Anesthesia, Naps, Deaths and Funerals – PediaCast 428

Show Notes

Description

  • We answer more of your questions this week! Topics include behavioral concerns following anesthesia, the importance (or non-importance) of naps, helping kids process death and funerals, sternoclavicular dislocation (we’ll explain what that means) and the best child health and parenting magazines. We hope you can join us!

Topics

  • Behavioral Concerns following Anesthesia
  • The Importance (or Non-Importance) of Naps
  • Helping Kids Process Death and Funerals
  • Sternoclavicular Dislocation
  • Best Child Health and Parenting Magazines

Links

Transcription

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.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.

It is Episode 428 for April 3rd, 2019. We're calling this one "Anesthesia, Naps, Deaths, and Funerals". I want to welcome all of you to the program. 

You can probably tell from the title of today's episode that we are covering listener questions again this week. Because trust me, I would not have thought of this collection of topics on my own. But here we are, it is an interesting collection, to say the least. But most importantly, these are the topics that you have asked about. It's what is on your mind this week. And if it's important to you, it is certainly important to me. 

0:01:25

I'll share a bit more detail of what these topics entail here in just a moment. First though, I have an announcement that I'm really kind of excited about. This has been a few weeks, maybe a month or two, in the making. And I am happy to report that you can now find PediaCast on SoundCloud, in addition to all of our normal places. 

So we're in Apple Podcasts, iTunes, Google Play, Google Podcasts, Spotify, Stitcher, TuneIn, iHeartRadio, all the third-party podcast apps that use the iTunes group of podcasts, which are most of them. But we were not in SoundCloud, but we are now. Not all of the episodes, I think we've got 22 episodes. 

0:02:11

So all of the episodes of the regular PediaCast program for this year are there, along with all of our Pediatrics in Plain Language Panel, sort of a series within a series. All of those podcasts are in SoundCloud, even ones from previous years. Because the cool thing with SoundCloud that you can do that you can't do with any of the other places where podcasts live, you can create playlists. So we have a special Pediatrics in Plain Language playlist for you on SoundCloud. 

And we have about the last 10 episodes of our PediaCast CME programs, the ones from this year, then all the ones from 2018 as well. And we have a playlist of those, too. So you can go to SoundCloud, look up PediaCast, click on playlists and all the CME episodes will be bundled together there for you, if you're interested.

So just another way, hopefully, to make it more convenient for some of you if you already are SoundCloud listener. And if you're not, you can listen to all of these free on SoundCloud. Just download the app. And it might be, like I said, a little bit an easier the way for you to connect with the program. So we're kind of excited about that. 

0:03:18

All right, so let's delve into these topics in a little bit more detail. A couple episodes back during our Pediatrics in Plain Language podcast on ear infections and spring injuries, one of our panelists, thanks Dr. Alex Rakowsky, mentioned the remote possibility of anesthesia causing behavioral and developmental problems down the road. 

Well, one of your fellow listeners said, "Wait a minute, what is that all about? Is that really a problem? If so, when should we worry and what can we do?" So I'll share some additional thoughts and information on that topic today. So stay tuned for that. 

And then, nap time, another of your fellow listeners, this one in the Philippines, has heard that naps are important for vertical growth. In other words, the more you nap, the taller you grow. She doesn't necessarily believe this, but she wanted to hear our opinion. 

0:04:15

So we'll talk about it, along with some additional information on naps. Are they really important? How long should they last? When do kids stop needing to take naps? That sort of thing. 

And then, we'll also touch on sleep in general, including how much sleep kids need at various ages and the consequences of not getting enough sleep. So that's coming up. 

Then, this is a great conversation, deaths and funerals. It's a terrific question. It comes from a fellow pediatrician in New York and he wanted my thoughts on how parents can best help young kids process through the death of a loved one. Which really gives us the opportunity to think about how we present death to kids. 

What do you do when they keep asking questions about it? How do we explain things that maybe we aren't so sure about ourselves? Then, we'll expand that conversation to include funerals and working through grief. And I'll have some terrific resources to share, ones that I think will be useful for families encountering the death of a loved one, especially if you have kids at home and you're all dealing with this event together.

0:05:25

And then, sternoclavicular dislocation, it's a rare injury but when it does occur, there is the potential for dangerous complications. So this is a serious injury and returning to playing sports is not necessarily a fast thing. So our listener is finding out. So we'll explain what a sternoclavicular dislocation is all about. 
Actually, this will be fun. Make your guesses now. What do you think that word means, sternoclavicular dislocation? And then, we'll see if you're correct later in the program. 

You know we're all about plain language and health literacy and helping you understand. So we wouldn't just leave a word like sternoclavicular dislocation out there without explaining what it is. But I'll wait to explain it until we get to that segment. And in the meantime, try to figure it out, sternoclavicular dislocation. 

0:06:20

And in addition to defining the term, we'll explore the dangers associated with this injury, along with the treatment and the process for returning to sports participation.

Then, finally, a listener wants my recommendations on magazines and journals geared toward moms and dads, ones that cover child health and parenting topics. A couple of weeks ago, we explored online resources for finding evidence-based trustworthy medical information, again, online. Today, we'll add some more digital resources to our list. And we'll consider print publications that can also help parents stay up to date with pediatric and parenting topics. 

0:07:02

So more resources coming your way, which we'll end up sharing with you in the show notes of this episode which is 428 over at pediacast.org. So we'll have links to all the things that we're going to talk about, all the resources, as we think through magazines and journals for parents. 

So lots of your questions answered this week. Don't forget if you have a question that you would like us to talk about. Maybe something crossed your mind, you've seen something in the news. Whatever it is, we love to hear from you. And we'll try to get your question, your comment, your topic on the program. 
It's easy to get in touch, just head over to pediacast.org and click on the Contact link. And we try to get through those and have an episode like this where we just have a whole bunch of listener questions for you. 

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. 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 audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

0:08:15

So let's take a quick break and then I will be back to talk about anesthesia, nap time, death and funerals, and more. That's coming up right after this.

[Music]

Dr. Mike Patrick: Our first question this week comes from Marla in Great Neck, New York. Marla says, "Hi, Dr. Mike. I love your podcast. I particularly want to thank you for Episode 123, which I just discovered after my older son was diagnosed with a submucosal cleft palate and we've been struggling to sort out what to do and what it all means. It was incredibly helpful to put everything in perspective."


0:09:15

So thanks for that feedback, Marla. Really appreciate it. You kind of bring up a good point, because Episode 123 was quite awhile ago. And in our feed which is where folks are going to find episodes in places like Apple Podcasts and iTunes and Google Play and most podcast apps, our feed doesn't go back, it goes back about 100 episodes or so. 

But you will find all of our past episodes, including ones that were hundreds of episodes ago in the archive over at pediacast.org. So if there is a topic that you're looking through wherever it is that you're finding podcasts, if you don't find the topic, there's a particular thing you're looking for, check the archive out at pediacast.org because you'll probably find it there. 

We've been doing this program since 2006 and we have over 400 episodes, 428 actually, to be exact. So be sure to search the archives if there's something that you want to listen to. And just like Marla did when she was curious about cleft palate. 

0:10:19

All right, so Marla goes on. She says, "Now, for my question, I was listening to your podcast on ear infections and ear tubes, number 426. And Dr. Rakowsky mentioned that there are concerns about exposure to anesthesia in terms of mental illness and development. 

"My 12-year-old daughter was born with a cleft palate. That was repaired at 13 months of age. She's had six separate ear tube procedures, all very necessary, and over the last two years, seven retina surgeries, stemming from complications from retinal detachments. 

"What are the risks exactly? The ear tube procedures were all short, but the cleft palate repair was four hours. She had double inguinal hernia surgery and each eye procedure was between one and half to three and a half hours depending on what was happening. That's many hours of exposures. Is there anything we can do proactively to help mitigate the possible long-term consequences. Thanks so much, Marla."

0:11:17

Well, thanks for your question, Marla. I certainly can understand when you have a kiddo who has needed all of these surgeries and they've been under anesthesia so long. And then, we just kind of flippantly say, "Oh, you know, that's one of the reasons that we don't want to do anesthesia, unless you have to, because there could be long-term behavioral mental health, developmental kind of consequences."

Let's look at the evidence of this. And this is going to be one of those instances why I think it is important to sort of put this into perspective, where is this information coming from? How strong is the evidence and how does that fit into everything else that we know? And also, as parents who are trying to think about risks and benefits as it relates to surgery. 

0:12:02

One of the studies where we get idea that maybe there's a connection comes from researchers at Mayo Clinic. And this was published in 2011 in the journal, Pediatrics. And basically, they looked at over a thousand kids, about 1,050 as it turns out. So just over a thousand kids born between 1976 and 1982 in a single school district in Rochester, Minnesota. 

And 350 of these 1,000+ kids, had one or more surgeries requiring general anesthesia before the age of two. They compared those 350 kids with 700 children who had no history of anesthesia before age two. So that was the control group. They never had any anesthesia, 700 of them. 350 of them had one or more surgeries. 

0:13:03

And then, they compared the two groups for the presence of learning disabilities down the road. So this is retrospective. They're looking at, okay, who has learning disabilities? Or, do you have learning disabilities or not now? And then, let's look back and see if you had anesthesia before the age of two.

So of the group who had no surgeries, 21% of them had learning disabilities. For the kids who had one surgery, 24% had learning disabilities. And if they had two or more surgeries, 37% had learning disabilities. 

I'm going to put a link actually to this article if you're in interested, in the show notes for this episode, 428. So you can look at the study yourself, if you're interested.
 
There are some problems here. First, this is not a particularly large and diverse population. It's one single school district. It is a thousand kids, but it's over a large population. And as I mentioned, it's retrospective study. We don't have any indication how long the anesthesia lasted. They had one or two surgeries, or they had at least one, one or more. But we don't know, what did that look like? And we don't know why they had the surgery.

0:14:27

So this is one of those things where we have to keep in mind that association does not mean something caused the thing. And I recently actually had a pediatrician tell me on social media that we talked about association does not equal causation too many times. That's not true. This is really is an important point. 

Because it does not mean that the anesthesia caused more kids to have learning disabilities. We have to remember, sick kids tend to need more surgeries and sick kids also tend to have more learning disabilities. So was it their underlying conditions that made them have to have more surgeries that then ended up causing also learning disabilities? And then, the anesthesia has nothing to do with it at all if that's the case.

0:15:19

So this is a sort of study where, yeah, it shows that the more anesthesia you had, the more likely it was that you had a learning disability. But that does not mean that anesthesia had anything to do with it at all. It might have, but it also may not. And so, it's something that we take note of but we don't really have firm evidence that it was the anesthesia that did the thing. 

Okay, so moving on, another journal article that has been kind of influential in this. This one, it was called Behavioral and Emotional Effects of Repeated General Anesthesia in Young Children. This was published in 2015 in the Saudi Journal of Anesthesia.

0:16:01

Now, this is a really small study. This looked at 35 kids, 35, who were between 18 months of age and five years of age. That was the experimental group. And these kids were all presenting for pre-operative assessment number three. So what that means is for all of these kids, this is their third surgery. All of these 35 kids. They've had two previous surgeries. 

We do not know the details of those surgeries. We don't know how long the anesthesia lasted. We don't know what they were having surgery for. We just know this was their third surgery. 

And then, they matched those kids with 35 healthy controls that had no history of ever having surgery. And these were kids just being seen in a vaccine clinic. So we're going to take 35 kids, never had surgery, who are between 18 months and five years of age. And we're going to take another 35 who this is they're having their pre-operative assessment by an anesthesiologist before they have their third surgery.

0:17:07

And then, they collected behavior data with the questionnaire for the family for both of these groups, the one who had never had surgery, and the other, they're having their third. So they've had two previous surgeries again, we don't know why or how long. 

What they found was that the repeat anesthesia group had increased incidence of behaviors related to anxiety and ADHD. There was no increase in depression or oppositional defiant disorder kind of symptoms and no increase in developmental problems. 

So the authors, their conclusion was that young children who undergo repeated surgical procedures under general anesthesia were at risk for subsequent behavior and emotional disturbances. Proper perioperative pain management, social support, and avoidance of unpleasant surgical experiences could minimize this untoward consequences. 

I'll put a link to this study also in the show notes for Episode 428. So again, you can look at it if you're interested. 

0:18:16

So some issues with this one, it's a very small sample size. The other one was a thousand kids, plus. This is only 35 children. The oldest these kids were is five. And ADHD, so the two things that they said were associated, one, behaviors related to anxiety and behaviors related to ADHD. 

Well, it sort of makes sense that these kids have a little anxiety, right? They've had two surgeries. And so, whatever it is, whatever the underlying disease process is that has caused them now to have a third surgery or maybe a series of processes, does it make sense that these kids might be a little more anxious in general because of these other things that they're dealing with. 

0:19:01

So again, we don't know it's the anesthesia. I mean, that could just be an association, not necessarily the cause of this.

And then, ADHD, I don't know, it's difficult to diagnose in five-year-olds to begin with let alone because normal behaviors sort of overlap with ADHD symptoms, age-appropriate behaviors, up until school age. So that's kind of hard one to make an association with. Again, we don't know how long the anesthesia lasted or why it was used.

So I'm going to say it again, association does not equal causation and that's an important point as we think about medical science. Sick kids need more surgeries and they're going to have more anxiety and disruptive behaviors.

There are other studies with similar pretty soft findings. However, and I think this is important, prospective studies are underway. They just take time. So what a prospective study would do is they would follow kids along as they grow up and really look more into what kind of surgeries, how long were they having the anesthesia, and then following them long term to see what sort of problems develop. But again, that takes some time. They're better studies but they take awhile. 

0:20:13

So the bottom-line right now, based on what we know, it's always important to do the least that you have to do. So the first thing you have to ask is, is the surgery necessary and beneficial. If so, does the benefit of having anesthesia and having the surgery outweigh this risk? Which is a pretty soft risk at this point. 

And you also have to take into account your family's risk tolerance because nearly everything we do has risk, right? You strap your kid into a car and get on the highway at 70 miles an hour, there is a risk. But the benefit outweighs the relative risk for your family. So you have to decide, does the benefit of the surgery outweigh this risk?

And ultimately, that decision may be different for each situation, each family. And it's helpful to have a medical provider kind of walk you through thinking about the risks of having the surgery and the risks and of possible complications of not having the surgery.

0:21:12

What about mitigating long-term effects? Marla asked about that, if there are any. We don't know. I would say it's the same as for any kid. Anything you can do to help their development is going to help mitigate whatever kind of risks are out there. 

So, you know, read to your children. Encourage them to read. Get down on the floor and play. Use your imagination, use screens in moderation. Watch for any early signs of developmental and learning problems and intervene sooner rather than later. Voice your concerns to your child's medical providers and also their educational providers in daycares, preschools, and regular school, all going to be important. 

So I hope that discussion helps, Marla. That's sort of where we are in terms of the science behind this. I'm not throwing it out the door because it makes sense, if you have something that's affecting the brain for a little while, could it continue to have some sort of effect? And could there be problems down the road?

0:22:10

Maybe, but again, surgeries are often necessary and not a lot that you can do to avoid them when they are necessary. But you'd want to figure that out, if it's necessary or not. 

And there's more to come. We'll find out more about this as a future, better designed prospective studies with large groups of folks in the experimental group and in the control group. 

All right, I hope that helps, Marla, from Great Neck, New York. Thanks so much for asking the question. 

Next up, we have a question from Elle, in the Philippines. Elle says, "Hi, Dr. Mike, and to the PediaCast family. First of all, I wanted to thank you for providing everything that parents must know. I really appreciate your show, and I wish I could pay you back for everything you've taught us. I don't know what to say anymore, just wanted to let you know that families are lucky to have you, guys."

0:23:01

That is very sweet, Elle. Thank you very much.

"Anyway, I have a question about baby's nap time. Here in the Philippines, it's a habit for parents to put their kids ages 0 through 10 to sleep typically between 1:30 and 4 in the afternoon. There's a belief here that if our kids don't sleep in the afternoon, there's a chance they will not grow tall. And Filipinos are quite short in height to begin with.

"In other words, we tell our kids that if you want to grow taller, you should go to sleep in the afternoon. I browsed the web to check for information regarding this. I even asked some pediatricians and family doctors in my region, but I really wanted to hear it straight from you. Does taking a nap in the afternoon really affect the child's height? Does it affect other things, especially with development. Thank you so much for being our guide, Elle." 

Well, thanks for the question, Elle. It is a good one and it gives us a chance to talk about naps and sleep in general for young kids and older kids as well. 

First, let me say there is no scientific evidence to support that taking nap in the afternoon will help you grow taller that I've ever seen. And if anyone out there has seen something that is evidence-based that would suggest this, please send it my way. But I have not seen anything of that nature. 

0:24:12

It is easy to understand though how this myth got started. As Elle says, Filipinos are quite short in height to begin with. It's a widely accepted observation in her culture. And I would imagine that there is probably an unspoken, and sometimes spoken desire among kids and parents to grow as tall as possible. And there's also likely an unspoken, sometimes spoken, desire for parents, for moms and dads, to be productive and enjoy some peace and quiet in the afternoon.

So both of these things, you want to grow taller. You also would like a little time in the afternoon. And the third observation is that children are likely to resist taking a nap. So the pieces come together, you think about a nap, I can have peace and quiet. It seems like a good idea for my kid to have a nap. My child doesn't really want to. Hey, we can say, "You'll grow taller if you take a nap." 

0:25:22

So that way, you can get your peace and quiet, productivity, feel like you're doing something good for your kid. And your kid can feel like, "Hey, maybe I'll grow taller, so I won't resist so much." So it's a win-win. And you can see how then a myth or misconception gets started. But again, I couldn't find any evidence that this is true.

So let's move on, are naps important from a health standpoint? What does the evidence say about that? Well, rather than simply considering naps, it appears that overall sleep during a 24-hour period is what really makes a difference. And that includes napping.

So there's no evidence at this point that the amount of sleep you get in a 24-hour period is better all at night, is better in long naps, better at short frequent naps. But all that we really know is that overall sleep in 24 hours is really what's important. 

0:26:21

We know that adequate overall sleep in 24 hours has been associated with things like improved immune system function, improved IQ. Your IQ can actually get better when you get more sleep. Better memory, better school performance, improved behavior and decreased incidence of anxiety, depression, and other mental health conditions, less impulsivity, better able to pay attention and concentrate. 

And we know that not getting enough sleep overall in a 24-hour period, not getting enough is associated with irritability, difficulty concentrating, obesity, high blood pressure, and headaches. And there is good evidence in the peer-reviewed literature that would suggest all of those things are true. That overall sleep does all of those things, and inadequate sleep is going to cause those bad things. 

0:27:16

So sleep is important. But the next question is how much sleep do you need in a 24-hour period knowing that naps count, but aren't 100% necessary? Although the younger you are, the more overall sleep that you need. And so, you're going to get to that total number a little easier if you do take naps during the day. 

But there's no hard and fast rules of when you need a nap, how long the nap should be, how many naps you need, when you can stop. What's important is how many hours of sleep are you getting in a 24-hour period and then comparing that with your age. And if you meet the right number, you're more likely to have the good things happen and less likely to have the bad things happen. 

0:28:00

So what then is the number of hours that you need? And really, it depends on your age, and this is according to the American Academy of Sleep Medicine. They would say that when you are under four months of age, oh, that's rough, just let them sleep when they want to sleep. They're going to sleep when they're going to sleep. 

But between 4 months and 12 months, when you can start to put them down for a nap, in a 24-hour period, you need 12 to 16 hours of sleep. Between one and two years of age, 11 to 14 hours of sleep. Between three and five years of age, 10 to 13 hours of sleep. Six to twelve years, between 9 and 12 hours of sleep. And 13 to 18 years of age, 8 to 10 hours of sleep.

So I'm going to say those again real quick, have in your mind which age group that you're looking for. And if you have more than one, just rewind 30 seconds and listen again. So 4 to 12 months of age, 12 to 16 hours of sleep. One to two years of age, 11 to 14 hours of sleep. Three to five years, 10 to 13 hours of sleep. Six to twelve years of age, 9 to 12 hours of sleep. And 13 to 18 years of age, 8 to 10 hours of sleep.

0:29:25

And by the way, I was kind of making fun, like, "Oh, parents, put your kids down for a nap so you can have some quiet time and rest or productivity in the afternoon." There's something to be said for that, right? When you feel well rested and you get some adult things done, you are better to parent when your child is awake. So please don't think I was being too tongue in cheek there. That is important as well. 

Healthy Children, which healthychildren.org from the American Academy of Pediatrics, has a really good write-up on this -- Healthy Sleep Habits: How Many Hours Does Your Child Need? And I'll put a link to that in the show notes for this episode, 428, so you can find it easily. 

And I teased these questions in the intro. So I just wanted to double check and make sure that I answer them. Are naps important? Maybe. I think the verdict is still out. We don't really have evidence that napping is necessary in addition to overnight sleep as long as you're getting the right number during a 24-hour period. 

0:30:23

We also don't really know how long they should last or at what age they can stop. If your child's irritable in the afternoon and they take a nap and they're better, that's a good indication that your child needs a nap in the afternoon. So a lot of this varies from one kid to another. But what we do know is that the total number of hours of sleep is what's most important.  

So I hope that helps, Elle. You're right, you're not going to grow longer, you're not going to grow taller from napping. But overall sleep does have some good advantages health-wise, whether that's just at night or during naps. It doesn't really matter. 

Thanks, Elle, for the question. I really do appreciate it. 

[Music]

0:31:28

Dr. Mike Patrick: Our next listener question comes from Dr. Allen Lebowitz in New York. He says, "Dear Dr. Mike, I am a pediatrician. And today, my nurse assistant asked me if it's okay for a three-year-old to attend her grandmother's funeral. The three-year-old had a very close relationship with her grandmother who is there to help raise her while the parents were busy working.

"Sadly, the grandmother passed away from cancer. And now, what does one tell the three-year-old? How does one prepare the three-year-old? Should the three-year-old attend the funeral? And is there an age when this is not appropriate? 

"My suggestion is that funerals are human experience and not only for adults. I offered some online material on how best to approach children with this subject. I was curious if there's any evidence base for this and how best to educate families on involving their children in this human experience.

0:32:17

"Curious if you could speak about this subject. And any suggestions you have for how to approach the topic of death and funerals with different age groups and any recommendations on books or videos on the subject will be great. Also, what to do after the funeral or months later when the child may want to discuss the loss of the grandmother. Thanks, Dr. Allen Lebowitz, New York."

It is a terrific question and really brings up some important points. First, let me say I completely agree with you, Dr. Lebowitz. Death and funerals are most certainly a human experience and folks of all ages can and should participate in that experience. But of course, we want to facilitate that in an age-appropriate and developmentally appropriate way. 

0:33:05

And I would even say in a kid-sensitive way, which is going to be different from one child to another. Each child and family is different. Parents know their kids. You tend to have some instinct about what your child can and can't handle and what's the best way to approach topics. And I would encourage parents to sort of trust your instinct. 

I could not find anything significant in the way of research in this area, like what are best practices for approaching this topic in helping kids cope with funerals and with death. And if any of you do find something of interest that the audience would appreciate knowing more about, let me know. I do have some resources that I'm going to share. But in terms of research that really shows one approach being better than another over a set of a population, let me know that. It's unlikely because again, each kid and family is so different. 

What I will do though is make some observations based on being a parent for 24 years and also talking about this with many families also over 20 years. 

I would say that with kids, surprises generally don't go over so well. So if you know someone is going to die, it's not like a sudden unexpected death. But you know, death is expected, it's imminent. 

0:34:24

It's probably best to prepare by talking about that in an age-appropriate and developmentally appropriate sort of way, just to prepare them. This is a good thing to know, people and pets, animals and people die. It's a part of life. And as soon as kids are able to understand that concept, what age is that, I don't know, it depends on one child to another. But probably sometime between two years of age and three years of age, there begins to be some understanding about this.

And they'll probably going to have a lot of questions when you bring it up and let them know, "Hey, this person that you love is sick, or they're old, or they have a disease or condition in which it is likely that they're going to die." And as you start to talk about that, likely, your child is going to have questions. 

0:35:12

And here's where I think it really becomes important is to answer your kids' questions honestly, to their satisfaction, in a way that they can understand. And it fits it to your family's cultural and religious beliefs, I think that's important as well. You don't have to have an answer for every one of their questions if you don't know the answer. But at least say, say you don't know the answer. Just be honest with them. 

And when you're answering, you don't have to provide every single nitty-gritty detail, but they should be satisfied with your answer. And if they have follow-up questions, answer those, too. We don't have to know all the answers, but when we don't an answer, again, it's important to say that, to be honest. And process what that means together, again, in a way your child will understand depending on their age and their developmental level. 

0:36:02

And then, I would also let them talk about death whenever they bring it up, it's important to them. So it's not necessarily a good thing to squelch or discourage the conversation no matter how many times it comes up. You don't want to belabor it either, but just be reassured that it will come up less often over time. As you live your life, you'll just need a little tincture of time and then you'll be talking about it less. And then, it will come up again. And then it will be less, and then, again, repeatedly. 

So just when they want to talk about it, talk about it. Answer the question to the question to their satisfaction and then move on to something else, but be prepared to answer any follow-up questions. And to be honest, just to be honest but don't provide more details than they're ready to necessarily hear. 

So I hope that helps some folks who may be struggling through that. And I know that I am being a little wishy-washy. But it's because there's not a right answer that really could be applied across all kids. It really is child and family specific. 

0:37:05

In terms of funerals, absolutely, it's okay for kids to go. And it's okay for kids not to go. It just depends on the child, the family, your culture, what's expected. So I don't think that there's a hard fast rule that your children have to go. But I also don't think that they should be prohibited from going.

If they do go, I would prepare them for what they're going to see and experience upfront. Like, "This is what's going to happen. This is who's going to be there. It's going to be kind of quiet." And explain what the atmosphere's likely to be depending on how funerals go in your family. And get them to anticipate what they're going to experience and what they're going to see.

And what they're going to feel, I think that's important, too. And to let them know what your feelings are. And to be open and honest about this is really going to be best practice. 

Check in with your kids during and after the death. Even after the funeral, "How are you doing? How are you feeling?" It's absolutely okay to express those feelings and it's good for parents to express those feelings back. 

0:38:10

But again, with sensitivity. If your grief is much more than your child's grief, then maybe exhibit that more in private depending on the situation. And again, each kid and family is unique, but if your child's doing well, you don't necessarily want to upset them and cause them to have more grief because you're experiencing grief. 

On the other hand, they may be experiencing a lot more grief than you are. And grief in kids can look all sorts of ways. They can express their grief directly. Sometimes, it will seem like it has nothing to do with the loss or with the death at all. And they just seem more irritable, or they act out more. They're more disobedient. 

So if their behavior is changing after a big significant event, it may very well be because they are experiencing grief and it just shows up in different ways. But that will give you a clue that, "Hey, let's talk about this." If your child's acting up, instead of yelling at them, having some empathy, understanding where the behavior is coming from and then asking them how they're feeling and do they have questions.

0:39:17

And sometimes, that will go nowhere, and they'll just clam right up. But at least, you've given them the opportunity to talk and you let them know that you care. And I think that's going to be important. 

Now, the other important thing is we've talked about this being normal and expressing grief and emotions and talking about it when children want to talk about it. However, at some point, grief becomes so intense and so prolonged that it begins to interfere with the function or quality of life in a prolonged way. 

There's no number to put on it, but it's okay to be sad, it's okay to express that. It's okay for that to come up over and over and over again, sometimes unexpectedly. And it's okay for your kids to act out and maybe have behavioral problems because of grief. 

But when these things begin to interfere with quality of life and with development and functioning and moving on, especially in a prolonged way, it's good to seek some help working through that grief. And that's true for kids, too, and young kids. 

0:40:24

And if you aren't sure where to get that help, talk to your regular doctor because they should have some great resources in your community that they could point you to. 

A couple of final points, number one, it's always good to have a chuckle in the midst of dealing with heavy issues. That's always welcome. And I'll tell you a story. You know, my daughter who is 24 years old now, when she was young and we had several deaths in the family, kind of one after another. And we were in the phase of our life where we were really were focused on death. 

0:41:00

And like lots of curious toddlers, my daughter wanted to know when she was going to die. And she kept asking, "Am I going to die? Am I going to die?" And you want to be reassuring but they keep asking, they keep asking, they keep asking. And you know, you're hedging because you don't know what tomorrow brings. 

But finally, I just said, "You're not going to die until you're really, really old." Which is probably not the best thing to say because I don't know that. But that's what I said. I said, "You're not going to die until you're really, really old," because I just want to shut that conversation down. And my daughter said, "But mommy's really, really old and she's not dead yet."

[Laughter]

Dr. Mike Patrick: You know, just one of those moments that you'll remember forever. My wife, yeah, she appreciated that. So it is good, in the midst of heavy issues and talking about it over and over. We certainly got a chuckle out of that one. 

The other point that I wanted to bring up is just resources, which I had promised. And some of these resources, I have heard of before. Others, I came across as I was doing some research for this segment. 

0:42:09

One is Attending Funerals or Memorial Services, How Children Understand Death and What You Should Say, and I'll provide a link to that for you. It's through the American Academy of Pediatrics, healthychildren.org is the one that has this.  And it's a fantastic article. Again, it's called Attending Funerals or Memorial Services, How Children Understand Death and What You Should Say. And it has a ton of resources at that site that you can look into. 

A picture book that is really good. It's called I Miss You: A First Look at Death. And it's not only a picture book. It also has some coaching for parents. So if this is something that's you're just talking about for the first time, it gives you some talking points, ideas for approaching the subject. So at its heart, it's a picture book, but it also has some parent coaching it.

Again, that's called I Miss You: A First Look at Death. And I'll put a link to that in the show notes for this episode, 428, over at pediacast.org. 

0:43:12

Another one is called The Memory Box: A Book About Grief. And it just is a book that you can use to help children process through grief. 

Another one is called The Invisible String and it provides more tools for helping process not just death, but also anxiety that comes from separation, when kids go to babysitters or parents have to travel, and you're away from one another. And that's separation anxiety. It's not really death but it's still kind of like death in that it's a temporarily loss and a significant one. And so that book really helps kids process through that. Again, it's called  Invisible String.

And then, another one that I came across as I was doing research, actually just released, it was just published yesterday. So as I was doing the research I was reading reviews of it that people who had advanced copies had written. And this book sounds really good. 

0:44:10

It's by author, Lori Gottlieb. And she is a counselor and psychotherapist. And the book is called Maybe You Should Talk to Someone: A Therapist, HER Therapist, and Our Lives Revealed. And just looking at the description of this in the reviews, it looks fantastic. It's an insider's look at counseling and psychotherapy from a counselor who needs a counselor, which I think we can all relate to. 

And it promises to be a timely and poignant and funny, thought provoking, all of the same time. Again, I say promise because I don't really know which is again released yesterday. And this is not a paid endorsement. In fact, I paid for my copy on Audible, because I listen to a lot of audio books. And so when I came across it, I pre-ordered it. And I haven't listened yet, but I'm really excited to take a listen to that one based again on the description and the reviews. 

0:45:03

By the way, it already has won Oprah Magazine's Best Nonfiction Book of 2019, Apple Best Books Pick for April. It's a Book of the Month selection. It's Book Riot's Most Anticipated Book of 2019. And it's already being developed into a television series on ABC. 

So you were going to hear about this, I think. And now you can say you heard about it first on PediaCast. So check it out. Again, it's called Maybe You Should Talk to Someone: A Therapist, HER Therapist, and Our Lives Revealed by author, Lorie Gottlieb. Again, I'll put a link to that and all those resources in the show notes for this episode, 428, over at pediacast.org. 

So I hope that helps. And thanks very much to Dr. Allen Lebowitz for bringing up the topic and giving us the opportunity to talk about it.

We had one listener question today from the Philippines. This one comes from Ireland. It's from Katy. Ireland say, "Hi, Dr. Mike. Sorry to distract you from your work." It's not a distraction, Katy. I love getting questions and comments from you, guys. 

0:46:05

She says, "I've been doing some research on sternoclavicular dislocations. And I discovered that they have a very low rate of athletes going back to sport after suffering one of these. Would you be able to give any advice for an athlete who got this injury playing rugby and is eager to return? It's been a week since the surgery and the bone had been set and anchored to the sternum. I know it will be a year of rehab and rest, but I'm just wondering if there is any hope at all about returning to sport. Thank you for reading this, Katy."

Let's define what a sternoclavicular dislocation is. Sterno refers to the sternum or the breast bone. And during the intro to this episode, I had mentioned, "Hey, try to figure out, what do you think sternoclavicular dislocation means." So here's where you get to check yourself. Sterno is the sternum, which is the breast bone. Clavicular refers to the clavicle which is the collar bone. 

0:47:02

So this is the joint where the breast bone, down the middle of the chest, up at the top of that, and the collar bone which goes across the shoulder, it's where these two bones meet. So it's where the breast bone and the collar bone meet. And dislocation means the joint is disrupted. So that joint is broken or torn and the bones are moved apart. 

Now, the good news is these are rare. The not good news is if you are one who has this happen, because this is a very dangerous situation. The usual cause for this is high velocity blow to that region. So again, where the collar bone meets the breast bone. You can feel your own anatomy. So the very top of the chest, just off to the center of midline and pretty high up.

And so a high-velocity direct blow, so think contact sports like rugby, baseball, if the ball hits you there, hockey, if the puck hits, high energy falls, motor vehicle accidents, ATV, all-terrain vehicle accidents. So you need high-velocity energy to dislocate that. 

0:48:15

And again, fortunately, these are rare. And I say fortunate because there are a lot of complications that can result from these. Because there are many critical underlying structures. The trachea, the air goes down to the lungs is right there. The lungs are very close. And so, you can get a pneumothorax where air enters outside of the lung in the chest cavity. 

The trachea, the windpipe can be compressed. There are nerves in the area that can affect the larynx or the voice box which can result in hoarseness and speech difficulties. The brachial plexus is a group of nerves that go through that area, that go to the arm, hand, and fingers. So you can get arm, hand and finger dysfunction. 

There is some major blood vessels in the area, big ones, and so internal bleeding is a possibility. 

And some of these can be life-threatening injuries, like internal bleeding, like the pneumothorax I had mentioned, like compressing the trachea or the windpipe. So there's significant injury that can occur with this and so, we take it very seriously. 

0:49:19

The treatment is pretty straightforward. You want to reduce the dislocation. In other words, put the bones back together. But that's something that, obviously, you don't pop it back yourself like you would let's say a knee. This really has to be done by a trained professional, usually an orthopedic surgeon, usually in the operating room in a very controlled environment. 

And this is not an area that you can cast. You can't put bone pins. Sometimes, if we can't cast something, you can put pins in the area. But you can't really put pins in the area because if they migrate, again there's critical structures there. So you really just rest and a lot of time and you wait for the bones to heal. 

0:50:00

And in the meantime, chronic pain and problems with shorter movement are very common. Physical therapy and rehabilitation are usually required and it is a slow long process to get those bones healed. There's not a lot you can do to help that process along. 

So then, really, Katy's question is so when can  you return to play. And the answer to that is, you should not return until everything is healed up completely and you have rehabilitated the area. So it's going to be when your doctor says you are ready. 

And if you return too soon, a couple of things can happen. If the joint is weaker to begin with because it's not all the way healed, a similar injury could be devastating or life threatening. Because now, you had a nice strong joint the first time. But if you have a similar injury and it's still healing, now it can be much worse because you have that same amount of energy impacting a joint that is weaker now and not completely healed. 

So, a second injury could be a devastating or even could kill you. And so, this is one that you really do want to wait until it is completely healed and the doctor says you are ready to go back to that sport. 

0:51:10

The other thing, you need rehab because you're going to lose a lot while you're waiting. You're going to lose in terms of your flexibility, your strength. And then, because of those losses, you're maybe at an increased risk of injury in that sport because you're not fully conditioned and ready to go. So, not only is there healing, there's long rehabilitation that goes along with it, too. 

And it doesn't mean that you never are able to do it again. But it is true that a lot of people after an injury like this elect to drop out of that sport, because to them, they've lived through this. They've lived through knowing that this could had been a life=threatening injury, the long healing time, the long rehabilitation. 

And then, when you think about your individual risk versus benefit and your risk tolerance, for a lot of people, it's just not worth the risk of going through this again, or having a worst outcome next time. And so many do find a different sport. Many drop out of their sport. 

0:52:06

On the other hand, these injuries are rare to begin with, so repeat injuries are also going to be rare. So, as long as you have the blessing of your orthopedic doctor, you're completely healed, you've done the rehabilitation, and you're willing to accept that risk, there's certainly hope for returning to play. It's just that many don't, again, it was not a fun process to journey through. And their risk tolerance is really what keeps them from returning. 

So that's sternoclavicular dislocations in a nutshell. Again, they're rare. They can be very serious and it's important to follow the directions of your medical provider, especially your orthopedic surgeon, sports medicine doctor, athletic trainers, physical therapists, and all the people who are involved in your care. It's important to follow their directions and take their advice as you consider returning to high-risk activities, which again are those in which high energy impact to the upper chest is possible. 

So thanks, Katy in Ireland. I don't think that without you asking that question, that I ever would have covered sternoclavicular dislocations on PediaCast. And that's not to say that I shouldn't, it just wouldn't come up. I wouldn't have thought about it. But it's an interesting process and condition, and I'm glad you brought it up, Katy. 

0:53:17

Once again, if you have a question that you would like us to consider or a topic that you want to suggest, easy to get in touch with me, just head over to pediacast.org, and click the Contact link. 

Our final question today comes from David in Atlanta. David says, "Hey, Dr. Mike, love the show. Do you have any suggestions for publications, magazines, journals, etc., that would be good for a layman to read on a regular basis. Dave." 

Well, great question, Dave. I really appreciate you writing in. I will point out that few episodes back, PediaCast 425, we did a show that really dealt with finding the best medical information online. So be sure to check that one out. Tons of resources to help you as you seek answers to particular questions, finding answers that are evidence-based and trustworthy, where can you look, who can you trust. That was our goal, sharing lots of resources that empower parents with good answers. 

0:54:13

But that really focus on when you have a question, where do you go to get a good answer? What about simple browsing, especially as it relates to child health and parenting? Yeah, maybe you don't want an answer to a specific question, you just want to know what's out there. How can you stay up to date with the latest pediatric and parenting news? 

For one, you can listen to PediaCast, which, David, you're already doing. So I appreciate that. But there are many resources where you can just sort of browse and stay up to date as a parent with pediatric and parenting sort of news. 

And many other resources that we talked about in Episode 425 can also be used for that purpose. You can just go there and look around. And  in particular, Medical News Today, HealthDay, HealthLine,  Vox Health & Science, NPR Health News, New York Times Health and Wellness sites. All of these are great places to browse and stay current. 

0:55:11

Many of them have a dedicated health and medical writers and editors. Often, there's specific pediatric and parenting pages. So it's easy to find the stories that interest you. And there are links to all of those places and many more in the show notes of Episode 425.

However, Dave mentioned specifically magazines and journals. And so, I did just kind of add to our list as we think about print publications, good old fashion magazines and journals that you can hold in your hands, that are not on the screen necessarily that can help parents and help you stay up to date and empower you with the information to keep your family healthy. Now, I think that's the heart of David's question. 

The American Academy of Pediatrics actually puts out a terrific magazine for parents. But it went all digital around 2012 because print is expensive. And if you don't have a large enough audience to meet your cost or to make it worthwhile the time and effort you put into it, it's easier just to put it online. And so, that's what the American Academy of Pediatrics did. And again, they transitioned from print to all digital around 2012.

0:56:23

It's called the Healthy Children e-Magazine. They actually have an app for it now on iOS and Android. So if you'll just look up in the App Store, American Academy of Pediatrics or Healthy Children e-Magazine. And it's online as well. And I'll put a link to it in the show notes for 428, this episode over at pediacast.org. 

And a lot of these print magazines that we're going to talk about also are all digital now because everything's transitioning to digital. However, despite this, there are still some good print publications for parents and families out there. And again, many of them have pediatricians on their editorial boards and they seek out pediatricians for expert guidance as they prepare news stories.

0:57:07

So, there are still good magazines out there that you can hold in your hand. And so, some of those that I have found out to be good, the ones that I've actually provided information to many of them through interviews. And as part of my job here at Nationwide Children's Hospital, I engage the media often. So when reporters want answers to pediatric questions, they call around the children's hospitals and I get connected with them in that way. 

So these are some magazines that you can hold in your hand that are aimed at parents, that I had found to be good. And those would include Parenting, Parents magazine, Disney Family, Family Fun, American Baby, BabyTalk, New Parent Magazine, Scholastic Parent & Child, You and Your Family, and Working Mother. And I'll put links to all of those, because they all have digital sites too in addition to their print publications, again in the show notes for this episode, 428, over at pediacast.org.

Which one is the best? That depends on you. Explore their websites, see what resonates. Each of them are going to have a little bit of a different niche. The writing style may be better for you, some, more in depth, some, more pictures. Some focus more on babies and toddlers, as opposed to older kids or the entire family. 

0:58:31

So I would say there's not a right or wrong answer, and there are a lot of them. So kind of explore their websites to figure out which one you really connect with before you order a subscription and get the print publication.

Now, if you want something a little more science-y, there are some great pediatric journals. There aren't any journals that target lay persons or parents. These are really written for the medical community. But you know, we have a lot of sophisticated listeners in our audience. And we have a lot of science type people, people who are interested in health, and in particular, child health.

0:59:06

And so, you can be a lay person and the more that you start to look into science and read articles and listen to programs like this. Then, you may be at the point where you could read a pediatric journal and get something out of it and be able to evaluate science, which is a pretty cool thing. 

So the journal, sort of the go-to-journals in the world of pediatrics would be the journal from the American Academy of Pediatrics that's called Pediatrics. There's The Journal of Pediatrics, JAMA Pediatrics, Child Development, and Journal of Adolescent Health. Again, they target physicians and scientists but parents can get something out of them if you are so inclined. And I'll put a link to those in the show notes for you.

And then, there are some others, these are not journals but they are professional publications. Some of them, they do have print versions and some are just online. And examples of that is this thing called Pediatrics Online, Pediatrics Nationwide, and Research Now. And these are all put out by Nationwide Children's Hospital and I'll put links to them in the show notes. 

1:00:21

So they do have regular online material that's kind of bridging the gap between a peer-review journal and just a pure lay person's magazine. So it sits in between those two. So it's got some great scientific information, some terrific science writing. Target audience really usually more providers of healthcare, but gain, a sophisticated parent, I think, could get something out of those publications. 

And again, I'll put those Pediatrics Online, Pediatrics Nationwide, and Research Now in the show notes for this episode, 428, over at pediacast.org.

I should also mention, here at Nationwide Children's, we have what's called Health e-Hints Newsletter. And that is different information depending on the age of your kids. And it can get delivered to your email inbox on a regular basis. So you can sign for that, and I'll put a link to the sign-up page again in the show notes.

1:01:15

So between Episode 425 and this episode, 428, between those two show notes, tons and tons of resources for you. So just click some of those links and then save them to your browser bar, maybe in a folder Pediatric Resources, and just start putting all those links in there. And when it comes up, and you're thinking, "Okay, what do I want to browse? Or what questions do I want answers to, you'll have a nice little folder up there with tons of resources. And again, between 425 and 428, there should be plenty for you. 

And really, I have to thank David in Atlanta for bringing this up because I probably wouldn't have. Since we just did this similar episode back in 425, I would have just thought, "Well, that's enough of the resources." But I came up with a whole bunch of new ones. And so, thanks David. Your question benefited the entire audience. 

1:02:10

And that often is true. If you have a question or something's really on your mind or you have a question about a new story that you saw, it's likely that lots of other people have that same question. But everybody's busy and none of them may write in. But when you take the initiative to contact PediaCast with your question or with your story idea, that really benefits lots of people who really have the same question that you have. 

Again, it's so easy to get in touch. Just head over to pediacast.org, and click the Contact link. 

[Music]

1:03:10

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that. 

And really, thanks to all of our listeners who wrote in with questions and comments today. Really do appreciate you taking the time to write in. And we just really love getting your questions. The more that we can make this show what you wanted it to be about, the better for everyone. And so, it's easy to get in touch again. Just head over to PediaCast and click on the Contact link there. 

You can find PediaCast in all sorts of places, including a new location which I mentioned during the introduction. SoundCloud, we are in SoundCloud now. So if you are in SoundCloud, be sure to search for PediaCast and like us, we'd really appreciate that. If you do not use SoundCloud, they have a convenient app. It's free. They have a great robust website. 

1:04:01

And all of our shows moving forward will be in SoundCloud. We've got  about 22 past episodes there. That's probably where I'm going to stop because it starts to get confusing if you start putting old stuff in front of new stuff and it's a little difficult to rearrange. But the one thing which is a disadvantage to SoundCloud, it would be nice if you could then, once things are published kind of put them in a nice order. 

But the nice thing about SoundCloud is that you can have playlists. And so, we have created one playlist on our Pediatrics in Plain Language Panel where it's three pediatricians in a room. The ideal goal is for it to become like a sports radio program. You got three pediatricians in a room just kind of batting things back and forth. I know we don't quite live up to that, but that's our goal. That's what we're trying to do. 

So those are kind of fun episodes and even though we speak in plain language, we don't dumb down the science. We still try to explain things. So those are some of my favorite programs because there's some camaraderie and it's fun getting three pediatricians in the room just to talk about stuff. 

1:05:07

And so, I have all of the past episodes with that panel in a playlist on SoundCloud called Pediatrics in Plain Language. And then, all of our CME programs. So, not all of them, the last ten. We've done like 42 of them. But the ones that are available for free Category 1 Continuing Medical Education Credit, the most recent one of those are also in the playlists so you can find them grouped together easily. 

And then, otherwise all of our new shows moving forward will be in SoundCloud. And they have a great app. So you can search for PediaCast and it makes it really easy to listen there. 

We're still in all the same places. We're in Apple Podcasts, iTunes, Google Play, Google Podcasts, iHeartRadio, Spotify, Stitcher, TuneIn, most mobile podcast apps. If there's a place you listen to podcasts and you can't find us, let me know with the Contact page over at pediacast.org and we'll try to get the show added to their line-up as well.

And then, there's the landing site, pediacast.org. Our entire archive of past programs, because the feed in all of these places usually have about the last 100 shows or so. But we have hundreds more in the archive, over at pediacast.org, along with all of our show notes, links to all the things we talked, our transcripts, our Terms of Use Agreement and our Contact page, so you can ask questions and suggest show topics. 

1:06:24

Also, remember that reviews are very helpful. Wherever it is that you listen, please just to give back to the program, just take a couple of minutes and write us a review, we really do appreciate that. It helps other parents who are coming along. Because there's just so many. I mean, there are literally I think 500,000 podcasts now. 

So there's a lot of competition out there. We try to be the best. And if you really enjoy PediaCast, you feel you're getting something out of it, please consider writing a review, so that others will give us a try when they come along and try to figure out what they want to listen to. 

1:07:00

We're also on Facebook, Twitter, and Instagram. In addition to promoting the podcast, we also try to share on a daily basis news articles and blog posts from other places, not just here at Nationwide Children's that I think parents would get some benefit from, good evidence-based sort of stuff. And even when it's written in the mainstream media, if it's something good and I think that parents would benefit from it, we try to share that on Facebook and Twitter. 

Instagram, a little a more personal, what's going on in my life inside the studio, that kind of thing. In Instagram, if you connect with us there, we'll likely connect back because I'm interested in what's going on in your family and in your world as well. 

So please do consider connecting with us on social media. That's really what makes podcasts very interactive, when the community comes together. And again, we're primarily on Facebook, Twitter, Instagram, also on LinkedIn. But Facebook and Twitter, we're probably the most active. And Instagram, we're ramping that up, but it's taking some time. 

1:08:01

I also appreciate it when you tell others about the program face to face, your family, friends, neighbors, co-workers, babysitters, anyone who has kids or takes care of children. And, of course, that include your child's pediatric healthcare provider. Please let them know about the program so they can share it with their other patients and  families.

And while you have their ear, please let them know about PediaCast CME. That stands for Continuing Medical Education. It is similar to this program but we turned up the science a couple notches and offer free Category 1 Continuing Medical Education Credit for those who listen. Shows and details are available at the landing site for that program, which is pediacastcme.org.

Those shows are also available in all the same places you can find PediaCast, pretty much wherever podcasts are. Just search for PediaCast CME and you'll be able to find those there. On SoundCloud, just look for the playlist, PediaCast CME. 

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

1:09:05

[Music]

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

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