorespiratory events.

It also suggest there was a period of time, at 33 weeks gestation and beyond, when the infant's auditory development is most intact and maternal sound stimulation intervention could be most impactful. Dr. Lahav concludes by pointing out a study, had a small sample size of just 14 infants and says further research is needed to verify if this intervention could have an impact on the care and health of preterm babies.

13:50

And from the newborn nursery to the top of the stairs, nearly 1 million children under the age of five were taken to hospital emergency departments from 1999 to the end of 2008 in the United States, that's according to research from the Center for Injury Research and Policy, right here at Nationwide Children's Hospital. This is a study recently published in the journal, Pediatrics.

There is good news to report from these numbers, over the study period, the total yearly number of stair-related injuries to those under the age of five dropped by 11.6%. Still, a child under five years currently presents to an American emergency department every six minutes for a stair-related injury. The research team gathered their data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission.

Senior author, Dr. Garry Smith, said, "While we are pleased to see a declining trend in the number of stair-related injuries, stairs continue to be a common source of injury among young children. Through a combination of educating parents, use of stair gates and modifying building codes to make stairs safer, we can prevent these types of injuries. One quarter of the injuries experienced by children 12 months or younger occurred while somebody was carrying them and those injured while being carried were three times more likely to be hospitalized to those injured while not being carried."

15:09

And it sort of makes sense when you think about it, you sustain a bigger fall when you're being carried as opposed to a series of little falls when a baby goes down the stairs on their own. Not to minimize a baby tumbling down the stairs on their own, of course, but when they're being carried not only is it a farther drop to the ground but you also have the likelihood of the carrier falling on top of the baby, which is not good.

In addition to the nearly 1 million stair-related injuries sustained by children under the age five and seen in U.S. emergency departments from 1999-2008, the team reported a few more interesting statistics – 2.7% of the children required hospitalization; 35% had soft tissue injuries; 26% had punctured wounds or lacerations associated with their fall; 76% had head or neck injuries; and 11% had upper extremity injuries.

The research team has some recommendations parents can follow to keep your child safe around the stairs. Be sure to keep stairs in good order and clutter free. Stair gates should be fitted to the bottom and top of the stairs and although gates are effective in reducing injury risk, adult supervision is still vital. When possible, do not carry a child up or down the stairs and if you must carry a child, don't carry other things including laundry baskets, and be sure to hold on to the hand rail. Don't use strollers or carriages underneath of the stairs. Avoid mobile baby walkers. Teach your child to hold on to the hand rail at all times and if your small child wishes to carry something on the stairs, teach them to ask an adult for help. Teach your child to always walk up and down the stairs, never run. And teach your kids to respect the stairs; they aren't a place for jumping or playing on.

Looking back at these recommendations, our family, I think we did a pretty good job of following these rules when our kids were young. There might have been some exceptions, you know, for slinkies, which never seem to work quite as well as you want them to, and rolling super bouncy balls down the stairs. But it was always accompanied by plenty of supervision and only when the kids were little older.

17:18

All right. We're going to move on up front to a new few stories on academic success and how you the parent can promote it. Children may perform better in school and feel more confident about themselves if they are told that failure is a normal part of learning rather than being pressured to succeed at all costs. This is according to new research published by the American Psychological Association. Dr. Frederick Otten, a post doctoral researcher at the University of Poitiers in France, says his team focused on the widespread cultural belief that equates academic success with a high level of competence and equates failure with intellectual inferiority.

By being obsessed with success, students are afraid to fail so they are reluctant to take difficult steps to master new material. Acknowledging difficulty is a crucial part of learning could stop the vicious cycle in which difficulty creates feelings of incompetence that in turn disrupts learning. The study published online in the American Psychological Association's Journal of Experimental Psychology could have important implications for teachers, parents and students.

Dr. Jean Claude Croizet, a psychology professor at the University of Poitiers, says, "People usually believe that academic achievement simply reflects a student's inherent academic ability, which can be difficult to change. But teachers and parents may be able to help students succeed just by changing the way in which the material is presented."

In their first experiment with 111 French sixth graders, students were given very difficult anagram problems that were virtually unsolvable. Then a researcher talked to the students about the difficulty of the problems, one group was told that learning is difficult and failure is common but practice helps just like learning how to ride a bicycle.

19:05

Children in the second group also had a discussion with researchers but they focused on how the children tried to solve the problems rather than talking about how difficult learning can be. All students then took a test that measures working memory capacity, a key cognitive ability for storing and processing incoming information. Working memory capacity is a good predictor of many aspects of academic achievement, including reading comprehension, problem solving and IQ.

The students who were told learning is difficult performed significantly better on the working memory test, especially on more difficult problems, compared to the second group. They also had a third control group who took the working memory test without doing the anagrams or having discussions with the researchers.

A second experiment with 131 sixth graders followed a similar procedure with difficult anagrams and discussions and it showed similar results. The second study included an additional group of students who took a simpler anagram test that could be solved but this group was not told that learning is difficult. All the students in the second study completed a reading comprehension test and the children who were told learning is difficult scored higher than the other groups, including the students who had just succeeded on the simple test.

The author's point out how students think about failure may be more important than their own success when learning challenging skills.

A third experiment with 68 sixth graders measured reading comprehension and asked questions that measured students' feelings about their own academic competence. The group that was told learning is difficult performed better in reading comprehension and reported fewer feelings of incompetence. The study noted the students' improvement on the test were most likely temporary but the result showed that working memory capacity may be improved simply by boosting students' confidence and reducing their fear of failure.

The study team concludes by saying our research suggests students will benefit from education that gives them room to struggle with difficulty. Teachers and parents should emphasized children's progress rather than focusing solely on grades and test scores. Learning takes time and each step in the process should be rewarded, especially early stages when students will most likely experience failure.

21:16

And here's another way parents can promote academic success, the ways in which parents engaged with their children at the age two predicts their children's future academic outcomes, according to results of a 15-year study. This project began in 1996 by researchers from Utah State University's Department of Family Consumer and Human Development.

In order to find out the extent of influence, early parent-child engagement has on a child's future academic success, the team examined families participating in the U.S. Early Head Start Research and Evaluation Project. Results from the study we published in an upcoming special issue on Fathers in the Family Science Journal. According to the researchers, parent-child activities demonstrated to have a positive impact on children's future academic outcomes include elaborating on the words, actions and pictures in a book were on unique attributes of objects relating book, text or play activities to the child's experience and encouraging and engaging in pretend play.

Also presenting activities in an organized sequence of steps seems to help. Investigators say there has been extensive research done on the importance of early parent-child interactions on future educational experiences but most have focused on the relationship between the child and the mother. This study looked at the combined long-term impact of both maternal and paternal interactions in these critical stages of early development and discovered that children not only benefit from the interactions they have with their mothers but also with their fathers.

In 229 low-income families, the researchers examined mother-toddler and father-toddler interactions at age two, these observations were then analyzed in relationship to child outcomes at three years of age and in the fifth grade. The team examined families with resident biological parents, as well as single mom homes. Results from the study showed that in both of these family types, toddlers who were taught more during play with their mothers performed better academically, in addition to mother's play, the child's gender and participation in the early head start program seem to help.

23:21

Resident biological fathers who teach during play with their toddlers also positively impacted the child's fifth grade reading and math performance. The study suggests that in homes with both biological parents, toddlers receive higher levels of cognitive stimulation from the mother, when compared to single mothers and in families with both biological parents, fathers contributed to later academic outcome significantly more than the mothers.

Investigators say it's interesting that when a biological father is living with the biological mother and his child, the mother tends to provide more cognitive stimulation to their toddlers and when the biological father is engaged with the toddler, it really adds something more to later academic performance.

Researchers conclude it's important for parents to engage with their children during the vital early stages of brain development because early exposure to cognitive stimulation with both mothers and fathers can have a long lasting and positive influence on the educational success of at risk children.

24:22

And finally, high doses of ADHD drugs may cause more academic problems than they solve.

New research with monkeys sheds light on how the drug, methylfenidate, may affect learning and memory in children with Attention Deficit Hyperactivity Disorder. The results parallel a 1977 finding that low dose of the drug boosted cognitive performance of children with ADHD but a higher dose, while further reducing hyperactivity, impaired performance on a memory test. Many people were intrigued by that result but their attempts to repeat the study did not yield clear-cut results, so it says Dr. Lewis Populin, PhD, an associate professor of Neuroscience at the University of Wisconsin-Madison, School of Medicine and Public Health.

Dr. Populin is senior author of the new study exploring the same topic and recently published in the Journal of Cognitive Neuroscience. In the study, three monkeys were taught to focus on a central dot on a screen while a target dot flashed nearby. The monkeys were taught that they could earn a sip of water by waiting until the central dot switched off and then looking at the location of the now vanished target dot.

The system tests working short-term memory, impulsiveness and willingness to stick with the task as the monkeys could quit working at any time. The study is different doses of methylfenidate, which is the active drug in Ritalin, Concerta, Metadate and Methylin and it use doses comparable to the range of clinical prescriptions for ADHD in humans.

The study is important because according to the Centers for Disease Control, almost 5% of American children are taking medications for Attention Deficit Hyperactivity Disorder. So what did they find? Well, a degree of dosing had a major and unexpected impact. At low dose, the performance scores improved because the monkeys could control their impulses and wait long enough to focus their eyes on the target. All three were calmer and could complete a significantly larger number of the trials. But at the higher doses, performance on the task was impaired.

Dr. Populin says, "At the higher doses the monkeys didn't seem to care. All three continued making the same errors over and over. They stayed on task more than twice as long at the higher dose but they had much more trouble performing the task. Although ADHD are commonly thought to improve memory, if we take the accuracy of their eye movements as a gauge of working memory, memory was not helped by either dose," says Dr. Populin. It did not get better at the lower dose and there was a negative effect on memory at the higher dose.

26:52

"Memory is the root of many intellectual abilities, but it can be affected by many factors," says Dr. Bradley Postle, a professor of Psychology at the University of Wisconsin-Madison. Dr. Postle, an expert on working memory, was not involved in the study but he says methylfenidate affects the brain executive function, which can create in the internal environment that depending on the dose is either more or less amenable to memory formation and/or attention.

If you can concentrate and are able to process information without being interrupted by distracting thoughts or distractions in your environment, you will perform much better on a memory test. Apparently, the lower dose of methylfenidate helped create the conditions for success without actually improving memory itself. Of course monkeys are not people, but the monkeys in the studies still reminded the researchers of school children. Dr. Populin says, "They made premature movements, could not wait to look at the target before they could be rewarded for doing so. It's kind of like a kid with a teacher says when you complete the task raise your hand, but he can't wait even if he knows that by responding prematurely, he will not get rewarded. The study results had another parallel with daily life. Drug dose induced are often set high enough to reduce the characteristic hyperactivity of ADHD, but some children said that makes them feel less creative and spontaneous, more like a robot. If learning drops off as it did in our study, that dose may not be best for them. Our monkeys actually did act like robots at the higher doses, keeping at it for seven hours even though their performance was bad."

28:21

Researchers say, "The logical way forward would it be to involve a similar study with people diagnosed with ADHD, not monkeys. With millions of children and an increasing number of adults taking these medicines for the condition, we have to be very careful about finding the right spot on the dose curve or we may get changes in behavior that we don't want. People think these drugs improve memory but our data said no. Your memory's not getting better. And at the higher doses, while you get more behavioral improvements, that improvement comes at a price and that price is cognitive ability."

All right. So something to think about, especially for those of us with kids who take medication for ADHD. We are going to take a quick break and we'll be back with some of your comments and your questions right after this.

[Music]

29:41

All right. We are back and appreciate you sticking with us. We are going to turn our attention to our listeners segment now and we're going to start with something that we haven't done for a little while, and that's to get to some of your comments. So not just your questions but some other things you have to say about the show.

And the first stop is Wheezy in Austin, Texas and Wheezy says, "I just wanted to express my gratitude to you and Nationwide Children's for providing this podcast. Recently my son was sick and I had a febrile seizure. Fortunately due to this podcast, I knew what it was and why it happened, so I didn't flip out as much as I would have otherwise, especially if I had no knowledge at all. I still got slightly panicked when he began to turn blue from not breathing since I didn't know how long the seizure would last. He is of course doing great now. Thank you so much for arming me with great and helpful information."

Thanks to you Wheezy for writing in, you are welcome. Next stop, Melissa in Westerville, Ohio says, "Thanks for all your information with the 15-year old who suffered from Kawasaki at 18 months. It was good to hear the progress that has been made. I also appreciated the information on the long-term care, especially as an adult, I will encourage my daughter to continue seeing a cardiologist after leaving home." And thank you for your thank you, Melissa, we always appreciate hearing how we helped. That's why we're here and why we do this.

And I do want to mention for those of you who may not have tuned in to the Kawasaki program because you think well I don't know what Kawasaki disease is, it doesn't affect me, I really don't care. Actually it is something you want to know about because it's important. Kawasaki disease can cause quite a bit of heart damage and it's important to recognize in its early stages and so it's something that all parents should be aware of, so that they can be on a lookout for in their own kids. It can get diagnosed as quickly as possible. So you may want to tune in to one of our recent episodes that dealt with Kawasaki disease.

31:35

All right. We also have some feedback from you. Heather in Milwaukee, Wisconsin said, "Listened to a recent podcast, you asked for some feedback on the show. I'll admit I like the old format because you hit on listener questions and news more often. Now it seems to be more interviews, which are fine, if you have kids with these diseases or you're in the medical field. But I don't connect so much with those types of shows and find myself waiting longer between episodes that spark my interest, as just my two cents, but overall, I love the show and look forward to each one coming out. Thanks, Heather."

And I would love your two cents, Heather, thanks for sharing. And we are trying to strike that perfect balance between the interview shows and the news and listeners shows because we do have listeners out there who like both. But we are trying to find that balance and we'll continue to search for just the sweet spot with that.

And next up we have Michelle in Columbus, Indiana. She says, "I really enjoy the listener questions in your episodes. You did ask for feedback. I wanted to let you know I enjoy the interviews and definitely the regularity and frequency of the shows. I would prefer interviews about once a month and three episodes of research roundups or listener questions each month. Thanks for asking for feedback and thanks for a fantastic podcast. It's in my top three and has been since the beginning." And thank you, Michelle, for letting us know what you think as well.

For the rest of you, comments, suggestions and feedback are always welcome and you can do that at pediacast.org.

33:00

All right. Let's get to some of your questions now. First stop with that is Jane in Alexandria, Virginia. Jane says, "I am a happy listener of the show, while this won't help you determine format, I enjoy the long shows, short shows and everything in between. Not only are the topics interesting, but you've taught me medical information in a more analytical way. My question for you is about labial adhesions. I recently noticed that my 10-month old daughter's vagina was closed which was a bit shocking as I've never heard of such a thing. But we're visiting our doctor about this but I was curious what you have to say on the subject and think others may benefit from the information too."

OK. So labial adhesions, what's this all about? It's a common condition that pediatricians see quite often and basically if you think about a little girl anatomy, they have the labia majora, which are the skin folds down there around the vagina, and then you have the labia minora, which are the smaller folds that are sort of tucked in beneath the labia majora. So these are the smaller folds that kind of close up over the vagina. And this is a connective tissue and what will happen with the labial adhesions is the labia minora on each side kind of fused together. And it's usually when this happens, the uppermost portion is spared and the reason for that is just the active peeing keeps it open. So when your child urinates it has to get out and the urethra is located on top of the vagina, sort of more superiorly. And so that top part of the labial minora when this happens typically doesn't fuse all the way to the top, because the active urinating several times a day helps to keep that open.

So what do you do for this? Well, the biggest thing here is that like many things in pediatrics, if it's not causing a problem you don't necessarily have to fix it. And something to consider here is that the tissue of the labia minora in little kids tends to be sticky and what happens is when the kid goes to puberty, the epithelium or the outside layers of the labia minora kind of change to a more slippery and less sticky component.

And so what'll happen is that those adhesions typically will just go away on their own as a child progresses through puberty. So it's not something that you necessarily have to do anything about, as long as it's not causing a problem.

35:25

Now, what are some potential problems that you can have this? Well, one would be if because of what your child does, it has a tendency to sort of self-reduce, in other words it kind of rips apart on its own. So let's say you have a kid who does gymnastics or they ride horses or they're going up and down rough terrain on bicycles so things are getting charred. You have this possibility that what's adhered could kind of rip open and then that can cause pain and bleeding. And if this is a recurrent thing, then you may want to do something about this problem, because now it's not something that isn't causing issues, it's actually causing pain and bleeding in an intermittent fashion and so you want to do something about it.

Another potential problem with this is that you could have a partial blockage of urine and so it's not necessarily that you're completely closed but it does obstruct the urethra a little bit and some of the urine may then actually flow behind the labia minora and actually go up into the vagina and it can stay in the vagina and then can harbor bacteria in there so that you can get a vaginitis or an infection in the vagina because of residue urine that's entering that space. It's not supposed to be there.

Or you can also get incomplete emptying of the bladder and that can actually cause urinary tract infections as well because the urethra, which is the little tube that connects the bladder to the outside world, is kind of short in girls and so it's easy for skin bacteria to go up the urethra and enter the bladder. But the active urinating or peeing frequently kind of rinses him out so that they can't set up shop in the bladder and actually cause an infection. But if you have a partial obstruction of flow out because of the labial adhesions, then you could potentially have the residual of urine that's staying in the bladder and that kind of set you up to get urinary tract infections.

So if you have a kid who gets urinary tract infections and they have labial adhesions, the labial adhesions could be playing a role in that and so now, you do have an issue that you would want to do something about the adhesions.

37:40

And then finally, a total blockage, so in other words if the labia minora is adhere together all the way up and it's causing total blockage, then you can get bladder distension, pain, you can get some kidney dysfunction, but this is rare. This is something that very, very seldom seen. Don't quote me on numbers here but if you took a thousand kids who all had labial adhesions, probably one would have a significant issue where you really have bladder distension and pain and backing up of urine up to the kidney. It may not even one, it's really, really rare.

But again, something that you need to think about with this. So if you have a kid with labial adhesions and it's not causing any problem, again when they go through puberty it's probably going to fix itself and not really be something that you have to worry about. You just want to let your pediatrician know it's there, watch it with yearly visits, kind of follow it along. And again, as long as your kid's peeing OK, they have good urine output, they aren't getting frequent urinary tract infections, it's not a problem where it keeps pulling apart and bleeding and painful and then goes back together, then you don't need to do anything.

But if you do need to do something, typically, what we'd do is a cream called, Premarin Cream, and this is a topical estrogen and the way you're basically doing is just tricking those cells of the labia minora into thinking that puberty has hit. So you're providing an estrogen topically and that causes the epithelium to change, as I mentioned from that sticky epithelium to more of a slippery epithelium, so it goes from sticky to slippery and that helps by using that every day and just kind of providing some genal attraction that can help the adhesions to separate and not come back.

And once it's separated, some daily Vaseline just helps to keep that area slippery and helps it to not stick back together. Something to keep in mind when you stop using Premarin Cream or the estrogen creams, when you stop using them, typically the epithelium, it's kind of hard to fill the body on a permanent basis and so that surgeon's gone and they'll say, hey we need stickiness instead of slipperiness again; and then it's possible for the problem to come back when you're not using the estrogen cream anymore.

40:07

And then that's when it's going to be important to use the Vaseline and really try to keep things slathered down so that it doesn't stick back together. Or you need to just kind of wait till it happens, see how long it is, did your child start to have problems again and then use the estrogen cream again when you need it.

More aggressive maneuver's where you really pull that apart and cause pain and bleeding, really is not necessary, unless the kid really does have obstruction of urine outflow that's causing kidney issues. But that's a very rare and of course it'll only be done by your doctor and under their supervision.

Again, if it's not broken, don't fix it. That's a very important point in the world of pediatric medicine. Otherwise, you're on the risk of causing problems.

All right. Next stop we have Kate in Chicago and Kate says, "Dr. Mike, love your show and appreciate your straightforward approach to medicine and helping parents deal with behavior. On to my question, my almost 6-year old son had these tonsils and adenoids out last summer due to obstructive sleep apnea. His tonsils were huge, he snored constantly and he would stop breathing for up to 20 seconds at a time. He was a restless sleeper before the surgery and we thought that would calm down once his breathing and sleeping were better. Tonight, about an hour after putting him to bed, he came downstairs crying. My husband and I tried to ask him what was wrong but got no response. I asked him if he had an accident and touched the front of his jammies to feel if they were wet and he started to go pee right there. We got him into the bathroom and we started to undress him and he began laughing. He still did not seem fully awake and aware of the situation. By the way, we have also heard the same laugh coming from his room in the middle of the night. After getting him cleaned up and changed, he was fully awake and had no recollection of how he having come downstairs. Is he sleepwalking? I also found him some mornings asleep with his feet on the floor and his body bent over his bed like he was climbing in or out of the bed. I did a search and did not find any subject covered in any of your podcasts. Is this something I should bring to the attention of our pediatrician or wait and see if it continues more? I would love to hear your thoughts on this subject. Thanks again for your wonderful show, Kate."

Well, thanks for your question, Kate. My simple answer is yes, you should definitely bring this up with your pediatrician and I'm inclined to do it sooner rather than later. And just so you folks know, when I get questions like this where I have a concern and think something should be looked into quickly, I don't really wait to do it on the show here. I did email Kate back and let her know my thoughts on this.

42:43

Now, we don't provide personalized responses for everybody. In fact, we don't do it very often at all because we aren't here to give medical advice. But when it's more of a significant situation, just rest assured we do get back to folks and say yeah, this is something you should get checked out. We can't comment on exactly what this is but there are some concerning things here that you probably ought to have your doctor look at, we let you know.

Another example of that is when we talked about mercury from CFL light bulbs not too long ago. Again, when there are urgent things, we do get in touch with people so you don't have to wait until the show comes out where we talk about it. And in this situation though, we certainly did do that for Kate.

OK. So let's talk about some of the possibilities here and keep in mind as we discuss this. And again, this is not new news for my regular listeners, but as always we can't make a diagnosis on a podcast, over the Internet or by email and interactive discussion and physical examination by your doctor are absolutely required. But having said that we can look into some of the possibilities.

43:51

Sleepwalking is a definite possibility. So you can have a kid who is sleeping but they still have enough of their brain, even though they're in a sleep mode, they still have motor and sensory input that allows them to get up and walk around without necessarily being aware of what they're doing. And so this would be sort of the classic sleepwalking where your cognition isn't there but your body works and it does do some automated things and does able to go up and downstairs and laugh and do some other things.

Sleepwalking is definitely a possibility. And if it is sleepwalking, unfortunately there's not a lot you can do other than it does seem that better sleep hygiene tends to help with sleepwalking. So if you have a regular bedtime routine, kids are getting a good night sleep, they are necessarily taking mood-altering medications before bedtime, if they do have obstructive sleep apnea that you've gotten that taken care of, and so just good sleep hygiene kind of stuff can help.

Although if there's a strong family history of sleepwalking even though those things may not help and then the best thing is just making sure that your child is in a protected environment. In this kind of situation, it may not be a bad idea to have doors closed, to have your door open, so the door closed or try to make a barrier so that it's less likely they'll get out into the hallway and fall down some stairs, but still possible.

45:18

If you have a first floor bedroom, kind of move in their bedroom to the first floor against they're not at the top of the stairs, especially if they're venturing out frequently. Just having baby monitors, even though it's an older kid, so that you can be aware and hear and kind of guide him back into their room.

So for a safety conscious standpoint, it kind of depends on what their typical sleepwalking behavior is like and then just trying to make sure that the environment that they're going to be sleepwalking in is as safe as possible. But that's not too common, those kinds of sleepwalking things.

Another possibility is night terrors. Now, usually with the night terror and this doesn't happen during the dream part of sleep. It happens during more of a deep sleep where the emotion centers of the brain suddenly start firing and in most kids this kind of shows up as a kid who starts crying and is upset and is screaming in their room and you rush into their room and they're in bed and they don't really seem to be with it and then they slowly wake up out of it and don't remember having it.

And we talked about night terrors in lots of detail back in PediaCast #188, so I'm not going to go into those in too much detail here again. But if you are interested in hearing more about night terrors, again, PediaCast 188 and just to make it even easier for you to find; actually, if you do a Google search and just put in PediaCast 188, that show should come up for you. But in the Show Notes to this episode 205, it did put a link for you so you can find it easily if you want to go that route.

So, night terrors, if you want to know more PediaCast 188. So that's a possibility, although, usually with night terrors you don't get up and walk around. Laughing, so when you hear him laughing in his room in the middle of the night, if he really is not awake and laughing consciously, and he's laughing and you walk in and he's doing his laughing thing and then you kind of wake him up and he doesn't remember laughing, then it's possible that that's a night terror kind of thing.

Usually, it's more of an emotional response where you're upset and crying, but laughing, you could see that. It's a little more rare but you could. Although walking down the stairs and that whole business doesn't sound as much like night terrors as it does sleepwalking, but maybe of a combination of things going on.

47:34

But, the reason that I would see your doctor about this is because I'd also be worried about something called complex partial seizures. Now what's that?

Well, a classic seizure that we think about where your whole body goes stiff and you're shaking and you lose consciousness, those are called tonic-clonic seizures. And it does involve basically the entire brain sending out signals at the same time. So you have all your muscles kind of working together, then you get stiff or you can shake and you lose cognition or consciousness so you're not going to be able to be up and walking around.

But other seizures can only involve a specific part of the brain. And if that part happens to be a motor area, you can have an increased tone or shaking of one part of the body, the part that's controlled by the part of the brain that's affected. And this is what we call a focal seizure. So if you have a brain abnormality that only involves the part of the brain that controls the right arm, you can have a seizure that only involves the right arm and again, we call this a focal seizure instead of a generalized tonic-clonic seizure.

But what if the problem is part of the brain that controls emotion or thinking or complex movements, like chewing or picking or fumbling? Well depending on the area affected, you could see something like what Kate has described. So you could see a kid who isn't really aware of and responsive to their surroundings but who could still manage to get around, even up and downstairs. They can lose control of their bladder during a complex partial seizure and they could exhibit strange behaviors like laughing for no apparent reason, particularly if that laughing is happening when they're not otherwise normally responsive

So complex partial seizure is also possible explanation.

49:21

So there are lots of different things that could be doing this and that's why I recommended to Kate that she definitely let her doctor know about this as soon as possible. A child with this kind of symptoms might need some head imaging and EEG and may need to visit a pediatric neurologist to get to the bottom of it.

In the end, it may be sleepwalking. But again, I wouldn't assume that from the get-go. Sleepwalking is what we'd call a diagnosis of exclusion in this sort of case where you want to make sure it's not something more serious before you settle on sleepwalking as the reason.

And you'll notice again I'm using lots of non-committal words like might and maybe and likely and again, that's because you cannot practice medicine on a podcast or over the Internet, so make sure you see your pediatrician, Kate, and do it soon.

All right. Let's move on to our final listener question of the day. This one comes from Tanya in Quito, Ecuador and Tanya says, "Dear Dr. Mike, I am a new but very happy fan of your show. I started listening this year and have been catching up on many of your past shows. All the topics are very interesting to me. We have two kids, a 4-year old and a 1-year old. I would like to ask you two different questions and hope so much you can help me. One year ago, when my baby was only 21 days old, she got meningitis. I took her to the hospital at a very early stage of the illness. The doctors put her on antibiotics as they did not want to lose any time. They found she had staphylococcus aureus and she spent two weeks in the Neonatal Intensive Care Unit and then one week in a regular hospital room. In November 2011, we did several medical exams at the Miami Children's Hospital and all the results came out great. She's doing well and her development is completely normal. I have a couple of questions, can we be sure the diagnosis of staphylococcus aureus was 100% sure or are there false positives? How can a newborn contract staphylococcus aureus? Even if the latest medical exams came out completely normal, is there a chance she might have some meningitis-related problems in the future and what problems might we see? Would you recommend future medical exams to confirm she is over this? Thank you so much for all your information and for sharing your knowledge. Warmest regards from the middle of the world, Quito, Ecuador. Hasta pronto (meaning see you soon), Tanya."

51:37

Well, thanks for writing in, Tanya. So let's answer your questions about meningitis during the newborn period. First, I want to say that staphylococcus aureus is a bacteria and it's ubiquitous, meaning it's everywhere. So it's on our skin, it's in our noses, it can be in your mouth, it's all over the place. But as long as it stays in those places, it's not a big deal. But if the staphylococcus, the staph bacteria, if it invades your skin or it gets into your urinary tract or gets into your bloodstream, then they can cause a problem.

So, we understand it's everywhere. You're not going to be able to get rid of it. If you throw in antibiotics all over the place and then cleaning solutions and try to get it off of your skin and out of your nostrils, what you're going to do is just the bacteria is going to find a way to live in the presence of those chemicals and that can create resistance and then it's harder to fight the bacteria off when there really is a problem.

The other thing, there are chemicals that will kill all bacteria but they tend to be toxic to yourselves, as well and so they're not going to be as helpful either. So we just live knowing that the staphylococcus is on us and as long as it's on our skin and not invading, then it's not a problem. If it does invade your skin or it gets into your urinary tract or it gets into the bloodstream, well then it can cause a problem, unless your immune system is quick to kill it. But if your brand new baby and you don't have that great of an immune system, then it can become a problem.

So if the staph bacteria invade your skin or gets into urinary tract or into your bloodstream, it can be a problem, especially if your immune system is not up to the task of protecting you. So, how did it get into your baby? There's lots of ways that it can happen and the issue here is not that it did. It's that your baby's immune system didn't take care of it. That's the issue.

53:34

But it's not a surprising issue, but it's the issue, it happens. And it happens fairly often, which is why all 21-day olds with fever get a whole septic work-up. They get blood work, they get urine, they get a spinal tap, they get admitted to the hospital, they get placed on IV antibiotics because it does happen. And the body's immune system just isn't able to take care of it. So how?

Let me just give you an example. Let's say your baby has a diaper rash and they've got staph aureus in the diaper area, they've got skin that's kind of broken down because of the rash, it's easy then for the bacteria to invade the skin and end up in the bloodstream. Or it could go up the urinary tract and into the bladder, we already talked about baby girls having a really short urethra earlier in this show, and so it is easy for skin bacteria to get up there. And then if got the bacteria grow in the urine, it can get up to the kidney, it can get into the bloodstream, so that's another way.

If your child has eczema, they have dry skin and flaky, scaly skin, that's another area where bacteria can possibly invade. Or the bacteria could just be in the nasal cavity and just get in burled into the mucus membranes and get into the bloodstream that way. And that sort of thing is happening to all of us all the time, but again if you have an intact immune system, it takes care of it before you ever get a fever and know that you even have a problem.

That's what our immune system is designed to do. But in little babies, the immune system isn't up to the task quite yet and so it's a little bit easier for the infection to get inside of them, into the bloodstream. So the staph bacteria gets into your baby into the bloodstream and then what had to get meningitis, what happens at this point is that the bacteria crosses what we call the blood-brain barrier and it gets into the cerebral spinal fluid and causes what we call meningitis.

55:23

Now that blood-brain barrier in older kids and adults is pretty resilient and it's difficult for bacteria to cross it. But again, in little babies, who are less than a month old, it's much easier for the bacteria to cross that blood-brain barrier and get into the cerebral spinal fluid which is the fluid that covers the brain and the spinal cord. And the way we diagnose that is with a lumbar puncture or a spinal tap where we put in needle in the lower back into the cerebral spinal fluid space and collect that fluid off and send it for a chemical analysis and culture to see if anything is growing in there.

And in your case, Tanya or in your baby's case that staph bacteria did cross, got into the blood, crossed the blood-brain barrier and caused meningitis. And the meningitis is just a fancy way of saying that the organism got into the cerebral spinal fluid, that fluid surrounding the brain and the spinal cord. And again it got there from the blood and how it got into the blood, I don't know exactly how but it happened and it happens.

All right. So let's tackle your questions. Can we be sure the diagnosis of staphylococcus aureus is 100% or are there false positives? Well, labs are pretty good in identifying this organism. The question doesn't become so much of was the staphylococcus aureus really there or not. If it came up with the positive, I would suspect that it means that they grew a culture, they found that organism growing, they identified that organism and labs around the world, including in Ecuador, going to be pretty good at saying this is staphylococcus aureus. So false positives of identification are probably not going to be an issue.

57:03

Now with some of the rapid tests, there can be problems. We talked in the show, not too long ago, about dogs being false positives for strep, human group A strep, and really that's because they did a test that wasn't really designed for dogs and so the test was sort of tricked into thinking that it was human group A strep when it was really a type of dog strep and so that was a false positive.

But in this case, we're not really talking about a rapid kind of test. We're really looking and this is a culture and so identifying that organism is a pretty straightforward thing. And it's unlikely that this was a false positive that your baby probably did have as staph aureus growing.

But, there is a question that comes into play here and that's the possibility of contamination. So, sure we've identified staphylococcus aureus but it's a possible, so we did a lumbar puncture, we got the cerebral spinal fluid or blood culture, we grew staph aureus, did it really come from the CSF or the blood or did it come from the hands of someone handling the specimen? So the person who drew the blood or the person who did the lumbar puncture, is that possible that they contaminated the specimen and that the staph aureus that we're finding really came from them and not from inside your baby. That's a possibility. But, that's not something that you want to assume.

So if you have a baby with the fever, who's 21 days old and they grow a staphylococcus aureus, you're going to assume that that's correct and you're going to treat it. You're not even going to entertain the possibility that this was contamination, even though it's possible. So the doctors who started on the antibiotics right away did the right thing in that situation.

58:46

You asked how can a baby, a newborn, contract staphylococcus aureus, I think we've covered that one pretty well already. You know it happens. And then your next question, even if the latest medical exams came out completely normal, is there a chance she might have some meningitis-related problems in the future and what problems might we see?

So you can have long-term consequences from meningitis during the newborn period. Meningitis causes severe inflammation as the body tries to kill the organism and that inflammation that's killing the organism can also damage the brain; so you can see developmental delay; you can see seizure disorders develop because you've damaged part of the brain; you can have vision problems; hearing problems; all of these things are possible.

You can also sometimes see toxic effects caused by certain antibiotics used to treat the organism. So there's definitely the potential for brain injury and long-term effects from having meningitis and from fighting meningitis with antibiotics, which you have to do because the risk of having a toxic side effect from the antibiotic still outweighs the risk of what would happen if you didn't use an antibiotic.

But there are certain antibiotics we can choose to use that are safer than others and we can measure blood levels to make sure we don't get toxic effects outside of a certain range. In particular, I'm talking about Genomycin when that particular antibiotic is used to treat meningitis. But the good news for you, Tanya, is that you usually see evidence of these kinds of problems fairly soon. So the fact that you're a year out and your child is developing normally, that is great and that's really good news.

01:00:17

Could she still develop an issue at this point? It's possible that she can have some developmental issues in the future and that the only thing that you can figure that caused them was this bout of meningitis that she had. But it's not probable. In fact, I'd say the chances are pretty slim of that happening.

Is there anything that you could do at this point right now to prevent that from happening if it's going to happen? There really isn't. So your best bet is just to be on the alert and if any problems arise with your child's development or hearing or vision or your child starts to have seizures, any of those kinds of things, you want to see your doctor and deal with them right away when they appear.

But the fact that you've gone a year and your child's doing well and developmentally appropriate and everything seems to be great, that's a really good sign. But you do want to know to identify problems and address them as soon as possible if they happen down the road in order to intervene and maximize future developmental potential by figuring out what's going on and dealing with it right away.

So how do you watch for these things? And that sort of leads us in to your next question. You ask, would you recommend future medical exams to confirm she is over this and the answer to that is yes, I would recommend future medical exams, not necessarily to confirm she's over this. These examinations your child should have anyway. So you want to see your pediatrician on a regular basis, 12 months, 15 months, 18 months, 24 months. In your case, 2 1/2 years is not a bad idea and then at three, maybe 3 1/2 and then yearly at that point.

Your doctor's going to check growth, he's going to check developmental milestones, he's going to check language development, hearing and vision, all things we normally checked in all kids. And to deal with problems as they arise.

01:02:01

So those routine, well checkups are going to be really important. And then you just want to be on the lookout, know what next developmental stage that you're looking for. Is your child progressing through development and your pediatrician can help you with that. And then if your child's not meeting those milestones then you want to bring that to your doctor's attention sooner rather than later, or if you notice any problems with vision or hearing.

Again, it's unlikely you're going to see problems as far out, but it is possible. Oh and by the way, if some problem does occur, maybe difficult to say for sure that it was the meningitis that caused it. I mean, certainly, kids are going to go on to develop autism; subset of them had meningitis when they were babies, and it doesn't necessarily mean that the meningitis caused their autism. Even if they happen to have that episode of meningitis, they may have developed autism at a certain point in the future anyway.

So if something does go wrong with development or does start to be a problem, we can say well maybe that episode of meningitis caused it but it's also possible that it's not related at all. Now, here's one thing that I would not worry about. And my gut is kind of telling me that this is something that you, Tanya, might be still worried about. And that is I wouldn't worry that the staph is somehow still in there causing damage.

The antibiotic that your child had killed the staph, the fever went away, she got better, she's well now, you're a year out, she's developing normally, the staph is gone. Staph does not go dormant in the brain and then reactivate it some later time. I've never seen that, never heard of that happening. Could she get staph again in her bloodstream and then have a go to her cerebral spinal fluid again and causing a new bout of meningitis? That's possible but it's also possible for that to happen to you and it's also possible for that to happen to me.

As I said before, staph is everywhere, it can and does invade our bodies but most of the time our immune system takes care of it quickly, just as our immune system was designed to do. And since your child is now a year old and healthy and growing and developing well, is every reason to believe that now, unlike when she was 21 days old, that her immune system is up to the task.

So, I hope that helps, Tanya, and thanks for writing in and contributing to the show, from Quito, Ecuador.

01:04:17

Don't forget if you'd like to participate in PediaCast, it's an easy thing to do. Just head over to pediacast.org, click on the Contact link, you can get a hold of me that way. Also email pediacast@gmail.com or you can call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

All right. We're going to take a quick break and then we're going to come back to wrap up the show and also talk about healthy snacks. That's coming up, right after this.

[Music]

All right. We are back and I've kind of hung this out in front of you. I feel a little bad about it, when you're watching TV and then the news folks come on to give you a little teaser about what they're going to have in their broadcast. And then there's something you're really interested in and they save it for the very last part of the show. And I kind of did that here and now I'm feeling a little guilty about it.

But I do want to get to healthy snacks. This is a service that's offered here at Nationwide Children's. It's called Snackwise and it's a snack nutrition rating system that's free to use. If you head over to snackwise.org, that's how you find it. It basically helps you choose healthy snacks for your family. It has a nutrition calculator for snacks and you can find that at a lot of different websites. But Snackwise goes a step further and has a unique snack rating system. So not only will it calculate the nutritional value of a specific snack, it also looks at the ingredients and the nutritional information for that snack and then puts it into one of three categories – either Best Choice, something that you should Choose Occasionally or something that you should Choose Rarely.

And it's not just for families. They also have a service for schools where it helps schools meet the Child Nutrition and Reauthorization Act's Local Wellness Policy and so this is a tool that you can use if you're a school administrator or involved with school lunch program or you do lunches for preschools and daycare facilities. You can use this site to make sure that you are in compliance with the Child Nutrition and Reauthorization Act.

01:06:55

But it's also there for families so that you can make good choices when you're thinking about snacks. And it does include basically every snack you could think of that would be in a vending machine. So we'll put links on the Show Notes to get in to snackwise.org and the Show Notes for this episode 205 will have a link for you.

There's also a link to the Child Nutrition and Reauthorization Act's Local Wellness Policy if you're interested in what the government has to say about healthy snacks. You can find that in the Show Notes as well.

In the meantime, I want to share with you the top 10 Healthy Vending Machine Snacks as outlined at the snackwise.org website. And again, we'll go to the top 10 here in terms of the most healthy snacks, but if you're interested in your snack that you like to eat and if it's something that's the best choice, something you should choose occasionally or something you choose rarely, you can go to snackwise.org and look it up.

By the way, my favorite snacks and the Chili Cheese Fritos and Classic Doritos are among them, they didn't fare so well. They're on the Choose Rarely side of things. And fortunately, I do choose them rarely, although they're my favorites.

01:08:09

OK. So what are the top 10?

Number 10 is the South Beach Living Snack Bar Delights, Chocolate Raspberry. Number 9 is the South Beach Living Cereal Bars, Peanut Butter, Cinnamon Raisin, Cranberry Almond, Maple Nut and Chocolate. They all tied for number nine. Number eight is the Solo Nutrition Bar, Chocolate Charger and Mint Mania (that, I might have to check that one out). Number seven is the itaMuffin VitaTops (all flavors). Number six is the Power Bar Pria Complete Nutrition Bar, Chocolate Peanut Butter Crisp. Number five is the Herbalife Protein Bar, Chocolate Fudge. Number four is NutriPals Snack Bars, Peanut Butter Chocolate. Number three, Quaker Oatmeal To Go for Kids, Apple Cinnamon. Number two, CLIF Kid Organic Z Bar, Peanut Butter; and drumroll please. The number one, Nutri, the number one, I almost gave it away. The number one, top 10 healthy vending machine snacks is NutriPals Fruit Bars, Strawberry.

And again, unfortunately for me, Chili Cheese Fritos and Classic Doritos didn't do so well. You can see how your favorite snack fared, again, at snackwise.org. So check that out.

01:09:37

All right. I want to thank all of you for taking part in the program. We went a little long today with our news and listeners show, we sometimes do, apologize for that. But we have lots to pack in. Also, I want to remind you, as I mentioned at the beginning of the program, iTunes reviews are most helpful as are mentioned in your blogs, on Facebook and in your tweets.

And don't forget about our different options for community participation through our Facebook feed and Twitter and Google+. You can also share Show Note pages through those social media outlets and of course, spreading the word by telling your family and friends about the show.

We also have PediaCast fliers available on the Resource tab at pediacast.org. And most of all, let your primary care doctor know about PediaCast the next time that you go in for a well checkup or sick office visits, so they can check us out and spread the news with the rest of their families.

I want to remind you, too, if there's a topic you'd like us to talk about, just head on over to pediacast.org, click on the Contact link or you can email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

And as always, 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.

Topics

Children's on Quality meets PediaCast
PediaCast meets Children's on Quality

Guests

Dr Richard McClead
Medical Director for Quality Improvement
Host of Children’s on Quality Podcast
Nationwide Children’s Hospital

Dr Mike Patrick
Medical Director of Interactive Media
Host of PediaCast
Nationwide Children’s Hospital

Links

Children’s on Quality
PediaCast
Quality and Safety at Nationwide Children’s Hospital
Patient Satisfaction Surveys at NCH

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!

Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcasts for moms and dads. It is episode 204 from March 21st, 2012 and we’re calling this one The Children's on Quality Mashup.

Now, you probably wondering what does a mashup mean. Well, PediaCast is not the only podcast here in Nationwide Children’s Hospital. We have others. And today, we are going to do our first ever podcast mashup and what that means is we've asked another podcast host from Nationwide Children's to join us in the PediaCast studio so we can mash our shows together. So we're going to check in with one another this week. It's a little bit different but we’re excited about it.

01:19

Today's mashup is going to be with Dr. Richard McClead. He's the host of Children's on Quality podcast here in Nationwide Children's Hospital. So this means the show is not only an episode of PediaCast but a bonafide Children's on Quality episode as well. So the show will be going out on both feeds.

And a couple of reasons for this, you know, it gives us a chance to kind of share between our audiences exactly what each show is about, who our audience is, what our content is, where we get our information. So we're really excited about that. But the other cool thing is that each audience is going to be able to hear their host as the guest. So you’ll find out a little bit more about your host, why they got started podcasting, sort of the history of how things got going, how they do what they do, how they pick the content that they have.

02:15

So I think this will be interesting. They really hope you get to know us a little bit better, but also to talk about the shows in general. In particular, for those of you who don’t listen to one or the other, give you a chance to know little bit more about what’s happening podcast-wise here in Nationwide Children's.

Before we get started though, I do want to cover our usual disclaimer. And that is the information presented in this podcast is for general education 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, make sure you call your doctor and arrange a face to face interview and hands-on physical examination.

Also, the use of this audio program is subject to the PediaCast terms of use agreement which you can find over at pediacast.org.

03:04

All right, so without further ado, let's get started. And we'll begin with Dr. Richard McClead in the hot seat.

Dr. McClead is a physician with the Section of Neonatology in Nationwide Children's Hospital and a professor of Pediatrics at the Ohio State University College of Medicine. Dr. McClead also serves as the Medical Director of Quality Improvement for Nationwide and in that capacity hosts the Children's on Quality podcast, which is why he's joining us today.

So welcome to the PediaCast Studio, Dr. McClead.

Richard McClead: Thank you, Dr. Mike. I'm happy to be here.

Mike Patrick: We really appreciate you stopping by and I did a little calculating. We actually go way back. We first met when I was a fourth year medical student. So this was back in 1994. So 18 years ago and I was doing was called a sub-internship. So there are people lower than interns. At the time. I was one of them.

Richard McClead: Pretty close to Niagara Falls.

Mike Patrick: Yeah, in the Neonatal Intensive Care Unit here at Children's. So 18 years ago, I thought… As I was calculating that, it made me feel old. But I suspected makes you feel a little older.

[Laughter]

04:11

Richard McClead: I've been here, you know. This is my 32nd year.

Mike Patrick: Yeah, a long time.

Richard McClead: And you know, it's kind of funny because when I left my fellowship at Case, finished my fellowship and I came here to be a brand new attending, I figured I'd be here five years. Because by then, I'd probably be a Nobel laureate and have my academic career at the NIH or whatever. But of course, that didn't happen and here I am still 32 years later and having a great time doing things.

Mike Patrick: It’s amazing how much the place has grown in those years.

Richard McClead: Well, most of the buildings that were here, even in '94. Many of those buildings had been torn down. I mean, every building has a letter and A, B, C… I think A is still here but B, C, D and E and F were all gone, you know, but we put new ones up. They all got letters, too.

05:08

Mike Patrick: And we have a really big one that’s opening up in June in a couple of few months.

Richard McClead: Twelve-storey tower. You know, when you're driving in town – they're at the 70, 71 split – this is the biggest thing in this part of the town. It’s a huge tower.

Mike Patrick: Yeah. Yup, yup, it's really impressive.

So, let's talk about Children's on Quality. What exactly is the podcast or what's your audience and what kind of things do you talk about?

Richard McClead: Well, I'm trying to focus on bringing to the public, parents and others but also the medical public – the physicians who are interested in quality issues – but I’m trying to tell people about all the exciting quality initiatives we have ongoing at Children's Hospital.

Hey, all hospitals have quality initiatives but they're often not willing to talk to you about them in great detail. And so I thought, "Well, this is a new media that we could try to reach out to people and let them know about some of the great things that are going on and some of the not so great things." I mean, it's not that everything we do, we're only telling you the good things. There are some things that we do that we're working on. We know we've got opportunities improvement but…

06:26

Mike Patrick: But if you don’t talk about those things you’re not going to ever improve.

Richard McClead: It’s all about transparency. And I think this is probably one of the greatest struggles that healthcare is facing today is the reluctance to be transparent about quality issues.

Mike Patrick: Right.

Richard McClead: Everybody's willing to say how great you are. But are you willing to share what you're not doing well and what you’re working on? I don't think people expect that we're always going to be perfect but what they expect us to do is to work on our problems and make them better.

Mike Patrick: Yeah, absolutely. And if you don't identify those and have that transparency, that's not going to happen. Yup.

Richard McClead: Right.

07:06

Mike Patrick: Just in terms of some recent shows, you did a show on button batteries, hand hygiene here in Nationwide Children's Pastoral Care. At Nationwide Children's – reducing the frequency of pediatric pressure ulcers, breaking the language barrier where you talked about our interpretive services. So, lots of great content, very broad-based sort of stuff.

Richard McClead: I guess the whole issue of quality improvement covers the gamut of what we do in healthcare. So there's just a lot of opportunity. The biggest problem that Kelly Nightingale, my producer, and I face is trying to narrow it down to what we can focus on and doing a 15-minute, 20-minute presentation.

Mike Patrick: Yup. You have a producer.

Richard McClead: Well, I do have a producer. So I guess, the trade-off between all the great audio equipment and having… I'd rather have a producer.

[Laughter]

Mike Patrick: We were just commenting before the show that the PediaCast studio, equipment-wise, is a little more high tech, but you have more people help.

Richard McClead: I have…

Mike Patrick: I really shouldn't say that because we have some great folks on our interactive team, and just not a producer.

08:17

OK.

[Laughter]

Now, you talked about quality being important because that's how you improve yourself. What are some other reasons you think that a culture of quality is important for today's healthcare industry other than just improving yourself? What else?

Richard McClead: Well, I think we're all aware of the financial struggles our country is in and a big piece of that is the entitlement associated with our healthcare coverage both from Medicare and Medicaid. And these are important services that we need to continue to provide, but there's only so much money available. We need to focus on eliminating that which does not bring value to the healthcare delivery system to optimize outcome and reduce the cost.

Can we do the same thing even better and do it for less cost because I think the reality is we've got, 40% of our patients, I think, varies from unit to unit, but on average about 40% of patients are Medicaid patients. They're government insured and there's not going to be more money down the road.

Mike Patrick: Yeah.

09:43

Richard McClead: So we're still going to have these patients to take care of whether the government cuts our budget or not. So we need to figure out how we can do things even better and there's so much opportunity. We have to standardize our care and to create some efficiencies and we've just done so much here in the past 15, 20 years. It's just amazing.

Mike Patrick: On a national level, here in Central Ohio, we don't have a ton of competition. So if a child get sick here, it's kind of a no-brainer. We're going to take him to the Nationwide Children's. But in some places and in the adult world where there is more of a competition issue, I guess quality in that case too, if you can present to the public, "Hey, we're really working on being the best." I mean, that may help you get more business that way, too.

10:30

Richard McClead: It is. But it is interesting though, and this is in Columbus, we are the only show in town when it comes to pediatric care. On the other hand, we've got a whole bunch of adult hospitals that are in competition for one another. And you can watch the television at night, everybody is advertising about how great they are but not a lot of data being put out there for the public to really compare. Although that's changing with stuff coming out of CMS Medicare people. They're starting put up those quality metrics for number of things. That should be helpful if the metrics are valuable.

11:20

Mike Patrick: Yeah, right.

Richard McClead: And are they informative? And are they worth paying attention to? And I’ve not always been convinced that some of those metrics are that valuable.

Mike Patrick: Yeah, kind of depends on who… Because you can spin metrics.

Richard McClead: You can.

Mike Patrick: Kind of watch where they're coming from.

Richard McClead: They often have to be… A lot of those metrics that government reports about individual hospital – performance is based on what we call administrative data. These are the codes that we put in when we submit our bills for patient care. And a lot of times in pediatrics, those codes may not just quite fit.

Mike Patrick: Right.

Richard McClead: And so if the government is taking those codes and evaluating the performance of a hospital based on their coding, they may be making some assumptions that are not valid and that's frustrating.

So I think it's important – decide what you want to measure and then go out there and do it. And then as much as possible, let the public know how you're doing.

12:26

Mike Patrick: Yeah, yup. And you touch on outcomes, too. Of course, from a parent point of view, that's really foremost on their mind. They want their kid to get better and they want it to be done in a safe, efficient manner. And so by kind of focusing on quality, we can improve care.

Richard McClead: Right.

Mike Patrick: So we don't want to forget mentioning that.

Richard McClead: No, I mean, that's kind of…

Mike Patrick: No brainer.

Richard McClead: Everyone of our quality projects has associated with it a balancing measure. A balancing measure is a measure that is our way of confirming that "improvement", so called, that we've implemented is actually a change that is a true improvement and has not had a consequential adverse effect.

13:13

So, you know, a project that I've been working on now for two and a half years is reducing length of stay in the intensive care nursery. And a balancing measure for that is, of course, the readmission rate. If I send them out sooner, that's great. But if they bounce back within 30 days, that's not so great. Nobody expects to leave the nursery and then come back in 30 days unless there's something that they have to do.

So, it's important to have that. Quality is – we have to be focused on the same quality or better outcomes. But there's so much variability in the systems that we have lots of opportunity to reduce that variability and improve the overall quality of patient care.

Mike Patrick: What specific quality initiatives are happening here? You mentioned the neonatal intensive care readmission rate. We mentioned hand hygiene before. What are some other sort of big package programs that are quality focused that are happening here in Nationwide Children's?

14:15

Richard McClead: Well, I think that's a great question. It's actually, an opportunity for me to call attention to your audience of our website. If they will go to www.nationwidechildrens.org, all one word, to the website and then look for the Quality and Safety and pull that up, you can see that they have a quality and safety measures webpage. And so, there we publicly report adverse drug events. Medication errors are a significant cost of patient harm within any hospital and so we're focus on eliminating, by 2013, our harmful events.

I have a podcast, hopefully coming out here in the next month, that's actually going to talk about a little bit of our Zero Hero program that is focused on eliminating preventable harmful events that occur in our children that are under our care, within, by 2013.

15:20

But if you look at how children are harmed, about 50% to 60% of the cost, when we started this was due to medication errors. Errors, mistakes that are made in the medication management process that reached the patient and caused some degree of harm. We have a method to rank her injury.

In the most of more relatively minor things, if it gets the patient, maybe have increased monitoring a little bit whatever, rarely, and we haven't had one for a long time. They cause really bad outcomes.

And so we track that, each event that is reported. Now, given this is based on our… We have various methods for monitoring adverse drug events but certainly the big part of it is our staff, their comfort level at reporting events. We're trying to create a safety culture where people are focused on identifying an error that they made and then feeling comfortable about sharing that information with leadership so that we can set about fixing those aspects of the error that are system related and then can be prevented.

16:34

A lot of cultures come out… A lot of hospitals, especially, come out of an environment that it is a shame-and-blame environment where if somebody makes a mistake, they're fired or they're punished in some way. They're put on administrative leave and things like that. We think it’s important to have a culture that is, you have to be accountable. If you’ve made a mistake and it's because you chose to ignore some key safety measure intentionally, you have to be to be held accountable for that. But most of the errors that people make are in part related to the system problems. So adverse drug events is a major issue for…

17:17

Mike Patrick: For all hospitals, yeah.

Richard McClead: For all hospitals but we're really and we've – I came from meeting this morning where we heard our current results to date. Our goal for… We started out… We did a podcast some time ago on adverse drug events, but at the time we were having – our peak was about 85 harmful events per quarter, every three months. And that's based on about 140,000 doses per month. So 500,000 or so medications dispensed, we had 85 errors. Well, our goal for – and that was peak of 2010, February first quarter of 2010. First quarter of 2012 through February, we've had a total of 12 errors.

Mike Patrick: Wow.

18:05

Richard McClead: And we're on track to hit our target of 20. And then, we'll keep driving because the goal is to get zero. You just have to really focus on the systems. So that's been a big measure.

Other elements of harm have to do with infection, a lot of things related. You mentioned hand hygiene is one of the process measures we track. But the outcome measure that we're looking at are surgical site infection, ventilator associated pneumonia, and urinary tract infections, and the central line catheter infection, bloodstream infections. And we are having tremendous success at driving those infections down.

We haven’t totally eliminated, but for instance, in our NICU – the Neonatal Intensive Care Unit – the bloodstream infection which is, because we're dealing with immuno-compromised population, it's not surprising that it would be up. Ours is some of the best in the country. If you go to the website you can see how well we're doing at Children’s Hospital with infections.

19:11

Asthma is another area, and then the overall serious safety event. And, I think, I really like people to take a look at this because you will not find very many hospitals in the entire country that's willing to put a rate of how often they have a series safety event.

Now these are our pretty significant events that occur to patients, cause a great deal of harm. And fortunately, they don't happen very often but we're willing to talk about how often. And then, we'll give you a little detail about the event and let people know about it.

Mike Patrick: Great. What did we learn from it, what did we change because of it.

Richard McClead: Exactly.

Mike Patrick: Now you've mentioned the Zero Hero program, what exactly is that?

Richard McClead: Well, the Zero Hero program was the vision of our new Chief Medical Officer, Dr. Rich Brilli who came in Fall of 2008. And his idea was to eliminate preventable harm.

20:17

I mean, there are some harm that is not preventable. But there are lot of things that happen to children that could be prevented if somebody… I mean, something as simple as acquiring central line catheter infection, hand washing is a key part of that. If you're not washing your hands, your increasing the chance. So monitoring hand washing is an important element.

But his goals, his vision, was to eliminate preventable harm by 2013. That gave us, when we started and actually it went up being by the time we got it up and running, 2009. So within four years, we were going to… Our set of vision of something what is really… We talk about being audacious or bodacious. It's just amazing to make that kind of commitment.

Mike Patrick: Yeah.

Richard McClead: It was hard to believe that we could do it. But now that we've been in it and we've seen the results, it's happening. I don't know that we'll get to zero but we're making great progress at eliminating all these different ways that children could be harmed while in our care.

21:24

Mike Patrick: Yeah, you know, I love the name, too. I don't know who came up with that. But the idea being that you don't want to be in a situation where you need a hero.

Richard McClead: Right.

Mike Patrick: Is that the … Or is this zero means we're trying to get to zero events?

[Laughter]

Richard McClead: Well, we're trying to get zero events but we want our heroes to be the staff that help us identify the various system problems that are contributing to errors and being willing to report.

Our Zero Hero Program was associated with a phenomenal training program in the culture, in patient safety. We created tools working with our consultants that people can use to help minimize the risk that they would make an error.

Mike Patrick: There is a lot of training that goes on. Anybody who's a new hire to the hospital goes through Zero Hero training.

22:19

And one of the things that I like about it is the whole buddy system idea where you have sort of have someone that you're accountable to and that's kind of looking over what you're doing. But then, you're also looking over what someone else is doing. So that we're all kind of a team and in this together and kind of have each other's back.

Richard McClead: You know, we call that 200% accountability – that if somebody makes a mistake and I'm standing there watching them make mistake, I'm just as accountable as they are for making that mistake. So my role is to use my Zero Hero tools to tell my colleague that, "You know, I think you're forgetting to do… Maybe you’re forgetting to put your mask on when you're about to do an invasive procedure. That's part of the checklist of things that we focus on to prevent infections. And you forgot to put your mask on. Would you put your mask on?” Just to remind people. We have to look out for each other to keep errors from happening.

23:22

Mike Patrick: Now, what are some areas where Nationwide Children's could do better?

Richard McClead: I think we still have a ways to go with eliminating our harm. And I think that probably is the focus for attention – all these different ways that children can be hurt are areas that we want to continue improving. We're making progress but it's not zero. Until we get down to zero, that's got to be our focus.

Mike Patrick: So just as new things come up, we need to…

Richard McClead: Yeah, we take care of… For instance, there are a number of projects I've been asked to take on because there's a lot of variability in the various processes measures, outcome measures, and they may be very costly.

24:12

For instance, recently, I was asked to focus on one of the gases we use in the Critical Care unit. Very expensive gas, it has indications, but we use it for a lot of reasons. And there is not always the literature to support its use but the clinical impression of the physicians is that this is beneficial. So working with the doctors, we've established some standard pathways that they're going to follow for the use of this particular gas. And we think, over time, use of good compliance with those protocols will lead to reduced variability in the usage.

It's easy to start some of these medications but then the fear of stopping it because you're not sure what's going to happen, so if you a priori decide what are the stopping criteria and how are we going to wean this medication. And you get that all written down on paper and then you hold each other accountable for following it. And if you decide that you're not going to follow the protocol, that's OK, just tell us why so that we learn.

25:20

A lot of this improvement is about us, one, creating a belief that we can make a difference, and two, that the difference will have…

Mike Patrick: An effect, yeah.

Richard McClead: Have an effect later on.

Mike Patrick: I think some may be wondering in their minds. We're talking about nitric oxide.

Richard McClead: Yeah, nitric oxide.

Mike Patrick: And there was a study that just came out. I forgot what's the journal. But there was a study that looked at whether it's really helpful or not. I think we have that lined in our future PediaCast.

Richard McClead: OK, great.

Mike Patrick: So, just in case parents are wondering what that's all about.

So I'm just going to turn our attention here to the podcast itself. How did you get started podcasting?

26:09

Richard McClead: Well, when we started our program in Quality and Safety, the Zero Hero and eliminating harm, we kind of create this focus. One of the things we want to do was to begin the process of sharing our data publicly.

That was new for us and there were some concern that we wanted to make sure that the public understood what it is that we're talking about. And so we decided that in addition to showing some of the data for different metric, we'd actually record an interview with experts to talk about what it is we're doing and why we're doing it.

So the marketing department asked me to be the interviewee and we hired a professional audio firm to come in and record these files of me interviewing various experts about the different metrics that we're reporting publicly. And I thought, "Oh, this is kind of interesting." It was very high quality. They're still on the website. If you go and click on them, you can see those. They're very high quality. They were somewhat expensive.

27:19

And I realized, "Wait a minute, I want to do something like this as a podcast. I can afford to pay somebody to record these things" So we kind of decided, "Hey, let's try this and see what happens with it and we'd have the focus of each show a different aspect of some of the quality efforts we have going at Children's Hospital."

And that's how it all kind of started. It came from that – how do we tell public about our metrics that we're measuring?

Mike Patrick: Yeah. Because when you look at numbers, just the numbers, they can be misleading. You might not really understand the story behind the numbers and they gave you a chance to talk about that.

Richard McClead: Absolutely, yeah.

Mike Patrick: How do you choose which topics you're going to talk about?

Richard McClead: Well, usually at the beginning of the year, Kelly and I will sit down and come up with a list of possibilities. I'm quite familiar with all the different things going on. So it's not a problem of finding what to talk about. It's a question of having enough time to put together a podcast for all the things we'd like to share.

28:20

Mike Patrick: Right.

Richard McClead: And then, trying to make some sort of a… Have it set up far enough in advance that we can kind of anticipate what the next one's going to be. I got to line up individuals for the interview. I have to identify the expert, line them up, schedule the room where I'm going to do the recording and kind of go from there.

Mike Patrick: How often do you produce shows?

Richard McClead: I'm at best trying to do once a month. And with my busy schedule, it's sometimes difficult to pull that off. Ideally, I'd like to do a podcast every week. I think we could do it. But I just…

Mike Patrick: It takes a lot of time.

Richard McClead: It takes the time. You know yourself, you get your audio file, then you got to edit it. So that takes a flicker of time. Then you need to have it vetted by the crew. So I'll send it out to Kelly and she'll have a listen. And then, sometimes I have to have other individuals take a listen to it to make sure they think it's OK and then go from there.

29:26

Mike Patrick: Now, where can folks… Where's the best place to connect with the Children's on Quality podcast?

Richard McClead: Well, if you go that website of Children's Hospital – www.nationwidechildrens.org – and then click on the tab at the top that says Quality and Safety, it will bring up the Quality and Safety Page where there's an intro by Dr. Brilli that talks about our focus on quality and safety. And then on the left hand side, it lists the quality metrics. Then you can see from the Quality Metric Safety Measure, down just below that is the link for the Children's on Quality blog and the audio file.

30:04

Mike Patrick: Sure.

Richard McClead: So this month, we've got surgical hypothermia as our topic that we're covering. Because I got a team of anesthesiologists and perioperative quality improvement people that are working on trying to reduce the cold exposure, the unplanned cold exposure. Because sometimes we plan to make it cold as part of the surgery. But when it's unplanned , it increases the risk of infection. So if we're going to drive our surgical site infection rate down, we got to address the issue of surgical hypothermia.

Mike Patrick: Yup.

Richard McClead: And they have a big team around that.

Mike Patrick: Yup. That sounds interesting. And that show's coming out later this month?

Richard McClead: It's out now.

Mike Patrick: Oh, that one is the one that just went.

Richard McClead: Yeah, it is out there now. Yeah.

Mike Patrick: OK. And you can also hit childrensonquality.com. You guys have that as your kind of landing page.

Richard McClead: Right, exactly.

Mike Patrick: Just for the podcast itself with the Show Notes to let people know what particular topics. But again, the Safety and Quality tab is on the main website over at nationwidechildrens.org and people can look up links to both of those things in the Show Notes over at pediacast.org for folks at least who are going over there so they can find it as well.

31:14

All right. Well, this show is not only a PediaCast episode but it's Children's on Quality show as well, so it will be on both feeds. And even though, it may seem I kind of hijacked the operation here, I am going to turn the rings over to Dr. McClead. And for the first time in PediaCast history, I'm going to be playing the role of guest.

Take it away, Dr. McClead.

[Laughter]

Richard McClead: Well, I appreciate the opportunity to share in this mashup podcast. I think, 1994, you were the resident, Then you left and then, you were down in Florida?

Mike Patrick: Yeah, yeah, yes.

Richard McClead: And so you're down there in private practice?

Mike Patrick: Great. You know, actually, I was working… I was in private practice in the city here in Ohio, in Springfield, Ohio, for 10 years. And I got kind of burnt out with private practice and was still trying to do PediaCast on top of a 40-hour work week. And an opportunity arose to go to Orlando and work with the Pediatric Urgent Care Group. So I did that for about three years.

32:18

Richard McClead: And the Urgent Care gives a little more…

Mike Patrick: A little more…

Richard McClead: Control of your time.

Mike Patrick: Yes. Yes. Yes.

Richard McClead: Well then, so the PediaCast began in Springfield.

Mike Patrick: It did, yes.

Richard McClead: And so what motivated… I mean, what we're looking at, early 2000?

Mike Patrick: Yeah, it was 2006, July of 2006, when we first started.

Richard McClead: So what was the motivation to you to say, "Hey, there's a need for a podcast for parents about pediatric health issues."?

Mike Patrick: Well, I have to go back to when I was 10 years old. The reason for that is my parents at the time manage a skating rink. In fact, this is the late 70s, so roller skating was kind of a big thing and they were the professionals. You know, they did the classes and the people who were competing, they would coach them, so to speak. And then there were also managers at the skating rink.

33:18

So when I was 10 years old, I started to work as a DJ for the kid's fun skate on Saturday mornings. And they paid me by letting me pick out from the concession stand anything that I wanted to eat after the skate session was over.

So that's how I got started behind the microphone, when I was 10 years old. And throughout middle school and high school, I increased that, I kept doing it. It got to the point in high school, I was doing the Friday and Saturday night sessions, the all night skates. The skating rink then started to do other deejaying events. So I would go into pool parties, dances, kind of traveling DJ kind of gig.

And then I started working at a couple of radio stations, campus college kind of radio stations in Springfield. And then, when I went to college at Ohio Wesleyan, I worked at their radio station throughout college as well.

34:11

I liked it, but I wanted to do something where I was really helping people more than just doing broadcasting. And I was interested in medicine. No one in my family were doctors. I just thought it'd be kind of cool to be a doctor. I didn't really look into it as much as I probably should have.

So I went to medical school, really forgot about broadcasting completely, went into pediatrics. And it was in 2005 when podcasting was born and I started listening to podcast. And I just kind of rekindled that, "You know, this is something I could do. It would kind of get me back behind the microphone again in a way that I could connect with parents."

Because the problem that I find in private practice is you see a lot of the same things over and over again but you only have a snippet of time to be able to talk about it. So if a parent wants to know, "Why does my kid keep getting ear infections over and over again?" I mean to really explain on terms that they can understand but still going into the path of physiology of why this happens and why we need to do what we're doing, it just takes up a lot time.

35:18

So I thought if I can come up with some sort of canned spiels that went into it in more detail, then I could say, "Here's the quick story but if you go to this website, you can listen to me talk about it in a longer way to help you understand." Because parents are, you know, they're just thirsty for knowledge in whatever realm of medicine that's affecting their child at that time. And getting good quality information out there is sort of hard to find.

So my OCD nature and my ADHD nature both kind of played a role here. I couldn't just record spiels and put them out there. I had to really research this. So I started listening to podcast about how to make podcasts. What kind of equipment do I need? What kind of planning? What's going to make it sound the best?

So l looked into all that. This is now late 2005 and in the early 2006. So I really had to have a plan. And as that came together, I thought, well, I don't want to just make canned spiels. I want there to be a little bit of an entertainment factor involved, too.

36:20

So this idea came to cover news, answer list in our questions, do it more of an entertainment kind of show that still has a primary focus of education that people might be interested in listening too, and doing interviews. And so, when I started up in 2006, that was sort of the vision and just put it together and people started listening.

iTunes kind of grabbed a hold of it. Because it was still in the early days of podcasting. I think what helped me out was not submitting it as a medical podcast. I submitted it to the iTunes directory in the Kids and Family section, because that's really where the audience is.

Richard McClead: Right. Yeah.

Mike Patrick: And so people started listening. iTunes, its still on their featured page. So if you go to iTunes, to Podcasts and click on Kids and Family, it's right there on the front page of it.

So that's really helped recruit the audience. So just been doing it and keep doing it and here we are.

37:13

Richard McClead: But it began as a way to actually improve…

Mike Patrick: The quality.

[Laughter]

Richard McClead: The quality of how you communicate with your families, because in your private practice setting, you didn't feel like you have enough time to really provide the families what they needed.

Mike Patrick: Yeah.

Richard McClead: And that's just great.

Mike Patrick: And, you know, it comes back down to the money factor. Because in order to operate a pediatric practice, you have to pay staff, you have to pay the bills and the rent and vaccines and all that. And so, in order to keep that going, you have to see X number of patients of day or you're not going to have the income to pull it off.

And so, that's really the pull – that you don't have enough time to really sit down with parents and give them the information they want. And that's happening in pediatric offices, and not just in pediatrics, in medicine in general all across the country. I mean, I'm sure doctors would love to see half the number of patients that they see in a day to be able to explain to parents exactly what's going with their kids.

38:08

I know in our specialty clinics, you have a kid with a seizure disorder and they're on their seizure medicines, they would want to know more than what the neurologist has a chance to sit down with them. But when you have a three-month waiting list to be able to get them to see the neurologist, they have to click along and see people quickly.

So I knew there was a need to get quality evidence-based information in the hands of moms and dads and this seem like a good way to do it.

Richard McClead: Wait, you remember our good friend, Dr. McClung.

Mike Patrick: Oh, yes. Yes.

Richard McClead: Years ago, he's passed on now.

Mike Patrick: He's a GI.

Richard McClead: A GI doc. But Dr. McClung had written one of the most popular articles – I think it was published in Pediatrics – forewarning the public about some of the bad information out there that they can get from the Internet that just isn't correct.

Mike Patrick: Oh yeah. Yes.

Richard McClead: So he kind of given everybody a heads up.

39:04

Mike Patrick: Yeah. Anybody with an agenda can write anything they want and if it looks professional, in a blog, in parents, especially…

I guess a good example is the whole vaccine thing. When you have a kid who has autism, you want to know why. I mean, you want to be able to say, "Why did this happened? How can I prevent it from happening to my next child? How can I get the word out and prevent this from happening from other parents having to go through the same thing?"

And so when you get a hold of information that would suggest immunizations do it, I mean, you can understand from a parent's point of view, you would become passionate about wanting to do this if you truly believe vaccines were the cause. So I think the Internet is really responsible for the misinformation that's out there about vaccines.

So again, we're just trying to make a place where parents can come and get the right information based on studies and science and experience.

Richard McClead: So how do you go about deciding? I mean, I have lots of things in Quality to talk about here but I just think about the myriad of possibilities to talk about with pediatrics health issues.

Mike Patrick: [Laughter]

Richard McClead: How do you go about deciding what your agenda's going to be for the coming year?

40:16

Mike Patrick: You know, to be honest, I can't even do an agenda for a year because I… I'd go out about three months or so. And the reason for that is because I wanted to be fluid in terms of what's happening now.

Richard McClead: Right.

Mike Patrick: Sort of, what's the mainstream media is talking about? What studies are coming out? What in pediatric medicine are the hot topics that we're discussing? And so if you kind of plan out a year at a time, you're going to miss the miss the boat on some of that stuff. So there's a little bit of a shorter lead time for this show.

The first place I get ideas for topics is just people writing in. So we got lots of emails through the Contact page at pediacast.org where people have questions. So we try to be responsive to those first and foremost. So we're here for the audience. If there's particular issues you want to know about, we try to get those in the line up and talk about it.

41:08

Just an example, recently someone wrote in because they had broken a CFL bulb and they were worried about mercury exposure. So we got Dr. Marcel Casavant to stop in. We talked about mercury exposure just based because someone had written in with that particular topic. And we do funnel this a little bit to make sure it's a topic that's just going to appeal to…

Richard McClead: A wide audience.

Mike Patrick: Yeah.

And then, the next thing is to look and see, like what I said, what's happening in the mainstream media. So if there's… Dr. Oz comes out and talks about arsenic in apple juice, we're going to talk about it and say, "Is this really a problem? Are kids really having symptoms of arsenic poisoning all across the country that we don't know about?"

So any things that are kind of hot topics in the media, we try to pick those up. And then we also look at what kind of things, what kind of programs here at the hospital do we want folks to know about. I mean, there's some great programs that we have. They're maybe under utilized because people don't know about them.

And we also, being a big tertiary care center, there are a lot of folks out there who don't live next to big children's hospital and so they have some choice where they want to go. So if you live in rural Iowa and you have a kid with Kawasaki Disease, you may want to take the trip up here to see one of our cardiologist to have your echo done. If it's something you're only going to be following up with once a year, it might be a place you want to be because we got the top folks here.

42:31

And so just getting that kind of information out into the hands of moms and dads.

And then, we also have a large international audience. When we were looking at our metrics from last year, PediaCast is actually heard in a couple hundred countries. And so, again, they don't necessarily have access to great information in a lot of places so we try to provide that.

So we try to get more bread-and-butter pediatric topics in there too – eczema, asthma – just stuff that's little easier to find but for other places, it may be more difficult. So we try to go into those things as well.

Richard McClead: And you're producing a show weekly?

43:10

Mike Patrick: Once a week.

Richard McClead: Once a week?

Mike Patrick: Yeah. I had the good fortune to be with the Marketing Department a couple of days a week. To prepare a show with good evidence-based information, it's anywhere from a half hour to sixty minutes per show. I mean, there's a lot of prep time and of course, coordinating interviews and getting them to schedule and do them and all the post-production work.

And we're now, and I think your podcast is too, we're transcribing the podcast so that it's not only an audio file but there's actually a written documentation of what we're talking about. And that's, of course, helpful for Google because the search engines crawl and get all that information. So if someone searches for asthma, they're more likely to get one of our shows that were talking about asthma a lot. Where if it's just the audio file, that doesn't…

Richard McClead: They might not pick that up.

Mike Patrick: Yeah. Right.

And there's some people who just, you know, they prefer to read it.

Richard McClead: Yeah.

44:05

Mike Patrick: One of the things about podcasting that I really sort of fell in love with is that you can do other things. I mean, there are just so many things competing for our time these days but with podcasts, you can listen to them while you're commuting, while you're exercising, while you're cooking dinner. So it doesn't take a 100% of your time, but you can still get the information into your head.

[Laughter]

Richard McClead: Yeah, for sure.

Now, the program when it started in Springfield, was that immediately affiliated with Children's Hospital? How that all come about?

Mike Patrick: No. I put together a studio in our basement and I was just doing it on my own. I was kind of a victim of my own success a little bit because I was with a host, where you have the audio files – and I won’t mention their name – but when it started to really pick up traffic, it was on a shared server and pretty much crippled their service. Which I didn't realize it was happening.

So I got an email from these folks that says you have 24 hours to take your show off our servers. And at that point, I had a thousand listeners and it was in iTunes. And so I really had to switch to something that was more stable and would allow me to have higher traffic. That cost more money and I footed that for awhile.

45:27

In Springfield, we're close enough to Nationwide Children's. We have physician liaisons that came out to our office every few months. He would just kind of check in with us, what kind of services. And so I mentioned the podcast to him and just said, "Would you be interested in being a bandwidth sponsor, just helping me?" Because this has always been a free program and we never wanted to put that obstacle on there to make parents pay for it.

So I just mentioned, "Would you be willing to help foot the cost of it?" I don't remember the exact… I want to say it was maybe late 2007 when we started with the relationship and so they were our bandwidth sponsor. And then, even when I moved to Florida, they continued to do that for me.

46:08

And then, what happened is, I found that even though I have less time working in Florida… I mean, really it was a better… Compared to private practice, it was fewer hours that I had to work. But when you live in Florida and you have kids and you live… Literally, we were five minutes from the Magic Kingdom at Disney World, I seldom have a lot of free time to do the podcast because we were going. We'd do a lot of fun things.

And then this opportunity came up though to actually make PediaCast a part of my 40-hour week job and I couldn't resist, so that's why we came back up.

Richard McClead: That's pretty neat.

What do you think is the next big thing when it comes to social media that you might want to take advantage of?

Mike Patrick: Yeah. You know, this is still me talking to people at the end of the day. So folks can write in questions but it's still not as interactive as I would like it to be. And I kind of envision the day when there's something that we could do more live with people.

47:22

So folks, they have laptops with web cams on them. And so sort of a conference kind of thing where folks can show up and ask questions live. It can really be more interactive. I mean it is interactive in that people write in questions and we cover them and talk about them, but there's still that production nature to it.

And I think, with social media, what that will open up in the future is for us to be able to be more interactive and actually be more one-on-one. More like a radio show, so to speak. Google Plus does have gatherings, I think it's called, but there's still a limit. I think it's only 10 people or so that can do it at one time. So it wouldn't work as well with a bigger audience. But I guess, that more interactive component to it is what I'm looking for, too. I think we'll get there.

48:11

Richard McClead: Have you given any thought to actually having a broadcast video show?

Mike Patrick: We've talked about that as well. Again, I think… I don't like the camera as well.

[Laughter]

I got a good face for a radio.

[Laughter]

So the camera, you know, is not my favorite thing. And I do think, I mean, eventually, we do have some plans with Facebook and video for later this year that we're going to be discussing and working with. And that's really at the pull of the marketing folks here. It's not my initiative but we are kind of heading in that direction with video as well.

But again, I think that for folks who really are interested in in-depth information, the podcast is still the best way because we have more time. The video clips still have to be short, because when people are spending their whole time, video requires a 100% of your attention. You can't do something else while you're watching video.

49:15

And in our society today, people don't want to sit and watch a video for a half an hour unless in front of their TV. And so, I don't think that… I think we will have to have less depth if we go the video route.

And the whole reason for doing this was to be able to say, "Let’s explain why kids get ear infection. Let's talk about eustachian tube, the cilia, how a virus infects those little cells so the cilia don't work and bacteria." You know, really getting more in-depth about why this happens so people can understand it. And I don't think video lends itself to that quite as well as audio does. But maybe that's old fashion of me and I'm going to get pulled into doing more video anyway.

[Laughter]

Richard McClead: There's a video podcast, iPad Today, that I started watching. It's an hour show and the problem I had is just to sit down for an hour, it's not like watching a basketball game or something like that in television when you're doing it. So I tried to do it and man, it just didn't work.

50:26

I listen to a lot of podcasts. Most of the podcasts I listen to are business related because I happen to be chairman of the pension plan committee for our corporation. So I need to learn something about finances and things like that even though I've got some grad work in that area.

So I listen to Marketplace. I actually started off when it was free, listening to Bloomberg on the economy. But it was, you know, 15 to 20 minutes and that's a drive in from home.

Mike Patrick: Yes. Yeah.

Richard McClead: I listen to, usually, two podcasts a day from various sources just driving back and forth to work.

Mike Patrick: Yeah. Yeah.

Richard McClead: And so it is a great tool for me to learn about some topic or some area of interest or to keep up in what's happening in the economy today. And I'm sure it's the same for parents who want to keep up with what's happening with healthcare issues for their children.

51:23

Mike Patrick: Right now, we kind of have a hybrid audience in that still the majority of our listeners are parents. But we're getting more listeners who are clinician. And so we have medical students. We have nurse practitioners, nurses, pediatrician, family practice doctors who write in. They make nice comments on iTunes, because we have iTunes reviews. So someone will say, "I'm a pediatrician. This is a great resource" kind of thing.

So I know we’re getting more of a professional audience. And that's another reason to go more into details. So we had a Kawasaki interview here recently. We had a pediatric cardiologist and an infectious disease person, and I mean, we really unpacked Kawasaki Disease in detail. But we still kept the language where parents can understand.

52:09

But I do think that in the future, there's interest I think in a podcast that's aimed at pediatric professional. That kind of kicks it up a notch. We can use a little bit different language. And maybe even make it available for CME kind of stuff.

But as you know, there's a lot more work that goes into that in terms of quality control and making sure that we're hitting goals and there's a way to evaluate. It's more difficult. But I think doing a consumer podcast takes time. Doing that kind of thing will take you even more time. But I mean that's a direction that we could head also in the future.

Richard McClead: It just occurred to me that with the interaction that you want to see happen, my role is Medical Director for Quality. I'm engaged in a lot of quality collaboratives around the country. So we might have 15, 20 hospitals all over the country that are participating in a specific quality improvement project.

53:11

And so, we have webinars that we use, the commercial platforms to… So it is not… There are some videos associated but usually it's slides the people are presenting. And then, it's hooked up to your phone lines so that I got an email that says, "At 9:00, we're going to have a webinar. This is the number and the pass code" and things like that. Do you think that might play a role in creating the interaction that you might want to see with your audience?

Mike Patrick: Yup. And that kind of thing too then kind of get you into a little bit of a different audience in terms of more healthcare professional kind of stuff. So sure, yeah.

Richard McClead: That might work down the road.

Mike Patrick: All right. Well, I really appreciate you stopping by the studio today.

Richard McClead: It's been fun.

Mike Patrick: I definitely has.

Before you go, there's one more thing that I have to ask you. All of our guests that come in to PediaCast, we ask the same question. One of my passions – and the audience kind of rolling their eyes right now because they know exactly what I’m going to say. One of my passions is that families spend time together that doesn't necessarily involve TV screens, video games, computers, just really quality time together. I think in our busy society, there's less and less of that.

54:22

And in our house, one of the things that we like to do is sit down and play games – so board games and card games. And so every guest that comes by we just ask him, "Hey, what's your favorite?" I think there's a lot of folks out there who find new games through doing this. I know there's been several games that we have played here recently that I have never even heard of but by asking folks I kind of found out about it. And it's now a new favorite.

So what's one of your favorite games.

Richard McClead: Well, let me preface things by saying my wife is a gamer.

[Laughter]

She is in the games and gets very upset if I don't play with her. I guess she will play any games and it doesn't matter what it is. But I prefer the card games, because there is usually some sort of challenges associated. It's not so much about winning but the strategy involved in planning a set of cards. You know, something as old as euchre. I've never been a poker player but I'm kind of fascinated. I watch poker on TV. There's Texas Hold Them, I guess, whatever it is called.

55:35

Mike Patrick: Yeah.

Richard McClead: But I think the card games, any of the card games…

Mike Patrick: Yeah, euchre, we love euchre. We thought our kids to play euchre at a young age. So they're big euchre players and we do play that quite often.

I'm going to answer this question because, you know, since I'm one of the guests. We actually had Dr. Maya Spaeth. She's a plastic surgeon here at Nationwide Children's. She came by the studio last summer and talked to us about microsurgery. But she introduced us to Settler of Catan.

Richard McClead: OK.

Mike Patrick: Have you heard of that?

Richard McClead: No, I haven’t.

Mike Patrick: I hadn't heard of it either and it is really fun. And there's a ton of strategy involved. It basically is, there's an island and you're trying to set up a civilization. You have to get like 10 growth points and you can get those by building roads, by building cities, by having an army, different ways that you can get points.

56:32

And so all the players are trying to build their own civilization on this fairly small island. And you have to barter with one another. So you may need coal but you don't own any property that has coal on it so you have to barter with other people. It's really a lot of fun.

So anyway, it's called Settlers of Catan. We got it for Christmas and we've been playing a lot since then.

Richard McClead: Do you play any of the interactive games?

Mike Patrick: I only play much to my chagrin – I probably shouldn't do this as often as I do – the Words With Friends kind of thing like through Facebook. One of the nurse practitioners I work with introduced me to that and I wish she hadn't.

Richard McClead: [Laughter]

It's addictive.

Mike Patrick: It is. And so, right now…

Richard McClead: It's another one of those Angry Birds.

57:15

Mike Patrick: Yeah, yeah, yeah. Exactly.

So I got games going with my wife and with my kids. And there's a new one called Picture This, I think. It's like a Pictionary game but it's also through Facebook. And so you draw picture and they have to guess what it is. But it's kind of fun because then, when it's you’re turn again, it actually draws what you drew in real time and shows you how long it took them to guess. And any move that they made, so if they started to guess something wrong, you'll see that. Kind of records what their screen is doing. And then they'll draw something that you have to guess. You hook up to it like you do with Words with Friends.

But again, there's so many things that want your time, you know what I mean. So I try to stay away from online gaming as much as I can.

Richard McClead: I’ve never been in the online gaming. But my wife would play Words of Friends, or I think it's one of the word games, with my daughters who were out and about.

58:10

Mike Patrick: Well, my daughter's going to college in the fall. And my wife in particular already told her, "You know, you have to keep playing Words With Friends when you go away."

[Laughter]

So I'm not sure if that was a good thing for my daughter or not. But we'll find out.

All right, well, again, really appreciate you stopping by. And on behalf of Dr. Rick McClead and myself, thanks for joining us for Children's on Quality and PediaCast for our first ever mashup.

I know it's been a little different from our regular shows and we hope you enjoyed it. Don't forget to tell your families and friends, also your healthcare providers, about both of these great shows from Nationwide Children's.

Remember, it's easy to get in touch with us again. If you just head over to pediacast.org, we have the contact link there. And for Children's on Quality, you can go to childrensonquality.com. Or better yet, go to nationwidechildrens.org and click on Safety and Quality. It's a big tab, you can’t miss up. You can hook up with the Children's on Quality podcast that way as well.

We're also available in iTunes. And for PediaCast specifically, if there's a topic that you want us to talk about, you can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

59:23

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

[Music]

Topic

• Kawasaki Disease

Guests

Dr Preeti Jaggi
Section of Infectious Diseases
Nationwide Children’s Hospital

Dr John Kovalchin
Director of Echocardiography
The Heart Center
Nationwide Children’s Hospital

Links

• The Heart Center at Nationwide Children’s

• Infectious Diseases at Nationwide Children’s

• Kawasaki Disease Foundation

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!

Mike Patrick:: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. We are, of course, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.

It is Episode 203, two-hundred and three, and this one we're doing on Kawasaki disease. It is March 14th, 2012. I would like to welcome everyone to the program. Kawasaki disease, this is not about motorcycles, folks. This is a disease that affects kids, and we want to talk about it for lots of reasons.

01:02

It's an interesting disease, and I think this one's really going to appeal to science lovers out there because it's complicated and it requires a little bit of thinking to understand it. But never fear, we're going to unpack it in a way that doesn't require you to have a health degree. I think this one will also appeal to mystery lovers because we still don't know the exact cause of Kawasaki disease. We have some ideas but still working on specifics.

And really, I think parents should be aware of Kawasaki disease because it's one of the leading causes of acquired heart disease in children. It's also a disease that can be recognized if you know what you're looking for, and since it has the potential to cause serious and sometimes deadly complications, early recognition and intervention are important.

To help me talk about Kawasaki disease, we have a couple of great guests lined up for you in the studio. Dr. Preeti Jaggi is an Infectious Disease specialist here at Nationwide Children's Hospital and Dr. John Kovalchin is a pediatric cardiologist and Director of Echocardiography with the Heart Center here at Nationwide Children's.

02:03

But before we get to them, I want to remind you, if there's a topic that you would like us to talk about, it's easy to get a hold of me. Just go to pediacast.org and 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.

I also want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make 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.

All right, let's turn our attention to our studio guests. Dr. Preeti Jaggi is a physician with the Section of Infectious Diseases here at Nationwide Children's Hospital and an Assistant Professor of Pediatrics at the Ohio State University College of Medicine.

After attending medical school at Ohio State, Dr. Jaggi traveled to Chicago where she completed her pediatric residency and Pediatric Infectious Disease fellowship at Loyola University Medical Center and Children's Memorial Hospital.

03:12

Of course, we're glad to have her back in Columbus and here with us in the PediaCast studio, so welcome to the show, Dr. Jaggi.

Preeti Jaggi: Thank you.

Mike Patrick:: I really appreciate you stopping by.

Also, Dr. John Kovalchin is a pediatric cardiologist and Director of Echocardiography for the Heart Center here at Nationwide Children's Hospital. He's also an Associate Professor of Pediatrics at the Ohio State University College of Medicine.

Like Dr. Jaggi, Dr. Kovalchin is no stranger of Columbus, having completed his pediatric residency here at Nationwide Children's before traveling to Texas Children's Hospital and the University of California Medical Center at Parnassus for Pediatric Cardiology fellowships.

Like Dr. Jaggi, we are happy he's back and here with us in the PediaCast studio, so a warm PediaCast welcome to you as well.

John Kovalchin: Thanks, Mike.

Mike Patrick:: I appreciate you stopping by.

Let's start with Dr. Jaggi. If you could just define for us, if you can do that in a few sentences, just in general, what is Kawasaki disease?

04:08

Preeti Jaggi: Sure. Kawasaki disease is a disease that typically affects children under the age of five, although it can affect older children at times as well. It causes prolonged fever. We usually see fever for at least five days before making the diagnosis.

It can cause some other features that can be similar to other things that children have. Some of those things include rash on the body, red eyes that don't have any discharge from them or goopy stuff coming out of them, we can see sometimes a lot of lip changes where the tongue and the lips can be inflamed and cracked and fissured, and then we also see sometimes hand and feet changes where the hands and feet look puffy, as well as swelling in the neck.

It is a disease that can look like a lot of different other diseases so it requires us to keep reassessing children and thinking about the disease, and then we often do some lab testing to help us make the diagnosis.

05:08

Mike Patrick:: Sure. Now you said swelling in the neck; we're talking about lymph nodes that are swollen there with this, and then of course there are a lot of different diseases that can do that.

Preeti Jaggi: Yes.

Mike Patrick:: Just briefly, inside of the body, what are some of the issues that happen with Kawasaki disease that make this particularly important to diagnose?

Preeti Jaggi: It is a disease that causes inflammation of the vessels of the body. Those vessels are all over the body, and that's why we see symptoms in many areas of the body.

It's a disease that we think is caused by inflammation of the immune system, so to help us evaluate with that, we usually do a blood count that just looks for the hemoglobin and the white blood cell count. We also do a urine test typically to look for white blood cells in the urine.

And we do some tests that look for inflammation in the body. Those tests for inflammation, they don't tell us why there's inflammation in the body, but they are usually elevated in a little bit higher number range in Kawasaki disease so those can help us as well, as well as looking at the liver functions, again, because these vessels are all over the body and they're inflamed, and that's why we see inflammation in many different organ systems of the body.

06:16

Mike Patrick:: Gotcha. Now are there particular groups of children who are more at risk for this? You had mentioned that you see it more in young kids. At what age range typically would you cut off that you're not going to see it as often?

Preeti Jaggi: We can see it in older children. Most of the time we're seeing it in less than 10 years of age. There have been some even adult cases reported, but those are quite, quite rare.

We know that certain races are more apt to get Kawasaki, especially Asians. The disease was actually first described by Dr. Kawasaki, who is a Japanese pediatrician, and he's still alive today and he is the first one who described the illness, and the rate of Kawasaki disease is much higher in Asian individuals than it is in other races, although we do see it in all different ethnicities.

07:03

Mike Patrick:: Sure. Is there a difference between boys and girls, or they get it pretty much equally?

Preeti Jaggi: There's a slight predominance in boys and a little bit higher also in male infants, and it can be a little bit harder to diagnose in infants, but it can definitely affect both sexes.

Mike Patrick:: Now, you talked about inflammation of blood vessels in the body that end up causing lots of different symptoms and problems. What causes that inflammation to begin with? We're talking to an infectious disease specialist; do we think it's an infection that does this?

Preeti Jaggi: At this point, we don't know what for sure is the cause of Kawasaki, but we think that it is an infection, probably a virus or maybe a group of viruses that may be very, very common that all people are exposed to but only some people who might be predisposed to have this intense inflammation response are the people that actually get the disease. That's kind of our leading thought at this point.

I just returned from the Kawasaki meeting in Japan, and a lot of people have looked at even wind patterns to see if there's any correlation epidemiologically with the rate of Kawasaki. Some people have looked at patients who have died in the past from Kawasaki and they've looked at their lung tissues and they've seen the presence of some viral particles, so that's where we think maybe that there's a virus that is inhaled in the body and then you have this intense inflammation response.

08:27

Mike Patrick:: So let's say it is a virus. It's not necessarily the virus causing the illness, it's the body's immune system trying to fight the virus, and a by-product of that is the immune system attacks the body as well?

Preeti Jaggi: Correct. That's called an autoimmune illness, which we have a lot of different autoimmune illnesses that affect people like Crohn's disease and lupus and rheumatoid arthritis and other diseases like that, and this is a little bit unusual in the sense that the inflammation response is not lifelong. It is a self-limited inflammation.

Mike Patrick:: Sure. I do want to, even though you touched on this, just outline the progression of symptoms again so the parents can really pay attention to this, and if this is the kind of thing that they are seeing in their kid, hopefully the doctor would be cued into it.

09:14

But sometimes parents do a lot of research on the internet, listen to programs like this, and if they have a kid who has these symptoms, they shouldn't be afraid to say to their primary care doctor, 'Hey, could this be a possibility?' because that might get the doctor thinking along a different path than they might already be thinking about.

Preeti Jaggi: Absolutely.

Mike Patrick:: You talked about fever. Is there a certain high of fever that it goes, or can it be low-grade fever?

Preeti Jaggi: Typically, we're seeing fever at least 100.5 or greater is when we're thinking about it. Usually, the child doesn't look very well. They usually are irritable. The little bit older children tell us that they're achy and the little kids just cry a lot because they don't have the ability to tell us what's going on. So even when we give Tylenol or Motrin, the child still usually looks pretty irritable, and it's a pretty persistent fever.

10:08

Usually, it takes us a few days to make the diagnosis. We might start thinking about the diagnosis on the second day of fever or the third day of fever, but we usually don't make the diagnosis until closer to the fifth day of fever.

Mike Patrick:: So you have to have the fever at least that long before you would…?

Preeti Jaggi: For the most part. If we have a child, occasionally we'll treat a little bit before Day 5, but for the most part, yes, Day 5. I think a lot of different viruses can cause fever, and they typically will cause fever between three and five days and then stop, so that helps us time-wise start thinking about this illness as well.

Mike Patrick:: Right. And then you had mentioned conjunctivitis or very red-looking eyes, but not necessarily the goop that's coming out. Is there a rash associated with it?

Preeti Jaggi: There's definitely a rash that can happen in Kawasaki. It can be all over the body. It tends to be accentuated in the diaper area, groin area, and it can be a fairly impressive-looking rash, it can be an itchy rash, it could be a lot of different kind of rashes.

11:06

We usually don't see blisters on the body with Kawasaki. That's the only thing it doesn't usually look like.

Mike Patrick:: Sure. The tongue, sometimes the tongue gets real red and a little swollen, and we call that a 'strawberry tongue'.

Preeti Jaggi: Right.

Mike Patrick:: But does it have to be present?

Preeti Jaggi: No. That doesn't have to be present.

The way we diagnose Kawasaki is fever for a prolonged period of time, and then usually four or five other features. So the challenging thing for us can be when the children don't have all the symptoms, they might have two or three of the symptoms, and that can be a little bit more challenging to diagnose. When somebody has four of the clinical features, then it's a little bit easier for us to diagnose.

Mike Patrick:: Now what are some other diseases that could cause similar symptoms to this?

Preeti Jaggi: One of the major things that we look for is Adenovirus. Adenovirus is a virus that can cause typically really red eyes, goop coming from the eyes as well. It can cause you to have lip changes and throat changes like pus on your tonsils and rash on the body. That's a big thing that we look for.

12:09

Strep throat. We can get strep throat with a rash. That's called scarlet fever. That can look like Kawasaki as well. One of the clues that we have for that is if the child hasn't responded to antibiotics, if that was placed, and we can also do a strep test, so that's a little bit helpful. There is also some kind of less common illnesses that can look like that as well in the summertime as well. One of those things is called Rocky Mountain spotted fever that we can see.

There's a lot of different illnesses, but I think that probably the main two are the Adenovirus and the scarlet fever or the strep infection.

Mike Patrick:: Sure.

Now let's switch over to Dr. Kovalchin. We have a pediatric cardiologist here to talk about it as well. So Kawasaki disease can cause some inflammation in blood vessels and some heart issues. What exactly are the heart complications that are seen with Kawasaki disease?

13:02

John Kovalchin: The main heart complication that we worry about is involvement of the coronary arteries, and those are the very small, tiny blood vessels that supply oxygen and blood flow to the heart, and as Dr. Jaggi said, Kawasaki disease is a diffuse vasculitis or inflammation of the small- and medium-sized blood vessels, and that includes the coronary arteries.

Most, if not all, the other sequelae or problems seen with Kawasaki disease spontaneously resolve, except the coronaries. Sometimes if those are involved, those may involve persistent problems and can cause issues down the road for the patient.

Mike Patrick:: Now, do all kids with Kawasaki disease end up having heart issues? Is it pretty much a 100% thing or is it just some of the kids?

John Kovalchin: It's just some of the kids.

Without treatment, about 15% to 25%, as high as that number, will develop coronary artery development. And there's really two types of coronary artery involvement: one is just diffuse enlargement or what we call 'ectasia' and the other is aneurysms or diffuse localized area of swelling in the blood vessel or enlargement with normal areas of blood vessel around it.

14:17

Those are broken up into different categories. The most common type of involvement is the diffuse dilation or the ectasia. That most often spontaneously goes away and regresses and doesn't cause major problems down the road.

The aneurysms, however, are more significant, and those are usually broken up into different categories: small, medium and large, and sometimes the large are considered giant aneurysms.

We know that the patients with giant aneurysms are at the highest risk for problems like clotting off their coronary arteries, calcification, thrombosis, things that can cause damage to the heart muscle, infarction or heart attacks, things like that, things that can require heart intervention down the road or may even cause the patient to have significant problems, even death in the worst extreme. Most small aneurysms typically go away on their own and don't cause any long-term problems.

15:11

So whether they have aneurysms is a big determinant off the bat, and then secondly, how large those are.

Mike Patrick:: Sure.

John Kovalchin: So coronary artery problems are a primary concern.

There are also some other things that can occur with the heart. There can be involvement of the cardiac valves or valvulitis. Sometimes we can see the valves leak a little bit. That again is usually a transient thing. That's not usually something that causes long-term problems. And then the other minor thing that sometimes we see is a small amount of fluid around the heart called ' pericardial effusion'. Again, those don't often lead to problems. Those things usually go away on their own.

Almost all patients will have some what we call 'myocarditis' or inflammation of the heart muscle itself, and that can affect their ventricular function in the short term. Most of the time, it's not significant to the point where they're having problems or needing medicines or things like that, and again that typically resolves or goes away on its own.

16:11

Mike Patrick:: Now, when you talk about aneurysms, just for folks out there who may not know exactly what that term means, what is an aneurysm of the coronary artery?

John Kovalchin: An aneurysm is kind of a weakening in the blood vessel wall that makes it enlarged compared to the blood vessels around it, like a little ballooning.

Mike Patrick:: OK. The coronary artery is how the heart muscle itself gets oxygen, so it's important, and if you had a clot in there that occluded it, then the heart wouldn't get enough oxygen, and then that leads to what would commonly be called a heart attack or an MI or myocardial infarction.

John Kovalchin: Absolutely, and that's why it's very important to recognize this disease early on and get treatment.

As we said earlier, up to 15% to 25% of patients with Kawasaki disease without treatment can have coronary artery involvement, but with appropriate treatment, and I'm sure we'll go into that in a minute, the incidence of coronary artery anomalies goes down to about 5%, so a very significant decrease in involvement.

17:08

Mike Patrick:: Now, once a child has been diagnosed with Kawasaki disease, how do you go about evaluating the heart to see if any of these things are happening?

John Kovalchin: The most important test that we do is called echocardiography or ultrasound of the heart, and that allows us to assess all the things that we just talked about: the coronary arteries, measuring the size, looking for any dilation or aneurysms. It allows us to evaluate the valves for any leakage, it allows us to evaluate the cardiac function, and also to evaluate whether there's any fluid around.

So that's probably the most important test that we do right off the bat when the patient's in the hospital and diagnosed. And it's very important, sometimes these patients will even need to be sedated for us to get a very good-quality study, and then we'll do those in follow-up as well.

The other tests that we frequently do is an EKG, and that gives us an idea of what's going on with the rhythm of the heart or the electrical part of the heart, whether there's any abnormalities with that that may lead us to suspect inflammation of the heart or infarction or decreased blood flow to the heart.

18:11

Mike Patrick:: Sure. Now, there's some things that you're going to do to protect the heart, so to speak, even if a kid who's initially diagnosed with Kawasaki doesn't have any evidence of any heart problems. What are some of the things you do to protect the heart?

John Kovalchin: The biggest thing that we do in the treatment of Kawasaki disease while they're in the hospital is they get a dose of IVIG, high dose-IVIG. That's a medicine that's given to help modify the immune response that the body is having, and Dr. Jaggi went into that a little bit. That's probably the most important thing and the thing that shows decreased involvement of the coronary arteries in the short and long term.

The other thing that we do while the patient's in the hospital is give them high-dose aspirin. High-dose aspirin in the amounts that we give has another anti-inflammatory effect and it helps the patients out.

19:04

Occasionally, a patient will have continued fever and they'll need a second dose of IVIG when they're in the hospital, and some patients will continue to have problems after that, rarely, and may need another type of medicine.

Typically, after their fever goes away, we decrease the dose of aspirin from high dose to low dose, and at low-dose aspirin, that really has not so much anti-inflammatory effects but more anti-platelet effects. The platelets are the little pieces of blood that help clotting, and patients with Kawasaki disease often have elevated levels of platelets that may be more prone to clotting or thrombosis, and if you've got a problem with the coronary arteries, that's something that you don't want to happen. You want the blood to flow freely through the vessels and not clot off.

Mike Patrick:: Now, we always like to talk about benefits and risks, and parents want to know, 'If we're giving some medicines to my kid, what could be the side effects of those things?' The IVIG, is it a blood product?

20:06

John Kovalchin: Yes, it is. The risks of that are very minimal. Occasionally, a patient will have a reaction to that; most often it's low blood pressure or an allergic reaction or something like that. But in this case, the benefits by far outweigh the risks of this treatment.

Mike Patrick:: Right, and the sources where it comes from is tested for other infectious diseases, so that becomes much less of an issue today than it was years ago.

John Kovalchin: Absolutely.

Mike Patrick:: Now, another thing that parents hear from their pediatricians is, 'Don't give kids aspirin.' Why do we give aspirin in this case? Again, it's a 'risk versus benefit' thing. Can you just talk about that a minute?

John Kovalchin: Absolutely. Low-dose aspirin is typically used in the first six to eight weeks of the illness, and if there are not any coronary artery problems after that, then it's stopped.

21:00

Problems with aspirin can be, the most common one is it's a mild blood thinner, if you will, and sometimes patients may have issues with bruising or bleeding or things like that. That's pretty uncommon in the dosage that we use.

Another thing that people get concerned about with aspirin is something called Reye syndrome, and that's been shown to have a higher incidence in patients that are on aspirin if they're exposed to something like chickenpox or the flu. In those cases, if a patient's exposed, sometimes we'll stop their aspirin, put them on a different drug or something like that. But those are very rare complications.

Mike Patrick:: Yeah, and again, when you look at risk versus benefit and play that all out, the benefit far outweighs the risk in that situation.

John Kovalchin: Absolutely.

Mike Patrick:: What kind of long-term heart follow-up is required?

John Kovalchin: We follow the patients usually at two weeks from the time of discharge. They get an echocardiogram and an EKG in our clinic. And then they're followed at about two months and they get the same test, and then, really, their follow-up after that is dependent on whether or not they've got coronary artery involvement.

22:05

In most cases, they don't have significant coronary involvement, or if they do, it's resolved, and at that time we typically will stop their aspirin and then usually follow up at a year with an echocardiogram, an EKG. If everything is fine after that, then we typically will follow those patients every three to five years for surveillance.

If patients have coronary artery aneurysms or other coronary involvement, they're followed more closely and we will typically continue their low-dose aspirin. If a patient has giant aneurysms, then they're usually on more significant blood thinners like Coumadin and things like that, and those patients will oftentimes have additional tests to evaluate their coronary arteries such as MRI, CAT scan or cardiac catheterization.

Mike Patrick:: If a kid does not show any sign of heart involvement, is there a point in time when that's probably not going to happen, or is this something that all kids with Kawasaki need to be followed by a cardiologist every three to five years the rest of their life?

23:05

John Kovalchin: That's what we recommend now. A large part of Kawasaki disease is we don't really know what the long-term implications are 20, 30, 40, 50 years down the road.

There was some information that was out from the Japanese literature that said that if you have Kawasaki disease, even if you don't have coronary involvement early on, you may still have some issues down the road with difficulty in the coronary arteries relaxing, for example, during exercise. But there's some conflicting information about that, and the short answer is we don't really know what happens in the long term.

Mike Patrick:: Sure.

John Kovalchin: Rather than letting these patients go and getting out of the system, we're keeping them involved because more and more information is coming out every few years about what happens in the long term in these patients and how to follow them, and that's one of the things that we're doing research on in these patients.

Mike Patrick:: Sure. Now, you talked about, if kids do have aneurysms that start to develop using blood-thinning products to try to prevent platelets from grouping up and causing clots where the aneurysm is, if they're at larger aneurysms, are there some surgical things that might have to be done?

24:08

John Kovalchin: Usually that's reserved for cases where there is a problem with blood flow to the heart. Occasionally, a patient will require some cardiac catheterization intervention where they would go in almost like an adult with a coronary artery blockage and put a stent in or something like that. That's very rare.

Occasionally, we'll see a patient who's got severe multiple areas of blockage in the coronary arteries. I saw one patient, this was several years ago, who had terrible heart function as a result of that, and there really wasn't anything that the catheterization doctors could do as far as stenting those areas, or the surgeons couldn't really do a bypass procedure, and that patient ultimately got listed for heart transplant. That's a very, very rare case, but still that's one extreme at what we can see.

Mike Patrick:: Yeah. Coronary artery bypass is another thing that sometimes has to happen, just like it would in an adult who has a blockage in their coronary artery.

25:03

John Kovalchin: Yeah. Again, very uncommon and very rare, maybe one case like that every several, three to five years.

Mike Patrick:: Yeah, gotcha.

You had mentioned we don't really have a lot of experience or numbers to know, but what do we think right now in terms of a long-term outlook with these kids? As long as they're followed up regularly, and when things are discovered you deal with them as they come along, but they have a pretty good chance at living a healthy long life?

John Kovalchin: Yeah, I would say so. I think the vast majority of our patients do very well and we let them do normal activities, normal life expectancy and all those things.

We would recommend for them, like we would for any other child, a heart-healthy diet, getting good exercise, avoiding obesity, making sure they've got all their pediatrician visits, avoiding hypertension and smoking, things like that, things that you recommend for any teenager, child or adult.

Mike Patrick:: Sure. Maybe both can speak on this: in terms of follow-up here at Nationwide Children's Hospital, kids who are diagnosed with Kawasaki, what does that look like in terms of a follow-up clinic that they come to here at Children's?

26:12

Preeti Jaggi: We usually see them together. The most important thing that we always remind parents is to come back for those cardiology visits because we don't usually see any swelling or aneurysm of the coronary arteries when they're initially in the hospital when they're having fever.

They come back about two weeks after their initial illness, and then between five and eight weeks after the initial illness, they have their ultrasound and EKG tests like Dr. Kovalchin was mentioning, and then we usually see them from Infectious Disease also at that time, make sure that there's no fevers going on. It's quite uncommon to have a recurrence of the fever, but it can occur. And then some of the kids can also have some joint issues after the illness, so we just monitor for those things.

So we usually see them together at those time points, and then after their long-term follow-up, the most important person to visit with us is the cardiologist.

27:09

Mike Patrick:: Sure. In terms of evaluations, let's say there was a kid who was diagnosed with Kawasaki at another place and they didn't have as much experience dealing with Kawasaki disease, is this something that you guys would see, folks from not necessarily in Central Ohio?

Preeti Jaggi: Yes. If there's heart issues, certainly we can deal with that. Sometimes we might have a child who had had an unexplained febrile illness, and then one of the things that we sometimes see is some peeling of the fingertips really right close to the nailbed, and if there's some concern that the diagnosis may have been missed, we will see those children in clinic as well.

So, yes, we're happy to see people who've had a history or might have a questionable history of Kawasaki.

28:00

Mike Patrick:: Sure. We'll put the contact information for the Heart Center. That would probably be the best place to get plugged in.

John Kovalchin: Absolutely.

Mike Patrick:: And we'll have that in the Show Notes here, and of course it's on the website at NationwideChildrens.org as well.

Preeti Jaggi: And I would probably just recommend to parents that it's really important for us to think about the diagnosis. When we're in sort of a bad spot is when nobody has thought about the diagnosis.

If your child is having a lot of fever, you can bring it up with your doctor. They may have other things that they think the child has, because there are lots of other things that can look like Kawasaki, but bringing it up to ask them, 'Why do you think it's not that?' is a very reasonable thing to do, and looking out for the symptoms is very reasonable.

Mike Patrick:: Great. Now, this may seem obvious to us but maybe not to some listeners out there: is there any way to prevent it?

Preeti Jaggi: At this point, we really don't know what the cause is, so we don't have any way to prevent it. We are working very hard on trying to find out what the cause is, but there's no way that we can prevent it at this point.

29:00

Mike Patrick:: Right. For more information, too, I want to mention the Kawasaki Disease Foundation has an excellent website with lots of resources for parents, so that's another place you may want to check out. We'll have a link to that in the Show Notes as well.

All right, well, we really appreciate both of you stopping by today. Before we let you go, off the hook, one of the things that we ask all of our guests at PediaCast is, if you remember from your own childhood or now with your own families, board games, because we like to encourage parents to do some fun interactive stuff with their kids that doesn't necessarily involve TV screens and computer screens and iPads and iPhones and all of those things, so if you just think back, Dr. Jaggi, what's one of your favorite board games?

Preeti Jaggi: Board games? Well, my kids love Uno right now. That's a card game.

Mike Patrick:: That counts. Card games count.

Preeti Jaggi: That is our ritual every night when we come home is playing Uno right now.

Mike Patrick:: That's a fun one.

Preeti Jaggi: That's a fun one.

Mike Patrick:: Do you have some house rules or you just go with the standard?

Preeti Jaggi: We go with the standard rules. I don't know, they might want to change after a while. It's getting a little old now.

[Laughter]

30:03

Mike Patrick:: Add some new excitement into it.

And what about you, Dr. Kovalchin?

John Kovalchin: I played Uno last night.

[Laughter]

John Kovalchin: I've got a reputation of being the worst Uno player and checker player in my house. But anyway, yeah, Scrabble's another popular one and Monopoly's another popular one in our house.

Mike Patrick:: Do you do Words With Friends?

John Kovalchin: I don't. I think I'm a little old-fashioned; I do the old Scrabble one. But I should get on…

Mike Patrick:: You want the tiles in your hands.

John Kovalchin: Yeah.

Mike Patrick:: And it's easier to cheat on the old one because you can try to convince people, 'No, that really is a word!' With Words With Friends, if it's not in the computer's dictionary, it's not happening.

John Kovalchin: That's right. With younger kids not on Words With Friends yet, the old board game still works.

Mike Patrick:: Yeah, yeah. Absolutely.

All right. Well, again, I want to thank both of you for stopping by.

I also want to remind all of you out there that if there is a topic you'd like us to talk about, it's easy to get a hold of me. Just hop on over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS.

31:05

I also want to remind you, in your blogs, on Facebook, and in your tweets, make sure you mention us, and the next time you're at your primary care doctor's office, whether it's for a well checkup or a sick visit, just mention PediaCast to them so they can spread the word with their other patients. We'd appreciate that.

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.

John Kovalchin: I've got a reputation of being the worst Uno player and checker player in my house. But anyway, yeah, Scrabble's another popular one and Monopoly's another popular one in our house.

Mike Patrick:: Do you do Words With Friends?

John Kovalchin: I don't. I think I'm a little old-fashioned; I do the old Scrabble one. But I should get on…

Mike Patrick:: You want the tiles in your hands.

John Kovalchin: Yeah.

Mike Patrick:: And it's easier to cheat on the old one because you can try to convince people, 'No, that really is a word!' With Words With Friends, if it's not in the computer's dictionary, it's not happening.

John Kovalchin: That's right. With younger kids not on Words With Friends yet, the old board game still works.

Mike Patrick:: Yeah, yeah. Absolutely.

All right. Well, again, I want to thank both of you for stopping by.

I also want to remind all of you out there that if there is a topic you'd like us to talk about, it's easy to get a hold of me. Just hop on over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS.

31:05

I also want to remind you, in your blogs, on Facebook, and in your tweets, make sure you mention us, and the next time you're at your primary care doctor's office, whether it's for a well checkup or a sick visit, just mention PediaCast to them so they can spread the word with their other patients. We'd appreciate that.

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.

Topics

• Infant Tylenol Recall

• Tumblekins Recall

• Colic and Migraines

• Colic and Nicotine

• Lingering Symptoms of Concussion

• Underage Drinking

• Moving to a New Home

• Mercury Exposure from CFL Bulbs

• Ear Infections and Ear Tubes

• Reactive Airway Disease

Guest

Dr Marcel Casavant
Medical Director
Central Ohio Poison Center

Links

• Nationwide Children’s Hospital Columbus Marathon

• Patient Champions Info Page (NCH Columbus Marathon)

• Children’s Champions Info Page (NCH Columbus Marathon)

• Infant Tylenol Recall Information Page

• Tumblekins Recall Information Page

• Link Between Infant Colic and Mothers’ Migraine

• Hospitalization of US Underage Drinkers is Common

• Adolescent Impulses to Drink Can Be Curbed By Strict Parental Rules About Drinking

• PediaCast 186 – Asthma

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!

Mike Patrick: Hello, everyone, and welcome once again to our little show. It is PediaCast episode 202. Yes that means we've done 202 episodes. And this is for March 7th 2012, and were calling this one Colic, underage drinking, and mercury exposure.

Of course we'll have lots more topics coming your way and we'll get to exactly what it is we're going to talk about in just a couple of minutes. Fist we have some housekeeping items though. As most of you know who listen to the program regularly, we sort of have two general types of programs that we do.

01:04

This would be one of our news and listener programs. And then we also do interview shows, and the interview shows we kind of cut to the chase and get right to the topic without a lot of chitchat at the beginning. And the reason for that simple, we have a lot of folks who do Google search on a specific topic come across the show and they want their information.

And so we present it to them, and that way they can get what they need quickly. But then that lives us with these news and listener shows which tend to go on a little longer. And we do a little more chit chat at the beginning. And so, that brings us to some housekeeping matters that I want to catch up on.

The first is, we are back on Stitcher, so PediaCast used to be on Stitcher. Stitcher for those of you who don't know is kind of a way to put all of your listening things into one application. So, if you have a Stitcher account you can collect podcasts, you can listen to mainstream media shows.

02:06

It's just a place where audio can live in the form of an App on your iPhones, iPads, through Sonos which is a home audio system. Lots of ways that you can interact with Stitcher by having an account that's free of course. And for more information on that, you can visit them online.

But we were on Stitcher and we got booted off, and it was not because of a problem with our material, it was really more of what we weren't doing. And they were sending me emails, that I needed to complete a specific application or some form, and said, you've got until this deadline date to get it done, and I kept putting it off and putting it off.

And next thing you know we were off of Stitcher and it didn't take long for some of you to let me know about it. And so, I got myself in gear and did what I needed to do, and within 24 hours we were back on Stitchers. So, we are there again.

03:03

And I want to bring it up now because there was actually a new version of Stitcher for iPhones and iPads. So, if you are a Stitcher user, make sure that you get the newest version because this is kind of cool, and now integrates with Facebook so that you can set it up whenever you're listening to Stitcher and automatically post to your account and let's your community of friends and family know what you're listening to.

And the cool thing for that with regard to us is that it's press the word automatically about PediaCast it goes out as a status update all your family and friends that you are listening, that you're really cool because you're listening to the show. But it has helped us spread the word.

If you don't want those things on you Facebook, you can turn it off in the Stitcher App. And I'm not sure if the default is that it's on or if it's off, you have to check that out. But it's something cool, and if you aren't using Stitcher to listen to PediaCast perhaps you should consider using it or at least trying it out.

04:05

All right. Also want to remind you that speaking of social media, we're not only on Facebook, we're also on Twitter, and we're on Google+ as one out too. So if you are a Google+ user, make sure that you look for PediaCast and add us to your circle of friends and we can hang out there together.

And they do have a hang out feature at Google+, and I think we need to do that, not necessarily doing the show live in the curse of a hang out. But you know, schedule on a time and we can all get together and kind of chit chat on Google, and I can answer some of your questions there as well.

So something to think about in the future, but first you have to find us on Google+ and add us, and then we can do a cool hangout in the future. One other thing for the runners out there, the Columbus Marathon is now the Nationwide Children's Hospital Columbus Marathon, it's going to be run on Sunday October the 21st 2012 starting early in the morning.

05:05

And the race has been run since 1980. So, this is the 33rd running of the Columbus Marathon. They do a marathon, a half marathon, walkers are also welcome. And it's a popular marathon for folks looking to qualify for the Boston Marathon because the course is relatively flat, we are in Central Ohio after all.

And so, it's suitable for obtaining good times. And as it turns out thousands of runners travel to Columbus each fall and about 20% of those who come are rewarded for their effort by qualifying for Boston. In fact that makes Columbus one of the leading marathons when it comes to the percentage of runners who obtained a qualifying time.

So, it's a flat, fast course. And this year is the first year for our partnership between Nationwide Children's Hospital and the Columbus Marathon, in fact it's such a strong partnership, the event has a new name, the Nationwide Children's Hospital Columbus Marathon. And to celebrate that, they're doing really something cool.

06:00

Each mile of the marathon will feature a patient champion. And these are kids and families whose lives have been touched in some way by nationwide Children's. And I bring this up because right now they are searching for these patient champions.

And to be considered, you just have to write in and tell us your story. It's easy to do and we'll put a link in the show notes, so you know exactly which site you need to go to to tell us your story and then maybe you'll be chosen as one of our, you or child will be chosen as one of our patient champions.

Again, we'll have one those for each mile of the marathon. And for the runners out there, this is an opportunity for you to become a children's champion and do a little fund raising not only for our patient champions, but for all the kids whose lives are touched by Nationwide Children's.

And for more details on being a Children's champion and help raising funds for the hospital. I'll put a link in the show notes to that as well. We'll also have a link to main Nationwide Children's Hospital Columbus Marathon page. So, if you want to register and come to Columbus to run, you can get all the details and get yourself registered.

07:05

You do want to hurry with that though because it does sellout every year, and so you want to get in and get yourself registered. We'll put all three links in the show notes for episode 202 over at pediacast.org.

And also if you're planning on coming to Columbus to run in the marathon in October, let me know that you're coming through the contact page over at pediacast.org, and perhaps we can arrange a PediaCast family gathering for all the participants while you're in town.

You know a little carb loading dinner or something to that nature. Maybe a little tour of the hospital too. Anyway, So what are we covering today, we have some recall information for it's pretty important with regard to infant Tylenol.

And I'm going to explain exactly what's going on with that and why it was recalled after -it hit then off the market for quite sometime and came back, and now it's off the market again. We're going to talk about why that is. Also there's a recall on Tumblekins, so if you have any Tumblekins in your home, we're going to tell you why those are not safe and what you should do about it.

08:08

Also colic and this is something that really affects lots of new parents who have young, young babies at home. We're going to talk about colic and its potential relationship to migraines. and to nicotine also the lingering symptoms of concussion.

Concussion symptoms may last a whole lot lower than we have previously thought. And could be the reason that your child is doing poorly in school even months after they've had a head injury, so we'll talk about that.

Also, underage drinking, hospitalization, and the injury toll of it. And also what you -the parent can do to prevent your underage child from reaching for the bottle. We've talked about moving in the past, we do have a listener question specifically about moving to a new city and how you can alleviate the stress of that on your kids.

And as it turns out I'm a bit of an expert at uprooting your family and moving thousands of miles, you know more than once.

09:06

And so, we'll talk about how to prepare your kids from moving to a new city. Also, Dr. Marcel Casavant is scheduled to stop by the studio here soon, and we're going to discuss mercury exposure.

We had a listener who dropped a compact fluorescent light bulb on the floor and had a little mercury incident in the house. And so, we're going to talk about what you should do if that happens in your home.

Also, ear tubes, ear infections, reactive airway disease, wheezing, these are questions from listeners. It must be winter, when we get the onslaught of ear infection and wheezing reactive airway disease type of questions.

I do want to remind you if there's a topic that you would like us to talk about, it's really easy to get a hold of me, just head over to pediacast.org, and click on the contact link. You can also email PediaCast@gmail.com.

And again the voice lines are available for you if you want to call and leave a message that way. In fact one of our listener question coming up is from the voice line. And that number is 347-404-KIDS, again 347-404-K-I-D-S.

10:07

Also 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 to call your doctor and arrange a face to face interview and hands on physical examination. Also, your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org.

And with all that in mind, we will be back with the News Parents Can Use, right after this break.

[Music]

11:08

Our News Parents Can Use is brought to you in conjunction with news partner Medical News Today, the largest independent health and medical website. And you can visit them online at medicalnewstoday.com.

We'll begin with a couple of recalls you should know about. Just when you thought it was safe to go back in the water, we have another recall from the makers of infant Tylenol. Johnson & Johnson has recalled its entire US supply of grape flavored one ounce bottles of infant Tylenol.

Which is just great because in a previous episode of PediaCast, I touted the product highly and recommended parents should run out and grab some. So, here's the deal, and the reason that pretty much everyone in the pediatric world thought this was a great thing.

As you recalled the old infant Tylenol was dispensed by a dropper. And the concentration was 80 milligrams in .8ml. Parents out there who've had kids for a while, you know what I'm talking about. It's got the dropper, it's got a .4 and a .8 milliliter on it. And so, you dose the infant Tylenol that way.

12:08

Well, the problem was it's a different concentration than the children's Tylenol which is 160 milligrams per teaspoon. And so there could be dosing confusion if the doctor told you how much Tylenol to give if you're not using the right product, the concentration is different.

And so, there was this concern that all the liquid Tylenol product should be the same concentration which I still say is important, I mean, we really need one uniform concentration for all liquid Tylenol products.

And so, this new infant Tylenol came out which was a 160 milligrams per teaspoon, just like the children's Tylenol, except that instead of coming with a cup to those, that it came with a syringe. To make it easy just to pull up the right amount and squirt it in your baby's mouth.

And another good thing about that is that it's less concentrated than the infant drops where it actually taste a little bit better because there's less medicine and more flavoring in a given amount.

13:02

So, we said this which was a good thing, and that you should throw out your bottles of the old stuff, and really jump on board with the new infant Tylenol. And so, now those have all been recalled, so all grape flavored, one ounce bottles of infant Tylenol, which I think is what all of it was. I don't think there was any flavor other than the grape.

And they all come in one ounce bottle. So, they say all grape flavored one ounce bottles. I think it's all bottles of infant Tylenol, if I'm wrong about that write in and let me know, and we'll correct it, but I'm pretty sure it's pretty much all of it.

Over half a million bottles in al and the problem though this time it's not with the medicine, it's not that the concentration was wrong, or there were impurities, nothing like that, like was the issue in the past. But with this one, the medicine delivery system was the problem.

And as it turns out there's a cap on the top of the bottle with the small hole in it. So, you open up the top, and the top of the bottle is capped with a small hole.

14:01

And then the package also comes with the plastic syringe. and the idea here is that you insert the tip of the syringe into that hole, no needle of course just plastic on plastic, but you insert the tip of the syringe into that hole, turn the bottle upside down, and draw the appropriate dose of medicine into the syringe.

And this makes it easy to drop the medicine, it prevents the outside of the syringe from getting sticky, it minimizes the risk of spills, and it reduces the flow of medicine out of the bottle in case a kid gets the top off and attempts to guzzle it down.

There's a flow restrictor there because it's just a small hole. So, this new system was well thought out as a convenient and safe design. So, what's the problem? If parents insert the tip of the syringe and push that top cap is prone to falling into coming apart and falling into the medicine.

So, if parents use the mechanism as it was designed, this wasn't likely to happen and it makes sense to those of us in the medical field, it's just like drawing up any medicine into a syringe, you know, you insert it, turn the bottle upside down, draw up the medicine.

15:07

But most parents don't get that which is understandable. They put the tip in and just try to drop the medicine, but of course when the levels starts to drop no medicine comes into the syringe any longer.

And as if turning it upside down to get the medicine out, parents were just pushing harder and that's our natural instinct, right is to push harder. It's locked up, it's not working. Unfortunately this results in the top breaking and falling into the medicines.

So, now you have a new obstruction to getting the medicine out. You're more likely to make a sticky mass and we have a greater risk for accidental ingestion and overdose if the kid opens the broken bottle.

More information on this recall, you can head over to the infant Tylenol recall site and we'll have a link to that in the show notes over PediaCast.org for episode 202.

Hopefully they'll get this fixed, redesign the bottle, and get it back on the market because it's a great idea and theory, they just need to work out the nuts and bolts a little bit.

16:05

And another recall we want to tell you about, this one will affect fewer of you, but I think it's another important one to point out. International Playthings is recalling 31,000 Tumblekins.

Because the wooden toys can break into small pieces with sharp points which are then a chocking hazards and put your child at risk for skin lacerations or cuts. The toys are manufactured by China's Lishui Treetoys Trading Company and distributed by International Playthings.

All tumble can toys are affected by the recall and that includes the farm play set, the fire station, police car, roadster, off loader, fire truck, and school bus. And for more information about the Tumblekins recall, we'll also provide the show note a link in the show notes at pediacast.org.

All right. Let's move on to a couple of stories related to infant colic. A study of mothers and their young babies by neurologist at the University of California San Francisco has shown that mothers who suffer migraine headaches are more than twice as likely to have babies with colic, than mothers without a history of migraines.

17:08

The work races the question of whether colic maybe an early symptom of migraine and therefore whether reducing stimulation may help just as reducing a light and noise can only alleviate migraine pain in children, teens, and adults.

This is significant because excessive crying is one of the most common triggers for shaken baby syndrome which can cause death, brain damage, and severe disability. If we can understand what is making the babies cry, we may be able to protect them from these very dangerous outcomes.

As Dr. Amy Gelfand a child neurologist with the Headache Center at UCSF who will present the findings at the American Academy of Neurologist, 64th annual meeting which takes place in New Orleans this April.

Colic or excessive crying in an otherwise healthy infant has long been associated with gastrointestinal problems presumably caused by something the baby ate. However despite more than 50 years of research, no definitive link has been proven between infant colic and gastrointestinal problems.

18:05

Babies who are fed solely breast milk are just as likely to have colic as those fed formula and giving colicky baby's medicine for gas, does not appear to help. Dr. Gelfand says, "We've known about colic for a really long time, but despite this fact and no one really knows why these babies are crying.

I want to pause here and point out, it's easy to kind of blame stomach problems or to blame colic on stomach problems because when babies cry what do they do? They kind of ball up their belly and bear down as they are crying. And so, their belly gets kind of hard and you just kind of assume that they're having a belly ache.

But really they may be crying for some other reason and it's natural when you cry, and when you're really upset that you bear down and tighten up your belly so that just because their belly gets tighten hard, doesn't mean that that's the cause of the crime.

19:02

Also what happens when you get really upset and you bear down and you tighten up your belly, you stinker, you can. And so, babies oftentimes pass gas when they're crying and colicky, and so then that kind of reinforces.

And some parents might say, 'oh they just pass gas and now they're not crying anymore', gas must have been the problem. But now we're really thinking that it's not related, and in fact when I trained many, many years ago, even back then it was not you know in the pediatric field.

We didn't think that it was a gastrointestinal problem, we really did think that it was more of a neurological issue. And so, now we have little more proof of that. So, Dr. Gelfand again says, "We've known about colic for a really long time, but despite this fact, no one really knows why these babies are crying.

She and her colleagues surveyed 154 mothers with two month old babies, they picked this age because two months is when the symptoms of colic typically peak. The mothers were asked about their baby's crying patterns, and the mother's own history of migraine.

20:00

Researcher analyzed the responses to make sure the reported crying did indeed fit the clinical definition of colic. A mother who suffered migraines were found to be two and a half times more likely to have colicky babies.

Overall 29% of infants whose mothers have migraines had colic compared to 11% of babies whose mothers did not suffer from migraines. Dr.Gelfand believes colic may be an early manifestation of a set of conditions known as childhood periodic syndromes believed to be precursors to migraine headaches later in life.

Babies with colic may be more sensitive to stimuli in their environment, just like migraine sufferers. They may have more difficulty coping with the onslaught of new stimuli after birth as their thrust from the dark warm muffled life inside the womb and into a world that is bright, cold, noisy, and field with touchy hands and bouncy knees.

The UCSF team's next plans to study a group of colicky babies over the course of their childhood to see if they developed other childhood periodic syndrome such as migraine headaches, cyclic vomiting, and abdominal migraine.

21:01

And in another study related to infant colic, maternal smoking or the use of nicotine replacement therapy like the nicotine patch during pregnancy, appears to also increase the risk of infantile colic. That's according to a report published on that is recently been published online on the online version of the Journal Pediatrics.

This research comes from the Herning Regional Hospital in Denmark, where investigators looked at over 63,000 infants. Mother's nicotine exposure whether by smoking or by nicotine patch during pregnancy was compared to the incidents of colic in their babies.

The result; researcher's report there is a statistically significant positive association between these two events, meaning moms who smoke or use the nicotine patch while baby is inside the womb have an increased risk of dealing with colic once the infant is outside the womb.

The authors report that the mechanism responsible for the association between prenatal exposure to nicotine and infantile colicker are known. They say their study does not warrant a contraindication for using nicotine replacement therapy for woman who cannot stop smoking while pregnant.

22:07

And they call for more studies to investigate the relationship. So, here's an idea and admittedly it's my own idea. Maybe these babies are addicted to nicotine when they're born. And what we are calling colic is really a baby battle with the symptoms of nicotine withdrawal. Something to think about.

Let's move on from colic to concussions. Now, I know we've covered concussions often, and the reason is simple; they're common, they're debilitating, and the symptoms can last a long time. In fact longer than we may have previously been aware.

Also recurrent concussions can be dangerous. So, it's important that parents know the signs of concussion and what to do when their child has one. Again, today we're highlighting the lingering nature of concussion symptoms.

This information comes from a study conducted here at Nationwide Children's Hospital, and Rainbow Babies, and Children's Hospital in Cleveland. And it was recently published in the archives of pediatric and adolescent medicine.

23:03

This was a prospective longitudinal study which means researchers identified kids with concussions and followed them long term to see what symptoms they have and how long the symptoms last.

Now, you remember a couple of weeks ago we highlighted the difference in concussion symptoms when you look at boys versus girls. And this week we're concentrating on how long those symptoms last. So, what did the investigators do? Well, they identified children between eight and 15 years of age who presented to the emergency department with head injury and concussion.

They interviewed parents and asked about any pre-injury symptoms their children may have experienced, and this makes sense because you don't want to blame symptoms on a concussion if the child was experiencing those symptoms before a head injury occurred, right?

Then they interviewed parents again at three months and 12 months post injury, to see what post concussion symptoms persisted at those time frames. The study also included a control group, kids who presented to the emergency department with orthopedic injuries rather than head injuries.

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Dr.Keith Yeates, Director of Behavior Health Services at Nationwide Children's Hospital, and one of the study authors points out the importance of this control group.

He says, "Group differences and post concussive symptoms are most pronounce shortly after injury comparing group averages' informative, but does not indicate whether individual children show significant increases in post concussive symptoms following mild head injury more commonly than after other injuries. Health providers need to be able to identify children with mild head injury who are at risk for persistent post concussive symptoms so they can target such children for appropriate management."

In other words, is it really the head injury causing the neurological problems we see following mild head injury or could this neurological issue be something that a company any traumatic injury whether that injury involves the head or not. So, what kind of neurological symptoms are we talking about?

Well, we can divide those into two categories, somatic symptoms which are things like headache, dizziness, and nausea. And cognitive symptoms which initially include amnesia and confusion, and persist as difficult concentration and impaired thinking skills which can lead to poor academic performance.

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And cognitive symptoms which initially include amnesia and confusion, and persist as difficult concentration and impaired thinking skills which can lead to poor academic performance.

All right. So, what are the investigators find, well, first these neurological symptoms both semantic and cognitive reliably develop in kids following head injury. So, symptoms that were not present prior to the head injury do develop after the head injury. And the kids with broken bones did not see reliable increase in the somatic and cognitive problems.

So, it appears the head injury really is the cause of the symptoms and not just traumatic injuries in general. And then how long did the symptoms last, well at the three month follow up, somatic symptoms -so these are the headache, dizziness, nausea kind of stuff, and cognitive impairment, so thinking skill problems were reliably present at three months.

And at the 12th month follow up, many children still show signs of cognitive impairment including difficulty with attention and concentration, problems with critical thinking skills, and poor academic performance.

26:05

Dr. Yeates warns these findings don't encompass the entire population presenting to the emergency department for minor head injury. Many kids hit their heads and do not suffer any sign of concussion at all. But when post-concussive symptoms do appear, this study suggests they may last much longer than previously thought.

The authors sum up by saying, "Researchers needed to clarify which injury and non injury related factors increase the likelihood of reliable increases in post concussive symptoms." The current research suggest the injury severity is one key factor and advanced neuro imaging techniques may more clearly differentiate injury severity and its relationship to outcomes.

And finally in this week's News Parents Can Use, hospitalization for underage drinking is common in the United States and it comes with a price tag. The estimated total cost of this hospitalization is about $755 Million per year, that's according to a male clinic study in which researchers also found geographic and demographic differences in the incidence of alcohol related hospital admissions

27:06

The findings were recently published in the online version of the journal of adolescent health. On the roughly 40,000 youth aged 15 to 20 hospitalized in 2008, the year with the most data available, 79% were drunk when they arrived at the hospital.

abuse and addiction, and drinking are related emotional problems were among the diagnosed disease. When teenagers drink they tend to drink excessively leading to many destructive consequences including motor vehicle accidents, injuries, homicides, and suicides.

Says researcher Dr. Terry Schneekloth a male clinic addiction expert in psychiatrist."Underage drinking is common in the United States, 36% of the high school students reported having consumed alcohol at least once although the prevalence of heavy drinking which is more than five drinks in a row during any previous two week period is lower at 7%.

Alcohol use resulting in acute care hospitalization represents one of the most serious consequences of underage drinking," Dr.Schneekloth says.

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Harmful alcohol use in adolescence is a harbinger of alcohol abuse in adulthood. The average age of those admitted to the hospital for alcohol related problems was 18 and 61% were male. Nearly a quarter of the hospitalizations included an injury, traffic accident, assault, or altercation.

For adolescent males and females hospitalization incident was highest in the Northeast and Midwest, lowest in the South, and intermediate in the West of the United States. Black Americans had lower hospitalization rates than whites. And Hispanics and Asian Pacific Islanders have the lowest rates.

Researchers say these demographic findings may help target substance abuse prevention effort toward geographic and ethnic groups at greatest risk. Of the 40,000 teens hospitalized, 107 of them died. The average age at death was 18, and 82% were males, 73% percent of alcohol related deaths involved in injury.

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So, we know underage drinking can lead to substance abuse problems, injuries, hospitalizations, and even death. But how can you the parent -encourage your child not to drink when they're offered the choice.

The new study to be publish in the May 2012 issue of alcoholism clinical and experimental research suggest, teen impulses to drink can be curved by strict parental rules about drinking. The study comes from Rad Bow of the University in the Netherlands.

Researcher Sarah Peter says, "With the repeated alcohol consumption, cues they are previously associated with alcohol use such as the side of the beer bottle become increasingly important. This might be due to alcohol induced changes and the brain's reward system and the formation of memory associations."

The term approached tendencies, Peters added, "can be understood by asking if a person is inclined to approach or to avoid a stimulus. And most people tendencies to avoid are automatically triggered by threatening stimuli such as a snake, and approach tendencies can be triggered by appealing stimuli such as water when you're thirsty.

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And heavy drinkers stimuli that have been associated with alcohol use automatically trigger a tendency to approach. So, if you see a beer bottle, you grab it. Studies have shown the adolescence is marked by a temporal lag in the maturation of two brain systems.

One related to emotional and motivational processes and one to control behavior and thoughts. Motion and motivation develop relatively faster in puberty, but control takes longer and is not fully develop until adulthood at around 25 years of age.

This means adolescence have less control than mature adults and are more likely to engage in reckless behavior. In addition alcohol affects the emotion and motivation system by making them hypersensitive to cues associated with alcohol use while it affects the control system by decreasing the ability to control behavior.

This means that adolescence are the higher risk for an imbalance between impulsive behavior and reflection. So, this really kind of describing something that we as parents of teenagers and as adults in the society.

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Fellow teenagers we kind of understand that teenagers are impulsive and sometimes reckless. And this just kind of explains it from a neuro developmental point of view. So, a total of 238 adolescence aged 12 to 16 years participated in the study with equal number of boys and girls included.

Peter says, The team's results indicate that approach tendencies are related alcohol, however the team also found that if parents set strict rules regarding their offsprings alcohol use, adolescence could inhibit this approach tendencies particularly males.

On the other hand permissive parenting seems to exacerbate the link between approached tendencies and alcohol use. So, if a kid who has drink before and the bottle is kind of their approach thing.

They see the bottle, they want to reach for it, impulsively and grab it, and start drinking. That process can be inhibited by strict parental rules about drinking and permissive parents then does not inhibit that behavior.

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Previous research has shown that stricter parental rules tend to be associated with less alcohol use among children, however this is the first study that specifically investigated the role of parents in relation to teenage impulsivity.

Peter speculates that young adolescence likely internalize parental rules in such a way that approach tendencies can be more successfully inhibited. In summer the research team says, 'The link between parental rule setting and adolescent alcohol use is well established with more rules being associated with less alcohol use.'

This study extends previous research on this topic by showing parental rules might also be related to the degree to which approached tendencies are linked to changes and alcohol use with approach tendencies predicting an increase in alcohol use for teenagers who have permissive parents.

The study suggest that parental rule setting is particularly relevant to adolescents who are already in an increased risk to develop alcohol related problems for reasons such as genetic factors.

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So, the take home for parents, if you don't want your children to battle alcohol problems, set rules now. And I'll add this, be sure to model acceptable adult drinking behavior.

All right. That concludes our News Parents Can Use, and we're going to come back and answer your questions right after this.

[Music]

All right. first stop in our listener's segment is Crystal from Utah. And Crystal says, " Dr. Mike, I begin listening to your podcast in 2007, and I'm so grateful for this invaluable resource that you provide.
34:05

We just found out that we may be relocating to Denver sometime during the summer, and is neither my children or I have ever moved from our home state before. I am nervous about how my children are going to handle this.

I have two sons ages eight and five. And two daughters ages six and 18 months. Do you have any suggestions of how to help my children prepare for and handle such a drastic change? Thanks, Crystal.

Well, Crystal thanks for your question. And I love these questions where there is no definite science behind it. We've talked about one research study of that moving causes stress a couple of weeks ago. But that didn't really offer any suggestions on how to help your children adapt.

And so, this is really just coming from mine, and this is certainly not something that you learn in medical training. But just from my own experience as a parent of kids who have done this. I can talk to you about it from that perspective.

And first I would say for your six month old, it's not going to be a big deal at all. Your six month old, as long as they see your face and you change their diaper, and you put food in their belly, they're going to be happy.

35:09

Your 18 month old, yeah they'll probably do fine, you know the people in their life are traveling with them, their toys travel with them, that's really -they're going to feed more off if your older kids are having issues that anything else.

But just in a perfect stay, again as long as their little bubble were all be 18 month old still surrounding them, which it will be, I mean, you still have your things and you still have the people in their life. Then they're going to be less affected by this. It take some to getting used to a new house, a new room, but your 18 month should do pretty well with that.

Now we come to your five year old and your eight year old. And it's going to be more difficult for them, I mean they have a history with your home, with the community. And the first thing to realize is that there are going to be fears and tears.

And each kid is different, you know, it's going to affect some more than others. But you'll realize that that could be there. That your kids -your older kids really may have difficulty with this, and no matter what you do.

36:09

And so, you do have to support a healthy morning, be there, hug them, and encourage them. My daughter Katie, I think when we looked back at every move, she would say that overall she love being where we were. I mean, when we moved to Florida, she loved being in Florida.

When we move back to Ohio, she loves being in Ohio now. But at the same time she cried with each of those moves. And as much as she was looking forward to going to the new place, there is still a part of you that's left behind and mourns that.

And so, I think there's a normal mourning process when kids are upset, and there's a new magic way to get around that, it's just part of the grief stages that you go through, and you just have to love them and support them, and let them know you're there.

And the degree of control has been taken away from them because they don't really have a choice in this. You know, you didn't sit down as a family and vote on it.

37:04

And so, I mean, you have to be sensitive to that and just give them encouragement and support and love, and that's going to be really important. Now, there are some things though that you can do to make this an exciting process at the same time.

And one of those is to sort of guide and engage discovery that is customized to your child's currency. What do I mean by that? Well, it's just -what do your kids love? And what can you explore in the new place based on what they love. I mean, if they love playgrounds and parks, you know, what facilities are available close to where you're moving.

If they love to ride their bike, well bike trails are available. What kind of entertainment do they like? Theater, theme parks, you know. What kind of restaurants, what sports team are there? So, if you are getting ready to move to Denver, it might be a good time and say, "Hey, let's look into the Denver broncos", especially if when your kids loves football.

Let's get to know the team players, the season before let's start to follow them a little bit, I know it's a little bit late now for – and you have been disappointed when you followed them.

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You know what I'm saying. You really just take whatever it is that your kid's currency is. What do they really like? And try to explore what's at this new location that they can really kind of dig into. And start that now, you know just some pre-moving exploration to get a taste of that.

So, you know, just an example from our own move and sometimes it's process backfires a little bit. My son loves a particular pizza based in Ohio called Donato's. I mean, it's like his all time favorite food. In fact when he was younger, when you ask him what he wanted to do when he grew up, he wanted to volunteer at a Donato's Pizza place because he loved their pizza so much.

Like -you don't have to pay me, I'll just show up and make these things as long as they'll let me eat a little bit of when I'm at work. So, he loves Donato's Pizza.

39:00

And when we moved to Florida, it was like -that was his big thing -do they have Donato's? I mean, if they have Donato's I'm fine move me anywhere, it's the Donato's that I want.

And so we looked it up online and as it turns out, Donato's is pretty much grew in Central Ohio, it's kind of a Mom & Pop Pizza Place. And then it became more of a bigger company -I think McDonald's bottom for a little while than it was sold back to the original owners. And they did expand the market out of the Ohio, and Kentucky, Indiana kind of region into two markets, one was Charlotte, and one was Orlando.

So, there were Donato's in Orlando where we were moving. So, we're really excited, we Google mapped it, we found out hey, one of them would deliver to our new house, this is cool. All right. We are really excited about this.

So, we moved and comes time to get our first Donato's, and we call, and I tried to call the number and when they said that it has been disconnected, that was our first sign that 'uh oh, there's going to be a problem'.

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And so, we couldn't get a hold of them and little Google search later and we find out that the week before we moved, all of the Donato's in the Orlando area closed down. They pulled out of the Orlando market, I kid you not. And so, we had a pretty disappointed guy on our hands.

Now, fast forward almost three years later, we're back in Ohio and -actually four years later, we're back in Ohio and he is reunited with Donato's Pizza. Of course whenever we came to visit family, we had to make sure Donato's trip was in line.

So, anyway getting back to Crystal's question. This is just one example, it did backfire on us. But he was still looking forward to the move because Donato's was there. So, what in Denver can your kids get really excited about? And really try to push that on.

There may be some tears, but this is also a time for you to venture and a time for your family to sort of come together as a team. So, hope that helps Crystal, and as always thanks for the question.

41:07

All right. Next stop we have Tara in Irvington, New York. And Tara says, "I recently knocked over a lamp in my bedroom, and the compact fluorescent bulb shattered next to my seven month old son's crib. He was setting in his crib at that time.

I didn't preceded to do everything wrong, I cleaned it up as I would any light bulb. I began by taking my son to the living room and placing him in his pack n' play, I didn't seal the room or open a window.

I cleaned the hardwood floor with the broom and vacuum the entire carpet and threw it all in the kitchen trash. I didn't brought my baby back into the room. It was then, that I remembered there were some precautions I should take, so I Googled it. I was shocked at the complicated procedure I should have followed.

And I'm most alarmed about my son's possible exposure to Mercury vapors. I called poison control and they told me to throw out my vacuum and don't let the baby sleep in the bedroom for 24 hours. The next day, my pediatrician said to wait 48 hours. The doctor told me she was more worried about mercury's effect over time and that it wouldn't make any sense to test him now.

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She suggested I clean again and wait for symptoms of mercury poisoning. Also, my son's nebulizer fell right next to the light bulb so it's covered in mercury too. I threw that away. So, my question is, could my son really suffer permanent damage due to one light bulb?

Should I tear up the carpet in the rooms, since he will soon be crawling on it. My pediatrician seemed alarmed and she said, she would freak out too which wasn't really what I was looking for. Your opinion. Thanks, Tara.

Well, thanks for the question Tara, we really appreciate you writing in. And just in the nick of time, Dr. Marcel Casavant has popped into the PediaCast studio to help me answer this one. Dr. Casavant is the Medical Director of the Central Ohio Poison Center. He's also chief of pharmacology and toxicology here at Nationwide Children's Hospital.

And a professor of Pediatrics and Emergency Medicine at the Ohio State University College of Medicine. So, Dr. Casavant, thanks for stopping by and helping us out.

43:02

Marcel Casavant: You're welcome. Good afternoon.

Mike Patrick: Great to have you here. So, what's the deal with compact fluorescent bulbs? I thought they were supposed to be better for the environment, but apparently they have mercury inside of them. So, what's up with that?

Marcel Casavant: Well, it's a very complicated story. Yes, they are supposed to be better for the environment and they clearly are in that they use a lot less energy to produce the light for our homes and so where you burning less fossil fuels and that's great for the environment.

However in the process they are using mercury and that as long as mercury stays in the light bulb we can all be comfortable with that. But when the mercury comes out of the light bulb there are some issues. The good news is the amount of mercury in one of those complex fluorescent bulbs is very small.

And there's no real acute danger from mercury poisoning. The bad news is, if that mercury stays in a carpet or in some other areas where a child may have long term exposure, many hours per day, for weeks, months, or years, it's possible that there could be some accumulation of mercury in that child.

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Mike Patrick: Sure. Now, mercury sounds dangerous. What exactly does it do inside the body? Why is that a problem?

Marcel Casavant: You know, it's funny that you say mercury sounds dangerous, to me mercury sounds dangerous, and to you it sounds dangerous. It's remarkable how many people in the community remember playing with quicksilver as kids, and it doesn't occur to a lot of people that mercury can be dangerous.

Mike Patrick: Yeah.

Marcel Casavant: Yes, mercury really is dangerous. The good news with quicksilver is there's minimal absorption through the skin. The bad news.

Mike Patrick: Now, when you say that you're talking about like you'd have the ball that you could kind of roll around and you would split into little -yeah.

Marcel Casavant: Yeah. Do you remember we did that when we're kids on the counter, on the doors, and that sort of stuff. The trouble is if a little bit if that spills, and then over weeks or months they vaporized and we are breathing those vapors over long period of time, that can cause some problems.

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Mike Patrick: And what exactly in the body does the mercury do?

Marcel Casavant: Well, the mercury finds lots of enzymes in the body that are used to using what we call divalent cations, so things like calcium and magnesium, and iron that have 2+, and the mercury can have 2+ and so, all of these enzymes will try using mercury the way they use the other metals in the body and don't stop working correctly.

What we mostly worry about is how the brain develops in the presence of mercury. So, kids in particular exposed to mercury vapors over long period of time, we worry about how their brain develops.

Mike Patrick: So the symptoms of mercury poisoning then would be cognitive kind of issues if you were exposed over a long period of time?

Marcel Casavant: For the issue of today's discussion, yes that's exactly what we're worried about is brain development, it's IQ points, it's how am I able to learn in school and master sensory input and control of language, and all of those kinds of things as we grow up.

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Mike Patrick: Sure.

Marcel Casavant: Other kinds of mercury can cause other problems. Mercury salts can cause gastroenteritis, vomiting, and diarrhea, and kidney trouble. Mercury fumes and vapors in high concentrations can cause some lung injury.

Mike Patrick: Sure.

Marcel Casavant: But what we're mostly worried about when we talk about the broken light bulb, the broken fever thermometer, other sources of mercury in a child's environment is the brain development.

Mike Patrick: Now, once you have an exposure to mercury, so let's say a bulb broke, or thermometer broke, and you're worried that you're baby did have breath in vapors of mercury. How is that treated?

Marcel Casavant: The treatment is to first to recognize that it's happened and then to stop the exposure. So, as your listener wrote, she did all the wrong thing. So, the room was not sealed off, the child was in the area, the child was brought back in very quickly, all of those are sources of further exposure. So, the real treatment for an acute vapor exposure is to stop the exposure.

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Mike Patrick: And once you stop the exposure, you know, as long as it hasn't been continued exposure over many weeks, the body will make more of those enzymes that then aren't bound to mercury and that should kind of correct itself.

Marcel Casavant: Correct. Over a few hours of exposure there's minimal uptake from most of the situations. And certainly from a compact fluorescent light bulb that broke, there's minimal exposure in the first few hours.

Mike Patrick: Sure.

Marcel Casavant: And the mercury that has been taken up by the child will be eliminated. And safely so, and without causing any problems.

Mike Patrick: Yeah. Now, I'm sure that with as many compact fluorescent bulbs as there out there right now, there are a lot more listeners than just Tara who have probably had this happened where a CFL bulb is broken, or they have them in the house and so they're wondering, OK, if an accident happens and one falls and breaks, what should they do?

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Marcel Casavant: Great. So, the first thing is to be aware of the fact that they can fall and break. And if you're smart you'll put out a tarp or a drop cloth first before you're even adjusting any of those light bulbs. I remember the first one I put in had no problems at all.

But the next time I wanted to replace the light bulb I pulled the package off the shelf, package of six, and all five of the remaining ones dropped.

Mike Patrick: Oh no. The medical director of the Central Ohio Poison Center.

Marcel Casavant: Absolutely. Very susceptible to the same kinds of problems with these products as everyone else's. So, now there's some advice that when you're working with these you put down a drop cloth first, and the if it falls and breaks, it's easily contained.

Mike Patrick: Oh, great idea.

Marcel Casavant: So, the next thing is if it falls and breaks you do want to take children, pets out of the area quickly. You don't want them breathing the vapors, but you also don't want them walking through the broken parts and then tracking the fragments throughout the rest of the house.

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Marcel Casavant: If you have an air conditioner turn that off, or your heating system HPA doesn't turn that off, so if there are vapors being generated you don't spread those throughout the house. And it's great to close off the doors to the rest of the house and open up the windows to fresh air to increase the ventilation. And in case there is any vapor building up, to get that ventilated outdoors as quickly as possible.

Mike Patrick: Sure.

Marcel Casavant: After that what we do is try to find all the pieces and put them all together in a plastic bag. Many of these CFL bulbs contain their mercury in the form of a small pellet, and if you can find that pellet and just pick it up and put it in a plastic bag, there's no further worry of vapor for days, weeks, or months down the road.

Mike Patrick: Sure.

Marcel Casavant: Pick up all the glass pieces, any dust that's with it, any fragments. You can use things like duct tape to pick really small pieces that you might be able to see, but are hard to pick up.

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Marcel Casavant: You definitely don't want to use a vacuum cleaner because that can contaminate the vacuum cleaner really permanently. When I learned how to do this, I was taught it's OK to use the vacuum cleaner just throughout the bag, but that was wrong advice.

So, anybody who's heard that from me or from other experts over the years, it's been shown that even the fanciest vacuum cleaners can be contaminated all the way through when you clean up mercury with them.

Mike Patrick: So, it's not a good idea?

Marcel Casavant: So, we want to get all these pieces together and put them in a plastic bag, and then we want to get that plastic bag safely disposed off. Now, all these works perfectly for non porous surfaces. If this falls on a wood floor, if it falls on a formica counter for instance, clean up is very easy.

It gets more complicated when the mercury is broken over a porous surfaces, and when it's broken over furniture or carpets, it can be very hard to find all those pieces and clean them up. You may think you've done a great job with it, but still left behind some beads of mercury.

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And in those cases sometimes the best thing is just to get rid of that porous items, and sometimes that means cutting the hole in your wall to wall carpet, and sometimes it means just getting rid of the carpet.

Mike Patrick: If there's a question of whether there's mercury vapors present or not. So, let's say that happened and you cleaned it up, so you're really kind of worried about it, and you want to rest at night. Is there someone you can call to come out and test for mercury vapors?

Marcel Casavant: Yes. You know, the mercury vapors are invisible to ordinary humans like you and I. But health department folks have meters that they can use. The Environmental Protection Agency has meters they can use to come out and check you home.

Not might be one piece of advice, not for the ordinary spill, but the entire situation where a lot of bad things have happened all in a row, and the mercury contamination has been spread from room to room, a vacuum was used.

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It's on a porous surface -that carpet, I suspect to call to their local health department would be very helpful. To have somebody come out, and measure, and say, 'there is no mercury vapor here. You and your child are safe. Or there is mercury vapor here, and here's where it is, and here's what we need to do to get rid of that ongoing exposure.'

Mike Patrick: Sure. Now, knowing that there's mercury and these bulbs when one of them has reached the end of its life, and isn't working anymore, so it hasn't broken. It doesn't sound like a good idea to just throw in the trash can and it ends up in the landfill. What should folks do with CFL bulbs that don't work anymore?

Marcel Casavant: In many places you're not allowed to throw those in the trash. I just checked with our local regulations and here in Central Ohio we are allowed to throw them in the trash, but I agree with you, that's not a very good idea. Many communities have solid waste recycling place, and hazardous waste recycling places.

53:00

And in Central Ohio the solid waste authority of Central Ohio will accept those bulbs back, and they will recycle not only the mercury, but the other components of the bulb as well.

Increasingly around the country more and more retailers are saying when you're ready to buy new bulbs, take the old ones back to us and we'll get them recycled safely.

And then there are number of places you can find on the Internet that are willing to for a price take your recyclable bulbs back -mercury containing bulbs back for recycling.

Mike Patrick: Now, what about other kinds of bulbs? So, we see the traditional incandescent bulbs that are out there, and there's halogen bulbs, and LED bulbs, are there any chemical or toxicologic hazards with those light bulbs?

Marcel Casavant: I'm not aware of any other particular concerns with those kinds of light bulbs that you mentioned. The older fluorescent light bulbs contain even more mercury than these compact fluorescent bulbs. So, those are real concerns as well. Those long 4 foot two, those contain mercury in significant quantities.

54:04

But as far as incandescent's and the LED's, and the halogen bulbs, I don't believe those are any particularly toxic.

Mike Patrick: Great. That's Dr. Marcel Casavant, ladies and gentlemen. And we appreciate you stopping by. Let's move on to our next question, and this one comes from the Skype line.

Marcy: Hi, Dr. Mike this is Marcy from Bellmore, New York. I had a question about my daughter who is four years old. She has had frequent ear infections, and has had fluid in her ear that has been very difficult to go away, hasn't gone away.

And her pediatrician has recommended that she might be a good candidate for ear tubes or tubes in her ear. I was wondering if you could talk a little bit about that on the podcast. Thanks very much. Bye.

Mike Patrick: All right. Well, thanks Marcy for using the Skype line we appreciate it. So, kind of to sum up, your four year old daughter and she has frequent ear infections, she has chronic fluid behind the eardrums, and your pediatrician recommended ear tubes, and you want us to talk about ear tubes a little bit.

55:09

So, what are ear tubes? Well, it's a little piece of plastic with a hole in the middle of it. so, kindly think of it as a small tunnel. So, a link of plastic and in terms of size, if you want to kind of picture in your mind.

If you think about an ink pen, so just kind of a standard cartridge ink cartridge that goes into an ink pen, that's about the diameter with a hole in the middle. And basically just fits right through the ear drum. And so, the idea here is that the space behind the ear drum will ventilate to the space in front of the eardrum at a kind of drain that area out to get the fluid out.

And we'll talk in a minute about other indications for putting ear tubes in. But in your case it sounds like there's fluid that's been there for a long time, and your doctors talking about getting that fluid out.

So, if you put a tube through the eardrum it will help facilitate the drainage of that fluid and possibly help prevent that fluid from re accumulating in that space in the future.

56:08

And then with the ear tube what it'll end up happening is over time the body kind of forces that out and then you get a little scar where the tube was, but it's very small, so we're just talking about very small scar and generally that doesn't cause much of a problem for most kids although we'll talk about complications in just a couple of minutes.

And sometimes the tube doesn't come on its own like it's supposed to and so your child has to have another procedure to get the tube out at some point in the future. So, why would you do this? Why would you put a plastic tube to the ear drum that's got a little hole in it.

Well, in the case of recurrent bad ear infections, it's a pretty easy decision, you have this kid that's just miserable with fever and pain, and perhaps vomiting, and they get on antibiotic. And soon as their off of that antibiotic, it just comes back and you do the second antibiotic, and they'll give you a third antibiotic. And at some point you're just -is as craziness and you're just sick of it, and you want your child to be better.

57:06

And so, ear tubes can help break that process. And we're going to talk about exactly why they work to do that in just a minute. And in that case, it's kind of an easy decision to put the ear tube in.

The other situation where we talk about ear tubes are when you have chronic fluid behind the ear drum which in your case Marcy is what you're talking about. And this is actually more of a difficult decision because you have to consider many factors.

If it was a perfect world and there were no risks or complications associated with ear tubes, you could say, yeah fine drain the fluid off. It's not supposed to be there, let's put the ear tube in. But there are complications and problems that can arise, they're not common, but they can arise with this.

So, you have to look at a risk benefit kind of ratio, and when you're talking about a kid who has acute ear infection that are recurrent, and they're having fevers, and they're uncomfortable, and they're on multiple antibiotics, you know it's easier to say that the benefit outweighs any risk.

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But if the kid is not having any issues associated with it, it's a little harder to try to figure out that risk benefit balance, and it's something that you and your doctor have to come to agree together.

Now, if that fluid is causing any kind of discomfort, if it's causing enough of a hearing loss, and it's affecting their quality of life, if it;'s causing enough of a hearing loss that it's causing speech problems. You know, these are the kind of situation where it maybe worthwhile to put the ear tubes in.

And I will point out with regard to speech, there have been some studies that looked at kids with chronic fluid -not infection, but just chronic fluid from a past infection that's just still there behind the ear drum. And it does show that they do have some hearing loss that's there when the tube is there.

They're not deaf, but it's a little bit of a hearing loss. And so, they looked at a group of kids with that kind of hearing loss and then kids who didn't have any chronic fluid behind the ear drum.

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And then they followed them out prospectively in a longitudinal study to see what the rates of speech delay and speech problems were. And what they found was that there was really no difference between the two groups, so that yes chronic fluid there can cause speech or hearing problems, but it does not appear to cause speech problems that degree of hearing loss.

Now having said that, we're again looking at a group average of kids with chronic fluid versus kids without chronic fluid. And your individual child may not hold true to that observation. So, in other words, even though study show that having chronic fluid behind the ear drum, it can lead to hearing loss that's temporary, but it won't cause speech problems.

Well, maybe in your child it is causing speech problems because not all kids you know, follow -we're talking studies versus looking at the average. It is statistically significant that these things are correlated, but in any individual kid the opposite might be true.

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And so, this is again something that you just have to kind of come to an agreement between you and your doctor of whether the benefit versus risk ratio is really there for you.

But if your kid has chronic fluid and their speech is fine, their hearing is not affected to any significant degree, they're comfortable. How long do you let that fluid set there? You know, talk to your doctor about it, they may want you to have an interview with the pediatric ENT doctor -ear, nose, and throat doctor kind of get their opinion.

But you have to run in and do surgery? Maybe not. That's something that you may be able to watch for quite a long time. So, let's go ahead and focus on why do ear tubes work in the case of recurrent ear infections.

And to do that we have to think about a structure in the body called Eustachian tube, and that's a tube that connects the back of the throat to the middle ear space. And the purpose of this tube is to equalize the pressure on both sides of the ear drum.

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So, you doesn't get a fluid build up, I mean in order for the ear drum to move when sound waves move it, you want equal air pressure on both sides. And so, you have air coming in to the ear canal on the outside, and air coming into the mouth and up to the Eustachian tube on the inside, and that equalizes the pressure so that the ear drum can move freely.

Now in order to keep stuff from the mouth out of that space, the Eustachian tube is lined with little hair cells that have cilia like hair like projections. And their job is just to anything that enters the Eustachian tube from the mouth, it's their job is to push it back down to the mouth, and say,'hey you're not supposed to be here'.

And so, that's kind of what happens with the Eustachian tube. Now, what occurs when you have a virus is a couple of things. So, you get a viral upper respiratory infection, and the virus can infect those cells, so the cilia doesn't work properly. So now, mouth bacteria is able to go up the Eustachian tube, and those hairlike projections don't work to push the bacteria back down to the mouth.

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Also, you get mucus that gets made when you have an upper respiratory infection. And that mucus can block the Eustachian tube, so now any bacteria that went up there not only does it not get pushed back down to the mouth, it can't even get back down to the mouth because now you get mucus kind of blocking that tube.

And so, the bacteria stay in that middle ear space and set up shop, they reproduce overwhelm the space. The body says, 'Hey, this bacteria is not supposed to be here sends in white blood cells to kind of mop them up and take care of the infection.' And next thing you know, you have puss and inflammation, and you have an acute air infection. So, it's kind of the process of why that happens.

Now, why do some kids gets more than others, you know some kids get viral infections than others because they're in day care or around other kids, and more prone to getting infected. Some kids have a problem with their immune system, and so they get infections more often. And other kids have an anatomy problem where their Eustachian tube is wider and kind of floppy.

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And so it's easier for bacteria to get up there and if they kind of flop closed and you got mucus sort of gum and everything up, that can also obstruct that Eustachian tube and make it not do its job properly.

Other kids may have thinner kind of skinnier, longer, more rigid Eustachian tubes that are going to work better. So, these are other factors that kind of go on to why some kids gets lots of ear infection and other kids don't.

So, that's kind how ear infections oftentimes happen. And so, what does the ear tube do? Well, if that whole process is happening and bacteria get up into the middle ear space behind the ear drum, and can't get back down to the mouth through the Eustachian tube, rather than being trapped in the middle ear space, they can actually go through that tube and becomes skin bacteria on the outside of the body.

So, in that way it kind of helps to ventilate that middle ear space and prevent ear infections from occurring, and then when they do occur, the fluid can drain out through that tube, and that's why they're helpful.

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In terms of risks with putting ear tubes in again it involves general anesthesia which has it sown risk, it's a surgery, you can get recurrent infection associated with the tube itself sometimes and then especially fungal infections can happen.

And then we talk a little bit about scar tissues a possibility too in the ear tube fall off. So, each case is unique, it's definitely something you want to talk with your doctor about, but hopefully that discussion helps you out, Marcy. And again thanks for writing in.

And finally, we have Maria in Indianapolis. And Maria says, "Hi Dr. Mike. Love your podcast. You've really answered many of my questions through this wonderful source of information.

My question now is this, I have a 14 month old boy who's had a chronic cough since he was four months old. His symptoms are always the same runny nose followed by a very harsh, forceful, and wet sounding cough, no fever, and he sleeps well.

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He sees the pulmonologist and is currently on Qvar also Albuterol as needed and Prevacid for possible silent reflux. They have not given me a diagnosis except that he has reactive airway disease, his chest and lung X-rays are all normal.

Can you elaborate on reactive airway disease. Every time this happens what seems to be two weeks out of every month, my pediatrician attributes it to viral infections and we just wait it out. I feel helpless seeing him cough and be sick so often. Thanks, Maria in Indi.

Thanks for the question Maria. So, let's talk about reactive airway disease. First we have to sort of define what it is. You know, it's really a nice way to say that a baby has asthma. It doesn't mean that they're going to have it their whole life, and it may only last one year kind of on and off.

It may last longer than that. But it's kind of instead of using the word asthma which has kind of a stigma chronic disease feel about it. What we call -what happens with asthma in younger babies we call it reactive airway disease. Kind of nice way to say asthma without saying asthma.

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And we do recognize that not all kids with a reactive airway disease will have asthma as they get older, and they try to weed out which ones will and which ones won't. Probably the most reliable way to do that is to look at your family history.

If there's a family of baby history of babies who wheeze when they're babies, who then don't wheeze as they get older, then that's more likely to be the case that you're child is going to follow. On the other hand if a lot of babies grow up to be kids with asthma, who grow up to be adults with asthma, then it's a little less likely that your child is going to outgrow it.

Now again it's not 100%, but is is helpful if you look at your family history to kind of determine where your child is going to go with their reactive airway disease/asthma kind of pathway. Now, so what exactly is happening here? Well, the bronchials which are the small airways down deep in the lungs, they're lying with smooth muscle.

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In response to certain things and it can be viruses, it can be cigarette smoke, it can be -you know, any kind of Anogen substances not suppose to be down there. The body can react by causing lots of inflammation, and in kids with reactive airway disease, their lungs react more to those foreign invaders than other kids do.

So, if you give a kid with reactive airway disease a virus, they are more likely to over react to that virus and cause inflammation down deep in their lungs. And that inflammation obstructs airflow and that causes wheezing.

And when it's significant it can cause you to have to work harder to breathe, to move air in and out, and kids can tire in. So, the danger is that if you don't treat it, of you're not up on it, that kids could get into problems breathing because of their reactive airway disease. Now, in contrast to that, there's another disease that we see in little babies called Bronchiolitis.

And in this situation rather than there being a lot of inflammation that's causing this wheezing, it's really more that the virus and the one in most particular that does this is called RSV or Respiratory syncytial virus.

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And it causes a lot of mucus and cellular debris that causes the obstruction. And so, the types of things that we use to treat reactive airway disease which will get to in a minute, don't help as much with RSV Bronchiolitis because it's a different mechanism of what's happening to cause that air flow obstruction down deep in the lungs.

So, how do we treat reactive airway disease? Well, just as your doctor is having you do the type of things that we do. One is the Qvar that you're using. Qvar is an inhaled steroid medicine, and the idea here is that if you do an inhaled steroid, steroids reduce inflammation.

And so, if you kind of have a lower level of inflammatory ability down deep in the lungs when those irritants come whether their virus or something in the environment, you're going to have less of an immune response, and less inflammation because of this inhaled steroid that's there everyday.

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So, that's what the Qvar. The Qvar is for prevention. To prevent bad inflammation from happening in the first place when you're expose to the things that normally would cause the inflammation.

But not only helps to prevent, once you actually have lots of inflammation and health steroid isn't going to help you out too much. Then what we do is the first thing we use is what's called a rescue medicine. And this is what the Albuterol does. And the idea here is that remember these small bronchials are lined with smooth muscle, and Albuterol relaxes the smooth muscle.

And so, if you can relax that muscle, you increase the diameter of the airway and then that is going to allow more airflow despite the inflammation that's there.

Now, if you have a kid with RSV or Bronchiolitis, and the airflow obstruction is not from inflammation, it's more from mucus and cellular debris, then dilating that smooth muscles is not really going to help you out too much because you just have a lot of gunk inside the actual bronchial itself.

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And so, you still have airflow obstruction even though you're relaxing the muscle. And so, that's why kids who have RSV typically wheeze regardless of what you do, and it's just a matter of getting the mucus sucked out and supporting them.

And by kids with reactive airway disease the rescue medicine like Albuterol does help. And then the other thing that we do with those kids is start them on an oral steroid so it's a much more potent steroid experience than their inhaled steroid is.

These are medicines like prednisolone or Orapred, and so they decrease the inflammation inside the lungs in a bigger way, and help them get through that episode. I do want to point out that the rescue inhaler is you have to know which one your rescue inhaler is.

So, if you have a kid with reactive airway disease and they start wheezing, they start having trouble breathing -Albuterol you have to know your rescue medicine is the Albuterol or the the Zopanax is the other one.

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And so, that's the first one that you have to use, you don't monkey around with the steroid medicine, you get the bronchodilator in to relax those smooth muscles and open up the airways a little bit bigger. And that's the first thing that you have to do.

Now, so how do you prevent reactive airway disease. Well, you have to avoid whatever it is that's irritating you. So, for some kids if they're young and they're in day care, and they're getting virus after virus after virus, so they're exposed in some other fashion.

They go on to a church nursery, or you're involved in a social organization and your kids are out and about, and they're around other kids. Whatever it is, if they're prone to getting their reactive airways disease acting up when they get a virus, then you have to kind of avoid them getting viruses.

And sometimes that means taking them out of certain situations. Or if it's cigarette smoke that initiates it, or if it's cat dander that causes it to occur, you just kind have to look at their life and figure out what their initiating factors are and try to remove that as much as you can.

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And then of course the inhaled steroid medicine we've talked about. There's also some non-steroid agents that decrease the immune system from overreacting and those are medicines like Singulair is one example that many of you that probably heard of.

In terms of prognosis or expectation with reactive airway disease, again a lot of kids outgrow it. The reactive process kind of burns out, and their immune system kind of simmers down, and doesn't have these overreactions anymore. Also as you get older the diameter of the airways increase so there's less obstruction.

And for a lot of kids, it's sort of a combination of those two things as they get bigger, they kind of outgrow their reactive airway disease because their bronchials are getting bigger, and because their immune system kind of slows down and doesn't have this crazy reactions to whatever it is that Anogen is for them.

So, then other kids their reaction stays the same even though they get bigger and it turns into what we then called childhood asthma. And again, you got to look at your family history to try and figure out which of those things is going to happen in your particular case.

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So, I hope that helps Maria, just a little discussion over reactive airway disease. If you like to hear lots more about asthma, check out PediaCast episode number 186 where we have Dr. Karen McCoy join us.

She's a pulmonologist here at Nationwide Children's Hospital and we'll put a link to that episode in the show notes for you. All right. We're going to take a quick break because we're running way over. And we'll get back to some final thoughts right after this.

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All right. I want to remind you that if there's a topic you like us to talk about or you have a question for us, it's easy to get a hold of me, just go to pediacast.org and 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, if you're a runner, think about joining the Nationwide Children's Hospital Columbus Marathon, and we'll put links in the show notes for you. We're looking for a patient champions and we're looking for children's champion to help us raise money, and it's a great way for you to qualify for the Boston Marathon if you're looking forward to that.

Again, the links are all in the show notes for you. And if you are planning on traveling to Columbus for the marathon, make sure you let us know because we make it a little get together for those coming in to Columbus. We can meet in person, have dinner together, I think that will be a lot of fun. So, let us know if you're planning on.

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In terms of do I run, so I know that's part of the next question on your mind. And as my daughter likes to say, "I only run if there's a pack of wolves chasing me." But hey, we can eat dinner together.

All right. I have someone to thank. Dr. Marcel Casavant for stopping by the studio and talking to us about mercury. And of course thanks to all of you for making PediaCast a part of your day. Don't forget to let your friends and family know about PediaCast through your blogs, on Facebook, in your tweets. And remember that we're available with social media as well.

We're on Facebook, Twitter, and Google+ now, and we have to look into having a hang out at some point here in the future. Again we also, and I think this is important, we'd like for you the next time you're at your pediatrician's office, just to mention us.

So, when you go in for your next well check up, or your having a sick office visit, just tell your doctors say, "Hey, there's this great evidence based pediatric podcast. out of Nationwide Children's Hospital. that I would encourage you to let all of your patients know about. So, that's a great way that you can spread the word about the show

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