Migraine Headaches – PediaCast 221
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Dr Ann Pakalnis joins Dr Mike in the PediaCast Studio to discuss Migraine Headaches. We’ll cover the presentation, diagnosis, treatment, and prevention of this common, and often debilitating, disorder.
Topic
- Migraine Headaches
Guest
Links
- Comprehensive Headache Clinic at Nationwide Children’s Hospital
- International Headache Society
- American Headache Society
- National Headache Foundation
Transcription
Announcer 1: This is PediaCast.
[Music]
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is Episode 221 for August 8th, 2012 and we are calling this one Migraine Headaches.
Before we get to the topic, though, I want to welcome you to the show and let you know we are back from California. I had mentioned a couple of weeks ago that we were going to be taking a week off. I know we had a show last week on pediatric residency, but I had recorded that before we left, so this is actually my first show since we are back here in Central Ohio.
01:09
And I do want to send a special shout-out to big guy Dalton and cute little Paige, and of course their mom and dad, for sharing Disneyland with us. Now, those of you who are longtime listeners to the show, you know that my family are big Disney fans, and in fact, before we moved PediaCast up here to Nationwide Children's Hospital, the PediaCast Studio was about five minutes from the Magic Kingdom in Florida, so we spent quite a bit of time over on Disney property.
And I have to say, despite Walt Disney World feeling a bit more like home, because it really was, we really did enjoy the California version, and in particular the new Cars Land really was just amazing. I mean, the Disney Imagineers outdid themselves on this one. And from what I understand, it was about a billion dollars to build this thing.
02:01
You really feel like you stepped right into Radiator Springs. Those of you with kids out there who are fans of Lightning McQueen and the rest of the "Cars" gang, you know what I'm talking about with Radiator Springs. You feel like you're right there. There's this huge mountain range that they built. I could go on and on because it was really cool.
In fact, my son decided on this trip that he wants to be a Disney Imagineer. Now, of course, we had to sit down and talk. It's no easy task, there's a lot of physics and calculus, and you need some lucky breaks to be able to have a job like that, too. But he's gung-ho. We'll see where that goes.
All right. We do have a studio guest today, so I'd better move things along. I suspect that today's topic, migraine headache, will end up being a pretty popular one. Several reasons for this. First, migraines are a common problem. It's estimated that 10% of all U.S. kids and teens suffer from at least one migraine headache prior to age 18, and it's also estimated that one in four households in the United States has at least one migraine sufferer living there.
03:11
Migraines cost lots and lots of money every year, not only in medical costs but in loss productivity from school and work. And I mentioned work because not only do kids and teens suffer from migraines but lots of moms and dads do as well.
And that leads me to another reason I think this will end up being a popular episode. Even though PediaCast is geared toward moms and dads who are interested in knowing more about the health of their children, today's show touches on a problem many parents deal with not just in the lives of their kids but in their own lives as well. And since the presentation, diagnosis, treatment and prevention of migraines in children, teenagers and adults is roughly the same, there's going to be lots of info in this show that moms and dads may get for themselves as well as for your kids.
So who is visiting us in the studio today to help me talk about migraines? I'm so glad you asked. Dr. Ann Pakalnis is a pediatric neurologist at Nationwide Children's Hospital and Director of our Comprehensive Headache Clinic.
04:06
She'll be joining me in a moment, but first I want to remind you, if there is a topic you'd like us to talk about here on the show, just head over to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S.
Also, 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, and you can find that at pediacast.org.
All right, let's turn our attention to our studio guest today. Dr. Ann Pakalnis is a pediatric neurologist here at Nationwide Children's Hospital. She's also a professor of Pediatrics and Neurology at the Ohio State University College of Medicine. Her clinical and research interests involve the diagnosis and management of headache and the identification of comorbid disorders linked to migraine.
05:06
Dr. Pakalnis also serves as Director of the Comprehensive Headache Clinic at Nationwide Children's Hospital. She joins us today in the studio to talk about migraines. Welcome to PediaCast, Dr. Pakalnis.
Ann Pakalnis: Thank you so much, Dr. Mike.
Mike Patrick: I really appreciate you stopping by.
So I guess a good place to start is, what exactly is meant by the term 'migraine headache'? I think a lot of people, they come to see the doctor and they have a bad headache and they call it a migraine, but a migraine truly is something different, isn't it?
Ann Pakalnis: They are something different. Migraines are a primary headache disorder that in tension-type headaches, and we have fairly strict criteria that we use to diagnose migraines. It's called the International Classification of Headache Disorders and it comes from an organization called the International Headache Society.
To make a diagnosis of migraine, a child, adolescent, or adult, they have to have five separate attacks over any period of time, and those headaches have to have nausea and/or vomiting, light or sound sensitivity, moderate or severe in intensity, and they have to last between one and 72 hours, three days in time.
06:15
Mike Patrick: So it's really pretty strict criteria before you can really call it a migraine.
Ann Pakalnis: Definitely. And that's very important for different reasons, because of treatment plan, prognosis, and also there's many research studies that are going on in migraine, so physicians, neurologists here in America, they have to be on the same page as those in Europe or South America as far as regarding what is a migraine headache.
Mike Patrick: Sure. Just to contrast migraines with some other types of headaches, what are some other types of headaches that are out there, and just briefly, what are their characteristics like?
Ann Pakalnis: Probably tension-type headaches are generally the most common. They're not as severe as migraine headaches, you don't have nausea or vomiting with those, physical activity doesn't worsen them, and the duration can be a lot longer. Sometimes they last 15 minutes, sometimes six or seven days.
07:06
Mike Patrick: The tension-type headaches?
Ann Pakalnis: Yes, the tension-type headaches.
Cluster headaches are a variant of a vascular headache, and those are usually most common in adolescents and adults. They are very localized and behind one eye and can be quite severe, but are shorter than migraine headaches.
Mike Patrick: Now we talked about migraines being pretty common, and one number I came across was 28 million migraine sufferers in the United States, and I had mentioned in the intro 10% of all children and teenagers will experience a migraine. So we know they're common. Who gets migraines?
Ann Pakalnis: You know, that's a very good question. When you look at children and adolescents with migraine, there are two separate groups that tend to have the highest predisposition to have migraines. Those are young boys between five and nine years of age, and then teenaged girls, of course, is the other significant age group that tends to have migraines.
08:05
Mike Patrick: Sure. Do you tend to see migraines running in families?
Ann Pakalnis: That's a very good question. Yeah, migraines, about 80% to 90% of the time, you will see a history in family members of migraine definitely.
Mike Patrick: Sure. So there may be a genetic component of some sort to them.
Ann Pakalnis: Yes.
Mike Patrick: Let's talk about, in the brain, what's happening that causes a migraine.
Ann Pakalnis: Yeah. Migraines, we think they are more of a neurogenic headache as opposed to truly 'starting on a blood vessel' beginning of a headache. There's probably some abnormality in some nerves in the back of the brain, and people who are predisposed to migraine in certain situations can cause them to be very irritable and fire off impulses, and then they cause the throbbing headache, the nausea, the vomiting, dilate the blood vessels, and that throbbing, pounding headache pain.
Mike Patrick: Sure. So there's an environment that will trigger that happens. What are some of those triggers that are common that could cause a migraine?
09:08
Ann Pakalnis: They're oftentimes very individual per person, but some of the common ones generally we see are sleep, either too little or too much sleep, skipping meals, and low blood sugar with slipping meals. Not enough fluids; dehydration can really tend to trigger headaches. Stress can do that; certainly school is very stressful for kids, any stressful situation. And in teenage girls, hormonal changes can certainly be associated with migraine.
Mike Patrick: So around the time of their periods, they maybe have more migraines or less depending on how their body is reacting to the changes.
Ann Pakalnis: Exactly. Exactly.
Mike Patrick: And then, in our own house, my wife, she doesn't get them very often and they're not terribly severe, I don't think she's ever had to go to an emergency room for one, but she gets that set of symptoms. And for her, I know one of the things it does is at sensory, like flashes of light. Is that pretty common as well? Like if you're driving on a sunny day and there's a lot of trees so you're getting the dark-light-dark-light-dark-light-dark kind of thing.
10:15
Ann Pakalnis: Right, right. It can definitely do that. Or the sun on water or waves or something, that can be a trigger also. Sunglasses are great to wear outdoors, especially on weather like this.
Mike Patrick: Yeah, if you're prone to that…
Ann Pakalnis: Definitely.
Mike Patrick: …as a stimulus to it.
What about medication? Are there certain medications that could predispose you to migraines?
Ann Pakalnis: Some medications, as far as predisposing to migraines, they can be associated with more frequent headaches. Sometimes some of our seizure medicines can induce more headaches. Sometimes, the neuro-stimulant medicines that children take for ADD or ADHD, they can cause more headaches, not particularly migraine unless you're predisposed, but they can be associated with headaches.
11:02
Mike Patrick: I would suspect maybe oral contraceptives would maybe play a role, too, just since they can affect some hormonal changes.
Ann Pakalnis: Sometimes. Sometimes they can help the headache, sometimes worsen them. It's an individual thing.
Mike Patrick: Sure. So let's talk about, in terms of the symptoms, you had mentioned some of the things that are happening during the headache itself, the nausea and the vomiting, the sensitivity to light, sort of the classic migraine where it's one side of the head and throbbing. What about before the headache? Are there some things that happen with migraines that might give you an idea a headache's coming?
Ann Pakalnis: Right. Some individuals will have what we call an 'aura' with the migraine, and those are sensory symptoms, either numbness or loss of sensation in this one side of the face or one arm or one leg. Some individuals will see some vision changes. They can see lightning lines or zigzaggedy lines, sometimes blind spots, sunbursts before the headaches start, so they can be associated with that. Usually they tend to occur probably an hour or less prior to the headache.
12:11
But some individuals, when they become quite familiar with their migraine, sometimes they are excessively thirsty or they don't want to eat or they crave certain foods sometimes a day or two before they will have a migraine attack, or they don't sleep well at night. So if you're very well-attuned to your body, so to speak, some people can figure out that they're probably going to get a headache.
Mike Patrick: Which is helpful, because as we get to the treatment, there may be some things that they could do to avert the actual headache from happening if they could, so it's kind of an advantage that we have those symptoms before the actual headache starts.
Ann Pakalnis: Exactly. Exactly.
Mike Patrick: In terms of frequency, so if you have someone who suffers from migraines, and I had mentioned that my wife gets them very rarely, but some people get them more often. What is the typical range that you see for how often a migraine attack might occur?
13:03
Ann Pakalnis: Predominantly, most of the children or teenagers that we see in the office, they have them fairly frequently, probably once a week or more. But that's generally the exception. Most individuals, they may have one to two to three headaches a month and don't require very extensive treatment for their headaches other than abortive therapy when they have a headache.
Mike Patrick: Yeah. So it really ranges pretty widely from person to person.
Ann Pakalnis: Very much so.
Mike Patrick: Would you say that it tends to follow the family pattern? If you have the family pattern, you get a migraine once a month versus a couple of times a year, do you see a follow pattern like that or not really?
Ann Pakalnis: Occasionally, in some individuals, it can, or if a parent has an aura with the headache like visual changes, oftentimes the child will have the same thing with their headaches. And sometimes they respond to the same medications, believe it or not.
Mike Patrick: Now, I do want to point out that there are some other conditions that could cause a severe headache, and since a lot of people say, well, a bad headache is a migraine without knowing that it's this set of symptoms where it's a true migraine, we don't want people to mistake a bad headache because there are some bad things that can cause bad headaches.
14:22
Ann Pakalnis: Definitely. There can be, yes.
Mike Patrick: So what do you suggest when people, they have a bad headache, what should they do?
Ann Pakalnis: I think some recent studies have tried to differentiate what headaches are, quote, "bad headaches," and what are more typical with migraine.
So generally, if the headaches are, if you have a diagnosis of migraine and they're fairly similar or maybe more severe, then not to worry so much, but migraines or tension headaches are always usually in the front or the sides of the head. A headache that is in the back of the head or in the neck, that is something really to worry about, because migraines or tension headaches aren't in that location.
15:01
Mike Patrick: Sure.
Ann Pakalnis: Also, if there's a fever associated with the headache or weakness, numbness, vision changes that are long-lasting and don't go away, that's something to be concerned about.
And then also, if you can't really describe the pain. Oftentimes with migraines, they're throbbing, pounding, pulsing. If you're not able to describe the pain using an adjective and it's a very vague type of pain, then that's something more to be worried about.
Mike Patrick: Yup. And some of the things that would be more serious causes of headaches, what are some of those things?
Ann Pakalnis: Probably the most common cause of headaches that when children or teenagers present to the urgent care emergency room, infections are probably the most common cause. Sometimes sinus infections can do that, severe upper respiratory tract infection, a common cold that's quite severe. Sometimes a meningitis or an encephalitis, an infection of the brain, can cause a very severe headache that can mimic a first migraine episode.
16:08
Mike Patrick: Sure. When parents come into the emergency department, having worked there and seeing a lot of these kids that come in, the first thing that's on the parent's mind is they have a brain tumor. What would a brain tumor headache be like?
Ann Pakalnis: Those headaches, many of them follow a particular pattern. Sometimes the location is in the back of the brain, and also they're headaches that generally tend to wake you from sleep at night. Because the pressure in the brain goes up, they wake you from sleep with a lot of nausea and vomiting and they wake you from a sound sleep at night. Migraines generally don't tend to do that and they're very repetitive headaches. You may notice that occurring most nights, and migraines generally don't occur that frequently.
Mike Patrick: Yeah. But it is a good idea, especially if a kid for the first time has a severe headache and they're vomiting with it, parents shouldn't say, 'Oh, it's just a migraine and it will get better on its own in a few hours or a day or so.' They really ought to be seen.
17:08
Ann Pakalnis: Yes, yes.
Mike Patrick: Now so then how do you decide if a headache is a migraine? We talked about the specific criteria. Is there any more of a workup other than just the history that you would do to diagnose someone with migraines?
Ann Pakalnis: We do take a good history. Also, neurologic examination is really important. We look at their eyes to make sure there's not any abnormalities that we can detect, eye findings related to the brain. We look at their reflexes, their strength, how they walk and describe the character of the pain. Sometimes we'll order some laboratory tests if we have a concern about other factors going on. We always check blood pressure because that can be associated with headaches.
At times, we make a decision, some children, even though we feel fairly comfortable that they're migraine, we do order imaging tests like brain MRIs. In some instances, we will do that.
18:02
Mike Patrick: Yeah. I guess that would give parents some peace of mind, too, if they have in their head that could this be something other than a migraine. Just to give them some peace that there's not something else going on.
Ann Pakalnis: Very much so, yes.
Mike Patrick: And I guess MRI would be better than CT where it's a better picture but you don't have the radiation exposure, either.
Ann Pakalnis: Yeah, the MRI, far better, and for what we're looking at, a far better picture for that.
Mike Patrick: Sure. So once you decide that this is a migraine pattern that they're having, how do you go about treating that?
Ann Pakalnis: Probably, and that's really the hallmark of treating migraine, Dr. Mike, I think the most important thing is for parents to keep an event calendar or a diary of the child's headaches so they can bring to the doctor's office. Also, it's important if you keep certain factors going on like they had a sleepover the night before, didn't get any sleep, exam at school, teenage girls, oftentimes related to their period, if they didn't get enough sleep the night before too much.
19:02
Also, the calendar, and then the lifestyle issues are so much important. Pushing fluids. We recommend 48-64 ounces of fluids a day. We try to minimize caffeine, because caffeine can cause more headaches and impair sleep, and lack of sleep is a significant factor. So we want to make sure the sleep schedule is very good. Regular meals. Just those good lifestyle type of issues are so important.
Mike Patrick: Sure. And the journal is helpful in that it helps you see what those associations might be, so then if you can make the changes, that will then help the headaches not come.
Ann Pakalnis: Right. And it's very easy to do. Very easy to do.
Mike Patrick: Now, once you do have a bad migraine, how do you get rid of it?
Ann Pakalnis: As far as therapies that we use for an acute migraine attack, probably first to start out with is ibuprofen, probably better than Tylenol. Most of the research studies suggest that it is. The effects are long-lasting. So an appropriate dose of that.
20:08
Oftentimes, if children do have a lot of nausea and vomiting, their pediatrician or neurologist can prescribe the medicine for the vomiting, and we do use that at times.
Oftentimes, we do have to go to other prescription medications for use in headaches, and those are medicines of a class generally called Triptans, and they have been out since 1993. There are several approved for pediatric use by FDA, so we use those not infrequently, and they are by prescription.
Mike Patrick: What are some names of those?
Ann Pakalnis: Some names of those are Imitrex or sumatriptan would be the generic. Medicine that we use quite frequently is called rizatriptan and the brand name is Maxalt. The Maxalt is approved for children from six to 17. Another medicine that is approved for teenagers from 12 to 17, and adults, of course, is called almotriptan or Axert is the brand name.
21:07
Mike Patrick: Yep. And we do have some folks in the audience who are a little more scientifically inclined, and we have some clinicians in the audience as well. What do those kind of medicines do in the brain? What's their mechanism of action?
Ann Pakalnis: What we know physiologically with migraine, there's a biochemical called serotonin that works with migraine in sleep and also mood issues, and people who have migraines, they have low serotonin levels, and these medications, the Triptans, they work specifically on serotonin receptors in the blood vessels, and that is how they decrease the migraine attacks.
They also help a lot of the symptoms. They're not just analgesic or pain relief medicines. They can help the nausea, the vomiting, the light sensitivity, that movement-worsening component of the headache.
Mike Patrick: When it gets so bad that someone ends up in an emergency department for it, are there other things that you can do, then, for the headache there that we want to do or we want to avoid maybe?
22:06
Ann Pakalnis: Going to the emergency room for headaches, I think one of the most important things that can be done there, oftentimes the children have so much nausea and vomiting by the time they get there. They're dehydrated. So in the emergency room, they can give them lots of fluids in the emergency department, and that is very important.
Medicines for vomiting can be very important, and there are some very good pain medicines we can use there. We really try to stay away, even in our teenagers or an adult, even, from narcotics. We really don't like to use that. Steroids can sometimes be helpful. Prednisone-type medications can work.
Mike Patrick: Sure, because we think there's an inflammatory component to this.
Ann Pakalnis: Exactly. Yes, yes. And they're generally very safe when they're used for a short period of time.
Mike Patrick: In terms of prevention, we talked about having the journal and trying to figure out what triggers you might have and lifestyle changes, but are medications sometimes needed on a daily basis to prevent frequent migraines?
23:05
Ann Pakalnis: Well, sometimes they are needed on a daily basis. Unfortunately, there are no medications that FDA has approved for the population under 18, so there are only four approved for adults for prevention of migraine.
Mike Patrick: OK. We'll just skip on to the next topic, then. [Laughter]
Ann Pakalnis: OK. We can do that. It's all off-label, yes. Yeah.
Mike Patrick: What kind of complications can arise from migraine? I mean, is it just a headache and it's going to go away so it's more of a nuisance/inconvenience kind of thing, or are there real complications that you can get from migraines?
Ann Pakalnis: Complications, there are some that are concerned with the comorbid factors, especially in our children or teenagers that have frequent headaches. They miss school, they're very stressful. Oftentimes, anxiety and depression and sleep disorders run heavily comorbid. They occur very commonly in children who have migraine, and it's hard to say…
Mike Patrick: …which caused which.
Ann Pakalnis: Yeah, exactly. Exactly. We employ the services of our psychologists at our Headache Clinic, and oftentimes children will benefit, or a teenager's cognitive behavioral therapy, working on those types of issues with their headache, so that can be a very important component of treatment.
24:15
Mike Patrick: If stress and anxiety are a trigger for a particular person and then having the frequent headaches causes anxiety and stress, which causes more the headache, you just get into a bad cycle.
Ann Pakalnis: Very vicious cycle, yeah, and you have to break that, and oftentimes on many different fronts to do that.
Mike Patrick: Yeah. I guess, looking on the research end, is there anything new out there being looked at in terms of treatment or preventions, cures? Anything sort of new on the horizon?
Ann Pakalnis: Excellent question again, Dr. Mike. We are very excited at Children's. The National Institute of Health in conjunction with…can we mention Cincinnati Children's?
25:00
Mike Patrick: Absolutely.
Ann Pakalnis: Good.
Mike Patrick: Yes.
Ann Pakalnis: OK, we'll mention Cincinnati Children's. Those two institutions, they are sponsoring a multisite, about 15 to 20 pediatric centers in the country, so we are going to undertake a study on topiramate and amitriptyline in prevention of childhood headaches, childhood migraine. So we're going to start the study in the fall.
We hope to have about maybe 600 patients enrolled over the next three to four years, and maybe one of those two medications or both will have enough information to get approved by the U.S. Food and Drug Administration. It would be wonderful.
Mike Patrick: To make it an actual indication for migraine prevention.
Ann Pakalnis: Exactly. It would be wonderful if that would happen.
Mike Patrick: What is the long-term outlook for kids who have migraines? Whatever pattern they have during childhood, can they expect that same sort of pattern the rest of their life, or does it get better sometimes, does it get worse, does it ever just go away?
26:01
Ann Pakalnis: It can change quite a bit. Oftentimes, the outlook going into adulthood, and I do see some adult patients at Ohio State, the outlook for teenage boys and adult men is that the headaches tend to get significantly improved as they get into adulthood.
Because when you look at the adult population, probably about 17% of adults in this country have migraine. It's three to one women to men. So oftentimes, when they start to occur in teenage girls, they will persist through adulthood. Sometimes they can get better for a period of time in mid-life or older ages, but oftentimes they will persist in teenage girls.
Mike Patrick: Sure. Now, tell us a little bit about the Headache Clinic here at Nationwide Children's.
Ann Pakalnis: OK. Our Headache Clinic, predominantly we see patients at the Dublin offsite off Perimeter Drive, and myself, I have our psychologist that works with us, Dr. Cathy Butz. We have a nurse practitioner, Donna Crane. We see patients in Dublin several days a week. We offer a multi-disciplinary approach to migraine treatment.
27:11
And hopefully we'll be starting a headache fellowship, so we'll be training future physicians in headache treatment in the future.
Mike Patrick: Oh, very nice. If a patient is suffering from migraines and they wanted to see you in the Headache Clinic, do they need a referral from their primary care doctor to do that, or is that something that they can refer themselves to get in?
Ann Pakalnis: They would need a referral from their primary care physician.
Mike Patrick: A lot of it has to do with insurance and…
Ann Pakalnis: Yes.
Mike Patrick: …whether things get paid. Yeah.
Ann Pakalnis: Definitely. All those types of paperwork things.
Mike Patrick: Sure. We'll put a link in the Show Notes to the Comprehensive Headache Clinic here at Nationwide Children's Hospital so people can get more information about it.
It's something, too, that if they're suffering from migraines, they shouldn't be afraid to tell their doctor, 'Hey, can you refer me?' I don't know, sometimes people think, 'Well, my doctor's going to be offended if I say that I want to go somewhere else to seek treatment,' but really, I think doctors want their patients to be happy and have the best care. So we'd encourage folks out there to do that.
28:09
Ann Pakalnis: Definitely, yes.
Mike Patrick: All right, we really appreciate you stopping by the PediaCast Studio to talk about migraines. And again, we'll have a link in the Show Notes to the Comprehensive Headache Clinic at Nationwide Children's Hospital.
I probably also ought to look at the International Headache Society. It sounds like they probably have a good website with lots of information.
Ann Pakalnis: They do. Another good website, American Headache Society. It's very good. And National Headache Foundation has a wonderful website. It's www.headaches.org, and that's very good also.
Mike Patrick: Headaches.org.
Ann Pakalnis: Yes.
Mike Patrick: All right. We'll put all of those resources in the Show Notes so people can find them. Just go to pediacast.org, find the Show Notes for Episode 221, and we'll have links to all of those resources.
So thanks again for stopping by. I really appreciate it.
Ann Pakalnis: Well, thank you so much for inviting me.
Mike Patrick: Yup. I also want to thank all of you out there for taking time out of your busy day to listen to PediaCast. We really appreciate it.
29:04
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30:00
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.
