Infant Potty Training, Cockroaches, Scarlet Fever – PediaCast 244

Join Dr Mike in the PediaCast Studio for another edition of news parents can use. Is it possible to get your infant out of diapers by 9 months of age? What do air pollution, cockroaches, and asthma have in common? Did scarlet fever cause Mary Ingalls’ blindness? And if so, could it cause blindness in your child? Answers to these questions and more… in this week’s installment of our program!

Topics

  • Infant Potty Training

  • Knee Injuries

  • All-Terrain Vehicles

  • Spine Injuries

  • Air Pollution

  • Cockroaches

  • Asthma

  • Scarlet Fever

  • Dance Injuries

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

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

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. It's episode 244 for February 27th 2013. We're calling this one Infant Potty Training (and I'm talking really about infants here, little infants), Cockroaches and Scarlet Fever.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. And as you can tell we have a motley crew of topics this week. I'd like to welcome all of you to the program. It is a news parents can use edition of our show. We have lots coming your way this week, more than just mentioned in the title, which is usually the case.

But we have a lot so we're going to get right to the lineup. What exactly are we talking about? I mentioned infant potty training. Can an infant be potty trained? I mean like completely out of diapers by nine months of age. Is that possible? Well some folks in Vietnam claim to be doing and we'll let you know if the reports are true. And if they are how in the world are they accomplishing this task? Is it something you could do?

We're also going to talk about knee injuries today. They are common, you and/or your child may have experienced one for yourself maybe in the course of playing sports. There is a potentially dangerous form of knee injury on the rise that affects children and teenagers and they could cause chronic pain and mobility problems down the road, especially if it's not diagnosed and treated properly.

So we're going to have a word from the American Academy of Orthopedic Surgeons on the identification and proper management of this particular knee injury, so that's coming your way.

Keeping it real in the orthopedic world we'll also touch base on spine injuries and in particular, how are they related to the rising use of all-terrain vehicles. It's a problem that helmets won't help and it is a growing concern and a growing source of significant injuries in kids, so we'll talk about that.

02:29

And then what does air pollution, cockroaches and asthma have in common? We're going to reveal that secret and let you know how these things might affect your family.

And then finally, scarlet fever, what is it? Could it have been the cause of Mary Ingalls blindness? Yes, Mary Ingalls from Little House on the Prairie. The book says scarlet fever was the cause, but researchers at the University of Michigan aren't buying that story.

Actually, they did buy the story, which is how they discovered the claim in the first place. But seriously, if not scarlet fever then what? And speaking of scarlet fever, it's not considered dangerous today but back in the 1800s during the "Little House" days scarlet fever was a leading cause of childhood death.

So what gives? How can a disease that was once a deadly no longer be a significant concern? The answer to that question may surprise you, even for our seasoned clinicians in the crowd.

So stay tune for those interesting answers and then finally we'll wrap up the show with final word on dance injuries.

I do want to remind you PediaCast is your show, so if you have a topic idea or a question or you wish to point me in the direction of a news story or if you just want to say hello you can do that. Simply head over to the Contact page at pediacast.org, click on the Contact link.

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

Also I want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. 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 show is subject to the PediaCast Terms of Use Agreement, which as always you can find over at pediacast.org.

All right. We are going to take a quick break and we'll be back with News Parents Can Use, right after this.

[Music]

04:57

All right. First up in our News Parents Can Use, wouldn't it be great if babies were born potty trained? Now I know they're too small to use a potty, not to mention they can't support their own weight or sit up on their own. But what if they peed and pooped when you told them to?

You could throw away the diapers, have them go on demand and be done with it, right? Now I realize long time listeners are scratching their heads at the mere suggestion because we've covered potty training many times on PediaCast and in the past I've pointed out that one of the prerequisites for potty training is being developed mentally ready; so being able to relax the muscles that let the pee and the poop flow.

These muscles aren't ready to relax on demand until a child reaches a certain age. So any attempts to potty train prior to your child being developmentally ready are destined to fail. Well someone didn't hand that memo to mothers and babies in Vietnam.

As it turns out many families in that country start potty training right from birth. Now you may be wondering how well does that really go? If so, you aren't the only one wondering. Swedish researchers from the University of Gothenburg also wondered and they sent a research team to Vietnam and followed 47 Vietnamese mothers and their infants for a total of two years.

Surprisingly, they found the rumors true. Vietnamese moms do begin potty training babies at birth and they found out it works with most making significant progress at three months of age and most babies are completely potty trained and diaper-free by nine months. And by two years nearly all children are 100% completely taking care of their own potty needs.

Now I'm not kidding. Compare that to children in western countries including the United States where aren't potty trained until they are three or four years of age. So the question becomes how in the world do Vietnamese moms accomplish this amazing task and is it something you can do at home?

06:54

So let's tackle the how first. Vietnamese mothers provide constant attention to their babies and catch them in the act of urinating and each time they catch them in that act they make a distinctive whistling noise. Pretty soon babies associate that whistling noise with going potty. And by three months many of the infants use the whistling sound as a queue to make urine. By nine months they're so good at doing this when mom makes the noise that their moms just throw away the diapers.

So what makes Vietnamese develop faster? Why can they relax the necessary muscles on demand earlier that their western counterparts? Well according to Dr. Anna-Lena Hellstrom, one of the lead investigators of the project, which by the way was published in the Journal of Pediatric Urology, she says her team's evidence suggests that age is not the primary factor determining when these nerve muscle connections mature but rather the act of potty training results in pathway connection and control.

So moms and dads, despite my previous comments on potty training and despite what your doctor has told you about potty training and despite what nearly every baby and toddler care book out there proclaims, it appears you can sort of potty train a young baby.

However, and this a big however, you have to seriously be in your baby's business. It amounts to classic conditioning. It's sort of like clicker training your baby except instead of using a clicker noise you're using a distinctive whistle and that whistle needs to occur as often as possible when your child goes potty.

So have to know exactly when that happens and then as you progress with the plan you have to be able to anticipate when your baby should go next so you can give them a little whistle and have them do their business. It becomes obvious pretty fast that a working mom or dad simply can't do this and it's probably impossible to find a willing babysitter, nanny or daycare, but if you have the time and the inclination it does sound possible.

09:06

All right. Next up, knee injuries, they are common, especially for active and sports playing children and teens, but they can also be a bigger problem than you might think. In many cases, knee injuries result in damage to the anterior cruciate ligament, also known as the ACL.

The ACL is the primary stabilizing ligament in the knee and when it's damaged the ligament require special care and treatment to ensure appropriate healing and to prevent long-term complications. And this is particularly true in children and teenagers whose bones and joins haven't yet fully matured.

According to a recent review article in the journal of the American Academy of Orthopedic Surgeons, ACL injuries were once considered in kids, however, the number of these injuries in young athletes is on the rise. Dr. Jeremy Frank, an orthopedic surgeon at Joe DiMaggio Children's Hospital in South Florida and lead author of the review says, "This rise in ACL injuries probably results from year-round training, less free play and increased single sport concentration."

To avoid potential future complications such as early onset osteoarthritis the literature review includes recommendations based on the specifics of a child's injury and the child's skeletal maturity. Among these recommendations, when an ACL injury is diagnosed children should be treated by an orthopedic surgeon who has expertise in the operative treatment of pediatric ACL injuries.

For ACL tears involving less than 50% of a ligament's diameter, non-surgical management including activity modification, bracing and physical therapy may be considered, but these measures should be supervised by a qualified pediatric orthopedic surgeon.

When a child does need surgery for an ACL tear it's important that the surgeon spares as much of the growth plate at the end of the femur, so the top part of the knee, spares much of that growth plate as possible. This is important because adult style ACL repair operations typically disrupt this growth plate and result in more problems down the road. So that's why you want a pediatric expert involved absolutely for children but it's also important for teenagers who are still growing.

11:12

Post-operative management includes a carefully selected regimen of weight-bearing and activity modifications, bracing, physical therapy, strengthening and a slow return to normal physical activity that continues to be monitored by a pediatric orthopedic expert.

Dr. Frank says, "There are currently numerous safe and effective surgical techniques to reconstruct the ACL in the skeletally immature sportsperson to restore stability and forestall the early progression towards meniscal and cartilaginous disease." He says, "Complications from ACL surgery are rare in children when the appropriate operation is performed on the right patient."

So the take home for moms and dads here knee injuries are common and injuries involve the anterior cruciate ligament or ACL, those injuries are on the rise. And I'm going to have another piece of important information — plain X-rays of the knee won't show a damaged ACL, OK?

There may be suggestions of it on plain film, but they won't show it. So you need a CT scan or preferably an MRI to see an ACL injury. Now, if you're a million dollar athlete you're probably going to get that MRI right away, but for the rest of us normal folks doctors usually start with the plain film just to make sure there aren't any broken bones.

If the bones look fine we usually give the knee some support, could be a splint or a knee immobilizer or perhaps something we call a shunt's wrap. And then depending on the mechanism of injury and the physical exam findings then we say, hey, you're going to rest, ice, elevation, Ibuprofen, you know the drill with what we do with injuries.

And then we say follow-up in a few days with your regular doctor or sports medicine or an orthopedic surgeon. And here, moms and dads, really is where your role comes in, take that follow-up advice seriously, do it even if your child seems better.

Second, when you do follow-up if your child's symptoms or disability persists then you want to make sure that your child gets advanced imaging to evaluate the anterior cruciate ligament like an MRI because if that ligament is damaged then you want a referral to a pediatric orthopedic surgeon.

13:24

Now, it is true when you still have knee injury symptoms after a few days after the plain films are done your doctor may skip the MRI and say, hey, I'm going to send you to a pediatric orthopedic surgeon and let them order the MRI. That's OK. But you do want to make sure that that gets done and that you are seeing a pediatric orthopedic specialist. Not one who sees adults, you want one who sees plenty of kids.

If you do have a pediatric sports medicine in your area a referral to them would probably be fine, too. They can also order the MRI and they know that if there is a significant injury to the ACL they're going to get you the referral that you need, again to a pediatric orthopedic specialist.

And again, you don't want to see one who just sees adults, you want one who sees plenty of kids and has plenty of experience operating on children and teenagers who are still growing. That's important. So knee injuries in kids think ACL damage, think MRI if symptoms persist and think pediatric orthopedic surgery, even for teenagers, pediatric that sometimes teens don't want to go see a kid doctor but it's important because they're the ones that still treat of those still growing kids and teens.

So if the ACL is damaged that's who you want to see and that advice, by the way, is courtesy of the American Academy of Orthopedic Surgeons.

14:41

All right. Let's move from the knee to the spine. Children continue to account for a disproportionate percentage of injury and death from accidents involving all-terrain vehicles or ATVs, that's according to pediatric orthopedic surgeons at Le Bonheur Children's Hospital in Memphis, Tennessee.

Their study published in the Journal of Pediatric Orthopedics says the number of these injuries has risen 240% since 1997. The surgeons studied data from the Kids' Inpatient Database (KID) and found spinal-relate injuries from ATV accidents in the United States are more common in older children and also in females.

The authors say the increase use and power of ATVs has not only resulted in more injuries but also an increase in the severity of injuries. Between 1997 and 2006 the number of kids admitted to the hospital for ATV-related injuries increased 240%, but what's even more striking is the rise in severity with accidents resulting in spinal fracture up 476% since 1997.

Dr. Jeffrey Sawyer, MD, Associate Professor of Orthopedics at the University of Tennessee and s spokesperson on ATV injuries for the American Academy of Orthopedic Surgeons says, "We want to encourage physicians to be aware of the potential for associated injuries, including abdominal trauma, thoracic trauma, closed head injury, fractures of the arms and legs, fractures in the other areas of the spine and neurologic injuries. Of special interest was the frequency of noncontiguous spinal fracture because a second spinal injury at a different location than the first might be missed."

16:15

In another study, Dr. Sawyer and colleagues reviewed 53 ATV-related spine injuries in 29 children over a five-year period. They found the average age of children with ATV-related spine injuries was 15.7 years; 55% had an associated nonspine injury; 44% had multiple spine injuries, contiguous in nine cases but noncontiguous in four. Contiguous just means that the vertebrae next to each other are involved; noncontiguous means that they're at distant sites on the spine where you have two different fractures or more.

Four patients, all under the age 15, had neurological injuries. Children older than 16 were more likely to have a thoracic spine fracture, so the posterior or back part of the chest, than younger children. And younger children were more likely to have lumbar spine fracture, so that would be in the lower back.

Fourteen patients required surgery; seven for spine injuries and another seven for nonspine injuries. That study was also published in the Journal of Pediatric Orthopedics and it drew the following conclusions — ATV-related accidents are high-energy events with a high rate of associated spine and non-spine injuries; ATV-related spine injuries are more common in older children and females; for younger children, musculoskeletal injuries are more common than spine injuries; and all doctors evaluating ATV accident victims should have a high index of suspicion for associated injuries, including additional and often noncontiguous spine fractures.

Dr. Sawyer says, "Parents need to know that ATVs are not toys, they are motor vehicles, which can weigh more than 500 pounds. But unlike other motor vehicles they lack safety features such as airbags. If you wouldn't let your 12-year-old drive the car why would you let them operate an ATV? All too frequently we see children unnecessarily severely injured and killed on all-terrain vehicles."

So well-stated, Dr. Sawyer. Moms and dads draw your own conclusion but before doing so, ask yourself this – are the potential consequences worth my being looked upon by my child or the neighbor's child as the cool parent? Something to definitely think about.

18:22

All right. We are going to completely switch gears now and talk about air pollution, cockroaches and asthma. An allergic reaction to cockroaches is a major contributor to asthma in urban children. But new research suggests that the insects are just one part of a more complex story.

Very early exposure to certain components of air pollution can increase the risk of developing a cockroach allergy by age seven and children with a common mutation and a gene called GSTM may be especially vulnerable, so say researchers at the Center for Children's Environmental Health at Columbia University's Mailman School of Public Health.

The report, the first to examine this interplay of risk factors appears in the Journal of Allergy and Clinical Immunology. Dr. Matthew Perzanowski, one of the authors of this study, says, "Allergy to cockroach is one of the greatest risk factors for asthma in low income urban communities. Our findings indicate a complex relationship between cockroach allergen and air pollution exposures early in life and a possible underlying genetic susceptibility. Combined these findings suggest exposures in the home environment as early as the prenatal period can lead to a greater risk in some children for developing an allergy to cockroach, which in turn heightens the risk of developing asthma."

Dr. Perzanowski and his co-investigators looked at 349 mother-child pairs in the Northern Manhattan area and in the Bronx. During the mother's pregnancy exposure to cockroach allergen, which are proteins in the poop, saliva and bodily remnants of the insects always measured by collecting dust from the kitchen and bed. That's lovely, right?

Researchers also sampled air in the home to measure the mother's exposure to polycyclic aromatic hydrocarbons, which are combustion products and harmful components of air pollutions. Researchers also drew blood to determine the presence or absence of the GSTM1 genetic mutation.

More blood was drawn when the children reached age five and seven years to identify the presence of anti-cockroach IgE antibodies, which are immune markers of cockroach allergy. So what did they find?

20:32

Well researchers found that 279 or 80% of the homes tested positive for a high level of cockroach allergen, which again are these proteins in cockroach's poop, spit and body remnants. By age seven, 31% of the children living in these homes had indeed developed a cockroach allergy, but the presence of high levels of cockroach allergen, so the proteins, only led to actual cockroach allergy in children whose mothers had also experienced exposure to high levels of air pollution during pregnancy.

So this suggests that prenatal exposure to air pollution enhances immune response to cockroach proteins during the childhood years. The combined impact of air pollution and cockroach exposure was even greater among the 27% of children with a common mutation in the GSTM gene. This mutation is suspected of altering the body's ability to detoxify polycylic aromatic hydrocarbons, which again are commonly present in polluted air.

The doctors report that minimizing exposure to air pollution during pregnancy and minimizing exposure to cockroaches during early childhood could be helpful in preventing cockroach allergies and the subsequent development of asthma in urban children.

Dr. Rachel Miller, a co-author of this study, says, "Asthma among many urban populations in the United States continues to rise. Identifying these complex associations and acting upon them through better medical surveillance and more appropriate public policy may be very important in curtailing this alarming trend."

So take home for moms and dads, don't pass along a mutated GSTM gene to your kids, OK, that's less than helpful. Avoid air pollution during pregnancy and rid your house of cockroaches, at least while you're pregnant and your children are young, then maybe, just maybe, you'll reduce your child's chance of living with allergy symptoms and asthma.

22:27

All right. Finally, in this News Parents Can Use edition of PediaCast, we keep a collection of News Parents Can Use over at Pinterest. I always remark how our Pinterest board continues to grow and it contains stories that you won't find in the podcast, which is generally true.

So it gives you an incentive to head over there and check us out on Pinterest because we'll pin up some great stories that are useful for moms and dads that we don't cover here on the podcast. But I'm making an exception today. Why? Well really it's just because I'm allowed to.

It's not that this story is earth shatteringly important, but I think it's interesting and after I posted it on Pinterest I sort of regretted it. I kept thinking that one belongs on the podcast. So I kept it on the Pinterest board because at that point it had already been repinned. And so I kept it there but I kind of went back and said I've got to put this one on the podcast because I really like this story.

So what is it? Here it goes, Mary Ingalls of Little House on the Prairie fame her blindness despite the facts revealed on the story was unlikely to have been caused by scarlet fever. That's the word on the street from researchers at the University of Michigan as published in the Journal of Pediatrics.

Senior author of the report, Dr. Beth Tarini, says, "Since I was in medical school I wondered if scarlet fever could really cause blindness. I remembered Mary's blindness from reading the Little House stories and knew that scarlet fever was once a deadly disease. I asked other doctors but no one could give me a definitive answer so I started researching it."

Mary Ingalls went blind in 1879 at age 14. Her little sister Laura Ingalls Wilder wrote about Mary's blindness and her writings became the basis for the popular Little House on the Prairie books. So Dr. Tarini and colleagues went to the source, searching the memoirs and letters of Laura Ingalls Wilder along with local newspaper articles of the time.

These writings described Mary's illness as "spinal sickness" with symptoms suggestive of a stroke. One newspaper article reported Ms. Mary Ingalls was confined to her bed and it was feared hemorrhage of the brain had set in with one side of her face becoming partially paralyzed.

24:46

Dr. Tarini says, "Meningoencephalitis could explain Mary's symptoms including the inflammation of the facial nerve, which caused one side of her face to become temporarily paralyzed. This could also lead to inflammation of the optic nerve, which would result in a slow and progressive loss of sight."

She adds, "It's not surprising that scarlet fever was labeled culprit in the books because between 1840 and 1883 scarlet fever was one of the most common infectious causes of death among children in the United States."

Sarah Allexan, another author of the paper and now a medical student at the University of Colorado, says, "Laura's memoirs were transformed into the 'Little House' novels. Perhaps to make the story more understandable to children, the editors revised her writings to identify scarlet fever as a cause of Mary's illness."

Why? Because it was so familiar to people back then. They understood the term scarlet fever and recognized how dangerous it could be. Now many of you out there, doctors and nurses included, are asking yourselves how does scarlet fever kill someone?

Because as we know it today, scarlet fever is the term used to describe a strep infection usually in the throat that has an associated fever and a distinctive rash. That rash is caused by a toxin called the erythrogenic toxin, which the strep bacteria produce, but they only produce that toxin when the strep bacteria, itself, is infected by a specific virus. Well that gets complicated.

So you have strep throat, the strep that happen to be causing that strep throat they, themselves, are infected with a virus, which we call a bacteriophage and that is what causes them to make a specific toxin which is what causes the distinctive rash that we know of now as scarlet fever.

And that explains why some strep cause scarlet fever and others don't. Now today's erythrogenic toxin while it causes that distinctive rash that last a few days it's not otherwise dangerous. The reason today that we really worry about strep infections is the risk of developing rheumatic fever following a strep infection.

So today, rheumatic fever is a dangerous complication of strep, but scarlet fever not so much. It's just strep throat with a fever and a distinctive rash. But as it turns out, scarlet fever in the 1800s did result in many deaths and it was a feared diagnosis.

27:12

Now interestingly, the severity of scarlet fever, including the number of cases that resulted in death, fell dramatically during the early 20th Century. So you may ask yourself, why? Why did the severity of scarlet fever fall dramatically so that today it's really not a dangerous illness?

You may think well because of the arrival of antibiotics on the scene. No. That's not the reason. The dramatic decline in scarlet fever morbidity and mortality fell well before the discovery of antibiotics. Now, Dr. Tarini points out one other thing, even now a diagnosis of scarlet fever can strike fear into the hearts of parents and patients because of past stories about the disease.

She says, "Familiar literary references like these are powerful – especially when there is some historical truth to them. This research reminds us that patients may harbor misconceptions about a diagnosis and that we, as physicians, need to be aware of the power of the words we use – because in the end, illness is seen through the eyes of the patient."

So interesting stuff. I sort of hate to burst Dr. Tarini's bubble here, but let's just think about this for a moment. If a virus, which is known as a bacteriophage, as I mentioned, if it or a little virus can cause strep to make a toxin which results in a distinctive rash, which we call scarlet fever today, maybe back in the 1800s strep bacteria were infected with a different strain of bacteriophage or a different virus that infects bacteria.

And maybe that resulted in a dangerous form of the toxin and maybe it's this different toxin or the addition of a different toxin that allowed the strep bacteria to become more invasive, more dangerous, create a worse disease. And maybe that's why there were so many scarlet fever deaths in the 1800s because strep back then was making more potent toxin because of the influence of specific bacteriophages back in the 1800s and the reason we see a dramatic decline in scarlet fever severity and deaths in the early 20th Century, before the antibiotic era, is because that bacteriophage mutated and no longer causes the strep to produce a dangerous form of toxin.

29:41

Now I realized this is pure speculation, but I think I have license here because this entire article is speculation. So let's take that step further, if the strep that caused scarlet fever was more invasive and more dangerous in the 1800s compared to today, then it stands to reason that one of the infections that this strep could cause is meningoencephalitis, which is an infection of the brain, its coverings and the spinal fluid.

So maybe Mary Ingalls' blindness was caused by meningoencephalitis as suggested by Dr. Tarini, but maybe Mary's case of meningoencephalitis was in turn caused by an invasive form of strep, which because of its own bacteriophage infection or viral infection was producing a dangerous toxin or toxins, which strep of today is not producing and thank goodness for that.

So maybe Mary Ingalls' blindness was caused by scarlet fever but a case of scarlet fever which led to meningoencephalitis caused by the strep. Things that make doctors go hmmm. But again, it's all speculation. Interesting speculation, but speculation just the same.

All right, that concludes our News Parents Can Use this week. I will be back with a final word. This week it's going to be on dance injuries, we'll be back with that, right after this.

[Music]

31:44

All right, we are back. Dance is a beautiful form of expression but it could be physically taxing and strenuous on the human body, particularly for children and adolescents. A new study by researchers at the Center for Injury Research and Policy of the Research Institute here at Nationwide Children's Hospital examined dance-related injuries among children and adolescents 3 to 19 years of age from 1991 to 2007. During the 17-year study period, an estimated 113,000 children and adolescents were treated in U.S. emergency departments for dance-related injuries.

According to the study, which appears in the Journal of Physical Activity and Health, the annual number of dance-related injuries increased 37% from 1991 to 2007. Sprains and/or strains were the most common types of dance-related injuries at 52%; falls were the most common causes of injuries at 45%.

The most common ages for injury were between 15 and 19 years, which accounted for 40% of all dance-related visits to emergency departments.

Kristin Roberts, lead author of the study, says, "We believe this could be due to adolescent dancers getting more advanced in their skills, becoming more progressed in their careers and spending more time training and practicing. We encourage children to keep dancing and exercising. But it is important that dancers and their instructors take precautions to avoid sustaining injuries."

Dr. Lara McKenzie, PhD, a principal investigator with the Center for Injury Research and Policy, adds, "Safety precautions such as staying well-hydrated, properly warming up and cooling down, concentrating on the proper technique and getting plenty of rest can help prevent dance-related injuries."

Eric Leighton, an athletic trainer with Sports Medicine here at Nationwide Children's, says, "Adolescents are still growing into their bodies and often coordination and balance problems that can lead to injury. It's critical that intervention and injury prevention be made available to them to address balance, strength and functional body control deficits as they grow. From ballet pointe readiness screens to injury prevention programs, a sports medicine team has a comprehensive approach to address the needs of these athletes."

33:52

So moms and dads, think of your dancers as athletes, realizing dancing is absolutely beneficial from an overall health perspective. But as with any sport, getting your child connected with an age-appropriate sports medicine program to deal with issues of readiness and injury prevention, strengthening, conditioning, evaluation of management of injuries that do occur and supervision of return to play. All of these things are essential for continued participation and good health.

If you are in or close to Central Ohio, we have a fantastic sports medicine program for you here at Nationwide Children's. They're here for the little athletes, but the big ones who are still growing as well. High school athletes do belong in a pediatric sports medicine program because as we talked about earlier with the knee injuries, still growing bodies do need special care and attention.

And I'll put a link to our sports medicine program in the Show Notes. I just realized this whole thing kind of sounds like an advertisement; it's really not, folks. If you're not in Central Ohio I'm certainly not suggesting you fly your athlete to Columbus.

But find a pediatric sports medicine program in your area, that is important and that's my final word.

35:03

All right. I want to thank all of you for taking time out of your week to make PediaCast a part of it. We really appreciate your support. I do want to remind you that reviews in iTunes are most helpful. So if you have not written us a review on iTunes, really it just takes five minutes of your time to boot up iTunes, find PediaCast, just search for it and write a little review for us. Just a couple of sentences is all we need. We'd just really appreciate your input.

And getting new those reviews, getting new ones helps to put us up a little bit higher in the listing in iTunes so that helps to get us in front of more moms and dads so that they see PediaCast. As I'd mentioned here before, we don't a big advertising budget so it is important that parents find us in iTunes. And one way that you can help us do that is just by writing a review so that we get in front of more moms and dads' faces.

Also links and mentions and shares and retweets and repins, all these things are important as well; on the web, in your blogs and on the numerous social media sites that are available. PediaCast is on Facebook and Twitter and Google + and Pinterest, so you can find us there and help spread the word by sharing our stuff.

And then also be sure to tell your family, friends, neighbors and coworkers about the program. And most important of all, be sure to tell your child's doctor. So when you head to your doctor's office for the next well check-up or a sick office visit just say, hey, there's a great evidence-based pediatric podcast I want to tell you about.

And then we do have posters available under the Resources tab at pediacast.org if your doctor is interested in putting up a poster in the office or in the exam rooms just to help spread the word about the program. Very much appreciated for the docs who do that.

I want to remind you that if you have a question for me or you have a show idea or a news story, a topic suggestion, really anything at all; if you just want to say hi that's fine, too, just head over to pediacast.org, find the Contact link and there's a form you can fill out and get in touch with me that way. I see every one of those forms, so if you write to me there you are writing directly to me.

We also have a Skype line where you can leave a message if you want to give an audio question or comment and the number for that is 347-404-KIDS, 347-404-K-I-D-S.

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

[Music]

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

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