PediaCast 154 * Body Odor, Common Cold Vaccine, Febrile Seizures
Listen as Dr. Mike discusses how obese kids benefit when parents watch their weight, Allegra becoming an over-the-counter drug, running-related injuries, and an increase in doctors prescribing Amoxicillin for sinus infections. He also tackles the issues of toddler body odor, a possible vaccine for the common cold, cystic fibrosis, spinal muscle atrophy, and how viral season can lead to the onset of febrile seizures.
Running Related Injuries
Common Cold Vaccine
Spinal Muscle Atrophy
- Hospital Administration.org
- Creative Mamma.com
- Nursing Schools.net
- Cystic Fibrosis – MORE INFO
- Spinal Muscle Atrophy – MORE INFO
- Febrile Seizures – MORE INFO
Announcer: Bandwidth for PediaCast is provided by Nationwide Children's Hospital for every child, for every reason.
Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from Birdhouse Studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone and welcome to PediaCast, a pediatric podcast for moms and dads. It is Episode 154 for Thursday, February 10, 2011.
We're calling this one Body Odor, Common Cold Vaccine and Febrile Seizures. Yes, you heard it right, body odor. You guys come up with this stuff. Not me, I'm just answering your questions. So we're going to talk about that in toddlers. Of course, we have lots more coming your way.
First now, I just want to say, we're here. We made it safely, Birdhouse Studio, I'd like to say it was airlifted from Orlando to Columbus, but it wasn't. We actually drove all the equipment and ourselves and our children and our belongings from Orlando up to Ohio. And I have to tell you, it was 75 degrees and sunny when we pulled out of Orlando. I mean, here, that's to be expected. And we arrived in Ohio just in time for this gigantic ice storm.
Now I know most of you out there know exactly what I'm talking about because it affected something like one third of the Continental United States so a third of Americans experienced the storm and a two thirds of you, I know you've heard about it because, I think, the ice storm and it was a snow storm up north around Chicago and in the New England, but the storm in Egypt, I think, were pretty much the only two things in the news, so I know you heard about it.
An inch of ice, that's how much we got all together and let me tell you, if you've never experienced driving in an inch of ice, it's definitely not something to take lightly. Give me snow, give me lots of snow to drive in, I don’t mind that. But the ice, you just have no control and then these bozos who were flying by in SUVs who think they can do anything, there are more SUVs off the side of the road than anything else. I think because you get that false sense of confidence that you have four-wheel drive.
But you know, those of you who go way back on PediaCast, we started in Ohio, so we certainly aren't new to winter weather. But we've been in Orlando the last two and a half years and we were spoiled. We were spoiled. But we're excited to be back in Ohio. You know most of the people here are like, you just moved from where, seriously? You just moved from Orlando and you're coming here this time of year, why?
Well, a great reason and that is because you've heard Nationwide Children's Hospital has been our bandwidth sponsor now for a long time. And so you hear at the beginning of the program, to begin with for PediaCast, is provided by Nationwide Children's Hospital. Well, they're providing a lot more for us now. We are actually moved on to the campus of Nationwide Children's Hospital in Columbus, Ohio and it is seriously, I'm not exaggerating, one of the biggest and best children's hospitals in all the world.
And I'm not just saying that because I have had a relationship with the folks here for such a long time. That's really not the reason I'm saying it. It's because it's true. And it's an incredible campus, can't wait to share with you all that we're going to be able to do here. And we have at our beck and call, basically, every pediatric specialty you can imagine. So fire away, keep those questions coming and as the weeks go on, we pledge to you more information and more interactive interviews with pediatric specialists instead of just me talking, talking, talking, we're actually going to have some interaction here.
Alright, so what are we going to talk about today? In our News Segment, Obese Kids Benefit When Parents Watch Their Weight. Also Allegra Goes Over The Counter, Running-Related Injuries Are On The Rise and More U.S. Doctors are Prescribing Amoxicillin for Sinus Infections. We'll talk about why that's a good thing coming up in the news.
And then in our Listener segment, Toddler Body Odor, The Common Cold, is there a vaccine for it? Could there be a vaccine for it? Are they developing one? When can we expect it? When will we not have to face the common cold anymore? So that's coming up.
Also, Cystic Fibrosis and Spinal Muscle Atrophy. We're going to kind of nutshell those two diseases, a listener had a question about them. So we're going run through them, kind of briefly, their big topics and you could devote a whole hour show to each of them but we're going to just sort of nutshell them for you.
And then finally, in our In-Depth segment, this week, we're going to talk about febrile seizures. During virus season, we see lots of more kids with fevers and so some of those kids will have seizures with their fever. We're going to talk about the who, what, when, why, how, all that business in our In-Depth segment coming up a little bit later on in the program.
Don't forget if you have a question for us or a comment, it's really easy to get a hold of us here at PediaCast. Just go to pediacast.org and you can click on the Contact link. You can also email email@example.com.
You know it occurred to me that during the intro, I was talking a little bit fast and I think it's because I know the last show, I really thought that I have about a half an hour worth of material and somehow, I talked to that to an hour. And so somewhere in my sub-conscious, I think hey, if I talk a little faster, I can squeeze more in.
Alright, News Parents Can Use, our first stop, Obese Kids Benefit When Their Parents Watch Their Weight. This is from a new study from Australia that was published in this month's issue of the Journal Pediatrics. And what they found is that when parents take classes on healthy eating and exercise, their obese and overweight children lose weight and keep it off. That's the finding of Dr. Anthea Magarey and her team of researchers at Flinders University School of Medicine in Adelaide, Australia.
And the study looked at children who are ages five through nine. The educational measures were directed solely at the parents, so the children did not receive any training or instructions. Researchers enrolled mostly mothers of 169 kids who were all between the ages of five and nine and these kids are all moderately obese or overweight.
The parents took a six-month healthy lifestyle course which addressed portion size, nutrition labels, exercise, role modeling and setting limits. And at the end of the six months, the body mass index of the kids had dropped an average of 10%. And 18 months later, researchers found the children had kept off the excess weight.
Now, interestingly, the parents themselves did not lose weight during the two-year period, but they did report feeling better equipped to parent. They felt more comfortable saying no to their children's demands, they set limits on the types and amounts of foods that their kids could eat. And they limited the time children spent watching TV and playing video games. They learned other healthy strategies, as well, engaging in more active family time, eating more fruits and vegetables and using reduced fat dairy products and avoiding sugar-sweetened soda beverages.
So it appears that parental education is a great tool to combat childhood obesity. And it's an important fight when you consider the incidence of childhood obesity as rising steeply with 24% of U.S. children in the two-to-five age range and 33% of U.S. children in the six-to-eleven-year age range qualifying as obese or overweight.
So moms and dads, if you're worried about your child's weight and if they're overweight or obese, you should be, then you want to find a local educational course focusing on diet and exercise for yourself and enroll because it could make a lifetime of difference for your kids.
And here's some news that will impact lots of kids with allergic rhinitis. The drug, Allegra, is following in the footsteps of rival antihistamine's Claritin and Zyrtec in going over the counter, meaning parents won't need a prescription to purchase the medication.
The makers of Allegra, Sanofi Aventis, says FDA approval paved the way for them to offer the medication directly to consumers. You'd be able to find Allegra on store shelves sometime in March. Of course, a word of warning is offered to parents, if your insurance company is currently footing the bill for your child's Allegra, be prepared to start pocketing that expense yourself.
And I just want to mention here real quick, when drugs go over the counter, of course, there's the safety issue. So the FDA or the Food and Drug Administration arm of the government says hey, this drug is safe enough that parents can just pick it up over the counter and give it to kids. But that's not really the only thing that play when prescription drugs go over the counter.
I just wanted to mention a couple of these things too. Just so you have some knowledge about it. One, insurance companies, of course, want medicines like Allegra to go over the counter because they spend money paying for these things and they don't want to pay for them. They want you to pay for them and so, if it's an over-the-counter medicine, the insurance company can say hey, we don't cover it, we don't pay for it. So there is definitely some pressure from the insurance companies to get these medicines over the counter.
Also drug companies, they actually want the drug to be by prescription while it's under patent and not where they can market the drugs to doctors, but once it goes generic, they lose their market. And the reason they get a patent on a drug for x number of years and then, once it goes generic, you know the pharmacy is going to substitute the generic once the patent is gone.
So now, by getting it over the counter, pharmaceutical companies can market it directly to the consumers. So once Allegra went off patent and there were generic equivalents, you take your prescription in for Allegra, you're going to get the generic kind no matter what, because it’s cheaper and probably your insurance company is going to say hey, we'll only pay for the generic.
So now the drug company wants it to go over the counter because they can start marketing the consumers through commercials and advertisements and get you to buy just their brand over the counter directly. So there's a lot in play here, and unfortunately, money is a driving factor for lots of it. So I just want you to be educated about that.
Allegra is a good drug, I’m not saying it's good or bad compared to Claritin or Zyrtec. Certainly, talk to your doctor about what they prefer that you use when treating allergic rhinitis.
Alright, Running-Related Injuries Are On The Rise. The number of running-related injuries among children and teens aged 6 to 18 years has increased 34% between 1994 and 2007, that's according to investigators at the Center For Injury Research and Policy here at Nationwide Children's Hospital in Columbus, Ohio.
Dr. Laura McKenzie, the principal investigator for this study, which is published in this month's edition of Clinical Pediatrics, reports that the majority of these injuries are sprains and strains to the lower extremities falls account for one third of the injuries and more than half of them occur at school.
All told, there were over 225,000 running-related injuries treated in U.S. emergency departments during the study period. Kids ages 6 to 14 were more likely to fall while running at school and those 15 to 18 were more likely suffer a sprain or strain while running in the street or at sports and recreation facilities.
Dr. McKenzie says "Encouraging children in their adolescence to run for exercise is a great way to ensure they remain physically active. However, the findings from our study showed that formal evidence pace in age-specific guidelines are needed for pediatric runners, so parents, coaches and physical education teachers can teach children and teens the proper way to run in order to reduce the risk of injury.
And finally, in our News Parents Can Use, more U.S. doctors are prescribing amoxicillin for sinus infections. You know, sinus infections are a commonly diagnosed condition. In fact, from 1998 to 2007, U.S. doctors diagnosed the condition in 8.9 million children and teens. Now fortunately in most cases, the antibiotic amoxicillin is sufficient to treat the condition and the use of more expensive and broader spectrum antibiotics such as Augmentin and Omnicef contribute to the development of resistant organisms which make future infections more difficult to treat.
So how well are U.S. doctors following this guideline? Well, according to Dr. Adam Hersh from the University of Utah in Salt Lake City, they're doing better, but there's still room for improvement. And an article published in the Journal Pediatric's Dr. Hersh and Colleagues report only 19% of sinus infections were treated with amoxicillin at the beginning of the study period which was 1998. But by 2007, this number had risen to 58%. While it appears more physicians are following the AAP guidelines, a substantial number of doctors are still prescribing the more expensive and broad spectrum antibiotics.
Of course, there are instances when these stronger antibiotics are warranted. For example, when a child has recurrent sinus infections caused by resistant organisms or when amoxicillin has been recently used to treat other infections in a given child, but there are also instances when children are diagnosed and treated for sinus infections which aren't really sinus infections at all.
A recurrent viral illness is, and especially in those attending day care and school, can mimic a bacterial sinus infection and antibiotics are not indicated for these kids because they won't kill the virus and they may lead to colonization of the child's mouth and nose with the resistant, harder-to-kill organism.
So even if you're child has a true bacterial sinus infection, the researchers note there is mixed evidence for the effectiveness of antibiotics to make your child better because many sinus infections, including those caused by bacterial organisms, resolved on their own.
Dr. Hersh says because there is a continued tenancy of physicians to prescribe antibiotics for the treatment of acute sinusitis, the condition remains an important target for campaigns promoting judicious antibiotic use. Alright, that concludes our News Parents Can Use. We're going to come back and answer some of your questions right after this.
Alright, before we jump into our listener segment, I wanted to give a ShoutOUT to a few of you who had been kind enough to mention PediaCast in your blogs. And this is one of those ways which you really help to get the word out. And getting the word out about PediaCast is not about trumping our own – or tooting our horn, blowing our own trumpet, however you want to put it. We really just want to get the word out so that more parents can get educated about their child's health from a source that you trust.
And the reason that you can trust PediaCast is we put lots and lots of time into researching the topics that we present so that you have the latest information available. And it's really about the education, but again, we don’t diagnose particular kid's problems or say, hey, here's what you need to do for your child. You definitely want to see your doctor. But hey, we can tell you about this disorder, what causes it, why it's generally treated the way we generally treat it and that sort of things.
So I have asked in the past that folks, mention us on Facebook, mention us in your blogs, and I just wanted to give a ShoutOUT on some folks who have done that. Hannah, over a hospitaladministration.org, mentioned us in her Top 50 Blog Posts on Parenting Teens, so we appreciate that. And Joy, at creativemama.com, included us in her list of 5 Awesome Podcasts for Moms; and Ken at nursingschools.net, included us in the 50 Best Blogs for School Nurses. So we really appreciate that. I just want to give you guys the ShoutOUT.
Those three blogs we have links to them in the Show Notes for this episode, Episode 154 of PediaCast. So if you got pediacast.org, you can find the links to those blogs. So thanks, we appreciate it. And if you mentioned us in your blog post, shoot us an email at firstname.lastname@example.org and let us know and we'll also mention your blog here.
Alright, first up in our Listener segment is Karen in Johnson City, New York. And Karen says, “Hi, Dr. Mike, I have just discovered your podcast within the last month and just love all the great information and advice. My job is doing data entries, so I can listen to my iPod while I'm working. I've been listening to you everyday.
My question is about body odor. My three and a half year old had very bad underarm odor. He has had it or I have noticed it since he was about a year and a half old or so. I have questioned my pediatrician and we have had my son tested for hormone levels. I have basically been told some kids are more stinky than others.
My son's father and I think it's not normal to have body odor for a three-year-old and requested copies of the test results. After many questions about getting the results on paper, I finally received them. All the levels seem to be in the normal range according to the results. He has a few fine body hairs in the diaper area but nowhere else.
Shall I pursue it further or do you think some kids are just stinky? I'm afraid he has a hormone imbalance. He's rather large for his age and in the 90 to 100 percentile for height and weight. What do you think? Thanks for the question or thanks for answering my question, Karen.”
Well, thank you for the question, Karen. First, let's talk about the causes of body odor at any age. And then we'll talk more specifically about at toddlers. Skin itself does not have an odor. So what is it that causes body odor? Well, there are many causes and one major source is drum roll, please, sweat.
Now, I know what you're thinking, no kidding, right, sweat results in body odor. But how, does the sweat itself stink? Generally, no, it doesn't and the process by which sweat causes body odor is a bit complicated. So let's talk sweat. The skin has two types of sweat glands: eccrine glands and apocrine glands.
Now, eccrine glands occur over most of the body, they open directly to the skin and their functional right from infancy. So when your baby or your young child sweats, for instance, when they're breaking a fever or you've got them dressed a little bit too warmly, this is eccrine sweat. And when you're out working outside and it's hot and you break out a sweat all over your body, this eccrine sweat.
So eccrine sweat is made mostly of water and salt and its function is pretty simple. It just cools the skin by evaporation. So as the sweat evaporates off of the skin, it takes heat with it and so it cools the skin by that mechanism.
But there are other chemicals that can be excreted in the eccrine sweat, which may contribute to body odor. So usually, the sweat itself does not have the smell to it, but there are certain things in your body that can be excreted in the sweat that can cause it to smell. And food is the major source of this so especially herbs, a curry, garlic, onions and also alcohol. So ethanol, when consume in large quantities over a long period of time, that can start to be excreted into the sweat and can cause some unique body odors. And everyone out there knows what I'm talking about.
There are also certain medications and really chemicals that aren't broken down correctly in the body. Some other examples, if some children have what they call inborn errors of metabolism. And there sometimes can be some chemicals that aren’t broken down correctly in the body and those can be excreted in the eccrine sweat and can cause a specific odor. So this is one source of smell to your skin.
Now at apocrine glands are a little bit different, rather than opening directly to the surface of the skin, these glands empty into hair follicles, so they're most abundant where you have hair. So in the scalp, armpits, groin regions and they become increasingly active at puberty. These glands secrete in oily or fatty sweat and as skin bacteria digest and break down the fat in apricone sweat, fatty acids are produced which have a pungent odor.
Apocrine sweat glands also contain proteins and these are also broken down by skin bacteria into amino acids. And again, these amino acids have an odor too. And so basically, the apocrine sweat being broken down by bacteria, the by-products that have been broken down caused body odor. And the way you get rid of it or prevent it is by washing so that you get the apocrine sweat off of your skin so that the bacteria don’t have it available to break down and make their by-products which have the smell.
Now certain medications may cause you to make increased amounts of apocrine sweats which leads to more bacterial breakdown products, which in turn, leads to increased body odor. So there are some medications that basically make you sweat more so that can contribute to more of a body odor as well.
Now there's some other sources of body odor. For instance, there are also glands called sebaceous glands. These are another skin gland that produces an oily substance called sebum, which is thicker than sweat. It lubricates the skin and again, it's most abundant where there's hair, so scalp, underarms and groin. And sebum is thicker than sweat, but skin bacteria still break it down into a fatty acid, which again, have a smell. Yeast and funguses grow in warm, moist places like underarms and groins and now these can produce odor especially when the growth is heavy.
Other sources of body odor, sort of non-skin-related, breathing and bad breath, you know you can exhale a certain chemical, certain medicines in your breath. You're going to smell as it gets basically excreted in the lungs. And then also the oral cavity, obviously, we can have halitosis bad breath.
Urine smells can sometimes be the culprit, especially in young kids who aren't toilet-trained of their peeing into a diaper and they're on a certain medicine, if you're on amoxicillin and certain antibiotics, you can smell it in the urine. So again, chemicals being excreted in the urine and especially in kids wearing diapers, you may smell that. And that maybe a source of a body odor as well.
So and incidentally not just medications, there are also certain foods that can cause urine to smell and some diseases, diabetes, inborn errors of metabolism. There's one in particular called maple-syrup urine disease which again can all play a role in body odors. So there's lots of potential sources.
So let's address Karen's question now more specifically. What about in a three-and-a-half year old with body odor for a couple of years? Well, first why did your doctor check hormone levels? Likely, they were looking for condition called precocious puberty, and this results in the appearance of body hair in areas you don’t really expect until puberty. And it's adult-type, dark, coarse body hair rather than sort of the fine fuzz that you would expect in kids.
Precocious puberty also results in premature development of apocrine and sebaceous gland activity. So you get the hair, you get the glands maturing just like you would in adolescence. And then you also get some secondary sex characteristics, for example, breast enlargement. So when these things are happening, it may be precocious puberty or early onset of puberty which can be caused by hormone imbalances so that's probably what your doctor was looking for.
Now I don’t know which hormone test your doctor ordered, and really, that's not the point here whether he or she ordered the right ones or only some of the right ones or none of the right ones. To me, if you're concerned about this and your doctor ordered hormone levels and it was just your doctor who did it, but this odor is still there or you're noticing hair that shouldn't be there, I think it make sense to request an appointment with the pediatric endocrinologist.
In that way, you can make sure that all the correct tests were done to rule out a hormonal cause of the odor especially if there's some questionable groin hair that's present or if there's any breast development that's going on. But even if you don’t have those things and you're worried about it and you're wondering hey, did my doctor order all the right things? A referral to a pediatric endocrinologist, I think, would be useful. It would also be useful to check for diabetes and various inborn errors of metabolism, which again, your pediatrician, in conjunction with the pediatric endocrinologist, will be able to do for you.
So let's say there's no evidence of precocious puberty, no inborn errors of metabolism, no diabetes, no other hormone or chemical cause of the odor, some other things for you to think about and actually, some of these things you might want to think about first before you do a big work-up.
You know, one is diet. If you have a three-and-a-half-year old and they eat lots and lots of food with curry or onions or garlic or certain herbs, you may want to cut those things out of their diet and see if the smell goes away. So I mean, you might want to do those kind of things before you do the big work-up.
Also think about, is your child on medications? Less likely, in the toddler age group, it certainly not impossible. Also fungal growth, under the arms, in the groins, warm moist place, yeast and funguses can grow there. And also some kids just may have increased apocrine or sebaceous activity. Not all kids follow the rule book and so even though in most kids, those glands develop more at adolescence, you may have a kid who does have a little bit more of an increased in apocrine and sebaceous gland activity so they're making those kind of sweat or sebum, the bacteria is breaking them down and you smell it.
Now you don’t want to assume that without doing the work-up that we mentioned before seeing a pediatric endocrinologist. But if everything is checking out fine, it may just be that your kid is developing these glands earlier than other kids do and especially if there's a family history of that.
If you go to a family reunion and everyone says, I think my kid smells just that same way when they were little, and so that Aunt Barbara's and Uncle Joe's seems to be a family treat that there's a little bit of an early development of the more mature sweat glands, that's a possibility as well. So I hope that helped, Karen.
If the smell persists and the other thing is too, and I'm assuming that you're doing this. I'm assuming the best with my listeners, but it's been a year and a half or two years since your child had this odor. I'm assuming you're washing your child regularly and if it is the sweat issue, you know, frequent bathing should take care of that or if it's the fungal thing, again frequent bathing should take care of it because you're getting rid of sort of the cause of the odor. So you may just have a kid that needs to wash a couple of times a day. Alright, in general though, I would say refer to a pediatric endocrinologist is a good idea if you have concerns.
Alright, moving on, we have a great question from Justin in the Woodlands, Texas. And Justin says, “In your most recent Episode 153, Emmanuel from Paris asked about viruses, this question kind of touch on something I've wondered for a long time, both the flu and the common cold are caused by a virus. Every year, we are advised to get flu shots to build up antibodies so our immune systems are better equipped to stay off of on infection. Since the flu and the common cold are both caused by viruses, why is there not a vaccine for the common cold?”
Well, that's a fantastic question, Justin, and a great observation as well. You know what we call the common cold can actually be caused by a large variety of viruses. Rhinovirus is the one we've most often think about as doctors and it's probably the most common cause of the common cold. And it's the one we'll sort of focus on here, but there are many other viruses that can cause the common cold.
So even if we could make a virus against rhinovirus, there's still other culprits left to cause symptoms of the common cold. And these viruses include coronaviruses, the various influenza viruses which we do have vaccines for, parainfluenza viruses which we don't have vaccines for, respiratory syncytial viruses, adenovirus, enterovirus and plenty of others and we don't have vaccines for any of those really except for influenza.
But let's focus here first on rhinovirus since that's the most common pathogen behind what we call the common cold. Vaccines, how do they work? Just in a nutshell, they present an antigen that mimics a protein on the surface of a virus so that your immune system makes an antibody against that protein so when the actual virus comes along, your immune system can make the antibody against it and attack it.
Well, different strains of rhinovirus and there's 99 strains of rhinovirus that we know of and they are distinguished by the collection of surface proteins that they have on the outside of the virus. Now each strain of rhinovirus, so each of those 99 different strains has its own set of external proteins, some of which are immunogenic, meaning that the body's immune system is able to make an antibody against it, and other surface proteins are not. So you have to figure out which proteins on the surface of the virus are immunogenic.
So that if you made an antigen that mimic that particular protein, you'd be able to merit an immune response to make antibodies against it. So to have an effect of vaccine, you'd need to identify an immunogenic protein that is common to the surface of all strains of rhinovirus or you'd have need to have 99 different proteins so that you had one immunogenic protein from each of the 99 strains.
Now this is actually more difficult than it sounds. And when you think about it, there's in the flu vaccine, each year they pick three strains that they're going to put in the vaccine. So we're not talking now about creating a vaccine with three strains, we're talking about creating a vaccine with at least 99 strains and there's a big step-up in actually producing such a thing that works.
Or you'd have to find one protein that's common to all 99 and we have not found that protein although, it appears just within the last year that maybe we have found a protein that's common. We don't know for sure yet if it's immunogenic. In other words, if making a vaccine to that one protein would protect you against all 99 strains, but there is research going on to try to figure that out. So there's some hope that we could have an effective vaccine in the future maybe but it's not ready.
Now let's say we do one day, get a rhinovirus vaccine and it protects you against all 99 strains. It still won't be the end of the common cold. Remember those other viral causes that I mentioned? Enteroviruses, there's another 100 strains of those, 100 different strains of enterovirus. There's 40 to 50 different strains that we know about of adenovirus and immunity to one strain of each of these is not confirmed unity immunity against the others. So it appears that common cold's going to be with us for a very long time. Thanks for the question, Justine, and I'm sure there's one many parents have asked themselves.
Alright, moving on to our listener question, Sarah in Australia says, “Hi, Dr. Mike. I was hoping you could do a segment on cystic fibrosis. We have a new student with special needs starting at our school next year and at the transition meeting last week, the support worker dropped into the conversation that in addition to the spinal muscular atrophy that we knew about, she also has cystic fibrosis.
I knew very little about this condition as most CF kids don't come into special ad services. This young lady has a tracheostomy and a ventilator and uses an electric wheelchair and a laptop for writing due to muscle weakness.
What do we, as a school, need to know about CF? Can you recommend books or websites to read and are SMA Type 2 and CF connected or close to each other on the genome? It seems really harsh for one child to get two such serious conditions.”
Well, thanks for the question, Sarah. Now you've asked about two very different genetic conditions, cystic fibrosis and spinal muscle atrophy and they're both pretty complex and we could easily do an hour show on each one. But given we're that crunch for time today and still need to get to our in-depth segment of febrile seizures, let's do a quick overview of each condition and then I'll end by pointing you to some resources with more information about each one.
First, while cystic fibrosis and spinal muscle atrophy are both genetic conditions, they are not related on the genome. Cystic fibrosis maps out the chromosome 7 and the most common forms of spinal muscle atrophy map the chromosome 5. So if you have a child with both disorders, they would have been inherited independent of one another.
So let's take first a look at cystic fibrosis or CF, sometimes called 65 roses, especially in the blogger's fear after a child overheard his mother talking on the phone about his illness and thought she was saying 65 roses, instead of cystic fibrosis. That's cute.
Cystic fibrosis or 65 roses, what is it? Well, it's a genetic defect which is autosomal recessive. So let's go back to high school genetics here. Autosomal means it's not on the X or Y chromosomes. It's not one of the sex chromosomes. And in particular, it's linked to chromosome no. 7.
Now recessive means that both parents must contribute a cystic fibrosis gene in order for their child to have the disease. So if only one parent passes on the gene, then the child would be a carrier, they won't have the disease, but they'll have the 50% chance of passing the cystic fibrosis gene to their offspring. And then their offspring then would be another carrier if they inherit one copy of the gene or they'll have the disease if they inherit a copy of the CF genes from both parents. So hopefully, that makes sense to you.
If you kind of remember back to making those little squares in high school biology, where you have like the capital letter and the little letter for dominant recessive, it's that. So you have to inherit it from both of your parents who have to either have the disease or be carriers for the disease. In most cases, it's two carriers who have a child with cystic fibrosis, and this is because infertility rates among those with the actual disease are quite high. And we'll find out why that is here shortly.
Now in terms of epidemiology outcome in the cystic fibrosis, it's pretty common and the CF gene that causes it is primarily seen in the European Caucasian and Jewish gene pools. So the carrier rate among folks of European descent and Jewish descent end up being about 1 and 30. So if you get 30 Caucasian or Jewish folks together in a room, at least one of them is probably a carrier for cystic fibrosis.
And then the birth rate of the disease in those ethnic groups is about 1 in every 3,000 live births. It's a little bit lessened, Hispanic American's carrier rate is about 1 in 45 and about 1 in 8,500 live births who's on cystic fibrosis. And African Americans 1 in 65 carry the disease, 1 in 15,000 babies born have it. And among Asian Americans, it's the least common there where the carrier rate is 1 in 90 and the birth incidence of it is about 1 in 32,000.
Now exactly what happens with cystic fibrosis? Well, the cystic fibrosis gene codes for a defective protein and the normal function of this protein is to manage the transport of salt in and out of certain cells. And if you have cystic fibrosis, basically the protein is not made right.
And what happens is that protein is particularly important in mucus-producing cells in the respiratory digestive and reproductive systems. And this mismanagement of salt and water movement in people who have cystic fibrosis, because this protein is being coded for wrongly, what the end result is it that they have a thick, sticky mucus secretions in these organ systems, in the respiratory tract GI, gastrointestinal tract and the reproductive tract.
And this mucus is supposed to be thin and slippery. So what's the result of having this thick, sticky mucus with low water content? Well, in the respiratory system, the thick, sticky mucus blocks passageways in the upper and lower respiratory tract and that results in persistent coughing, wheezing, clogs of mucus with repeated lung infections and repeated sinus infections.
In the digestive tract, this thick, sticky mucus blocks passageways that carry digestive enzymes from the pancreas to the small intestine and that results in your food not being broken down correctly, you get mal-absorptions so nutrients just passed on through rather than getting absorbed into the body like they should be.
You also get decreased in fat breakdown so you get fowl-smelling, greasy stools and because these nutrients are just passed it on through instead of being broken down and absorbed properly, you get poor weight gain and poor growth. In the reproductive system, this thick, sticky mucus blocks passageways that transport sperm and eggs and that results in infertility.
So I'm simplifying to some degree, but again we're just trying to nutshell this illness so that you understand it a little bit better quickly. Now in terms of treatment, there's no sure fire way to cure cystic fibrosis. So there's no way to force the body into making a thin, slippery mucus instead of the thick mucus.
One option, especially when it comes to respiratory issues is lung transplantation. So a new lung would have the proper DNA, lungs that's coming from someone who doesn't have cystic fibrosis and it would make the correct type of mucus. But you'd have to do a double lung transplant because you'd want both lungs to be making normal mucus since, you know, lungs are connected to one another and if you had one making the wrong kind of mucus, it certainly could plug off the other lung as well.
So you'd have to do a double lung transplant and that's not easy business. I mean lungs aren't easy to come by and double lung transplant is risky, especially in a kid who's very sick with cystic fibrosis, there's a lot of risk involved with doing a double lung transplant. Pancreatic and liver transplants are also possible.
But what about gene therapy? Well, there is ongoing work on that. So in other words, if there was a way that you could code the DNA to start making the right protein, then the body would be able to make the mucus properly. So again with gene therapy and genetic engineering, we're trying to figure out a way to alter the DNA in the cells that need it so that the right protein can be made.
What about just giving the protein, like there's a pill or an injection? The problem there is you're not getting the protein down to the cellular level where it needs to be all the time. So you really need that protein manufactured by the cells that need to use the protein and just taking the protein in is not good enough. So that's why you'd have to do the genetic therapy to really get the protein being made down at the cellular level.
So if we can't change the kind of mucus, what do you do? Well, mucus-thinning drugs in the respiratory system using bronchodilators to open up the airways a little bit more so that you can tolerate that thick mucus down there and then responding with the antibiotics when respiratory infections are present. Also, oral replacement of digestive enzymes and then mobilizing lung mucus by mechanical means through percussion and other ways that we use to move that mucus.
So that's sort of the mainstay of treatment right now, but there's lot of research going on including here at Nationwide's Children's Hospital which we'll talk about in a minute. What's the prognosis for kids with cystic fibrosis? Well in the past childhood and teenage mortality was high and that was secondary to recurrent lung infections. But today especially in specialized are regional CF centers, lifespan frequently reaches the 50s, thanks to aggressive mucus mobilization techniques and broad spectrum antibiotics use to fight lung infections.
However, with the continued emergence of resistant bacteria, there is concern that our current arsenal antibiotics will fail and life expectancy for those with cystic fibrosis will take a turn for the worst. And so that's the reason why all of us should be concerned about improper of use of antibiotics.
So that's cystic fibrosis in a nutshell. Let's move on to spinal muscle atrophy. This is another genetic disorder. It is also autosomal recessive. It's really a collection of disorders and we're going to focus on types 1, 2 and 3. It's usually the most common ones that affect kids.
We don't see much ethnic disparity in terms of the carrier rate with the spinal muscle atrophy. Yet worldwide, it ends up being about 1 in 40 people are carriers for at least one of the three types, the three major types of spinal muscle atrophy. It maps out the chromosome 5, so there's a section on chromosome 5 that codes for proteins that help keep motor neurons healthy.
So the nerves that go to the muscles need a certain protein around to stay healthy and if these proteins aren't around, the motor neurons start to degrade, it starts to not work properly so that you have muscle weakness. And in folks with spinal muscle atrophy, what happens basically is these proteins aren't coded properly. So they don't work correctly. And the type of spinal muscle atrophy that a child has is determined by what set of these proteins get made.
So the result of having an improper set of proteins is that the motor neurons start to degenerate. And of the three types of spinal muscle atrophy that we're going to start to talk about here, Type 1 is also known as Werdnig-Hoffmann disease. That's the most severe. Type 2 SMA is Dubowitz disease and it's less severe and then Type 3 is Kugelberg-Welander disease and this is the least severe.
The symptoms of SMA really, the basic symptom for all three of these types is progressive weakness of muscles. It's just when the weakness starts, how long it lasts and how severe it is, that's what differentiates between the different types. And again, it's just a matter of what proteins are not being made correctly that determine all of these.
Type 1 SMA, this is really a devastating disease and babies who have it are floppy pretty much from birth. They have difficulty holding their heads up. It progresses fairly rapidly to labored breathing and can lead to respiratory infections and apneas so I mean even the muscles that make you breathe become weak.
And most children with this die by their first birthday. Nearly all of them die by the time that they're two years old and unfortunately, this type of spinal muscle atrophy accounts for 60% of all SMA cases. Now Type 2 is the less severe ones.
Symptoms with Type 2 SMA emerge 6 to 18 months of age rather than at birth, and the progression of weakness various greatly from child to child. Many sit up finally in six months, but then the weakness begins and most of them never walk independently. They need help walking. They never walk is very common and they need wheelchairs from a very young age.
Life expectancy is really determined by the severity. Some of them die in childhood, but the majority do live into adulthood. But again, the weakness usually progresses to the point of being wheelchair-bound and nearly everyone with Type II diabetes, including the person and our listener was asking about. And respiratory infections are the most common cause of death. So again when you're not taking big deep breaths, it's easy for bacteria to get down into the lungs and grow down there and cause pneumonia and that can become life-threatening.
Now Type 3 SMA, again, the onset in progression very widely, onset typically now as anytime between 18 months and early adulthood. All of these folks have difficulty walking. Some become wheelchair-bound, others don't. Some just have mild muscle weakness but there's still the increased risk for respiratory infection but most with Type 3 SMA do have normal life expectancy.
So what's the treatment for SMA? Well, it's supportive. You want to aid them — there's no way to make their muscles stronger so you want to aid them in whatever way you can to overcome the muscle weakness that they have. Again, through keyboards, wheelchairs, just physical medicine-type stuff to really help improve the quality of life. And then you want to watch for an aggressive retreat respiratory infections because pneumonia is very serious for folks who have this.
Again, why not just give the required protein that they need. Again, you need that protein at the cellular level. You need the body to be making the protein, not giving it, because you just aren't going to be able to get enough of the protein down to the cellular level where it's needed to make a difference.
Again, gene therapy is something that can help with this so if you could change the DNA, so that the person encodes for the proper protein theoretically could do this. We're not there yet, but again research is ongoing and hopefully someday, we'll be able to do that.
So I was going to mention too, here in Nationwide's Children's Hospital, we have one of the Top Rank Pediatric Pulmonology Programs in the Nation according to U.S. News and World Report and we're just one of a handful of centers designated as a cystic fibrosis translational research center and they are working hard to find the cure for this devastating disease. We do have some resources for you, links in the Show Notes at pediacast.org with more information about cystic fibrosis and spinal muscle atrophy.
Alright, we are going to take another break here real quick and then we're going to come back and talk a little bit about febrile seizures. Christopher in Cleveland asked a question about that. And we'll hear from Christopher right after this.
Alright, we are back with our In-Depth segment on febrile seizures and Christopher in Cleveland says, "Hi, Dr. Mike. I just wanted to drop you a line summarizing a recent scare we had and was hoping to hear your insights and perhaps spread the word to other new parents out there.
We have a very active and curious 17-month old son at home. He is our first child so no prior experience parenting. He recently had what we thought was a slight cold. He had a runny nose, a suppressed appetite, a little bit lethargic.
And on a Monday morning, we're watching cartoons in bed with my wife, he started to shake. She thought maybe he was just shivering so she wrapped him up in a blanket and cradled him in her arms. His shaking continued and she saw his eyes rolled back. He was still breathing but then it become very rugged.
She immediately called 911 and paramedics showed up within minutes, benefit of living close to a fire station. He was unconscious but breathing. They had stabilized him in the ambulance and took him to the local emergency room. Once there, they examined him and found his temperature to be 102.5 degrees Fahrenheit.
My wife had checked his temperature 20 minutes prior to all these and it was 99.4. We were told that this was a febrile seizure and could have been brought on by the sudden rise in temperature. If this is accurate, can that be the case, what are they, we've never heard of them before. Are these some obscure condition or is it a case of new parent syndrome and that we've never just heard of it?
This all just happened this morning and it shook my wife up pretty bad. We had an appointment to follow up with our son’s pediatrician in the morning. He is concerned but not alarmed. The hospital had kept him informed while we were there. Thanks for your wonderful podcast, Dr. Mike, and welcome to Ohio. Sorry about the weather, Chris.”
Well, thanks for your question, Chris, and the nice welcome to Ohio, we appreciate that. My daughter actually, I kind of went through what you went through. I was an intern at the time, so it was my first year of being sort of a pediatrician, alright. I was a pediatrician in training, fresh out of medical school and we were moving from a town home to our first house. And everything was in boxes including the thermometer.
And I had just gotten home from work. My wife informed me that our daughter was hot and had a fever and that she didn’t even know where the Motrin was and she was going to run out to the pharmacy and grab some Motrin and also run and bring us back some dinner and could I just hold our daughter until she got back.
So I sit down on a rocking chair, holding our 18th month old at the time and she starts to have a seizure. And being fresh out of a medical school, I really sort of experience the seizure more from a parent’s viewpoint than from a doctor’s viewpoint, so I was just too new of a doctor. And it’s scary. She got stiff, she started shaking, she was not responsive.
And the whole thing only lasted for about five minutes, but boy, when your child’s having a seizure in your arms, it seems like it’s lasted a whole lot longer than five minutes. And as it turns out, it was a febrile seizure. So I agree with you, it is a scary situation, but it’s very common. So this is not some obscure thing. Febrile seizures are very common. They’re actually the most common childhood seizure disorder.
Now febrile seizures in kids are divided into three types: simple, complex and symptomatic. Simple ones are the most common and they occur in the presence of a fever in children who are six months to five years old. The seizure is generalized tonic-clonic so there’s stiffing, shaking and lasts less than 15 minutes. This happens in a child who has no history of significant neurological problem and the neurological exam after the seizure episode, after – they have sort of this time period where we call it being post-ictal over. They’re sort of sleepy but they’re awake, but not as responsive as they normally would be. So you kind of get them past that sort of post-ictal period. So let’s say 30 to 45 minutes after their seizure, by that point, they should have a normal neurological exam.
And you have to ensure that the fever that they’re having is not caused by meningitis or encephalitis which is an infection of the brain or the fluid in membranes that are covering the brain. So again, a simple febrile seizure is a healthy kid, no neurological problems, they have a reason other than meningitis or encephalitis for having the fever and they just have a brief seizure associated with their fever.
Now a complex febrile seizure is a little bit different. In this case, the seizure maybe focal rather than generalized. So instead of their whole body going stiff and shaking, you know maybe just an arm does it or a leg does it or a focal seizure rather than it being generalized or it’s a prolong seizure meaning that it lasts longer than 15 minutes or they have multiple seizures in close succession with one another. So that would be the definition of a complex febrile seizure.
A symptomatic febrile seizure is a child who has a pre-existing neurological abnormality or their neurological exam after the seizure episode is abnormal or if the child has meningitis or encephalitis at the time of the fever and the seizure. That’s sort of how we classify febrile seizures and most kids are going to fit into the simple febrile seizures.
And those kids don’t necessarily need to see – they need to see your pediatrician or they need to be seen in the emergency room or an urgent care center but they don’t necessarily need long-term follow up or need to be seen by a pediatric neurologist. On the other hand, if you have a kid with a complex febrile seizure or a symptomatic febrile seizure, then they usually need to be seen by a specialist.
Now again, we’re just doing this for general information only. If you’re child has a seizure, they need to be seen. And you worry a kid can have a fever because of a mere infection, but be having a seizure because they have a new brain tumor, or because they just fell and hit their head and they’re having a seizure because of a head injury.
So we’re talking about normal – normally kids having known us that you can identify they have a fever from it and then they have a seizure. But they still need to be seen by someone even though we’re going to say, hey, simple febrile seizures aren’t really that big of a deal. You still want to see someone to make sure that your child’s seizure is a simple febrile seizure and not something else that’s going on.
So what causes febrile seizures? Well this is one of those big misconceptions in pediatrics. So a lot of people think that fevers are bad and that a fever can cause a seizure in any kid. And that’s really not true. A current thinking suggests that most febrile seizures occur as a result of a rapid rise in temperature after a long period of temperature stability in a person with a genetic predisposition to this happening.
Now what does that mean? So what it means is that most kids to have a febrile seizure first, you have to have sort of a genetic predisposition to this. So a lot of times you’ll hear kid who has a febrile seizure, it runs in the family. There’s other instances of febrile seizures and other kids in that family. So there seems to be a genetic group of people who are more susceptible to having seizures with fever compared to other groups of folks. So we know that there’s a genetic thing at play here.
The other thing is it seems that in most kids with febrile seizures, it’s not how high the temperature goes, but it’s how quickly it changes especially when the temperature has been one thing over a long period of time. So if you have a kid, you noticed he has a normal body temperature for a weeks and weeks and weeks, and suddenly they spike up high and they’re genetically predisposition to this happening, that change, rapid change in body temperature, their brain reacts sort of by rebooting and when it reboots, the beginning of the brain starting to say, come back active, is a brief seizure.
So that’s the most typical scenario and what that looks like at a hey, my kid’s at home kind of thing is that you have a kid who seem – maybe they seem a little sick but they don’t necessarily have a fever yet and suddenly they have this brief seizure. And then you feel that they’re hot. So the seizure happens at the onset of the fever, that first spike-up. And so sort of the first evidence that they even have the fever is when they have the seizure, then they feel hot. So it’s less common to have a kid who has a fever and then they have their seizure.
So my own daughter had a little bit of a different presentation. She had the fever and then she had the seizure. So again, it’s not everybody, of course, my daughter would be the one who unlike most. But in most kids with febrile seizures, it happens with that first spike in their temperature.
Now again, I said most. There are exceptions. In some kids, they have the high fever and then regression to normal temperature, after that hot spike is what provokes it. And again, usually it follows whatever family pattern that you have, but that sudden rapid rise is the most common trigger.
The take home here is it’s not the temperature that’s causing the damage. It’s really more temperature change, it’s the brain reacting to temperature change. It’s not high temperature-causing damage. That we know. It’s more temperature change, this is how the brain responds in some people.
That’s sort of a bottom line, we don’t know why. We still really, there’s not been any research to explain why the brain responds in this way to changes in body temperature, but we do know in the case of simple febrile seizures, it’s not dangerous. So the kids don’t die from simple febrile seizures.
Now if they weren’t really having a simple febrile seizure, they had meningitis or they had hit their head at the same time that they have a fever because of a near infection and that’s why they have a seizure, then we’re talking about something different. And that again is why you need to see a doctor when this sort of thing happens.
Now what about frequency and patterns? Well in the United States, 2% to 5% of all children between the ages of six months and five years who have a febrile seizure. And 70% to 75% of those have simple febrile seizures. 20% to 25% will have complex febrile seizures and 5% who had the symptomatic febrile seizures.
Children who have had a febrile seizure are more likely to have another one. A third of children who have one will have another one at some point before age five and if the first seizure is prior to 12 months of age, the chance of recurrence is 50%. If the first seizure is after 12 months of age, then that chance reduces to 30% and this again, reflects the fact there is some genetic component to febrile seizures.
Kids with a history of febrile seizure have a slightly increased risk of epilepsy and epilepsy is a chronic seizure disorder. We have seizures that take place not necessarily in the presence of fevers, but just happen. The rate of epilepsy for kids with a history of febrile seizures is around two and a half percent which is twice the risk of the general population. But it’s still low risk.
Now what do you do when a febrile seizure happens? Often, the seizure is the first sign that there’s a problem especially if it’s with that first rise in temperature. And as a parent at home, you always want to address the ABCs first: airway, breathing, circulation. And it’s a good idea for parents of kids of any age to have CPR class under your belt.
Call your local red cross, call your local children’s hospital, have a CPR class so if something happens at home with your kid, well you want someone calling 911 but you want to be able to address airway, breathing and circulation through CPR as well. So if you’re child’s having a seizure, you want someone to be calling 911, you make sure your child’s in a safe place, make sure you’re addressing their airway, their breathing and their circulation, and you want to keep them on your lap or on the floor, away from objects where they can hurt themselves.
You definitely call 911 especially if they’re blue in the face, they’re not breathing, if the seizure’s lasting more than 15 minutes, all these things you want to get help especially if it’s the first time that your child’s had one of these.
And then your child should be examined to determine the cause of the fever and to make sure it really was just a febrile seizure. You want to be either be seen by your doctor, seen by an emergency department, an urgent care center, you really want someone to address that and make sure that, that is what it is.
Now if they’ve had one febrile seizure and then they have another one and then they have another one down the road, not right away, like six months later, do you need to see someone every single time? Not necessarily if it’s a simple febrile seizure, but again, talk to your doctor about that. At least call them on the phone. Someone’s always on call for your doctor and talk to him whenever your child has a seizure.
In terms of work-up for febrile seizures, really little work-up is needed for simple febrile seizures especially if the fever has a known source. But this again, this is more advanced PediaCast. I’m talking now, more to pediatricians and residents and medical students.
Blood count may be helpful to determine if it’s bacterial versus a viral process that’s occurring; electrolytes may be useful if the child has a history suggesting they might have an electrolyte problem causing the seizure, for instance, if they have diarrhea. EEG is where they put the electrodes up to your head is not indicated for simple febrile seizures. So that if you have a kid with complex febrile seizures or symptomatic febrile seizures and they may be seeing a pediatric neurologist and then probably would get an EEG. But for with just simple febrile seizures, it may not be needed.
Now if your child is less than six months of age and maybe between 6 to 12 months of age, your doctor may suggest or strongly suggest a spinal tap to rule out meningitis. If your child is older, say 12 months to 18 months or older, then would they need a spinal tap to see if they have meningitis? That’s going to depend on the circumstances. Not all kids with febrile seizures are going to get spinal taps, but if you have a kid who’s very irritable or have a stiff neck with their high fever, you can’t find the source of their fever, those kids may end up needing spinal taps.
Also, there are also imaging studies that can be done with febrile, CT scans or MRIs to look at the head and again, those are going to be most helpful in kids with complex febrile seizures or symptomatic febrile seizures to make sure that there’s not some other thing other than just simple febrile seizure going on or did they hit their head, is there a tumor, those kinds of things.
So things like spinal taps, CT scans, MRIs in kids who have seizures may be some things that need to be done or it may not need to be done. It really just depends on the presenting history and the physical exam. And that’s again is why you really want to see a pediatric practitioner with this, either with your doctor, an urgent care or emergency department.
And again, it makes most sense if you can, to have a pediatrician be the one to do this evaluation to make a decision on hey, can we just call this a simple febrile seizure or do we need to look further and do things like spinal tap and CT scans or MRIs or EEGs or electrolyte panels or neurology referral. So again, this is not something you manage at home.
In terms of a prevention, there’s really no good way to prevent a febrile seizure, but if your child has had febrile seizures in the past, you really just when they’re sick want to aggressively treat the fever with Motrin and Tylenol to try to prevent quick temperature changes so that they don’t have another seizure. Although oftentimes, it just doesn’t work because the first time that they’re sick is sometimes the febrile seizure. So there’s really no good way to prevent that.
But if your kid has the pattern of well, no, they have their seizure more when the temperature goes from being high back down to normal, that’s what causes them to have their febrile seizure, then those kids you may want to – of course, you need to call on your doctor. You did the Tylenol or Motrin, the fever comes down, then they have their seizures. Even in that situation, you may not be able to actually prevent the seizure.
I think the take home here really, and well first, let me say the good news. The good news is in the end, the overwhelming majority of febrile seizures are not harmful even when they recur. And kids usually outgrow the tendency to have febrile seizures by the time of their school age. So usually by age five or six, the tendency to have febrile seizures is going away.
But the take home here, is that fever – febrile seizures are not because you have this high fever and this high fever causes some sort of brain damage which cause the seizure. That’s not what happens. It’s really that change, that rapid change of temperature and it’s just a response of the brain. It’s not from damage, it’s just response in people who are genetically predispose to having this happen.
So I’m really hoping that, that helps you understand a little bit better. We do have 11 links in the Show Notes to use to some more information about febrile seizures. So just head on over to pediacast.org and it will have a link for you so that you can read more about febrile seizures.
Alright, we have of course, gone way over our hour, as usual. And we’ll be back to wrap up the show right after this.
Alright, we are back, just basically to say goodbye. Thanks a lot go out to Nationwide Children’s Hospital once again for taking us under their wing. And you’re going to be hearing a lot more about this wonderful institution and we’re going to be using the resources of the hospital and the network of specialists and sub-specialists and so we’re really excited about it.
And of course, we also want to thank Vlad over vladstudio.com for helping us out with the outwork at site. And of course, we want to thank listeners like you. I want to remind you, iTunes reviews are very helpful. I know a lot of you have discovered PediaCast through iTunes and so by providing a review, you could help us recruit new listeners. Also, if you want to mention us in your blogs and on Facebook, and again, if you do mention us in your blog, shoot us a link to it and we’ll include that on our blog as well over the Show Notes so that we can help each other.
We also have applications available in the Android store and very soon, in the Apple store so you’ll have a PediaCast app for the iPhone and iPod Touch that should be coming out here shortly. Again, all of these things to say why do we want to get out the word about PediaCast? It’s not to toot our own horn really, it’s not. It’s to empower parents, we just want the best information in your hands as you think about your child’s health. So with just help us spread through iTunes and your blogs and Facebook, that will be very helpful.
Also don’t forget, if you have a question or comment for us, it’s really easy to get a hold of us here at PediaCast. Just go to pediacast.org and you can click on the Contact link. That comes directly to me, I read every single one of those. You can also email email@example.com. And again, just get those questions and comments in and we’ll try to get them on the show for you.
Alright, until next time which hopefully, will be soon. This is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long, everybody.