Ear Infections and Ear Tubes; Outdoor Fun and Spring Injuries – PediaCast 426

Show Notes


  • Our Pediatrics in Plain Language Panel returns as we consider ear infections and ear tubes. Plus, warm weather is on the way (finally!) We have terrific ideas for outdoor fun… and tips for responding to Spring injuries. We hope you can join us!


  • Ear Infections
  • Ear Tubes
  • Outdoor Fun
  • Spring Injuries




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 is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. 

It is Episode 426 for March 21st, 2019. We're calling this one "Ear Infections and Ear Tubes, Outdoor Fun, and Spring Injuries." I want to welcome you to the program.


So our Pediatrics in Plain Language Panel joins us again today as we consider a listener question regarding ear infections and ear tubes. It's a great question, by the way, and it provides me with an ideal opportunity to remind you that we love to entertain questions from the audience. 

So if you have a question about the health and wellbeing of your kids and teenagers, or you have a parenting question, you want to hear our comments maybe on a news story or journal article that you've come across, something in your social media feed, you just have a question about it, anything like that, we'd love to hear from you. 

And it is very easy to connect with us, just head over to pediacast.org, that's the landing site for this podcast and click on the Contact link. Ask your questions, suggest your topic, point us in the right direction of what you want us to comment on. And we'll do our best to get it on the program. We do read each and every one of those that come through and love hearing from the audience. 

Now, if you are new to the program, you may be wondering what in the world I meant when I said the Pediatrics in Plain Language Panel is joining us today. It's a good question. 


With every episode of PediaCast, we aim to improve health literacy. In other words, we want to help parents understand what's going on underlying, what's going on under the skin related to the health and wellness of our kids. 

So just as an example, we're going to be talking about ear infections today. Why is it that some young children get one ear infection after another, but only in the winter, while other kids do not get any at all or some get them sporadically throughout the year? Why are there differences from one kid to another in terms of how often they get ear infections? Or at what age they tend to start to outgrow ear infections?

And health literacy really involves understanding why ear infections happen in the first place. And then, you can begin to understand how some kids are different than others in terms of their anatomy and physiology, the way that their bodies work. 


And once you understand that, then you have a better idea of how maybe you can predict when they're going to get an ear infection or even prevent the cascading events that can lead up to that. Typically, it's not water in the ear, it's not wind in the ear, it's not cold weather. There's really processes going on under the skin.

And when you understand those, it becomes easier then to understand how to prevent, how to treat. Treatment makes more sense, and you're more likely to follow through with the recommendations. You know you can make smarter decisions about what treatment options you're going to do when you sort of understand the underlying things that are going on. 

Again, prevention is really big, and when you understand how something happens, you can be much smarter about how to prevent it. 

So health literacy is important. Plain language is also important. And by that, we explain sometimes very complicated things using language everyone can understand, but without necessarily dumbing down the science. Because you have to understand some of the science to understand how things work, to improve health literacy. 


So it's all connected. And sometimes, we do use the big terms but then hopefully explain what we mean by that. So that not only then do you understand it with simple language, but you can start to build your vocabulary to some degree as well. 

Now, of course, health literacy and speaking in terms parents can understand are always important on PediaCast. But in this particular series of episodes, when the Pediatrics in Plain Language Panel joins us, we try to do an extra good job of avoiding jargon and holding each other accountable. And it's just being careful to explain things in simple terms as we move along. 

You recall that our panel includes Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both general pediatricians, primary care providers here in our ambulatory medicine section at Nationwide Children's Hospital. We will get them settled into the studio momentarily and talk about ear infections and ear tubes. And then, they're going to stick around as we consider outdoor fun and spring injuries. 


Because at least here in the Midwest, spring has sprung, or at least by way of calendar, if not by way of actual weather this week. That means hopefully, warm weather is around the corner. And in my mind, it cannot get here fast enough. It's been quite the trying flu season this year. And hopefully, spring will get here and we'll get the kids out on spring break and stop passing things around. 

Before we get to our interview today and our discussions on ear infections and outdoor activities, and injuries for spring, I would like to remind you, PediaCast is on social media. We are on Facebook, Twitter, also Instagram. And we try to add value above and beyond what we offer in the podcast. And particularly on Facebook and Twitter, we try to share things multiple times a day that's really aimed at further improving health literacy and understanding with evidence-based information that parents can use as they learn more about child health. 


And just to give you some examples of recent things that we've shared on Facebook and Twitter, of course, measles is big on the news right now. So we've been covering the measles outbreak. 

Also, actions in state legislatures that are aimed at making personal exemptions to vaccines either easier or more difficult, depending on which state you live. So some states are trying to make it easier for parents to opt out of vaccines, and some states are trying to make it more difficult. So we've been covering the latest news for you there on what specific individual states are doing. And of course, continuing to talk about MMR vaccine and measles because they continue to be hot topics in the news. 


Another good one, teens with high blood pressure have a greater risk of kidney disease during middle age. So it is important that your kids and your teenagers have their blood pressure checked regularly. And if the readings are high, especially on multiple dates and multiple situations, if it's really high, not just only high every now and then when I go see the doctor but we really think that the blood pressure is high on a regular basis, that's something that's important to treat. 

And unless it's really high, it might not be life-endangering now. But when you understand what the blood pressure does to the kidneys over time, again, the self-literacy thing, you understand that it starts to damage the kidney kind of in a wear-and-tear sort of way. 


So it is important to those high blood pressures under control in kids and teens who have those. And so we've been sharing some of those information on Facebook and Twitter. 

Speaking of teenagers, the number of high school students who are vaping has increased exponentially in the last couple of years. The FDA has been trying to crack down on retailers selling nicotine to underage vapers. I guess, is that what you call them, if you're vaping, you're a vaper? So we've been watching those developments closely and sharing them with you. 

One-third of US kids suffer from back pain at one time or another, especially those involved in sports and those with big heavy backpacks. So we've been sharing some of that information. 

We also covered a terrific story on the stress that mothers face as they attempt to balance home and career. Many women are drowning in stress and the story we shared has great ideas on how to help. 


So lots of great content, hopefully. We think it's great content. Hopefully, you'll think it's great as well in our social media feeds. And it's material that you won't find in the podcast, except for those five articles which I just shared with you. 

But there's much more details if you look at the articles themselves. And we share a handful like that every single day. So hopefully, though there'll be something you can find. If you don't follow us on Facebook and Twitter, please consider doing that. 

And then, Instagram, a little more personal, a glimpse into the studio, into my family life, what we're up to. I really enjoy seeing what you're up to as well. So if you follow us on Instagram, we'll probably ask to follow you back. 

And really, just trying to build a community of parents there that are sharing what's going on in their lives. You can get some good ideas from one another. In fact, just a couple of days ago, there was a family that was visiting a zoo. And it just sparked in my mind, man, I can't wait for really warm weather to get here. At least not freezing weather, all right? Sometimes, the animals are more active and out and about when it's not super hot. But at least give me 50 degrees. And thinking, yeah, we need to get to the zoo.


And so we can get ideas from each other with what we're doing with our families on Instagram. But the ultimate goal really in all of these places and with the podcast is just to provide you with information and the tools you need to improve the health and wellbeing of your family on a daily basis. 

All right, one more last bit of housekeeping before we get to our guests. The information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination. 

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


So let's take a quick break. And then, the Pediatrics in Plain Language Panel will join me as we consider ear infections, ear tubes, and spring activities and injuries. That's coming up right after this.


Dr. Mike Patrick: Our Pediatrics in Plain Language Panel joins us again this week. You recall them, Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with the Hilltop Primary Care Center at Nationwide Children's Hospital. 

And Dr. Alex Rakowsky, also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's Hospital.  Really appreciate both of you joining us again. 

Dr. Alex Rakowsky: Thanks, Mike. 

Dr. Mary Ann Abrams: Great to be here. 

Dr. Alex Rakowsky: And welcome to spring.


Dr. Mike Patrick: Yes, oh, I am so happy about that. Except for my allergies are going to kick up with the pollen, but the warm weather is definitely appreciated. 

So Mary Ann, just a real quick reminder, why pediatrics in plain language is important? Why are we using that terminology.

Dr. Mary Ann Abrams: We just find it so easy and seamless to speak our language of technical healthcare terms in our everyday care for patients. And while that, it works for us when we're talking to each other, we forget that not everybody speaks that healthcare language. And it can be very confusing, it can be worrying when patients and families hear us, use words that can sound frightening. And even more important, words they don't understand so they don't know what they really have perhaps. 


They don't quite know for sure what they need to do, and they can leave us. Because they don't often tell us. They may not want to take more of our time, or they may be embarrassed. So we may not even realized they didn't catch it all when we were meeting with them in our offices, or in the hospital even. 

So we need to take that extra step of making sure we explain things in plain language. Which means everyday terms that living room language, and really just watch for those technical terms and also those words that have special meaning to the healthcare field that may mean something entirely different in everyday life.

Dr. Mike Patrick: Yeah, absolutely. And I don't have any research behind this to back me up, but I'm also a proponent. So use the technical terms now and then, but explain what they mean. Because then, you're also building up people's vocabulary to some degree. Especially if it's a chronic illness that a kid deals with, so it's a term that the parent may come across over and over. 

Dr. Mary Ann Abrams: They likely will come across it, they didn't know those words. But especially early, when they're first learning about this, we got to make sure we explain them. 

Dr. Mike Patrick: So we're not dumbing down the science, we are explaining as we go in regular language, so the people can understand. Our ultimate goal is to improve health outcomes by improving health literacy. And health literacy is really just understanding how things work and what it means. 


Okay, so we have a listener question and I thought the Pediatrics in Plain Language Panel would be fantastic to answer this. You have three board certified pediatricians in the room, folks and hopefully, we'll get a good answer here for you. 

This comes from Melanie in Narberth, Pennsylvania. She says, "Dear Dr. Mike, thank you so much for creating this podcast. It's incredibly difficult to find evidence-based health resources for children. Your podcast is a huge asset to me and I believe it makes me a better parent to be able to make these health related decisions with the appropriate facts. 

"So here's my question, my 22-month-old daughter started daycare in June. Since then, she's been diagnosed with four ear infections and treated with antibiotics each time. Based on what I learned in your previous podcasts, I believe they're all bacterial infections. I know that if she continues to get ear infections at this rate, our pediatrician will want to start talking about getting tubes in her ears. 


"I'm wondering if you can tell me what the current thinking says about ear tubes. I know we don't want children on antibiotics all the time and there are concerns about language development at this age. However, surgery with general anesthesia is very scary. Thank you. Melanie."

So thanks for the question, Melanie. I thought a good place to start with this right off the top is there are some terms that doctors use frequently surrounding ear infections and ear tubes that we ought to define right up front, so people have heard these terms. 

One is otitis media. Otitis is the ear, media means the middle ear. So it's an infection in the middle ear is what otitis media is.


Tympanic membrane is another name for ear drum. And then, ear tubes have all sorts of names. PE tubes which stands for pressure equalization. Tympanostomy tubes, myringotomy tubes, ventilation tubes, if you hear the word tube associated with the ear, there are no other tubes. All right, well, except the eustachian tube, but we'll get there. 

Dr. Mary Ann Abrams: You may want to point out too that they may hear otitis media, and then they can hear acute otitis media, and otitis media with effusion. And those are two very different things. Both of those can end up leading potentially to needing ear tubes. And acute otitis media really means that you've got an ear infection that's just started and currently infected and having symptoms going on right now. 

And then, otitis media with effusion means that you've got heavier infection. You may have had several and an effusion is kind of like an accumulation of fluid and maybe some mucus and broken down cells that kind of stay in the middle ear after the infection has gone away. And that can cause a problem too which we'll talk about. 


But you may hear those words and those are the kind of things that can come trippingly off the tongue of somebody who's trying to explain ear tubes to you and you may be confused, "Why, I didn't think she had an ear infection." Well, she has otitis media with effusion. 

Dr. Alex Rakowsky: I'll throw in also serous otitis. And I think the best example that I heard a resident gave is if you sprain your ankle that day, it's sort of like an acute otitis media. But then you had that swelling of that ankle for awhile and some people will call that a serous otitis or swelling behind the ear drum. So that's a term you may hear as well, in addition to otitis media with effusion.

Dr. Mike Patrick: And then, recurrent otitis media versus chronic otitis media. Or chronic serous otitis media mean that fluid's been there for awhile. And recurrent just means kind of in short order. Not necessarily back to back but also not months apart. It's usually you get one, and then you may go a couple of weeks, you get another cold, then you get another ear infection. It keeps recurring. 


Dr. Mary Ann Abrams: But you got over one episode before the next one started. That's kind of the difference between that and chronic which means it never really goes away. 

Dr. Alex Rakowsky: We have all those terms. Basically, it boils down to two questions. And it's question number one is the infection. So if your child is getting infected over and over and over again, then do you worry about a lot of antibiotic exposure? And then your child develops resistance to a certain antibiotics till the antibiotics don't work. 

And then, the second question is if you have over and over ear infections, you got that swelling in there, does that impact their one, behavior; two, pain -- because you have fluid in your ear, it hurts you; and three, language. 

So those are like the two big questions. So just as a plug for the parents, just be clear to the ENTs, whoever you end up seeing, what are you most concerned about here? 

Dr. Mary Ann Abrams: ENT, meaning the ear, nose, and throat doctor. 


Dr. Mike Patrick: Yes. 

Dr. Mary Ann Abrams: The person to put those tubes in. 

And when Alex talked about language, that's because when the fluid builds up behind the ear drum, that decreases the ability of child to hear well. And that is what can impact language development at a really critical part of a child's speech and language growth. So I think that's what...

Dr. Mike Patrick: I think Melanie showed great insight in asking her question because these are the things... And I don't think you were thinking about her question when you said, hey, this can cause hearing problems. This can be recurrent antibiotic exposure that could be a problem. I mean, Melanie had that sense that these are real things that we worry about. 

And we talk about risk versus benefit. And in order to think about whether you do surgery or not, you want to think about the benefits of the surgery, what are the risks of surgery versus what's the risk of continuing to treat ear infections that keep coming back. Because that's what you're really weighing, all of those things, when you try to make a decision. 


But I want to take a step back. And let's just talk about what causes ear infections, first of all. What do parents often think, especially if you aren't medically savvy, what do you hear parents say, "Oh, this must be why they're getting ear infections?" What are some of the myths? 

Dr. Alex Rakowsky: I think one of the big myths is the fact that the ear infection's in the canal. And so, the biggest discussion we have with families, especially the residents that I work with, is just kind of drawing it out on a piece of paper. The canal essentially is the canal down to the ear drum, and the infection's behind that ear drum. 

Most people say I got water in there. We went swimming, therefore he got an ear infection. And you can get some cold swimmers which is the canal getting infected, but what we're being asked here is an infection of the actual middle ear, the more common sort of ear infection. 

Just to kind of start with the basic anatomy of the ear that the infection's behind the actual ear drum. 

Dr. Mike Patrick: Yeah, that's a good point. And so, cold, the cold weather, going outside without a hat on. Hats are great thing. It keeps you warm. But it doesn't necessarily cause ear infections. 


So what does? And water in the ear, you mentioned, doesn't really cause middle ear infections which is what we're talking about, unless you have a hole in the ear drum and the water gets into the middle ear space. But that's a little more complicated. 

So what does cause an ear infection? 

Dr. Alex Rakowsky: It's the fluid behind your ear drum getting infected and there are various types of ear infections. You can have a viral ear infection that does not need to get treated with antibiotics. When you need to get antibiotics, what happens is that the fluid from a virus, the cold, etc., has built up. And now, bacteria that live in your nose and throat naturally has worked their way up to the ear and then they set up shop. 

It's like a 7-11 in teenagers. Fluid is sort of like attracts the teenagers to the 7-11. So the fluid attracts the bacteria to the ear and then it starts living there. And then, you get a massive infection in that ear. 


Dr. Mike Patrick: And then, that kind of brings in this idea that I sort of mentioned, the eustachian tube, which is a big word. I don't have any idea where the word eustachian comes from. I don't know if it's a guy's name or it described some Latin word, I just don't know. But it's called the Eustachian tube. 
And it's a tube that connects that middle ear space that we're talking about that's behind the ear drum to the back of the throat, back of the nose kind of area. And it normally is lined by little cilia cells. So these are like hairlike projections into the middle of the tube that serve to kind of sweep bacteria that crawl up there back to the mouth to kind of keep it out of that space. 

But when you get a cold, the virus infects those cells, and so the cilia doesn't work right anymore. And now, it's easier for bacteria to get up into the middle ear space than it otherwise would have. 


And then, the other thing to consider with eustachian tube is the anatomy of the eustachian tube different from one kid to another. So some kids have longer rigid eustachian tubes and others are kind of short and fluffy just depending on genetics. And those with short fluffy eustachian tube, because they're shorter, it's easier for bacteria to get in the middle ear space and then they can sort of flap close and then all that mucus kind of sticks together. 
So now, the eustachian tube is blocked and any bacteria that went up into the middle ear space is trapped there and reproduces and as you say sets up shop. And then, you get that ear infection.

Whereas some kids have a longer rigid eustachian tube, it's more difficult for bacteria to get all the way to the middle ear space. They don't flap close. And then, as kids get older, as their face grows, the eustachian tube just naturally gets longer, more rigid, and that's sort of like kids outgrow. Some, a lot of them, outgrow ear infections as they get older. 

So just knowing the anatomy of that tube itself kind of explains why some kids get them, why other ones don't, why they often follow cold viruses. You see them more in the winter time when there's a lot of cold viruses out there. So I think that's something that's helpful for parents to understand.


Dr. Alex Rakowsky: If I can add two more things, one is genetics. So the kids who actually have fluffy or shorter tubes, it tends to be genetic. So if you have a strong family history of mom or dad that had tubes, grandpa had tubes, then there's a much stronger chance of having infections over and over again. So we'll probably talk about that a little bit later. 

The second thing is that tube has to drain somewhere in the back of the nose and sort of like the back of the throat area. So if you've been sick a lot, you have a lot of allergies, somebody smokes in your house, which irritates the back of your nose, that actually stops that tube from draining properly.

So one of the main risk factor is just having smoking in the house or getting exposed to a lot of smoke in the environment, let's say in the car. Because that will irritate the back of the nose, now the tube can't drain. 

So we tend to think of this as infections. But there's some setup that makes that infection kind of settle on to that ear. 


Dr. Mike Patrick: Yeah, that's all excellent points. That's a really good point with the smoking in the house because that's also going to create mucus and dysfunction and can get you set up for ear infections, too. 

So if your  child does have recurring ear infections and there are smokers in the house, one of the things you can do to prevent this is to stop smoking. If possible, get help to stop smoking because you can't do it without help. It's very difficult. And then, smoke outside and put on a different jacket. Don't wear the coat inside that's got the smoke in it. 

Please don't smoke in your cars because it really will result in more ear infections for kids, based on what we're learning about the anatomy of the this area. 

Dr. Mary Ann Abrams: It's one more reason not to smoke and not to let other people smoke around you or your kids. 

Dr. Mike Patrick: Yeah, yeah, absolutely. 

So now let's talk what does the ear tube actually accomplish? So as we think about how ear infections get started, what is the purpose? And I guess, first, will someone of you just tell us what an ear tube is. What does this thing look like? 


Dr. Mary Ann Abrams: Well, there's a lot of different kinds. But the kind I'm most familiar with are, they're actually really small. People think, "Oh, my gosh." It's easy to lose one if it comes out and you're trying to find it. But it's like a little tube. Most of the ones that I have seen have a little rim around either side, so that one set is inserted into the ear drum itself and it goes through the ear drum. 

You want it to stay, so it has a small rim on either side that kind of anchors it there, so it can't slip out or in. And they're made out of all kinds of materials. So I'm sure every month, there's a new better one being made. But that's basically what it is. And the point is to equalize the pressure. So there's a lot of pressure that's built up behind the ear drum. By creating that little tunnel if you will between the middle ear and the outer ear and the ear canal to the outside, air can pass in and out. 


Before they put it in, they usually drain all the gunk that has been built up behind there, the mucus and dead cells and things like that. And that helps promote healing. And it allows drainage if that should occur again. 

Dr. Mike Patrick: And it also provides an exit route for the bacteria that maybe had migrated up the eustachian tube into the middle ear space rather getting trapped. Now, they can actually become skin bacteria in the ear canal. 

Dr. Alex Rakowsky: Also, we all get colds. Mike and I do urgent care and ER, so I'm probably sick as much as a toddler in the dead of winter. 

Dr. Mike Patrick: Me, too. 

Dr. Alex Rakowsky: So I have fluid in the back of my ears all winter long. So these tubes actually help drain some of fluid as well, because we all get the fluid up there. And if you're prone to have enough fluid sitting there and then getting infected, it's a nice way to kind of drain at least some of that pressure off for the pressure equilibrium or pressure balancing. And also to make sure that the fluid doesn't sit there for a long time, so the bacteria set up shop. 


Dr. Mike Patrick: Yeah, absolutely. So we've talked about, so we have an idea of what causes ear infections, why an ear tube would prevent them. We've talked about sort of the complications of ear infections. There are others, pain, fever, vomiting, just the sickness itself, the infection can spread. You can get a bone infection called mastoiditis which is just a bone that's close to the middle ear space. 

You can get a blood infection, you can get meningitis. I mean, these are rare things but possibilities with acute otitis media, ear infections. If too much pressure builds up, you can get rupture of the ear drum and then scar tissue that builds up there. 

So, also, if you have that chronic effusion, you talked about that, can actually over time, even damage the little bones. And you can get arthritis where the bones articulate or where the joints are of those bones. So that can cause hearing problems. And not just hearing problem because there's fluid there but hearing problem that can be more long lasting because you damaged those bones that conduct sound waves through the middle ear space. 


Dr. Mary Ann Abrams: Those the famous hammer, anvil and stirrup, the middle ear bones. 

Dr. Mike Patrick: Yeah, the smallest ones in the body. 

Dr. Mary Ann Abrams: Very, very tiny.

Dr. Mike Patrick: And which you can actually replace. They have a... Well, that's a whole another story. My son actually does have arthritis of one of the bones, and at some point we'll probably need it replaced.

So these ear infections that are recurring and they keep happening do have consequences that are associated with them. 

So Melanie is concerned about the complications and the risks of surgery. Because that's really what you're weighing, right, when you decide do I want to put ear tubes in or not? Is the benefit of those ear tubes worth whatever risks that are associated? 


So let's kind of talk through what are the real risks of getting ear tubes put in? 

Dr. Alex Rakowsky: It's a fairly short surgery but you still have anesthesia. Because you have to have a child who's not moving around so you're probably looking at some level of general anesthesia to kind of get the child sedated and sort of not moving at all. So we're not talking like a two, three-hour surgery. Well, probably a 15, 20-minute procedure. This child's not conscious of what's going on.

So that is a real risk. And the risk factors, some general anesthesia, short term, having allergic reaction, things like that are fairly well worked out and kind of rare. 

But then, the longer term risks, there's about anesthesia and mental health, and problems with your development, etc. There's a growing sort of field looking at that but it doesn't seem to have as much impact from the short anesthesia. So I don't think there'll be as many concerns for the long-term health from a short ear tube surgery.

Dr. Mike Patrick: And there's risk really with everything that we do. And if you look at real numbers, and so what is the relative risk? It's probably just as dangerous driving in your car to go get the surgery as it is having the surgery. 


Dr. Mary Ann Abrams: Probably more so, to be honest.

Dr. Mike Patrick: Yeah, I agree. That doesn't mean the risk is zero.

Dr. Mary Ann Abrams: Right. 

Dr. Mike Patrick: But there's risk in every... Your child plays on the playground, there's a risk that they could fall off the slide and break their arm, which is a much greater risk than a problem with anesthesia. But we recognize that it really is a risk. 

Dr. Mary Ann Abrams: And the care point is the risk of not doing the surgery if indeed your child would likely benefit from having the ear tubes. So repeated courses of antibiotics like Alex talked about. Now, we try not to use antibiotics as much as we used to. If we think it's much more likely to be a virus or if the child's really overall healthy or little bit older, or if...


Dr. Mike Patrick: The watch and wait kind of thing. 

Dr. Mary Ann Abrams: Yeah, the parents and everyone, the child really looks comfortable and healthy, we can observe. Because a lot of them will get better on their own. But we also recognize that we don't want them to be at worst, so we don't them to have a child who's in a lot of pain in the middle of the night and no recourse there. 

So there's that, as well as overusing those antibiotics so that they don't work anymore. The couple other big risks are you take the antibiotic and it wasn't really needed for the ear infection because they had a virus. And then a lot of viruses cause rashes. So as your child is going through this viral infection, they break out in a rash, we don't really have a choice other than to say he was taking antibiotic and he got the rash, could it be an allergy to the antibiotic? Can't say for sure, but got to be safe. 


So many people, children and adults even are labeled as allergic to very good antibiotic, especially some of the best ones that aren't really expensive or really broad. Because we like to focus as narrowly as possible, we use antibiotics, and then you can't use them when you need them. So that false labeling is an issue.

And then, there are side effects with them, diarrhea, nausea. And then, as you were talking about new research, that was the effect of antibiotic have on your body's natural bacteria that are good for you. The biome is the word we're using. 

Dr. Alex Rakowsky: Let me throw one out as well, and again this is urgent care experience speaking where if you've been on a lot of antibiotics, sometimes the last choice is to get shots of antibiotic called ceftriaxone. And most of us will get three days worth of shots. And invariably, the kids will always come in for their first day on a Friday. So our office may be open on a Saturday but then they have to go to ER urgent care on Sunday.


And now, that child's being exposed to the flu, the stomach virus, whatever else is sitting in that lobby. And I can count on my hand, it will take me two hands, just this one tray alone where I had children need the three shots of antibiotic and a week later, we're seeing them in the clinic and diagnosing them with the flu that they probably picked up in the lobby. We're diagnosing them for stomach virus which they probably picked up in the lobby because you're going to see sick kids in the ER urgent care lobby. 

So that's another sort of risk factor where just the chronic exposure in the dead of winter to other kids who have illness and you have to give the three days of shots, they're no way around it. And if it's a week and you're probably going to a place that's jam-packed. 

Dr. Mary Ann Abrams: To say nothing of the time it takes for the family and the cost, because it's a lot more expensive. They have to go back especially to emergency room. 


Dr. Mike Patrick: I want to take a couple of steps back because this is an important thing for parents to hear. My good friend, Dr. Dave Stukus, who's a pediatric allergist here and he's been on this program several times and we work together in a lot of things, he likes to say that 10% of the population, things that are allergic to penicillin type antibiotics, all of those people, only about 10% of them really are. 

And there's become more evidence that it's probably a combination of the antibiotic and the particular virus together that your body is reacting to, when you have these rashes that aren't hives, they're not really anaphylaxis, which means a very severe allergic reaction, can be life threatening. 

And if there is question about whether your child really is allergic to antibiotic, you can always see an allergist and they can do a challenge where they give you the medicine, because if you have a life threatening allergic reaction, it's always within an hour that you're going to have the symptom start.

If you have or on antibiotic and you get a rash a few days later, it's a different mechanism. You might get a rash again if you have that antibiotic in that particular strain of virus, but it's not life threatening. It's just inconvenient and should we really be labeling those allergies?

If you Google PediaCast and drug allergies, you'll find lots more information on this kind of thing. 


Dr. Mary Ann Abrams: And that sound like that like not big of a deal, but it is a really big deal. 

Dr. Mike Patrick: Well, it is. It's a big deal if you think you're allergic to something that you're not really allergic to. 

Dr. Mary Ann Abrams: For you and for the doctors and nurses that are taking care of you. 

Dr. Mike Patrick: Yeah, yeah. 

Dr. Mary Ann Abrams: Because then, you have to think what other antibiotics? And they're more expensive, and as we'd said a lot of them are...

Dr. Mike Patrick: Broad.

Dr. Mary Ann Abrams: Broad spectrum, which... 

Dr. Alex Rakowsky: And more side effects.

Dr. Mike Patrick: Yeah.

Dr. Mary Ann Abrams: Broad spectrum means it attacks a lot of bacteria instead of just the main ones, and that can lead to complications, too. 

Dr. Mike Patrick: And then, my second point is we've really been kind of hammering complications of the ear infections. There's another complication of ear tubes that I think parents really do need to take into account. And that is when you put on ear tube, if you have a series of ear infections that will go away on their own, you won't necessarily going to get a long-lasting effusion or fluid build-up that can lead to language delay. Which we didn't really talked about that, but if it interferes with your hearing, that can also interfere with language development. 


But that doesn't always happen. And so, a lot of times, it may just be two or three ear infections and then maybe spring gets here and the viral season goes away. And then, maybe you're not going to get another ear infection until the next fall. 

So when you get to late part of winter, maybe you do give it a little longer before you do a surgery, because there's more of a chance that these things are going to go away. And then, your child has another year of growth. Maybe they won't be so prone to it the next season. 

But I mentioned this because ear tubes sometimes stay in long. And when the ear tubes pops out, there is a hole there, and you can get a scar tissue from that hole. And then, that creates a weak point, and sometimes kids or teenagers, and they go doing flips in the pool and they have increased pressure in the ear. And now, they get a ruptured ear drum from the lid point of the scar tissue that could have been there from an ear tube. And now, you're talking ear drum reconstruction. 


That's a real risk, too. Again, it's a low risk but it does happen. And so, when you're trying to make this decision between tubes and not tubes, it can be kind of a complicated decision for parents. And I think your best bet is to find a pediatrician who is going to walk that path with you and help you make a decision that's right for your family. Because we all have different risk tolerances and there's not necessarily a one right answer all the time, right? 

Dr. Alex Rakowsky: Yeah. Also, a pediatrician who knows and trust a ear, nose, and throat group. And I work with residents a lot, and we did a journal club last year about effective ear tubes and how useful they are and when you shouldn't be giving them. And compared to say 10 years ago or 20 years ago when we trained, ear tubes were used commonly. Three infections in six months, four infections in a year is an automatic ear tube. 

The ENT, the ear, nose, and throat docs are now a lot more watch and wait. If there's a strong family history, a hearing problem, they're more prone to put the tubes in. But a lot of times, they'll sit down and talk to the families and say, "This is why I'm waiting," "This is what I'm looking for," "Here are the rest of the tubes." 


So if you find an ENT who honestly does a fair number of pediatric cases, doesn't have to be a pediatric ENT, but somebody who has expertise in pediatric ears, they'll usually do a really nice job of talking to you about, "This is why I think this tube should be put in."

Dr. Mike Patrick: I love that. 

Dr. Alex Rakowsky: And the way the literature has changed, the ENTs are less probably to say let's just move forward with the tube. 

Dr. Mike Patrick: Yeah. And where getting the advice of your pediatrician because your pediatrician is going to know which ENTs always do surgery no matter what, and which ones are really going to take a case-by-case example. 


Again, this is making a broad generalization, but I think your pediatric ear, nose, and throat specialists who work with these kids day in and day out and do these surgeries over and over again might be a little more sensitive to that than say person who's mostly an adult ear and nose throat doctor. Again, generalizations, I'm sure that there's great adult ENT doctors out there. But you know, another consideration. 

So I'm hopeful, Melanie, that we didn't cause more confusion than we helped, but oftentimes these are complicated discussions and they're nuance. And it's hard to explain what nuance means. I don't even know how to... I'm not sure what it is. What's a synonym for nuance? 

Dr. Mary Ann Abrams: Well, it's not a straightforward answer. There are a lot of layers, a lot of different issues that you need to take into account. And as you said, Mike, some things are going to be more important to one family and other things will be more important to another family. And that's important too as you're making these decisions. So don't undervalue, Melanie, what your family's main concerns are. And obviously, you care deeply about your child. 


And she did raise that issue about language development. And we've mentioned it but I don't know that we talked about it maybe quite enough since that was one of the things in her question. We talked a little bit about why it's an issue, but as we talked about in our last PediaCast, we know that the first three years of life are critical for our language development. 

So that's why when kids get lots of ear infections in those first few years, it can really interfere with their hearing. And how do they learn language? So they learn it by hearing language and then responding to that language. So if something interferes with that, it can really affect their language. And okay, what a big deal, well, I can just learn later. It has to do with their ability to learn, to interact with others, to learn to read and sound outwards for school success, etc. 


So that's a very important consideration, and I think that you need to take that into account, too. 

Dr. Mike Patrick: I think that's a really good point. I mean, even let's say you do have a teenager who now has a ruptured ear drum that needs a tympanoplasty, which is a reconstruction surgery of the ear drum. Those things, you can do those, but failing behind in terms of language development and not doing well in school, that can set you up for a whole different life as an adult. 

And so, again, just lots of things that we have to take into account. And that's why you want a good pediatrician who'll walk through that balanced discussion.

Also, Melanie, and everyone else in the audience, we're going to have some resources for you in the show notes over at pediacast.org for this episode, 426. I have a really good information page on ear infections for you, also one on ear tubes including a video of an ear tube surgery. So if you are interested in seeing exactly what that looks like, and that was actually produced here at Nationwide Children's. 


And then, a blog post, Ear Tube Removal: Is It Necessary? So some great resources surrounding this topic we'll have in the show notes. 


Dr. Mike Patrick: We are back with our Pediatrics in Plain Language Panel. We have Dr. Mary Ann Abrams from the Hilltop Primary Care Center and Dr. Alex Rakowsky with Olentangy Primary Care, both at Nationwide Children's. 

We are continuing our valiant effort to improve health literacy using plain language. We're ready to discuss spring activities and injuries. Before we do that, Mary Ann, just remind us, what do we mean by Pediatrics in Plain Language and how does that tie in to health literacy? 


Dr. Mary Ann Abrams: Well, in plain language, plain language is language that people can read, use, and understand easily. Another way to describe it is living room language, the kind of words people use when they're at home just talking to each other about health, because we're talking about health literacy. Words your grandmother would understand if you were trying to explain something to her. So that's really what we mean when we're talking about pediatrics in plain language. 

Dr. Mike Patrick: Great. So we are explaining things in terms people can understand. We're not dumbing down the science. We're just explaining as we go along, hopefully with vocabulary that we all know. 

Dr. Mary Ann Abrams: In some ways, I'd say we're improving the science, we are not ever dumbing it down. 

Dr. Mike Patrick: Yes. In fact, it was Albert Einstein who said to really know something well, you have to be able to explain it simply. That shows that you really do understand it. 


So we're going to talk about fun outdoor activities. Spring is here officially. Here in the Midwest, it's still not as warm as I would like it to be, but spring has sprung as they say. Because you kind of forget what sort of activities are possible when you've been cooped out in the house all winter long. So let's just kind of talk through, what are some fun things families can look forward to doing to get outside and be active in the springtime? 

Dr. Alex Rakowsky: I'm going to throw out some more bizarre ones. We have a large family. We do a lot of walks in the summer, fall, spring and by winter, I think most of the kids were sort of, "Oh, let's go for a walk outside." And you don't want to make it boring because the trees that are on here at least were still fairly dead and the flowers aren't really coming up. But there is a lot of bird activity. 


So three or four years ago, in a park near our house, there was an eagle who set up a nest. And we would actually walk to the park and then walk half mile in the park to see this eagle's nest. And then, the kids started noticing, I told some of my patients and their kids started noticing that there's birds building nests down the street from me. And it was like a nice way to kind of go, "Let's go see what the birds doing today." Or, "Let's see if the trees are blooming and have leaves." Or, "Let's see if those daffodils are coming up, or the pansies are coming up." 

So some of these are just the little things that you tend to ignore that it's a lot easier to pick out in the early spring because there isn't as much competition for your eyesight. I thought that would be a good one to kind of throw out there. 

Dr. Mike Patrick: Yeah, and the leaves, with the leaves not being on the trees quite yet, you can see those birds easier. I mean, they're kind of hidden behind the leaves otherwise. 

Dr. Alex Rakowsky: Yeah. 

Dr. Mary Ann Abrams: I really love that because I heard the word a few years ago, 'winter interest'. Everybody likes to cut things back in the winter and it looks blah, dark. And somebody said, "We'll leave some of those grassy things up for whatever because it gives a place for the birds to land. It gives a place for the snow to fall."


And that just changed my whole perspective. And I think it's changing your perspective as a grownup that even though spring is coming, it's not quite there yet. And that don't perceive it as dull and bleak but look for those places where, "Oh, my gosh, look at how the snow is still laying on that. Look at these puddles and how the water is dripping." "Look at these tiny green things that are coming out through Mother Earth that we didn't even notice."

And then, as parent with kids, point that out. So if it's a little child, you can say, "Let's see who can find more little green things coming up in the ground." If it's a teenager, it might be shifting their perspective, but just seeing with new eyes. And if you haven't been outside in awhile, just being out. And it smells different in spring, doesn't it? 


Dr. Mike Patrick: Yeah, yeah. 

Dr. Mary Ann Abrams: And it sounds different because you hear the birds chirping and it makes you feel different. 

Dr. Mike Patrick: We love scavenger hunts and you can be creative and make up your own list of things that you're looking for. But you can also find lists online and give everybody in the family the list and a pencil, head out to a metro park, go for a walk in the woods, and try to find everything on the list. See who can find it first. When one person points it out, then no one else gets to claim that one. You got to find it again. That was what our rules were. 

But even like a leaf falling off of the tree, there's all kind of cool stuff that you could look for. That makes it kind of fun, being out and about. 

Dr. Alex Rakowsky: And again, we have a Midwest bias where people tend to stay home for three, four months in a row, but a lot of organization, and nationally as well, a lot of organization has spring events. So some of the hospitals here have Walk of a Duck, because they've been eager to do it all winter long and now they can. We'll see a lot of festivals come up. A lot of libraries will have sort of like the first outdoor activities. 


So just look around your neighborhood, see if somebody's doing something. Some of the farmers' market start opening up in the early spring. They may not have fresh produce, but at least they're trying to get out to just kind of get people to start coming through. 

Dr. Mike Patrick: The zoos are great places to go. And often in the spring, it's not really hot yet. It seems in the middle of summer, the animals are just trying to stay cool...

Dr. Mary Ann Abrams: Wilting.

Dr. Mike Patrick: And lying under a tree and aren't really moving much. But in the spring, they're out and about and moving around, and then there are babies that are born. So a trip to the zoo I think can be fun. 

Another place that our family loves to go, it's a little bit of a drive. I know that we have a national audience, but we have a lot of folks, local as well. And that's Young's Jersey Dairy in the Yellow Springs area. It's a family dairy but they also have a restaurant. And you can tour the barns and see the cows. And they have mini golf and that kind of thing. It's kind of a fun place to go. 


I'll put links to both of those places in the show notes. 


Dr. Mike Patrick: No, you know, maybe I will, for Episode 426 over at pediacast.org. 

And then, in the spring, we still have rainy days though. What are fun inside stuff they'll still think about doing? 

Dr. Mary Ann Abrams: I was going to say I think if kids and families have two things, if they have a big round bouncy rubber ball to play with outside and a nice Nerf ball or spongy ball inside, you can do a million things. You can go outside and you can kick that ball. You can throw it at each other, you can chase it, you can do a hundred things.

Dr. Mike Patrick: Four square. 

Dr. Mary Ann Abrams: Four square and dodge ball and so many things. Then, inside you can do a lot of those things and you won't break the lamps and the furniture. And so, you can still be active. 

So you don't need a lot of gear. You don't need an Xbox to keep you entertained in the middle... There may be a little noise, there may be a little rowdiness, but that's not bad either as long as you're a little bit careful. Because we want kids to be active. 


So the other fun thing and you can do this outside and inside too, I love obstacle course. And that means, look around you, you're outside and go in your garage and get some launchers of torn-up, broken jump rope, and five other things. Or inside, get the pillows and the blankets and a box and a couple of chairs and create your own obstacle course.

And then, race each other going through it or time yourself or come up with different ways of doing it. You don't need any special things. And they're creative and they're active and they're a lot of fun. And it take some time to put it together, so they use a lot of different positives. 

Dr. Mike Patrick: Yeah, yeah, love that. Love that idea. 

Dr. Alex Rakowsky: I got a few other different ones here. And one is, it's funny, some of the residents actually started doing is in their house, is starting potting, starting seedlings at home. And then, you can put them in the garden in the summertime. And if you don't have a garden, you can always start working on getting a big pot, filling it up and started seedlings you're going to put in that pot. 


You can grow tomatoes, etc. And just having the kids involved with, "Let's get a couple of small pots from Home Depot," one of those places, put seeds in there. And they get their hands dirty and then in a couple of weeks, they'll see some of the tomatoes start coming out or peppers start coming out. And then, you put them in the garden so they see their whole extension from the spring into the summer. 

Thematic decorations around the house, so I have a daughter who loves her... 

Dr. Mary Ann Abrams: Dramatic? 

Dr. Alex Rakowsky: Dramatic, wah, wah, wah! No, it's something related to your holidays. So for example, first day of spring, she made tulip-shaped pancakes this morning. They had different colors. 

She puts up stuff for Saint Patrick's Day. I mean, you have the Easter coming up, you have other holidays coming up, and something where the kids can say, "Okay, we're going to put this up for Saint Patrick's. We're going to put this up for the first day of April." Or for Easter, he's going to put these things up in the house. And sort of like, you can make these things at home and just start decorating the house for spring. 


And other one I thought about is building a birdhouse. And we got a kit from either Lowe's or Home Depot or local mom-and-pop hardware store couple of years ago. They're for $5, we actually able to make out of fairly cheap wood, we made a small birdhouse and we hang it on a hook not far out from our front window. 

And they decorated it and put some bird seeds in there. And literally, for three months, there were birds coming in and out of that bird house. It was cheap to do. It took about four or five hours of putting these thing together and then the rest of that spring, early summer, they actually saw birds use this house that they built. They had birdlings, I guess, or baby birds whatever they call them coming out. 



Dr. Alex Rakowsky: It was cool. It was just something where, you know, it was a rainy day, which we have a lot around here. But it was a rainy day, we just kind of pieced this together. It's become a tradition just to kind of do this every so often. 

Dr. Mike Patrick: That sounds fun, great ideas. And then, you'd mention being active with your kids. So put the Xbox away and let's do something where we move. Although dance, Dance Revolution, there are some Xbox games that can be pretty active. 

Dr. Mary Ann Abrams: That's right.

Dr. Mike Patrick: But what are some other ways, just incorporating more exercise into our daily routine, whether it's inside, outside, whatever it is, what are some ideas you guys came up with for that? 

Dr. Alex Rakowsky: Now that it's not below zero some days, you can actually park a little bit further away. 

Dr. Mary Ann Abrams: Yeah, that was one of mine, too. 

Dr. Alex Rakowsky: And if you go to the local store, park it in the parking lot. Or actually say, "Okay, we're going to this store and then, we're going to walk to this next store." 

Dr. Mike Patrick: Now, you will drive your kids crazy doing that. 

Dr. Mary Ann Abrams: What? 

Dr. Alex Rakowsky: I know, yeah, yeah. 

Dr. Mike Patrick: It's like my wife would park fairly far out and the kids would be like, "Why are you parking out this far?" And she'd move the car ever farther out so they learn not... 

Dr. Mary Ann Abrams: Good for her.


Dr. Mike Patrick: Yeah, they learned not to say anything about it at all. But I love that idea. Just get some more steps in, just walking from the parking lot in and from store to store. That's a great idea. 

Take the stairs instead of the elevator. That will get you lot of burning some calories that way, too. 

Dr. Mary Ann Abrams: One other things is I told my patients a lot to walk and they do. To try to rev that up a little bit, depending on where you are, especially if say a parent is taking some kid to the park and then they're walking, talk about having them race each other. Or see who can run from one tree to the next faster. 

Because that little element of competition and exhilarating a little bit, to get burn a little bit more calories and build a little more fitness with their muscles. So look for these kind of built-in opportunities to speed up and run instead of walk. 

I say never sit when you can stand. Never stand when you can walk. Never walk when you can run. Just look for these chances to make your body work a little bit more. 


Dr. Mike Patrick: Yeah, and every little bit matters. 

Dr. Mary Ann Abrams: Absolutely. It builds up over time. You don't have to do a 90-minute fitness workout every day. You can get bits of that in throughout the day and that's incredibly helpful. 

Dr. Mike Patrick: Dance parties.

Dr. Mary Ann Abrams: Yup.

Dr. Mike Patrick: I mean, just put on some music and dance around the house. Kids love that. 

Dr. Mary Ann Abrams: Dance is a wonderful exercise, excellent. 

Dr. Mike Patrick: All right, well, if we're going to be more active, then we can expect some injuries, it just happens. It's life. So sprains and strains, let's talk through those. 

So right there is I think sprains and strains are probably... I got to give myself a gong here. I mean what exactly are those? Are they the same thing? Are they different? It's not really plain language. I mean, it's language that everybody hears but I'm not sure everyone understands the definition of these things? 


Dr. Alex Rakowsky: I have a sort of strain, I'll take the easier one. 


Dr. Alex Rakowsky: And it's usually when you have a muscle that pulls a way it shouldn't or a ligament that pulls a way it shouldn't. So if you haven't stretched your hamstring in awhile and you go running, you'll feel a little, in my case, more than a little twinge in that muscle. 

So strain is when you're actually have been sitting around for awhile and now, that muscle's being used. And actually, it's almost like a tear of that muscle. There's more like a smaller tear of a muscle or a ligament that just haven't stretched in a lot.

Dr. Mike Patrick: And the good news is when you heal, and the muscle is a little stronger and healing. And so, I guess that's where this thing no pain, no gain comes from. That if your muscles are aching a little bit, not to the point where it's a disability, but if it hurts a little bit after being active and running, you're going to make that muscle stronger. 


Dr. Mary Ann Abrams: Yeah, it's like stretching a little bit beyond its normal range of motion, a normal range would be. That's putting a strain on it, just like you're putting a strain on a rope maybe that you're pulling or something like that. It may have some tear if you look from under a microscope but it's not the same thing as tearing your rotator cuff or something like that. 

Dr. Mike Patrick: Yes, you're tearing the fibers, not the whole muscle. 

Dr. Mary Ann Abrams: Yeah, the microscopic, those micro-level. Because I don't want people to think, "Oh, my gosh, it's got a torn ligament or whatever." 

Dr. Mike Patrick: Yeah. Now, you mentioned ligaments, but sprain technically is more around joints, right? And that's where the ligaments are kind of connecting bones together. 

Dr. Alex Rakowsky: I think a quick way is a strain is kind of pulling something too much in a direction that it should be going. A sprain is pulling a ligament in a direction it shouldn't be going. 

So if you sprain your ankle, your ankle has gone in or out. And now, all of a sudden, that ligament's screaming at you that "I shouldn't have done this." Or, "You shouldn't have done this to me." So it's kind of like a quick and dirty way to think about strains and sprains.  


Dr. Mike Patrick: Yeah, I like that. So how do we treat these sprains and strains? What do you do when you're hurting? 

Dr. Mary Ann Abrams: Well, I don't know if everybody's heard the kind of famous word RICE, but it makes sense. RICE stands for Rest, Ice, Compression. C is compression meaning putting pressure on it. 

Dr. Mike Patrick: Like a wrap, like an nice wrap kind of thing.  

Dr. Mary Ann Abrams: Yeah, yeah. And E is elevate or raising it up. So you want to take the pressure and the burden off of it for a while so you go easy on it. 

Ice is a really, really good friend. It cuts down on the body's response to that strain or sprain by we call that inflammation. That's what ends up causing the pain and a lot of the swelling. So by putting the ice on it, we can decrease that. 

Compression, again, kind of helps keep a lot of fluid and extra swelling from developing. And keeping it elevated or keeping it up helps any swelling that occurs run back down the arm or the leg into the regular part, the central part of the body to the bloodstream. 


Dr. Mike Patrick: And the ice, we tell folks, well, first, you don't want to put ice directly on the skin. You can cause frostbite and damage. So you want to use like an ice pack, have a washcloth or some fabric between the ice itself and your skin. And then, about 20 minutes every couple of hours for the first couple of days after an injury is pretty good guideline. 

Compression, you don't want it to be so tight that you're really in a dangerous way cutting off blood supplies. You want to make sure there's no abnormal numbness or tingling on the side of the injury farthest from your body, that you're cutting off the blood supply to that area. You want to be real careful about that. 

One way to know for sure is to pinch the skin. It turns pale, and then it turns back its regular color afterward. And that should happen right away. If there's a delay, then maybe the compression is too tight. Just some things to think about. 


Elevation, really important at night because that's many hours at a time. And you know if you injure an arm or leg and a lot of kids will sleep with their leg dangling off the side of the bed, and now it's way below the heart. And they wake up in the morning and it's much worse. So maybe put a pillow or two under that extremity. And just keep it elevated above the heart during sleep can be good as well. 

Dr. Mary Ann Abrams: And sometimes with the ice, again, don't just fill up a bunch of ice cubes in a black bag or whatever. Try to, if you can, mash it up a little bit or put a little water in. Not a lot of water, but enough water so that it's got some room to kind of mold it around the area that you want to apply the ice tube with a towel or something in between. 

Dr. Alex Rakowsky: And just a quick plug, strains and sprains are very common but a lot of them are avoidable. So make sure to just stretch before you run for the first time in a couple of months. Make sure you're not wearing flip-flops when you go running around track. We have people who are like, "I haven't worn flip-flops in five months, so I want to take them out because it's a whooping 45 degrees and go running, play tag."


Oh, I just saw this the other day in clinic. And just the basics sort of how can I prevent this from happening? We all get them, but you can prevent some of the more serious ones by a good stretch, good foot gear. Make sure you're not running in a place that has a big pothole because they tore it up off the ice in the winter. 

Dr. Mike Patrick: And then, ibuprofen is an anti-inflammatory medicine. If you have any question about what dose to give, call your healthcare provider or read the label if you have an older child. And so, those more than acetaminophen which is the big name for Tylenol and there's other brands. And  ibuprofen's like Advil, Motrin, the ibuprofen is better at reducing inflammation. And the Tylenol, acetaminophen, not so much. 

So that's kind of an important distinction that parents ought to know about. It will help with pain, but not necessarily the swelling and inflammation part of it.


And then, ankles are a little special, and wrists too, because they are growth plates. And so, you can damage a growth plate which can cause more long-term problems. So if you have a significant amount of pain or child's limping and it doesn't seem to be going away quickly, you do want to see a medical provider because sometimes you do need X-rays. 

And even if the X-rays are normal, you might still need some kind of splints or immobilizations, something to kind of keep the joint stable and still until it had some healing. And then, if the symptoms go away, great. If they don't, you may need another X-ray to see if there is some healing around that growth plate because they don't always show up on initial X-rays. 

The point really is just that if it's significant pain, make sure you see someone so they can make some decisions based on whether you need an X-ray or not. Because you can always tell if a bone is broken just by symptoms, right? I mean, you can still move a broken bone. And so, it's important to seek medical help if you have significant pain. 


Dr. Mary Ann Abrams: Sometimes, it's hard for people to sort out what is significant pain. "My child's really crying and it really hurts. And it's black and blue and it's swollen." Unless you obviously saw what happened and it was just so horrible and things move where they should not move, it's reasonable to comfort your child. Help them settle down, do these things we've been talking about. Give it a little bit of time. 

And if it's midnight and they're fairly comfortable, it's okay most of the time to wait until the morning or to call your doctor, your health provider and ask what they think. So there's a little bit of a balance between racing off and kind of waiting and seeing and doing all these things that are helpful. Not that we don't want people to get help when they need it, but we also don't want them to have to go and spend three hours when they didn't need to. 

And everything is painful in the beginning. And sometimes, you would like to sort it out. 

Dr. Mike Patrick: Yeah, good advice. 


Dr. Alex Rakowsky: There's some obvious ones, if you see a bone, that's really gory, but a bone sticking out. Or if you see the bone has a different angle than it should. 

Dr. Mike Patrick: Yeah, if the arm is not straight anymore. 

Dr. Alex Rakowsky: Yeah, yeah. If you have a child, when you touch the bone, you feel what we call crepitus, which is fancy term for almost like a popping noise because their bone is now also like brittle. And you can almost feel like the crackle underneath your fingers, which is really gross to touch. But there are some things that kind of scream, "I need to get seen now." 

Dr. Mary Ann Abrams: Absolutely. 

Dr. Alex Rakowsky: But I agree that in most cases, you can probably just wait. 

Dr. Mike Patrick: Kids bump their heads a lot. And we've talked about concussions many times in this program, ankle injuries too, by the way. And I'm going to put some links to some other PediaCast programs in the show notes for this episode, 426, over at pediacast.org. So if you want to hear a lot more about ankle injuries from the sports medicine people, PediaCast 364 is where you going to want to go. 


And on concussions, the recent one was PediaCast 362. Big long conversation about concussions there. And so, we'll have some of these for you in the show notes. 

But concussions, how do you explain to parents when they say, "Someone said my child had a concussion." What does that mean in plain language?

Dr. Alex Rakowsky: I can take this one. So it's sort of like a brain sprain. I love that term, where the brain went where it shouldn't. And now, it has some swelling. It's going to be using microscopic swelling. So a scan's not usually going to easily pick up anything. Parents, some of them get frustrated that they want a scan done to prove it's a concussion. 95% of a concussions, you basically see nothing on a CT scan or like a CAT scan. And it's essentially a sprain as they brain move in places that it shouldn't have. 

Dr. Mike Patrick: There's a lot of chemicals in the brain that are working and they have to work in particular places. And when the brain gets jostled, those chemicals kind of move around and then the brain doesn't function quite right until it puts those chemicals back where they're supposed to be. And of course, that sort of thing's not going to show up on the CAT scan at all. 


What things do show up on the CAT scan?

Dr. Alex Rakowsky: If you have a child who's not acting right, really sleepy, passed off for a long period of time, fell from a large height and that's defined different ways, you can see a bleed. And that's what you're really thinking about when you're doing a CT scan in urgent care, emergency room. Is that child fell now has a bleed, is it of a broken skull above the brain? Were the tissues around the brain do not have a bleed? And that's really the purpose of the scanning. 

And particular things that we really worry about, persistent vomiting after head injury, changes in behavior that go beyond just being sort of subdued. I mean, a lot of kids with concussion will be always seem they're bit depressed and that is interested in the things that they usually are interested in. And kids sit quietly on mom's lap. And that all goes with concussion. But if they really like don't recognize people or people who normally or if they're family, they're acting like they're afraid of them. 


Just weird behavior that puts up your mom or dad radar that something's not right other than just being a little depressed. I use that term loosely but just not as interested in things you usually are. That goes along more with concussion but real behavior change, we'd worry about. And the vomiting and severe headache, and particularly in light of a more higher mechanism of injury, like of a fall from a height, car accident, where there's more energy and the impact can make you more concerned. 

But you know, and this gets back to what you were saying Mary Ann, it is okay to wait? On the flip side of that, if you're concern as a parent, call your doctor. 

Dr. Mary Ann Abrams: Absolutely. 

Dr. Mike Patrick: That's why we're here. And we may complain, especially in the middle of flu season that we get a lot of phone calls and lots of people, I mean, because it's human nature, doctors complain a little bit. But in our heart of hearts, we would rather have people call and ask than to wait and then there was something there, right? All of us feel that way. 


Dr. Mary Ann Abrams: Absolutely. Another thing I think that's really scary to people and most of the time, it's really scary but not a bad thing, but it's important to know if it's not a terrible big fall or bad entry, but a lot of times kid will run into something and they'll get a cut on their scalp. Well, the scalp has a ton of blood vessels. So when those get cut when you fall against maybe something sharp, and if they didn't get knocked out, they're acting fine except the crying, and they're not vomiting or whatever, it's very common to see a lot of bleeding.

And it's very scary, "Oh, my gosh, she has suddenly these bleeding everywhere, there must be something terribly wrong." Put pressure on that and clean it. Hopefully, you got something clean that you can put pressure on that to stop the bleeding, give it some time. And most of the time, those are just cuts in the part of the body that has a lot of blood vessels. 

So as long as everything else is okay, don't let the blood scare you or make you drive unsafely because you're so worried about your child, to get them somewhere. 


Dr. Mike Patrick: Yeah, great point. And when you do have bleeding, the best way to get it to stop is put pressure on it, right? And for five minutes, don't peek. Set a timer. 

Dr. Mary Ann Abrams: Set a timer, right? 

Dr. Mike Patrick: Yeah, yeah. Because five minutes is always longer when you're actually holding a squirming toddler. 

Dr. Alex Rakowsky: Oh, yeah. 


Dr. Mary Ann Abrams: Or yourself, feels like ah, no, no, it's... 

Dr. Mike Patrick: Yeah. And that constant steady pressure usually stop bleeding. If it doesn't, do it again for another five minutes. And do it again for another five minutes. And if something's still bleeding after 15 minutes of you applying pressure, it's probably time to go get help. 

Dr. Mary Ann Abrams: You're good to go, yeah. 

Dr. Mike Patrick: Although usually then, by the time you get to emergency room or the urgent care, it has stopped. Most of the time. 


We're talking about cuts and scrapes, what's good homecare for those. Obviously, if it's gaping and you can see fat or tissues underneath, you want to go get health because it may need sutures or stitches.

And also that you want to do that fairly quickly because you don't want to wait two days. Most things, you can't even wait a full day. If it starts to heal and you sew those up, you can sew more bacteria in there and it's more risk for infection. So you want to do that fairly quickly. 

So we're not talking about that. We're talking about scrapes, small cuts, where things aren't gaping and open. How do you care for those at home? 

Dr. Alex Rakowsky: I think you have to remember pain management. So a lot of kids with scrape, it's almost like getting a rug burn. Or if you played basketball, or football, or something, you get like a burn for falling underground or the field. Those things hurt. They may not look that bad but those things can hurt. And they're kind of gross and they leak. 

So a good pain management and then, keep it nice and clean. A lot of case for scrapes, you keep the clothes when they're outside. And then, at night time, put something light on. And so, when they're sleeping, it doesn't really push on that scrape all that much. 


Scrapes are just annoying and it's one of those things that can take three or four days. And child goes to school and they have an open scrape and their pants hits them when they're sitting. It's going to hurt. 

Dr. Mary Ann Abrams: And you do want to clean it off right away, soon after it happens because what you want to avoid is whatever they run up against or cut themselves on, you have no idea how clean or dirty that was. And you don't want bacteria to get down in there. And as they start to feel better, they're you're like, "Oh, now, we're going to wash it off." That just opens everything up again and it hurts even more. 

So kind of comfort them, try to gently clean it off. Use cool or lukewarm soap and water. Pat it dry. You don't have to scrub and rub it. And then try to keep it protected with something clean and something light. 


Dr. Alex Rakowsky: Another thing about the scrapes that you brought up is the fact that a lot of them are caused by falling outside, falling at cement. And once you get the pain under some management, you really do have to clean that up because you may have a piece of dirt that sits in the deeper part of the scrape. And then, three days later, that's infected. 

So you're going to have a couple moments there. Might got hurt a little bit, but the better you can clean with soap and water, the better it's going to do down the road. 

Dr. Mike Patrick: And if you're worried that there's anything stuck in the wound, any foreign objects, if there was a little piece of glass or there's anything outside you're worried, then you do want to get help and have someone take a look at that. 

Dr. Alex Rakowsky: Yeah, I agree. 

Dr. Mike Patrick: And then, tetanus is going to be important, if you're up to date in your tetanus shots, especially for deeper wounds and if it's a dirty wound. So if your child's not up to date on their immunizations. And there was a case of tetanus, a real tetanus, in Oregon I believe of a young boy. And a significant amount of time in the hospital, $800,000 medical bill in the intensive care unit, all preventable with routine immunizations that include tetanus vaccine. 


If you're interested in a lot more discussion on cuts and scrapes, PediaCast 345, we talked about those in depth. So I'll put a link to that one in the show notes as well. 

And then, sometimes, parents do have a question, do I call my doctor, do we go to an urgent care? Do we go to an emergency department? Do we call 911? And the answer is really sort of common sense to some degree. If your child seems like they're... You're worried about their life. They fell out of a tree, they're laying there still, they're having a seizure, they're having difficulty breathing, you want to call 911, right?

Dr. Mary Ann Abrams: Right. 

Dr. Mike Patrick: If you think, "Should I call 911?" you should call 911, if that enters into your mind. Otherwise, it's always okay to call your doctor, right? To say, "Should we go to an urgent care?" "Do we go to the emergency room?" 


Dr. Mary Ann Abrams: Can it wait till tomorrow?

Dr. Mike Patrick: If there's time to stop and think about it, your regular doctor, I hate to drum up more phone business for you, but it's always a good idea to get their idea. "Can this wait? Should we go somewhere now?" 

Dr. Alex Rakowsky: And almost every practice is going to have two or three what we call sick visits or same-day visits per shift. And if there's something, I go, "Well, let me see that scrape. I can see you at three o'clock today. And it's fine." So I think the doctor is, again, if it's something 911, I'd bolt and call 911.

If it's something you can call your doctor about, they almost always have a triage line or some kind of nurse that can answer your phone call. Even the doctor answers the phone or the nurse practitioner. Just discuss the case with them and see what they think. 

Dr. Mike Patrick: I'm an urgent care doctor and emergency room doctor now by trade. But for ten years, I was a general pediatrician. And my stance on this is still always just call your doctor and get their impression on where you should go or can it wait or how urgent is this? Because they know you best and know a little more context for your family. 

I did write a blog post, Urgent Care or Emergency Department: Which One Is Right for Your Child's Needs? And I'll put a link to that in the show notes as well for Episode 426 over at pediacast.org.


All right, well, always a pleasure when our Pediatrics in Plain Language Panel joins us in the studio. And we got to plan some more of these in the future. I think the audience really loves them, too. And I love putting these together. 

So once again, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, thanks both of you so much for stopping by today. 

Dr. Alex Rakowsky: Thanks. 

Dr. Mary Ann Abrams: Thank you, Mike. Happy Spring. 


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

Also thanks to our guests, our Pediatrics in Plain Language Panel, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with the ambulatory pediatrics at Nationwide Children's Hospital. 


Don't forget, you can find PediaCast in all sorts of places. Hopefully, wherever you listen to podcasts, we're there. If not, let me know and we'll try to get PediaCast available for you at that location.

Just a handful, to remind you, we're in Apple Podcasts. We're in iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps. 

Soon, we'll be on SoundCloud and I'm really excited about that because you can make playlists. And so, we can take episodes of similar topics and make playlists that you can follow. So we're trying to get that organized and off the ground. Hopefully, it won't be too much longer. If you do listen to some of your things through SoundCloud.


And of course, reviews in all these locations are always very helpful. Wherever you listen, please let other moms and dads know that we have evidence-based information aimed at improving health literacy, hopefully in plain language. But really trying to help parents understand what's going on with their kids and what the evidence is that would suggest that that's really true, that that really is what's going on with your kids. 

So, hopefully, we're increasing health and wellbeing in children everywhere through this program. But we do need your help in terms of letting other parents know it's a valuable resource. And so, those reviews are always very helpful. 

Then, just talking us up with your family, friends, neighbors, co-workers, babysitters, anyone who has kids or takes care of kids, please let them know in your face-to-face, real-time interactions that we do have an evidence-based podcast for parents. 

And that includes, by the way, your child's pediatric healthcare provider. Please let them know about the program so that they can share it with other parents and families in their practice.


While you have their ear, please let them know we also have a podcast for them called PediaCast CME. That stands for Continuing Medical Education. That's similar to this program, we turn the science a couple notches. Maybe don't use as much plain language as we explain things. But we do offer free Category 1 Continuing Medical Education Credit for those who listen. 

Shows and details are available at the landing site for that program, which is pediacastcme.org. That one is also on Apple podcast, iTunes, Google Play, iHeartRadio, Spotify, and most mobile podcast apps. Simply search for PediaCast CME.

You know, I didn't mention this program also has landing site. So we have all 425 past episodes at pediacast.org. Only the most recent 100 or so episodes are in the feed and those are the ones then that end up in places like Apple Podcast and Google Play and iHeart Radio. However, all of our episodes going back to day one are available at pediacast.org with the audio players. And those work on mobile devices as well. 

And then, of course, our show notes will all of the links we talk about. Those are available at pediacast.org, written transcripts of the program, and of course, our Terms of Use and our Contact page, which is very important if you have a topic you would like us to talk about here on the program or you have a question for us. So be sure to check that out. 


And once again, thanks to all of you 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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