Codeine Dangers, Corporal Punishment, Indoor Tanning – PediaCast 286

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Join Dr Mike in the PediaCast Studio for more News Parents Can Use. This week’s topics include the dangers of codeine, “I Spy” Language, corporal punishment, concussions & suicide, indoor tanning & eating disorders, basketball injuries & athletic trainers.

Topics

• Codeine Dangers

• “I Spy” Language

• Corporal Punishment

• Concussions & Suicide

• Indoor Tanning & Eating Disorders

• Basketball Injuries & Athletic Trainers

Links

• CONTACT DR MIKE – Ask Questions, Suggest Show Topics

• CONNECT NOW with a pediatric specialist from Nationwide Children’s – Referrals and Appointments

​

Transcription

Announcer 1: This is PediaCast.

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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 Patrickhello everyone and welcome once again to PediaCast. We're a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in beautiful downtown Columbus. And as the sun is shining, and the temperatures are warmer and the tress are green after that long terribly cold and snowy winter. It really is a beautiful downtown, beautiful everywhere really. Even in the backyard, and on the bike trails, and on the parks it's just fabulous being able to finally get outside.

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It's episode 286 for May 14, 2014. We're calling this one Codeine Dangers, Corporal Punishment, and Indoor Tanning. You don't need to tan indoors on days like these, but people still do it and we'll talk a little bit about it. I want to welcome all of you to the program, we have a News Parents Can Use edition of the show lined up for you this week, I'll get to a rundown of the entire line-up in a moment. But first the Nationwide Children's Hospital blog, 700 Children's you can find it at 700childrens.org. I've talked about it the last few episodes if you're an avid PediaCast listener you're going to love our hospital blog. We're coming up on our one year anniversary, over 50 authors many doctors including myself and we cover a wide range of pediatric and parenting topics. A recent one of interest, "Why Your School Needs an Athletic Trainer?" Does your child's school utilize certified athletic trainers, if not, why not and you may be wondering yourself why exactly our athletic trainers important. 

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You can discover the answer by checking out the 700 Children's blog at 700childrens.org or you can hang with me clear through to my final word this week because I'll be talking about basketball injuries and the importance of having a certified athletic trainer courtside to help care for injured student athletes. Don't get me wrong, even if you are sticking around for the entire show and you listen to my little spiel on the importance of athletic trainers. You still want to check out the 700 Children's blog because we have many more interesting stories lined up for you there. What are we talking about this week on this show? You've probably heard of Tylenol with codeine, or Tylenol number 3 which is been used extensively in the past to treat kids with pain. And you've probably heard of cough syrups containing codeine, but did you know that recommendations against using codeine in kids have been in place since late 1990's yet many doctors are still prescribing these products to children. 

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So what's the big deal how is codeine dangerous? Why aren't doctors getting the message? And what should you the parent do if a doctor wants to prescribe codeine to your child? So I'll have the answers coming up. You've seen the I Spy books and games are a lot of fun for little kids and big kids. But did you know language development plays a role in how well you can spy objects in the picture, I'll explain. Plus I give you some tips on developing language skills and thereby improving your I Spy performance which by the way translates in the help with attention and learning difficulties. Yes it all ties together in the fascinating way so stay tune for that. Then corporal punishment, a new study looks at the results of a so called humane corporal punishment program. 

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Basically researchers taught parents humane way to spank their kids, and then why are the parents subbed with audio recorders to see how well they follow the instructions. Our report are not too surprising results and tip toe into the hot water of spanking by giving you my two cents on corporal punishment, so that's coming up. Then concussions and suicide, it seems like we covered a concussion story like every month or so in PediaCast but concussions are so common and researches are flying out in every direction, much of it interesting. This latest study takes a look at a plethora of mental health problems including suicidal thoughts associated with traumatic brain injury which includes concussions. So stay tuned for more on that. And then finally indoor tannings, we all know the risk tanning beds play in the development of skin cancer. But did you know that tanning beds are also associated with eating disorders. 

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And if your teenagers want to tan, what do you say? What do you do? How likely is it that he or she also has an eating disorder? How can you tell? So that too is coming up. And as I mentioned, stay tune for my final word at the very end of the program regarding basketball injuries and athletic trainers. I do want to remind you that PediaCast is your show so if there's a topic you like us to discuss, if you have a question for me, you want to point me in the direction of a new story or journal article, it's easy to get in touch just head over to pediacast.org and click on the contact link I do read each and every one of those that come through. I also want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you do 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. Let's take a quick break and I will be back with News Parent Can Use right after this.

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0:06:52.4

Dr. Mike PatrickDespite its potentially harmful effects in children, doctors practicing and US emergency departments continue writing prescriptions for products containing codeine. This according to new research from the University of California at San Francisco's Benioff Children's Hospital and reported in the May 2014 issue of the journal Pediatrics. Investigators say doctors should change their prescribing behaviors and promote the use of safer alternatives such as ibuprofen and products containing hydrocodone. Dr. Sunitha Kaiser, lead author of the study and assistant clinical professor of pediatrics at UCSF says, "Despite strong evidence against the use of codeine in children the drug continues to be prescribed to large numbers of them each year. It can be prescribed in any clinical settings, so it is important to decrease codeine prescription to children in other settings such as clinics and hospitals, in addition to emergency rooms…. Codeine is an opioid used to treat mild to moderate pain and suppress cough. Because of variability in how children process the drug, about a third receive no symptom relief from taking it, while up to one in 12 can accumulate toxic amounts of morphine.

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This occurs as the liver breaks down codeine turning it into morphine which may cause breathing to slow down and possible death. As a result, several national and international organizations advise against the use of codeine in children. Guidelines from the American Academy of Pediatrics issued in 1997 and reaffirmed in 2006 warn of its potential dangers and lack of documented effectiveness in treating children with coughs and colds. The American College of Chest Physicians issued guidelines in 2006 on the treatment of pediatric cough and they too advised against using the drug. Until now it was unknown to what extent doctors in US emergency departments were still prescribing codeine to children for the treatment of painful injuries and coughs and colds. To gain insight, Dr. Kaiser and her colleagues used the National Hospital and Ambulatory Medical Care Survey, provided by the National Center for Health Statistics, to determine the frequency of codeine prescriptions to children ages 3-17 during U.S. emergency department visits from 2001-2010.

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The researchers say the rates of codeine prescriptions did decrease from 3.7 to 2.9 percent during the 10-year study period. However, this represented a significant number of children still receiving the drug, over half a million prescriptions each year. In addition researchers point out there was no appreciable decline in the number of codeine prescriptions written following the release of warnings by the American Academy of Pediatrics and the American College of Chest Physicians in 2006. Codeine prescriptions were higher in children ages 8-12 and in regions outside the North-eastern United States, and lower for non-Hispanic black children and those covered by Medicaid. Dr. Kaiser says, "Further research is needed to determine the reasons for these lower rates so we can reduce codeine prescriptions for all children…. She adds, "Many children are at risk of not getting any benefit from codeine, and we know there are safer, more effective alternatives available….

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"A small portion of children are at risk of fatal toxicity from codeine, mainly in situations that make them more vulnerable to the effects of high drug levels such as after a tonsillectomy…. According to Dr. Kaiser, ibuprofen is equal to or better than codeine for treating injury pain, and hydrocodone is a safe and more effective opiate alternative. She also points out that dark honey has been shown to be better than over-the-counter cough medicine and the American Academy of Pediatrics recommends it for children over the age of one. She recommends a multi-pronged approach for effecting change including an alteration in codeine prescribing habits, removing codeine from hospital formularies adding pop-up warnings in electronic medical record and prescription writing programs in changing insurance plan reimbursement policies. 

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SO no more codeine for kids to take home here it's really pretty simple. For practitioners, stop prescribing codeine, find a safer alternative. And for parents, make a mental note, no more codeine for kids. If your child's injured or has cough and somebody wants to prescribe a product containing codeine, politely tell them, the American Academy of Pediatrics has warned against using that stuff since 1997, get with the program. Maybe find a more tactful way to put it but the basic message should be the same. In a new study from cognitive scientists at Indiana University, Dr. Linda Smith and PhD candidate Catarina Vales demonstrated that children spot objects more quickly when prompted by words rather than images. Language, the study suggests, is transformative: More so than images, spoken language taps into a child's cognitive system, enhancing their ability to learn and helping to navigate cluttered environments. 

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The study recently published in in the journal Developmental Science, opens up new avenues for research into the way language might shape the course of developmental disabilities such as ADHD, learning difficulties, and other attention-related problems. Investigators asked children to play a series of I Spy games by looking for one image in a crowded picture on a computer screen. Researchers showed children a picture of the object they needed to find — a bed, for example, hidden among a large group of couches. Ms. Vales says, "If the name of the target object was spoken along with showing the picture, the children were much faster at finding it and less distracted by other objects in the scene." Dr. Smith who serves as Chancellor's Professor in the Department of Psychological and Brain Sciences at Indiana University adds, "What we've shown is that in 3-year-old children, words activate memories which rapidly deploy attention and lead children to find the relevant object in a cluttered array." 

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"Words call up an idea that is more robust than seeing an image and to which we more rapidly respond. Words have a way of calling up what you know which filters the environment for you." She says, "The study is the first clear demonstration of the impact of words on the way children navigate the visual world and is a first step toward understanding the way language influences visual attention, raising new testable questions about the process." Ms. Vales explains how the use of language can change the way people inspect the world around them. She says, "We know language changes the way people perform in a lot of different tasks. If you have a child with ADHD who was having a hard time focusing, one of the things parents can do is use words to walk the child through what he or she needs to do. So there is already this notion that words change cognition. The question is 'how?'"

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Ms. Vales says, "The study begins to tell us precisely how words help, it brings to light the kinds of cognitive processes words tap into to change how children behave. For instance, the difference between search times, with and without naming the target object, indicate a key role for a kind of brief visual memory known as working memory, this helps us remember what we just saw as we look for something new. Adding spoken words to images puts ideas into working memory faster than looking at the images alone." For this reason, language may play an important role in a number of developmental disabilities. Dr. Smith says, "Limitations in working memory have been implicated in almost every developmental disability, especially those concerned with language, reading and negative outcomes in school. These results suggest the culprit for these difficulties may actually be language in addition to or rather than working memory itself." 

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"This study changes the causal arrow a little bit. People have thought that children have difficulty with language because they don't have enough working memory to learn language. This turns it around because it suggests that language may also make working memory more effective." How does this matter to child development? Dr. Smith says, "Children learn in the real world, and the real world is a cluttered place. If you don't know where to look, chances are you don't learn anything. The words you know are a driving force behind attention. People have not thought about it as important or pervasive, but once children acquire language, it changes everything about their cognitive system." Dr. Vales adds, "Our results suggest that language has huge effects, not just on talking, but on attention — which can determine how children learn, how much they learn and how well they learn." So for me this is a pretty fascinating study. We see so many kids with attention and learning problems these days. 

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The question is if we intervene by promoting language skills at an early age, if we drastically reduce screen time, if we interact face to face with our children, if we read and talk to them, if we point out objects and speak the object's name as we play and engage the environment, if we do the things we know enhance language skills can we make a difference in attention and learning problems down the road? And is it any wonder learning an attention problem are so pervasive given our busy lives with less time spent face to face with our kid s and more and more time spend in front of a screen, time and more research will tell. But for me the take home message for moms and dads right now and I've said this before, in fact many time before, turn off those screens, spend more time engaging, and reading, and talking with your kids. It's important advice at all ages but especially during the early years when your child is learning language. 

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A new study based on real time audio recordings of parents practicing corporal punishment discovers that spanking is far more common that parents admit. In addition children are hit for trivial misdeeds and that children typically misbehaved again within 10 minutes of being punished. Advocates of corporal punishment have outlined best practices for responsible spanking. But real-time audio from this study reveals that parents fail to follow the guidelines, so says psychologist Dr. George Holden who is lead author of the study and a parenting and child development expert at Southern Methodist University in Dallas. The real-time audio interactions revealed that parents were not always calm, as the guidelines recommend, but instead were often angry when they spanked or hit their child; they didn't spank as a last resort; and they gave spankings for minor infractions, not just serious misbehavior. And while spanking advocates recommend hitting children no more than twice, parents in the audio recordings were slapping and hitting their children more often.

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Dr. Holden says, "From the audio, we heard parents hitting their children for the most extraordinarily mundane offenses, typically violations of social conventions. Also, corporal punishment wasn't being used as a last resort. On average, parents hit or spanked just 30 seconds after the conflict began." Parents who used corporal punishment commonly violated three of the six "use" guidelines the researchers examined, those are spank infrequently, use it only for serious misbehavior, and only as a last resort. Dr. Holden who favors humane alternatives to corporal punishment says, "The recordings show that most parents responded either impulsively or emotionally, rather than being intentional with their discipline." The findings are reported in the article "Eavesdropping on the Family: A Pilot Investigation of Corporal Punishment in the Home," which was recently published online by the American Psychological Association and will soon appear in print form in the Journal of Family Psychology.

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For the study parents agreed to wear tape recorders to capture home interactions. The unique recordings captured parent and child interactions in 33 families over the course of four to six evenings. Parents volunteered to wear the recorders; most were mothers who were home with their children after a day's work. The recordings captured 41 instances of corporal punishment, mainly during everyday activities such as fixing supper and bathing children. More than 80 percent of the moms were married and had completed more education than the general population. About 60 percent were white and worked outside the home, and their children averaged just shy of 4 years. In 90 percent of the incidents, noncompliance was the immediate cause, such as sucking fingers, eating improperly, getting out of a chair, and going outside without permission. In 49 percent of the incidents, the parent sounded angry prior to spanking or hitting. On average, less than 30 seconds elapsed from the time when parents initiated nonviolent discipline to when they used corporal punishment.

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In 30 of the 41 incidents, the children misbehaved again within 10 minutes of being hit or spanked. The youngest child hit was 7 months old. One mother hit her child 11 times in a row. Most remarkably, the researchers noted an unusual finding: The rate of corporal punishment exceeded estimates in other studies, which relied on self-reporting. Those studies found that American parents of a 2-year-old typically report that they spank or slap about 18 times per year. Dr. Holden says, "The average rate we observed using the real-time audio equates to an alarming 18 times per week." Dr. Holden is a professor with the Southern Methodist University department of psychology and is carried out extensive research on spanking. He adds, "Although spanking advocates may acknowledge these incidents as inappropriate use of corporal punishment, evidence from their studies indicate that parents who spank their children are also more likely to physically abuse their children."

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So here's the deal, I am not an advocate of spanking. The parents in this study had been instructed on a method of "humane corporal punishment" and look what happen, they lost control, they were impulsive, they were emotional, they struck their children for trivial reasons, they displayed anger, there were no reported attempts of loving correction and look at the result, the kids were misbehaving again 10 minutes later. In my mind the behavior of the parents was worse than the behavior of the children. We have to be role models for our children, they're looking at us as the gold standard on how they should respond to others and when we resort to impulsive violence, we're teaching them to do the same. Now sure discipline is important, there're real world consequences to our behaviors and children need to learn this at an early age. But a kind word and general guidance commands more respect than repeated violence. 

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Better to reward positive behaviors, better to explain why rules exist in language a child could understand. Better to take away privileges with a clear path for reinstating them, and better to model the behaviors you want your children to learn. Think about the shepherd's rod, it's not used to beat the sheep into submission. The shepherd uses it to guide his flock in the way they should go. So parents please lovingly guide your children, is it easy? No, it's not easy raising children is difficult but when you do it right the rewards are beyond compare. Teenagers who have suffered a traumatic brain injury such a concussion are at a significantly greater odd of attempting suicide, being bullied and engaging in a variety of high risk behaviors. This according to a new Canadian study published in the journal PLOS ONE. They are also more likely to become bullies themselves, to have sought counseling after through a crisis help-line or to have been prescribed medication for anxiety, depression or both.

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Dr. Gabriela Ilie, lead author of the study and a post-doctoral fellow at the University of Toronto in Scarborough says, "The problems don't end here, after traumatic brain injuries teenagers have higher odds of damaging property, breaking and entering, taking a car without permission, selling marijuana, running away from home, setting a fire, getting into a fight at school, or carrying or being threatened by a weapon. The study provides the first population-based evidence demonstrating the extent of the association between traumatic brain injury and poor mental health outcomes among adolescents. Dr. Ilie says, "These results show that preventable brain injuries and mental health and behavioural problems among teens continue to remain a blind spot in our culture. These kids are falling through the cracks." The data used in the study is from the 2011 Ontario Student Drug Use and Health Survey developed by the Center for Addiction and Mental Health. 

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The survey, one of the longest ongoing school surveys in the world, contains responses from about 9,000 students from Grades 7-12 in publicly funded schools across Ontario, Canada. The survey began as a way to measure drug use survey, but is now a broader study of adolescent health and well-being. Questions about traumatic brain injury were added to the survey for the first time in 2011. Dr. Robert Mann, senior scientist at the Center for Addiction and Mental Health and director of the survey says, "We know from a previous study that as many as 20 per cent of adolescents in Ontario say they have experienced a traumatic brain injury at some point in their life time. The relationship between traumatic brain injury and mental health issues is concerning and calls for greater focus on prevention and further research on this issue." Dr. Ilie says, "The teenage years are already a turbulent time for some, as they try to figure out who they are and what they want to be." Since a TBI can exacerbate mental health and behavioural issues, she said primary physicians, schools, parents and coaches need to be vigilant in monitoring adolescents with this condition.

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In addition, she says, "Many traumatic brain injuries experienced by youth occur during sports and recreational pursuits, and are largely preventable through use of helmets and the elimination of body checking in hockey." The study found that adolescents who had suffered a traumatic brain injury sometime in their lifetime had twice the odds of being bullied at school or via the Internet and almost three times the odds of attempting suicide or being threatened at school with a weapon compared to those without a traumatic brain injury in their history. So you know we've covered the lingering symptoms of concussion many times on this program as well as the dangers of multiple concussions. But here we see some significant mental health fallout. This study did not sort out the exact causes of head injury and did not look for signs of mental health problems before the traumatic brain injury occurred. I mean after all it is possible that those with mental health issues might be more prone to head injury either through fights, or not paying attention, or engaging in risky behaviors. 

0:26:06.6

So maybe which came first scenario, the traumatic brain injury or the mental health issue still I think this is an association that parents should know about. If your child suffers a concussion, be on a look out for anxiety, and depression, and suicidal thoughts, keep track of their conduct, make it your business to know if they're being bullied or bullying someone else, these are all things we should be doing anyway. But if your child has had a concussion, be extra vigilant and at the first sign of concern be sure to seek some help. High school students who use indoor tanning also may have higher rates of unhealthy weight control behaviors such as taking diet pills, or vomiting to lose weight. This according to a recent report in the Journal of Developmental and Behavioral Pediatrics. Not only this but the association between indoor tanning and unhealthy weight control methods may be even stronger for males than females.

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Stephen Amrock and Dr. Michael Weitzman both from the New York University School of Medicine say their results suggest that, in addition to being a major risk factor for melanoma, indoor tanning might identify a group of teens at increased risk of eating disorders. Investigators analysed nationally representative survey data on nearly 27,000 high school students. About 23 percent of females and 6.5 percent of males reported indoor tanning within the past year. For older teens, indoor tanning was even more common: 33 percent of females and 11 percent of males aged 18 years or older. And by the way Indoor tanning did not include pray-on tans. We're talking about tanning in a tanning bed with UV light exposure. Students who reported indoor tanning were also more likely to report various unhealthy weight control behaviors over the past month. These included fasting for over 24 hours; taking pills, powders, or liquids; or vomiting or taking laxatives to lose weight.

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With adjustment for other factors, females who used indoor tanning were 20 percent more likely to report fasting, 40 percent more likely to report vomiting or taking laxatives, and more than twice as likely to report taking weight-loss pills, powders, or liquids. For males, the associations were even stronger. Males who used indoor tanning were more than twice as likely to fast, four times more likely to use pills, powders, or liquids, and seven times more likely to report vomiting or laxative use. The survey adds to previous evidence linking indoor tanning to negative body image. Females who used indoor tanning were more likely to perceive themselves as normal weight, yet more likely to say they were trying to lose weight. Indoor tanning is a preventable cause of melanoma, which is increasing at epidemic rates. Previous research has suggested that people who use indoor tanning have skin or body image concerns and are more likely to engage in other risky behaviors.

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While the study can't show a definitive link to eating disorders, it does suggest that teens who use indoor tanning have higher rates of unhealthy weight control behaviors linked to eating disorders. Negative body image may also contribute to high rates of indoor tanning among adolescents, although the mechanism of the association may differ for males versus females. The researchers suggest that screening adolescents for indoor tanning could serve a double purpose: addressing a major risk factor for skin cancer as well as identifying teens at risk for unhealthy weight control behaviors. The authors conclude by saying greater attention to these issues by pediatricians and I'll add, by parents as well may help reduce the number of adolescent's risk for melanoma which can be deadly and may identify previously undiagnosed eating disorders which can also be deadly. In an accompanying editorial Dr. David Schwebel from the University of Alabama at Birmingham further discusses the possible associations among tanning, risk-taking behaviors, and eating disorders in teens.

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He says, "Poor body image is associated with both indoor tanning behavior and eating disorder behaviors." And while doctors and parents play a role in talking to teens about the risks of indoor tanning, Dr. Schwebel believes that more communities and states should enact laws to prohibit minors from using tanning salons. With all due respect Dr. Schwebel, parents can do more than talk to their teens about the dangers of tanning beds. They can also forbid their teenagers from using them. I don't understand, let's enact laws and say minors can't tan indoors. But parents tell your kids not to do it and don't let them do it. In all seriousness if your teenager has an interest in indoor tanning, think about the symptoms of eating disorders. Could that be an issue in your house as well? 

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PediaCast episode 249 can help you out, that's one in which we covered eating disorders quite extensively. That wraps up this week's News Parents Can Use, I will be back with a final word on basketball injuries and athletic trainers right after this.

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Dr. Mike PatrickI can't stop thinking about it, if you have a teenager at home talk to them about the dangers of indoor tanning but at the end of the day if they're living under your roof and you're paying the majority of the money to support them, I think parents have every right to say you can't do it, you're not allowed, indoor tanning off limits. Until you're out on your own and making your own way in life. Basketball is a popular high school sport in the United States with 1 million participants annually. A recent study by researchers in the Center for Injury Research and Policy at Nationwide Children's Hospital is the first to compare basketball related injuries treated in emergency departments with those treated on the court by certified athletic trainers. The study published online in the Journal of Athletic Training examines data relating to adolescents 13-19 years of age who were treated in US emergency departments from 2005-2010 and those treated in the high school athletic training setting from the 2005 through the 2010 academic years for injuries associated with basketball. 

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Nationally 1.5 million student athletes with basketball related injuries were treated in emergency departments and just over 1 million were treated in the athletic training setting. The study found that in general injuries that are more easily diagnosed and treated such as sprains and strains were more likely to be treated on sight by an athletic trainer or more serious injuries such as fractures that require more extensive diagnostic and treatment procedures were more commonly treated in an emergency department. Dr. Laura M. MacKenzie the study's lead author and principal investigator in the Center for Injury Research and Policy at Nationwide Children's says, "Athletic trainers play a really important role in helping to assess those more mild or moderate injuries, and that helps alleviate a burden on the health care system and on families. They are right there on the side-lines. They are there when some of these things happen. And they can be a great resource for families to evaluate that injury immediately." 

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In 1998 the American Medical Association recommended all high school sports programs enlist in athletic medicine unit consisting of a physician director and athletic trainers. However as of 2009 the National Athletic Trainers' Association estimated only 42 percent of high school sports teams met this recommendation. With more than half of US high school athletes not having access to an athletic trainer during practice or competition, a vast majority of injured players wind up in urgent care facilities and emergency departments, some unnecessarily. Dr. McKenzie says, "While athletic trainers cannot treat every injury, they can make the system more efficient by only sending athletes to the hospital when it is necessary and helping athletes return to play when it is safe." Kerry Waple, certified athletic trainer in Sports Medicine at Nationwide Children's says, "We are there to prevent injuries, evaluate them quickly, treat them immediately and try our best to make sure that as we return them to play we do it in the most safe and efficient way possible….

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She adds, "There are a lot of injuries that happen which wind up in urgent cares and emergency departments that don't need to be there…. So certified athletic trainers use them, if your child's school doesn't, find out why and advocate strongly for their presence. Having an athletic trainer at the side-line can help your child get the right diagnosis and the right treatment without the expense in time consuming process of the urgent care or emergency department. Unless your child needs an advance medical facility which the athletic trainer can direct you to but only if it's necessary. So certified athletic trainers can be worth their wait in gold, and that's my final word. I want to thank all of you for taking time out of your day and making PediaCast a part of it, just really appreciate the listeners in the audience. That does wrap up our time together. I want to remind you that PediaCast is a production of Nationwide Children's Hospital. 

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Don't forget, PediaCast and our single topic, short format program PediaBytes are both available on iHeart Radio Talk which you'll find on the web at iheart.com and the iHeart Radio app for mobile devices. Our show archive which includes over 250 programs as well as our show notes, transcriptions, terms of use and contact page are available at our landing site which is pediacast.org. We're also on iTunes under the kids and family section of their podcast directory, and you'll find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Podbay most other podcasting apps for iPhone and android. We're also on Facebook, Twitter, Google Plus, and Pinterest and of course we really appreciate you connecting with us there and sharing, re-tweeting, and re-penning all of our post so you can tell your own online audience about our little show. We also appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids or anyone who takes care of children. And as always be sure to tell your child's doctor about the program. Posters are available under the resources tab at pediacast.org. Until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.

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

0:37:35.0
 so long everybody.

0:37:11.9

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

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