Kawasaki Disease – PediaCast 203

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Dr Preeti Jaggi and Dr John Kovalchin join Dr Mike Patrick in the PediaCast Studio to discuss Kawasaki Disease. We cover the who, what, why and how of this interesting disease, from its probable infectious beginnings and characteristic presentation to potential heart damage and long-term follow-up. Whether your child has experienced Kawasaki Disease first hand or you just want to be in the know and on the look out, join us for the details!

Topic

  • Kawasaki Disease

Guests

Dr Preeti Jaggi
Section of Infectious Diseases
Nationwide Children’s Hospital

Dr John Kovalchin
Director of Echocardiography
The Heart Center
Nationwide Children’s Hospital

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

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

Mike Patrick:: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. We are, of course, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.

It is Episode 203, two-hundred and three, and this one we're doing on Kawasaki disease. It is March 14th, 2012. I would like to welcome everyone to the program. Kawasaki disease, this is not about motorcycles, folks. This is a disease that affects kids, and we want to talk about it for lots of reasons.

01:02

It's an interesting disease, and I think this one's really going to appeal to science lovers out there because it's complicated and it requires a little bit of thinking to understand it. But never fear, we're going to unpack it in a way that doesn't require you to have a health degree. I think this one will also appeal to mystery lovers because we still don't know the exact cause of Kawasaki disease. We have some ideas but still working on specifics.

And really, I think parents should be aware of Kawasaki disease because it's one of the leading causes of acquired heart disease in children. It's also a disease that can be recognized if you know what you're looking for, and since it has the potential to cause serious and sometimes deadly complications, early recognition and intervention are important.

To help me talk about Kawasaki disease, we have a couple of great guests lined up for you in the studio. Dr. Preeti Jaggi is an Infectious Disease specialist here at Nationwide Children's Hospital and Dr. John Kovalchin is a pediatric cardiologist and Director of Echocardiography with the Heart Center here at Nationwide Children's.

02:03

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

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

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

All right, let's turn our attention to our studio guests. Dr. Preeti Jaggi is a physician with the Section of Infectious Diseases here at Nationwide Children's Hospital and an Assistant Professor of Pediatrics at the Ohio State University College of Medicine.

After attending medical school at Ohio State, Dr. Jaggi traveled to Chicago where she completed her pediatric residency and Pediatric Infectious Disease fellowship at Loyola University Medical Center and Children's Memorial Hospital.

03:12

Of course, we're glad to have her back in Columbus and here with us in the PediaCast studio, so welcome to the show, Dr. Jaggi.

Preeti Jaggi: Thank you.

Mike Patrick:: I really appreciate you stopping by.

Also, Dr. John Kovalchin is a pediatric cardiologist and Director of Echocardiography for the Heart Center here at Nationwide Children's Hospital. He's also an Associate Professor of Pediatrics at the Ohio State University College of Medicine.

Like Dr. Jaggi, Dr. Kovalchin is no stranger of Columbus, having completed his pediatric residency here at Nationwide Children's before traveling to Texas Children's Hospital and the University of California Medical Center at Parnassus for Pediatric Cardiology fellowships.

Like Dr. Jaggi, we are happy he's back and here with us in the PediaCast studio, so a warm PediaCast welcome to you as well.

John Kovalchin: Thanks, Mike.

Mike Patrick:: I appreciate you stopping by.

Let's start with Dr. Jaggi. If you could just define for us, if you can do that in a few sentences, just in general, what is Kawasaki disease?

04:08

Preeti Jaggi: Sure. Kawasaki disease is a disease that typically affects children under the age of five, although it can affect older children at times as well. It causes prolonged fever. We usually see fever for at least five days before making the diagnosis.

It can cause some other features that can be similar to other things that children have. Some of those things include rash on the body, red eyes that don't have any discharge from them or goopy stuff coming out of them, we can see sometimes a lot of lip changes where the tongue and the lips can be inflamed and cracked and fissured, and then we also see sometimes hand and feet changes where the hands and feet look puffy, as well as swelling in the neck.

It is a disease that can look like a lot of different other diseases so it requires us to keep reassessing children and thinking about the disease, and then we often do some lab testing to help us make the diagnosis.

05:08

Mike Patrick:: Sure. Now you said swelling in the neck; we're talking about lymph nodes that are swollen there with this, and then of course there are a lot of different diseases that can do that.

Preeti Jaggi: Yes.

Mike Patrick:: Just briefly, inside of the body, what are some of the issues that happen with Kawasaki disease that make this particularly important to diagnose?

Preeti Jaggi: It is a disease that causes inflammation of the vessels of the body. Those vessels are all over the body, and that's why we see symptoms in many areas of the body.

It's a disease that we think is caused by inflammation of the immune system, so to help us evaluate with that, we usually do a blood count that just looks for the hemoglobin and the white blood cell count. We also do a urine test typically to look for white blood cells in the urine.

And we do some tests that look for inflammation in the body. Those tests for inflammation, they don't tell us why there's inflammation in the body, but they are usually elevated in a little bit higher number range in Kawasaki disease so those can help us as well, as well as looking at the liver functions, again, because these vessels are all over the body and they're inflamed, and that's why we see inflammation in many different organ systems of the body.

06:16

Mike Patrick:: Gotcha. Now are there particular groups of children who are more at risk for this? You had mentioned that you see it more in young kids. At what age range typically would you cut off that you're not going to see it as often?

Preeti Jaggi: We can see it in older children. Most of the time we're seeing it in less than 10 years of age. There have been some even adult cases reported, but those are quite, quite rare.

We know that certain races are more apt to get Kawasaki, especially Asians. The disease was actually first described by Dr. Kawasaki, who is a Japanese pediatrician, and he's still alive today and he is the first one who described the illness, and the rate of Kawasaki disease is much higher in Asian individuals than it is in other races, although we do see it in all different ethnicities.

07:03

Mike Patrick:: Sure. Is there a difference between boys and girls, or they get it pretty much equally?

Preeti Jaggi: There's a slight predominance in boys and a little bit higher also in male infants, and it can be a little bit harder to diagnose in infants, but it can definitely affect both sexes.

Mike Patrick:: Now, you talked about inflammation of blood vessels in the body that end up causing lots of different symptoms and problems. What causes that inflammation to begin with? We're talking to an infectious disease specialist; do we think it's an infection that does this?

Preeti Jaggi: At this point, we don't know what for sure is the cause of Kawasaki, but we think that it is an infection, probably a virus or maybe a group of viruses that may be very, very common that all people are exposed to but only some people who might be predisposed to have this intense inflammation response are the people that actually get the disease. That's kind of our leading thought at this point.

I just returned from the Kawasaki meeting in Japan, and a lot of people have looked at even wind patterns to see if there's any correlation epidemiologically with the rate of Kawasaki. Some people have looked at patients who have died in the past from Kawasaki and they've looked at their lung tissues and they've seen the presence of some viral particles, so that's where we think maybe that there's a virus that is inhaled in the body and then you have this intense inflammation response.

08:27

Mike Patrick:: So let's say it is a virus. It's not necessarily the virus causing the illness, it's the body's immune system trying to fight the virus, and a by-product of that is the immune system attacks the body as well?

Preeti Jaggi: Correct. That's called an autoimmune illness, which we have a lot of different autoimmune illnesses that affect people like Crohn's disease and lupus and rheumatoid arthritis and other diseases like that, and this is a little bit unusual in the sense that the inflammation response is not lifelong. It is a self-limited inflammation.

Mike Patrick:: Sure. I do want to, even though you touched on this, just outline the progression of symptoms again so the parents can really pay attention to this, and if this is the kind of thing that they are seeing in their kid, hopefully the doctor would be cued into it.

09:14

But sometimes parents do a lot of research on the internet, listen to programs like this, and if they have a kid who has these symptoms, they shouldn't be afraid to say to their primary care doctor, 'Hey, could this be a possibility?' because that might get the doctor thinking along a different path than they might already be thinking about.

Preeti Jaggi: Absolutely.

Mike Patrick:: You talked about fever. Is there a certain high of fever that it goes, or can it be low-grade fever?

Preeti Jaggi: Typically, we're seeing fever at least 100.5 or greater is when we're thinking about it. Usually, the child doesn't look very well. They usually are irritable. The little bit older children tell us that they're achy and the little kids just cry a lot because they don't have the ability to tell us what's going on. So even when we give Tylenol or Motrin, the child still usually looks pretty irritable, and it's a pretty persistent fever.

10:08

Usually, it takes us a few days to make the diagnosis. We might start thinking about the diagnosis on the second day of fever or the third day of fever, but we usually don't make the diagnosis until closer to the fifth day of fever.

Mike Patrick:: So you have to have the fever at least that long before you would…?

Preeti Jaggi: For the most part. If we have a child, occasionally we'll treat a little bit before Day 5, but for the most part, yes, Day 5. I think a lot of different viruses can cause fever, and they typically will cause fever between three and five days and then stop, so that helps us time-wise start thinking about this illness as well.

Mike Patrick:: Right. And then you had mentioned conjunctivitis or very red-looking eyes, but not necessarily the goop that's coming out. Is there a rash associated with it?

Preeti Jaggi: There's definitely a rash that can happen in Kawasaki. It can be all over the body. It tends to be accentuated in the diaper area, groin area, and it can be a fairly impressive-looking rash, it can be an itchy rash, it could be a lot of different kind of rashes.

11:06

We usually don't see blisters on the body with Kawasaki. That's the only thing it doesn't usually look like.

Mike Patrick:: Sure. The tongue, sometimes the tongue gets real red and a little swollen, and we call that a 'strawberry tongue'.

Preeti Jaggi: Right.

Mike Patrick:: But does it have to be present?

Preeti Jaggi: No. That doesn't have to be present.

The way we diagnose Kawasaki is fever for a prolonged period of time, and then usually four or five other features. So the challenging thing for us can be when the children don't have all the symptoms, they might have two or three of the symptoms, and that can be a little bit more challenging to diagnose. When somebody has four of the clinical features, then it's a little bit easier for us to diagnose.

Mike Patrick:: Now what are some other diseases that could cause similar symptoms to this?

Preeti Jaggi: One of the major things that we look for is Adenovirus. Adenovirus is a virus that can cause typically really red eyes, goop coming from the eyes as well. It can cause you to have lip changes and throat changes like pus on your tonsils and rash on the body. That's a big thing that we look for.

12:09

Strep throat. We can get strep throat with a rash. That's called scarlet fever. That can look like Kawasaki as well. One of the clues that we have for that is if the child hasn't responded to antibiotics, if that was placed, and we can also do a strep test, so that's a little bit helpful. There is also some kind of less common illnesses that can look like that as well in the summertime as well. One of those things is called Rocky Mountain spotted fever that we can see.

There's a lot of different illnesses, but I think that probably the main two are the Adenovirus and the scarlet fever or the strep infection.

Mike Patrick:: Sure.

Now let's switch over to Dr. Kovalchin. We have a pediatric cardiologist here to talk about it as well. So Kawasaki disease can cause some inflammation in blood vessels and some heart issues. What exactly are the heart complications that are seen with Kawasaki disease?

13:02

John Kovalchin: The main heart complication that we worry about is involvement of the coronary arteries, and those are the very small, tiny blood vessels that supply oxygen and blood flow to the heart, and as Dr. Jaggi said, Kawasaki disease is a diffuse vasculitis or inflammation of the small- and medium-sized blood vessels, and that includes the coronary arteries.

Most, if not all, the other sequelae or problems seen with Kawasaki disease spontaneously resolve, except the coronaries. Sometimes if those are involved, those may involve persistent problems and can cause issues down the road for the patient.

Mike Patrick:: Now, do all kids with Kawasaki disease end up having heart issues? Is it pretty much a 100% thing or is it just some of the kids?

John Kovalchin: It's just some of the kids.

Without treatment, about 15% to 25%, as high as that number, will develop coronary artery development. And there's really two types of coronary artery involvement: one is just diffuse enlargement or what we call 'ectasia' and the other is aneurysms or diffuse localized area of swelling in the blood vessel or enlargement with normal areas of blood vessel around it.

14:17

Those are broken up into different categories. The most common type of involvement is the diffuse dilation or the ectasia. That most often spontaneously goes away and regresses and doesn't cause major problems down the road.

The aneurysms, however, are more significant, and those are usually broken up into different categories: small, medium and large, and sometimes the large are considered giant aneurysms.

We know that the patients with giant aneurysms are at the highest risk for problems like clotting off their coronary arteries, calcification, thrombosis, things that can cause damage to the heart muscle, infarction or heart attacks, things like that, things that can require heart intervention down the road or may even cause the patient to have significant problems, even death in the worst extreme. Most small aneurysms typically go away on their own and don't cause any long-term problems.

15:11

So whether they have aneurysms is a big determinant off the bat, and then secondly, how large those are.

Mike Patrick:: Sure.

John Kovalchin: So coronary artery problems are a primary concern.

There are also some other things that can occur with the heart. There can be involvement of the cardiac valves or valvulitis. Sometimes we can see the valves leak a little bit. That again is usually a transient thing. That's not usually something that causes long-term problems. And then the other minor thing that sometimes we see is a small amount of fluid around the heart called ' pericardial effusion'. Again, those don't often lead to problems. Those things usually go away on their own.

Almost all patients will have some what we call 'myocarditis' or inflammation of the heart muscle itself, and that can affect their ventricular function in the short term. Most of the time, it's not significant to the point where they're having problems or needing medicines or things like that, and again that typically resolves or goes away on its own.

16:11

Mike Patrick:: Now, when you talk about aneurysms, just for folks out there who may not know exactly what that term means, what is an aneurysm of the coronary artery?

John Kovalchin: An aneurysm is kind of a weakening in the blood vessel wall that makes it enlarged compared to the blood vessels around it, like a little ballooning.

Mike Patrick:: OK. The coronary artery is how the heart muscle itself gets oxygen, so it's important, and if you had a clot in there that occluded it, then the heart wouldn't get enough oxygen, and then that leads to what would commonly be called a heart attack or an MI or myocardial infarction.

John Kovalchin: Absolutely, and that's why it's very important to recognize this disease early on and get treatment.

As we said earlier, up to 15% to 25% of patients with Kawasaki disease without treatment can have coronary artery involvement, but with appropriate treatment, and I'm sure we'll go into that in a minute, the incidence of coronary artery anomalies goes down to about 5%, so a very significant decrease in involvement.

17:08

Mike Patrick:: Now, once a child has been diagnosed with Kawasaki disease, how do you go about evaluating the heart to see if any of these things are happening?

John Kovalchin: The most important test that we do is called echocardiography or ultrasound of the heart, and that allows us to assess all the things that we just talked about: the coronary arteries, measuring the size, looking for any dilation or aneurysms. It allows us to evaluate the valves for any leakage, it allows us to evaluate the cardiac function, and also to evaluate whether there's any fluid around.

So that's probably the most important test that we do right off the bat when the patient's in the hospital and diagnosed. And it's very important, sometimes these patients will even need to be sedated for us to get a very good-quality study, and then we'll do those in follow-up as well.

The other tests that we frequently do is an EKG, and that gives us an idea of what's going on with the rhythm of the heart or the electrical part of the heart, whether there's any abnormalities with that that may lead us to suspect inflammation of the heart or infarction or decreased blood flow to the heart.

18:11

Mike Patrick:: Sure. Now, there's some things that you're going to do to protect the heart, so to speak, even if a kid who's initially diagnosed with Kawasaki doesn't have any evidence of any heart problems. What are some of the things you do to protect the heart?

John Kovalchin: The biggest thing that we do in the treatment of Kawasaki disease while they're in the hospital is they get a dose of IVIG, high dose-IVIG. That's a medicine that's given to help modify the immune response that the body is having, and Dr. Jaggi went into that a little bit. That's probably the most important thing and the thing that shows decreased involvement of the coronary arteries in the short and long term.

The other thing that we do while the patient's in the hospital is give them high-dose aspirin. High-dose aspirin in the amounts that we give has another anti-inflammatory effect and it helps the patients out.

19:04

Occasionally, a patient will have continued fever and they'll need a second dose of IVIG when they're in the hospital, and some patients will continue to have problems after that, rarely, and may need another type of medicine.

Typically, after their fever goes away, we decrease the dose of aspirin from high dose to low dose, and at low-dose aspirin, that really has not so much anti-inflammatory effects but more anti-platelet effects. The platelets are the little pieces of blood that help clotting, and patients with Kawasaki disease often have elevated levels of platelets that may be more prone to clotting or thrombosis, and if you've got a problem with the coronary arteries, that's something that you don't want to happen. You want the blood to flow freely through the vessels and not clot off.

Mike Patrick:: Now, we always like to talk about benefits and risks, and parents want to know, 'If we're giving some medicines to my kid, what could be the side effects of those things?' The IVIG, is it a blood product?

20:06

John Kovalchin: Yes, it is. The risks of that are very minimal. Occasionally, a patient will have a reaction to that; most often it's low blood pressure or an allergic reaction or something like that. But in this case, the benefits by far outweigh the risks of this treatment.

Mike Patrick:: Right, and the sources where it comes from is tested for other infectious diseases, so that becomes much less of an issue today than it was years ago.

John Kovalchin: Absolutely.

Mike Patrick:: Now, another thing that parents hear from their pediatricians is, 'Don't give kids aspirin.' Why do we give aspirin in this case? Again, it's a 'risk versus benefit' thing. Can you just talk about that a minute?

John Kovalchin: Absolutely. Low-dose aspirin is typically used in the first six to eight weeks of the illness, and if there are not any coronary artery problems after that, then it's stopped.

21:00

Problems with aspirin can be, the most common one is it's a mild blood thinner, if you will, and sometimes patients may have issues with bruising or bleeding or things like that. That's pretty uncommon in the dosage that we use.

Another thing that people get concerned about with aspirin is something called Reye syndrome, and that's been shown to have a higher incidence in patients that are on aspirin if they're exposed to something like chickenpox or the flu. In those cases, if a patient's exposed, sometimes we'll stop their aspirin, put them on a different drug or something like that. But those are very rare complications.

Mike Patrick:: Yeah, and again, when you look at risk versus benefit and play that all out, the benefit far outweighs the risk in that situation.

John Kovalchin: Absolutely.

Mike Patrick:: What kind of long-term heart follow-up is required?

John Kovalchin: We follow the patients usually at two weeks from the time of discharge. They get an echocardiogram and an EKG in our clinic. And then they're followed at about two months and they get the same test, and then, really, their follow-up after that is dependent on whether or not they've got coronary artery involvement.

22:05

In most cases, they don't have significant coronary involvement, or if they do, it's resolved, and at that time we typically will stop their aspirin and then usually follow up at a year with an echocardiogram, an EKG. If everything is fine after that, then we typically will follow those patients every three to five years for surveillance.

If patients have coronary artery aneurysms or other coronary involvement, they're followed more closely and we will typically continue their low-dose aspirin. If a patient has giant aneurysms, then they're usually on more significant blood thinners like Coumadin and things like that, and those patients will oftentimes have additional tests to evaluate their coronary arteries such as MRI, CAT scan or cardiac catheterization.

Mike Patrick:: If a kid does not show any sign of heart involvement, is there a point in time when that's probably not going to happen, or is this something that all kids with Kawasaki need to be followed by a cardiologist every three to five years the rest of their life?

23:05

John Kovalchin: That's what we recommend now. A large part of Kawasaki disease is we don't really know what the long-term implications are 20, 30, 40, 50 years down the road.

There was some information that was out from the Japanese literature that said that if you have Kawasaki disease, even if you don't have coronary involvement early on, you may still have some issues down the road with difficulty in the coronary arteries relaxing, for example, during exercise. But there's some conflicting information about that, and the short answer is we don't really know what happens in the long term.

Mike Patrick:: Sure.

John Kovalchin: Rather than letting these patients go and getting out of the system, we're keeping them involved because more and more information is coming out every few years about what happens in the long term in these patients and how to follow them, and that's one of the things that we're doing research on in these patients.

Mike Patrick:: Sure. Now, you talked about, if kids do have aneurysms that start to develop using blood-thinning products to try to prevent platelets from grouping up and causing clots where the aneurysm is, if they're at larger aneurysms, are there some surgical things that might have to be done?

24:08

John Kovalchin: Usually that's reserved for cases where there is a problem with blood flow to the heart. Occasionally, a patient will require some cardiac catheterization intervention where they would go in almost like an adult with a coronary artery blockage and put a stent in or something like that. That's very rare.

Occasionally, we'll see a patient who's got severe multiple areas of blockage in the coronary arteries. I saw one patient, this was several years ago, who had terrible heart function as a result of that, and there really wasn't anything that the catheterization doctors could do as far as stenting those areas, or the surgeons couldn't really do a bypass procedure, and that patient ultimately got listed for heart transplant. That's a very, very rare case, but still that's one extreme at what we can see.

Mike Patrick:: Yeah. Coronary artery bypass is another thing that sometimes has to happen, just like it would in an adult who has a blockage in their coronary artery.

25:03

John Kovalchin: Yeah. Again, very uncommon and very rare, maybe one case like that every several, three to five years.

Mike Patrick:: Yeah, gotcha.

You had mentioned we don't really have a lot of experience or numbers to know, but what do we think right now in terms of a long-term outlook with these kids? As long as they're followed up regularly, and when things are discovered you deal with them as they come along, but they have a pretty good chance at living a healthy long life?

John Kovalchin: Yeah, I would say so. I think the vast majority of our patients do very well and we let them do normal activities, normal life expectancy and all those things.

We would recommend for them, like we would for any other child, a heart-healthy diet, getting good exercise, avoiding obesity, making sure they've got all their pediatrician visits, avoiding hypertension and smoking, things like that, things that you recommend for any teenager, child or adult.

Mike Patrick:: Sure. Maybe both can speak on this: in terms of follow-up here at Nationwide Children's Hospital, kids who are diagnosed with Kawasaki, what does that look like in terms of a follow-up clinic that they come to here at Children's?

26:12

Preeti Jaggi: We usually see them together. The most important thing that we always remind parents is to come back for those cardiology visits because we don't usually see any swelling or aneurysm of the coronary arteries when they're initially in the hospital when they're having fever.

They come back about two weeks after their initial illness, and then between five and eight weeks after the initial illness, they have their ultrasound and EKG tests like Dr. Kovalchin was mentioning, and then we usually see them from Infectious Disease also at that time, make sure that there's no fevers going on. It's quite uncommon to have a recurrence of the fever, but it can occur. And then some of the kids can also have some joint issues after the illness, so we just monitor for those things.

So we usually see them together at those time points, and then after their long-term follow-up, the most important person to visit with us is the cardiologist.

27:09

Mike Patrick:: Sure. In terms of evaluations, let's say there was a kid who was diagnosed with Kawasaki at another place and they didn't have as much experience dealing with Kawasaki disease, is this something that you guys would see, folks from not necessarily in Central Ohio?

Preeti Jaggi: Yes. If there's heart issues, certainly we can deal with that. Sometimes we might have a child who had had an unexplained febrile illness, and then one of the things that we sometimes see is some peeling of the fingertips really right close to the nailbed, and if there's some concern that the diagnosis may have been missed, we will see those children in clinic as well.

So, yes, we're happy to see people who've had a history or might have a questionable history of Kawasaki.

28:00

Mike Patrick:: Sure. We'll put the contact information for the Heart Center. That would probably be the best place to get plugged in.

John Kovalchin: Absolutely.

Mike Patrick:: And we'll have that in the Show Notes here, and of course it's on the website at NationwideChildrens.org as well.

Preeti Jaggi: And I would probably just recommend to parents that it's really important for us to think about the diagnosis. When we're in sort of a bad spot is when nobody has thought about the diagnosis.

If your child is having a lot of fever, you can bring it up with your doctor. They may have other things that they think the child has, because there are lots of other things that can look like Kawasaki, but bringing it up to ask them, 'Why do you think it's not that?' is a very reasonable thing to do, and looking out for the symptoms is very reasonable.

Mike Patrick:: Great. Now, this may seem obvious to us but maybe not to some listeners out there: is there any way to prevent it?

Preeti Jaggi: At this point, we really don't know what the cause is, so we don't have any way to prevent it. We are working very hard on trying to find out what the cause is, but there's no way that we can prevent it at this point.

29:00

Mike Patrick:: Right. For more information, too, I want to mention the Kawasaki Disease Foundation has an excellent website with lots of resources for parents, so that's another place you may want to check out. We'll have a link to that in the Show Notes as well.

All right, well, we really appreciate both of you stopping by today. Before we let you go, off the hook, one of the things that we ask all of our guests at PediaCast is, if you remember from your own childhood or now with your own families, board games, because we like to encourage parents to do some fun interactive stuff with their kids that doesn't necessarily involve TV screens and computer screens and iPads and iPhones and all of those things, so if you just think back, Dr. Jaggi, what's one of your favorite board games?

Preeti Jaggi: Board games? Well, my kids love Uno right now. That's a card game.

Mike Patrick:: That counts. Card games count.

Preeti Jaggi: That is our ritual every night when we come home is playing Uno right now.

Mike Patrick:: That's a fun one.

Preeti Jaggi: That's a fun one.

Mike Patrick:: Do you have some house rules or you just go with the standard?

Preeti Jaggi: We go with the standard rules. I don't know, they might want to change after a while. It's getting a little old now.

[Laughter]

30:03

Mike Patrick:: Add some new excitement into it.

And what about you, Dr. Kovalchin?

John Kovalchin: I played Uno last night.

[Laughter]

John Kovalchin: I've got a reputation of being the worst Uno player and checker player in my house. But anyway, yeah, Scrabble's another popular one and Monopoly's another popular one in our house.

Mike Patrick:: Do you do Words With Friends?

John Kovalchin: I don't. I think I'm a little old-fashioned; I do the old Scrabble one. But I should get on…

Mike Patrick:: You want the tiles in your hands.

John Kovalchin: Yeah.

Mike Patrick:: And it's easier to cheat on the old one because you can try to convince people, 'No, that really is a word!' With Words With Friends, if it's not in the computer's dictionary, it's not happening.

John Kovalchin: That's right. With younger kids not on Words With Friends yet, the old board game still works.

Mike Patrick:: Yeah, yeah. Absolutely.

All right. Well, again, I want to thank both of you for stopping by.

I also want to remind all of you out there that if there is a topic you'd like us to talk about, it's easy to get a hold of me. Just hop on over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS.

31:05

I also want to remind you, in your blogs, on Facebook, and in your tweets, make sure you mention us, and the next time you're at your primary care doctor's office, whether it's for a well checkup or a sick visit, just mention PediaCast to them so they can spread the word with their other patients. We'd appreciate that.

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

[Music]

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

John Kovalchin: I've got a reputation of being the worst Uno player and checker player in my house. But anyway, yeah, Scrabble's another popular one and Monopoly's another popular one in our house.

Mike Patrick:: Do you do Words With Friends?

John Kovalchin: I don't. I think I'm a little old-fashioned; I do the old Scrabble one. But I should get on…

Mike Patrick:: You want the tiles in your hands.

John Kovalchin: Yeah.

Mike Patrick:: And it's easier to cheat on the old one because you can try to convince people, 'No, that really is a word!' With Words With Friends, if it's not in the computer's dictionary, it's not happening.

John Kovalchin: That's right. With younger kids not on Words With Friends yet, the old board game still works.

Mike Patrick:: Yeah, yeah. Absolutely.

All right. Well, again, I want to thank both of you for stopping by.

I also want to remind all of you out there that if there is a topic you'd like us to talk about, it's easy to get a hold of me. Just hop on over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS.

31:05

I also want to remind you, in your blogs, on Facebook, and in your tweets, make sure you mention us, and the next time you're at your primary care doctor's office, whether it's for a well checkup or a sick visit, just mention PediaCast to them so they can spread the word with their other patients. We'd appreciate that.

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

[Music]

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

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