Flame Retardants, Throwing Injuries, Alice in Wonderland – PediaCast 374

Show Notes


  • We have lots coming your way this week! Our news segment covers the relationship between pets, allergies, obesity and the microbiome. We also consider flame retardants & behavior and the ideal start time for school. Then, Dr Drew Duerson and athletic trainer, Herman Hundley, stop by to talk about throwing injuries in student athletes. Finally, we answer your questions on Alice in Wonderland Syndrome, wheezing and adult health podcasts. We hope you can join us!


  • Pets, Allergies and Obesity
  • Flame Retardants & Behavior
  • School Start Time
  • Throwing Injuries
  • Alice in Wonderland Syndrome
  • Wheezing & Asthma
  • Adult Health Podcasts




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 is Episode 374 for April 26th, 2017. We're calling this one "Flame Retardants, Throwing Injuries, and Alice in Wonderland". Yeah, what's that going to be about? Welcome to the program.

I do have a full show for you this week. We're going to include some news parents can use, also an interview with pediatrics experts and some answers to listener questions, including Alice in Wonderland.

So, I'd better make the intro quick this week and get to the point, so we can get right into the meat of the program, which is going to cover more than the topics I mentioned in the title, including in our first segment, which will be pediatric news — pets, could living with a pet be related to the development of environmental allergies, seasonal allergies, and obesity? And if so, what's the relationship?

So, if you have a pet or you're more likely to have those things — or less likely, or maybe more likely for one, and less likely for the other — and when is the best or worst time to own a pet? And which pets are we talking about? That one I'll want to answer now. It's mostly dogs. At least in the 70% of the families studied, dogs were involved. Few weeks ago, we talked about cats and mental health. So, today it's mostly dogs and allergies and obesity.


So, dog lovers and those who don't care so much for dogs, stay tune for more information and we'll clarify things shortly for you. And then, as we mentioned in the title — flame retardants. So these are chemicals that are sprayed on lots of household items, furniture, mattresses, carpeting, electronics.

Also inside vehicles, that new car smell maybe associated with flame retardants. I don't know for sure if it is. I don't know what that smell is. But you all know what I'm talking about. There are flame retardants inside the vehicle, though.

And, on one hand, they're a good things because they prevent things from catching on fire, which is important. The problem is they aren't permanently bound to the surface of the products they protect. Meaning, they can escape the surface and hang in the environment.
So, what effect do they have there? Well, some researchers believe they have the potential to alter childhood behavior. So, we'll explore study that looks into that. And then, we'll ask our own question. Can we prevent fires and keep kids safe from chemicals at the same time? Or is it that too much to ask?

And then, school start time, how early is too early to start school? We all know sleep is important. So if we start school later, will kids get more sleep, which is an especially important question for teenagers who tend to stay up late and start school earlier. The answer is as it turns out is not a simple one due to light-darkness cycles and biological rhythms and mathematical models. But it does make for an interesting discussion.

And researchers also provide some very practical tips for getting enough sleep regardless of school start time. And it involves a little home improvement product, which is always fun and exciting. So, let's stay tune for that.


And then, we're going to have the interview with two sports medicine experts, Dr. Drew Duerson, and athletic trainer, Herman Hundley, both from Nationwide Children's. They're going to stop by the studio as we consider throwing injuries in student athletes. We'll talk about high risked sports, the reason throwing injuries occur, where they occur, how they're diagnosed and treated and prevented? So, that's coming your way after the news.

Then, we'll wrap up with some listener questions about Alice in Wonderland Syndrome. And yes, it's real and a pretty interesting condition and one that's more common than you'd probably think. We have another question on the difference between wheezing and asthma and when parents should be concerned. And finally, what are some good adult health podcasts?

So, you like PediaCast. You bought in to the whole idea of podcasts and you want to hear more about your health as an adult. Where can you turn? I'll provide some ideas at the end of our time together.

So, let's get to it. First, though, a quick reminder, if you would like to get in touch with me, it's really easy thing to do. Just head over to PediaCast.org, click on the contact link. I do read each and every one of those that come through.

Also, I want to remind you that the information presented in PediaCast always 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, make sure you 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 then, I will be back with lots more on all of the topics I mentioned. It's all coming your way right after this.



Dr. Mike Patrick: If you need a reason to become a dog lover, how about this? They may help protect kids from allergies and obesity. This, according to a recent study from the University of Alberta and published in the journal, Microbiome.

The study shows that babies with families that have pets — and in 70% of the cases, the pets were dogs — have higher levels of two types of gut microbes, which are associated with lower risks of allergic disease and obesity. And gut microbes, you'll remember are microorganisms including bacteria that live in the digestive tract of humans and other animals, what we sometimes are good bacteria.

Now, don't rush out and adopt a furry friend just yet. Dr. Anita Kozyrskyj, study co-author and epidemiologist at the University of Alberta and one of the world's leading researchers on gut microbes says, "There's definitely a critical window of time when gut immunity and microbes co-develop, and when disruptions to the process occur it can result in changes to gut immunity."

This latest findings from Dr. Kozyrskyj and her team's come from fecal or stool samples collected from infants registered in the Canadian Healthy Infant Longitudinal Development study and they built on two decades of research which indicate children who grow up with dogs have lower rates of asthma.

The theory is that exposure to dirt and bacteria early in life — for example, in a dog's fur, and on its paws, and on its mouth — can create early immunity. Although researchers aren't sure whether the effect occurs from bacteria on the furry friends or from human transfer by touching the pets and then each other.


The University of Alberta team takes the science one step closer to understanding the connection by identifying that exposure to pets in the womb or up to three months after birth increases the abundance of two specific bacteria, Ruminococcus and Oscillospira, which have been linked to reduce incidences of childhood allergies and obesity, respectively.

Dr. Kozyrskyj says the abundance of these two bacteria were increased two-fold when there was a pet in the house. She adds that pet exposure was shown to affect the gut microbiome indirectly — from dog to mother to unborn baby — during pregnancy, as well as during the first three months of the baby's life.

In other words, even if the dog had been given away for adoption just before the mom gave birth, the healthy microbiome exchange could still take place.

The study also showed that the immunity-boosting exchange occurred even in three birth scenarios known for reducing immunity — including C-section instead of vaginal delivery, antibiotics around the time of birth, and lack of breastfeeding.

An additional finding for the team, the presence of pets in the house reduce the likelihood of the transmission of vaginal group B Strep during birth, which can cause life-threatening infections in newborns and is prevented by giving mothers antibiotics during delivery.

Dr. Kozyrskyj says, "It's far too early to predict how this finding will play out in the future." But she doesn't rule out the concept of a "dog in a pill" as a preventive tool for allergies and obesity at some point in the future.

She says, "It's not far-fetched that the pharmaceutical industry will try to create a supplement of these microorganisms, much like they've done with probiotics."

So, we've talked about this before, the gut microbiome which are all a little microorganisms living in our intestines. Remember, babies are not born with gut microorganisms. They live and they eat and their gut becomes colonized with bacteria as they move forward after birth. And it turns out this is an important process because we know that when and how the gut gets colonized and the microorganisms it is colonized with.


These things have an effect on the development of the immune system which end up affecting things like allergies and even obesity down the road. So, still a work in progress, still much to learn, which is why the researchers say don't run out and get a dog just yet, at least not based on the results of this study alone.

Still this connection between pets and microorganisms and allergies and obesity, certainly an interesting piece of the puzzle. We still have lots more pieces to put together before the picture becomes clear. And we'll be sure to update you here on PediaCast as new developments and new understanding occurs.

Some, chemicals added to furniture, electronics, and numerous other goods to prevent fires may have unintended developmental consequences for young children. This according to recent study from Oregon State University and published in the journal, Environmental Health.

Investigators found a significant relationship between social behaviors among children and their exposure to widely used flame retardants. Dr. Molly Kile, co-author of the study and an environmental epidemiologist and associate professor in the College of Public Health and Human Sciences at Oregon State says, "When we analyzed behavior assessments and exposure levels, we observed that the children who had more exposure to certain types of the flame retardant were more likely to exhibit externalizing behaviors such as aggression, defiance, hyperactivity, inattention, and bullying,"

She adds, "This is an intriguing finding because no one had previously studied the behavioral effects of organophosphate classes of flame retardants, which have been added to consumer products more recently."


Flame retardants are found throughout the built environment in furniture, mattresses, carpeting, electronics, vehicles and more. The chemicals are added to the surface of the products and are not bound to the material, which causes them to be released into indoor environments.

Manufacturers began adding flame retardants in 1975, in response to new legislation in California designed to reduce flammability in common household items. The state updated its flammability standards in 2014 and now allows furniture manufacturers to meet the standards without adding flame retardant chemicals to their products. But the chemicals are still widely used and they linger in the indoor environment.

Investigators say there are growing concerns that some flame retardants may have unintended impacts on health and development in children, and this study contributes to that body of research.

The most common types of flame retardants found in the built environment are brominated diphenyl ethers or BDEs and organophosphate-based flame retardants also known as OPFRs, which emerged as an alternative to BDEs in an effort to address some of the environmental health concerns posed by BDEs, which tend to remain in the environment for longer periods of time.

Past research had shown that both BDEs and OPFRs are linked to poorer cognitive function in children. But less is known about the relationship between the flame retardants and children's social and emotional health, particularly during early childhood and a key developmental period for learning.

Dr. Shannon Lipscomb, another of the study's co-authors and associate professor of human development and family sciences at Oregon State-Cascades says, "The social skills children learn during preschool set the foundation for later success in school, and also for social and emotional health and well-being later in life." So, it's an important age to study any factor that affects behavior and learning.


For this particular study, the Oregon State research team recruited 92 Oregon children between ages of three and five and had them wear a silicone wristband for seven days to measure exposure to flame retardants.

The wristbands have a porous surface which mimics a cell and absorbs chemicals the wearer is exposed to through their environment. When the wristbands are returned, researchers can screen for up to 1,200 different chemicals that may accumulate, making the wristband an easy and non-invasive way to sample a child's chemical exposure.

The researchers had parents and other primary caregivers complete questionnaires about socio-demographics and the home environment. And preschool teachers completed behavior assessments for each participating child. In all, researchers had complete data and wristband results for 69 children.

So, what did their finding show? Well, all of the children were exposed to some level of flame retardant. Children who had higher exposure rates of OFPRs which are the newer organophosphate-based flame retardants showed less responsible behavior and more aggression, defiance, hyperactivity, inattention and bullying behaviors.

Children with higher exposure to BDEs, which are the older flame retardants, were seen as less assertive by their teachers. All of these social skills play an important role in a child's ability to succeed academically and socially.

Dr. Lipscomb says, "We detected these links between flame retardants and children's social behaviors while controlling for differences in family demographics, home learning environments, and adversity. This suggests that flame retardants may have a unique effect on development apart from the effects of a child's early social experiences."

Researchers note that further study is needed to better understand the links between flame retardants and a child's social skill development. And they plan to pursue funding for a new study that continues for a longer period of time and considers how other aspects of a child's life might affect the impact of flame retardants on development.


Dr. Kile says, "The results of this research to date have shown potential impacts for child health and warrant a more thorough investigation. If scientists find strong evidence that exposure to flame retardants affects behavior, we can develop strategies that prevent these exposures and help improve a child's life.

"This type of public health science is needed to figure out how to address the root causes of behavioral concerns which can affect school readiness and overall well-being."

So, interesting stuff, there's really a dilemma here, right? The safety experts want to protect their children from fire which is a noble cause. And the developmental experts want to protect their kids from a behavior-altering chemicals, which is an equally noble cause. At the end of the day, I think you and I, and the safety experts, and the developmental experts would like to protect our kids from both flames and toxins.

Scientists are searching for more connections and solutions. And as they make new discoveries and evaluate and recommend best practices, we'll keep you informed and up to date here on PediaCast.

Delaying school start times at least in United Kingdom is unlikely to reduce sleep deprivation in teenagers. This according to researchers at the University of Surrey in collaboration with Harvard Medical School and published in the journal, Scientific Reports. Investigators including mathematicians and sleep scientists together predict that dimming houselights in the evening would be far more effective than delaying the time school starts as a solution to the problem of short sleep.

Now, the researchers admit the teenagers like to sleep late and they struggle to get up in time to go to school. They say the commonly accepted explanation for this is that adolescents' biological clocks are delayed. And some have suggested to remedy this that school start times should be delayed, at least for older teenagers in order to tune these kids back into their biological clock.


However, investigators used a mathematical model that took to account several factors whether person is naturally more of a morning or an evening person, the impact of natural and artificial light on the body clock, and the typical time a person sets his or her alarm clock. And they used this factors to predict the effects of delaying school start times.

So, what did they find? Well, according to their mathematical model, delaying school start times in the UK would not help reduce sleep deprivation. And here's how they explain their finding. Just as when clocks go back in the autumn, most teenagers' body clocks would drift even later in response to the later start time. And in a matter of weeks, they would find it just as hard to get out of bed.

Now, researchers say these results really only apply in Great Britain because in other countries including the United States, when schools starts really early like 7AM, then their model does lend some support for delaying the start time. But when school starts later like 8 or 9 AM, the model did not reveal a benefit for kids sleeping later.

Now, here's where things get more interesting. Investigators say their mathematical model has its roots in the work of the 17th century Dutch mathematician, Huygens. He saw that mechanical and biological clocks can synchronize, but it depends on both the clocks and how they influence each other.

From research over the last few decades we know that the body clocks typically run a little slow. So they need to be regularly 'corrected' if they are to remain in sync with the 24-hour day. Historically, this correcting signal came from our interaction with sunlight and darkness.

The mathematical model shows that the problem for adolescents is this, their light consumption behavior interferes with their natural interaction with sunlight and darkness which is the environmental clock. In other words, getting up late in the morning results in adolescents keeping lights on in the house until later at night. This in turn delays the biological clock, making it even harder to get up in the morning. The mathematics also suggests that the biological clocks of adolescents are particularly sensitive to the effects of light consumption.


This observation led to an alternative remedy to moving school start times. If teens dim lights in the evening and turn them off at night, the decrease in artificial light consumption will help the environmental and biological clocks sync back up.

But there's a limitation to this plan, you can't practically back-up the onset of dimming prior to sunset which is what you'd have to do for a 7AM start time at school. Which is why delaying school start time might be beneficial for countries where the start time is super early like the United States.

Dr. Anne Skeldon, lead author of the report says, "The power of the mathematics is that we're able to use existing knowledge about how light interacts with the biological clock to make predictions about different interventions aimed at reducing what we call 'social jetlag'."

She adds, "Adolescents are not 'programmed' to wake up late. By increasing exposure to bright light during the day, turning lights down or dimming them in the evening, and turning them off at night should enable most of us — teens and adults — to get up in time for work or school without too much effort and without changing school timetables."

Dr. Andrew Phillips, co-author of the project says: "The most interesting part of the analysis for me was the counterintuitive finding that the most extreme evening types, or night owls, are predicted to get the least benefit from a delay in school start time because they tend to use evening artificial light for a longer periods of time."

He adds, "For these evening types, it's critical to keep evening light levels low in order to benefit from a delay in morning wake up times. Otherwise their bed time is prone to shifting later. Understanding these individual differences and how they are influenced by light consumption is necessary to maximize the effects of any policy change."


Prof. Derk-Jan Dijk, another of this study's co-author says, "Just as mathematical models are used to predict climate change, they can also be used to predict how changing our light environment will influence our biological rhythms. This model shows that modern lifestyles make it difficult for body clocks to stay on a 24-hour schedule.

"The tendency is for our rhythm to shift resulting in sleepiness and subsequent alertness happening at later times — meaning, we are sleepy until late in the morning and remain alert until later in the evening." All thanks to artificial light in the home.

As a result, during the work week, the alarm clocks go off before our body clock naturally wakes us up. This mean we get insufficient sleep during the week and compensate for it on the weekend. Unfortunately, emerging research shows us that these patterns of insufficient and irregular sleep again known as 'social jet lag' are associated with a variety of poor health conditions.

Investigators say, "Their mathematical understanding of biological clocks suggests that adolescents are particularly sensitive to the effects of light consumption. However, the model can be applied to other age groups as well. It can be used to design new interventions not only for sleepy teenagers but also for adults who suffer from delayed sleep phase disorders or people who are not in sync to the 24-hour day at all."

And as research draws attention to light, light consumption, and darkness consumption, and how light cycle affects behavior and health, new implications emerge for designing proper light environments at home, work, and school in our modern light-polluted societies.

So, there you have it, dimmer switches — install them, use them. Dim your indoor environment in the evening. I'm loving this because I've always been an advocate for dimmer switches in just about every room of every home we've ever owned.


Sometimes though my family's chagrined. They've made fun of me for this at family functions and gatherings. But I feel vindicated now. See, kids dimmer switches are good.

Of course, if you're installing dimmer switches please do so safely. Better yet pay to have them installed by someone who knows what they're doing. It'll be worth the cost to get a better night sleep.

Also pay attention to screens in the home. You know, televisions, gaming consoles, computer, tablets, mobile phones. They're a significant source of light pollution. So get those turned off and put away in the early evening for a better night sleep.

One more takeaway from this news story, starting school at 7AM or earlier is just too early, because you can't start dimming the lights earlier enough the night before. It's still light outside, at least part of the year. I guess you could use room darkening shades. But you still have to go to bed way too early for a 7 AM start time, which just doesn't work with our busy lives . You need some time in the evening for sports, at homework, and family time, and some personal time.

So, really folks, 7 AM is just too early to start at school. Something to think about and maybe raise your voice about if your school district is one of those early starters.


Dr. Mike Patrick: I'm joined in the studio today by two fine representatives of the sports medicine program here at Nationwide Children's — Dr. Drew Duerson, one of our sports medicine physicians, and Herman Hundley, who serves as an athletic trainer. Both are experts at diagnosing, treating, and preventing throwing injuries in young athletes. And since the weather is warm and spring ball is in full swing, I thought it will be a great time to talk about throwing injuries and student athletes.

So, let's give a warm PediaCast welcome to Dr. Drew Duerson and Herman Hundley. Thanks both of you for stopping by today.


Dr. Drew Duerson: Thanks for having us.

Dr. Mike Patrick: I really appreciate it. Dr. Drew, let's start with you, why do throwing injuries occur in a young athletes? So, pretty common, right?

Dr. Drew Duerson: Yeah, very common. I think they happen because of several reasons, but the big one is overuse. So, kids are throwing too much, pitching too much, playing year round with not enough breaks, maybe their own multiple teams. So they never give their arm a rest. And that's why we see most of these injuries.

But it's not all overuse. There could a number of things. Sometimes, they're trying to throw pitches that they shouldn't be throwing, trying to throw too hard. And then, doing all while they're showing improper throwing mechanics, which leads to a lot of these injuries.

And it's mostly the shoulder and sometimes the elbow as well. And we know that in our young athletes, the growth plates are still open. And they are the most vulnerable part of the shoulder or elbow to be injured. So, we really focus on those areas and that's where we see a lot of our injuries.

Dr. Mike Patrick: Yeah. So, really a lot of force and the muscular skeletal system is still a little immature. And then, you add repetitive nature on there. It's just a recipe for injuries.

Dr. Drew Duerson: For sure.

Dr. Mike Patrick: Herm, which sports are typically involved? So, I think the one's that come to immediate mind are going to be baseball and softball, but there are other sports where throwing injuries can occur also correct?

Herman Hundley: Yeah, absolutely. We see it most with baseball and softball, but you're going to see it with quarterbacks in the fall — kids who play baseball all year round and then play quarterback in the fall. You'll see it with javelin throwers and shot put throwers, discus throwers, things like that. But like I said, most often, it's going to be from baseball or softball, for sure.


Dr. Mike Patrick: And Dr. Drew, you've mentioned that shoulder is really the most common place that you see injuries. Also the elbow, and we'll get to the elbow. But in thinking of the shoulder, what are some of the common injuries that you actually see?

Dr. Drew Duerson: Like I've mentioned before we really pay close attention to the growth plate. If the growth plates are open, it's going to be the weakest part of that shoulder and it's typically what's going to be affected first. So we look at what's called proximal humeraphysis. That means the upper arm bone, the growth plate of that bone. So we pay very close attention to that.

And it's not just growth plate injuries, although we do focus on that. It could be a number of injuries. And it may not even be a chronic injury like a growth plate injury. It could be an acute injury. So, they came in after one hard pitch, one long throw from the outfield. They felt it popped, had some maybe bruising, swelling.

It could be a number of things. Some of other common diagnosis we see, rotator cuff strains, tendonitis. We see impingement syndrome, instability of the shoulder. Sometimes, the proximal or the upper part of the biceps tendon can be involved.

So, it's not the growth plate, even though we focus there. It could be a number of things.

Dr. Mike Patrick: How do you go about figuring out exactly where the injury is? You have a kid with a shoulder pain. Maybe their velocity is down compared to what it was and they're having some discomfort or limited range emotion. How do you go about figuring out what sort of injury they have in the shoulder?

Dr. Drew Duerson: Yeah. It's a good question. I think it all starts with the history. So we ask the patient or family some questions that you already alluded to. So, where is their pain at? When did it start? Did they have an acute injury? What were they doing at the time? How many pitches? What kind of pitches? What part of the throw does it hurt?

And then, we rely on our physical exam quite a bit as well. So we examine the shoulder. We look at the shoulder. Are there any deformity, swelling, bruising? Look at their posterior, how are they sitting in the exam room.


And then we check range of motion, strength. Then we some "special tests" that we try to do to sift through some of the different possible diagnosis that could be causing their shoulder pain. And then, if we haven't figured it out quite yet, we'll rely on X-rays at some point. That either confirms what we're kind of suspicious of clinically or maybe we found some surprises.

Then, I think most importantly, we rule out the bad things, the breaks, the dislocations the things that are growing in bone that shouldn't be growing. That type of thing..

Dr. Mike Patrick: Some of the structures that you've mentioned are what we call soft tissues. So things like ligaments, and tendons, muscles, even growth plates are made out of cartilage. And those don't show up on regular X-rays. So sometimes parents come in and think, "Oh, we just need to get an X-ray and that's it." But really, you may need to go beyond just a plain X-ray and do something more.

Dr. Drew Duerson: Right. Yeah, if we can't figure it out with their history, physical, and their X-rays, somewhat inconclusive, sometimes we do have to go to more advanced imaging. Sometimes, it's an MRI. And a lot of times with the shoulder, that includes an aortagram where we'll inject dye into the shoulder joints, so we can get a better look at the shoulder.

And there's also some good use of ultrasound now, that we can really look at the shoulder in a lot of different ways that we use to not be able to.

Dr. Mike Patrick: Yeah. And both the MRI and the ultrasound, the added benefit is there's no radiation exposure with those, too.

Dr. Drew Duerson: Correct. Right.

Dr. Mike Patrick: So, once you figure out what is going on in the shoulder, how then, Herm, do you go about treating that?

Herman Hundley: So the first step in treating any kind of shoulder injury is going to really rely on our docs coming through with a good diagnosis, and then allowing us to see them in functional rehab. We usually bring the kid in and we'll take a look at the shoulder and really see what's going on. And then, kind of really review doc's notes, even sometimes talk to the doc in person about the kid coming in.


And then, we individualize each rehabilitation for each kid. So, two kids may come in and have the same injury, but they may require very different treatments. One kid maybe in a more acute injury, whereas another one is truly a chronic overuse, that kind of thing.

So, we bring him. We'll kind of differentiate what's going on, what we need to work on, where are their weaknesses, and what we need to work on with that particular kid. And then we just kind of break it down from there.

We usually start out with a flexibility being a big one. Range of motion at the shoulder being probably the other big one that we usually initiate right away. Just really trying to gain that range of motion back if they're certainly lacking in range of motion. And also target any flexibility deficits at the shoulder, but also at the lower extremities.

Too often, our kids are like, "Well, I have full motion in my shoulders." I'm like, "Yeah, but you have full flexibility, so your mechanics are going to suffer because of that."

So, we usually break it down that way. And then, we kind of start to attack the strength deficits both in the core and the lower extremities as well. And so, and then we work into that shoulder as well, the big thing being scapular stability maintained in that shoulder blade. A lot of kids, specially our developing kids, there's not a lot of stability there.

The way I explain it to my kids is kind of like building a house on a sand foundation. If you don't have scapula stability, it doesn't matter what happens at the shoulder, you're going to have issues. So we need to a kind of stabilize that shoulder blade and then now, we can attack the rotator cuff for sure.

Dr. Mike Patrick: And how do you go about stabilizing the scapula? Is it really strength and flexibility both that are involved in that?

Herman Hundley: Yeah, so definitely we start the flexibility and range of motion of the shoulder, obviously. But the big thing we want to target is strengthening that posterior shoulder, that posterior chain, meaning the muscles of the upper back, the traps — upper, middle and lower traps — and also the posterior rotator cuff as well.

But the big one's being rhomboids and traps, trying to get those stronger. A lot of times our kids have really strong upper traps. And then you start to look at that middle and lower area. And there's not a lot of strength, there's not a lot of definition. And that's really what keep that shoulder blade pinned down to their back. The other one being serratus anterior, where you get some weakness there and they get some of that scapula wing. We're not sure but they're soft at back.


Dr. Mike Patrick: Yeah. It's sound like even kids who may not have an injury, but are really just trying to become better throwers, that getting hook up with an athletic trainer and really helping them through that strength training and conditioning flexibility is going to be something important.

Herman Hundley: Yeah. Absolutely. And folks in our area, we typically only see patients who are injured or who had an injury and that sort. But definitely work with strength conditioning specialist of some kind, whether it be certified strength conditioning specialist or an athlete trainer to school. Or like I said, another athlete trainer has a kind of dual credential. But really important to definitely target that stuff early on, before an injury, ideally. In that way, you're not trying to play the catch-up after the fact. It's prevention at a time.

Dr. Mike Patrick: A lot of kids and families want to know, how long is this going to take? Once you start a rehab program — and I'm sure it's going to be different for each kid and each injury — what's a realistic timeframe?

Herman Hundley: So, I think Dr. Duerson can attest to that as well, but yeah, that's the first question, how long are we talking? And, really, what I tell my kids is as long as it takes. And usually, kids tend to respond well. And it just depends on the type of injury, for sure, and the type of kid that you're dealing with as well. Are they high level athlete? Are they older, more mature? Are they younger kid? That kind of thing.

Some kids respond quicker to treatment. Some kids aren't as compliant with treatment. That's a big part of it, what I tell my kid is the more compliant you are with the treatment, the faster you're going to get better. And we're really going to be aggressive with rehab and try to get you better as fast as we can. But I'm not going to put you back out there, at risk for another injury that could be more severe in nature.

Usually, it's between four to eight weeks. That's usually what we see. Like I said, some kids are shorter than that. Mild strains, things like that, tend to respond faster. And then, some other kids a little longer as well.

Dr. Mike Patrick: Are there injuries of the shoulder that rehab alone is not going to take care of. So maybe they need an orthopedic intervention or even a surgery for it. Or you'd imagine that families would be very concerned and when they come to see you, that may be one of the top things they're thinking about. How often do shoulders need surgery?


Dr. Drew Duerson: Yeah, I'll try to answer that one. I think in kids, it's pretty rare but it does happen. I think a good indication that something else is going on is we start them in functional rehab. They're not getting better. So we need to look a little bit further.

And that's where the advance imaging may come into play. So we'll get an MRI. And maybe something is torn. Probably, most commonly, throwing athletes, after chronic use of that shoulder, you can have a labral tear. That's some people will go on and live with, but sometimes it does need to be surgically corrected to get rid of their pain, especially if it's a high level thrower to get them back to throwing the way they used to throw. That may be indicated.

Dr. Mike Patrick: Moving down to the elbow, what are some of the common elbow injuries that we see in throwing athletes?

Dr. Drew Duerson: Kind of like the shoulder, we look at those growth plates, if those growth plates are open. Unlike the shoulder, there's a lot more of them. So at the elbow, there's actually six. And it can be somewhat confusing. They open and close at certain times.

We pay close attention to the inside of the elbow, the medial epicondyle. That's where we'll see something called apophysitis or Little League elbow. Similar to the shoulder like Little League shoulder, it's irritation of that growth plate. And it typically comes for some of the same reasons that the shoulder pain comes from, so just improper mechanics throwing too much, that type of thing.


But it's not always the growth plate. We look at the ligaments and that type of thing. So once the growth plate closes, we pay close attention to the ligaments that are attaching around elbow.

And you probably heard of the ulnar collateral ligament. That's the one that a lot of the Major League pitchers have to deal with. Sometimes they strain those. Sometimes they tear and need reconstruction.

It's not just inside the elbow. We look kind of all around the elbow because it could be a number of different things.

Dr. Mike Patrick: And you also have the ulnar nerve kind of running through against the bone. And there's tendons, ligaments in that area. And so, you see some inflammation of the ulnar nerve sometimes.

Dr. Drew Duerson: Yeah, and sometimes you can have that numbness, tingling down into your hands. It's traditionally in that fourth and fifth fingers. So sometimes, it's transit comes and goes, but it may be persistent. And sometimes that nerve can even move around too much. And you can feel some almost popping or clicking in the elbow from that as well.

Dr. Mike Patrick: And I would imagine, elbow injuries in terms of diagnosis is pretty similar to the shoulder in terms of the things you described?

Dr. Drew Duerson: Yeah, very, very similar. We start with that history and physical. And then, a lot of times, we do rely on those X-rays, like I mentioned. We have several growth plates around the elbow that we need to make sure we look at with X-ray. Yeah, very similar. And then, once we come with the diagnosis or if we can't, sometimes we do get around again the more advance imaging, such as MRI or ultrasound.

Dr. Mike Patrick: And Herm, in terms of elbow injury treatment, is the rehab process pretty similar for the shoulder or are there differences?

Herman Hundley: There are some differences with it. It's very similar. And typically, a lot of times what we see, and Dr. Duerson touched on that a little bit is we see a kid come in for an elbow injury, and we take a really good history. And one of the things I ask is "Have you had pain in your shoulder recently?" And almost every time they're going to tell me yes. And, "My shoulder start hurting a couple of months ago. It wasn't a big deal. And then, it kind of went away. And now, my elbow start hurting."


So usually, what you see is a shoulder injury that's now lead to a change in mechanics that gives them pain for shoulder motion but now has put their elbow in jeopardy. It's created an elbow injury.

So with the elbow, we look a lot more into that kinetic chain like we will with the shoulder. So we'll look from the elbow. We'll look at the risk and the form and see what's going on in there and really work on strengthening that, work on through some motion there. But really go back to the shoulder, for sure.

Because usually, that's what we're going to see. We're going to see some kind of mechanical error at the shoulder, some kind of lost range of motion, some tendonitis, some pain when something is there. Almost always that's kind of leading to those change in mechanics. It's going to lead to elbow injury for sure.

Dr. Mike Patrick: What do you do to evaluate the throwing style? So if you're really looking at it from a mechanical standpoint and saying this is a good throw and this is not, how do you go about doing that?

Herman Hundley: So what we do is in functional rehab, when a kid is ready to throw — and some kids who are uninjured have the availability to come in and do video analysis, as well — but when they're ready to throw and they're able to throw light toss pain free, what we'll do is we'll have them throw and do a biomechanical video analysis using our iPad software. We'll break down the video and kind of really look at joining or things like that.

So what I'll do is approach it from the ground-up approach. If there's an issue down the legs and lower extremities, I'm going to look at that first. Because typically, if there's some issue there, it's going to lead to a problem at the upper extremity. Rarely, do we see a kid have great lower extremity form in terms of their mechanics all the way up through. And then, it's just "Oh, it's just something with their arm." Almost always, it's something at the lower body that's leading to an issue with the arm.

So we'll break it down from the ground. We'll work our way up. We'll look at the feet and ankles and the knee and the hip. And then, we'll look at their shoulder and kind of how they're rotating and how they're turning their body and things like that.

Oftentimes, I tell a kid, "I can tell how you throw just by seeing how you move." And I'm like, "You throw like this," and I'll show him. And then, they're like "No, no, I don't throw like that." Or somebody, "You probably throw a side arm," and they're like, "No way." And then, I showed them the video and they're like, "When did I start throwing like that?"

Dr. Mike Patrick: Yeah, yeah, is that me?


Herman Hundley: Yeah, exactly. And I'm like, "Well, you know, it's something that you may have started recently. It may be something that a shoulder injury created. But whatever the case, we need to work on it." And so, we'll work on some corrective in there.

Dr. Mike Patrick: It's pretty interesting. I bet it's sort of an Aha! moment for the parents and the athlete when they have the elbow pain. But the problem is really with the way that they're using their shoulder to throw.

Herman Hundley: Yeah, absolutely. A lot of times, I joke around with my kids when they come in, "I'm in here for an elbow injury, and you're looking at my shoulder for 20 minutes. You're looking at my back. And you're looking at my shoulder blades, and you're looking at my feet and my leg. What's going on? Why are you looking at my lower extremity flexibility if my elbow's hurting?"

I explain it to him, usually, elbow injuries are mechanical issue. It's not truly just "Oh, I just overdid it a little bit." It's truly a mechanical issue, an overuse issue, and something else is going on. So, definitely an Aha! moment.

And then, when we bring him to that video analysis, I say here what's going on at your lower body. We found that tightness here, whatever the case may be. This is leading to this, and now, it's a domino effect. And it's creating the side arm throw or whatever the case may be.

Dr. Mike Patrick: A lot of parents want to know when a child can start particular pitches. Is there any guidelines for sort of which pitches they should start with and when they can progress.

Herman Hundley: For me, I recommend, and I tell most of my parents, and I get him a lot of kids who are 11, 12, 13 that are throwing four and five pitches, and I'm like, "That's not necessary." If you're a good pitcher and you can command the ball, you really need a fast ball and changeup until high school. And once you're in high school and you're starting to mature, then that's when I'm willing to look and say, "Hey, that's when you're going to want start learning new pitches."

But too often, I see kids who have been pitching for three years. They know four pitches. I'm like, "How have you mastered the fastball and the changeup in three years?" And now, you have a knuckleball and a curveball and a slider inside. There's probably not great mechanics there. So you really want to focus on… I mean, if you can put the ball in a strike zone and you can change speeds at the changeup, you're going to get some strikeouts and you're going to have a hard time getting hit.


Dr. Mike Patrick: And less likely then for injury.

Herman Hundley: Yeah, for sure. Fastball change at very similar mechanics. You don't get a lot of that same torque on the elbow. There's still a lot of force there, for sure. But when you start talking about breaking pitches, you're starting to change the mechanics. You're changing the arm motion, the arm action. So you're going to pull over more stress in that elbow.

And that's of definitely of concern. Like Dr. Drew said, those growth plates are still open when those kids are young. As they get older, they start to close and it becomes less of a concern.

Dr. Mike Patrick: What about pitch counts? So a lot of families are concerned about that. When are you pitching too much?

Dr. Drew Duerson: Yeah, there are certain guidelines out there. Most of them come from the League Baseball, starts at the youngest of ages. And it's number of pitches in a day, in a week, in a season. And it varies on age group all the way from I think the lowest number is 50 up to a 105 in a day.

And then, they have recommendations on how many days of rest you should have in between pitching so many pitches. So there's some good guidelines out there and we just need to make sure we're following them closely.

Dr. Mike Patrick: One of those comes from the American Sports Medicine Institute. And I'll put a link in the Show Notes, PediaCast.org for Episode 374, so folks can find that pretty easily. It's just a nice chart with ages and, as you mentioned, pitches per day, pitches per week, innings per year. Consecutive months of play, that sort of thing.

One of the recommendations I hadn't thought of that I saw and it made sense, was that pitcher should not then, as rest, be a catcher.

Herman Hundley: Yeah, absolutely. That's one of the biggest things in terms of risk factor. And I tell my kids, "Yeah, you're not throwing as hard, but you're throwing as often." And catchers have different mechanics. That throwing mechanic is very different than any other position in the field.

Too often, we'll see kids, they'll go from pitching and they'll pitch six innings and throw a 100 pitches, when they're 6, 15, 16 year old. And then, they'd turn around and they go play catcher for the rest of the game. Or they'll some from playing catcher and pitch and relief.


And so, it's like you're dealing with two very different mechanics there and you're also dealing with a lot of volume. And I tell them, you know, as a pitcher, yeah, you only need 200 pitches but then as a catcher, you could throw the ball 300 times in a games. So between pitches, you're talking about throwing down the first, throwing down the second, things like that. So definitely of concern.

Dr. Mike Patrick: Yeah, I would imagine that proper warm-up is also going to be important to prevent injury.

Herman Hundley: Yeah, absolutely, warm up and an arm pair, probably two biggest things that most of our patients could be doing better before they come in, obviously, before they get seen. So the idea is we want you to warm up your full body. Make sure your lower body's warmed up. A lot of times, we see kids that kind of just go out and they stretch their arm, and they start throwing the ball as they warm up. And that shouldn't be the case.

You should definitely warm up the entire body. Warm up your shoulders, get yourself ready. And then, an arm maintenance after throwing is really important, making sure you're taking care of recovery, and stretching your shoulder and doing all those things and rotator cuff strengthening things, stuff like that, after the fact when you're not throwing a ball.

Dr. Mike Patrick: Again, definitely good idea to be involved with an athletic trainer to help you through all these things you got to be doing to strengthen, improve flexibility, and prevent injury.

Herman Hundley: Yeah, absolutely. Like I said, those are all crucial in terms of preventing the injury. So get with your athletic trainer if you have one at school. Find out what you can do to kind of prevent those injuries, things like that. That way, you're not coming in to see docs. But if you need us, we're here.

Dr. Mike Patrick: Dr. Drew, tell us about the sports medicine program here at Nationwide Children's, with really comprehensive care for student athletes.

Dr. Drew Duerson: For sure, yeah, Nationwide Children's Hospital Sports Medicine is a team made up of eight physicians which I'm actually the newest member. We have over 30 athletic trainers. We have a dietitian just to name a few. We help to take care of young athletes all across Central Ohio.


We have eight different locations that we see patients at. These are located in Westerville, Dublin, Hillard, New Albany, Main Campus here downtown, Canal Winchester, on East Broad Street, and Marysville.

Not only do we see the previously mentioned throwing athletes but we see them all. We see everything from ankle injuries all the way up to concussions, so wide variety of things.

Dr. Mike Patrick: And we'll put a link in the Show Notes for this episode, for this sports medicine program here at Nationwide Children's. So just head over to PediaCast.org. Look for Episode 374, the Show Notes for that episode, and we'll have a link to Sports Medicine. We'll also put a link to more information on the biomechanics video analysis for throwers that we do here at Nationwide Children's.

And then, the American Academy of Orthopedic Surgeons has a great website for parents that show what different shoulder injuries there are, with diagrams that show you exactly which components are involved, but for shoulders and for elbows. Really great information that goes into a lot of detail for particular injuries of the shoulder and elbow.

And so, I'll put links to those two in the Show Notes so you can find it easier if you are interested in more of the details.

And then also, Herm, you wrote a blog post for our hospital's blog, 700 Children's, Injury Prevention in Softball and Baseball. We'll put a link to that too so folks can share that — just good information in terms of what injuries are common, how you treat them, and ways to prevent them.

Herman Hundley: Yeah, absolutely. And we have a Nationwide Children's Sports Medicine webpage as well which has a lot of resources for throwing injuries and other injuries as well. And there's some Facebook Live posts there that's quite along this topic. There's some of those where we're talking throwing injuries, burning injuries, things like that.

Dr. Mike Patrick: And we'll get links to that on the Show Notes, too.


Before you guys go, we're talking before we start to record, and I know both of you have young kids at home. It's getting warm outside and great time to get out with the family, do some fun things. So I'm going to just ask you, what is it that you like to do with the kids outdoors.

Herman Hundley: So we have a park in the neighborhood. I have a two-year-old daughter and she likes to walk or ride a bike down to the park. And so, we'll ride down and let her play for a little while. And we have a couple of ponds that we'll go and we'll feed the ducks and things like that.

Dr. Mike Patrick: That's fun, yeah.

Dr. Drew Duerson: I have a 15-month-old boy that's just mastering walking so he's into everything. We actually just moved here. So we just got grass laid a couple of days ago, so that's pretty exciting. So he's getting out a little bit more. Loves to write with chalk on the sidewalk, goes to the park quite a bit. His favorite thing probably right now is the zoo. We pretty much go there every week. He loves all the animals.

Dr. Mike Patrick: That's fantastic. My kids are a little bit older, in their early 20s. But we still go out and do Pokemon Go. So we started that last summer, and they have a new batch of them that are out. And I actually wrote a blog post on doing Pokemon Go safely last summer, and I'll put a link to that in the Show Notes for this episode too, so folks can see it again. But that's what we've been doing, is going out and trying to get them all or catch them all.


Dr. Drew Duerson: Cool.

Dr. Mike Patrick: All right, Dr. Drew Duerson, sports medicine here at Nationwide Children's, and Herman Hundley, athletic trainer at Nationwide Children's. Thanks so much to both of you for stopping by today.

Herman Hundley: Thanks very much.

Dr. Drew Duerson: Thank you very much.



Dr. Mike Patrick: We have a couple listener questions for you this week. The first one comes from Anna in Toronto Canada. She says, "Hi, Dr. Mike. First of all, I wanted to thank you for your podcast. It is so informative. Our doctor would not have the time to explain everything in such detail.

"I am now getting information from Google about this condition called the Alice in Wonderland Syndrome. My six-year-old daughter has it and we're just starting tests to make sure everything is okay. I was surprised to learn this condition is very common. I just thought it might be interesting for you to talk about it on your show as it was very scary when I saw my daughter freaking out when she has an episode. Kind regards — Anna"

Thanks for the question, Anna. Really appreciate you writing in. So Alice in Wonderland Syndrome, it's a real thing. Let's start with the definition. It's really just what it sounds like. Something happens in the brain which results in abnormal perception of vision, of what you're seeing, also one's body image.

And even the experience of time can be altered. Things become distorted in size and or appearance or how fast or slow things are moving. Things in the environment can be affected and the affected person's body, so you might think you are smaller than everything around you or that you are bigger. And things don't really appear as they really are in real life, including you. And the perception of time as I mentioned may be altered, either sped up or slowed down.

So you can see why it's called Alice in Wonderland Syndrome, pretty much speaks for itself. And as you can imagine, it's somewhat distressing to the person experiencing it. And the family, those around the person experiencing it, it can be very distressing.

There's some good news and some bad news that goes along with Alice in Wonderland syndrome. First, the good news. The symptoms themselves are not harmful. They're just a by-product of something that's going on in the brain. And in many cases, I mean, almost all of the time, it's short-lived, the experience. And in many case, it goes around its own and never comes back again.


The most common underlying problem associated with Alice in Wonderland Syndrome are migraines, with about 15% of migraines sufferers reporting at least some component of Alice in Wonderland Syndrome at some time in their life. Now, it may not be all of those things but some part of that perception issue happens at least once in the life of about 15% of migraine sufferers.

And again, it's not a sign that the migraine is any more severe or that there's a problem with it. It just happens. And it's part of the migraine and then goes away, and it's not anything serious.

And if you look at the entire population, migraine sufferer and those without migraines, it's still fairly common. About 6% of the girl population and about 5% of the boy population report at least one episode over the course of one's life. So I'm not sure I'd characterize that as very common, but probably more common than one would think it would be.

Now, for the bad news. There are a whole bunch of things besides migraine that can cause this. Migraines are the most common but there's a very long list of possibilities beyond migraine that could do this.

In fact, it's not really a syndrome in the sense of a single disorder with a collection of symptoms. Instead, it's a collection of symptoms brought on by brain dysfunction of one sort or another. And it turns out that can be caused by all sorts of things from migraines to seizures and medications, psychotropic substances, recreational drugs. Even some types of cough medicine can do it.

There are infectious diseases that can bring this on. Also, eye diseases and ear diseases. Some mental health disorders, really a huge list of possibilities.


But back to the good news, it often goes away on its own. And when it doesn't go away on its own, in many cases, once you discover the underlying cost, if this is something that's recurrent, oftentimes, you can treat the underlying cause and help these episodes go away. The important thing really is that your doctor knows about it and is thinking about underlying causes and working with you to figure things out.

One of the best sources of information I've come across for Alice in Wonderland Syndrome is a systematic review that was published in 2016 in the journal, Neurology: Clinical Practice. Very readable and informative. The author took into account a 169 published studies on Alice in Wonderland Syndrome and sums them up very nicely with tables of symptoms and known causes. Really, highly recommended for someone who wants to know more about this.

And I'll put a link in the Show Notes for this episode, 374, over at PediaCast.org if you'd like to see that article. You might have to pay a few dollars to get the entire article or jot down the article name which is Alice in Wonderland Syndrome, A Systematic Review. Also, write down the author, Jan Dirk Blom. And the Journal is the June 2016 edition of Neurology: Clinical Practice.
So, write those things down, and then call or visit a local library, and see if they can get the article for you if you're not able to get it yourself online.

Pretty good evidence-based review of the condition, definitely worth checking out if your daughter continues to have the symptoms and for anyone else who is interested and wants to know more.

Hope that helps, Anna. And as always, thanks for the question.

Next up is Laura in Milwaukee. Laura says, "Hi, Dr. Mike. First, I'd like to thank you for putting on such a great show. I'm a regular listener and love the program. I have two questions I'd like to ask. Number one, my niece is seven years old and there had been several incidents where she started with a could but then began wheezing. So she was given a nebulizer to use at home.


"I asked my sister if her daughter has asthma, since it runs in the family, and she said no, it's just wheezing. I'm confused about what is going on. Can you give a little more information on wheezing and when it's a concern? I have small children and don't know when it's appropriate to seek medical care."

So let's stop right there, Laura, and answer this one. And then I'll get to your second question. I really do appreciate your writing in.

So this is something that actually comes up a lot. The definition of asthma is really recurrent wheezing. And we're hesitant to call it asthma in little babies, tend to call it something like reactive airway disease. Bronchiolitis is a virus in babies that we've talked about before in this program that can result in infants wheezing.

But once you get to the point where very frequently when you get a cold or at a certain of the year, there's triggers such as outdoor pollens or molds and you have a predictable pattern of recurrent wheezing, then we would call it asthma.

And there are a lot of families that don't like to put a label on their kids and the doctors don't necessarily want to put a label on the kids, but it is what it is. We know you don't like that particular phrase, but it's true. When it's recurrent wheezing, we call it asthma. There's not really another definition than that.

So if you have a seven-year-old who starts wheezing every time they get a cold and has to use a nebulizer at home with Albuterol in it to help the wheezing, by definition, that's asthma. And I don't think that… You got a group of ten pediatricians, and ten pediatric pulmonologists, and ten pediatric allergists together, and ask them to answer that same question in a seven-year-old with recurrent wheezing every time they get a cold who uses Albuterol to help the wheezing, yeah, that's asthma by definition to clinical diagnosis.


And then, the next part of your question, Laura was when should you be concerned about wheezing. That means that there's inflammation in the airways. And that should always be a concern. So if kids had wheezing — if kids have wheezing — you should be in touch with your doctor.

Now, if you and your doctor have a plan — so if there's wheezing, I have an asthma action plan, or wheezing action plan if you don't want to use the word asthma, then this is what I'm going to do. I'm going to use my inhaler or my nebulizer with the Albuterol on it. And then, if the wheezing goes away, fantastic. And if it doesn't, I'm going to call my doctor and be in touch with him.

So wheezing is not something you want to treat on your own, unless you and your doctor already have a plan on how you're going to treat it. And if things don't go as planned, then you're going to be in touch with him. So wheezing should always be a concern because it can get worse quickly and then kids can have trouble breathing. So it's always appropriate to seek medical care if your kids are wheezing.

By the way, if you're interested in hearing lots more about asthma, we have done quite a number of episodes concerning asthma in one way or another. And in each of those we usually do go through a description and exactly what is asthma and wheezing. So I'll put links to all of those shows that we've done in the past in the Show Notes for this episode, 374, over at PediaCast.org, so you can find it easily.

One f the episodes, 186, was called All About Asthma, 242 (Asthma Technology in Mobile Apps), 295 (Asthma and Mobile Technology Part 2). And then, just recently, we did PediaCast 360, School-Based Asthma Therapy. And with all of those, we do cover exactly what asthma is with a little bit of a different twist or flavor to it.


And we cover asthma frequently on this program, because it's common. A lot of kids are affected with wheezing, and so we definitely want to get the word out and to keep everyone up to date on the latest on what we know about asthma and how it's treated.

And again, I'll include links to all of those shows in the Show Notes for this Episode 374.

Okay, question number two from Laura in Milwaukee, "I love listening to your podcast and would love to find similar information for adult health. Do you have any recommendations, preferably a podcast, but other forms of media as well? Thanks, again, Laura."

So thanks for that question as well, Laura. I'll be honest with you. I don't listen to a lot of medical podcast because I spent a lot of time producing one. So in my free time, my brain needs to go somewhere else. And oftentimes, that is either news and current events, politics, also, tech stuff. Also, I love listening to podcasts, even podcasts about podcasting. I do take those in.

But I don't listen to a lot of adult medical podcasts. However, I have listened to some and I have looked through reviews and user reviews. And three that come to mind that I would have no problem recommending.

One is the Dr. Drew podcast. Also, House Call podcast, and 2 Docs Talk podcast. And I'll put a link to all three of those in the Show Notes for this Episode 374 over at PediaCast.org. Those are all good ones with large audiences, seem to be evidence-based and get great listener reviews.

There's probably many more that those three. And so if anyone else has suggestion, feel free to write in. I'll share them with the rest of the audience.

Thanks for the questions, Laura. Really appreciate them.

Don't forget, if you have a question or a topic idea for the program, really easy to get in touch. Just head over to PediaCast.org, click on the Contact link and submit your question or your comment, or if you want to point me in the direction of news article or a journal article. I really do appreciate everyone's participation in the program and will certainly do my best to get your ideas and your questions on to the show.



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.

Also, thanks to our guests this week, Dr. Drew Duerson, sports medicine physician and Herman Hundley, athletic trainer, both from Nationwide Children's Hospital. Really appreciate them stopping by and sharing their knowledge and expertise with us regarding throwing injuries in student athletes.

Don't forget, you can find PediaCast in all sorts of places. So, wherever you found us, in addition to that, we're also on iTunes, Google Play, iHeart Radio, Stitcher, TuneIn, most mobile podcast apps.

And wherever you found us, and regularly listen to us, if they have a mechanism for reviewing the show, we'd really appreciate it if you take a couple minutes of your time and just write some thoughtful comments about the program. Reviews always help when other parents are stopping by and trying to decide what they want to listen to.

And we do want to get our evidence-based information in the ears of as many parents as possible. So please do share those and write reviews. Always, always helpful and we appreciate it.

Don't forget, we have a landing site with all of ours shows, the entire past archive, Show Notes, transcripts of each program, our Terms of Use agreement and the Contact page. That's all available at PediaCast.org.

Don't forget, PediaCast is also a part of the Parents on Demand Network at ParentsOnDemand.com, where you'll find a collection of free podcasts that are helpful for parents.


We're also on social media, on Facebook, Twitter, Google+, and Pinterest. And we always appreciate when you connect with us there and share our content with your own online audience.

And, we also appreciate you telling others face-to-face. So your family friends, neighbors, co-workers, the folks you do life with, baby sitters, day care workers, grandparents — really anyone who either has kids or takes care of kids — would benefit from the program. And that includes your child's doctor, by the way, because we always appreciate when physicians, pediatricians, family practice doctors, nurse practitioners, physician assistants, when they share the show with their other families in their practice.

And don't forget, we also have a show for the providers out there, PediaCast CME, which stands for Continuing Medical Education. Similar to this program, we turn up the science a couple of notches and 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, thanks again to everyone for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everyone.


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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