Influenza, RSV, Croup – PediaCast 276

Welcome to PediaCast 2014! We kick off the year with a Listener Edition of the program. Topics include skin wounds, finger gnawing (yes, you read that right), and a nuts and bolts approach to influenza, RSV, and croup. We also discuss daily routines… and The Best Doctors in America. Join us!

Topics

  • Daily Routine

  • Cuts and Scrapes

  • Finger Gnawing

  • Influenza

  • RSV

  • Croup

  • Best Doctors

Links

 

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, it's a pediatric podcast for moms and dads, this is Dr. Mike coming to you from the Campus of Nationwide Children's Hospital.  We're in Columbus, Ohio it is January 22, 2014, it's episode 276 and I'm calling this one Influenza, RSV, and Croup.  Now as most of you returning listeners all know, we're going to cover more topics than are just mentioned in the title of the program, I'll get to the entire rundown here in just a moment.  

0:01:03.3

First I do want to welcome you to the show 2014 style.  I do understand we're arriving to the party a little late, it's January 22nd, we're just not getting our first show of the year out but we took some time gearing up, I wanted to collect some new questions from you and planning our interviews for the year.  That's behind us and we are in full production mode now and ready to send a new show your way each and every week and since I consider PediaCast to be your show rather than my show I thought we'd start off the year with a listener episode.  At the end of last year I put on a call for questions and in typical fashion you responded, so we will get to some of those questions today as well as the complete line up.  Plus if you're new I'm going to clue you in on how you can submit a question to the program, that's coming up.  First, because of the holidays and our first of the year reset here it's been like a month since we chatted.

0:02:03.0

So a few things to catch up on, first I hope all of you had a great holiday with your family.  It's back to routine which is sub-welcome others aren't quite as excited about it.  I'm OK with routine, I think I sleep better well I'm kind of in the grind but it's also easier to get bored.  I mention this because you have more than one member in your family most likely and some are routine people and others aren't.  So consider this for a sort of a late New Year's resolution and that's just to take a step back and see where each member of your family lives with regard to routine.  Here's why I mention it, sometimes we get frustrated with our children, or with our spouse, maybe with our parents because we have different expectations when it comes to routine.  Some of us need routine and apply that need to others who may not share that need.  Others of us don't need routine at all, in fact we get frustrated when others try to impose routine upon us, it makes us feel a little claustrophobic when we're put into a routine.

0:03:15.6

So I think that just getting a feel for what works and what doesn't work for each member of our family and then tailoring our lives around it in a sensitive way, I think by doing that we can improve our family relationships.  I know this sounds a little lofty doesn't it?  I wanted to look at it on a practical level.  I've got a wife and two kids and one of my kids feels very secure with routine, she has to do her homework at the same time each day in the same place and she gets grumpy if she misses her favorite show when it airs.  The DVR is streaming it online the next day isn't good enough it's got to be the routine of seeing it on the same day at the same time. 

0:04:02.7

My son on the other hand, he feels claustrophobic with routine, sometimes he does his homework right after school, sometimes before bed, sometimes in the morning and he doesn't care how he catches his favorite shows long as he catches it.  Depending on how I feel about routine I might assign more worth to my daughter's approach to life or my son's and start comparing them with one another and I start wishing that the one that's less like me would be more like the one that's more like me and the next thing you know one of my kids feels like a failure.  They're not meeting my expectations, they might even try to become a routine guy but then feels claustrophobic, or they may try to go without their routine and then they all get stressed out.  I guess my point here is this, don't use cookie cutter with members of your family, be who you are, let them be who they are.  Now at the same time there are reasonable expectations, homework must get done.

0:05:01.4

We aren't going to watch a bunch of shows each week like a favor or two and we're eating dinner together and we're going to communicate with one another while we do it without our technology devices in front of us, that's none negotiable.  But there is room for negotiating and other things like when, not if you do your homework.  They say variety is a spice of life so embrace the variety in your family instead of setting out to make a bunch of mini me's.  How's that for a resolution this year?  I do think it's important stuff and another New Year's resolution that's great for families is plan more time together this year.  When the weather warms at the Metro Park, scroll out, toss Frisbee, get scheduled if you have to if you're a routine person, schedule in those family fun days.  

0:06:01.2

Like many of you Ohio has been in the tick of a pretty cold winter and what in the world was up with that polar vortex a couple of weeks ago, that was crazy, I was so cold and we were seeing cases of frost bite, I'm glad it's a little warmer now but I'm ready for it to be warm enough to get out to the Metro Park and grill out and toss a Frisbee or football.  Dinner in the movie at the cinemas, always another fun family outing.  We did see a couple of good movies over the break, Saving Mr Banks, and Frozen both of them highly recommended for families.  Really enjoyed both of those programs, and of course my favorite thing to do with the family is family game night.  We got some new games for Christmas as well that we're enjoying namely Squarrels and that's with an A, so just spell squirrel but put an A in there instead of the I.  Deer in the Headlights is a good one, and Joe Name It, so these are some games we got for Christmas, fun for the whole family whether you are a routine person or not so much.

0:07:04.2

I think we're caught up on everything here, hope you guys had a wonderful break and stayed warm in all that as well.  So what are we talking about today?  First I mentioned influenza, RSV, and the croup these are common respiratory illnesses this time of year and one of my British listener wants to hear more about them and I reckon many of you on this side of the pond would like to know more as well.  We're going to take a nuts and bolts approach to the flu, RSV bronchiolitis, and the croup, so that's coming up.  

Before we do that we're going to talk cuts and scrapes, which ones require a trip to the doctor, or urgent care, or emergency department?  And which ones can be cared for at home?  And if you do stay home and take care of your wound how exactly do you care for it?  Is a Band-Aid required?  That's coming up.  

Also gnawing on the fingers, we have a mother who writes in because her child gnaws on her fingers, why does she do it, and how can a mom get her to quit?  I'll add my two cents to that problem as well.  

0:08:04.8

And then at the very end of the show, stick around for my final word, we're going to talk about the best doctors in America, is your doctor one of them?  And I'll let you know how you can find out.  Finally a couple business items before we get started, if you have a question or comment for the program, it's easy to get in touch with me, just head over to pediacast.org and click on the contact link.  I do read each and every one of those that come through and let me know your question we'll try to get it answered on the program for you.  

Also a reminder that the information presented in 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 which you can also find at pediacast.org.  Let's take a quick break and I will be back to answer your questions right after this.

0:09:04.6

[Music]

Dr. Mike Patrick We are back and first up is Paul in San Diego, California.  Paul says, "Dr. Mike please cover the best treatments for cuts and scrapes.  In particular I'd like you to settle a dispute, a friend recently stated that Band-Aids were bad because they cut the oxygen to the wound and wounds need oxygen to heal.  My experience is that small cuts and scrapes actually heal the fastest with bacitracin and a Band-Aid, what are your thoughts?  Paul."  Thank you for writing in Paul, always appreciated.  

0:10:03.1

Let's talk cuts and scrapes, now I realize the cuts and scrapes that you're talking about are the minor ones, the ones that you're going to stay home, you're going to take care of them yourself and we're going to talk about that but first what's a parent to do if they don't know whether this is a wound that they can take care of at home or if it's one that needs to be seen by medical professional?  Whether that be your doctor's office, or urgent care, or the emergency department.  There's a lot of things to consider when we evaluate a wound, how deep is it?  How long is it?  Is it bleeding?  What's the mechanism of the injury?  What's the nature of the wound?  Is it a penetrating puncture wound?  Is it a dirty wound?  Could there be a foreign body in the wound?  Is there any underlying injury of blood vessels, nerves, bones, and what is your child's tetanus status?  Are they up to date on their tetanus shot?  So lots to consider and each wound is different, if you're having that trouble in your mind trying to decide, "Hey is this something I can take care at home or do I need to see someone for it?"  

0:11:05.2

If you can't decide, the best source to help you decide is your doctor, just give him a phone call, you talk to the doctor or one of the nurses, you describe the wound and how the injury happen and then they can give you a really good idea of where that wound needs to be cared for.  Now in general wounds that need attention are going to be large wounds and generally we're talking greater than a quarter of an inch on the face and greater than half of an inch elsewhere.  Deep wounds, so those that are gaping or if there's any subcutaneous tissue showing or fat tissue showing, persistent bleeding despite a few minutes of pressure with a clean cloth or bandage.  So if it's persistently bleeding you're going to need to be seen.  Penetrating injury, so puncture wounds they may be worse than they appear and so those really need to be evaluated if there's a possibility of a foreign body, a glass shard, or wood splinters, if it was a really high impact mechanism and worried about an underlying bony fracture, or dislocation then that's something that's going to need to be seen.

0:12:12.4

If there's any possibility of vascular injury, or nerve injury underneath the wound, so if you have numbness or tingling, changes in sensation, or weakness those are going to be all reasons to definitely have the wound looked at right away.  In the case of very dirty wounds, they may need to be irrigated by a medical professional and wound that are located on the face or on the mouth and lips, the ears, around the eyes, the groin, buttocks all those types of places are better off having those seen right away, and of course if your child's not up to date on their tetanus shot and that's going to be something to consider as well.  So again, lots of considerations and there are many skin wounds that do need medical attention and your doctor can help you decide whether yours is one of them or not.

0:13:00.6

I do want to also stress the importance of closing wounds if they need to be closed sooner rather than later.  So the sooner that they can be closed the less chance for complications including infections and the better the cosmetic effect meaning less scaring.  We never guarantee no scaring and scars even when they do occur in little kids often after a couple of years they look much better.  But again the sooner the wounds get closed the better cosmetic effect and the less chance for  complications including infection.  We do see a lot of folks who wait till the next day and then you know you look at that wound and you start thinking, "Maybe that should have been closed."  I do want to reassure you skin heals well even if it doesn't get closed.  There was a day in time before stitches were routinely done and wounds healed, skin does heal but the way that it heals is that it lays down what we call granulation tissue, it's healing by secondary intention.

0:14:03.2

And then it scabs over and you do get more scarring but it will heal it's just that there's going to be a bigger scar and more chance of infection but sometimes that happens and there's not much you can do about it, there's only a window of time in which you can close wounds and so we do see a lot of parents who feel guilty and you probably should come in the day before but it's going to heal, it's not the end of the world, but it still should be looked at though to make sure that it is something that mean there are some wounds that could be closed later and reasons for that depending on what the wound looks like and where it is in the healing process.  Paul's question deals with simple superficial cuts and scrapes the kind that don't need medical attentions, let's talk about those.

0:14:57.7

Caring for the wounds at home that do need medical attention, I'm not really going to cover that because the provider that takes care of the wound is going to instruct you on wound care for that particular skin lesion.  Most simple scratches and scrapes are going to heal best when the skin is kept clean and dry.  Generally I recommend you washing your hands and then gently washing don't scrub but gently wash the wound with mild soap and water once or twice a day, pat it dry and apply a thin layer of antibiotic ointment such as Neosporin or Bacitracin.  Now what about a Band-Aid?  And does the skin need oxygen to heal?  It's a bit difficult to deprive the skin of oxygen, at least here on planet earth unless you have very special facilities or if you have access to outer space I guess you may be in a different situation but for us earth dwellers Band-Aids will not shot out oxygen, so that's not an issue.  Here's a deal with wound dressings whether be Band-Aids or gauze, they have pros and cons and you have to look at each child's circumstance because the way the pros and cons play out will be different for each child and each wound.

0:16:12.0

Let's look at each of this, what are the advantages of a Band-Aid, or a gauze bandage dressing?  Well you're going to get protection of the wound, protection against scab, dislodgment, protections against picking fingers, protection against dirt and microbes, and then you're also going to have protection of the clothing, you're going to protect your clothes from any spotting of blood, or oozing of clear drainage especially the first couple of days.  That's the advantage as wound protection, and clothing protection that's the advantage of Band-Aid and gauze dressing.  Now there're disadvantages as well, if you keep it covered up especially if it's kind of warm and humid outside, not so much of an issue in the winter but during the warmer, more moisture filled humidified months then the presence of a bandage may promote skin moisture  which can interfere with healing. 

0:17:11.6

Remember we want to keep the wound clean and dry, and so if you use bandages too much it is possible that you provide too much moisture and that can interfere with the healing especially after the first couple of days.  The bottom line here, as long as the wound is not constantly rubbing against something or being picked, and as long as it's not soiling clothing, as long as the wound can be kept clean and dry then bandages are not absolutely necessary.  However if you have an active kid who might get the wound dirty, or rub it against stuff, pick at the wound, or if the wound might soil clothing then using a bandage especially in the first few days may be a good idea.  Now if you do use a Band-Aid or a bandage you still want to inspect and clean the wound once or twice a day.  

0:17:58.2

And another consideration, for some kids a bandage is actually going to draw their attention to the wound, they pick the bandage off and then they pick at the wound, where if you just let it be your child also might just let it be.  Other kids they freak out when they see the wound, they want to keep it covered and as long as it's covered they leave it well enough alone.  So you do have to know your child and the situation, and what is the wound like, where is it located to make a decision.  And really this is where the art of medicine comes into play they sell them a cookie cutter formula that applies across the board.  The most important things, bandage or not, to keep the wound clean and dry, wash your hands before messing with the wound, gently wash, don't scrub once or twice a day with mild soap and water, pat it dry, apply a thin layer of antibiotic ointment and do that until the wound is well healed.  You also want to watch out for signs of infection including redness or swelling to adjacent skin, increasing tenderness, recurrent bleeding more than just spotting for couple of days, yellow, green, or white cottage cheese looking drainage, fever, and vomiting, if any of those things occur you want to seek medical attention right away because those are signs of infection.  

0:19:13.8

For those of you who would like a written summary of this instruction for later reference, I do have a couple of links for you.  O course you can check out the transcripts for this episode over at pediacast.org show notes episode 276.  I also have a couple of links for you, small cuts and scrapes from the Nationwide Children's health library and a skin injury link from the American Academy of Pediatrics Healthy Children website and I'll put those links again on the show notes for episode 276 over at pediacast.org.  Hope that helps Paul and as always thank you for the question.  Up next is Amy in La Mirada, California.  Amy says, "Dear Dr. Mike my eight and a half year old daughter gnaws on her finger tips, she hasn't quite drawn blood yet but has on more than one occasion peeled off enough layers of skin to turn a patch pink or even reddish….

0:20:01.4

"I know of course you cannot diagnose a specific individual but wondered if you can tell me generally if this is unusual behavior.  At first I thought it was linked to anxiety but it seems to have degraded into a habit.  Almost anytime her hands aren't occupied she's gnawing at or peeling a fingertip.  Do you have any general recommendations for handling this type of behavior?  Is it ever indicative of a bigger issue like ADD?  We've tried reminding her to stop when we see her doing it which works briefly but mostly just makes her annoyed and or embarrassed.  For a while she was wearing gloves to bed but then she told me it's not much of a problem when she's going to sleep so we stopped.  

Also gloves and impede the use of her hands and can lead to mockery so aren't a practical solution for school and generally during the day.  Any suggestions you have will be appreciated.  P.S have you done a show about anxiety yet, I'm pretty sure I've listened to all the episodes but I don't remember the details of all the Early Birdhouse Studio days.  Thank you again, Amy."  

Well thank you for the question Amy.  I would not say this is unusual behavior, we see it a fair amount in kids and adults, sometimes it only involves nail biting but sometimes the skin around the nails gets gnawed.

0:21:10.8

So there are a couple of considerations to think about in this situation.  As you develop a plan to deal with this just some things you want to think through first.  The first thing I would think about is, is this behavior affecting your child's health?  And especially are they getting skin infections, paronychia which is an infection of the skin around the finger nail which often has puss in it.  Is there repeated trauma and scarring?  And if it's causing health problems then there is more urgency in dealing with it, if it's not causing any health problems there's less urgency and sometimes if you just leave well enough alone habits go away so you really got to look, is this affecting my child's health?  Second, you really got to look at the mental health aspects of this.  As you mentioned could this be a sign of anxiety?  

0:22:04.3

It could, and obsessive compulsive tendencies also come to mind, depression sometimes you see kids do this and this sort of behavior can lead to other self-injury events especially if it's the discomfort that they're seeking and really their goal is not just gnawing their goal is actually to cause that redness that you're seeing then that kind of thing can lead to other self-injury events like cutting.  

Not so much isolated ADD or ADHD but that can be accompanied by anxiety, and depression, and self-injury and so ADHD is something to think about as well.  Now on the other hand, the gnawing may just be a habit without any accompanying mental health condition.  As is typical of most things we talk about on PediaCast there's much to consider, I definitely would look at the stressors in your child's life, home and school and to see are there other signs of anxiety or depression and the best bet here if you're concerned is make an appointment with your child's doctor and sort through this things.

0:23:08.7

Make sure that it's just a habit and there's not anything else going on.  Now Amy did ask if we've covered anxiety in the past and we have but it's been preferably and I really do think that childhood anxiety and depression would make an excellent topic for one of our interview shows this year so let me work on finding the right specialist to stop by the studio and talk about these things.  Now in the meantime aside from underlying mental health issues which may or may not be present how can we eliminate this behavior?  And to do that that's where I'm really going to focus the rest of this discussion on is how do you get rid of a behavior and not necessarily just gnawing on the fingers but really any problem behavior you can apply this to and I would turn this into a project and really elicit your child's help and it works best if your child also wants to stop the behavior so they have some motivation in it. 

0:24:04.6

But even if they don't see the need to stop their behavior, if you know their currency and you dangle a nice reward out in front of them that will often do the trick.  Now in setting up a program you want to be creative, you want to start by setting small realistic attainable goals and if does are met you advanced toward the bigger goal.  How might that look for this problem that we're talking about?  What exactly, what kind of method or program could you come up with?  And again there's no right or wrong here it's really just all about getting creative and the method is going to differ from one child to another.  Again you got to know your child's currency when you're dealing with this sort of thing.  So here's how it would look in my house, first we set an in goal and some intermediate goals and we're going to make each one of this intermediate goals something that is attainable in a step wise fashion.  

So as an example for my son, the final goal when gnawing on the fingers are no longer a problem I'm going to buy him a new video game, it's the one he's really been looking forward to getting.  

0:25:10.3

Of course it's age appropriate, it's the right maturity level and I'm going to play it with him but that's fine we both benefit.  I mean it's a video game but we've talked about this sort of things appropriateness, and screen time, and spending time with your kids and all that.  So that's important too but it's his currency, video games are his currency like it or not.  Now notice I'm not buying his most anticipated release which is Kingdom Hearts Three by the way which probably isn't going to come out until 2015 anyway, but I'm not buying this in order to get him to stop, I'm not buying it as a bribe.  I'm buying it when he has successfully stop, so it's a reward nit a bribe and there's a difference and I'm going to help him achieve this.  First we're going to establish a reasonable first step goal and that's this: if I see you gnawing on your fingers and I mention it you stop and get your mind on something else.

0:26:08.1

It's OK you were doing it but when I bring it to your attention you stop.  At the end of each day if that plan worked well, if you saw him gnawing, you mentioned it, they stopped you had a pretty good day with that no matter how many times you have to remind them at the end of the day they get a point, or a sticker, or a star, or whatever your age appropriate game is that you're going to design here.  If it doesn't go well that day no yelling, no passive aggressive behavior on my part I won't play the disappointed parent but you don't get your point or your start or your sticker or whatever.  Once you get a pre-determine level of points, or stickers, or stars and you want to end the beginning makes this like, OK you only need two stickers you make this really easy to achieve in the beginning then they're going to many reward, maybe a stop for ice cream, or favorite meal, or some extra video game time with dad, again you got to know your child's motivating currency.

0:27:06.0

Once they've have success now we're going to step it up, now you'll only get three reminders a day in order to earn your star and we're going to put a little check mark each time I have to remind you and if I have to remind you not to gnaw on your fingers four times then no star.  Once they've been achieving success and earning stars with three reminders a day now we're going to move it to twice a day and then we're going to move it to once a day and this might be over the course of a few weeks that you do this.  And finally if I don't see you do it at all you get the star, or the sticker, or the points and then when you reach that level then you're going to get the big reward.  We slowly increase what's required over the course of a few weeks, we make each step attainable along the way but it becomes a little more difficult each time, we don't compromise once the goals are set but we also don't get angry which is don't reward.

0:28:02.0

If your child isn't interested in working for the reward then you're going to re-think their currency, the reward's not motivating for them you've got to find one that is.  What about school?  For most kids as this behavior extinguishes at home they will also slowly extinguish at school.  Now I suppose you can inspect fingers when your child gets home, new no marks mean no sticker but honestly you probably won't even have to resort to that.  Usually what's happening at home will be mirrored at school, you want to make it fun, you want to make each step attainable but don't compromise and slowly increase what's expected and gradually make the rewards better.  That's how I would go about eliminating this behavior, really any behavior and again your child's plan's going to be different, you want to be creative, know their currency and another important point this approach really is only going to affect the behavior if their underlying social or mental health issues, family problems, school concern, bullying, anxiety, depression if any of these exist you have to identify them and get help from your doctor or counsellor.  

0:29:11.2

I hope that helps Amy and stay tune for more on anxiety and depression in a future episode of PediaCast.  I do have a couple of additional resources for you, there is a nice article in the Nationwide Children's Health Library called When a Reward for Kids Becomes a Bribe and it looks at the nuances of a positive reinforcement and defines appropriate rewards.  A trip to Disney World is not an appropriate reward cause that's just terrible when they fail.  There are things that are appropriate and not appropriate and this article talks about that.  And then there's a nice article from the American Academy of Pediatrics and their healthychildren.org website called positive reinforcement through rewards and I'll put a link to both of those in the show notes for this episode 276 over at pediacast.org.  

0:30:01.6

Let's move on, next up is our discussion on influenza, RSV bronchiolitis, and the croup and I want to thank Pippa from Suri, United Kingdom she writes, "Hi Dr. Mike well it's a mild but snotty winter here at the United Kingdom and I have seen unprecedented levels of croup bronchiolitis and even a case of pneumonia and a collapsed lung amongst the children in our area.  We didn't escape unharmed in our family with my 10 month old daughter being given a course of amoxicillin and dexamethasone for nasty bronchiolitis.  Treatment which I'm not sure that there's a great evidence based form.  Could you please give me some information on the more serious respiratory illnesses in children or should we watch out for, are there any remedies we can try at home?  And when do we call for the ambulance?  Many thanks as always, Pippa."  Thank you for the question Pippa.  

0:30:53.8

There are many types of respiratory infections in children which have the potential to become serious, for the sake of time I decided to pull three of the most common ones to talk about in more detail and it is mentioned in the show title we're going to talk about influenza, RSV bronchiolitis, and croup.  Let's start with influenza, now this is going to be an overview of the flu, if you like lots more details, be sure to check out PediaCast episode 184 over at pediacast.org and I'll put a link in the show notes for this episode 276.  PediaCast 184 was an interview with Dr. Dennis Cunningham, he's an infectious disease expert here at Nationwide Children's and in that particular episode we talked through the flu and the flu vaccine so there are lots of details.  In the meantime let's embark on an overview so this is going to be much quicker than episode 184.  So what causes the flu?  Well it is a virus, it's the influenza virus and this is a virus that infects the respiratory tract, the nose, the throat, and the lungs.  

0:32:02.4

There're two major types of influenza virus, influenza A and influenza B.  Influenza A is divided into sub-types based on two surface proteins and then there's many strains of influenza A based on other proteins that are on the outside of the organism.  Influenza B does not have sub types but it still has many strains and this proteins on the surface, this become the basis of our immunization so we basically with the flu vaccine we inject folks with either a killed flu virus or a live flu virus depending on whether it's the nasal spray type or the injection type and your bodies make anti bodies against those proteins but this proteins are actually frequently mutating and so we have lots of strains and we have to make some prediction of which strains of flu are going to be in a given area each year and then the flu shots for that year are going to cover against those strains.  And most years we get a good match some years we don't but that's the reason that you have to have a flu shot every year.

0:33:14.5

The other reason is that the immunity is short lived and so it doesn't last much more than a year and that's another reason that you have to get a flu shot every year.  Now the flu as you can imagine affects millions of people around the world each year.  Here in the United States influenza associated deaths between 1976 and 2007 range from just over 3,000 deaths a year to almost 50,000 deaths a year so that's 1.4 to 16.7 deaths per 100,000 people per year in the United States.  We do still see a significant number of deaths caused by influenza despite the availability of a flu vaccine.  

0:33:58.7

Now those who are at most at risk for death by influenza are going to be infants and young children and the highest risk is for pre-mature babies, also the elderly pregnant women, those with weakened immune systems, those who may have HIV or other Immunodeficiency disorders, chemo therapy drugs can lead to weakened immune systems, so people with chemo treatment may have a harder time fighting off the flu.  Those with underlying respiratory illnesses like asthma, cystic fibrosis, babies with bronco pulmonary dysplasia and folks with other underlying chronic diseases like diabetes and heart disease these folks are all at a high risk for having more severe symptoms with the flu and more likely to have complications of the flu which we're going to get to in just a couple of minutes.  Now how exactly is it that flu virus makes you sick?  Well it invades the cells of the respiratory tract and it turns those cells into influenza virus making factories.

0:35:02.7

So instead of the cell doing its normal job the cell is now just going to become a factory for making more influenza virus and this destroys the cell in the process.  Normal cell function is lost and a lot of this cells in the lining of the respiratory tract is one of the major functions as protection against bacteria and so if you destroy this cells they makes it more likely that just normal bacteria that live in the oral cavity and the nose that they can invade the respiratory tract and that's why we get wheezy complications like bacterial pneumonia, ear infection, sinus infections, as a complication of a flu infection.  How do we get rid of it the body's immune system has to kill the virus and then the body has to make new respiratory tract cells to replace the ones that were destroyed by the virus.  Then what kind of symptoms do we see with this?

0:35:58.8

Well we see fever, chills and sweats, we see arthralgia or muscle aches, joint pain, head ache, nasal congestion, cough, sore throat this are all common symptoms of the flu.   And what Pippa wanted to know when do you call your doctor?  When do you call for an ambulance or call 911?  You call your doctor whenever you have any concerns.  In particular if your child has a fever for more than a couple of days, or they're having any kind of respiratory difficulties, labored breathing, fast breathing, wheezing, you definitely wanted want your doctor know about that if they're vomiting and you're worried about dehydration, if they have a strange looking rash these are all reasons and really any other concern that you have you call your doctor.  If your child's really having trouble breathing they're in respiratory distress then you're going to want to call 911 or call for an ambulance.  It's not just the flu that can cause these types of symptoms, other viral upper respiratory tract infections we'd see similar symptom and so other respiratory viruses like rhinovirus, corona virus, adenovirus, respiratory syncytial virus or RSV and parainfluenza virus which is one of the big causes of croup.

0:37:12.1

These are all things in the differential diagnosis and of course strep throat.  You can have a cold and strep throat at the same time so that's something else to consider as well.  How do we diagnose the flu?  Well we have a rapid flu test, the rapid flu test when it comes back positive we feel pretty good that you have the flu, if the rapid flu test comes back negative however there's a pretty high number of falls negatives that you get with the rapid flu test and so we can't eliminate the possibility of someone having the flu based on a negative flu test.  Positive flu test lets us know they have the flu, negative flu test they still could.  There is another more accurate test called the influenza PCR which stands for Polymerase Chain Reaction and this looks for genetic material.

0:38:06.9

It's pretty highly sensitive and highly specific for the flu, the problem is it takes longer to get a result, a special lab is required and the test is much more expensive.  It's not one that we typically do on everyone but if we do want to know, if a particular flu viruses in a community that can help with epidemiological purposes and then the old fashion viral culture is also way to make a diagnosis however this really takes a long time to grow.  In lot of times the person symptoms the illness is gone by the time that you find out the result of that.  Viral cultures are sensitive and specific but they take a long time which makes them not too useful.  How do we treat the flu?  The main stay for most kids is treat the symptoms, you want to use pain and fear reducers like Tylenol, or ibuprofen, rest fluids, salt water, nose drops, sucking up the nose blowing, the nose, humidifier in the bedroom that sort of thing.

0:39:09.5

There are anti-viral medications that can treat the flu, this work best if they're given pretty soon after the onset of symptoms, the longer you get into the illness the less likely they're going to help but they still may be useful depending on the conversation you and your doctor have.  Examples include tama flu and Relenza.  Complications of the flu as I mentioned pneumonia, sinus infections, ear infections by invasion of bacteria because of the damage lining of the respiratory tract and then acute exacerbation of reactive airway disease, translation asthma.  You can have asthma get worst when you have the infection with the flu.  In terms of prevention the flu vaccine yearly starting at age 6 months the reason for it that being yearly again mutations bring different strains around each year and immunity against this are short lived.

0:40:05.2

Proper cough, sneezing, runny nose, hygiene, blowing to tissues, wash your hand, use hand sanitizers and avoid large crowds where folks may have the flu and then you become expose to it and that's particularly important if you're in one of those high risk categories for the flu.  That's the flu overview and again if you want to know much more about the flu check out PediaCast 184 it's an entire episode that concentrate just on influenza and flu vaccine with Dr. Dennis Cunningham an infectious disease specialist here at Nationwide Children's he and I have a nice thorough conversation.  Let's move on to another respiratory infection caused by virus and this is RSV or respiratory syncytial virus bronchiolitis and I was looking into the PediaCast archives and I realize we've mentioned RSV before but we haven't really done the nuts and bolts approach ever on PediaCast which is pretty crazy when you think how common this is, so let's do that now.  

0:41:13.8

RSV bronchiolitis is caused by a virus in this case the particular virus is respiratory syncytial virus which is a mouth full and that's why we say RSV instead of respiratory syncytial virus it's very common in fact nearly all children have been infected with RSV by the time that they're two years of age.  There are fewer strains of RSV compared to influenza so there aren't as many types of RSV virus out there as there are flu viruses.  Infections are milder and shorter lived if you are infected with the same strain of RSV down the road and in adults and older kids symptoms may be limited to those of a mild cold, just get a runny nose, and then occasional cough, and then a few days you feel better.  

0:42:00.5

If you're dealing with RSV for the first time, so your immune system you do not have natural immunity against it so in particular we're talking about infants and young children and it's particularly dangerous for pre-mature babies, infants with underlying health conditions like asthma, or reactive airway disease, heart disease, metabolic problems.  Older kids and adults with asthma and heart disease or older adults the elderly those with compromised immune systems including folks on chemo therapy so again kind of like with the flu discussion those same types of people are high risk for having a more serious illness with RSV and it's most particularly dangerous for premature babies.  Now what happens with RSV again the virus infect cells of the respiratory tract but in particular with RSV we see lots of mucus production and we see the small air ways down deep in the lungs, the bronchioles, we see lots of inflammation and mucus production down in that area.

0:43:09.7

And so because we see so much of this in the bronchioles that's why we call it bronchiolitis.  So RSV bronchiolitis because down deep in the lungs are really small airways we see inflammation and mucus production.  So what  sort of symptoms do we see with RSV well we see fever, lots of nasal mucus, so really a ton of nasal congestion is very common with this, cough, sore throat, head ache.  In addition we see some lower respiratory stuff going on especially in little babies because the diameter of their bronchiole is pretty small so it doesn't take much inflammation and mucus to start to obstruct those and then we see once they become obstructed down deep in their lungs we see wheezing, rapid breathing, apnea, they can have pauses in their breathing and the reason they're breathing rapidly is because they're getting less oxygen delivery with each breath. 

0:44:06.3

And so to make up for that they take more breaths and so we see this rapid breathing but then the respiratory muscles can get tired and then we start to see apnea or pauses in their breathing and then after that we can actually see respiratory failure with a stop breathing.  We also see decrease blood oxygen because of all the inflammation in the mucus and so that can become an issue and the other thing with RSV particularly if it's the first time the child's had it the symptoms last quite a while they can last two weeks so this is a prolonged viral infection.  In the differential diagnosis so what other things can cause wheezing, and nasal congestion, and fever, other viruses so it's not just RSV that can cause bronchiolitis other viruses can do it as well when you hear kids wheezing it could be reactive air way disease or asthma.

0:44:57.5

And then in really young infants sometimes congenital heart disease will show up with the kid in respiratory distress and with wheezing because they have heart failure and fluid backs up in their lungs and causes this symptoms so in really young infants who present with wheezing we always our little concern that it could be their presentation of congenital heart disease so it's something that doctors can keep in the back of our heads when we're seeing babies who have this sort of thing.  In terms of diagnosis there is a rapid RSV test but likely influenza test if it comes back positive you feel pretty good that it's RSV that's causing the illness, but if it comes back negative there's a significant numbers of false negative since we can't rule out RSV based on the negative test we can only rule it in based on the positive test.  

0:45:52.5

Treatment, one big thing with treatment for RSV bronchiolitis is a nasal suctioning.  These babies are not only having trouble breathing because of inflammation and mucus in the lungs but then you add insult to injury and you got all this mucus in the nose which makes things even worse so you definitely want to keep that nose clear salt water nose drops and suck it back out, just get that mucus loosen up and keeps suctioning to keep their nose clear and that really goes a long way to help on these kids.  Of course if they have fever or they're fuzzy like they have aches and pains you want to give them Tylenol or ibuprofen as a pain reducer and fever reducer.   Of course remember if they're under the age of six months we don't use ibuprofen just Tylenol only and any kid less than two months of age they has a fever you want to talk to your doctor about that right away to make sure that they don't have a more serious infections.  Another treatment approach with RSV bronchiolitis is albuterol just like you would in someone who has asthma.  Albuterol is a smooth muscle relaxer and so if we relax the smooth muscle that's lining the air ways we can increase the diameter of the air ways which allows for more air flow.  

0:47:07.2

Now this doesn't work as reliably with RSV bronchiolitis as it does compared to a straight up reactive airway disease and the reason for this is because compared to asthma, with bronchiolitis there's way more obstruction of those bronchioles, there's just intense inflammation, there's mucus down there and it's really obstructing things and so when you have little baby whose bronchioles aren't very big anyway and you use albuterol to relax the smooth muscle and make the diameter a little bit bigger there's still just too much obstruction and so it just doesn't make as much of a difference compared to kids who have reactive airway disease.  Now we still try it and if it works and if it helps we use it, but if it doesn't seem to help much then we typically don't continue giving it to them because albuterol does have some side effects including rapid heart rate, anxiety, decrease sleeping we don't want to give side effects for something that's not working, so we try it if it works we keep doing it if it doesn't then we don't.

0:48:10.1

Now Pippa had mentioned a couple of things that her child had for their bronchiolitis, one was antibiotic amoxicillin she said.  Keep in mind RSV bronchiolitis is caused  by a virus and antibiotics aren't effective in treating viruses now sometimes you can get a secondary bacterial infection along with the bronchiolitis so you might have a kid that has an ear infection or pneumonia in addition to the RSV bronchiolitis and you might use an antibiotic to treat those conditions but if you just have straight up RSV bronchiolitis then antibiotic is not indicated.  And then she also mentioned steroid medicine, we do use steroids for reactive airway disease  and asthma to decrease inflammation and improve airflow but there's evidence based studies have not shown that steroids help kids with RSV bronchiolitis to get better any faster.

0:49:09.0

And so we do know that steroids decrease your immune system's ability to fight off virus infections and since RSV is caused by a virus we want the immune system to really be able to fight this off and we don't want to give something that is not evidence based research has not shown that it helps and in fact could potentially prolong the illness by interfering with the immune system and so we generally do not use steroids with RSV bronchitis.  In exception to that would be if there's a strong family history of asthma or if that child has had wheezing in the past and we think that there's a component of reactive airway disease to this then we might consider using a steroid and again this is where you can't approach medicine in a cookie cutter fashion you got to take each individual situation and then think about it.

0:49:57.8

Unlike influenza we don't have an anti-viral medicine that kills RSV.  So there's no anti-viral medicine like tama flu kills flu we don't have anything like that that kills RSV.  In terms of home treatment it's really going to be supportive, saline nose drops suck out that nose plus or minus on the albuterol and really close observation and you want to call your doctor as always if you have any concern definitely if your child has fever from more than a couple of days wheezing rapid breathing trouble feeding vomiting rashes all these things it really any concern that you have you want to call in touch base with your doctor and then you want to call 911 or call for an ambulance if your child has severe respiratory distress they're really working hard to breath and you're worried about them you want to get help right away.  Now some kids with RSV do need to spend the night in the hospital and the kids who have need for extra oxygen because their oxygen level's too low from their bronchiolitis, those with a very rapid breathing again we're worried about fatigue and respiratory failure, those kids who are feeding poorly had them worried getting dehydrated these would all be reasons for putting them in the hospital.

0:51:16.7

Then complications of RSV include decreased oxygenation and because swollen inflammation and mucus also again rapid breathing leading to fatigue, leading to apnea, leading to respiratory failure, and then pneumonia sometimes it's a complications of RSV as well.  Now RSV has a bad reputation because a lot of babies in fact probably most babies with severe respiratory illness during the winter time who require hospitalization a large percentage of these end up having RSV that's the cause of it but what you have to keep in mind is that's just the tip of the iceberg most babies and kids with RSV don't end up in the hospital there are some with very serious infection, there are some who die from it but most the overwhelming majority do well and in many cases the symptoms are just similar to a lingering cold.

0:52:10.9

In fact if you think as I mentioned before by the age of two almost all kids have had RSV but you may be a parent thinking a lot, "I don't remember my kid having RSV….  That's because they probably had it but it was just a bad cold and so we do see a big wide spectrum of severity with RSV and it's really the minority that do poorly with it but when they do poorly with it they can do very poorly with it and so we still treat it or we want to identify it and treat and watch for complications and things.  What about prevention?  There is a medicine called synagis, this is a monthly injection for five months during the winter time and these injections provide antibodies against RSV.  So this is not an immunization in the sense that you are stimulating the immune system to make antibodies we're just passively giving antibodies that protect against RSV.  

0:53:03.2

It's very expensive and so it's really reserved for those at the highest risk of complications the highest risk of having to be in the hospital in particular pre-mature babies and infants with congenital lung or heart disease that gets that synagis injection.  Alright so that is nuts and bolts approach to RSV let's talk next about croup.  The last time I covered croup  in a comprehensive fashion it was actually PediaCast episode 009, definitely time for an update on the croup but if you want to hear a blast from the past you can check out PediaCast episode 009 and I'll put a link to it in the show notes for this one 276.  Word of warning it might be a bit rough around the edges but it may be fun lesson so that's episode 009 and I'll put a link again on the show notes for this episode 276.

0:54:06.8

So what causes the croup?  Croup like influenza and RSV is caused by a virus.  Croup really more like a syndrome it's a collection of symptoms and so there are several viruses that can cause croup the most common is the parainfluenza virus which is not the same as the influenza or flu virus.  Even though it's got the word influenza in it this is not the flu, this is parainfluenza virus which is something different.  Croup is common we see it primarily in infants and young children and then those kids you got a barky cough, and you can also get something called strider but older kids and adults so those with bigger diameter to their airways their and if they've had croup in the past and so they have some immunity against the virus.

0:55:02.9

Older kids and adults may just have little runny nose and congestion and normal cough so it's basically like a cold virus.  Sometimes it gets a little a hoarse voice with the croup and you'll understand why that is once we get to exactly what's going on with the croup.  It is most common in children six months of age to three years of age, so about the time that moms immunity is wearing out and kids now are going to get every virus that comes along up to about three years of age and then the diameter of the airway is bigger and they've had croup a few times and so then you start to see less severe symptoms usually about age three.  But they can still get a bad croup after that, more likely in infant s and young children as compared to older kids and adults.  What happens with the croup?  Like the flu and like RSV the parainfluenza virus infects cells of the respiratory tract and in particular this virus tends to infect cells in the airway.  So in the vicinity of the vocal cords, the larynx, the voice box, the trachea, and the bronchi which is the large tube branching from the trachea. 

0:56:14.3

We're not talking down deep with the smaller bronchiole like we see with RSV but this is really more around the neck and the vocal cord so we see more upper airway inflammation compared to the lower airway inflammation that we see with the respiratory syncytial virus or RSV.  Swelling around the vocal cords, then you can see why that leads to a hoarse voice or a distinctive barky cough not so much like a dog barking but think a higher pitch seal barking.  So it's a very distinctive cough and once you've heard it then you know exactly what I'm talking about.  Now when this inflammation around the vocal cords becomes more intense then you start to get a noise with breathing and this is a high pitch noise that we call strider.

0:57:03.5

So kids when they breath in air is rushing across the inflamed area around the vocal chords and you get this high pitch noise with every breath and sometimes you hear it more when kids are taking a more forceful breath in or their breathing faster and that happens when they cry and get upset.  So a lot of times these kids as a medical practitioner when we approach the child they get upset the strangers there and so they start crying and they get their strider because they forcing air across that inflamed area  but once you get them calm down and settle down then the strider goes away.  So those are common symptoms with croup.  We also see a nasal congestion, again a cough that turns barky, the strider, fever is very common with croup in fact that can be a high fever and sometimes you'll get a sour throat along with it as well.  

0:57:58.1

Symptoms of croup usually only last three to five days, so it's a shorter lived infection compared to influenza and RSV.  Of course as always if you have any concerns with it you call your doctor, definitely a fevers lasting more than a couple of days, if they do have a severe barky cough, if they have that strider whether it's just when they're crying or whether it's at rest you should call your doctor and touch base with them.  And then you want to call 911 or for an ambulance for any child who has difficulty breathing really working hard to breath, any lethargy, just really decreased activity along with difficulty breathing or drooling, trouble swallowing you want to call 911 or for an ambulance in those situations.  What about the differential diagnosis of croup?  Well one is going to be foreign body, so if you think about it if you have a kid who has upper airway obstruction around the level of their vocal cords you can imagine and kids put stuff in their mouth if they aspirated on something meaning that whatever they put in their mouth is gone down the airway and now is obstructing around the vocal chords you could see why they would have a barky cough and possibly strider.

0:59:08.3

Now usually with a foreign body you're not going to have a fever and really not have much nasal congestion, however you could have a kid with cold who does put something in their mouth and they do have a foreign body so it's still something in the back of our minds when we see kids with these symptoms we want to make sure that that's not a possibility and so another reason to seek medical attention.  Another thing in the differential is something called epiglottitis.  The Epiglottis is a flap in the back of the throat that covers the entrance to the trachea when you swallow, so this prevents choking.  Epiglottitis is an infection of that flap usually caused by bacteria and requiring antibiotics.  Now this is a very dangerous condition because the swelling can become severe quickly and completely obstruct the airway which can lead to death.

0:59:57.5

The symptoms of early epiglottitis are similar to croup but they progress quickly and these children are often seen sitting upright and keeping still just to maintain their airway.  They often drooling and working hard to breath and they usually need a breathing tube put in and be ventilated until the swelling goes away and this tube is best inserted by a pediatric ear, nose and throat specialist in the operating room.  So this is serious business you want to get the airway controlled by someone who knows what they're doing.  Fortunately we don't see epiglottitis much this days because the bacteria that cause the vast majority of cases is rare today thanks to the hib vaccine which protects against haemophilus influenza type B which is a particular bacteria.  Incidentally that same bacteria once cause many cases of meningitis in kids which led to many deaths and it is too is now rare thank you to the hib vaccine but as a more and more parents put off vaccinating their children we still have to think about these things like epiglottitis.

1:01:02.4

In the back of our heads this medical practitioners and be on the lookout for them because parents think they're doing their kids a favor by putting off vaccines but trust me in many cases they're doing exactly the opposite because they're putting them at risk for this type of stuff.  How do we diagnose croup?  There's not a rapid test like there is with the influenza and RSV so in order to diagnose croup there's a clinical diagnosis we take all the facts, we examine the child that's how we make the diagnosis we might need to get x-rays if foreign body or epiglottitis is suspected.  In terms of treatment like our other viral respiratory illnesses it's mostly supportive care, rest, fluids, Tylenol or ibuprofen for fevers and head aches and pains more sever cases so when we are seeing a severe barky cough or they're starting to have little bit of strider we do use a steroid.  There is evidence to support the use of it unlike with RSV with croup there is pretty good evidence based of helping and so we do use decadron or dexamethasone as Pippa had mentioned.

1:02:10.3

This is usually given orally as a single dose and reduces airway inflammation for about two to three days.  It does not reduce nasal congestion, it may not completely eliminate the barking cough but it usually does help the croup not progress to a more severe where there's a lot of strider all the time and so it reduces the airway inflammation but it doesn't eliminate it completely and it last for about two to three days.  By then the immune system is kicked in and the symptoms are improved in anyway and occasional child will need another dose so they get the decadron to last two to three days starts to wear off and then you have another dose of it because their croup is lasting a little bit longer.  Unlike with RSV again we do have evidence that steroids help prevent airway obstruction in croup.

1:02:59.9

Now the most severe cases so kids who really have a lot of airway obstruction and persistent strider with every breath, for those kids we do give them a breathing treatment with racemic epinephrine and that greatly reduces airway inflammation and usually takes away their strider completely.  The problem is the effect is short lived and in many cases if they require one they're going to end up requiring another and we do have concern for something called rebound inflammation which means they have the inflammation, they got the racemic epinephrine aerosol, the inflammation get better but the epinephrine wears off, the inflammation returns and it's worse than it was to begin with.  And so we don't do this at home if kids need more than one racemic epinephrine we generally admit them to the hospital to watch them cause if again they need more than one, they're probably going to need several.  Also I want to put a word in about humidification of air when dealing with croups like a humidifier in the bedroom, or turn in the bathroom, the shower on hot real and getting the bathroom steamy, opening up the freezer and the moist air roles out of the freezer and letting your kids breath that, or taking your child outside then walking where the air is a little bit more humid outside compared to inside the house cause the force heater tends to dry the air out.

1:04:18.2

So does humid air help with croup?  We don't push this as much anymore because research on effectiveness is a bit lacking.  It may not hurt to try however you don't want to waste your time with it, if your child has persistent strider or difficulty breathing it's best to seek medical care as soon as possible.  And then the biggest complication the thing that we want to prevent with the croup is more significant upper airway obstruction that requires a breathing tube to be put in to maintain the airway so that's the reason we do get aggressive when we start to hear strider because we don't want that to progress.  In terms of prevention the biggest thing is avoid contact with those who have a barky cough, or hoarse voice and then lots of hand washing is the best way to prevent.

1:05:04.8

So there you have it a primer if you will on influenza, RSV bronchiolitis, and the croup.  There are other respiratory infections that affect kids others that are potentially dangerous but these three are right up there with the ones that you are most likely to encounter in your home.  I hope that helps Pippa and as always thanks for writing in.  Of course we start out 2014 with a listener show and I just blow over the time limits and we're already well pass an hour.  I'm going to try to do better this year with a little bit shorter shows for you but I was so eager to answer your questions this week that we went over.  Don't forget if you have a topic that you want us to talk about just head over to pediacast.org and click on the contact link, shoot me an email and send me a message that way through the contact link at pediacast.org and we'll try to get your questions on the program.  Alright let's take a quick break and I will be back with final word on the best doctors in America, that's coming up right after this.

1:06:09.4

[Music]

Dr. Mike Patrick Alright we are back more than 200 physicians on the medical staff at Nationwide Children's Hospital recently appeared on the best doctors in America list for 2014.  Only 5% of doctors in America earn this prestigious honor decided by impartial peer review.  

1:06:57.6

Best doctors has earned a worldwide reputation for reliable impartial results by remaining totally independent, doctors cannot pay to be included in the best doctors data base nor are they paid to provide their input.  The list is a product of validated peer reviews in which doctors who excel in their specialties are selected by their peers in the profession.  In bringing together the best medical minds in the world, best doctors' works with expert physicians from its Best Doctors in America list to help its 30 million members worldwide get the right diagnosis and the right treatment.  The list is sampled each year by best doctors incorporated and audited and certified by Gallop.  Results from exhaustive polling of more than 45,000 physicians in the United States.  Doctors in more than 40 specialties and 400 sub-specialties of medicine appear on this year's list.  How are the best doctors selected?  In the confidential review current physicians on the list simply answer this question, if you are allowed when needed a doctor in your specialty to whom would you refer?  

1:08:01.7

Best doctors evaluates the review results and verifies all additional information to meet detailed and inclusion criteria, the experts who are a part of the Best Doctors in America data base provide the most advance medical expertise and knowledge the patients with serious conditions often saving lives in the process by finding the right diagnosis and the right treatment.  Nationwide Children's group of experts listed in the data base includes world class physicians and various pediatric health care specialties.  So the question becomes is your doctor on the 2014 Best Doctors in America list?  Well if he or she practices at Nationwide Children's it's really easy to find out just head over to nationwidechildrens.org\best-doctors and I'll put a link to that page in the show notes for this episode 276 over at pediacast.org.  If your doctor's not affiliated with Nationwide Children's you can still inquire about their inclusion on the list by visiting the Best Doctors website at bestdoctors.com and I'll include that link in the show notes as well.

1:09:02.6

In addition to the United States, Best Doctors also maintains list for Australia, Canada, Ireland, and Japan, so be sure to check out the best doctors and that's my final word.  I want to thank all of you for taking time out of your day to listen, don't forget PediaCast and our single topic short format programs PediaBytes are available on iHeart Radio Talk which you'll find on the web and the iHeart radio app for mobile devices.  Reviews and comments on iHeart radio and on iTunes are particularly helpful as our links, mentions, shares, re-tweet, re-pens PediaCast is on all the social media sites, we're on Facebook, Twitter, Google Plus and Pinterest plus be sure to tell your family, friends, neighbors and co-workers about the program and of course be sure to let your child's doctor know about the show so they can share it with their other families and patients.  And we do have posters available under the resources tab at pediacast.org.

1:09:57.6

Again best way to get in touch head over to pediacast.org, click on the contact link and in the show notes we also have links that says contact Dr. Mike to get in touch with me and then we have another link that says connect with a pediatric specialist from Nationwide Children's, that's for referrals and appointments.  So we'll see you next week we're going to do a News Parents Can Use program it'll be a little shorter, and until then this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.

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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