Drowning, Story Time, Dosing Errors – PediaCast 380

Show Notes


  • This week we cover more pediatric news! Topics include drowning, colic and love, story time strategies, inactive teenagers, smartphones & parenting, lawn mower injuries and medication dosing errors. We hope you can join us!


  • Drowning
  • Colic and Love
  • Story Time Strategies
  • Inactive Teenagers
  • Smartphones & Parenting
  • Lawn Mower Safety
  • Medication Dosing Errors




Announcer 1:  This is PediaCast.


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's 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's Episode 380 for July 12th, 2017. We're calling this one "Drowning, Story Time, and Dosing Errors". I want to welcome everyone to the program.  

We have a big mid-summer pediatric news edition of the show for you this week. Lots of what I would consider interesting topics since I did handpicked them for you. Hopefully, you'll agree with me that they're interesting. And I'll get to a rundown of exactly what to expect in this week's show because as usual we have lots more than the title would suggest. 

But first, right out of the gate here, I want to get to our drowning topic and address a bit controversy in the world of water safety. A couple of years ago, I wrote a blog post for the 700 Children's blog here at Nationwide Children's Hospital. And in that post, I described a couple of terms that come up seems every summer, dry drowning and secondary drowning. And blog post made its way around the Internet and I've been asked to comment on these conditions by various reporters and websites over the past couple of years. 

Some of them did a better job of quoting me than others. We'll leave it at that. And then, I hear recently and you probably heard about this story, there was a news article about a little boy in Texas who died a few days — I said this again — a few days after a submersion event in a swimming pool. 


And this event brought these ideas about dry drowning and secondary drowning into focus again. And the reason they did that is because even when we've used those terms in the past, they have never really been accepted medical terms. But they're out there, parents use them. And we use common language on this podcast. So, the terms that parents use, it's more important to explain the concepts behind those terms. And you mention the medically appropriate terminology but also understand that there's other terms out there that are used and try to explain the folks what it all means. 

And so, even when we've used those terms — dry drowning and secondary drowning in the past — it was never meant to describe something that happens days later. So, when there is sort of a delay in the onset of symptoms or the evolution of symptoms, we're talk in hours. 

And in any place where you have seen dry drowning or secondary drowning explained from the medical point of view that's evidence-based and trustworthy and knows what they're talking about, it's always described in that delay being hours. Within the first 24 hours, you can see symptoms beginning or evolving, not days later. 

And so, the fact that some news stories are suggesting that symptoms days after an event could dry drowning or secondary drowning has really put a focus on these terms again and sparked some controversy. Again, because dry drowning and secondary drowning are not and have never been recognized medical terms. They're common language terms that people use.

But now, many folks are calling upon the medical community to stop using them because they're not accurate, and they can be confusing. Now, again just to explain, I've used those terms in the past because the media uses them, parents hear them, and I want you to understand the concept behind what we're talking about regardless of the words we used.


However, we have gotten to the point where lots of respected organizations are calling for a unified cease and desist. So, really, it's time to put these terms to rest. Now, you may be asking, "Okay, so which organizations have put out a call to stop using the terms dry drowning and secondary drowning?" 

Well, that would include the World Health Organization, the International Liaison Committee on Resuscitation, the Wilderness Medical Society, the Utstein Style system, which is actually very influential in the world of resuscitation, the International Life Saving Federation, the International Conference on Drowning, the Starfish Aquatics Institute which is a much larger place and more influential place than the name I suggest, the American Heart Association, the American Red Cross, and now the US Center for Disease Control and Prevention. So, pretty big impressive list and really time for us to stop using these terms.

Now, even though it is time to stop using these terms, the concept behind why these terms were ever used in the first place is still an important thing to consider. We just need to change the words we used to be more clear and more accurate.

So, first, what new words are we going to use? If you get rid of those words, okay, so what do we call these? And the answer is there are no new words. You just simply use the word 'drowning' to cover the entire spectrum. You could also say submersion injury. But drowning is drowning, and drowning is defined as "the process of experiencing respiratory impairment which includes persistent cough from submersion or immersion in liquid". 

So, you're submersed in liquid. Maybe you have an event in the swimming pool where you choked or gagged on a little bit of water. If after that event during the first 24 hours, you developed any respiratory impairment, whether it's mild or severe, that is drowning.


And then to explain it further, we can divide drowning into fatal or non-fatal. So those are the terms that we'll be using moving forward, it's either a fatal drowning or a non-fatal drowning. 

Now, fatal drowning is pretty easy, you die whether it's immediate or later as a consequence of the submersion event. But if you are going to develop symptoms that evolve and it's from that submersion event, you can expect the onset of the symptoms to be within the first 24 hours, not days later.

And the non-fatal drowning is a respiratory impairment again following contact with water in the airway with the onset within 24 hours but you end up recovering and surviving. That would be a non-fatal drowning.

Now, the thing to keep in mind is that there are several mechanisms by which water in the airway causes respiratory problems. Most of those mechanisms happen right away. But sometimes and it's rare, they can take up to 24 hours to develop and by describing this delayed onset as being rare, we're talking less than 5% of submersion cases.

So it's a pretty small number that this would happen where you would develop symptoms. And in most cases, those are going to be mild symptoms. And for them to progress after period of a child apparently looking well, for them to develop symptoms that then progress and become really severe symptoms, now we're talking like 1% to 2% of submersion cases.

So even when these symptoms are mild though, it's still less than 5%. So this is a rare occurrence. The majority of kids if they're going to develop breathing problems after some problem in the water, it's going to be right away. But you still want to watch them closely for 24 hours in the event your son or daughter becomes that rare case. 


And the symptoms you're going to watch for are persistent coughing, wheezing, chest pain or tightness, difficulty breathing or anything related to the respiratory tract. And if any of those things occur, you should seek medical attention right away.

Now, being tired or sleepy is sometimes included in the list or behavioral changes but lots of kids are tired and sleepy. And that's just an effect by the way of not getting enough oxygen to your brain. That's the reason that you would be tired or sleepy. You have behavioral changes after submersion event. But lots of kids are tired or sleepy after day at the pool. 

The key is, is this different than other days you've experienced with your child? Are they typically this tired after day at the pool? If they are, it's probably them still being tired just like they usual are after a day of exercise and fun in the sun. 

The question is, is it different than what you have experienced in the past? Can you arouse your child? Are they having any respiratory symptoms along with that behavior change or sleepiness? If you wake them up and they wake up easily. They look good, there's no coughing, no chest pain or tightness, no difficulty breathing. They look great. Let them get back to their nap. They deserve it after a day of fun in the sun.

On the other hand, if your mom or dad radar goes off, something really something just doesn't seem right to you — maybe because your son or daughter never gets this tired after swimming, or they're difficult to arouse, or there's a degree of persistent cough or breathing abnormality, there's something different — then it's worthwhile to visit an emergency department. 

And this is one of those cases where I would just go straight to the ER because they may need an X-ray. They may need to be observed for a period of time and there is the potential for things to get worst. It's a very small one, 1% to 2%. But if your child is in that 1% to 2%, you want to be in a place that's ready to handle that type of problem. And the pediatrics specific emergency department would be the best place. 


But if you don't have that available to you, then an adult ER, an urgent care, call your doctor. And if they're having significant breathing problems, call 911.

So, let's take this a step further and consider those mechanisms that take place in drowning. Because I know many of you in the audience are science-y and are interested in this sort of thing. The most obvious mechanism is the presence of water in the lungs which interferes with exchange of oxygen coming in into the body and carbon dioxide going out. 

And that's not good because your brain and your heart in particular really rely on a steady supply of oxygen. And so you interfere with oxygen getting to those organs and bad things happen. So, when you have a lot of water in the lungs than can interfere with gas exchange and so then, you'll have a low oxygen situation.

Now, very small amounts of water can also be a problem. You know, maybe it's not enough water to significantly interfere with gas exchange but instead that small amount of water disrupts a chemical that's down in the lungs, down deep in the lungs, called surfactant. 

And the surfactant is a soapy substance way down deep and it keeps the smallest of airways from collapsing and sticking together. So, if the surfactant chemical, if that get disrupted and the small airways began to stick together, air can't flow very well down deep and oxygen and carbon dioxide can't be exchanged. And again that's not good.    

Now, the thing is that may not be something that happens immediately. It may take a few hours for that loss of surfactant to start the cause of problem. And this mechanism by the way is what some have alluded to when using the term secondary drowning. It's not really secondary to anything. It's really more the evolution of symptoms take a little longer. But we're talking a few hours after the immediate submersion event, not days later. 


Another mechanism that is associated with drowning is laryngospasm. And this interferes with air movement at the level of the upper airway or around the vocal chords. So, the presence of water in the upper airway is irritating and causes a spasm. And you can think of it like your body's trying to keep water out, but in doing so it also keeps air out. And so, you don't get enough air moving in which means you're also not getting enough oxygen, which we've established is a bad thing. 

And this mechanism, laryngospasm associated with drowning is what some folks have in mind when they views the term dry drowning in the past. Because it's not really water going and causing a problem, it's the spasm around the vocal chords that prevents air from getting in. And so that's why it had been called dry drowning in the past.

Another mechanism by which respiratory problems develop in drowning victims is something called pulmonary edema. And this is when you get fluids in the lungs, it's not form the water you were submerged in but your own body fluid enters into the lungs and starts to cause a swelling and interferes with gas exchange because of your own body fluid that's there. And this can occur when the lung is damaged, whether it be from the presence of water or then subsequent to the lack of oxygen or subsequent to laryngospasm. 

There are some mechanisms in place that can cause pulmonary edema to occur in association with the laryngospasm. And there other reason as well. And that body fluid in the lungs will further interfere with gas exchange.

And then, ultimately, cardiac arrest, which happens, either your heart stops or you get into some wacky rhythms that are not capable of efficiently moving blood forward through your body. And so, that can happen when your heart's not getting enough oxygen and then that can also lead to more pulmonary edema. 


And as it turns out these mechanisms really play into one another. So you have water in the lungs, disrupted surfactant, the laryngospasm, pulmonary edema, cardiac arrest. They're intertwined and it can be complicated. But the process as a whole, with one or more of these mechanisms taking place, is simply what we call drowning, which can be fatal or non-fatal. 

And depending upon the number of those mechanisms that are involved and the degree to which they occur will also dictate the severity of symptoms and how long it takes for the symptoms to become apparent and to evolve. But again, we're always talking hours, not several days.

And so, it's really what we had done before was to pick a single mechanism and call it something. But it's not really appropriate to do that because these mechanisms oftentimes, again, are intertwined and work together. 

The other important thing to remember is that most, the vast majority, 95% or more of drowning victims are going to develop respiratory problems immediately. But a few, less than 5% can develop problems later, that are apparent later and will generally though be within 24 hours of the submersion event. And in even smaller number, 1% to 2% will go on to develop significant problem.

The issue is though, you can't really predict which kid is going to be in that 1% to 2% or in that less than 5% with the milder symptoms. So we say watch your child because you love him and you want the best for him, and so you want to be alert during 24 hours after a close call on the water. And you want to take him to the hospital if they're having respiratory symptoms. 


And the other thing is these symptoms are going to evolve slowly. You're not going to have a kid who looks fine one minute and the next minute they're in big trouble. If it takes a while for the symptoms to become apparent, it's also going to take a little while for them to become serious. So you want to get them to the hospital to be watched for a little while during that time when it could get worse. 

But you don't need to panic and think they look great and the next minute, they're not going to look great. That generally does not happen.

So if your child does start to have the symptoms, take them to the hospital. They might get a chest X-ray, they might watch them for few hours. And in most kids, they're still be doing fine and go home. That's really that 1% to 2% that evolves into  a life-threatening emergency, that we want them in the right place in case that happens.

It's rare, but it does happen and you love your kid, so you should watch him for 24 hours after submersion event. And again, the symptoms you're looking for are persistent cough. Not an occasional cough here there that's like, "Okay, they coughed two hours ago, and now they coughed once again." That's not we were talking about. 

But if they're coughing persistently, then you want them to be looked at. Or if they're having any other respiratory symptoms, wheezing, chest pain or tightness, difficulty breathing, significant behavioral changes that aren't usual for your child. If those occur seek help, preferably in the pediatric emergency department and call 911, if the symptoms are severe.

So, I hope this make sense. The take home points, let's stop using the terms dry drowning and secondary drowning but let's continue keeping a close eye on our kid for 24 hours or so, following a close call on the water and haven them checked out if symptoms develop.

I do want to leave you with a couple of great resources, the first is an article written by Dr. Seth Collings, Dr. Justin Sempsrott and Dr. Andrew Schmidt, and expertly curated I might add by Dr. Christina Johns in her blog. It's called Drowning in the Sea of Misinformation, Dry Drowning and Secondary Drowning. I'll put a link to it in the Show Notes for this episode, 380, over at PediaCast.org.


Couple of more resources for those who are interested, the Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning includes lots more rationale for the updated terminology and consensus statement for members of American Red Cross scientific Advisory Council called Dry Drowning, A Distinction Without A Difference. And that was published in the journal Resuscitation. 

And then, finally, one last resource, I don't want to talk about drowning without including the importance of preventing drowning. That's really important. So, I want to encourage everyone to check out PediaCast 348 which was my interview last summer with Dr. Lara McKenzie. She's one of our safety experts here at Nationwide Children's. 

And we covered water safety in great detail on the episode, again, PediaCast 348. It includes how to create and maintain a safe swim environment, what pool rules are appropriate, what are some water supervision tips and other water safety tips, hot tub safety, bath tub safety. And drowning, we do cover drowning and we do use the terms dry drowning and secondary drowning in that episode. 

Look, folks, I'm not going back in correcting this change in terminology everywhere because the recommendations have not changed. The concepts underlying those terms have not changed. It's just the words we use. We want to be clear. We don't want create misunderstanding that drowning symptoms can occur days after an event in the water. 

But just say, moving forward, we'll use the updated definitions and terminology. I'll put a link to that episode, again 348 in the Show Notes for this one, 380, over at PediaCast.org. 

I'll also include a link on finding water safety and CPR classes with the American Red Cross, because it's always a great idea to learn more about water safety and be prepared in the case emergency or tragedy strikes.

So, lots of links for you this as we think about water safety and drowning. And again, they'll be in the Show Notes over at PediaCast.org, Episode 380, you'll find them all there.


All right, let's move on. We do have some pediatric news for you this week. So, what topics are we covering? Colic and love. And yes, you heard me correctly. How do loving relationships affect infant colic? Stay tune to find out.

And then, story times strategies. Kids love story time and as a dad, I absolutely loved reading to my kids. I'll look forward to reading to my grandchildren. Now, there's evidence to suggest it's not only reading that makes a difference but also how we read. So, we'll explore those details, coming up.

And then, inactive teenagers, teens are not getting enough physical exercise. In fact, teens are on the move at about the same levels as 60-year-olds, I'm not kidding. And we'll look at the numbers and I'll leave you with some thoughts on getting everyone in the family off the couch and out the door.

And then, smart phones and parenting, turns out mobile devices can affect the relationships we have with our kids. I'll explain how and why and share some tips on striking a balance. 

We'll also cover a lawn mower safety and the best practices for avoiding medication dosing errors when giving your children liquid medication. If they're prescribed liquid medicine, you want to make sure you're giving them the right amount and we'll talk about ways that you can ensure that they're getting exactly what the doctor prescribed. 

So, a big show for you this week, chock-full of more information you and your family can use. Don't forget, I love hearing from you, the audience. So don't forget we have a Contact page over at PediaCast.org. Just find the Contact link up at the top and ask away.

Again, you can ask a question, you can suggest a topic, point me in the direction of a news of journal article. I'd love to hear from you. So I encourage you to contact us here at PediaCast.

Also, I want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.


Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at PediaCast.org. 

All right, let's take a quick break and I will be back with more news parents can use. It's coming up right after this. 


Dr. Mike Patrick: How happy a mother is in her relationships and the social support she receives may affect the risk of infant colic. This according to researchers at the Penn State College of Medicine and published in the journal Child: Care, Health and Development. 

The study sheds new light on the factors that may contribute to infant fussiness, a common complaint especially among first-time mothers. This isn't the first time that mental and social conditions have been linked to colic. Previous work has shown mental health during pregnancy, such as maternal anxiety, along with low social support and post-partum depression are associated with an increased risk of colic in babies.

However, this is the first study to measure first-time mothers' relationship happiness along with general social support and specific support in taking care of the baby by their partners. 


Researchers looked at these factors during pregnancy and one month after birth in more than 3,000 women who were 18 to 35 years of age and who gave birth at 78 hospitals in Pennsylvania between January 2009 and April 2011. Overall, 11.6% of mothers in the study reported their infants had colic, which was defined as crying or fussiness that lasted three or more hours each day. 

Relationship happiness, general social support, and partner baby support, all of these things protected against colic in the study. And the happier woman reported being in her partner relationship during and after pregnancy, the lower the risk of colic in her infant.

And this was the strongest association and it held even in women experiencing post-partum depression and in cases where the partner was not the biological father. 

Researchers say it is unknown why this association exists but they do offer a few suggestions. Dr. Kristen Kjerulff, professor of public health sciences at Penn State and senior author of the study says, "Maybe babies cry less when mom and dad are happy. Another possibility is that mothers in happier relationships may not perceive their baby's crying as negative and may not report it as colic."

Women who rated their partners as supportive also had babies with the lower risk of colic. In particular, the more helpful the partner with the baby and the warmer, more loving and more affectionate they were toward the infant, the less colic was reported.

General social support from friends and family was also associated with the lower risk of colic. Women who are less likely to report having a colicky baby, if they had someone to turn to for suggestions about how to handle a personal problem and someone with whom they could confide.

Interestingly, babies of single women had the lowest rate of colic. This association was not statistically significant but investigators say it make sense because the single moms also reported having higher levels of general social support.


Dr. Kjerulff says, "If you don't have a partner, you can still have lots of social support, lots of happy relationships and lots of love, all of which is good for the baby because it appears that love makes a difference." 

Dr. Chandran Alexander, assistant professor of Pediatrics at Penn State and first author of the study says, "Mothers' significant others have a role to play in reducing the burden of colic. And society should stop pinning the blame for colic on a mother's competence, self-esteem or depression."

She also points out that first-time mothers with colicky babies make frequent visits to the pediatrician and some treatments offered for the colic are expensive and not proven to work. 

Dr. Alexander adds, "We need to impress upon society the importance of supporting families in the care of their newborns."

So, what is the next step for these researchers? They plan to study whether relationships and social support factors influence other conditions such as gastrointestinal problems and even food allergies as children grow older.

So, we've talked about colic many times on this program. And today, we have another piece of data to add to the collective evidence, relationships matter, support matters, love matters. So lend some support and love to those new moms in your life because everyone including colicky babies need to be surrounded by those who care.

While reading to children has many benefits, simply speaking the words out loud may not be enough to improve cognitive development in preschoolers.

A new international study, published in the journal PLOS ONE and led by researchers at Cincinnati Children's Hospital Medical Center, shows that engaging with children while reading books gives their brain a cognitive boost.

In fact, functional MRI scans found significantly greater brain activation in four-year-old children who are highly engaged during story time. 

Okay, so what does it mean to be highly engaged while you're reading stories? 


Dr. John Hutton, a pediatrician at Cincinnati Children's and lead author of the study says, "Ask questions as you read, have your child turn the page, interact with each other. Engagement appears to fuel brain activation and turbocharges the development of literacy skills, particularly comprehension, in preschool-aged children."

For the study researchers obtained functional MRI scans of 22 girls, all four years of age, in an effort to explore the relationship between engaged reading between mother and child and neural activation and connectivity during the storytime task. 

Results of the functional MRI scans showed that children exhibiting greater interest in the narrative also showed increased activation in right-sided cerebellar areas of the brain, which is thought to support cognitive skill acquisition and refinement by connecting language and association with executive function (which is the mental skills children learn and develop to get things done and to understand the world).

Dr. Hutton says, "Our findings underscore the importance of parent and child reading engagement, including awareness and reduction of distractions such as cellphones, which were the most common preventable barrier that we observed."

Dr. Hutton says the study does not established causation, in other words does the activation seen on MRI really correlate with improved literacy skills and comprehension down the road? It's possible, but he points out long-term studies are needed beginning in infancy to better understand mother-child factors that contribute to healthy brain development.

Okay, sure. More studies are needed, we always hear that. And it's usually true. But at the same time in this case, I don't think it would hurt anything to put those cellphones away and actively engage preschoolers during story time. Have fun, I mean it just sounds like fun, right?

So, have fun. Do it often. The need for long-term studies shouldn't keep you from changing your reading habits and engaging with your kids today. And I really do think your kids and probably yourself would welcome the change.


Physical activity among children and teenagers is lower than previously thought, which is bad right out of the gate because I think most of us had an idea that in general and compared to previous generations that physical activity among kids is very low. But as it turns out, it's lower than even what we thought. And in another surprise finding, young adults after the age of 20 show the only increases in activity over the lifespan.

All these according to researchers from the Johns Hopkins Bloomberg School of Public Health and reported in the journal, Preventive Medicine.

Investigators say after a bump in activity during the 20s and early 30s so starting right around age of 35, physical activity level declined throughout midlife and older adulthood.

The study also identified different times throughout the day when activity was highest and lowest, across age groups and between males and females. According to researchers, these patterns could inform programs aimed at increasing physical activity by targeting not only specific age groups but also time of day with the least amount of activity, such as during the morning for children and adolescents.

These findings come during a time of heightened concern that exercise deficits are contributing to the growing obesity epidemic, particularly among kids and teens.

Dr. Vadim Zipunnikov, the study's senior author and assistant professor of Biostatistics says, "Activity levels at the end of adolescence were alarmingly low, and by age 19, they were comparable to 60-year-olds. For school-age children, the primary window for activity was the afternoon between 2 and 6 PM. So the big question is how do we modify daily schedules, in schools for example, to be more conducive to increasing physical activity?"


For their study, the researchers used data from the National Health and Nutrition Examination Survey which involve 12,529 participants ranging in age from 6 to 84 years. They wear tracking devices for seven straight days, removing them only for bathing and bedtime. The devices measured how much time participants spent being sedentary or inactive or engaged in light or moderate-to-vigorous physical activity. 

Activity among 20-somethings, the only age group that saw an increase in activity levels, was spread out throughout the day, with an increase in physical activity in the early morning, compared to children and teenagers. The investigators say the increase in physical activity for 20-year-olds may be related to starting full-time work and other life transitions.

For all age groups, males generally had higher activity levels than females, particularly high-intensity activity, but after midlife, these levels dropped off sharply compared to females. Among adults, 60 years of age and older, males were more sedentary than the females.

The study confirmed that recommended guidelines are not being met. For instance, the World Health Organization recommends at least 60 minutes of moderate to vigorous physical activity a day for children ages 5 to 17 years. The study found that more than 25% of boys and 50% of girls ages 6 to 11, and more than 50% of male and 75% of females between ages 12 and 19 had not met these guidelines.

While the World Health Organization advocates from moderate to vigorous activity, researchers say there is a growing consensus for the benefits of simply reducing sedentary or inactive behavior and increasing low-intensity levels of physical activity. In other words, every little bit helps.

Dr. Zipunnikov says, "The goal of campaigns aimed at increasing physical activity has previously focused on increasing higher-intensity exercise. Our study suggests that these efforts should consider time of day and also focus on increasing lower-intensity physical activity and reducing inactivity."


So there you have it. The bottom line here is you and your kids, everybody get off the couch and at the very least go for a walk. And if you go for a walk, take your kids with you.

Couple of days ago, the health insurance plan that covers our family offered a $150 in monthly premium savings, if I connect to my Fitbit  to their website, an average 6,000 steps a day for the next couple of months. And to be honest with you as invasive as that sort of feels, I'm also thankful for the incentive. 

In fact, knowing that this was coming up, I began bumping up my physical activities in terms of step counts when the weather started getting warmer.

So, you know, having a goal helps and there's a little accountability there because someone is watching my step count which again, as an American, someone watching my step count, I don't know. It just either something that bugs me about it. But at the same time, I think I'm more active because of it.

So, there you go. By the way, challenging others also help. My family is pretty competitive. So, each member of the family has a step counter. And we compete and challenges for digital trophies as we try to outstep one another on a daily basis. I think it's fun. And fun can also be a powerful motivator at least in my family's experience for adults and kids of any age.



Dr. Mike Patrick: A parent gets home from work just as a delivery of a new e-mail message dings on the phone. Meanwhile, the toddler's yelling for a snack or whining because big brother is not sharing. And big brother is trying to grab hold of the parent's attention because he's excited to show off his new Lego creation. The phone continues buzzing with more emails, social media notifications, a breaking news alert and an urgent text message. 

It's a common scenario in many American homes as smartphones and tablets blur the lines between work, home and social lives. Today's parent does his or her best to balance it all but a new studies suggest the use of mobile technology around young children, maybe causing internal tension, conflicts, and negative interactions. And it's a challenge that parents and pediatric providers should care about.

Dr. Jenny Radesky is a child behavior expert and pediatrician at University Michigan CS Mott Children's Hospital and lead author of the study, which appeared in the Journal of Developmental and Behavioral Pediatrics. She says, "Parents constantly feel like they're in more than one place at once while parenting. They're still at work. They're keeping up socially all on her phone while trying to cook dinner and attend to their kids." 

She adds, "It's much harder to toggle between mom or dad brain and other aspects of life because the boundaries have all blurred together." 

Dr. Radesky's team, which included investigators at Boston Medical Center, wanted to understand how this was affecting parents emotionally. 

She says, "We found that parents are struggling to balance family time and the desire to be present at home with technology-based expectations like responding to work and other demands."

The study involved in-depth interviews with 35 caregivers, which included moms, dads, and grandparents. Participants consistently expressed an internal struggle while multitasking with mobile technology trying to meet worker quests and engaging with their children. This often resulted in information overload, emotional tensions and disruption of family routines, including playtime and meals. As one mom in a focus group described it, "The whole world is in your lap."


Some parents also reported a trickle-down effect. Their emotional responses to whatever they were reading on their mobile device — whether it was a work email or bad news — sometimes affected how they responded to their children. Parents also described more attention-seeking behaviors from children when they were heavily attentive to their mobile devices, which prompted negative interactions such as snapping at their kids.

Now, at the same time, caregivers said that mobile technology provided an escape from the boredom and stress of parenting and home life demands. One mom said that after long days with kids, plugging into the outside world was a reminder that I have a life beyond this.

Other positives from mobile technology included the ability to work from home, easier communication with a estranged family members by allowing a more filtered view of their life and serving as a tool to keep peace and quiet in the house.

Dr. Radesky says, "You don't have to be available to your children 100% of the time. In fact, it's healthy for them to be independent. It's also important for parents to feel relevant at work and other parts of their lives. However, we are seeing parents overloaded and exhausted from being pulled in so many different directions."

Other studies show that parents use mobile devices such as tablets and smartphones nearly three hours a day. But few investigations have explored the role these technologies play in family interactions.

Dr. Radesky and her colleagues wanted to explore the issue further after an observational study of caregivers eating with young children in fast food restaurants. In that project, her team found that using mobile devices was associated with fewer verbal and nonverbal interactions between parent and child at the table.

She says, "Technology has transformed the way parents use digital media around their children compared to traditional distractions like books. Mobile technology is more commanding of one's attention. It's unpredictable and requires a greater emotional investment."


She adds, "Kids require a lot of different types of thinking, so multitasking between them and technology can be emotionally and mentally draining. As clinicians, we have an opportunity to start conversations with parents and help them manage this conflict with ideas on how to unplug and set boundaries."

Dr. Radesky offers some ideas for families struggling to stay unplugged. She advises parents first to set boundaries, create a family plan that includes unplugged spaces or times of day. For example, you can eliminate technology use at dinner or bedtime or maybe it's right when you get home and your kids are excited to see you. 

Another idea, plug in your device in a certain room and only use it there. Or agree not to use it in certain areas of the house such as the playroom or your child's bedroom.

Track your mobile use. Consider creating a filter or block on your device to avoid the temptation of tech use at home. Apps like Moment and Quality Time may also help track mobile use and see where you might be spending too much of your time. As an example, if 90% of your smartphone time is spent on Facebook or work email, you can think of ways to cut down times spent on those particular activities.

Also, identify device stressors. Think about which parts of your mobile device experience are most stressful for you. If it's reading the news or checking work email, for example, reserve those tasks for times when you know your kids are occupied. This way, you have your own time and space to process the information rather than interrupting time with your kids who may react to your negative emotions with their own negativity.


So, great advice all around. And I love the balance in this piece. On the one hand the use of smartphones really can interfere with the relationships and engagement that we have with our kids. But I also love the idea that it's not all bad. We have to have some balance here that parents are able to maybe spend more time at home because they have some connectivity to work. 

They certainly can extend their social life and especially for a parent who is sort of coop up with the kids, which on the one hand is great. You're really spending lots of times with your kids but you also need some social connections with other adults. And so it provides  that.

So there is this balance and I think that the ideas that Dr. Radesky presents in terms of certain boundaries and figuring out, "Okay, when is the great time to use my smartphone or mobile device?" And when is the time when it really does need to be… We say unplug but maybe that's the best time to actually plug it in and charge it while you're playing and engaging with your kids and really giving them your full attention. 

Let's move on to lawn mower safety. An average of 13 children each day in the United States receives emergency treatment for a lawn mower-related injury. That adds up to nearly 4,800 children injured each year. This according to numbers from the Center for Injury Research and Policy at Nationwide Children's Hospital and published in the American Journal of Emergency Medicine. 

Now, there is some good news to report. The study reveals a decrease in the number of children injured by lawn mowers over the last few decades but this cause of serious injury continues to be a concern. It still happens.

The most common types of lawn mower injuries were cuts — 39% caused those — and 15% were burns. The hand and fingers were the most commonly injured body region, followed by the legs, feet and toes. And while most children were treated and released, more than 8% were injured seriously enough to be admitted to the hospital. Bystanders and passengers were almost four times more likely to be admitted for a lawn mower-related injury than those operating the machine.


The report also says the way children are injured by lawn mowers varies by age. Children younger than five years are more likely to be injured from touching a hot surface while those five years and older were more likely to be struck or cut by the lawn mower or hit by a projectile.

Researchers suggest automatic safety measures designed into the lawn mower are the best way to prevent injuries. Shields can keep hands and feet from getting under the mower, while also protecting the blades from large objects. To help prevent back-over injuries, which are often the most devastating lawn mower injuries to children, every ride-on mower should be equipped with a no-mow-in-reverse mechanism, with the override switch for this feature located behind the operator's seat, which forces the person operating the ride-on mower to look behind them before backing up with the blades engaged. 

Current industry standards address some of these safety measures but it's on a voluntary basis.

Dr. Gary Smith, director of the Center for Injury Research and Policy at Nationwide Children's and senior author of the study says, "While we are happy to see the number of lawn mower-related injuries declining over the years, it is important for families to realize these injuries still occur frequently during warm weather months. 

"Improvements in lawn mower design over the last few decades are likely an important contributing factor in the decrease in injuries. But we would like to see manufacturers continuing to improve design and include additional safety features on all mowers."

Injury prevention experts have the following recommendations for keeping kids safe while you're mowing the lawn: number one, teach and supervise your teens. Children should be at least 12 years old to operate a push mower and at least 16 years of age before using a ride-on mower. The adult should supervise teenagers before they are allowed to operate a lawn mower on their own.


Number two, the yard should be a kid-free zone while you're mowing. Children should never be passengers on ride-on mowers and those younger than six years of age should really be kept indoors during mowing. Never let children play on or near a lawn mower, even when it's not in use.

Number three, before you mow, be sure to inspect the grass for stones and other objects. These become projectiles when thrown by a lawn mower and can cause severe eye and other injuries. Wear protective eyewear when you mow and also wear sturdy closed-toed shoes.

Number four, if you're using a walk-behind lawn mower, use one with the control that stops it from moving forward if the handle is released. Always mow moving forward. If you absolutely have to mow in reverse, always always always look behind you before backing up. It's extremely important.

And number five, turn off the blades when they're not in use. And this includes when you cross the road or driveway because gravel and stones are common in these locations and always wait for the blades to stop completely before removing the grass catcher or unclogging the discharge chute.

So, mowing, it can be a great form of exercise if you're using a push mower during the summer months rather than riding. But more importantly, you want to be safe. So follow these rules, use common sense and keep your kids away. 

More than 80% of parents have made at least one dosing error when measuring liquid medication for their children. This according to a study published in the July 2017 edition of the journal Pediatrics. 

Investigators asked nearly 500 English and Spanish speaking parents with children eight years of age or younger to measure three amounts of liquid medication — 2 milliliters, 7 1/2 milliliters and 10 milliliters. To accomplish these tasks, they were given three dosing tools, a medicine cup, a 5 milliliter syringe and a 10 milliliter syringe.


Label instructions provided were either text plus a picture or text only. And dosing tools had units that were either milliliters and teaspoons or milliliters only.

Researchers found that parents using tools with the size that more closely matched the prescribed dose made the fewest errors. For example, when ask to provide a 2 milliliter dose, the fewest errors occur with a 5 milliliter syringe. For the 7 1/2 milliliter dose, parents using the 10 milliliter syringe made significantly fewer errors compared to when they use a 5 milliliter syringe which was too small to allow a single fill and require parents to use math skills to correctly split the dose into two measurements. 

In addition, parents who used text plus picture dosing instructions as well as parents who used tools that only mark milliliters rather than milliliters and teaspoons had a lowest odds of making a dosing error.

The researchers who are using their findings to develop a comprehensive labeling and dosing strategy for pediatric liquid medications which they plan to test in a real world randomized trial.

So couple of important take-home points here and I have take-home points for both parents and pediatric providers. First, for the parents, make sure you're using a dosing tool that allows you to give an entire dose with the single fill. And always use milliliters when measuring the dose. Pretty simple really.

And don't be afraid to ask the pharmacist to provide the correct tool and show you exactly how to use it and where the measurement should be. 

We don't like to use teaspoons anymore because it does result in some confusion being technically 1 teaspoon is equal to 5 milliliters and 1 tablespoon is equal to 15 milliliters. The problem is you tend to think, "Hey, I have a teaspoon or table spoon in the kitchen. But all teaspoons and tablespoon are not created the same. Very few teaspoons are exactly 5 milliliters and very few tablespoons are exactly 15 milliliters." 


In fact, there can be big differences, I don't know if you have noticed but spoons have gotten larger over the years. And I know this because my daughter and her fiance have been spoon shopping for their wedding registry. And they are, they're bigger and definitely not 5 milliliters. 

So it's easier and moms and dads are less likely to make dosing errors if we're all on the same page and use milliliters and use something that can measure those milliliters exactly such as a syringe, an appropriately sized medicine syringe, or a cup.

So what about pediatric providers out there? I actually have more take-home points for all of us. And again, let's all get on the same page and stick to using milliliters as a unit of measurement to fill liquid medications. No more teaspoons in the prescription, that way we can avoid confusion. And I think most of us are doing that now. The biggest issue I come across from a prescriber point of view is how exact we give with our measurement.

The electronic medical record will very often figure out the dose for us which is convenient and then they'll spit it out on the prescription or send it to the pharmacy. The trouble is computers love being very exact. So, you see doses like 4.3 milliliters. I mean, really, we want parent to measure 4.3 milliliters in a cup or a syringe? 

It's okay to round up or down a little. Especially when we're talking about fractions of a milliliter. You know, you just have to take the time to correct it. We use to do this all the time in our head, back in the day of writing paper prescriptions. I mean, we would never write 4.3 milliliters on a paper prescription. 

But then computers took over and made our job easier but made the job of the parents sometimes more difficult by asking them to measure 4.3 milliliters. We sometimes let that measurement slide and give a printed prescription or let it get send to the pharmacy. Not necessarily out of laziness, it's usually that we're overworked and feeling rushed to move on to the next patient. And so, we just let it be.


But here's my call of action to the providers in the crowd — let's give parents a break and prescribe a dose of liquid medication they can easily measure in milliliters. And pharmacists out there, you have a role to play too by supplying parents with the right tool to make an accurate measurement with a single fill.

And the parents by the way, if you're getting an over-the-counter medication, don't be afraid to go to the pharmacy counter and ask for a syringe that will appropriately measure that medication for you even if you're buying it over-the-counter. 

And parents, be an advocate for your child, make sure you do have the right tool and the measurement you feel comfortable with in milliliters. And don't be afraid to ask for help whether it's finding the right tool or measuring the right amount or getting your child actually take the liquid medication. You may need some help there, which can often be a more difficult task to accomplish than the measurement itself.


Dr. Mike Patrick: All right we are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.      

Don't forget, you can find PediaCast in all sorts of places. Maybe you are listening because you click on a link, maybe on Facebook, or in your Twitter feed. But if you like to subscribe to the program, you can do that, really wherever you find podcast. 


So, we're in iTunes, Google Play, iHeart Radio, Stitcher, TuneIn, most mobile podcast apps. Just search for PediaCast, you should be able to find us and subscribe to the program so that the latest editions are always in your inbox within that program. And if you can't find the PediaCast in your favorite pod catcher, let me know and we'll try to get our show added to their line-up. I think we're in most of them but there may be one or two out there that we are not a part of. And we'd love for you to let us know if you come across that.

We also have a landing site at PediaCast.org where you will find our entire archive of past episodes, also Show Notes for each of those episodes. I'm getting all of my S's  mixed up here. If you have a PediaCast.org, click on Shows & Notes, and any of the links that we talk about, resources that we provide in a particular program, you'll find those in the Show Notes page. 

Also transcript, a written transcript of each episode, if you'd rather read than listen. Although I encourage you to listen. I mean, we spent the time putting the podcast together, it really is meant to be listened to. But we do have the transcript there in case you would rather read.

It also helps search engine index our content, since they can early index audio very well. So, that's another reason the transcript is there but you probably don't really care about that unless you're going to make your own podcast, and then it's something I'd recommend.

We also have our Terms of Use available at the website of PediaCast.org. Always important to take a look at that. And we have a Contact page there as well, where you can connect with the program. You can ask your own questions, submit comments, point me in the direction of a news article or journal article. Love it when you do that. And we'll try to get it your comment or your question or your resource that you like us to talk about on the program.

I do read each and every one of those that come through. If you head to PediaCast.org and click on the Contact Dr. Mike link, you'll find the easy page to submit your comments.


We also have a voice line if you'd like to leave a voice message. I haven't talked about that in a while, 347-404-KIDS, 347-404-5437. If you want to leave us a message that way, we can even get your voice on the show.

We're also in most social media channels like Facebook, Twitter, Google+, and Pinterest. Again, just search for PediaCast. And we love it when you connect with us in those places, and share our content with your own online audience. 

And, of course, we love when you tell others face to face. I mean that's really the best advertising that we could ask for — is when you're with your family and friends, your neighbors, co-workers, maybe your babysitters, daycare providers, even grandparents, really anyone who has kids or takes care of kids, when you tell them about PediaCast and where they can find us, that can make all the difference in the world. 

So that we can get our evidence-based content in front of more parents, in front of their attention. So that when they're out there on the Internet looking for a particular topic, they'd at least stop by and see what we have to say about it. Because, hopefully, we're providing a trustworthy evidence-based resource that's based on research, but also practical experience in taking care of thousands and thousands and thousands of children over the years. Rather than just one person's opinion that's not necessarily based on science.

And, of course, we always love it in particular when you share the show with your child's pediatric provider — whether that's a pediatrician, a family practice doctor, a nurse practitioner, physician assistant, nurses in the office, your pediatric specialist. Whoever it is that's taking care of your children medically, please let them know about PediaCast because then they know more likely to tell their other patients and families about the show. 

And again, to get evidence-based trustworthy content in front of those parents. Really, can make all the difference in them as a parent in taking care of their kids and their confidence that the information that they're hearing from their doctor's probably right rather than the information that they're getting on the internet from other sources. And, hopefully, we do a good job here explaining why your doctor recommends what they recommend. 

Also, let your child's provider know that we have a podcast for them as well called PediaCast CME. That stands for Continuing Medical Education and we do offer Category 1 CME credit for those who listen and participate in those podcasts. We do turn up the science a couple of notches and I say offer free Category 1 Continuing Medical Education Credit. Shows and details are available at the landing site for that program, which is PediaCastCME.org. 

All right, I want to thank you 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. 


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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