Pox Pops, PECARN, Night Terrors – PediaCast 188

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Listen as Dr. Mike discusses pox pops, sexting, growth chart, dried cherries, night terrors, and allergies.  It's all coming up on today's PediaCast!

Topics

• Pox Pops
• Sexting
• Growth Charts
• Dried Cherries
• Night Terrors
• Allergies

Guest

• Melissa Metheney
  Lead Clinical Research Coordinator
  Section of Emergency Medicine
  Nationwide Children's Hospital

Links

• PECARN – Pediatric Emergency Care Applied Research Network
• Emergency Services at Nationwide Children's Hospital
• Growth Charts from MedCalc

Transcript

Announcer 1: This is PediaCast.

[Music]

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

Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike and I'm coming to you from the campus of Nationwide Children's in cloudy Columbus, Ohio. We had sun for a couple of days, and for almost the middle of November it was pretty amazing. It was like 70 degrees. I don't know, I was feeling like I was in Florida again this time of year. But the clouds have rolled in. We're starting the continental cloud cover, as I like to refer to it, in Central Ohio. Sometimes when the sun goes away with that, it can take a few days to come back. But I hear the weather's going to change this weekend. We're going to have a little bit nicer, back up in the 60s, so that will be great.

01:14

All right. It is Episode 188 and we are calling this one 'Pox Pops, PECARN, and Night Terrors.' Now, you may be asking, what? What kind of podcast is this?

Pox pops, apparently, parents are meeting on Facebook, and if their kid has an active case of chickenpox, they're having them suck on a lollipop and then sending it through the mail to another parent to give to their child to intentionally give them chickenpox.

Seriously. I don't know. I think it's going to be on Snopes soon showing that this isn't even a real thing. But it's in the national media right now and lots of local television has picked it up in various places around the country, so you probably heard about it. I just wanted to weigh in.

02:08

PECARN. PECARN is the Pediatric Emergency Care Applied Research Network, and Nationwide Children's is a part of that. Basically it's a group of pediatric emergency medicine specialists or institutions at various and sundry academic places and pediatric facilities. It's basically research in pediatric emergency medicine, and the groups pool their data together so you get bigger sample sizes and collaborate on research projects.

If you go to a pediatric emergency department, whether it's here at Nationwide Children's or elsewhere in the country, you may be approached to be a part of a PECARN study. We're going to talk about the research recruitment process and exactly how it is that patients and families get involved with the research in the field of pediatric emergency medicine. We're going to have Melissa Metheney stop by. She is a research coordinator and will talk about that.

03:10

We're also going to answer some of your questions today. Growth charts. Dried cherries. Dried cherries, I love those in oatmeal and salad. Those are good. Night terrors. It's been a while since we talked about that; way back in Episode 36 was the last time. We're going to talk a little bit about allergies as well. Those are all questions from you.

You'll notice that we're doing kind of a news/interview/listener segment here again, and the reason for that is there were a couple important news stories that I wanted to cover. We've got our interview schedule kind of ramped up through the holidays, so I have several interviews going kind of bang-bang-bang, but I really did not want to delay in getting out these news stories. And then we're getting a little backed up on listeners' questions, too, so I wanted to get those out to you as well. So we have a full show lined up for you.

04:01

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

I also want to remind you, 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 child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

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

All right. Lots of press lately about parents purchasing lollipops over the internet that have supposedly been sucked on by kids who have an active case of chickenpox. So parents meet on Facebook and other social media sites, they strike up a deal, and the sucker gets sent. The thought behind this is that full-blown chickenpox is safer than the shot and provides better immunity, which of course is not true, and we'll talk about that.

05:14

I have not seen any reports on this with parents who have actually done this, and my hope is that when the dust settles, Snopes will report that it's all just a hoax. But on the other hand, large media outlets and local television is picking up the story, so I did want to, as I mentioned before, weigh in on this.

First, intentional chickenpox exposure is not a new thing. Back in the day, chickenpox parties were all the rage. Apparently, those have kind of come back as well. With the sucker thing through the mail, there has been some resurgence of stories about chickenpox parties. Again, you hear about these things, but have I ever talked to or seen a report where someone's been interviewed that's actually been to one? I haven't. So I think that some of this is fabrication.

06:03

But I do want to remind you that chickenpox is not a benign disease. Back before the varicella vaccine was widely used, complications from full-blown chickenpox were common and included flesh-eating bacterial infections of the skin at the side of the chickenpox lesions, and some kids could become septic from that. So you get bacteria in the blood, and then that can cause death.

It's also possible to get encephalitis, which is a swelling of the brain, and also possible to get pneumonitis, which is a swelling of the coverings of the lungs, and then you can end up intubated and on a ventilator in an intensive care unit, and that can sometimes cause death as well.

So it's not always death, but certainly, serious complications that cost hospital time. It means your kid is out of school, in the hospital, and you're worried. You're worried this could become life-threatening. Even if your child doesn't die from chickenpox, the complications are severe enough that it really causes a lot of distress and also cost a lot of money in your life. So this is why the chickenpox vaccine was started to be developed and came out 17, 18 years ago, something like that now. That's the reason behind it. So it's not always a benign disease.

07:21

During my training, I can recall, and this was right around the time the chickenpox vaccine was just coming out, there was always at least one child in the intensive care unit, it seemed, with some sort of chickenpox complication. I personally saw that and can tell you first-hand that it is not always a benign disease.

So you hear a lot of parents say, 'Well, I had chickenpox.' Well, I had chickenpox, too, and I think the vast majority of us who had full-blown chickenpox, I mean, my case was back in the 1970s and I recovered just fine. You're miserable for a couple of weeks, you miss school, parents miss work, but most folks with full-blown chickenpox didn't end up in the hospital. You lived to tell the tale and you ended up with great immunity against future chickenpox infection. OK, I get that.

08:08

But there's a significant number of kids who are out there who can tell you a different tale, and just because you don't know any of them or you've never come into contact with them doesn't mean it doesn't happen. And those of us in the medical field who have been around long enough to remember chickenpox remember that there were some kids who had a very rocky course and there were some kids who died.

In particular, the kids with immune system problems, kids with leukemia and those on chemotherapy or primary immune system disorders, chickenpox for those kids can be devastating and definitely be life-threatening. So these bad cases really did happen, and they happened with enough frequency that a vaccine was finally made. So let's not forget that.

So we've established that full-blown chickenpox can be dangerous. But this new trend, if it's true, with the suckers, is a little bit different from chickenpox parties, and I don't really know where to begin with the stupidity of it.

09:08

First, they probably won't work. Chickenpox is spread through the respiratory tract, so you have to breathe the virus in in order to get a true case of full-blown chickenpox that we see. It's not spread through the GI tract. You have to breathe it in, not swallow it. So the folks who are mailing suckers back and forth clearly don't understand the pathogenesis of the chickenpox virus.

Second, you don't know what other diseases the mystery child might have that can live on the lollipop and be transmitted through the mouth, things like Group A strep, hepatitis A, MRSA, which is the staff infections that are resistant to lots of antibiotics. So they may not get chickenpox from the sucker, but they may pick up something else.

Third, you don't know that the mystery kid really had chickenpox. In fact, you don't even know if there's a mystery kid at all who is at the other end of that sucker. Who's to say some old guy isn't licking lollipops and selling them for kicks? Do you really want your kids exposed to that? We all know that scams occur and people aren't always who they say they are on the internet, so you have to be careful with that as well.

10:20

And then finally, it's illegal to intentionally send a contagious item through the mail with the intent of transmitting infection. It's almost a terrorist kind of act. So you'd really just don't want to be involved with this.

As I said before, hopefully this is just a hoax. But it has had enough media attention that I wanted to mention it, and if there's anyone out there listening to my voice who has contemplated being involved with this, please wise up and don't even think about it.

All right. Our next news story, I just want to give a little listener warning here real fast. It's a sensitive topic. We're going to talk about sexting very quickly. If you have young ears in the car or you're listening at home right now and you have kids who are listening, just fast-forward until you hear the musical interlude and we'll get on to our interview on PECARN, which is coming up here in just probably five minutes or so. Then you can go back and listen to this news story at your leisure, when there aren't young ears listening.

11:21

So let's talk about sexting. This, on the other hand, is not a hoax. It's a very real problem, and it's causing emotional distress for lots of teens. Sexting is defined as sending or forwarding nude or sexually suggestive or explicit photos or video of a known person via cell phone or the internet. So we aren't talking about explicit conversation here, folks. We're talking about pictures and video.

So how big is this problem? Well, in 2010, investigators from the Education Development Center in Newton, Massachusetts surveyed 23,187 high school students in Boston. What they found is rather disturbing: 10.4% of students admitted to having sent, forwarded, or posted a photo or video that was sexually suggestive of someone they knew, 25.1% of students admitted to having received or viewed a post containing the same images, and 5% of all high school students in Boston that were surveyed considered themselves to have been a victim of this behavior.

12:28

Males and females were equally likely to send a sexting message and equally likely to consider themselves a victim. However, males were more likely to be the recipient of a sexting message; 31.1% admitted to having received one versus 19.1% for females.

Also, psychological distress was more commonly reported by students who sent or received sexting messages and by those who considered themselves victims of sexting. Compared to non-victims, sexting victims were twice as likely to report symptoms of depression and over five times as likely to report an attempted suicide in the past year.

13:07

So these are significant numbers, and as parents, we do have some culpability here. Are our children finding themselves in situations where explicit photos and videos are possible? Are they sending or receiving these kind of messages and are they the victims of sexting?

Most kids aren't going to tell Mom and Dad that they are victims of this because they don't want their parents to know that they were in a position where photos and videos were made or that they took photos or videos of themselves and then sent them on to their friends, and then someone got a hold of it and used it to blackmail or to bully.

So you may have a kid who's very distressed about this and they don't feel comfortable telling you about it because they're embarrassed or ashamed. So our kids are suffering, and in some cases they have no one to tell because of the embarrassment or the feelings of being ashamed.

14:01

So parents, we have to be the grownups here. And I know it's not easy. I know that most of you who are listening to this are going to say, 'Well, there's no way. There is no way that my kid is involved in this.' But when you look at the numbers and you look at an audience this size, I'm telling you, yes, there are folks out there listening to this right now who think that this is not happening in their home, but it is when we're talking numbers 10% to 25% of all high school students having either been sending, receiving, or feel like they're victims here.

So I ask you as parents: Do you know where your kids are and what they're doing? Do you have filters on your computer? Do you have texting rules and safeguards to enforce these rules? Are you fostering an environment that encourages teens to say, 'Hey, I made a mistake and I need help now. Please help me.'?

Again, I think that this is an important thing for parents to address. The way that I would handle this with my kids is have a family meeting, a conference, and say, 'This sort of thing happens. If this has happened to you, I will be disappointed, but I love you and I want you to get past this so you can learn from this experience. Let's deal with it.' Sometimes that's just the motivation that your teen would need to admit this to you and deal with it.

15:23

Now, not always, and this is not an easy thing. For some parents, you may have a hard time figuring out, 'How do I talk about this? How do I figure out if my kid's doing it?'

There are resources available. I guess a good place to start would be with your doctor if you have a concern. Your doctor sees lots of teenagers and may have come across this sort of thing in the past so may have information about bullying and sexting, resources that are available in your community to help you approach this and talk to your kids about it and, if you find out that it is happening, to figure out what to do with it.

16:01

I also want to mention, your religious community may be a source of information for you. Regardless of what that religion is, faith-based counseling, there may be some help there as well in dealing with this kind of topics. Local social service organizations and, of course, schools may be sensitive to the topic and have anti-sexting and anti-bullying resources available, not only for prevention but also what to do when this actually does happen.

Some signs. Obviously, depression is a key part of this in lots of kids, and you can imagine why. I mean, you're being blackmailed. 'If you don't do what I want' or do this or that, 'then I'm going to send these pictures to your parents.' This is a serious thing, and you can see why some teens would be depressed about it.

So if your child has some depression and you can't quite figure out, this may be, I'm not saying it is, there's lots of reasons for it, but this could be one of the reasons, and if you're not tuned to it and not thinking about it, then you're not going to be able to adequately address it.

17:03

I also want to mention, if you have younger kids, start talking about this stuff early. Really impress upon them, 'You know what, you take pictures of yourself that are compromising and they get out there, they're out there, and sometimes you can't get them back. Most often, you can't get them back.' So I think from an early age, as kids go in pre-adolescent, preteen age is really the time to start talking about this.

And of course, it's easier to install filtering software and establish texting and accountability rules right from the get-go when your kids start using social media and cell phones, easier to initiate that stuff then than it is to put it into place later on. Not to say that you can't or that you shouldn't, but it certainly is easier to put those safeguards in place as parents from the beginning.

All right, we are going to take a quick break and we will be back to discuss research recruitment in the emergency department and some of the studies that are going on with PECARN, the Pediatric Emergency Care Applied Research Network. We'll get with Melissa Metheney, our studio guest, right after this.

[Music]

18:37

Mike Patrick: All right, we are back, and joining me in the PediaCast studio today we have Melissa Metheney. Melissa is the Lead Clinical Research Coordinator and an RN care manager here at Nationwide Children's Hospital. We're going to be talking about research recruitment within the emergency department.

Playing a role in pediatric research doesn't necessarily cross most parents' mind when they take their child to an emergency department, but here at Nationwide Children's, we take research very seriously as we advance evidence-based medicine and communicate our results with other clinicians and parents.

19:14

Of course, one very large potential pool of pediatric research participants are kids and parents in the emergency department. So Melissa has joined me today to talk a little bit about recruiting research candidates in the ED.

Welcome to PediaCast, Melissa.

Melissa Metheney: Thank you so much, Dr. Mike. I appreciate being here.

Mike Patrick: And I appreciate you stopping by.

When we start, if you could just describe the role of the research recruiter within the emergency department. What exactly is it that you do?

Melissa Metheney: Sure. Initially, when patients come into the emergency department, they may encounter what we call the 'pink shirt squad'. Our staff has a uniform that we wear with the bright pink shirts and black pants. There are so many people that they encounter in the department with different clothes on, different colors and different roles, that we try to isolate ourselves a little bit with the color and make ourselves recognizable.

20:07

But the research coordinator, or clinical research coordinator, as we're called, are trained staff specifically in research. We go through lots of training about how to inform parents of studies and research studies, consent process, all of those things. So the clinical research coordinator is the primary person that they are going to encounter.

We also have a clinical research intern program with undergraduate students, and they also have pink shirts on. So parents may also encounter a student intern that is also very specifically trained in research and consent and all those things. So, yeah, they would see those different types of people.

Mike Patrick: Now, the pink shirts, this is just something that's specific to Nationwide Children's, so folks out in California go to their local ED, if someone's wearing a pink shirt doesn't mean that they're doing the research thing.

Melissa Metheney: Exactly. And it doesn't mean that other employees in the department who have pink on are necessarily part of our team, either. But there are so many people that the families encounter and talk to during their visit in the department, so we just wanted to try to come up with a way that we could stand out a little bit, be a bright color. There's a lot of psychology behind color. We wanted to come up with something that our staff could help to recognize us as well because there's a lot of us and it's hard to remember everyone's names. So we wanted something that would stand out a little bit but to help people recognize who we are.

21:29

Mike Patrick: Yeah. So parents out there, if you find yourself in the emergency department at Nationwide Children's, the pink shirts are going to be the research recruiters.

And really, this is where I think the feet hit the pavement on PediaCast because we talk about research projects quite often and we talk about the results and how parents can use the results and how clinicians, doctors and nurses really need to look toward evidence-based medicine to make sure that the recommendations that we give are backed up by research.

But research from the parent perspective, and for a lot of doctors, too, I think, tends to happen in kind of a black box. You're sort of, somewhere there's research being done and then we get this result, but in the emergency department we're actually actively involved in research projects, and you're the person who gets the patients and parents involved.

22:19

Melissa Metheney: Exactly. We love having the opportunity to involve parents right in the moment, as the patient care is happening. We don't want parents and families to be afraid of research. It's something that they can participate in a wide variety of ways. So right there in the emergency department, in between waiting for test results to come back or different things like that, we try to get in so that we're not delaying care but still having the opportunity to interact with them and get their children involved in projects, if they choose to participate.

Mike Patrick: Now, how do you determine which families or patients are candidates for a particular study?

23:01

Melissa Metheney: Each particular study has specific eligibility criteria, things that we're looking for specifically for that project, things like the age of the patient or the reason that they've come to the department, and we are given special permission, because we've applied to the hospital's review board for research and specifically trained in HIPAA and protection of their health information.

But we have a limited ability to see in our electronic medical record or the Epic system why the patients are there. We can see their chief complaint, we can see their age, some real basic information like that. So we do have permission to screen the track board, as we say, to see why the patients are there and kind of review that initial eligibility criteria, and then we can go forward with talking to the physician and asking the physician if they think it's OK for us to talk to the family.

Mike Patrick: Sure. So if you were involved in a study, and again, we'll get into more concrete examples in just a little bit, but let's say that you were doing a study on pneumonia. You would be able to see which patients were in the department maybe with cough and fever and be able to identify which rooms that they're in so you know where to find your subject?

24:13

Melissa Metheney: Exactly, exactly.

Mike Patrick: You mentioned that before you go in the room, you talk with the physician first. Why do you do that?

Melissa Metheney: We actually talk with both the physician and the nurse typically. We want to give the care team a heads-up that we are potentially interacting with their patient. It's not only a professional courtesy to the physician and the nursing staff but also to make sure it's appropriate for us to talk to that family. The emergency department can be a very stressful situation. We don't know what issues the family is dealing with outside of the initial reason they are there, so we want to make sure that it is OK for us to go talk to the family and introduce this idea of participating in a project.

Mike Patrick: Sure. So the doctor and the nurse say, 'Yeah, fine,' which I suspect is the vast majority of the time.

Melissa Metheney: Yes. Yes.

Mike Patrick: And you then enter the room. How do you present this to the families?

25:04

Melissa Metheney: We always, of course, introduce ourselves and that we're part of the research team in the emergency department and that we have a project that we would like to give them a little bit of information about. Typically we'll give a little quick idea of what the project is about and just ask them generally if they're interested in hearing about it, hearing more information.

We want to get that initial yes or no from the family. We don't want to sit there and talk for half an hour if they're really too stressed or not interested, so we kind of get that initial yes or no, and then we would go through the study specific details and the consent form and all that type of thing.

Mike Patrick: What kind of reception do you typically get from moms and dads? I mean, do you really have to apply the pressure to get them to do this or do you find people pretty willing? And I suspect that you don't really apply pressure.

Melissa Metheney: Right.

Mike Patrick: I mean, if they say no, you take this no and that's that. But I mean, do you get a lot of "no"s or is this something that parents generally, it's well-received with families?

Melissa Metheney: Well, we actually, in part of our training, we talk about the process of doing informed consent and conveying the study specific details to families.

26:08

Actually, at this point, families are very receptive. I think that we have done a good job in the community and across the country even if talking about research and making families feel a little bit more comfortable in hearing about it and potentially participating. We do so much research here at the hospital that a lot of times families have already participated in something, so that makes our job that much easier.

When I started in research eight, 10 years ago, it wasn't maybe as well-received just because it wasn't as well-known, especially on the ground, like we are doing in the emergency department. But really, families are very welcoming. We always get our occasional "no"s if it's a stressful situation or they just really don't want any additional happening with their visit. And that's understandable. Like I said, it is stressful. But for the most part, parents are very open and very willing to talk about what we're doing.

Mike Patrick: Sure. Now, for the family who've listened to this show and they find themselves in a pediatric emergency department and they are approached, whether it's here at Nationwide Children's or at any pediatric emergency department in the country, and we'll talk a little bit about the consortiums that exist that link pediatric ERs together in regards to research, but what advantage, as parents who are thinking about this as you're asking them, what advantage exists for families to participate, and why would the family want to do this?

27:33

Melissa Metheney: Probably our biggest advantage or benefit to the family is just knowing that you've participated in something that can help us learn how to take care of patients, how to improve patient care, and potentially for their child that you know at a future visit.

Obviously we don't want them to have to come to the emergency department, but we're learning things at each of these visits, at each of these encounters, and the studies that we're doing that help promote improvements in patient care. So just the satisfaction of knowing you're participated is probably the biggest benefit.

28:03

On occasion, we do have a little 'thank you' as a gift card or things like that that is just thanking the parents for their time and their attention, filling out surveys or things like that. We are able to sometimes offer those. But for the most part, the benefit and the advantage is just knowing that you've helped provide that information.

Mike Patrick: And they're occupying some time, too, because part of being in the emergency department is sometimes waiting. You're waiting for lab results to come back and waiting to go over to radiology, so it does help pass the time a little bit.

Melissa Metheney: Right. We always try to make sure that we're not delaying care when they come in. That's an important thing to note, that we try to look and see where there's a little bit of a gap where they're waiting for things like results, as you said, and we can try to slide in and fill up that time a little bit for them.

Mike Patrick: Are there disadvantages?

Melissa Metheney: There really isn't that much of an disadvantage. We talk a lot about benefits and risks when we go through that consent process.

29:01

Certain studies may have risks of an additional blood draw or things like that. Some of the more advanced clinical drug trials and things like that certainly have risks that they would thoroughly discuss with the families when they are participating so that they can make a very informed decision as to whether they want to participate.

But a lot of the time, the risks that we talk about are just that it takes a little bit of their time to fill out our survey or to have us collect some information from them. But there's such a wide gamut of research studies that the risk that they may encounter are really study-specific, and those would be discussed in detail.

Mike Patrick: I think, too, it's important for families to recognize the vast majority of the kind of research that we're talking about here are really sort of demographic studies where you're looking to see in a particular patient population what symptoms are more common, less common, or in the case of where some extra blood is drawn with whatever their diagnosis ends up being, is there a better way to diagnose this based on some blood tests, and it's not as common to have really a drug trial in this kind of setting.

30:08

Melissa Metheney: Right.

Mike Patrick: Because I think parents, when they hear about research, they don't necessarily want their kids to be a guinea pig.

Melissa Metheney: Exactly.

Mike Patrick: So do you go with an experimental treatment when you could also have the tried and true, is it better or maybe it's not better, and of course, every mom and dad wants what's best for their kid. So those kind of studies are a little bit more difficult to decide whether you want to participate or not.

But the kind of stuff that we're talking, really, it's not something that's going to impact probably their care on that day. Am I right in saying that?

Melissa Metheney: Exactly, yes. The other thing, too, especially in the emergency department, if we are doing the research study and the parents agree to participate, we try to lump some of those activities together. So, again, we're minimizing the chance that the child would have to get an additional needle poke or things like that.

So if we are collecting a blood sample, for example, we would link that into the blood sample maybe that the nurses are already drawing for the clinical test the physician would like. So one stick hopefully, we can get everything that we need and we don't have to ask the family to go through an additional poke.

31:15

Mike Patrick: Well, let's talk about some concrete examples. What are some of the projects that are currently going on in the emergency department here at Nationwide Children's?

Melissa Metheney: Well, we are actually participating in a nationwide consortium called PECARN. It's Pediatric Emergency Care Applied Research Network. We get multiple studies as participating site for that network. We're really honored to be part of it. It is a selection process.

One of the studies that we have through PECARN is a biosignature study, and it is a study that we're looking for patients who come into the department with a fever and infants that are two months of age or less and that the physician is looking for potential for bacterial infection or some type of infection. So anybody coming in with that age and has a fever and they're getting that blood culture blood test.

32:07

We would just ask the family if they were interested in participating. We would collect a little extra blood sample when we're already getting our labs, and then we send that off. They're trying to develop a new test, it's a biosignature kind of a GeneChip array that looks at the genetic material in the sample and can tell if the illness may be a viral illness or a bacterial illness. And that's a huge question that the physicians are always trying to look for to see. I'm sure parents hear a lot, 'It's just a virus.'

Mike Patrick: Absolutely, yeah, and a lot of babies who end up getting admitted to the hospital and IV antibiotics and big hospital bill just to say, 'Oh, no, it was a virus. But we did this in case it was a bacterial infection.' So if there is some way in the future that would be able to do a blood test and say yes or no right from the get-go, obviously that would save a lot of time and money.

Melissa Metheney: Exactly. The tests that we're using now is a blood culture test. It takes a couple of days. The physicians obviously are using all the other information that they have collected in the visit to make that determination as to what's the best plan for the patient, but to have that additional information during the care that day is really a good thing for them to have.

33:21

Mike Patrick: So this is something that, when the blood is drawn for the blood count and the blood culture and whatever else the doctors order, just some of that blood goes off to the research laboratory to see what kind of genetic signatures are in the blood.

Melissa Metheney: Exactly.

Mike Patrick: And then you can look back, once the cultures have come back and you find out what bacteria it is or if viral studies were done you can find out what virus it is, and then compare what genetic material you're seeing so that then in the future you'd be able to make some conclusion on that as a screening tool.

Melissa Metheney: Right. One of the ways that we convey the science behind this to the families is that the initial testing that we're doing now, the blood cultures and the CBC or the blood count, especially the blood culture, is all looking at the bug itself, the bacteria or the virus that's there.

34:14

And this new test is actually looking at the patient and how the patient responds to that infection or that bug, that bacteria. So it really is a different way of looking at the sample, and everybody's so excited about what that could mean for the future.

Mike Patrick: Absolutely, yeah. And once we have results of that, you have to come back and share those with us.

Melissa Metheney: Definitely.

Mike Patrick: All right. And then there's another study going on right now involving head injuries. Tell us a little bit about that.

Melissa Metheney: Yes. There's a lot of debate going on as to whether we should be getting CT scans or CAT scans on patients who come in with different types of head injuries.

We always want to make sure that we're keeping the patient as safe as possible and not exposing them to undue radiation that they could potentially get from the CT scan, but also making sure that we're identifying any potential problem they could have from their head injury, so this discussion of to get CT or not get CT has kind of been an ongoing topic.

35:11

So this study that we're doing is collecting lots and lots of information about patients who come in with head injury and what their signs and symptoms are and the outcomes and all those things, and we're coming up with a tool, we call it a 'decision support tool' that we can implement into the electronic medical record or Epic system.

Basically at the triage process, we collect a little bit of information, and then that information goes to this data center that has compiled all this information, and then it will send back a suggestion, given all the information that we've collected, to the care provider as to what the risk of this patient's injury is. So it's added information that the physician then can use in making their decision above and beyond their physical exam and the signs and the symptoms that the patient presents with.

Mike Patrick: So right now, you're collecting the data that just says, hey, this is historically what's going on, this is the type of fall or the type of injury with blunt head trauma, whether it be a car accident or a fall from a certain height, and then the symptoms that the patient has, whether they have headache, vomiting, do they have loss of consciousness, do they have amnesia for the event, you're collecting all those attributes of head injury and then seeing, did the doctor order a CT scan or not, and then what were the results of the CT scan so that then you can go back and say, 'For all of the positive CT scans, these were the most likely criteria to have been associated with it,' so that you can start to say, 'This picture is the ones that you really do need to get a CT scan,' whereas with other pictures, maybe not.

36:48

And I guess as physicians, we all have sort of an idea of what's high-risk, but until you really look at the numbers and the demographics, you say well, is that true or is that not true?

Melissa Metheney: Exactly. And we want to arm the physician with as much information as we can to help them in their decision-making process.

37:04

We're certainly not telling them what these 10 questions or whatever that they should be or not getting a CT. It is ultimately their decision. But the more information we can give them to be armed with in making that decision, the better.

Mike Patrick: So then the end result is hopefully, and we talk about translational research where we actually take then the research that's published and say how can we implement this in a clinical environment, so then you're talking about this decision tool that could be made to say, now that we know what are really high likely events to have a positive on the CT scan, then you go through a decision tree and it helps you decide. But it's just to help, right?

Melissa Metheney: Right, it's just to help. Just a suggestion of, gives kind of a risk of potentially what the patient would have. So, yeah, it's just that much added information. The end result is always to give the physician that added information but eventually to help reduce the exposure of patients to a CT scan that may be could've gone without one, given that they're at really low risk in that category.

38:08

Mike Patrick: Yeah, absolutely. The audience is familiar with this because we've talked about CAT scans before and that if it were free and there was no radiation involved, hey, just get a CAT scan on everybody. But with the cost and with radiation exposure, you really want to pick and choose who gets those.

Melissa Metheney: Exactly.

Mike Patrick: No, it's great. Now, you mentioned PECARN, the Pediatric Emergency Care Applied Research Network. So we're one institution that's involved with that. So other pediatric emergency departments across the country are also involved and then the data is pooled from all those different places, is that right?

Melissa Metheney: Exactly. It's a very highly-structured system where we have electronic data entry, programs, and we participate in multiple studies that are presented through the PECARN network.

We're able to capture hundreds and thousands of patients' information as opposed to just doing a study at maybe one particular site. It would take a lot longer. The higher numbers that we have, the more that we can put together and the quicker things can get out there.

39:16

So, yeah, the PECARN network is something that we're really proud to be a part of, and the biosignature study, as I mentioned, is part of that. This TBI or CT scans of patients with head injury is also part of that. It's just a really great network for us to be participating in as Nationwide Children's Hospital.

Mike Patrick: Yeah. Well, that's great. And as you get further in those projects, like I said, we'll have you back and we can talk about some of the results of those, and as new projects come online, I think parents would be interested to know what's going on and we'll have you back.

Melissa Metheney: Sure. Great. Thank you so much.

Mike Patrick: Yeah, you bet. We'll have a link in the show notes to emergency services here at Nationwide Children's Hospital if you'd like to know more about that.

Before you take off, all of our guests here at PediaCast, we are asking them about board games, because one of my passions is for families to spend more time together that doesn't necessarily involve television screens and video games. Sitting around the table and playing board games is one of our favorite things to do at home, so we're just kind of collecting a list here. So as you think about it, what's your favorite board game?

40:21

Melissa Metheney: Well, I definitely have to choose the game Life.

Mike Patrick: Oh, yeah. Yeah.

Melissa Metheney: That was a game that my brother and sister and I played many, many times, and it's kind of ironic as I think about it now.

At the beginning of the game, you go around the circle and you land on what your career is going to be. We eventually got to the point where the rule was you got to pick your career and go right to the beginning of your life, and I always picked being a doctor, being in health care.

Mike Patrick: That is funny.

Melissa Metheney: So, kind of ironic.

Mike Patrick: Yeah, absolutely. We love that game at home, too. They have different versions of it now, too. Or you like the traditional?

Melissa Metheney: The traditional game. I wasn't aware that there are new versions. Maybe I should look into that.

Mike Patrick: Yeah. "Monsters, Inc."

41:01

Melissa Metheney: OK.

Mike Patrick: I know that there's a "Monsters, Inc." version of it. I think there's a "Pirates" one, too. The Disney "Pirates of the Caribbean", I think there's a pirate's life version of it as well.

All right. Thanks to Melissa Metheney for stopping by. We really appreciate it. Again, she is the Lead Clinical Research Coordinator and an RN care manager for the section of Emergency Medicine here at Nationwide Children's Hospital.

We're going to take another quick break and we will be back to answer your questions right after this.

[Music]

Mike Patrick: All right, we are back with your questions.

First up is Numsa in Malamulele, which is in South Africa. I kid you not. Malamulele, South Africa. "My daughter is 24 months. What is the normal weight for her age?"

42:14

Well, thanks for the question, Numsa. This is a tough one because there's a lot that goes into determining what the, quote, "right weight" is for a boy or a girl of any given age. We want to consider height and weight, but we also want to take into account how height and weight relate to one another, which then goes into a concept that we call the 'body mass index' or BMI.

There are other things that play roles, too, in what the right weight is. Your ethnic background plays a role, your family's growth pattern plays a role, and any underlying chronic illnesses or genetic syndromes can play a role in determining what specific weight is appropriate at a given age for boys or for girls.

So this is why it's important to see a physician who can take all of these things into consideration and give you some guidance on whether your child is an appropriate weight or not.

43:05

Now having said this, there is, of course, a standard growth chart that your doctor's office most likely uses this to plot your child in comparison to thousands and thousands and thousands of other kids of a particular sex and age. To come up with this chart, doctors looked at a huge diverse population of kids at a particular age and then determined percentiles and plotted them on a graph.

The 50th percentile would be average for that group of kids that they weighed at a particular age. The 10th percentile means that 10% of the group is smaller than you while 90% are bigger, and if you're at the 90th percentile, it means that 90% of the group is smaller than you while 10% are bigger.

But again, this does not take into account special circumstances like prematurity or kids with Down syndrome, and there are special growth charts that only take those kids into account so you get a little bit of a better idea, if you're a premature baby, what's the 50th percentile for that level of prematurity, or what's the 50th percentile if I have a kid with Down syndrome. You don't necessarily want to compare those kids to a large population in general.

44:20

So what happens then if we do look at a standard growth chart that we use here in the United States? Well, for a 24-month-old girl, not a 23-month-old girl or not a 25-month-old girl but exactly 24 months, 50th percentile is 26 pounds, eight ounces.

So is this what your 24-month-old girl should weigh? Not necessarily. This is just the 50th percentile, the average for a big group of 24-month-olds who are girls. Twenty-six pounds, eight ounces would be the 50th percentile. The 10th percentile is about 23 pounds and the 90th percentile is about 31 pounds.

45:01

So most 24-month-old girls are going to weigh somewhere between 23 and 31 pounds with 26 pounds, eight ounces being the 50th percentile. But again, what your child should weigh really depends on lots of factors, which is why it's important to talk about growth with your doctor during well-child checks.

A nice resource for plotting growth charts is the interactive growth charts at medcalc.com, and they actually do include options for premature babies and those with Down syndrome. They have charts that cover newborns through age 20 and they have charts for height, weight, head circumference, weight for length and BMI. They're all free. You could just plug in your kiddo's data and then calculate it out onto a chart and it will give you a graphic one that you can print.

You can find that at medcalc.com/growth. To make it easier for you, there will be a link to that in the show notes for Episode 188 over at pediacast.org.

46:01

All right, next up is Amy in La Mirada, California. Actually, Amy called in on the Skype line, so we are going to head over there.

Listener: Hi, Dr. Mike. This is Amy from La Mirada, California. I've been listening, actually I don't remember, but I do remember you doing the original Skype interview with your daughter and that you didn't tell us she was your daughter until after the interview. Anyway, I have also been intending for about that long to write you a very long email full of questions, but in the meantime, in case you wanted Skype calls, I thought I'd call us a quick one.

My one-year-old, OK, 15-month-old son has become very fond of dried cherries, and I was wondering how many he can eat before I have to deal with adverse side effects. I thought that might be a problem, and then I noticed on his diaper the next day, they seem to come out in pretty much how they went in. Is it OK to let him have as many as he wants or would it be a better idea to cut him off after five or six or 10?

47:04

Anyway, have a great day. Love your podcasts. Bye.

Mike Patrick: All right. Well, thanks, Amy, for calling in on the Skype line. At the end of this show, we'll have the phone number again for you if you'd like to call in that way and ask a question.

Dried cherries. Why would you give your kid dried cherries? Well, they taste good. They're nice and sweet. They are a decent source of dietary fiber. You also get some carbohydrates, some simple sugars, a little protein. They're fat-free. So it's a good little snack.

Now, they may look like they come out the same way that they go in, but I suspect, if you were to actually eat what comes out, which I don't suggest that you do, but I think you would find it's really not the same at all.

What comes out is the fiber part, which you want. You want dietary fiber to go through. But the body does a good job of extracting out the carbohydrates, the sugars and the proteins, which is where the flavor comes from. So the fact that you see the fiber skin, even though it's in a similar shape, is not necessarily surprising, and it should not deter you from eating them.

48:11

So how much do you do? Well, I'm going to play the practical card here and say that there's not a right answer to this question. Certainly a small handful, even if it happens everyday, can be a part of a balanced diet. We all know kids like repetition and familiarity and they latch on to a snack and they want it day in and day out, so if the daily ration of dried cherries is a small handful, great. How big of a handful? That's up to you. There's not a right or wrong here.

On the other hand, if you're going through an entire pouch everyday, that's probably too much. Don't let the appearance of the dried cherries in the poop be your guide. Just use common sense and make it a small portion that's part of a balanced diet.

By the way, I love dried cherries in oatmeal and salad. It's a great natural sweetener.

49:00

I do want to give one word of warning, though, Amy. Dried cherries are trachea-sized and they do pose a potential choking risk, so you definitely want to be careful from that standpoint.

If you're worried about choking, cut them up into smaller pieces, maintain close supervision while they're eating, and don't let your son eat them while he's distracted with something else. It's a bad idea to eat chokeable-type foods when kids are watching TV or they're walking and they're not paying attention.

So hope that helps, Amy. Thanks for the question and thanks for calling the Skype line.

Next up we have Robin in Nanaimo, British Columbia. Robin says, "Hello, Dr. Mike. I've been listening for four years now and always appreciate what you have to say. I'm a second-year nursing student with three boys ages six, four and two, and nearly everything is relevant to either my personal life, my learning, or both."

"My two-year-old has recently entered the nightmare phase. His older brother's experienced this as well, but I wondered if you could explore this topic a little further. I can't remember what we did with the others. With this little guy, I have tried reading a story or watching 'Max and Ruby', then another story, and then bed. That worked well, but it seems to be losing its effectiveness."

50:09

"The first time he woke up, he was shaking tremendously and seemed terrified. In subsequent nights, he seemed very distressed and was still shaking a little. I don't think he's manipulating us to come to his bedroom. Last night we tried him in our bed, but this resulted in three people not sleeping well for three hours."

"I wonder what you think, or perhaps a pediatric psychiatrist. Thanks a bunch, Robin."

Well, thanks for the question, Robin. I don't think you need to get a pediatric psychiatrist for this. It sounds like your little guy might be having night terrors rather than bad dreams.

It's been a while since we talked about night terrors. We did way back in Episode 36. But it's been a while, so let's review this common condition.

Of course, Robin, always check with your doctor. I'm not saying your child definitely has night terrors. I'm just saying from the description you gave, it sounds like a definite possibility. So let's talk about this condition.

51:03

It is common. It's about 2% of children that are affected. I mean, it's not the most common thing in the world, but it does happen. So out of a group of 100 kids, two of them will experience this. It tends to run in families, so if grandma and grandpa tell you, 'Hey, you did this,' then it's a little more likely that your kids are going to have this experience. So 2% of kids affected, runs in families.

Usually we see it about one to two hours after a kid goes to sleep. It's usually in the first half of the night and most typically it's in the first one to two hours of them going to sleep.

On the other hand, maybe it does happen with some degree of regularity in the second half of sleep, but mom and dad are sleeping then and you just may not know it's happening. So the most common episodes that we know about are in the first one to two hours of sleep.

52:00

They usually last anywhere from 10 to 30 minutes. In my experience, it's usually more like 10 minutes. They're pretty short-lived.

Basically, what happens is your kiddo is sleeping and suddenly they become agitated and restless. They may sit up, get out of bed, they can cry and scream, they can talk wildly. While they're doing this, you may not be able to wake them up very easily, and normal comforting measures don't work. They may not even realize that you're there, even if their eyes are wide open and staring.

So it's a kid that's asleep, they sit up, their eyes are open, they're screaming, crying, you can't calm them down, as if they don't even recognize you, and then in the morning, your child does not recall the event even taking place, and then that crying, upset, agitatedness usually lasts 10 to 30 minutes, and again, closer to 10 minutes.

These are not nightmares, so they're not having bad dreams. They do not even happen during the dream stage of sleep. Basically, we think what's happening is the emotional activity center of the brain is simply firing on its own for no known reason and it just makes them be upset and cry.

53:12

I don't want to use the word 'seizure' but it's like the brain is just telling the body to get upset and cry, and that center of the brain that's responsible for that just fires and does it without your kid having any choice in the matter. It's most commonly seen in toddlers and young school-age children.

So what do you do? Well, you want to speak in a comfortable voice. If the child is up, you want to direct them back to bed. Avoid shaking them or shouting. You want to protect them against injury. Keep the floors clear of tripping hazards if they're going to be getting up. Make sure that they don't have access to stairs, because sometimes they do, they get up out of bed when they have these but aren't really aware of their environment. And basically, just wait it out. You wait for it to end, you comfort them, and you help them get back to sleep.

54:00

How do you prevent them? Well, it does seem that sleep deprivation does cause more non-dream deep sleep, and this is when night terrors occur, during non-dreaming deep sleep, and sleep deprivation can lead to that. So you want to make sure your child's getting enough sleep. You also want to make sure they're getting naps in, and if they won't take a nap, at least institute quiet time so the brain has some time to rest.

If your child is difficult to awaken in the morning, you want to move bedtime earlier by 15-minute intervals until your child wakes themself up in the morning at the time you want them to wake up.

So that's kind of how you judge bedtimes and kids. Whatever time you want them to get up, you want them to be waking up on their own around that time and you just want to move bedtime earlier by about 15 minutes each night until they are easily arousable at whatever time in the morning that you're aiming for. So that's one way to make sure that your kids are getting the proper amount of sleep.

55:00

Now, if that doesn't work, if your kid is getting enough sleep and they still do this, and the episodes are very upsetting to you and you want to make them go away, let me just say, you don't have to make them go away. I mean, you can live with these. Just understand it's a physiological thing and it's not really something to worry about. As long as you understand the whole process and how it happens and why it happens, just let it happen.

But if you're really distressed by this and you want to make it stop, prompted awakenings can help. If the episodes are frequent, and especially if your child's older, this does work for about 90% of affected kids, and what you do is you keep a diary of the episodes and you try to pinpoint about how many minutes into sleep that these episodes occur.

And then what you do is begin waking your child up about 15 minutes prior to the expected episode time. Keep them fully awake and out of bed for about five minutes, and then back to bed. You continue this for about a week, and then you stop.

56:02

Oftentimes, this will just extinguish the night terrors. Now, the thing is, though, a couple of months later they may start back up again, and you just repeat that as necessary when the night terrors return.

Again, this is more for your sanity as a mom or dad. Night terrors are not dangerous, so it is OK to let kids have them. But dealing with them can be taxing on the parents. I understand that. That's why we were talking about how you can prevent them.

Now, some warning signs of some other conditions. If your child is having this but they're also drooling, jerking, shaking, stiffening with the episodes, if the episodes are lasting longer than 30 minutes, if they do something dangerous during an episode, or the episodes are only occurring during the second half of the night, or if your child has several daytime fears, or the episodes correspond to personal or family stress, these are all things that are warning signs and know this may be something else. It could be a seizure, it could be an emotional issue or a psychiatric problem. Brain tumors can cause this kind of things.

57:06

So if there's anything outside of what we talked about, just being upset and not necessarily interacting with your environment and being upset and then the whole thing's over, if there are things like being stiff, shaking, drooling, longer episodes or there's other emotional things going on in the family, then that should prompt an immediate visit to your doctor because you want to make sure there's not something else going on other than just night terrors.

And, as always, with your particular situation, Robin, it's a good idea to get your doctor's take on this as well and to have an examination to make sure that that really is what's going on and that there's not something different.

OK, finally we're going to move on to Anna. Anna actually emailed pediacast@gmail.com and did not tell us where she's from. So just to make sure, if you do ask your question via email that you put in there where you're located, because we all like to know that.

58:05

Anna says, "Hi, Dr. Mike. Your podcast has been so informative to us. Thank you for it. I also got my brother and sister-in-law to listen in."

Well, thank you, Anna. We appreciate that.

She says, "Episode 178 was really good. It was nice to hear a doctor that works in the ER that has time to talk about anaphylaxis. We really liked that one. Now, talking about allergies, why is it that some children get over their allergies when they are over? Is it the immune becomes less picky?"

"I'd also like to know what are the causes of cavities besides consuming too much sugary stuff like candies, muffins, donuts, cookies, juice, etcetera and not brushing teeth. My son is five years old and gets one lollipop at the barber once every six weeks. He had three cavities on his last visit to the dentist. We were so surprised. We are strict with his diet but feel we are failing somewhere. Anna."

Thanks for the questions, Anna. Let's tackle them one at a time. Why do some kids get over their allergies as they get older?

59:00

What really hit the nail on the head, your immune system often does become tolerant of allergens with repeated exposure. And really, this is the whole idea behind allergy shots. So the idea is small frequent exposure leads to tolerance and less of an immune reaction.

That's what allergy shots do. You're basically injecting a little bit of the allergen frequently so that the body starts to become tolerant of it, and then over time you increase the exposure amount and eventually your body becomes tolerant of the allergen, and the allergy reaction goes away.

Now, the issue, of course, is balancing this exposure with the possibility of an extreme reaction in the process, like anaphylaxis, which can be life-threatening. So this isn't something that you want to intentionally try at home. Yes, it can work, but it should be done in a controlled way and definitely with medical supervision.

Then, your second question about cavities, I'm going to punt on that one, but I'm not going to punt for long.

1:00:05

Next week, we are going to be privileged by having Dr. Elizabeth Gosnell stop by the studio for an interview. She is a pediatric dentist and we're going to discuss cavities, we're going to discuss tooth care, fluoride, dental trauma. Really, we're just going to have a big long dental show. That's coming up, Episode 189, next week, so stay tuned for that and I'm sure that we'll get your question answered about cavities and the kids.

All right. I want to thank once again our guest today, Melissa Metheney, for stopping by the studio.

I'd also like to thank listeners like you for making PediaCast a part of your day. We know you have lots of podcast choices and lots of pediatric educational resources that are available on the internet and elsewhere, so we really appreciate you picking PediaCast as a part of that educational and information process.

I want to remind you, iTunes reviews are helpful, also mentions in your blogs and on Facebook and in your tweets. Also, be sure to tell your doctor about PediaCast so they can spread the news to their patients, and of course let your family and friends know, even the in-laws, as Anna did. We appreciate that.

1:01:16

We do have PediaCast flyers available. If you go to pediacast.org and click on the Resource tab, you'll find a flyer that you can download and print out and hang on bulletin boards wherever you like so you can help spread the word about the show.

And of course, to get involved with the program, if you have a question of your own or a topic suggestion, just go to pediacast.org and click on the Contact link. You can get a hold of me that way and also by emailing pediacast@gmail.com. If you go that route, just make sure you let us know where you're from.

And of course the Skype line is also available, 347-404-KIDS. That's 347-404-5437. Don't worry, we don't answer that. You don't actually have to talk to someone. So get your thoughts together and just call and leave a message with your question, and we can get you on the show that way as well.

1:02:06

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

[Music]

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