Gastroparesis – PediaCast 179
- Dr Hayat Mousa
Professor of Pediatrics
The Ohio State University
Nationwide Children’s Hospital
- GI Motility Center at Nationwide Children’s Hospital
- Gastroparesis Information Page
- Gastric Pacemaker Information Page
- Gastroparesis Support Groups (Inspire.com)
- Gastroparesis Online Support Group (MD Junction)
Announcer 1:Â This is PediaCast.
Announcer 2:Â Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike!
Dr. Mike Patrick:Â Hello everyone and welcome to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Childrenâ€™s Hospital in beautiful downtown Columbus, and Iâ€™d like to welcome everyone to the show.
Dr. Mike Patrick:Â We are joined today by Dr. Hyat Mousa. She is a gastroenterologist here at Nationwide Childrenâ€™s. Before we get to her though, let me remind you if there is a topic that youâ€™d like us to talk about here on PediaCast, itâ€™s easy to get a hold of me. Just go to pediacast.org and click on the contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. Thatâ€™s 347-404-5437.
Dr. Mike Patrick:Â 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. So, if you have a concern about your childâ€™s health make sure you call your doctor and arrange a face-to-face interview and hands on physical examination.
Dr. Mike Patrick:Â Also, your use of this program is subject to the PediaCast of use agreement which you can find over at pediacast.org. All right. So, Iâ€™m really excited about todayâ€™s show because I really feel like there are a lot of parents out there who have kids with chronic abdominal pain and they arenâ€™t quite sure whatâ€™s going on and perhaps their doctor is not sure whatâ€™s going on. Theyâ€™ve tried medicines and had x-rays done and they still just have this intermittent complaint that just doesnâ€™t seem to be going away.
The topic today, Gastroparesis, may be an explanation for some of those kids out there. So, Dr. Hyat Mousa is a physician with the section of Gastroenterology at Nationwide Childrenâ€™s Hospital. She is an associate professor of Clinical Pediatrics at the Ohio State University College of Medicine, and she also serves as medical director of the Center for Advanced Research in Neuromuscular Gastrointestinal Disorders here in Nationwide Childrenâ€™s.
Dr. Mike Patrick:Â Her clinical interest includes helping kids with gastroesophageal reflux, constipation and gastroparesis, which is our topic today. So welcome to PediaCast Dr. Mousa.
Dr. Hyat Mousa:Â Hello. Thank you.
Dr. Mike Patrick:Â Great. So, this is one of those things where thereâ€™s probably a lot of kids out there with abdominal pain and the parents canâ€™t figure out whatâ€™s causing it. The gastroparesis could be the answer.
Dr. Hyat Mousa:Â Yes, sure. Abdominal pain is one of the presenting symptoms for gastroparesis, definitely, and mainly the symptoms happen after they eat. So after meals, then the child will come with some kind of fullness or lazy diet, we call it, or they feel full right away, bloated, abdominal pain, discomfort, with nausea.
Most of the time, the nausea is there, and they might vomit a little later, an hour or so after they eat. So this is a combination of symptoms that they really should think about gastroparesis with that.
Dr. Mike Patrick:Â If we could just sort of define for the audience, what is meant by the term gastroparesis?
Dr. Hyat Mousa:Â Sure. Simply, we call it lazy stomach. So what it means, the stomach is not emptying well, delayed gastric emptying. So itâ€™s a delay in the emptying of stomach content without any obstruction. So itâ€™s a pure function of the stomach that is really not up to whatâ€™s expected.
Dr. Mike Patrick:Â So the kids eat, fill up the stomach, and it just doesnâ€™t empty in to the small intestine like itâ€™s supposed to.
Dr. Hyat Mousa:Â Thatâ€™s correct. Without evidence of anatomic obstruction or restriction.
Dr. Mike Patrick:Â Right. So, itâ€™s really the muscles of the stomach thatâ€™s at play here?
Dr. Hyat Mousa:Â Right. So the combination of the muscles and the nerves, they are not coordinated well to push the food out. And mainly is really the outlet of the stomach, which we call the pylorus, this kind of muscle that should open accordingly to the contraction or peristalsis in the stomach, then that pylorus should open.
So, sometimes we see higher pressure in that ring muscle in the pylorus, or it doesnâ€™t open and responds to this contraction in the muscle. And so, of course, you see delay in the emptying of the stomach.
Dr. Mike Patrick:Â How common is this condition?
Dr. Hyat Mousa:Â Surprisingly, itâ€™s really common and itâ€™s common in different populations. I would mention the two different populations like the functional dyspepsia kids, so that about 20 percent of the kids they might have functional symptoms or the altered physiology, the stomach doesnâ€™t work well or the bowel doesnâ€™t work well. So, out of those, up to 40 percent, close to half of them.
Dr. Hyat Mousa:Â The other population is the diabetic kids, kids with diabetes, especially if they have diabetes type 1 for more than 10 years or even before that if their sugar is not well-controlled, up to 40, 45% of those kids, and type 2 diabetes after having the disease again with poor control of the glucose.
Dr. Mike Patrick:Â Sure. And then, the problems may be even higher for kids because there are some kids who donâ€™t know that they have this until theyâ€™re not counted in.
Dr. Hyat Mousa:Â Thatâ€™s right. So they might come with late symptoms or with the complications of the gastroparesis.
Dr. Mike Patrick:Â I saw when I was doing research for the topic, I came across an article that said that the prevalence of gastroparesis in diabetics, and this is in adults, but just to show that thereâ€™s a lot of undiagnosed gastroparesis out there is that in a community study, it was only about 18% of diabetics knew that they had gastroparesis, but then when you look at a tertiary care study, 50 to 60% had it.
Dr. Mike Patrick:Â So, you think in the community setting probably just as many people have gastroparesis, they just donâ€™t know it.
Dr. Hyat Mousa:Â Thatâ€™s exactly right. So if they donâ€™t go and check, they canâ€™t tell. So we encourage family just to look at the symptoms and look into that.
Dr. Mike Patrick:Â Right. And thatâ€™s what weâ€™re trying to do to get the word out that hey, if your kid has chronic abdominal pain and youâ€™re not getting to the answer, this could be it. So, what exactly causes this condition?
Dr. Mike Patrick:Â We talked a little bit about the pylorus, an increase in tone is one possibility so that that sphincter is not opening and the foodâ€™s not getting out of the stomach into the small intestine. And we talked about the muscle being and issue and maybe the nerve. Is there anything in particular that causes the muscle or the nerve not to be functioning properly?
Dr. Hyat Mousa:Â We have to always think about the medication that the children are taking. Some of the medication they might have this side effect, the anticholinergic or narcotic, they will slow down the stomach function definitely. If the child is not on any medication, then there are couple of categories. So we have to think about, again, diabetes, one of the etiology. The other one is post-viral. So this is quite common in our population, in children more. So they will have like viral gastroenteritis. They will have r rotavirus or enterovirus.
They come with a type of stomach flu, if you will, and they will have vomiting, diarrhea, fever for a day or two and then, it will linger. Then they will eat. They canâ€™t tolerate to feed, they vomit right away, they get abdominal pain, and this we call post-viral gastroparesis.
The other one, as we say, the diabetes takes about one-third of the population. The idiopathic, which is we donâ€™t know the exact reason why the stomach is not working well. Thereâ€™s a group of disease that will affect like the collagen disease. We call it either scleroderma or kids with rheumatologic disease, this population.
So, it depends if the patient is taking medication, how it might affect the nerves or the muscles, or what disease they have, either diabetes or scleroderma or myositis or lupus. All these will affect the performance of the muscles and the communication between the nerves and the muscles.
Dr. Mike Patrick:Â The post-infectious kids, is that something that is temporary or does that become gastroparesis that last for a long time?
Dr. Hyat Mousa:Â Thatâ€™s a very good question. Thatâ€™s right. So, it varies. In one study from Pittsburgh that we reported that itâ€™s transient, but it might last more than 12, 13 months afterwards.
Dr. Mike Patrick:Â Transient in quotes, right?
Dr. Hyat Mousa:Â Thatâ€™s right. So, how long it will last? It might be a month or two, it might last up to a year. So, if these children after they have stomach flu and they are having some vomiting or abdominal pain, bloating, not eating well, losing weight â€“ weight loss is really an important symptom . We have to think about the performance of the stomach. Is it emptying well or not?
Dr. Mike Patrick:Â Now, those symptoms that you mentioned, so nausea, vomiting, feeling of fullness, bloating and then weight loss, malnutrition, possibly, if theyâ€™re not eating well. It seems like there are a lot of other conditions that could cause those same symptoms, what are some other things that we have to think about?
Dr. Hyat Mousa:Â Thatâ€™s also a very good question. So, some kids might have a simple gastroesophageal reflux, and also they might have symptoms after eating. So they eat and they start having regurgitation. The food will come up to their, maybe, mouth and they swallow it back, or they might vomit with forceful emesis. This is different than gastroparesis where they donâ€™t have the bloating; they donâ€™t have the abdominal distension and the risk of malnutrition if the vomiting is not severe. Usually, itâ€™s early; the vomiting is early after we eat. And gastroesophageal reflux they will have more heartburn. So they complain of the acid coming up with the vomiting.
The other one is peptic ulcer disease which is like stomach ulcer. Sometimes, the ulcer in the stomach is close to the outlet of the stomach, the pylorus we were talking about. So, this ulcer will cause almost slight delay in the function a little bit or because of the pain they donâ€™t eat. So, peptic ulcers reflux.
There is a category we call it rumination. Itâ€™s also common in kids and after they eat, as soon as they eat, they have this regurgitation up to their mouth, they swallow it back. And this is different than reflux. So we have to think about all these categories.
Now, even with delayed gastric emptying, we still have to think whether it belongs to a bigger entity, which is more like pseudoobstruction involvement of the dysmotility and not only the stomach, but also the bowel and the colon. So, if a child has also constipation, has also abdominal distension, we have to think about a bigger picture for the delayed emptying.
Dr. Mike Patrick:Â Is it common to have kids both with gastroparesis and constipation together?
Dr. Hyat Mousa:Â Yes, right. We see it, especially if thereâ€™s generalized. If the reason for the gastroparesis is affecting the nerve or the muscle performance, so the idiopathic type, it might be with a generalized dysmotility.
Dr. Mike Patrick:Â And I guess too with delayed gastric emptying, do you ever see tumors as a cause of obstruction or thatâ€™s not very common?
Dr. Hyat Mousa:Â In pediatric, probably, itâ€™s not very common. But if itâ€™s sudden onset for gastroparesis outlet obstruction withâ€¦ But actually, thatâ€™s a very good question. What we might see we might feel that there is almost like a mass in the abdomen. So with the gastroparesis they might not empty well so the food will sit in the stomach and form almost like bizarre and this bizarre might get larger and it feels like almost obstruction and mass in the stomach and this cause more of the complication later.
Dr. Mike Patrick:Â Sure. How do you go about differentiating then between, obviously, through the history of the symptoms, but in terms of testing and that sort of thing, how do you tell the difference between gastroparesis and other things that could cause abdominal pain and the other symptoms we talked about?
Dr. Hyat Mousa:Â Yes, definitely. So, when we take the history, definitely, we look at the child and the growth and how they are gaining weight, but one of the tests we do, initially, to make sure their nutrition is good, check their electrolytes. Make sure that their nutrition status is good, then endoscopy, upper endoscopy and biopsies we take from the different spots in the esophagus, the feeding pipe, the stomach and the small bowel and we make sure no inflammation or ulcer or bacteria that might be causing the H. pylori bacteria that might be causing inflammation in the stomach and thatâ€™s why itâ€™s not emptying.
So, upper endoscopy and biopsy is very important to be done. Then the diagnostic test for gastroparesis is really gastric emptying. Whatâ€™s gastric emptying? Itâ€™s a type of x-ray and the child will come to the x-ray area and they will eat a meal and this meal should have eggs, two slices of toast, water and jam and this meal is labelled with technetium. And then after they eatâ€¦
Dr. Mike Patrick:Â So itâ€™s radioactive?
Dr. Hyat Mousa:Â Radioactive, thatâ€™s right. So, itâ€™s labelled with a radioactive material and then will do x-ray to follow how this meal is emptying the stomach, and normally we should do x-rays, take picture at different time, one hour, two hours, three and four hours.
Dr. Mike Patrick:Â Right. Iâ€™m not trying to scare parents. Itâ€™s a very tiny amount of radiation, but then that substance is in the meal so that you can use a scanner then to see, to actually watch the food as it enters the stomach and then leaves the stomach so you can see how long it takes.
Dr. Hyat Mousa:Â Exactly. And there are normal values and we look exactly. However, we have to be careful when we do it for some criteria. In diabetic kids, we have to make sure that their sugar level is good. It should be below certain level, 275. If itâ€™s very high it will delay the emptying. They should be off medication for two to three days. And we look at the number.
If the stomach we see the gastric retention, if the part of the meal stayed in the stomach is more than 60 percent at two hours or more than 10 percent at four hours – so there are some guidelines, then it is gastroparesis.
Dr. Mike Patrick:Â You talked about endoscopy. So this is where you put a scope down and actually visualize whatâ€™s down there to make sure thereâ€™s not something thatâ€™s obstructing it. And then you can take cultures to look for H. pylori in tissue samples biopsy, that sort of thing. When we talk about endoscopy, thatâ€™s what weâ€™re talking about.
Thereâ€™s another test that parents may have heard about thatâ€™s a little more readily available than the gastric emptying study, called an upper GI. Is that something that can be helpful or not so much?
Dr. Hyat Mousa:Â Upper GI is a good test. It is good to look at the anatomy of the esophagus, the stomach, make sure nothing is obstructing or nothing is compressing from outside. However, the barium that we use for upper GI is kind of heavy so we donâ€™t depend on how soon it emptied stomach to diagnose gastric emptying. It might predict that this child, maybe, he might have gastroparesis, letâ€™s do gastric emptying. So, to label well when youâ€™re gastric emptying.
Dr. Mike Patrick:Â Because itâ€™s a lighter molecule thatâ€™s in the food itself where the barium is heavy and doesnâ€™t move through. And I think this is an important thing because a lot of community hospitals, so if youâ€™re a family thatâ€™s out in a small community and your nearest childrenâ€™s hospital is a couple of hours away, this is probably not a test that youâ€™re going to get very easily, the gastric emptying. Would you agree with that?
Dr. Hyat Mousa:Â Absolutely.
Dr. Mike Patrick:Â So, this is why I think itâ€™s important for a lot of parents out there if you have kids with chronic abdominal pain, your pediatricianâ€™s great. Iâ€™ve been there in those shoes myself in a small practice in a small town. Itâ€™s a big busy practice in a small town where you donâ€™t have those resources available to you.
And so sometimes itâ€™s got to be the parent to say, â€śMy kidâ€™s not getting better, can you refer me to see someone who can help?â€ť And get the gastric emptying study done.
Dr. Hyat Mousa:Â Yes, absolutely. Different facilities have different available testing.
Dr. Mike Patrick:Â OK. So, letâ€™s say you have a kid who has this chronic abdominal pain and the bloating and nausea, vomiting. So you get the gastric emptying study and they do have gastroparesis, how do you treat this?
Dr. Hyat Mousa:Â Yes, so these kids we have to look at their nutrition first. Make sure that they are well nourished, so we try to give smaller meals, smaller meals with less fat and less fiber and make sure they take it and they keep it and it canâ€™t pass. Why? Because high fat or the fat content of the meal will delay even more the gastric emptying, so we want it to be with lower fat.
We might use more supplement, liquid supplement, different brands liquid supplement, because liquid would not be affected by this gastric emptying. So the stomach will empty the liquid much better. It would not be delayed in gastric emptying. So we encourage the children to take supplement as liquid form and smaller meals, so this is a dietary change.
Other than dietary changes, we do medication. Some medication will help the stomach to empty better, and there are some medications that were tested, and some are still being tested now.
What we have now is not the best medication, but there are some including metoclopramide, including erythromycin, domperidone. We have different studies that prove that they will improve the function of the stomach and they should improve the emptying of the stomach.
In different mechanism, and they are like dopamine antagonist, the domperidone and the metoclopramide, with domperidone having less possible adverse effect or side-effect because it works more peripherally. So, we do the medication and we try to give the medication before the meal in order to improve the function and improve the emptying. Again, there are few medications that are being tested, but we donâ€™t have that much more.
If medications and a combination of dietary changes and these donâ€™t work with the pro-kinetics, then we seek for like placing tubes to improve their nutrition, improve their stomach emptying, and this tube will be to bypass the pylorus, bypass the gastric outlet. So we put the GI tube or a tube from the nose to the small bowel to bypass the stomach and the stomach willâ€¦
Because if itâ€™s transient post-viral, we want to allow a little bit more time with good nutrition to see if it will pass before we move to more invasive or more intervention.
Dr. Mike Patrick:Â And when youâ€™re talking about putting tubes in so that you can give supplemental feedings that bypass the stomach, this is something, I mean obviously, theyâ€™d have to have an extreme case of this where theyâ€™re really losing weight, their malnourished and it really is affecting the rest of their body and the rest of their life.
Dr. Hyat Mousa:Â Exactly.
Dr. Mike Patrick:Â Not something that you do, right?
Dr. Hyat Mousa:Â Thatâ€™s right.
Dr. Mike Patrick:Â Right from the beginning. What would you say, in terms of percentage, about the end up being able to be treated just with diet alone versus the ones who then end up needing medication or other procedures that weâ€™ll talk about?
Dr. Hyat Mousa:Â In our center, in Pediatric to Tertiary Center, we get the extreme cases. Maybe a third of them will do OK with medication, will improve and will be transient with the dietary changes and their nutrition status will improve. We still deal with other group thatâ€™s almost like two-third that they donâ€™t improve. They continue to have pain and bloating, distension, limit their ability to eat and to maintain their nutrition.
Dr. Mike Patrick:Â Sure. And then, letâ€™s say itâ€™s not getting better, what other possibilities are there in terms of treatment?
Dr. Hyat Mousa:Â The other possibility is a procedure, like the endoscopy we mentioned before, the endoscopy and we inject in this pylorus the muscle that ring muscle. We inject botox where we paralyze that muscle, we allow the muscle to be almost like open most of the time, and the effect of it is not permanent, will last between one and six months maybe. Three to six months, I should say.
And by injecting the botox in that muscle, it will improve the symptom; improve the emptying for a certain period of time. If itâ€™s again transient, it should take care. We might inject it more than once in three to six months repeat. And if that failed, then we move on to other options that right now we have developed in our center and it has been really showing us very good outcome, which is a gastric pacemaker.
So weâ€™ve been placing pacemaker in the stomach and this we start with, temporarily, gastric pace maker that we place externally and then check the result and check the outcome. If it works well, then we place a permanent pacemaker.
Dr. Mike Patrick:Â So, a pacemaker, explain what exactly this is and what it does.
Dr. Hyat Mousa:Â The pacemaker, we have in our site we have a pacemaker. So we have gastric pacemaker thatâ€¦
Dr. Mike Patrick:Â Kind of like for the heart.
Dr. Hyat Mousa:Â Kind of like for the heart, thatâ€™s exactly right. It sends the rhythm and then the muscles and the nerve coordinate the peristalsis, the contraction of the stomach. If we lose that function or the gastric pacemaker is really, we have dysrhythmia or itâ€™s not functioning well, then we place leads that generate electrical pulse.
And those leads in the musculature, initially, they temporarily will be just in the mucosa and it will generate certain rate. And the nice thing is that we can change that setting. We change how frequently, what the power of it, what the amplitude from outside. So we can, anytime, change it to meet the requirement of that patient.
Dr. Mike Patrick:Â So this uses electricity to stimulate the stomach muscle to squeeze.
Dr. Hyat Mousa:Â Yes. The study proved really that the way it generates the impulse, it is not exactly increasing the contraction or improving the emptying as much as improving the symptoms, and we think it is a mechanism affecting the afferent vagal so it works centrally or improve the symptom. So it really improves the symptom tremendously.
We reported these results and improved the nausea, the vomiting, the abdominal pain, all these symptoms improve and even resolved and they start eating, and then gradually, the function improved.
Dr. Mike Patrick:Â Wow, interesting. Now, this is something that you do here at Nationwide Childrenâ€™s. Is this something thatâ€™s done routinely in other pediatric centers or is this pretty unique to our program?
Dr. Hyat Mousa:Â Itâ€™s really unique to our program. Adult, they have done the gastric pacemaker for years in different centers and as a childrenâ€™s hospital, Children Nationwide is the only children hospital that provide that option.
Dr. Mike Patrick:Â Sure. And is this something that parents then would be able, if they have a child with gastroparesis and things arenâ€™t getting well, do you see kids from all over the place?
Dr. Hyat Mousa:Â Oh, definitely, yes.
Dr. Mike Patrick:Â Is there a long waiting list in order to get in?
Dr. Hyat Mousa:Â Itâ€™s a little long. We have priority list, so if the child is not doing well, is malnourished, we move them up and we communicate very well with the providing gastroenterologist and local hospital to provide the best care for them as they are waiting. But weâ€™ll be happy to start a referral and the triage.
Dr. Mike Patrick:Â Thatâ€™s the problem with your own success. Itâ€™s sometimes difficult to get folks in. But hopefully, other pediatric centers will take note of this. Has there been an interest in other places willing to learn more about it?
Dr. Hyat Mousa:Â Yes. There a couple of centers that contacted us, they will come and shadow for some time to learn the technique.
Dr. Mike Patrick:Â And I think this important because untreated or poorly treated gastroparesis obviously can cause complications, which weâ€™ve talked about, the malnutrition and weight loss, the bezoars or the undigested food that kind of clumps together and seams together can become an obstruction and which complicates things more. So this is something that really we need to pay attention to and get kids diagnosed and treated for.
Dr. Hyat Mousa:Â Absolutely. I want to just mention also, Dr. Mike, that especially in diabetic children that if we donâ€™t really take care of gastroparesis, itâ€™s going to affect the gastric emptying and affect their response to the insulin or response to their medication. So it will make the management of diabetes much difficult, more difficult.
Dr. Mike Patrick:Â Kind of a vicious cycle, really, because the gastroparesis makes the diabetes worse, which makes the gastroparesis worse, so once you get it, kind of cut that cycle off.
Dr. Hyat Mousa:Â Thatâ€™s right.
Dr. Mike Patrick:Â All right. We really appreciate you stopping by so that we can learn more about gastroparesis. And again, I want to really encourage parents out there, if you have a kid who has chronic abdominal pain and youâ€™re not getting to the bottom of this, Iâ€™d really ask your doctor for a referral to a GI specialist at your nearest childrenâ€™s hospital even if itâ€™s a couple of hours away because theyâ€™ll have the technology to hopefully be able to diagnose this and kind of get things going down the right path.
Dr. Hyat Mousa:Â Sure. Thank you for having me.
Dr. Mike Patrick:Â Absolutely. Before you take off, weâ€™ve been asking all of our guests on PediaCast this year to talk about their favorite board game because we want to encourage parents to do things with their kids that doesnâ€™t necessarily involve television screen and computers.
And as we kind of get into to colder weather and doing things indoors, one of the things I remember from my own childhood is playing board games as a family. So weâ€™ve asked all the guests, do you remember what your favorite board game was, is?
Dr. Hyat Mousa:Â Scrabble, I think. We used to do the Scrabble, for older kids maybe.
Dr. Mike Patrick:Â Yes, sure. Scrabble? Where you put the letters, or is it something different?
Dr. Hyat Mousa:Â No, thatâ€™s it.
Dr. Mike Patrick:Â Oh yes, I love that game. And no one has mentioned that one yet.
Dr. Hyat Mousa:Â Really? A little older kids, maybe.
Dr. Mike Patrick:Â Yes. It is a little bit more difficult for younger kids, but once they start spelling, thatâ€™s a great one. So, Scrabble. All right. I appreciate it. Well again, thanks for stopping by.
Dr. Hyat Mousa:Â Thank you.
Dr. Mike Patrick:Â I want to remind everyone out there. Before we go, I also have some great links in the show notes too. So if people go to pediacast.org and click on the show notes for episode 179, thereâ€™s a link to the GI Motility Center here at Nationwide Childrenâ€™s Hospital.
So, if you do want a referral to our center, we have all the information there that you can pass on to your primary care doctor. We also have a link to a gastroparesis information page and a gastric pace maker information both on the website here at Nationwide Childrenâ€™s.
And then, I also want to mention, thereâ€™s a couple of great support groups for gastroparesis out there, one of them through inspire.com and another one through MDJunction. I assume that these are pretty good support groups because you guys have them listed on your site, as well as things that parents may find helpful. So, thereâ€™s links to all of things over at pediacast.org on the show notes page for 179, so parents can look it up there.
Dr. Hyat Mousa:Â Good.
Dr. Mike Patrick:Â All right. I want to remind everyone, iTunes reviews are helpful as are mentions in your blogs, Facebook and tweets and be sure to tell your doctor and your family and friends about PediaCast. The way to get a hold of us, just go to pediacast.org and click on the contact link. You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. Thatâ€™s 347-404-5437.
So if you thereâ€™s a topic that you like us to discuss, just let us know, or if you have a question or comment for us, weâ€™d be happy to hear from you.
And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.
Announcer:Â This program is a production of Nationwide Childrenâ€™s. Thanks for listening. Weâ€™ll see you next on PediaCast.