Short Stature & Growth Hormone Deficiency – PediaCast 236
Join Dr Mike Patrick and Dr David Repaske as they discuss short stature and growth hormone deficiency. What causes these conditions? How short is too short? When should growth hormone be used? Does it work and is it safe? Answers to these questions and more. This week… on PediaCast!
Growth Hormone Deficiency
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It is episode 236, 2-3-6 for December 19th 2012. We're calling this one Short Stature and Growth Hormone Deficiency. It's a topic that a lot of families deal with, maybe struggle with a little bit and we're going to talk about those things.
So I like to welcome all of you to the show. Some of you may be wondering, hey, I thought you said last week you're not having a show for two weeks. I don't know what I was talking about. I just had my weeks confused. So we are here despite the fact I said we weren't going to be, but we are here.
But and I am absolutely positive about this, this is our last show for 2012. So we're going to take a two-week hiatus after this one and I checked, I'm absolutely positive about this, so we're going to be off next week for Christmas and the week after that for New Year's.
And then we will be back the week following, so the second week of January, we'll be back with a new show for 2013. So that's all coming up.
As Christmas approaches I do want to put in a quick plug. Over the holidays you're going to be seeing lots of relatives and friends and I just ask if you come across anyone who you think would benefit from PediaCast, please let them know about the show.
We don't have a big advertising budget. We really rely on word of mouth to spread news about the program. So while you're out and about this holiday season spreading cheer, please keep us in mind and consider spreading the word about PediaCast. We'd really appreciate it.
All right. So what are we talking about today? Short stature another common condition that parents deal with. What if your child is short compared to other kids his or her age? Sometimes, kids are programmed to be small, you look at mom and dad or the grandparents and you think no wonder they're short. But is there anything you can do to cheat those genes? Can you increase the height of a kid who is programmed to be small?
Some kids are short because they have medical conditions or genetic disorders and so you would want to know about that. Is my kid OK because he's short? And sometimes kids are short because of growth hormone deficiency and you may have wondered if growth hormone therapy is a good idea. Does it work? Is it safe?
So that's going to be our focus today – short stature and growth hormone therapy. And as always we'll cover the nuts and bolts of these issues with lots of detail but in language that you can understand.
And to help me do that, we have a great studio guest lined up for you today. Dr. David Repaske, MD, PhD, is the Chief of Endocrinology, Metabolism and Diabetes here at Nationwide Children's Hospital.
We'll get to him in a moment. First, I want to remind you PediaCast is on Pinterest and I know I've been pushing this a lot. We have an Episodes board where we pin up all of our episodes and we'd encourage you to repin those to help spread the word again. We also have a News Parents Can Use board with stories that you won't find on the podcast.
And then we do have a new board for you, the Blog board. Now, I've mentioned here before that I write a monthly blog post for iTriagehealth and I've never really tried linking up my podcast audience with the blog audience, so here's my attempt to do that. I'm going to have a pin for each of my blog posts on the PediaCast Blog board and that will just make it easy for moms and dads to read and share them.
So what is a pediatrician blog about? Well, past topics include the cinnamon challenge, CAT scans, trampolines, pink slime, circumcisions and at Halloween we talked about bats and rabies. So a wide range of topics and again stuff that's not really on the show here but you may be interested you can find them easily by adding our Blog board over at Pinterest and following along.
I also want to remind you PediaCast is your show, so if there's a topic that you'd like us to talk about or you have a question for me or a news story to suggest, just head on over to pediacast.org and you can click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
Also I 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 do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right. With all that in mind, we're going to take a quick break. We'll get Dr. David Repaske in the studio to talk about short stature and growth hormone deficiency and that's coming up right after this.
All right. We are back and joined in the studio now by Dr. David Repaske, MD, PhD. He is the Chief of Endocrinology, Metabolism and Diabetes at Nationwide Children's Hospital. He's also a professor of Pediatrics at the Ohio State University College of Medicine. He is not new to PediaCast. He joined us last year to talk about type 1 diabetes that was back in episode 191.
And he's back in the studio today to talk about another common at childhood issue and that is short stature. So welcome back to PediaCast, Dr. Repaske!
Dr. David Repaske: Well, thank you. I'm very glad to be here.
Dr. Mike Patrick: Great. We are glad to have you. Let's start out with just sort of a definition. What is short stature? I mean, what is short?
Dr. David Repaske: Well, honestly, it's arbitrary. Growth curves are made with different parameters. The most common is 5th percentile to 95th percentile. So anyone who is in the lower 5% is sort of arbitrarily called off the growth curve or short.
There are other growth curves that go down to the 3rd percentile. So the shortest 3rd percent are considered off the chart. And then most recently, the FDA decided that the lowest 1% were short. So it's fluid. It's a little bit arbitrary.
Dr. Mike Patrick: Sure. And you kind of have take into account a person's background too, like their ethnic background. If you had a growth chart where they looked at the population in Norway and they have a Japanese kid, you're comparing them to all the Norwegian kids they're going to be short. But it doesn't mean they have a disease or a problem.
Dr. David Repaske: Absolutely right. And unfortunately, we don't have quite enough growth curves to match every different population. But we do look at what we call the mid-parental height. So we sort of average the mom and dad's height and come up with a ballpark expectation for where the child should be growing toward and we use that benchmark pretty much.
Dr. Mike Patrick: Sure. There are also some specific growth charts for particular disease processes, like for Down syndrome, for instance, where we know it's a disease that can lead to short stature, so that at least you're comparing a kid with Down syndrome to other kids with Down syndrome.
Dr. David Repaske: Sure. Right. Right. Down syndrome, Turner syndrome, achondroplasia. It goes on and on.
Dr. Mike Patrick: Yeah. A lot of times on PediaCast we talk about epidemiology, just like what percent of the population is affected by this. And I guess by definition if we say short stature is if you're below the 1 percentile or 5 percentile or whatever, then we can say that means about 1-5% of the population would be affected.
Dr. David Repaske: Right. So 1 in 20 if it's the 5th percentile or 1 in 33 or 1 in 100 if you go down to the 1 percentile.
Dr. Mike Patrick: Sure. Let's talk about what causes short stature. What sort of things we have to think about when we do see a kid who's low on the growth chart?
Dr. David Repaske: Well, there are lot of things that can cause short stature and that will probably keep pediatric endocrinologists busy sorting it all out. It ranges from genetic conditions like you and I were talking about a minute ago – Down syndrome or Turner syndrome, kids tend to be short or Russell-Silver syndrome.
There are some single gene mutations like achondroplasia that make a child short. There's familial short stature, also what you were talking about. If parents are both relatively short then you would've expected the child to be short and maybe that's not a disease or an abnormal condition.
There's also a familial pattern called constitutional delay where a child is sort of they're just growing a little bit like they're a year or two younger than they actually are, so they're following just at the bottom or below the bottom of the growth chart, but they keep growing longer than typical child. So they catch up by young adulthood but during their growing years they're relatively short.
There are also medical conditions like malnutrition, it's like a social deprivation. There are problems that just tell your body don't put resources into growing more, let's just maintain what we've got, so a lot of chronic illness leads to short stature.
Dr. Mike Patrick: Yeah. And we've talked about some of those here on the show before like cystic fibrosis or Crohn's disease.
Dr. David Repaske: Those are the typical ones.
Dr. Mike Patrick: Yeah
Dr. David Repaske: But then finally, the big ones from the endocrine point of view are hypothyroid, growth hormone deficiency and cortisol excess, those all lead to short stature and poor growth.
Dr. Mike Patrick: So you have a kid who the parents are concerned that he's at the bottom of the growth chart and maybe there's not a family history of that and so their pediatrician refers to you. How do you go about knowing what kind of workup to do? Because with looking at such a broad range of things that can do it, how do you approach that patient?
Dr. David Repaske: We generally start with a broad screen. So we look at a number of different possibilities, not really with the idea of making a definitive diagnosis but just let's look for chronic illness; let's look for constitutional delay; let's look for the possibility of a thyroid problem or a growth hormone deficiency. And then if any of those sort of turned into red flags then we might chase down that avenue a little bit further.
Dr. Mike Patrick: So you might check their thyroid, you might check them for cystic fibrosis. How do you check for the constitutional growth delay?
Dr. David Repaske: There we usually are looking for a delayed bone age. A normal growth velocity, so the speed that you're growing is normal even though you're relatively short. And almost always, but not absolutely always, a family history. Usually there's one or the other parents or both had late puberty.
Dr. Mike Patrick: Back to the constitutional growth delay when you say you get a bone, some X-rays, what are you looking at exactly there?
Dr. David Repaske: There's disconnect between a person's chronologic age that is a little there and their physiologic age. Essentially, it's how much growth potential is remaining in the bones. So somebody who's 12 years old by the calendar might have bones with as much growth potential as a nine-year-old and so a guy keeps growing until they're 18 so if you got a three or four-year bone age delay maybe you'll grow until 21 instead of 18.
So the way we do that is we take an X-ray of the left hand and the reason that we use a hand is because there's so many bones in one small X-ray and you can look at the maturity. You can look at the growth plates on the bone and see how much growth is remaining and that's the bone age.
Dr. Mike Patrick: Sure. A lot of the bones in the wrist area start out as cartilage and so there's kind of a standard growth development that you see on the X-rays as they start to turn into bone.
Dr. David Repaske: Right. So we have a bone age book that has like reference standards and we can just compare the X-ray of the child to the standards on the bone age book and there's a different set for boys and girls.
Dr. Mike Patrick: Yeah. So if a kid's five, let's say, and they take the bone age and it's three and a half, four years old then you know that they're just maturing slower and you can expect them to grow longer and so they'll catch up.
Dr. David Repaske: But there's the tricky part, say you've got a three or four-year bone age delay that could be constitutional delay but it could be growth hormone deficiency or it could be thyroid hormone deficiency, those also lead to bone age delay. But with those endocrine problems the speed that the child is growing is usually less than normal.
So if you got a normal growth speed, normal growth velocity we call it, it's more likely to be constitutional delay. If you're growing slowly then I'm thinking more about thyroid or growth hormone. The problem is we don't always have that prospective. The child comes to my clinic and I've got today's height but I don't know how they got there, whether they're growing there with a normal speed or they're growing slowly or not at all for a period of time.
Dr. Mike Patrick: So it would be helpful if parents do go to see an endocrinologist for short stature that they take a copy of their growth chart with them.
Dr. David Repaske: Very, very important. Very important. Sometimes we'll have the child come back so they'll come back four months later or five or six months later and we'll get a really accurate growth velocity on the same measuring instrument using the same technique – shoes off and standing straight and so on.
Dr. Mike Patrick: And you do find that constitutional growth delay clusters in families?
Dr. David Repaske: It certainly does.
Dr. Mike Patrick: So if there's a family pattern of people, you know, they're all average size as adults and they have a child with short stature, if they kind of look back and oh yeah, we had several cousins and maybe dad's brother also had that issue, it's a little bit more reassuring?
Dr. David Repaske: It's a little bit reassuring although you want to know if the child is short that that really is the reason you want to rule out everything else.
Dr. Mike Patrick: Absolutely.
Dr. David Repaske: It's a little bit the diagnosis of exclusion.
Dr. Mike Patrick: And you talked about growth hormone deficiency. How do you test for that?
Dr. David Repaske: As I alluded to earlier, we have some screening tests so we check for IGF-1 and IGF-BP3. So those are two proteins that are in your blood that are made in response to growth hormone. So if you've been making growth hormone for the past two or three or four or five days then those proteins are going to be present in a reasonable amount in your blood.
If you haven't made growth hormone, they're going to be low. So you might ask, why don't we check growth hormone directly?
Dr. Mike Patrick: Yes.
Dr. David Repaske: And the problem is that growth hormone is normally secreted in a few pulses, three, four, five, six, seven pulses, after you fall asleep at night. And so during the day it's perfectly normal to have no growth hormone in your blood.
And it's inconvenient to try to catch the spikes after someone's fallen asleep, so we use the indirect test as the screening. So if the IGF-1 is low and the IGF-BP3 is low then that gives us a reason to go forward and do more formal growth hormone testing.
Dr. Mike Patrick: Sure. Do you think that growth hormone deficiency is a disease state or could it be that a child who sort of programmed to be short would have less growth hormone? This is kind of a philosophical question I think, but just in your opinion.
Dr. David Repaske: So I think it probably is more the IGF-1 than the growth hormone itself. So growth hormone doesn't actually cause growth itself. It works through this IGF-1 protein, which is the ultimate growth factor. And there is some correlation between the IGF-1 level and in somebody's height, but growth is multifactoral.
When people estimate that there are a hundred different genes that control growth and so it's not simply the amount of growth hormone or the amount of IGF-1 or even the response to IGF-1, many, many proteins and genes that affect height.
Dr. Mike Patrick: Sure. So there could be in some kids maybe they're not growing because that IGF protein is not enough and for other kids maybe the receptors aren't responding to it, kind of like diabetes sort of thing with insulin. Is that true or not?
Dr. David Repaske: I think you got a good concept going there. I wouldn't argue with you. But what I'm thinking more is like you were saying earlier that Norwegian population is very tall and other populations are shorter, it probably are variations in the genetics that determine that, so that maybe the Norwegians are more responsive to the same amount of IGF-1.
Dr. Mike Patrick: And maybe they are making more of it or maybe they're more responsive to it.
Dr. David Repaske: It's probably a hundred little things combined…
Dr. Mike Patrick: Right. Right. But not necessarily a disease, it's more that they're genetically programmed to respond that way.
Dr. David Repaske: Right. Right.
Dr. Mike Patrick: Sure. Now, before we kind of go into growth hormone therapy, I do want to point out there is an impact in a kid's life when they have short stature. This can be a real problem for folks and for other folks it is not really much of a problem at all. What is the impact and how do you determine whether that impact is enough to do something about it?
Dr. David Repaske: Right. I think this is sort of partly medical and partly philosophical.
Dr. Mike Patrick: Yes.
Dr. David Repaske: I split it personally into sort of two levels. One is some people can be so short that it's handicapping. If you can't reach the pedals on the car, you can't reach the grocery shelves in the store, then you really have a problem that is real, it's handicapping.
Other people feel that their stature is too short. I don't know, some families would like their children to all be basketball players even though they're perfectly normal height. They're feeling like the child is too short and want the child to grow taller.
Dr. Mike Patrick: And there are some studies out there and again not necessarily well done. I'm not endorsing these studies but that show shorter people make less money, maybe don't climb the corporate ladder. Now again, I don't know the bias of the investigators but you come across these things.
Dr. David Repaske: Yes. I'm not a psychologist. I'm not going there. But yeah, those studies are certainly out there.
Dr. Mike Patrick: Yeah. So let's say you take a kid who has short stature and you do figure that they have some growth hormone deficiency and the parents are interested… Well, first let me ask you this, if you do find that scenario where you have a kid who has short stature, they have growth hormone deficiency, do you recommend growth hormone therapy or could a parent go either way and still feel like they're a responsible parent?
Dr. David Repaske: Sure. Sure. So in most cases growth hormone deficiency is not life threatening in any way. So it is a bit of an optional thing. I should probably back up a little bit and say that growth hormone is kind of a misnomer.
It does a lot more than simply growth. It builds a muscle mass. It helps your heart beat healthy and strong. It helps put calcium into your bones and prevent osteoporosis. If you have growth hormone deficiency you have a tendency toward osteoporosis.
So it's doing a lot more than just growth. And growth hormone is also present in adults once you're done growing, smaller or lower level, but it's still present and still necessary even when you're completely done growing.
So some kids when they're growth deficient as little babies get hypoglycemia or low blood sugar. And there it is a medical emergency to start in growth hormone. But most kids come to see me at five or eight years old and it's not a medical emergency.
So really it isn't an option and you've got to weigh the pros and cons and some families will choose to do it and some will choose not and it's perfectly all right.
Dr. Mike Patrick: But it's interesting you point out that it's not just about growth, that there are other things that growth hormone is responsible for in the body that are important functions. And so if you have a kid with the deficiency a parent may go into it well, I'm not so much interested in their final adult height, but these other things could be a problem too, so that's something else to put into your risk/benefit meter…
Dr. David Repaske: Right.
Dr. Mike Patrick: … if you're trying to decide what to do. Let's talk about, how is growth hormone given?
Dr. David Repaske: Well, that's one of the downsides. It's given as an injection. It's a small injection just under the skin, sort of like insulin, so it's not particularly painful or difficult. But there is this psychological thing about hmm, I got to give my child a shot every day and some parents are just not so thrilled about that concept.
It would be great if there was a pill but growth hormone is a protein and just like a hamburger if you put it in your mouth it's going to get digested in the stomach and not absorbed.
Dr. Mike Patrick: Let me go back a second. How long do you use it?
Dr. David Repaske: Well, the shots today are once a day and they usually will go on until, I guess you could stop when you reach an acceptable height for the family and some people do stop before they're done growing. They just get tired of the shots.
Dr. Mike Patrick: OK.
Dr. David Repaske: And then they think well, we've achieved what we're after. But generally, we keep going until there's no significant growth left.
Dr. Mike Patrick: So once you start these the typical scenario would be you're going to do it every day till you're done growing.
Dr. David Repaske: Right. And so typically, although there's a lot of variation, for girls that's about 15 and for guys that's about 18.
Dr. Mike Patrick: And how well does it work?
Dr. David Repaske: Well that depends. Sounds like a simple question. If you were a growth hormone deficient it works predominantly well. I mean, kids will go from hardly growing at all to just rocketing up, the growth curve just heading north.
If you don't have growth hormone deficiency, say we also use growth hormone to improve the stature of a girl with Turner syndrome, for instance, and they're not particularly growth hormone deficient, so you're just adding some growth hormone to what they are already making and the effect is much more modest. Although over years and years and years it's cumulative and it is significant.
Dr. Mike Patrick: Yeah. I'm kind of thinking in my mind, my daughter is very and she's college age now and she has always been second to fifth percentile and we never had her tested for much to here chagrin probably. And the reason being that she's as tall as my wife's mother, she's as tall as my grandmother on my father's side.
I mean, there's a lot of short people in our family and so it kind of comes back to my mind again that for so many people when they have short stature is it really because they have a growth hormone deficiency because of a disease state or is this their programming. It's a tough issue.
And so the next part of this where I wanted to get into is because we want to look at risk versus benefit, are there risks when a family is trying to decide OK, there are short people in my family, there is some evidence that there's a growth hormone deficiency, if there's all benefit then it's easy to say hey, let's do it. But is there risk involve with this that makes you step back and say is this a good idea?
Dr. David Repaske: So there is risk. I think we are probably very, very, super over cautious about the risk because this is not a lifesaving therapy. So it is sort of optional and so you want to really air on the side of not doing any harm when there's not lifesaving benefit to the treatment.
So I think the risk it starts with things like you have to get an injection every day and is that going to have a psychological risk associated with it. Are you telling the child that there's something wrong with him when really as you're just pointing out it's just a variation of normal, it's part of the spectrum of normal.
But if we're telling the child that you've got to have these shots every day, for some kids that's probably a subliminal message that there's something wrong with you and that's maybe not a good thing.
A good thing about being an endocrinologist is we're generally putting back things that should be there anyway. And so like growth hormone it's exactly the same as growth hormone that your pituitary gland would make ordinarily. And so there's no allergies per say. There are no side effects like that.
Although we're not giving it exactly in the same way, as I was saying earlier it's usually secreted in pulses at night and when you're given a subcutaneous injection under the skin all at once, that's a little bit different than normal.
So there are some things that arise as the result of growth hormone therapy that fall in to the label of side effects. One is that you tend to retain fluid and so if you've been growth hormone deficient and suddenly you've got it for some reason you retain fluid, so you can get a little swelling in your hands and in your feet. That's not such a big deal.
But sometimes it's so much you get a little carpal tunnel syndrome, much, much more common in adults than in kids, but that's something that's out there. Something we worry about is swelling in the spinal fluid. So if the spinal fluid volume around your brain starts to increase it can cause some increased pressure in the brain and can cause something we call pseudotumor.
And if you don't decrease the growth hormone dose temporarily you can actually get pressure on the optic nerve and temporary or permanent blindness. So we are very cautious about headaches and stuff.
Dr. Mike Patrick: And too much growth hormone can be an issue. So if you have someone who wasn't really growth hormone deficient and you gave them growth hormone and then if you had too high of a level that can cause the organs to grow bigger so some heart issues, liver, kidney, like too much growth.
Dr. David Repaske: Right. Right. So everybody sort of the giants. So a giant, one of these people that are eight-feet tall, many but not most of them have growth hormone secreting tumor. And so they're making too much growth hormone when their growth plates are still open, when they're children. And so they grow and grow and grow. But that comes along with a lot of problems.
There's a lot of heart problems. There's a lot of joint problems. The growth hormone is anti-insulin in effect so enough growth hormone will actually give you diabetes. And so these giants generally don't live pass their mid-20s or so.
Dr. Mike Patrick: Yeah. What about leukemia? I think there were some studies out there that showed there was an increase risk of leukemia down the road in kids who receive growth hormone. Were those well done studies or could it be that maybe whatever caused their growth deficiency in the first place maybe that's what made them…
Dr. David Repaske: Yeah. There still is some controversy about that, but the studies are really coming down in favor of the fact that the growth isn't causing tumors. If there was something already there lurking it might speed up the growth. And think the complication as you're alluding to is that a lot of children get growth hormone because they've had cancer or they've had radiation therapy to their pituitary gland as a part of treating cancer that's in the spinal fluid.
And so they get growth hormone deficient. They get on growth hormone and then unfortunately, second, cancers are not uncommon, so that's after growth hormone. So the association is there but it probably is not the growth hormone.
Dr. Mike Patrick: Yeah. I think we've made a good case for doing growth hormone and I think we've made a case for there may be some hesitancy and some parents may not want to do it. How does a family come to a decision?
Dr. David Repaske: Well, I think just like any other medical decision, you lay out the pros and cons as objectively as I can and then the family…
Dr. Mike Patrick: Just has to make the decision. You just got to look at the risks and look at the benefits and go from there.
Dr. David Repaske: Right. Right. Sometimes the benefits are stronger than the low level of risk. Other times it's more of a balance.
Dr. Mike Patrick: Do you find and I suspect you see both ends of the spectrum, I mean you see parents who want their kids to be taller and they're really gone in for the growth hormone. Are there families that you have to say this is not a growth hormone deficiency situation, where not doing, you have to talk them down off a little bit?
Dr. David Repaske: Right. Right. So there are families that come wanting their child to be taller and if they don't have growth hormone deficiency it's just not going to work. If you give somebody a reasonable amount of growth hormone and we've talked about the giant where you give a huge amount a person is going to grow, but at the cause of really extreme side effects.
But if somebody is not growth hormone deficient and you just give him a normal amount of growth hormone they're just going to shut down making their own because their bodies don't know where it came from, it's like oh, there's plenty of growth hormone here, I don't need to be making anymore and they don't get a benefit from it.
Dr. Mike Patrick: And then you see the other end of the spectrum where parents are really hesitant to do it and you're kind of thinking to yourself oh, but this is going to be a good benefit for him.
Dr. David Repaske: Right. But again it's not a lifesaving treatment so it's very hard to push it.
Dr. Mike Patrick: Right. I think, parents, if there is this question they really want to see a pediatric endocrinologist and I would think they would want to see someone who is sort of open-minded to either doing it or to not doing it.
I wonder if there are some parents who are hesitant to go see the endocrinologist because they don't want their kid to have growth hormone and they think the endocrinologist is going to push for that. But I guess I would just want to say the workup is really important too and you're going to get the best workup with a pediatric endocrinologist for the most thorough, complete.
Dr. David Repaske: Right. And it's not always growth hormone. It's thyroid hormone deficiency causes poor growth, short stature that it's so easy to treat and you wouldn't want to…
Dr. Mike Patrick: Miss that. And then there are certainly things like Turner syndrome and other things that can be easily missed unless you're looking for them.
Dr. David Repaske: Absolutely.
Dr. Mike Patrick: Great. Well we really appreciate you stopping by again and talking about short stature and growth hormone deficiency. Thanks. Thanks a lot!
Dr. David Repaske: It's been my pleasure! Thanks a lot!
Dr. Mike Patrick: All right. We do have some links in the Show Notes for you – endocrinology at Nationwide Children's Hospital and also growth problems and growth hormone deficiency from the Nationwide Children's Hospital Health Library – we have those links.
And then a great article from Medscape on short stature that's very complete and thorough if you're interested in digging in and learning more about this condition.
All right. We're going to take a quick break and I will be back to wrap up the show, right after this.
All right. We are back to wrap up the show and I just want to thank all of you for your support this year. So as I mentioned in the intro to the program, this is our final show for 2012 and it's been a great year. We've covered lots of topics. We've answered tons of listener questions and covered all kinds of news stories. We've added Pinterest as a new social media outlet.
So lots of growth and exciting new stuff. And we have a bunch of new stuff and exciting stuff, really exciting stuff, on the horizon for 2013. And they are things I can't talk about quite yet even though I want to.
It's kind of like with Christmas coming you got those gifts and they're wrapped up and you just can't wait to give them to your loved ones because you're just so excited to see their reaction. So it's kind of how I feel right now. But the time will come soon enough when we'll be able to divulge our gifts to you even though it'll be past Christmas. So I am excited about that.
Speaking of gifts, I also want to make one final plea. If you are in a situation where you need to make a charitable contribution before the end of 2012, I would just ask that you please consider Nationwide Children's Hospital.
Even though we're not necessarily the children's hospital that's closest to your home, this is a big place and we do lots and lots of research and we do see kids from just a humongous service area and we have lots of folks who travel from out of state to come here to see our specialists as well.
So really one of the finest children's hospitals in the worlds and just with a world class research section here as well with just lots and lots of great stuff going on. And so I would ask that you consider giving a gift to Nationwide Children's Hospital.
And it's easy to do. You just head over to nationwidechildrens.org/giving, so nationwidechildrens/giving and you'll be able to make a contribution to help the kids here at Nationwide Children's Hospital and to help us help the kids as well.
All right. Again, I want to thank you for your support. I want to remind you that iTunes reviews are very helpful. We have not had a new iTunes review since August. And partly that's I haven't pushed it and I just want to give a little plea for that too. I know you're busy with the Holidays and so if you don't get it to it until after the first day of the new year that's fine.
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If you've not done a review on iTunes I would just encourage you to please swing by there and do so. It won't take long. I mean, literally, five minutes of your time. It probably will take longer to find PediaCast than it does to actually write the review. So it's quick and fairly painless. If you could do that I'd appreciate it since we haven't had any new reviews since August.
Also links on your webpages, mentions in your blogs, on Facebook, in your Tweets and on Google+ are always appreciated. You can join our community by liking PediaCast on Facebook if you haven't done so already. You can also follow us on Twitter and hang out with us over on Google+.
And again our Pinterest boards are available. We have the Episodes board, the News Parents Can Use board and a new Blog board with some of my blog posts on there for you. And we'd appreciate you sharing and repining those as well.
You can also swing by the Show Notes at pediacast.org to add your comments on today's show. And we appreciate you telling your family, friends, neighbors, relatives, all that about the program, especially when you're out and about this holiday season – you're at the in-laws, you're at the office party. If you know folks with young kids or expecting parents, just say hey, did you know about PediaCast, something you might be interested in. So we really appreciate that word of mouth.
And of course don't forget to talk us up with your child's doctor at your next well check-up or sick office visit. We also have posters you can download and hang up wherever moms and dads hang-out and you can find them under the Resources tab at pediacast.org.
One more time, if there's a topic you would like us to talk about, you have a question for me or you want to direct us to a news story, just head over to pediacast.org. We have a nice Contact link there for you. It's easy to use.
You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. 347-404- K-I-D-S. That's another way that you can leave your question or comment on the voice line for us. If you email or use the voice line, I would ask could you please let us know where you're from. That's always nice to know.
All right. So farewell to 2012, 2013 is on the horizon. And until then, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody!
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.