• Head Trauma Watch and Wait
• TVs and Daycare: A Bad Combination
• Should All Teens Have EKGs?
• Gastric Bypass (Bariatric) Surgery for Teens
• Sexy Clothes for Young Girls: Enough Already!
• An Apple a Day Keeps the Doctors at Play
• Backyard Trampolines
• Daytime Wetting
• Tick Bites / Lyme Disease​

Links

• TV Viewing Guidelines from the AAP
• Bariatric (Gastric Bypass) Surgery Program at Nationwide Children's
• Center for Healthy Weight and Nutrition at Nationwide Children's
• AAP Trampoline Policy
• Lyme Disease Treatment and Prophylaxis Recommendations

Transcript

Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital, for every child, for every reason.

[Music]

Announcer 2: 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's Dr. Mike. And it's episode 161 for May 11th 2011. And we're calling this one Head Trauma, Sexy Clothes and Lyme Disease.

Of course we have lots more heading your way as usual, although not quite as much as a typical show. Although I think we'll probably go just as long. It never seems to matter exactly how many segments or what we have planned. We usually find a way to fill the hour and I think that's just a reflection of my very talkative nature. But thanks to you for putting up with it because I appreciate it and I love our time together. And see I just kind of prolong it by talking more and more, sort of what I'm doing right now.

But anyway, we don't have a third segment for this show. We have a pretty extensive News Parents Can Use portion of the program and then we're going to get to answering your questions. I really spend a lot of time since our last program getting our interview setup because now that the studio is ready and we're able to have interviews, it's just a matter of them started. And it's just taking a lot of legwork, contacting people, getting things scheduled. But we do have lots of exciting stuff in the works.

02:11

So if you happened to be the one that wrote in a question, for instance about multicystic renal dysplasia and polycystic kidney disease, never fear, it won't be long. We will have a pediatric nephrologist joining us here soon to talk about those things.

Also we had some people write in about blood clotting disorders, Von Willebrand disease, so we're going to discuss those. We also have a pediatric plastic surgeon lined up to talk about cleft palate and the GI specialist lined up to talk about celiac disease. So we're getting this stuff into motion and within the next couple of weeks we will start to have actual interviews.

So anyway, I've been busy doing that and ran out of time preparing this show. We got the news segment and some answers to your question, but then I had to make a decision we're we going to go ahead and do a research round-up and then put off getting this show recorded and produced and out to you for another week or just go for it. And so I just went for it because I figured you'd like a little information is better than no information for this week. Although little information is a hardly an accurate description.

We've actually got lots of stuff we're going to talk about today. For instance, the FDA is warning parents about the use of baby teething gel, we're going to talk about that. Also head trauma, should you watch and wait or should you get a brain CAT scan if your kid's acting funny? Also TVs and daycare centers, they make a bad combination. And what your daycare center is doing with your child while they're there may be of interest to you, so we're going to discuss that.

Also, should your teenager have an EKG, just a routine EKG, whether they're going to play sports, whether they're active, not active, just should all teenagers have an EKG to look at their heart? Well some folks have something to say about that and we're going to discuss it.

Also gastric bypass, also known as bariatric surgery for teenagers. Sexy clothes for young girls, enough already. And an apple a day keeps the doctors at play. That's all coming in the news segment.

04:25

And then when we get to your questions we're going to talk about backyard trampolines, daytime wetting as in peeing your pants during the day in little toddlers, we're going to discuss that. And also tick bites and Lyme disease.

Don't forget if there's a question that you would like ask or you have a comment for us or a topic suggestion for when we get the specialists in the studio, just write in to pediacast.org, if you click on the Contact link there you can write question or your comment. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

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

And of course your use of this audio program is subject to the PediaCast Terms of Use Agreement, which can be found at pediacast.org.

I had my introduction all set here and we're going to talk while the intro music was going out and did have to talk about the fact that the specialists are coming, it's just a matter of getting to our first one. When you're scheduling physicians who are busy in their clinic and/or doing research it does take some time to find a spot in their schedule when they can stop by. But we're getting there. We're getting close and we've got the one scheduled.

06:03

So anyway, I was excited to tell you about that and I completely skimmed over a couple of other things I wanted to talk about in the intro, which seems like they don't really matter as much now that we're further into the show.

But I'm still going to mention it because they are important to me. First of all, the weather. I know in the intro we talk about the weather a lot, but when you're in Ohio but you spent the last few years in Florida, when the cold weather is finally turning warm it's an exciting thing. And we're definitely getting into Spring, it was in the 80s yesterday, it's supposed to be in the 80s today. Moving forward, it's going at least be in the 70s every day.

So this is exciting, the sun is shining. And I just wanted to mention that the family, we went to the Columbus Zoo two days ago. And I was reminded just how great of a zoo that it is. Of course as usual we're not getting any kickbacks from the zoo.

But I lived, I mean literally, in Walt Disney World's backyard for the last few years and we went to Animal Kingdom regularly. I mean when you live that close you have an annual pass and take advantage of being able to just pop in and out of the parks for an hour or two at a time if you like. So we did go to Animal Kingdom quite a bit and I've been to lots of other big time zoos. We've been to the San Diego Zoo, we've been to the Brooke Park Zoo in Chicago, I've been to the National Zoo in Washington DC.

And I have to say the Columbus Zoo is an amazing place. And if you ever find yourself in Central Ohio, make sure you check it out. It's the zoo that Jack Hannah started and it's an amazing place, it's a beautiful place, great animals, great environment, great time. Anyway, I just wanted to mention it's a great place to take the kids if you find yourself in the middle part of our Buckeye State here.

OK. So let's go ahead and move on. We're going to take a break and we will be back. We're going to talk News Parents Can Use and it's all happening, right after this.

08:32

All right. Our News Parents Can Use, this is going to be a little bit different this week as well. And my regular listeners who have been 'in' in with the program for a long time, I'm not going to say from the beginning, but if you've been around PediaCast, you've been around the PediaCast block, let's say, you're going to notice a different tone to the news segment this week.

And basically, rather than it being a packaged segment, this week it's going to be a little more conversational. And the only reason I bring attention to it is (1) it's going to be obviously different, if you've listened to PediaCast a lot in the past, you're going to be like hey, this is not like a normal news segment.

And I just want your feedback. If you could just pop me a line at pediacast.org on the Contact page or shoot me a quick email at pediacast@gmail.com. I read all of those personally and I just like to get your feelings on whether you like the new segment as more of a package deal where we're more news or this conversational tone.

OK. So first stop the FDA is warning parents not to use over-the-counter teething gels and these include products like Anbesol, Orajel and Baby Orajel. These products as it turns out contain benzocaine that's a numbing agent. But it can cause a rare but potentially fatal blood disorder called methemoglobinemia.

So this is interesting. You've heard of hemoglobin before. Hemoglobin is the oxygen-carrying molecule that's in red blood cells. And benzocaine is one of several substances that result in the oxidation of hemoglobin turning it into a substance called methemoglobin.

And methemoglobin has an increased affinity for oxygen. So what does mean is it holds on to the oxygen more tightly so the oxygen bonds to the red blood cells but it can escape from the red blood cell because it has such great attraction to the methemoglobin.

And so the tissue becomes hypoxic. There's plenty of oxygen in the blood but the red blood cells can't release the oxygen so the tissues don't get the oxygen that they need. And if there's enough hypoxia, if the brain is not getting enough oxygen, you can become unconscious, you can have seizures, you can have permanent brain damage and cardiac arrest. So this is serious stuff.

10:55

Benzocaine is also present in ear numbing drops. So parents with real small babies you want to be careful using those as well. Now here's the deal, will all kids and even small infants as most of them we're talking about here under the age of six months, will these young infants and young kids who are exposed to small amounts of benzocaine is this sort of thing going to happen to everyone?

And of course the answer to that is no, obviously, because there's a lot of parents out there in the past who have used teething gels and there's a lot of babies who get numbing ear drops when they have bad ear infections. So no, it doesn't always happen.

Again, infants under six months of age are most susceptible to this. But some babies and it's hard to know who these babies are until something bad happens. But some babies are born with a deficiency of an enzyme called methemoglobin reductase. And this is an enzyme that turns methemoglobin back into regular hemoglobin.

So if you're born with the deficiency in this enzyme, you're body has a harder time undoing the damage that the benzocaine caused to the hemoglobin. So kids who are born with the deficiency in the enzyme are more likely to have this problem. But the problem is you can't tell who is born with the deficiency in that enzyme until the situation shows itself. So that's why this can be a significant issue out of the blue.

Of course if you have normal amounts of methemoglobin reductase, if your benzocaine exposure and subsequent conversion of hemoglobin to methemoglobin is large enough, you may use up all of your methemoglobin reductase. Even though you're starting out with normal amounts you may use it all up and so your body doesn't have the capacity to turn anymore methemoglobin back into regular hemoglobin and you still wind up with a problem.

12:53

By the way, benzocaine isn't the only chemical that can cause this issue. Sulfa antibiotics and nitrates, which are sometimes found in drinking water, can also cause this problem. Now, some of you may be saying wait, my baby had a urinary tract infection and was treated with a sulfa antibiotic or even my baby is on a daily dose of sulfa antibiotic to prevent urinary tract infection because they have a condition of a vesicular utero reflux. So you may be asking yourself, wait a minute, isn't that dangerous? Should my child really be on a sulfa antibiotic if it can do this?

In the end it can be dangerous, especially if your child has a methemoglobin reductase deficiency. But remember this is a rare occurrence and as we talk about frequently on PediaCast, you have to look at risk versus benefit.

So is the benefit of treating a baby who has a urinary tract infection or to a UTI in a baby, which can then lead to kidney damage, can cause sepsis or blood infection and ultimately cause death, is treating them with an antibiotic that's known to be quickly effective is that benefit outweighed by the risk of a rare occurrence? Probably not. In that case, the benefit of the antibiotic is probably worth the risk or is worth the risk because of the fact that this occurs so rarely.

14:15

Now parents could say the same thing about teething gel since many parents out there who use it they're going to say, hey, wait a minute, this is such a rare occurrence, risk versus benefit, is the benefit of using the teething gel worth the risk is this is such a low, low risk?

Well, I question personally and I know that there are a lot of doctors who agree with me on this, I question if teething really hurts to begin with, that much or at all. And you look at older kids who have teeth coming in, it maybe itchy, it may kind of feel a little tingly. Even when wisdom teeth are coming in or molars are coming in as kids get older, wisdom teeth is kind of a bad example if they're impacted and they're pushing on things that they shouldn't be pushing on like bone and other teeth, I meant molars.

So as kids are school age and then 12 years old or so and they're getting more molars, you don't have kids crying that they're in terrible pain when new teeth are popping to the gums. So I do question whether kids really need teething gel in the first place. And kids certainly have lots of other reasons to be fussy including colic, which we've talked about before which probably is not related to an intestinal disorder even though it may seem like it by the way the children are behaving when they have it.

But anyway, babies are fussy and they're also teething. So it's easy to say hey, they're teething, they're fussy, teething must hurt. But really that is a leap and I'm not convinced that it's a true association. So if a kid doesn't really need teething gel because they don't really have gum discomfort to begin with, then is it really worth the risk?

And probably not at that point because there's a difference between treating something that could cause sepsis and death versus something that may be causing a little discomfort. So that's where the whole risk versus benefit thing comes into play. And I think that's really what the FDA is trying to say here that it's not worth the risk for that, for possible gum discomfort.

16:27

All right. Let's move on. We've recently talked about ways that doctors and parents can minimize a child's exposure to radiation by not getting unnecessary X-rays and CAT scans. Well, a study is set to appear in the June issue of the journal Pediatrics suggests that too many brain CT scans are being done on kids who present to emergency departments with head injuries.

And this study was a joint venture from the people of the Children's Hospital Boston and University of California Davis. The researchers combined data 25 different emergency departments. They looked at 40,000 kids in total.

And Dr. Lise Nigrovic of Children's Hospital Boston said, "There are actually three groups of patients that come in to an emergency room with pediatric head trauma. The first is the child that really has no symptoms and it's obvious to the doctors that the child is fine. The second is the child that has all the major symptoms, they have vomiting, headaches, they may have been unconscious, perhaps they have bleeding and that child is obviously a candidate for a CAT scan. But it's the children in the middle risk groups, those who don't appear totally normal but whose injury isn't obviously severe. Those are the kids whom observation can really help."

And in this middle group the researchers observed them for a period of time rather than going straight for the CAT scan and the idea is this, kids that are in this middle group are either going to get better, they're going to get worse or they're going to stay the same. If they get better and their symptoms completely resolved, you send them home. If they get worse, you get the CT scan. If they stay the same, you watch them longer or decide based on your clinical judgment and the parents' comfort level are you going to send him home or you're going to get a CAT scan?

But the majority of kids are either going to get better or they're going to get worse over a period of observation. And in this study, the researchers showed that their plan of watching and waiting to be a reasonable and safe one.

18:24

Now the next question becomes how long do you watch these kids? Guidelines from the American Academy of Pediatrics recommend a four to six-hour observation period. But researchers in this study say the length of ideal observation time is not clear and that something that should be studied further.

I think the biggest roadblock here are parents who go in to the emergency department with the idea that their child needs a CAT scan because a coach or a trainer or a friend or another doctor told them that that's what they need. And in their mind a CAT scan will put them to ease and allow them to sleep comfortable at night knowing that the inside of their kid's head is fine. And the CAT scan will also let them leave the emergency department a lot sooner than spending another four to six hours in the emergency room doing a watch and wait kind of thing.

The idea of having to stay and wait and watch is not really a great thing to most parents. But remember we're talking risk versus benefit. Brain CT scans can give you immediate reassurance and they're fast but they also expose your child to lots of ionizing radiation which increases their lifetime risk of developing radiation-induced tumor.

So the bottom line here for parents, I think, if the ER doctor is recommending a period of watchful waiting in the emergency department, go for it. I know it's an inconvenience, I know it's not the place you wanted to spend your evening, but don't pressure them into getting a CAT scan.

And if your child isn't acting right, but they don't have major symptoms, they don't have recurrent vomiting, they don't have a severe headache, they're just acting a little funny and the ER doc wants to get a CAT scan, I think it's reasonable to say hey, what do you think about just watching things here for a few hours?

I think that's something that's a reasonable thing for parent to bring up if you have a doctor who wants to go straight for the CAT scan and your child isn't having severe symptoms like there were unconscious for a while at the scene or we're worried about a skull fracture or they have vomiting that just keeps going on and on or they have the worst headache of their life. Obviously, those kids need the CAT scan but if you find yourself in the ER and your kid's in that middle group and the doc wants to get a CAT scan, as a parent, speak up, what do you think about just watching for a few hours? You have some science to back you up on that.

20:46

All right. TVs and daycare centers. A study presented earlier this month at the Pediatric Academic Society's conference in Denver, Colorado showed that many kids in daycare centers are plopped down in front of TVs rather than experiencing opportunities to play and enjoy hands-on learning.

The study looked at 255 commercial daycare centers in Ohio and did not include in-home daycare providers. Seventy percent of the daycare centers had at least one TV and of those 10% left the TV on in the background all the time and 60% failed to meet the American Academy of Pediatrics' TV Viewing Guidelines. And there is some good news, 80% of the daycare centers prohibited TV viewing for kids who are under the age of two.

So parents, if you are concerned about your child's media use at home and you should be, you'll want to know how much screen time that they're getting in their daycare setting. And if you're in the market for a daycare this is probably one of the things you should be looking at and asking about. Is this daycare center following the American Academy of Pediatrics' guidelines for TV viewing?

Now what exactly are those guidelines? Well if you check out the Show Notes at pediacast.org, we'll have a link to you to the AAP's website that has all the details on their TV Viewing Guidelines.

22:04

OK. Moving on to EKGs. Has your teenager ever had one and if not should they? A new study suggests that checking an EKG, it's where you put the electrodes on the chest and you get the strip that comes out of the machine; it's got the heart rhythms on it; a new study is suggesting that checking an EKG on all teenagers regardless of sports participation, regardless of activity level, regardless if they've had any symptoms or there's a family history, just getting an EKG on everybody, this study suggests that that could save thousands of lives.

The research behind this was recently presented at the Heart Rhythm Society's annual scientific meeting. The researchers looked at kids between 2006 and 2010 and they did EKGs on over 50,000 teenagers between the ages of 14 and 18 and they included athletes and non-athletes in 32 different Chicago schools.

Of those who were screened, over 1,000 had an abnormal EKG, of those 150 had evidence of left ventricular hypertrophy. Let's break that down – the left ventricle, remember the heart has four chambers, two pumping chambers and of the two pumping chambers the left one is the one that pumps the blood to the entire body except for the lungs; and if that is thick or a little bit too big, a little bit too thick and stiff we call that left ventricular hypertrophy.

And that's a condition that can progress into a disease called hypertrophic cardiomyopathy and that's a common cause of sudden cardiac death in teens. So 150 had evidence of left ventricular hypertrophy but didn't have any symptoms or problems to make them think that there was an issue.

Another 145 of them had a prolonged QTc wherein you do some math on the EKG and it potentially could mean that someone has a disease called the prolonged QT syndrome. And prolonged QT syndrome is another common cause of sudden cardiac death in kids that often has no symptoms before it happens.

24:18

The study's lead author, Dr. Joseph Marek said, "I think we should do this testing and find the kids who are at risk for sudden death and potentially save their lives. To me as a parent, this is a no-brainer. I think doctors should be recommending EKGs to all of their teen patients."

Now, there are of course those who disagree. And the study only identified the number of kids with abnormal EKGs. It did not go on to find the rate of confirmed disease. So even though 150 had evidence of left ventricular hypertrophy and 145 of the kids had prolonged QTc, they weren't ultimately diagnosed with prolonged QT syndrome.

So it's a little stretch for the authors to say that all of these kids would have a problem because they might not. We don't know how many of these 50,000 kids they looked ended up with confirmed disease.

And as we've talked about before on PediaCast, it was just a few weeks ago that we talked about EKG and pre-sports screening and talked then that EKGs can be falsely abnormal, meaning a child has an abnormal EKG and then they go on to have more costly and possibly invasive studies; they go see the cardiologist; they may have an echocardiogram; they may have more invasive things done and they're held back from playing sports while you're doing this evaluation, only to ultimately find that there was never a problem to begin with.

So the naysayers claim the number of healthy kids with a falsely abnormal EKG may be as high as 10-40% and sending all those kids on for further evaluation by a pediatric cardiologist could swamp the medical system.

But Dr. Marek points at that only 2% of his study population would have required further workup, which is a much more manageable number than what had previously been thought.

I should note also that this study was presented at a scientific meeting. It was not published in a peer review journal. And the American Heart Association and the American Academy of Pediatrics do not currently recommend routine EKGs for all teenagers.

Some docs do it anyway, others don't. So again, I ask, has your teenager had an EKG and if not, should they? The answer to that question of course lies with you and your doctor, I just wanted to raise a little of awareness.

26:37

And speaking of awareness, here's a story that lots of pediatricians sort of avoid talking about, but not here on PediaCast. We tackle all topics as they come. Gastric bypass also known as bariatric surgery.

It's been shown to reduce the risk of cardiovascular disease and improve the lifestyles of morbidly obese adults. But what about teenagers? Should these techniques of gastric bypass be used for them? It's a controversial question with passionate supporters on both sides of the aisle.

Those on the pro-bariatric surgery side have some new ammunition, thanks to researchers at the Stanford College of Medicine and reported at a Digestive Diseases week meeting in Chicago. Wow! Lots of windy city stuff this week.

And speaking of that, did you know the term 'windy city' was not coined from breezes off of Lake Michigan rather from the extensive verbiage of the city's politicians. It's true. Look it up. But I digress. Back to gastric bypass or bariatric surgery.

Dr. John Morton, that wasn't actually even, it sounded scripted, didn't it? But it wasn't. I just thought the whole windy city thing and I remember reading not too long ago about that being the politicians' windiness and not breezes off the lake.

Anyway, Dr. John Morton, a bariatric surgeon at Stanford, and his colleagues studied 99 adults and 33 adolescents who underwent the procedure between 2004 and 2010. The adults had an average age of 44 years with an average BMI of 52.3 and the teenagers age was 17 with an average BMI of 52.7.

The team looked at several biological markers which they described as things that help predict whether someone is going to have a heart attack down the road. And the markers included diabetes status, blood pressure, lipid levels, cholesterol levels, C-reactive protein and homocysteine levels in the blood.

The researchers recorded these markers pre-surgery and again 12 months after the procedure and they described the results as 'eye-opening'. While both groups lost about 70% of their excess weight, the teens showed far greater improvement in their numbers than the adults. Their blood pressure improved, lipids and cholesterol levels dropped, homocysteine levels plummeted and fasting sugars improved even a year out. And C-reactive protein, which the research team describes as the most predictive of all the markers as it relates to future heart health, dropped from an average of 7.0 to 1.4 over the 12-month study period. Doctors like that number to be less than 3.0, so going from 7.0 to 1.4 is fantastic.

29:20

Dr. Morton admits some of these improvements in the teenage group likely stems from teens being a bit more receptive to doing exercise compared to the adult group. And exercise, he says, is known to improve these markers and reduce risks.

You can't find teenage bariatric or gastric bypass surgery programs everywhere, but we do have an active program here at Nationwide Children's and patients are accepted from all over the country. So if this is something that you've contemplated for your child or your teenager listening and you thought about or you have family or friends that are dealing with obese issues and we're talking largely obese, you have to meet requirements in your BMI and you want evidence of other health problems like heading it toward diabetes or these markers that we talked about being bad.

If you don't have resources near you or even if you do have resources near you, you may still want to check out the Bariatric Surgery Program here at Nationwide Children's. And the program's website has lots of great information so I'll put a link to that in the Show Notes at pediacast.org.

I'll also put a link to Nationwide Children's Center for Healthy Weight and Nutrition because there's a lot of great information on that page as well. And just a heads up on a future episode, I'd like to get Dr. Marc Michalsky, he is our bariatric surgeon here at Nationwide Children's, in the studio.

So if you have questions about bariatric or gastric bypass surgery in teenagers go ahead and send them along to pediacast@gmail.com or use the Contact page at pediacast.org. You can even call the Skype line at 347-404-KIDS and we'll collect your questions and save them for an upcoming interview at a date yet to be determined. But it will be soon. We're definitely going to get him in the studio and talk about gastric bypass surgery in kids.

It's a controversial subject and it's not for everyone. So we'll talk about the pros and the cons and when you do it, when you don't, when does the benefit justify the risk?

31:29

All right. Moving on, clothing for young girls it's too sexy. Me, personally, I say enough is enough. I'm not the only one who thinks so. Samantha Goodin, a student at Kenyon College here in Ohio and Dr. Sarah Murnen, a Professor of Psychology at Kenyon, examined the frequency and nature of sexualizing clothes that's available for young girls, not adolescents. We're talking about toddler and school age kids here.

So they looked at the numbers of sexualizing clothes that we're available on the websites of 15 popular U.S. stores. And their study was published in the journal, Sex Roles. And it found that out of 5,000 clothing items studied nearly 1/3 of them had sexualizing characteristics that emphasized the look of the breasts or placed attention on the buttocks. Four percent of the clothing that they found online at 15 popular U.S. stores, 4% of the clothing included sexualizing characteristics only while 25% combined sexualizing characteristics with child-like features, which is particularly disturbing in my opinion.

The researchers state that confused parents might be persuaded to buy the leopard-print miniskirt if it's bright pink. Clearly, sexiness is still visible beneath the bows or tie-dye colors. We propose that dressing girls in this way could contribute to socializing them into the narrow role of the sexually objectified woman. That's according to the authors of the study.

And why are so many stores making and marketing young girls clothes with sexualizing characteristics? The answer to that is easy, because parents are buying them. The AAP has tackled TV viewing; they've tackled ads for junk food and countless other causes that put kids before profits in their mind. Anything that puts profit before kids such as TV shows, ads for junk food, the sort of thing, the AAP goes after it, the American Academy of Pediatrics.

And in my mind, they should put their sights next on these clothing companies who are sexualizing our youth because really enough is enough.

33:48

All right. That concludes our News Parents Can, oh no, it doesn't, we have one more. I'm sorry. It's my favorite one too. An apple a day keeps the doctors at play. And I'm not talking about fruit here, folks. I'm talking about the other Apple. The Apple who engineered the MacBook, introduced the world to the iPod and forever changed the face of the mobile phone.

It turns out the company is also the darling of the medical profession with 75% of doctors in the United States admitting to owning some form of Apple device. And as I say, here in front of my MacBook Pro and my iPad with the script on it, I can attest to that.

Seventy-five percent of doctors in the United States own some Apple device. An amazing 30% of U.S. doctors are using their iPads right now to access electronic health records, to view radiology images and communicated with their patients and an additional 28% of doctors who don't own iPad say they plan to buy one in the next six months.

These findings were reported by Manhattan Research. They planned to conduct this similar study this Summer looking at how pharmaceutical reps and medical device reps use communication technology.

So there you have it, further evidence that you should share PediaCast with your child's doctor so they can help spread the word about our little evidence-based venture here at Nationwide Children's.

OK. That's a stretch, I know, but I couldn't resist. If they're using Apple devices they're going to be fine listening to or checking out a podcast. So make sure you mention it to them.

All right. That really does wrap up our News Parents Can Use this week. See? Thirty-five minutes on the news segment, so I knew I was going to stretch this out to an hour even without having that third segment.

All right. We are going to take a break and we will be back. We're going to answer your questions, right after this.

[Music]

36:15

OK. I really do want some feedback on that. It was definitely a different flavor of news segment than we have done in the past. So just let me know. Do you like the packaged news where you really copy that I'm reading that's been changed and rewritten with permission, of course, from the people that we use it from.

Medical News Today has really been great to us in allowing us to use their information and stories that they have and being able to rewrite them just sort of fit the spoken podcast-type audience. So we really appreciated them in the past, but I just want to know what you guys think in terms of the flavor of the news.

Do you like the packaged news or do you like the more conversational news? Just shoot me an email pediacast@gmail.com or go to pediacast.org and use the Contact page. It won't take you long. I really would like some feedback to know sort of which direction you think we ought to go with future shows and the news segment.

All right. Let's get right in to your questions.

Elle Richardson in Atlanta, Georgia says, "Thanks for all the great information you provide and the attitude of a teacher that you share with your listeners. What's your opinion both as a doctor and as a parent of backyard trampolines? I tend to be an overly cautious parent but I'm trying to get better and not parent my children from a paradigm of fear. I was hesitant to get trampoline but after lots of encouragement and discussion with my husband we did get one for Christmas. We do have one of the safer, if there is such a thing. One of the higher in brands with the safest style of netting. We have rules about no flipping, one child at a time, etc. And for several months I've been feeling happy with our decision. Our three children, ages four, seven and nine, have spent more time in the backyard than ever before, lots of great exercise and lots of great fun. But then again, there are all of the horror stories that still scare me. The horror stories of broken necks remind me of the horror stories of autism after the MMR vaccine. And while we don't personally know anyone who has broken their neck, we do know several kids who have broken a wrist or a leg on a trampoline. Are we doomed to end up in the emergency room with this backyard death trap? My husband reminds me that the fear of obesity and the couch potatoism should be factored in there too since that health issue is more likely and more common than a broken neck. Help me look at this objectively, Dr. Mike. If I let my fear of broken bones drive my parenting decisions there will be no more gymnastics, no more baseball, no more bike riding and no more trampoline. Will that lead to fat, lazy kids? I don't know. Will that lead to fearful and trepidatious children? Probably. Then again, what if we end up with a broken femur from this crazy contraption that we chose to put in our own backyard? Give me some of your objectives, statistic-driven truth, Dr. Mike. I'm drowning in my duplicity. Thanks – A Recovering Helicopter Mom."

39:10

Oh! I love that! That's one of my favorite listener questions in a while. Thanks Elle Richardson in Atlanta, Georgia. First, I have to say, I had to look up the word 'helicopter mom'. And I'm a little bit embarrassed to say that I had to do that because I try to be hip with the parenting terminology that's out there right now. But I hadn't come across 'helicopter mom' before. But Wikipedia set me straight and it makes sense and now I know that I do know lots of 'helicopter moms' and of course I know lots of what would be the opposite of the 'helicopter moms', there's a term for that. Maybe a 'push-my-kid-out-of-a-plane-without-a-parachute-mom', I know lots of them too. And of course I think the best place to be is somewhere in the middle.

So how many kids break their necks on trampolines? Not many. But it does happen. And how many break their arms or their legs on trampolines? Well lots, lots do that, those are fairly frequent injuries. But how many of the injured kids were following your rules of using a safety net, no flipping, one child at a time on the trampoline?

I know personally most of the kids that I see who come in the course of working in a pediatric emergency department and urgent care network, most of the kids who present with trampoline injuries with broken arms or broken legs were not following those rules. And I do ask and they weren't most of the time.

And while I have seen research studies on the prevalence of trampoline injuries, I haven't seen a study that compares the number of injuries from safe use versus unsafe use. The so-called 'Landmark trampoline study' was actually done here at Nationwide Children's back in 1998 and that study showed that that time, back in the mid to late 90s, that there were approximately 58,000 trampoline injuries per year and of those 1,400 about 3% resulted in a hospital admission and on average about one child died each year from a trampoline injury.

41:14

The study's lead author Dr. Gary Smith, MD, said, "Trampolines were designed as training devices and were never intended to be used as backyard toys. People attempt to do somersaults but they come down on their necks and that can cause a permanent spinal cord injury."

A spokesperson for the nation's largest trampoline manufacturer didn't like this study at all. And that person responded saying, "You're several times more likely to wind up in a hospital from riding a bicycle than from bouncing on a trampoline, but they haven't suggested not riding bicycles."

Now I'm not sure that person's statistics really hold water because I imagine that he's talking about the relative risk of bike riding versus trampoline injury among all kids and so many more kids get hurt riding bikes. But the problem with that statistic is that lots and lots of kids never stepped foot on a trampoline, so of course they're more likely to get hurt riding a bike.

The AAP has something to say about backyard trampolines and I'll include a link to their trampoline policy statement in the Show Notes. In a nutshell, here is what the American Academy of Pediatrics has to say about backyard trampolines, they say, "Despite all currently available measures to prevent injury, the potential for serious injury while using a trampoline remains. The need for supervision and trained personnel at all times makes home use extremely unwise. The trampoline should not be used at home, inside or outside. During anticipatory guidance, pediatricians should advise parents never to purchase a home trampoline or allow children to use home trampolines. The trampoline should not be part of routine physical education classes in schools. The trampoline has no place in outdoor playgrounds and should never be regarded as play equipment."

43:00

So as a fellow of the American Academy of Pediatrics, I'm supposed to tell you not to buy or let your kids ever use a trampoline at home or at school. So I'll say that, Elle Richardson of Atlanta, Georgia, don't buy or let your kids use a background trampoline. There. I did what I was supposed to do.

Now, do I own a trampoline at my house? That's a good question. The answer to that is no and I have to admit it's mostly because I don't have a big enough backyard. If we had a big backyard, boy, my kids have lobbied and lobbied and lobbied for a trampoline.

Have I ever let my kids jump on a trampoline? I have, with rules in place that are similar to yours. It all boils down to risk versus benefit here, Elle. And that's what you were telling me in your question.

You know that I can't tell you what to do. But I can say kudos for your careful thought and analysis of the situation because you had a good handle on it before you ever wrote in. How's that for an answer?

44:04

All right. Let's move on to Tammy in Indiana. Our daytime, not daytime wedding, this is daytime wetting. I have to enunciate.

Tammy in Indiana says, "I have a four-year old foster son who experiences daytime wetting. The foster part is important because he has been through a lot emotionally and I know it can play a role in body function. His parents were exposing him to drugs. They weren't physically or mentally abusing him. He visits his mom four days a week, his dad is in jail. She's been consistently clean and working toward getting her kids back. He does asks sometimes if I will be coming back to pick him up after I leave him with his mom, I say yes and ask if that is OK and he says yeah, I want you too." Boy that's sad. Back to the question. "He frequently has wet underwear, just a spot the size of a silver dollar, not much at all. There are times when I know he went to the bathroom 30 minutes prior and had dry skivvies and then he was wet. A take him to the potty and he cannot get in a urinal. We talked about his body telling him he has to go and he says he goes when it does. Four-year olds do hold it to the last second, I realized. And he has done that three times in three months where he ends up emptying his bladder either on the way to the potty or while trying to undo his pants. I really don't think that is the case for all the wet spots. He does wet the bed so he wears pull-ups at night and that usually occurs four times a week. His urethra is positioned correctly and his flow is strong and consistent. I would like to know if there is anything I can do to help him keep his pants dry and how should I address this with him? He gets a down on himself when he gets wet, he has enough to worry about. I don't want him worrying about peeing his pants. Thanks for your time. Love the show."

45:48

Well, thanks for your heartfelt question, Tammy. First, let me say, you really should take your foster son to the doctor regarding this issue. I know foster moms don't always get lots of feedback or records on past health issues and if you can find out who his regular doctor has been, I'd go there.

Daytime wetting is common and most of the time is functional, meaning there's no really underlying medical condition causing it. But all kids with this should at a minimum have a urinalysis and a complete physical exam. Sometimes as a doctor you will find a kid who has diabetes or a spinal cord lesion or other medical condition and their only presenting symptom is daytime wetting.

Now, those things are unusual and are more likely to present with other symptoms alongside the daytime wetting. But unusual things happen so I would definitely have him checked out. Having said that, let's say you've seen your doctor, his urine is normal, his physical exam is normal, your doctor doesn't have any other concerns. We just think it's a functional daytime wetting problem.

So what causes daytime wetting in the absence of a medical problem in young kids? Well, the most common cause is what I like to call the busy kid or the lazy kid syndrome. And really Tammy, you had the same idea that's why you've been telling him to try and go to the bathroom if hasn't gone in a while and you know he has a tendency to get himself a little wet, so you tell him hey, why don't you go to try to use the bathroom because it's been a while even if he doesn't feel like he has to go.

So you've already done that so you kind of have in your mind that this sort of thing could be happening. So just to sort of catch everybody else up here's the problem, little kids are busy and can be lazy, like all of us, they feel the urge to go potty but they hold it back. And you know what happens when you hold it back the urge goes away. But of course you keep making urine, the bladder keeps filling and pretty soon urine leaks out because there's too much in there; or suddenly you feel like you have to go urgently and you leak out on your way to the bathroom.

And over time if you'd let this happen here's where the real problem is, you let this happen over and over again, your brain starts to ignore the fact that your bladder's stretched out. Normally, if you've ignored it enough you start to not feel the sensation that your bladder stretched because your brain just starts to ignore it. So over time that urge becomes less and less noticeable, I guess you're sort of holding it back without realizing that they ever had to go in the first place. So the brain is blunted to that urge as you let this happen.

48:29

So Tammy is reminding him to go try but when he tries he can't go. So what do you do about it? Well I found something like this to work, basically, you sit him down and you say hey, you don't like being wet. And that's a good thing. Your foster son is going to be motivated to get this under control because he's down on himself for, he wants to change this. So you say hey, I can help you change this but here's what we got to do and we're not doing this as punishment, we're doing this because it's going to work.

And what you do is you start with every hour and you need to set an alarm because it has to be every hour, you're going to make him go try to use the bathroom. He can stand there and try no longer than two or three minutes, it's no big deal if he doesn't go. You don't have to say try, keep trying. In a couple of minutes you try, you tried, you didn't go, fine go play. But an hour later, an alarm is going to go off, you got to go and then try again.

Even if he goes an hour later, you've got to go try again. For a whole day, every hour, you're going to go try. If he has an accident within that hour then you fall back to every 30 minutes. Every 30 minutes you got to go try, you're not being punished, I'm not mad at you, I'm not mad at you if you don't go, this is how we're going to fix it. So you have him go every 30 minutes and you do that for a day or two with the every hour.

Once you've gone a day or two and he stayed dry doing that then the next day you can go to every 90 minutes for a couple of days. And then you go to every two hours for a couple of days. And you go to every three hours for a couple of days and then you go to every four hours for a couple of days.

And the idea is here is really to awaken the brain to start paying attention to the bladder. And because going potty is constantly on their mind because you're telling them to go try so often, after a week or so usually the daytime wetting stops.

50:27

I have not seen research on this. It's anecdotal. But I can tell you as a pediatrician with 15 years of experience, telling parents to try this usually works as long as there's no some underlying medical condition associated with it. But you have to keep with it. And most of the time when it doesn't work is because you didn't really do it every hour.

So reminding them to go a couple of times a day doesn't cut it. You got to do the every hour thing and then graduate that to every 90 minutes and then graduated that to every two hours then every three hours then every four hours and usually it works.

Now, don't be surprise in a month or two you're right back to dealing with the same issue and you just do it again at that point. You do the plan again. Now to your point, Tammy, you may be able to prevent that recurrence then by settling back on to your plan of just reminding him now and then once you get this under control.

But in order to get it under control initially, you usually have to do the really frequent telling him to go. So I think you have a good shot at that working, Tammy, again because your foster son wants to stay dry. He's motivated and really that motivation is half the battle. You have to have a motivated kid, otherwise they're just going pee because they don't care.

So I do think that this will work, but you have to not let him perceive this as if you're upset at him or that you're punishing him. I would explain the whole thing of what you're going to do right upfront. No surprises here. This is the plan. This is how we retrain your brain to think about pee.

So just lay it out for him, hey, we're going to go every hour for a couple of days and then we're going to go for every two hours for a couple of days when you're awake and then we're going to try every three hours for a couple of days and then that should solve your problem. You do want to be right upfront with him.

52:16

Now I do want to say a word about constipation here. The intestine pushing on the bladder can make the brain think that the bladder is full. We've talked about his before too. And that can result in urinary frequency because you feel like you have to go pee, but you pee small amounts each time.

And I don't have research on this. I'm not sure that research has ever been done on this. I think, this is my own personal opinion, I think that there are some kids that when the brain gets the signal that the bladder is full, it loosens up this sphincter in the bladder. And so some kids, the brain thinks that your bladder is full and you might leak a little bit of urine because the brain thought the bladder was full and that then sort of subconsciously or involuntarily relaxes the sphincter that goes to the bladder.

Now, that may be in part, if kids were doing that, they may be at that age where they weren't quite ready to be potty-trained yet. So this may be more in three-year olds that this sort of thing happens.

As when you think about it, babies don't always wait until their bladder is like busting full before they pee. It's not like when you're a little baby and you wet your diaper that you didn't wet your diaper until the pressure of urine was so great on that sphincter that you just let it go. What happens is if the brain feels the bladder stretching and in response it opens the valve, hey, you're getting full, let's let some out.

And kids really aren't ready to be potty trained until they can overcome that reflex. They have to physically be ready to be potty trained, not just mentally ready. And so if you have a kid who's at this cusp of readiness and that may be some three and four-year olds, I mean they're ready, they're doing it but they still have some of those baby reflexes there and then you put constipation into the mix and you have the intestine so full that it's pushing on the bladder, if they still have a little bit of that old baby reflex in them, their brain may go ahead and loosen things up a bit and they can spill out some urine.

So I have found that there are some kids with daytime wetting that if you put them on a stool softener the daytime wetting goes away because you're treating their constipation. Again, you may not have known they were constipated. They may not have hard and infrequent bowel movements. But they had enough residual stool in their intestine that it was pushing on their bladder.

And so again I don't have proof, I haven't seen research, but anecdotally, I have seen some kids' daytime wetting get better with a stool softener. Now, having said all of these, Tammy, you should still see his doctor and hopefully the same one he's been seeing all along.

And once you've ruled out other potential causes, then I think you can think about the things that we've discussed.

55:12

All right. Let's move on, we have time for one more question and look at that, we're like five minutes to the top of the hour. So I knew it. I knew it. You don't need three segments on the show. I fill up an hour no matter what.

So this one comes from Tiffany in Concorde, Massachusetts. And Tiffany says, "Dear Dr. Mike, our two-year old was recently bitten by a tick on the back of her neck. We were not able to remove the head so at the advice of her pediatrician we took her to the emergency room. The doctor there said the head did not need to come out. We left the ER armed with plenty of information about Lyme disease. The next morning she developed a rash on her face. We took her to our pediatrician who told us the rash was not caused by Lyme disease and in fact the rash did fade and was gone by the afternoon. Since then I've heard from a few people whose doctors have treated their tick bites prophylactically with antibiotics and some friends including doctors question why her doctor did not do the same. We do live in an area with many Lyme-carrying ticks. There seems to be conflicting opinions in the medical world about this and I would love to hear your opinion. I believe that we removed the tick within 24 hours. I really love your show. Keep up the great work. Best – Tiffany."

All right. Thanks for the question, Tiffany. First, let me say in terms of the head of the tick needing to come out. You'd like for it to come out. It's the tick's mouth and saliva that end up transmitting the disease, so you'd like the head out. But if the body breaks off of the head and the head is embedded in the skin, it's probably not worth traumatic skin injury of digging the thing out. And often times it's so small, you couldn't tell if you've dug it out or not.

So I think that the information you got from the emergency department was reasonable that if you don't have anything to pull on it's going to fall out because you're going to make new skin and as your old skin on top gets sloughed off the head is going to slough off with it. So I think that that was good advice because you don't want to cut and pull at the skin because then you're increasing the risk of bacterial infection with the skin bacteria getting in the wound.

57:22

OK. There's a lot of ground we could cover with regards to Lyme disease but I'm going to keep my discussion of the disease itself pretty brief and really focus on the question of treating tick bites prophylactically with antibiotics.

So a little background about Lyme disease itself. Lyme disease is a bacterial illness that causes fever, headache, fatigue and a characteristic skin rash called erythema migrans. It's a very specific rash. It's not just any rash. It's a very specific looking progression of the rash that your doctor would be able to pick up on.

The bacterium that causes the disease is spread by a specific species of tick commonly called the deer tick. Now the deer tick is a parasite of the white-tailed deer and it's seen in greatest numbers on the East Coast and in the northern Midwest of the United States. It's a very small tick and an engorged nymph or juvenile and these are actually the ones that are most likely to pass Lyme disease are actually only one to two millimeters in diameter. One to two millimeters. They're tiny.

Adults who are less likely to pass Lyme disease, they're a little bit bigger. They're around three or four millimeters, but that's still small. Engorged nymphs and these are the ones that you're most likely to see on the skin because they are the juvenile forms, they're on the skin, they're eating, they're running to eat a lot because they're going to become adults and you notice them after they're engorged because they get bigger.

58:54

So how big is an engorged deer tick? Well if it's a juvenile or a nymph, they're still just about three to four millimeters. And an engorged adult is still usually less than a centimeter in diameter, which is not much bigger than the eraser of a number two pencil.

So these are small ticks. So those of you who live in areas where Lyme disease is prevalent, you know what I'm talking about. Usually there are education materials and drives to really try to get people to recognize what deer ticks look like so that you can watch for them on your kid's skin.

But in other areas where Lyme disease is not so prevalent, people hear about it, they hear about ticks causing it and so they become concern when they see a tick, any tick. But the tick they are seeing is much larger and these are usually something like dog ticks, which can transmit other diseases like rocky mountain spotted fever but not Lyme disease.

So this proper identification of the tick in question does come into play when we talk about prophylactic antibiotic use and we'll get to that. So we have the deer tick, very small, carrying these bacteria which causes fever and a rash.

Why is Lyme disease such a big deal? I mean lots of infectious diseases result in fever and a rash. Well, if left untreated Lyme disease can result on joint heart and nervous system problem. So it can be serious. And if a person has it you definitely want to recognize it and treat it.

But what about treating everyone who has a tick bite? Do you need a dose or more of an antibiotic to prevent Lyme disease? Well of course you'll be treating lots of people if you go that route and you'll be treating lots of people who never would have gotten sick. There are a lot people who get bit by deer ticks who never get Lyme disease. In fact, probably the majority of people who get bitten by a deer tick don't get Lyme disease or don't get Lyme disease that causes bad complication disease.

You're going to be treating lots of people who didn't really need to be treated and this does contribute to antibiotic resistance. And antibiotics, themselves, can cause significant adverse events including life threatening allergic reactions, bone marrow suppression and other problems. I mean, the antibiotic itself can be an issue for some people and you can't always predict who those people are going to be.

You don't want to be in a situation where you have a bad outcome or death from the antibiotic that you took that you didn't really need to take to begin with. So you don't want to use antibiotics injudiciously. So where's the balance? Where's the balance using a prophylactic antibiotic in a reasonable fashion and going over board and exposing people to unnecessary risk from the antibiotic itself?

01:01:38

In other words, how do we judge risk versus benefit. We keep coming back to that but it's a very important concept in medicine and health. Well when answering this question, the CDC, the Centers for Disease Control of the United States government, defers to the expertise of the Infectious Diseases Society of America. And in 2006 they published guidelines which answer your question, Tiffany.

And I'll provide link to their guidelines in the Show Notes, but I have to warn you they ran a published journal, so you may have to pony up some cash to actually read the entire journal article, unless you're logging in through an educational institution or some libraries subscribed to access to certain journals, so you may be able to get to it through there.

So because not everyone is going to have access to this, I just want to go through their guideline here really quick. And here it goes mostly in their words – For prevention of Lyme disease after a recognized tick bite, routine use of anti-microbial prophylaxis or serologic testing is not recommended. A single dose of doxycycline may be offered to adult patients and to children greater than or equal to eight years of age when all of the following circumstances exist; pay attention here, the Infectious Diseases Society of America who the CDC is hey, we want to follow their opinion on this, they're saying that a single dose of doxycycline may be offered to adult patients and to children who are eight or older when all of the of following circumstances exist: (what are those circumstances?) well, (a) the attached tick can be reliably identified as an adult or nymphal deer tick that is estimated to have been attached for greater than or equal to 36 hours on the basis of the degree of engorgement of the tick with blood or of certainty about the time of exposure to the tick; (b) that prophylaxis is started within 72 hours of the time that the tick was removed; (c) the ecologic information indicates that the local rate of Lyme infection from these ticks is greater than or equal to 20%; and (d) that doxycycline treatment is not contraindicated.

01:03:57

The time limit of 72 hours is suggested because of the absence of data on the efficacy of chemo-prophylaxis for tick bites following tick removal after longer time intervals. Infection of greater than or equal to 20% of ticks with Lyme disease generally occurs in parts of New England and parts of the Mid-Atlantic states and in parts of Minnesota and Wisconsin but not in most other locations in the United States.

Then they go on to say that the doxycycline is relatively contraindicated in pregnant women and in children less than eight years old. The panel does not believe that amoxicillin should be substituted for doxycycline and persons for whom doxycycline prophylaxis is contraindicated because of the absence of data of an effective short course regimen for prophylaxis, the likely need for multi-day regimen and its associated adverse effects.

The excellent efficacy of antibiotic treatment of Lyme disease if infection were to develop and the extremely low risk than a person with a recognized bite will go on to develop a serious complication of Lyme disease. To prescribe antibiotic prophylaxis selectively to prevent Lyme disease, healthcare practitioners in an area where Lyme is endemic should learn to identify deer ticks including its stages and to differentiate ticks that are at least partially engorged with blood. Testing of ticks for Lyme-born infectious agents is not recommended except in research studies.

01:05:21

So your pediatrician, Tiffany, did not actually see the tick, therefore she could not identify the tick plus your child is less than eight years old. So in not prescribing a prophylactic antibiotic, she was definitely following the current guidelines of the Infectious Diseases Society of America as it relates to the prophylaxis for Lyme disease after a tick bite. And those are the guidelines supported by the Centers for Disease Control of the United States of America.

So I'm most interested in your doctor friends who criticized your pediatrician, Tiffany. You should ask them exactly what drug is it that they would have used and for how long. See I'm getting snotty now. I'm sorry. You can tell them doxycycline is contraindicated in kids less than eight unless you're treating proven disease and that there are no other recommended alternatives in a two-year old.

If you do give him a little bit of lip, Tiffany, send him to pediacast.org, tell him to look in the Show Notes of PediaCast 161 and click on the link to the guidelines so they can educate themselves on this topic and they can stop criticizing your pediatrician for doing the right thing

All right. That wraps up our listener segment for this week. And as it turns out we are an hour and six minutes into the program, so we didn't need a third segment after all. And I kind of figure that because I knew we have a lot to cover.

So we're going to take a quick break and we will be back to wrap up the show, right after this.

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01:07:18

All right. And as always thanks go out to all of you for tuning in and listening to PediaCast, taking the time out of your day to join us. We always appreciated that. I just want to thank each and everyone of you for being a part of the audience.

Don't forget to help spread the word if you could. iTunes reviews are always helpful. Also shoutout in your blogs, on Facebook. And of course as we've mentioned before make sure you tell your doctor about PediaCast. You say hey, it's evidence-based. That's the talking point. PediaCast is evidence-based and it's brought to you by Nationwide Children's. Make sure you mention that to your doctor so they can help spread the word.

And we are going to have brochures or I should say a handout, a sign as you will, that you can print out and give to your doctors. They can hang in exam rooms and have all the information for how to get to pediacast.org. That is in the works. I know it sounds like it's an easy thing to do but there are some issues that I can't discuss quite yet with regards to some things. Can I be more cryptic than that? That prevents me from making signs quite yet. But we will have them soon, really we will.

And we're going to have the search function on the website soon too, which has been a thorn in my side for a while. But it's coming, it's coming. In fact, a brand new, redesigned website is coming with cool new features. But again, I can't talk too much about that.

In fact, I probably should just go ahead and sign off for the show before I get myself in trouble. I do want to remind you that if you have a question, a concern, a comment, an idea, anything for PediaCast, it's easy to get a hold of me, just go to pediacast.org, click on the Contact link and my eyes will read your words. Also you can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-5437.

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

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