Formula Intolerance, Fire Safety, Syrian Refugees – PediaCast 336

Show Notes


  • Join Dr Mike in the PediaCast Studio for a look at the latest research on formula intolerance. Does switching formula help fussy babies? We’ll take a look. Next up, Dr Lara McKenzie stops by the studio to talk about “Make Safe Happen,” along with a discussion on burns & fire safety. Then we’ll wrap up the program by considering the Syrian refugee crisis and evidence-based guidelines aimed at caring for children on the move.


  • Formula Intolerance
  • Make Safe Happen
  • Burns & Fire Safety
  • Syrian Refugees




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.

It’s Episode 336 for January 13th, 2016. We’re calling this one “Formula Intolerance, Fire Safety and Syrian Refugees”. I want to welcome everyone to the program.

Hope you all had some great family time over the holidays. Welcome to 2016, and welcome to our first show with a little bit of a tweak and modified format. I mentioned this plan in our final edition of PediaCast for 2015, and here we are, giving it a go.

The recap, for those who missed our two-part listener question extravaganza where we answered 14 of your questions between two shows, the idea for this year is to move from one long segment that constitutes an entire PediaCast episode that features either news parents can use or answers to listener questions, or an interview with a pediatric expert, instead of one long show on topic or one type of segment, what we thought we’d try doing is moving to three shorter segments so that we can include a variety of elements in the course of one show.

In doing so, we hope to be a little bit more flexible. We can answer more of your questions, interview more guests on a regular basis. We can also invite an old friend of mine into the mix, the Research Roundup — and for those of you who have listened for any length of time, you’ll remember those — where we take research topic and just go a little bit deeper into the journal article itself and talk about the methods and the data and the conclusions of the authors, look at the hypothesis. So we’ll get a little bit more science-y with it but not too much. And, of course, find topics that we think parents would find interesting.


As I look back, I realized that in the last couple of years, we really haven’t done any of those research roundups. So, that will give us a chance to put that back into the mix as well. Of course, I want to say most of all that I really welcome your feedback on the new format, which is really an old format because we’ve done it this way in the past with three shorter segments. In ten years, things change. You move back and forth. It’s like moving the furniture around in a room from one season to the next.

But I would love to hear your thoughts on the new way that we’re doing the show for this year. You know, we’ll stick with it if folks are liking it, and if it’s not working out, we’ll move back to the way it was before. It’s a podcast. We can do that. So I really would appreciate your feedback.

Also, I want to mention that at the end of 2015, we pretty much depleted the listener question bank getting everybody’s questions answered. So this is a great time to get in touch with me if you have a pediatric question. It’s an easy thing to do. Just head over to and click on the Contact link. You can also call the voice line, 347-404-KIDS, 347-404-K-I-D-S, and you can leave a question or a comment that way.

All right, so what are we talking about today? Well, first off, I think, will be a topic of interest to many parents out there with young babies in the home, especially if your young baby is fussy and you think their infant formula may be to blame. So we’re going to look at formula intolerance in the form of research roundup and see if switching formulas might help with fussiness in young babies.

Then, we’re going to move on to our interview segment after that, which introduces the Make Safe Happen mobile app. We’ve talked about it before on this program, but we’ll go in a little bit more detail on exactly what that is this week.


Speaking of Make Safe Happen, we’ll take an in-depth look at fire and burn safety — how can you prevent skin burns and house fires? Does your family have an emergency safety plan and what about smoke and carbon monoxide detectors? What kind do you need? Where should you put them? Dr. Lara McKenzie is a safety expert here at Nationwide Children’s and she’ll be joining me for that.

Then, in our final segment, it’s a news segment but one that’s primarily aimed at pediatric provider because we do have a lot of them in the audience. Of course, parents are welcome to the stick around, too. We do this from the time to time.

If you’re new to the program, we usually have news parents can use. Sometimes we focus on the providers. When we do, we tend to stick it at the end of the program so parents get their information first. We’re polite in that way, I guess.

Now, I know I’m breaking podcast and social media and PR rules by catering to more than one audience, but what can I do? The audience is what it is. We have lots of parents in the audience but we have lots of providers too. When you have a combination of the two, you do want to give some information that’s going to be helpful for both and to a degree what’s helpful for one is helpful to the others.

If you want to hear a little bit of news providers can use, stick around at the end of the program. It’s interesting because it’s about Syrian refugees. We’ve all heard about the Syrian refugee crisis with hundreds of thousands of people on the move, many of them children. Now, regardless of your opinion on this, regardless of your political persuasion or whether you think the United States should or should not take Syrian refugees in, the fact still remains that displaced children are on the move in a very big way, and somebody somewhere has to care for their medical needs.


Since PediaCast has a global distribution, I wanted to share some evidence based tools with those providers to help them best care for immigrant children that they encounter.

Now, before providing that, I’m also going to frame why so many people are moving with a couple of articles from medical journals that take a peek at conditions inside Syria and how those conditions affect children and the impact those conditions have on the Syrian healthcare system.

So a bit of a departure from our usual format and content this week. But again, we want to be flexible and useful to people and places who need evidence-based information as that information pertains to the health and well-being of children regardless of where those children live. I do think many of you who are parents rather than providers, I think you’ll probably stick around for that, because it is some interesting news article that come from journals and it’s still evidence based. Then, again, I’m a pediatric provider so I’m more inclined to think it sounds interesting.

If you do stick around for our new segment, and this is another reason that I tucked it in at the end, we are dealing with a war-torn region of the world, and as we talk about Syrian refugees, there is death and violence and destruction involved, especially as we consider why so many families are on the move. So if you have little ears in the vicinity, or it’s not something you’re interested in hearing, turn off the podcast and move on to another one when we hit that point. I’ll be sure to give you another warning when the time comes for that.

But again, everyone is welcome to stay. Just wanted you to know, to some degree, listener discretion is advised.

Also, I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do 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


All right, let’s take a quick break and I will be back with the latest research on formula intolerance followed by burn and fire safety and then evidence-based health care for Syrian refugees.

That’s all coming up, right after this.


Dr. Mike Patrick: So we’re going to do our first research roundup that we’ve done in quite some time. I think it’s been at least a couple of years since we’ve done one of this. Just a little bit of an introduction to what the research segment is, we call it research roundup because there was a time when I would do an entire show. We’d take three or four journal articles. I have feeling we’re just going to do one at a time, but I like the sound of research roundup, so I’m just going to keep it. Think of it as we’re adding another article to our research roundup. How’s that?

So the one we’re going to talk about today is on formula intolerance. This comes from a study that was done at Vanderbilt University in cooperation with Mead Johnson Nutrition. Just to be transparent, Mead Johnson is a maker of infant formula. So we want to keep that in the back of our minds. But this was published in a peer-reviewed journal– in fact, the Journal of Pediatric Gastroenterology and Nutrition — and it was published July 2015.

So the question before the researchers was, Considering infants with feeding problems, does changing their formula from cow’s milk-based, lactose-containing formula (some examples of those: Similac Advance, plain Infamil, many others), so considering infants with feeding problems, does changing their formula from a cow’s milk-based, lactose-containing formula to a lactose free milk-based or a soy-based formula, does making that change improve the caregiver’s distress or improve the caregiver’s perception of infant fussiness and behavior?


In other words, in the eyes of the caregiver, did changing the formula seem to make a difference for the baby and did it ease the caregiver’s stress levels regarding their fussy baby? Good question, right? So how did researchers go about finding an answer? Well, the type of study they did is a double blind randomized controlled trial.

So let’s break down what that means since it’s been awhile since we deconstructed a research study in this fashion. A randomized controlled study means that we enroll participants and place them randomly into either a study group or one of several study groups or into a control group. With that idea in mind, moving forward, we’re going to treat the two groups in a similar fashion with the exception of a single variable that we’re only going to apply to the study group or the study groups.

Then, you follow these groups prospectively, so as you move forward and you measure outcomes and then you compare the outcomes of the groups. You see if there’s a statistically significant difference in the outcome of the groups.

If you’ve done a good job controlling all of the variables, including variables you aren’t studying… So hopefully, those other extraneous variables are going to still be the same for all of the groups and you’re only changing the one that you’re studying, because you don’t want any extraneous variables leading to outcome change. So if you do all that successfully, and you find a statistically significant change and outcome between the groups, meaning that it’s unlikely that the change just happen by chance, then you make a case for your intervention being responsible for the change and outcome.


Now, sometimes it is difficult to control all of the variables, which can introduce subtle but significant air into the equation. So you do have to be very careful as you proceed. So in this particular study, we are measuring caregiver feelings as they respond to infant behavior. So one of the things we have to consider, could feelings change if the caregiver knows which group they’re in?

In other words, if a parent knows they’re in a study group that something changed that their infant formula changed, are they more likely to have a change in their perception based on simply knowing an intervention was applied? Likewise, if a caregiver is in the control group, so no intervention was applied, are they less likely to know the change simply by knowing that no intervention was done?

So for this study, the caregivers were blinded, meaning, they don’t know which group their child is in. They don’t know if their child’s infant formula was changed or if they’re drinking the same formula that they were drinking before, so that it’s blinded. And we take that step further and also blind the investigators who are collecting the data. They don’t know who is in which group either, and that’s what’s meant by a double-blinded study.

So, hopefully, that terminology makes a little bit more sense now — a double blind randomized controlled trial.

So what did investigators do? How did they conduct their study? Well, they looked for infants between 2 and 12 weeks of age. So two weeks old to three months of age who were currently and exclusively fed with a lactose containing cow’s milk-based formula, so just your standard infant formula, whose caregivers then reported perceived feeding problems. So the kids on a regular formula, they’re fussy. Their parents are like, “This isn’t really working out.” These are the kids that they wanted.


So they had to have been drinking their current formula for at least five consecutive days with a qualifying symptom in the past week. The qualifying symptoms were fussiness, crying, apparent cramping. Now, infants can’t tell you they’re having belly cramps but the parents had the perception that their child had cramping. Passing gas from either end or diarrhea. And this is important, the caregiver attributes those symptoms to the child’s formula.

So where did investigator find these infants? Well, families being seen in the offices of participating pediatricians. Yay! So these are folks just like you who are going to your pediatrician’s office and they use local community pediatricians. So, Vanderbilt basically said, “Hey, local pediatricians, we have this study. If you’d like to get involved, you can enroll patients from your practice, which is a great way to get community pediatricians and families involved in research which then helps all of us.”

A total of 291 infants along with their female caregivers, so we’re just looking at moms here, were enrolled and they were randomized into one of three groups, either a control group who would continue their lactose containing cow’s milk-based formula.

Study group number one was switched to a lactose free cow’s milk-based formula and study group number two was switched to a soy base formula which is as it turns out is also lactose free. Again, caregivers and investigators do not know who is in which group. So caregivers don’t know which product their child is going to be drinking.

So, how did researchers measured caregiver feelings regarding infant behavior? And notice, they may identify participants by the presence of symptoms like gas and diarrhea, but they’re not going to be measuring those symptoms moving forward. They’re going to be measuring parent’s perception of what’s going on.


So what did they do? Well, investigators had caregivers three baseline surveys at the beginning of the study — an infant characteristics questionnaire which measures fussiness and irritability (again, the parent’s perception that their baby is fussy and irritable), the maternity efficacy questionnaire which measures caregiver distress, and a current formula satisfaction survey. And then, caregivers fed their babies their assigned formula which may or may not have changed depending on which group they’re in for 14 days. So they changed their formula for two weeks or kept the same, and then they repeated those three questionnaires.

So what did researchers find? Well, of the 291 infants enrolled, 234 of them completed the study. We don’t know why some of them dropped out. Maybe they weren’t satisfied with how things were going. Maybe they simply didn’t return for the follow-up visit. We don’t know why, but 57 infants and their moms dropped out. That’s a little concerning.

So let’s look at those who did complete the study. Of the 234 babies, 85 were in the control group. So they continued feeding with their lactose containing cow’s milk-based formula. Eighty were in Study Group Number 1, so they were switched to a lactose free cow’s milk-based formula and 69 were in Study Group 2 and switched to a soy-based formula.

What were the outcomes? Did changing formula for two weeks make a difference in perceived infant behavior or mom’s stress level? So drum roll, please. The answer is yes, and the answer is no. Babies in all three groups had significantly improved scores on infant characteristics questionnaire (so the measure of fussiness and irritability), the maternity efficacy questionnaire which measures caregiver distress, when you compare answers before and after the study.

So, regardless of whether the formula was changed or not changed and regardless of whether it was changed to lactose free cow’s milk-based formula or changed to a soy-based formula, all of them felt that the baby’s fussiness and irritability did get a little better and the caregiver’s distress level went down.


However, when you look at the formula satisfaction survey, none of the groups had significantly improved scores on their satisfaction with their current formula. In other words, parents perceive their babies had improved. They reported lower stress levels but they did not report increased satisfaction with the current formula. So, they perceived things were better but they must have not been completely improved. Otherwise, you would think that they would have been satisfied with the formula that their baby was taking currently.

And this is important, they reported these things regardless of which formula they gave during the study, even if the formula hadn’t actually changed. In other words, the control group.

So here’s the next question, did the study groups have greater improvement compared to the control group? And the answer here is no. There was no significant difference between the groups with regard to degree of improvement. It didn’t matter if they continued the original lactose-containing cow’s milk-based formula or switch to a lactose free cow’s milk-based formula or switched to a soy-based formula. They all had perceived improvement but not complete resolution and none of the groups improved more than the other.

So the authors conclude that their findings suggest that commonly reported infant problems which caregivers perceived to be caused by the infant formula are probably not really caused by feeding problems, but instead are probably related to infant development. In other words, they just happen.

So there you go, if you have a fussy baby, switching formula may help a little bit with regard to your perception of infant behavior. But then again, doing nothing at all is likely to have the same result. And I’ll let you finish drawing up the conclusion from there.



Dr. Mike Patrick: Dr. Lara McKenzie is a principal investigator with the Center for Injury Research and Policy at the Research Institute at Nationwide Children’s Hospital. She’s also an associate professor of Pediatrics at the Ohio State University College of Medicine and the Division of Epidemiology in Ohio State’s College of Public Health. Her research focuses on injury prevention and childhood safety including raising awareness among parents. She’s been instrumental in the national Make Safe Happen campaign.

That’s what she’s here to talk about today, Make Safe Happen, along with some helpful hints related to fire and burn safety in and around the home.

So let’s give a warm PediaCast welcome to Dr. Lara McKenzie. Thanks for joining us today.

Dr. Lara McKenzie: Hi, Dr. Mike. Thanks for having me.

Dr. Mike Patrick: Really appreciate you stopping by the studio.

So tell us about Make Safe Happen and how you became involved with this project.

Dr. Lara McKenzie: Sure. Well, it starts with a personal story. About five years ago, my husband and I started trying to have a family. After we finally received the positive news of a positive blood test, we went to see our doctor for an ultrasound. The doctor started looking around and he said, “I see a baby and a heartbeat.” We thought, “Oh, great, we did it.”

The doctor was looking around a little more, and he said, “I see a second baby and a heartbeat.” We looked at each other and thought, “Twins, we nailed this!”


Dr. Lara McKenzie: The doctor was quiet again, and he was looking around a little more, and he said, “I see a third baby and a heartbeat.” And we went, oh, bleep.”

Dr. Mike Patrick: Yeah, yeah, exactly. Instant family.

Dr. Lara McKenzie: Instant family. So after we recovered from the shock and adjusted to the idea of triplets, we started to get ourselves and our home ready for three babies. Some people call this childproofing. Some people call it baby proofing. My husband call it ruining all the fun, one activity at a time.



Dr. Lara McKenzie: I’ve been an injury research scientist for more than a decade and I thought, with some confidence, I’ve got this. I know what to do. I know the statistics. I know the recommendations and to me, it’s just another day at the office.

So we set off on this journey to childproof our home, get everything ready and we started putting together three cribs and bouncy seats and Pack N’ Plays and everything we needed for the babies. We tried in vain to install stair gates on our stairs. We live in an older home and we have a wrought iron railing banister and it just became very difficult to do some of the things that I recommended to parents to do. So following my own advice was hard, that I found.

We tried to test our smoke alarms and like I said, install the stair gate and do all these things. And at the height of my frustration I said, “Why are we, injury professionals, making this so hard for parents? And why hasn’t somebody come up with an app for this?” And that’s how the Make Safe Happen app started.

Dr. Mike Patrick: My mom was living in Florida and planning on moving up. We were getting a condo ready for her. She has some little dogs that she wanted to keep out of the upstairs area and so we thought a baby gate would be a great idea. I agree with you. It was very difficult to try to figure out how to fit it on, how to do it safely. And I’m sure we kind of have to jimmy rig it a little bit. I don’t think it would be safe for babies, really.

Dr. Lara McKenzie: Exactly.

Dr. Mike Patrick: It serves the purposes, to keep dogs out of that. But I feel for you and I feel for parents out there who face that difficulty.

Dr. Lara McKenzie: Yeah, all homes are a little bit different. Even something as simple as the molding around the edge of your stairs or the type of banister that you have or railing is going to affect how something fits or whether or not it can be installed in that area.


Our solution and what we needed to do is actually block the whole area to get to the stairs rather than be able to install something on our stairs. So there are solutions around some of these things, but the idea for the app and how we got connected with the Make Safe Happen Program really came out of this personal experience.

Dr. Mike Patrick: It’s also important because accidental injury is the number one cause of childhood death, right?

Dr. Lara McKenzie: Exactly. Every year, millions of children are injured in and around the home. Thousands of children die each year from preventable injuries. But this is a problem that has a solution. Unlike some other health problems or diseases, we actually have a cure for this, and it’s doing some of the safety things in your home.

Dr. Mike Patrick: I think that if you just ask a random parent, like what is the number one cause of childhood death, I’m not sure that there is a ton of awareness out there that accidental injury is the number one cause.

Dr. Lara McKenzie: Right. And it’s something that people don’t want to think about. It’s something that’s beyond emotion and it’s just so overwhelming to think about your children either being hurt or dying from something that is potentially preventable. People don’t want to think about it, so it doesn’t come top of mind.

Dr. Mike Patrick: So Make Safe Happen is a website and there is also a mobile app, and I would assume that that’s on iOS and Android both.

Dr. Lara McKenzie: Yes, so we had the idea for the Make Safe Happen app and Nationwide was launching, or beginning to launch their Make Safe Happen program, their national program. We thought what a great fit this would be to have a hands-on tool for parents. So the app is basically the next best thing to having a safety expert in your home.

It goes room by room and gives you a checklist for each room of your home, giving you important tips and safety things to do. If there’s a specific product that you need, there’s a link for that, so you can go right out to Amazon and purchase that product if you want. Or you could put it on a shopping list and take it to your favorite store and get it there.


There’s a place to add reminders for things like testing your smoke alarms or changing your batteries and your carbon monoxide detector. There’s a place to add the poison control number to your Contacts in your smart phone. Lot of people have a sticker or had stickers by their home phone when we had home phones. But now, everybody uses their smart phones, so it’s important to have those emergency numbers in your phones.

There’s all other kinds of tips in there, pictures of how to do different things. We’re actually working on some new content and some new features for release this year.

Dr. Mike Patrick: We’ll have links in the Show Notes, so if folks head over to and they go to the Show Notes for Episode 336, and we’ll have links to both the website and the mobile app at the iTunes store and Android Google Play, I think it is.

Dr. Lara McKenzie: Google Play, yup.

Dr. Mike Patrick: I’m an Apple guy, so I’m getting the terms dim.

Let’s talk a little bit about burns and fire. What are some ways that parents can prevent children from suffering burns and scalds?

Dr. Lara McKenzie: Every year, hundreds of children die from fires in their home and even more suffer burn related injuries. But not all the burns that we talk about are the result of fire. Some cooking appliances and space heaters can also be really dangerous. So you need to know what to watch out for around your home.

So I have some tips that I can give, but I also want to talk about scalds because that’s another one that we encounter a lot. So babies and children have thinner skin than older kids and adults. And their skin can burn more quickly at lower temperatures.


About a 120,000 kids are treated in emergency departments each year for burn related injuries. So the things that you can do in your home to prevent scald related injuries have to do with the water temperature in your house. So hot bath water causes more than half of all the scalds in children. So what you can do is to set your water heater temperature to a 120 degrees Fahrenheit. This is the manufacturer setting on new water heaters. But if you have an older one or you adjusted the temperature over the years, you may need to go down and check what temperature is, how it’s set.

Dr. Mike Patrick: I know ours is, when I went down to check this awhile back, it didn’t have numbers on it. It just had like…

Dr. Lara McKenzie: Warm and hot?

Dr. Mike Patrick: Yeah, and like a graduated red line that just get thicker and redder. So is just somewhere in the middle going to be about 120?

Dr. Lara McKenzie: So you might want to just take a guess on the dial, but the way to actually test is to, when the water’s been off in your house for awhile — so no one’s taken a shower, you haven’t run the sink for awhile — go up, then run the water for about a minute on the hottest setting. You want to get a cup of that water and maybe a meat thermometer or a candy thermometer or candy and just dip it right in that water. That’s going to tell you the temperature. So based on that, you may need to go down and adjust that dial a little bit more.

Dr. Mike Patrick: Got you.

Dr. Lara McKenzie: Lower, hotter, yeah.

Dr. Mike Patrick: And no higher than 120 is where you want to be.

Dr. Lara McKenzie: No higher than 120. I think it’s important to talk about that this is still really hot enough to take a shower, to wash your clothes, to get your dishes clean. So you’re not setting the water in your house to be cold. You’re just setting it on a temperature where it’s not going to automatically burn your children if it’s on the hottest setting.

The other thing to do, is when you’re running a bath for babies or for toddlers, just to test that water. You can do that with a bath thermometer. One of the simple bath thermometers that sometimes look like animals or ducks that float around. They’ll tell you exactly how hot the water is. You can also test it with your wrist or your elbow just to make sure it’s not too hot for baby’s skin.


The other thing we recommend is anti-scald devices that can actually be installed on your faucets. So this wood, you can do it on a shower head, or you can do it on a faucet in your bathroom or on the tub. But it would actually turn off and stop the water flow if it gets above a 120 degrees. So this is like an automatic shutoff basically for hot water.

Dr. Mike Patrick: Wow. Are those expensive?

Dr. Lara McKenzie: No they’re not. They’re a couple of dollars. Again, some of these things have to be installed. This one, you’re going to have to find something that fits the right faucet that you have, but that’s another measure.

Dr. Mike Patrick: Yeah, absolutely. I suspect a lot of scalds also happen in the kitchen.

Dr. Lara McKenzie: Yes. I’ve heard anecdotally from some folks that work in the emergency department here that a lot of kids that are starting to learn how to cook on their own, putting things in the microwave like cup of hot noodles or something, and when they’re pulling those things out, sometimes spilling that. So kids can get scalded from hot liquids, drinks, things that are prepared in the kitchen.

We often see little kids, little toddlers or babies getting scalded by hot drinks that parents might put on a counter or on a table cloth and a kid is able to kind of pull on that tablecloth or reach something on the counter and pull it down on them.

Dr. Mike Patrick: So back burners are probably going to be better than front ones and you don’t want handles sticking out over the edge where they can pull down and grab it.

Dr. Lara McKenzie: Yeah, that’s a great tip.

Dr. Mike Patrick: Those are the kind of tips that are in the app as you kind of walk around your house. Some of these things that seems like they’re common sense but it’s so easy just to have a momentary lapse in the midst of a busy house and you got a bunch of things going on. So I think even though, some of these things, “Well, yeah, of course you do that,” but the more that it is ingrained in your brain, the more likely it is that you follow those when things are crazy.


Dr. Lara McKenzie: Right, I think sometimes parents don’t realize how much a child can figure out how to do something that they may have not done before yet, but they’ve seen you do it. Now, they want to reach out and do something. They’re clever little beings and they figure it out.


Dr. Mike Patrick: Yeah, absolutely.

Now, house fires, to think about that, that’s a pretty scary things. What are some ways parents can make their house safer, in terms of decrease the risk of a house fire?

Dr. Lara McKenzie: So the thing about home fire is that they’re really unpredictable and they can start and spread very quickly. So you need to have a warning system in your home and a plan to get out in case there’s an emergency.

So the first thing is to install smoke alarms on every level of your home including your basement and place them near sleeping areas and inside each bedroom. A little tip for this is to hear the beep where you sleep. So you want to have smoke alarms that are close enough to the areas where you sleep so that they are going to wake you up if there’s a fire.

Many house fires, we learned this from talking with our Columbus Fire Department, start in the middle of the night. And so you need to be woken up to get out of the house in time.

The good thing about smoke alarms is that working smoke alarms can reduce the chance of dying in a house fire by 50%. So this is something that really can save life. But the only way that they work is if you have working smoke alarms. So you need to test those smoke alarms monthly and change the batteries annually.

Dr. Mike Patrick: It’s not every six months anymore.

Dr. Lara McKenzie: No. Once a year, they say, for battery is enough.

Dr. Mike Patrick: Is going to be enough.

Dr. Lara McKenzie: Yeah. And they’re also saying to replace your smoke alarms every ten years, or whatever your manufacturer warranty says on your actual device. But about ten years is when you should start to get some new ones.

Dr. Mike Patrick: Got you. And then, what about carbon monoxide detectors?

Dr. Lara McKenzie: So carbon monoxide detectors do something different, as you would imagine, from a smoke alarm. They detect when the carbon monoxide level is dangerously high. Carbon monoxide poisoning comes from fuel burning appliances in your homes. So things like your heating and cooling system, your stove, fireplace, other things, can be space heaters or generators that people use sometimes when the power goes out and when we had a storm.


So all those things that are fuel burning actually can generate carbon monoxide. Now, carbon monoxide in an open ventilated area is not dangerous but it becomes dangerous when it can’t vent properly. And so, those levels can then rise and it becomes poisonous very, very quickly. People die within a few minutes, if the poison or carbon monoxide level gets too high. So a carbon monoxide detector or alarm is going to alert you when those levels are starting to rise.

Dr. Mike Patrick: Are the rules the same with regard to changing the battery once a year, changing the device every ten years?

Dr. Lara McKenzie: Yeah. Luckily, these things have a lot so it’s the same recommendation. You want to replace your batteries every year, and test them monthly. The placement is essentially the same, too. You want to put them near your sleeping area and on every level of your home.

Dr. Mike Patrick: Great.

Dr. Lara McKenzie: One thing that’s a little different about carbon monoxide detectors is you don’t want to put them too close to the source. So, you don’t want to put it within a couple of feet of your furnace because it will go off all the time. You want about 15 feet away from a fuel burning appliance.

Dr. Mike Patrick: So you would expect it to be a little carbon monoxide around that device but it shouldn’t be throughout the home?

Dr. Lara McKenzie: Correct. And if not’s venting properly, that’s when you’re going to get the build-up. So another recommendation is to have your heating and cooling system and your fireplace and your chimney inspected by a professional annually. So you want to have them inspected and cleaned to make sure they’re working properly.


Dr. Mike Patrick: Is it OK to use one of the devices that’s both a smoke detector and a carbon monoxide all in one fancy unit?

Dr. Lara McKenzie: Yeah, those are fine and some of them are really inexpensive. The dual alarm, so they’re both smoke alarm and carbon monoxide. Those are fine. I would just make sure people understand that their smoke alarm alone is not a carbon monoxide detector and vice versa.

Dr. Mike Patrick: Yeah, that’s important.

Dr. Lara McKenzie: So a carbon monoxide alarm alone is only going to detect carbon monoxide. It’s not going to tell you when there’s smoke from a fire. So you actually need both or you need what you said, a dual alarm.

Dr. Mike Patrick: And then when you’re looking at the smoke detector itself, I’ve seen two different kinds of those out there. Some will say they’re both for ionizing, and then there’s another one as well.

Dr. Lara McKenzie: Photoelectric I think and ionizing…

Dr. Mike Patrick: Do you need both of those?

Dr. Lara McKenzie: I don’t think you need both necessarily, although fire people might tell you differently.

Dr. Mike Patrick: You’re cringing right now.


Dr. Lara McKenzie: Yeah, I… OK, get both.


Dr. Lara McKenzie: I would just say the most important thing is that you have something that works. So, having an alarm that doesn’t have a battery in it, that’s not going to help you.

Dr. Mike Patrick: So prevention-wise, having that alarm system in place. And then you talked about a family plan. Tell us a little bit more about that.

Dr. Lara McKenzie: Yeah, I think a fire escape plan is probably the next thing that I would say is important after smoke alarms and carbon monoxide detectors. So having a way and practicing a way to get out of your home and a place to meet is really important.

We tell people to create a plan. Sometimes, people do this by drawing a map or floor plan of their house and figuring out two ways out of each room and a meeting place for their family that’s outside and away from the home. So that everyone in the house knows where that place is. Maybe it’s your neighbor’s mailbox. Maybe it’s a big tree in your backyard. Maybe it’s across the street from your house, but just a place that everyone knows. So when you all gather there, you know who’s out of the house.

So that’s really important. Make sure everybody knows what to do, where to go. You want to test your alarms when you’re doing these drills so your kids know what it sounds like when the smoke alarm goes off. So they know when to get out. And you never want to go back inside for anything. You don’t get back in for toys, pets, memorabilia, nothing. Just get out.


Then, you want to practice this plan two times a year. Once in a daytime and once at night, so you know how to do it, even if it’s dark. We also wanted to have escape ladders that should be near each window that’s above the first floor and make sure your family knows how to use them. You may need to practice with these ladders.

You want to show children how to crawl low to the ground and cover their mouth if there’s smoke and how to feel the door with the back of their hand to make sure it’s not too hot or that there’s fire on the other side of that door. So they shouldn’t go out.

We also want to teach kids how to call 911. Now, this is something that I’ve been thinking about a lot lately because my kids are four years old, that they’re learning how to do some of these things and understanding what fire fighters do, and what fire departments do and I realized that we don’t have a home phone anymore. So I started thinking about how to make sure my kids know what to do or how to make that call.

Of course, doing a little investigating, we realized that old cell phones, even cell phones that aren’t activated anymore can still be used to make emergency calls. So that’s something that I think people don’t know about. And that’s a good tip if you have an old phone that you’re not using but could be used for this purpose to call an emergency number, that’s great. Or get a really cheap home phone and plug it back in. That’s what we decided to do. So that our kids would know how to do it, and what phone to do it on.

Dr. Mike Patrick: When you talk about getting out of the house, do you have a parent who’s assigned to helping the kids get out? Or, it seems like, “OK, (you and the other adults) we’re getting out of the house,” and “Oh, where are the kids?” But at the same time, you want to be safe about it as well. Tell us a little bit about that.


Dr. Lara McKenzie: It’s really good to have an adult assigned to be a helper for small children, babies or for older folks that live in the home that may need assistance or other people with disabilities that are going to need help getting out. So you kind of want to match everybody up with able-bodied person that will be able to get everyone out of the house.

Dr. Mike Patrick: Yes, that makes sense.

Dr. Lara McKenzie: And also have a backup plan. If somebody isn’t there when this emergency happens, who’s going to get somebody in that case, too? So you might want to go through all those scenarios.

Dr. Mike Patrick: And you talked about practicing it twice a year, although I could see some kids might even want to do it more than that. And if you kind of make it a game, it’s serious thing, but if you engage the kids in the process, then maybe it will come back to them in the true emergency a little bit more easily.

Dr. Lara McKenzie: We’re working on a component for the Make Safe Happen app that would have a fire drill component in it. So a place to time your family, improve upon that time and record the place where you’re supposed to meet. The goal, I should have said this before, but the goal for fire escape planning and fire drills is to get out in under two minutes.

Dr. Mike Patrick: Yeah, that’s true.

Dr. Lara McKenzie: So, that’s really fast. And that’s because fire can spread so quickly. That’s why we need to get out that fast. And the smoke from even a very small fire can be deadly right away. That’s why you guys stay low and just get out of the house as fast as you can.

Dr. Mike Patrick: Then, you’d mentioned a meeting place. I think that’s important because you don’t want to wonder if someone’s still in the house or are they in the backyard, so that everyone knows, “Hey, where going to this particular location,” then you can do a head count pretty easily.

So we talked about the escape plan, the smoke detectors. There are some things that folks can do inside their house to make it less likely that there would be a house fire to begin with. There’s a big long list of those things which are included in the app, again on the website, and folks can go around the house and look.

But what are some of the key ones, or maybe some of the ones people don’t think about? It’s not on the top of your head, but “Hey, this is a hazard when in terms of fire.”


Dr. Lara McKenzie: So I would say there’s maybe five threats, fire threats, that we want to think about. The first one is cooking. So stovetop cooking represents the leading cause of home fires. Many of these things happen when something’s left on the stove and people become distracted. This could happen on a daily basis. When you got kids and getting dinner ready and something comes to the door, and you walk away from the stove.

So that’s how these fires start. They’re really small and they’re sort of like it’s unattended, your cooking something. Something is going to catch fire and a lot of people we’ve heard tried to take that pan that might be burning and ran out of the house. That’s absolutely the wrong thing to do because that’s going to give that fire oxygen. So we want to just cover if you can. And if you can’t, you need to just get out.

Dr. Mike Patrick: Fire extinguisher in the kitchen? Great idea?

Dr. Lara McKenzie: Fire extinguishers is a great idea, yeah. Our fire experts told us though if that doesn’t look like it’s something that can get put out very quickly, you really just need to get out.

Dr. Mike Patrick: Yeah, that makes sense.

Dr. Lara McKenzie: The second fire threat is heating. This is the second most common cause of home fires and in the winter months, it becomes the leading concern. So portable electric space heaters, they start a great deal of fires when sheets or window curtains or some kind of blinds accidentally come in contact with the unit and ignite.

So we say give heaters some space. Keep a three foot clear space around in all directions. Keep it away from drapes. You also want to have you central heating equipment professionally inspected and serviced each season.

So the third fire threat is smoking. This is the third most common cause of house fires and the top cause of home fire deaths. So take it outside. That’s the recommendation. Best way to prevent cigarette related home fires is to institute a policy of no smoking in your home.


Dr. Mike Patrick: Yeah, lots of good reasons for that.


Dr. Lara McKenzie: Lots of good reasons for that but fire is another one. If you do smoke, cigarettes need to be dealt with water before they’re thrown away. A lot of fire start with a cigarette butt in a waste paper basket that catches and then catches curtains or catches a couch on fire.

The fourth fire threat is electrical. So this would be faulty or deteriorating electrical cords. And that’s among the top causes again of home fires. These are cords that are frayed or cracked and they can send sparks to flammable surfaces and start a fire. So what we recommend here is a cord check-up. Just make sure all those cords are intact. We also don’t want to put too many things plugged in to one outlet or to plug surge protectors into another surge protector.

And the very last fire threat is candles. This is an obvious one, but something that you really don’t think about. An open flame, it’s one of the most common causes or sources of home fires. So here, we wanted to just think about using batteries instead. There’s lot of battery-operated candles that look and perform like real ones and if you do use real candles you want to extinguish them before you leave the room.

Dr. Mike Patrick: Our kids are older and we have three cats, and we do have candles but we’re always watching and making sure that the cats stay away from them. A few days ago, we walk back in the house after being out shopping for awhile. And it’s like wow, the house smells really good and realized we left three candles burning, and we were gone for ours.

Dr. Lara McKenzie: Oh, wow.

Dr. Mike Patrick: So I mean, it was just the recipe for disaster. So make sure those candles are out before you leave.

Dr. Lara McKenzie: Out before you leave, yeah.

Dr. Mike Patrick: I did get ahead of myself with the carbon monoxide thing. I wanted to circle back around to that really quickly. What are some of the symptoms of carbon monoxide poisoning? What would make you concern that… Because not everyone does have an alarm. We recommend that you do. But what would key you off to the fact that could be going on?

Dr. Lara McKenzie: Well, what’s confusing about carbon monoxide poisoning and sort of the low level poisoning, is it’s going to seem like the flu. The symptoms are very similar. You might have vomiting. You might have a headache. You maybe achy. And so, if more than one person in the house has it, you start to think maybe it’s the flu, but that can be a clue to health professionals that maybe there is a carbon monoxide poisoning in the house.


So in the very worst cases, you don’t even have that. You can just die from it, and it’s called the silent killer because carbon monoxide gas is odorless. There’s no sound. There’s nothing to tell you that’s occurring.

Dr. Mike Patrick: Again, children and elderly are going to be little bit more susceptible to having the symptoms earlier than maybe others in the home.

Dr. Lara McKenzie: Exactly, yup.

Dr. Mike Patrick: All right, well, really great things to think about, and there’s lots more. As I was preparing for the show, I thought we’re not going to be able… We’ll scratch the surface but there’s a lot more in the Make Safe Happen app just as it relates to fire and burn safety. There’s so much in fact that we’re going to have to ask you back.


Dr. Lara McKenzie: I’m happy to come back. I could talk about this for hours.

Dr. Mike Patrick: Yeah, and we can talk about different safety issues that are inside the app every few months, so we’re really, really excited about that.

Dr. Lara McKenzie: Great. Thank you. I just wanted to add that we’ve had about 20,000 people download the app so far since we launched last year. We hope to get a lot more people to download. Really having my own children and trying these things in my home made me realize in a significant way that it’s incumbent upon researchers to make the information that we provide easy to access and implementable.

So that’s really my goal in sharing this kind of information, working with Nationwide in the Make Safe Happen program and creating this app.

Dr. Mike Patrick: And, it’s free.

Dr. Lara McKenzie: It’s free.

Dr. Mike Patrick: When you look at the depth that it goes and it terms of really going from room to room and with product recommendations and, “Hey, these are the ones that we had found to be the safest.” Even though there’s some commercial bias there, it’s I think very helpful for parents to be able to know this is the one that we’re talking about. This is the one that we’ve tested and that others have tested.


Dr. Lara McKenzie: Well, I should just clarify. We don’t recommend a particular product over another. We put all the products that were appropriate for that problem area in a list for you. So, it’s really up to you to decide which one is going to be best suited to the features of your home, but we’re going to help you by figuring out, “This kind of lock is good for this kind of knob on your cabinet.” That’s the kind of recommending that we’re doing.

Dr. Mike Patrick: But if there’s an example that’s not so good, it’s not going to be included in that list.

Dr. Lara McKenzie: Correct.

Dr. Mike Patrick: So, if one of them is on the list, you can feel good someone has put some thought into, the fact that it’s there.

Dr. Lara McKenzie: Yup.

Dr. Mike Patrick: Again, folks can find this at That’s the website. And then, there’s iOS app and Android app. Again, in the Show Notes, we’ll put links to all these things to make it easy for folks to find. Again,, Show Notes for Episode 336.

Again, thanks for stopping by. Really appreciate it.

Dr. Lara McKenzie: Thank you.


Dr. Mike Patrick: I want to preface the following edition of News Parents Can Use with a few comments. Our new segment ordinarily deals with common issues parents face, the latest research surrounding those issues and helpful hints on making the research relevant and practical for your family.


This week, my new segment is directed more at the pediatric providers in the audience, which is one of the reasons I placed the segment at the end of the program rather than leading with it. After all, parents, you’re why we produced this podcast and you’re certainly welcome to stick around for today’s news because you may well find it interesting. But again, my primary audience is shifting right now to providers.

So let’s get to it. We all know the refugee crisis is coming out of Syria and other parts of the Middle East and that it’s a very real crisis. You read the news. You’ve seen the pictures and in addition to this, many people have a variety of strongly held opinions regarding the refugee crisis. Here in the United States, there are ongoing political discussions as to how many refugees we should take in if any, what dangers refugees pose, how will they affect our communities — lots of debate and opinions out there.

My goal here is not to speak to those opinion or pick a side or make a case either way. So what is my goal? Well, the refugee crisis affects lots of children. In fact, hundreds of thousands of children. So my first goal really is simple awareness of what’s happening to many families and kids on the other side of the world.

My second goal is this, when refugees enter a new country, wherever that country is, they enter with health care needs, and the local medical community isn’t always prepared with the resources they need to help. Material resources are, of course, an issue but evidence-based recommendations on how best to care for refugees is another important issue. And that’s my second goal here, to provide practitioners who find themselves caring for children wherever they are in the world with some evidence-based resources to help you do your job.

We have lots of health care providers in the PediaCast audience. We reach folks in over 100 country throughout the world. So after framing the extent of the crisis, I want to provide those practitioners who find themselves caring for these children who have been urgently displaced from their native country with some tools that you can use.


Here’s where parents come in to the picture as well. Your physician may be caring for refugees that you are unaware of, from Syria and other parts of the world. So please let your doctor know about this episode of PediaCast because I’m going to connect them with some very helpful evidence-based resources.

So how do I go about doing all of this in hopefully in unbiased and evidence-based way? Well, like most of our news stories, I turned to the health care literature in medical journals. So our first two stories will frame the issue of large numbers of people fleeing Syria. Why exactly is it dangerous for children to live there and what is the state of the Syrian health care system? I think that will help us better understand why massive number of people are on the move.

Then, I want to talk about best ways to care for these people from a healthcare perspective and also briefly from an educational perspective.

So we’re going to deviate a bit from our normal pediatric news focus. We probably are not going to be talking about your family but we are talking about someone’s family. Hundreds and thousands of people are on the move and medical providers must care for them. PediaCast is heard in over 100 countries and I really do want to connect the international community of health care providers who find themselves caring for refugees with evidence-based resources to help them do their job.

I also want to mention that we’re talking about a war-torn region of the world. There may be something that may be difficult to hear. So if you have little ones listening right now, this is a good place to stop and maybe come back later if you’re interested in hearing more.

For those of you who are sticking with us, let’s begin by framing why so many people are on the move, and I think this story from the British Medical Journal gives us one of the reasons.

Using explosive weapons in populated areas in Syria has disproportionately lethal effects on women and children and should be urgently prohibited. So say a team of international experts in The British Medical Journal, who report that for Syrian children, explosive weapons such as bombs and missiles are the most lethal.

This is the first study that analyse the impact of different weapons on civilians and indicates that using explosive weapons in populated areas in Syria has disproportionate lethal effects on women and children and should be urgently prohibited.

The author say violent deaths have been considerable in Syria. They say the report commissioned by the United Nations which found that from March 2011 to April 2014 over 190,000 verifiable violent deaths of individuals had occurred, including both combatants and civilians.


But associations between weapon types and victim characteristics in armed civil conflicts are not well understood and are rarely studied. So a research team, led by Dr. Debarati Guha-Sapir at the Universite Catholique de Louvain in Belgium, examined 78,769 civilian violent deaths that occurred in Syria from March 2011 to January 2015 for associations between weapon types and demographic groups.

Of this total, 77,646 deaths were in the rebel controlled areas and 1,123 were in government controlled areas. Although the majority of deaths were of men, nearly 25% of Syrian civilians killed were women and children. The results show that children are more likely to be fatal victims of air bombardments, shells, and ground level explosives than men or women.

In government held areas, child deaths were five times as likely to be due to ground level explosives, such as car bombs compared to deaths among men. Women were the second most likely to die due to explosive weapons, while the likelihood of death for men was higher for shootings and executions.

The government and rebel factions in Syria typically claim that the targets of their bombs and shells are enemy combatant strongholds, but the authors of this report say, “Our findings indicate that for Syrian children, these are the weapons most likely to cause death.” They argue that air attacks and explosive weapons in populated areas should be prohibited or systematically monitored to demonstrate civilian protection.

Furthermore, the evidence that child deaths from air bombardments, shells, and ground level explosives were equal or higher than those caused by chemical weapons, should prompt equal international condemnation and control.


They conclude by saying, “Our study shows that civilians become the main target of weapons and bear a disproportionate share of the burden of bombings. If we are to look for root causes of the migrant and refugee crises in Europe today, this is surely a major contributor.”

In an accompanying editorial, Hamit Dardagan, Co-director at Every Casualty Worldwide, says, “These findings should give pause to anyone who thinks there can be a safe hiding place for women and children in populated areas when high explosives are being used, or who imagine that Syrian’s many bombed-out apartment blocks must have first been emptied of civilians.” It also underlines the urgency of growing moves to ban the use of such indiscriminate weapons in highly populated areas.

So here’s the thing, the international community can call for a ban on explosives in populated areas but this is war, with indiscriminate bombings that affect hundreds of thousands of people including many children, so the ban is likely to be heeded… I’m sorry it’s unlikely to be heeded. So kids and families are fleeing for their lives and one of the main reasons is just this violence in these populated areas. There’s just nowhere to escape from it.

Here’s another snapshot of life in Syria. This one comes from the New England Journal of Medicine. Even in war, hospitals have a kind of invisible bubble around them, making them neutral territory and off limits for aggression for the sake of medical teams and their patients. But in Syria, that bubble has burst dozens of times according to a new report from the group physicians for humans rights. The hospitals in just the eastern half of Aleppo City has suffered 45 attacks in three years and two-thirds of them have closed. That may put medical facilities and workers in other conflict zones in danger, too. This, according to a report in the New England Journal of Medicine which cause on the international community to react on these violations of international humanitarian law and the principle of medical neutrality.

Dr. Michele Heisler, a professor with the University of Michigan Medical School who also volunteers to do research with physicians for human rights, says “Medical professionals around the world think of Syria as not affecting them, but the situation there is setting a terrifying precedent throughout the world. For much of the 20th century, warring parties for the most part had respected medical neutrality and allowed doctors and nurses to provide health care in conflict. But once that starts to erode, it could make even the basic provision of health care impossible.


Heisler and her colleagues documented the plight of Aleppo hospitals by interviewing 25 Syrian physicians and other health care workers. Many had crossed the border into Turkey to attend a medical conference held this past July by the Syrian American Medical Society. They returned to their posts afterward, despite knowing that over 95 percent of Aleppo’s doctors have fled the country, or been detained or killed.

The report examines the impact of attacks on the medical infrastructure and personnel in the portion of Aleppo held by oppositional forces and health care status and needs of the civilians in eastern Aleppo.

Dr. Heisler and her colleagues recount some of the report’s major findings and the history of the Geneva Conventions dating back to 1864 that have protected hospitals and medical teams in wartime. They describe the particular effects of the barrel bombs dropped on hospitals and other civilian spaces, and the strategies that Aleppo’s health professionals use to treat those wounded by these bombs and provide medical care despite shortages of human and material resources.

Filled with explosives, shrapnel, nails, and oil and weighing 200 to 2000 pounds, barrel bombs are dropped from helicopters and break into thousands of fragments upon impact. The numerous wounds they cause require trauma care, and the remaining hospitals and teams struggle to provide needed treatment. No working MRI or CT scanners remain in Aleppo.

Because of this targeting, hospitals have literally had to move underground. When possible, operations had been moved into basements. Most hospitals still functioning in Aleppo have been attacked repeatedly. One has been hit with barrel bombs seven times.

Researchers point out that Syrian hospitals and medical teams aren’t the first to suffer direct and even deliberate hits. They note instances in Afghanistan, the Democratic Republic of Congo, Rwanda, Somalia, the former Yugoslavia, Iraq, Bahrain, Libya, Ukraine and Yemen.


But the attacks in Syria are the most egregious, they say, because there are so many. They call the targeting of medical care particularly troubling since the leader of the Syrian government, Bashar Al-Assad, is a physician by training. Just as the international community stood up to Syria’s government over its use of chemical weapons, Heisler and her co-authors call for an international stance against violations of medical neutrality.

They say, “The longer the international community fails to enforce humanitarian law, the greater the chance that these violations will become the ‘new normal’ in armed conflicts around the world, eroding the long-standing norm of medical neutrality. Left unchecked, such attacks on medical care will become a standard weapon of war.”

Dr. Heisler expresses admiration for the medical professionals who have stood by their oath to provide care for patients, despite the risk to themselves. The report highlights the improvisation, ingenuity and persistence they have shown in Aleppo, keeping even dialysis units running without any nephrologists. Researchers believe the international medical community needs to hear their story.

She says, “They are true heroes. All the doctors we interviewed expressed their determination to stay as long as there are still civilians living in Aleppo who need medical care.”

Dr. Heisler says, “The conditions under which they work must not become the norm. If this is not stopped in Syria we’re going to see more direct attacks on what we’ve thought of as sacrosanct. The right to provide and receive medical care is also under siege.”

So I think this snapshots from the medical literature provide some insight in to why families are fleeing. And they are fleeing. They’re going somewhere. It could be that some of these folks end up in your community. So how do we care for them as providers. How can we as parents, advocate for these displaced children if they happen to show up in our community?

Well, one way we can make a difference for them is by empowering pediatric providers with evidence based information on how to care for them. So the next set of stories is primarily aimed again at the providers in the crowd. But parents, if you’re still with me, I think this information may also be of interest to you and you can help spread the word to providers in your local area wherever you are in the world by pointing them in the direction of this episode of PediaCast so they can find helpful evidence-based resources and guidelines on caring for refugees, regardless of where those refugees are coming from.


As we embark on this journey, I have to give a shout out and credit to the folks in Canada, because researchers there are the forefront of providing refugees with evidence-based care. The first story in this regard is from 2011. It comes from the Canadian Medical Association Journal.

Even though it’s from 2011, it’s really the latest evidence-based guidelines out there that specifically deals with health care concerns related to refugees. The CMA Journal calls their resource the largest, most comprehensive evidence-based guidelines to immigrant health designed to help Canadian physicians meet the unique needs of this group.

Immigrant and refugee health needs may differ from those of Canadian-born people, and they have been exposed to different diseases, environments and living conditions as well as genetic factors. The guidelines, based on evidence from around the world are focusing on helping primary care physician provide for the often complex health needs of immigrants and refugees.

Created by the Canadian Collaboration for Immigrant and Refugee Health, the project involved more that a 150 investigators including 43 family doctors, 34 researchers, staff and nurse practitioners as well as other authors.

The size of Canada’s immigrant population is growing but there is lack of evidence-based information on approaches to immigrant health worldwide. This was in 2011 prior to current Syrian crisis. Back then, there were 200 million international migrants whose movement across borders have significant health impacts from any countries. While health task forces in Canada and the US had developed clinical prevention recommendations, they are not directly tailored toward the unique backgrounds and needs of immigrants and refugees.


Dr. Kevin Pottie, one of the co-authors of the report and a professor with the University of Ottawa, says “Use of evidence-based methods has yet to substantially affect the field of migration medicine. Our evidence reviews synthesized data from around the world, and our recommendations focus on immigrants, refugees and refugee claimants, with special attention given to refugees, women and the challenges of integrating recommendations into primary care.

“Our recommendations differ from other guidelines because of our insistence on finding evidence for clear benefits before recommending routine interventions. For example, in the case of possible intestinal parasites but no symptoms, the guidelines recommend blood testing for certain parasites and foregoing traditional stool testing, marking a shift in practice.”

The recommendations are available as a free online package which include a summary document, clinical guidelines to immigrant health, online case studies and detailed evidence and methodologies. Content focuses on four areas — infectious disease, mental health, , physical and emotional maltreatment, chronic and non-communicable diseases and women’s health. Detailed indexes on specific illnesses and conditions including post-traumatic stress, mental health, pediatric issues and more to make it easy for physicians to find information.

The author conclude by saying, “More work must be done to improve immigrant access to health services. We hope this evidence-based initiative will provide a foundation for improved preventive health care for immigrant populations.”

I’ll put links in the Show Notes for this episode, 336, to the entire package of evidence-based recommendations from the Canadian Medical Association Journal along with the link to a nice evidence-based preventive care checklist from the University of Ottawa which is tailored to the region of the world where a particular refugee that you are caring for is coming from.


I’ll put links to the checklist and the whole package of evidence-based guidelines again in the Show Notes for Episode 336 over at

But what about now, in 2016? What unique health needs will Syrian refugees face and how can physicians best provide health care to them and their families? An updated article posted online by the Canadian Medical Association Journal provides recommendations on screening and advice for primary care physicians to deal with these specific population’s health care needs.

The goal of health settlement is to link newly arriving refugees to the primary health care system in that local community. Canada, like many other countries is preparing for a large influx of Syrian refugees with an estimated 25,000 newcomers or more to arrive in the next 12 months. Many of these families who have lived in the past three to four year in refugee camps in the Middle East.

Although all refugees will have received a government immigrant medical examination as part of the immigration process, Canadian physicians will need to provide a health assessment as part of the health settlement. In terms of mental health, practitioners should convey willingness to talk about traumatic events. However, pushing for disclosure of traumatic events in well-functioning individuals who have survived torture could be harmful.

Individuals with high levels of symptoms or persistent impairment over several months should be referred to appropriate psychotherapeutic interventions.

Dr. Kevin Pottie, with the University of Ottawa says, “We hope these recommendations will help physicians provide evidence-based care for Syrian refugees. These people have encountered the trauma of war, repeated displacements, refugee camp life and poverty. Access to safe housing, employment and health care may have strong protective health effects.”

Recommendations for caring for asymptomatic refugees include: not screening routinely for trauma, but physicians should be alert for anxiety, sleeplessness, depression and other mood disorders that could be linked to post-traumatic stress disorder; vaccination of children and adults without valid records for measles, mumps, rubella and other illnesses, depending on age; screening of all children and adults for chronic Hepatitis B and vaccination of people who are at-risk; not screening for tuberculosis as incidence is low in the Middle East.

The authors suggest that physicians should consider screening for Hepatitis C, testing and vaccination for varicella also known as chicken pox in people who may be susceptible and checking serology for the intestinal parasite Strongyloides.

I’ll include a link to the entire article from the Canadian Medical Journal. It’s called “Caring for a newly arrived Syrian refugee family”. You can find the link again in the Show Notes for this episode 336 at


There’ll be another link to additional refugee health articles, previously published guidelines and other resources ion the Show Notes. So lots of stuff there if you do find yourself caring for Syrian refugees.

Then, there are also the educational considerations. There’s an urgent need to improve both short-term and long-term approaches to education for the large number of Syrian refugees children in Turkey, Lebanon and Jordan according to a new RAND study. Improving the quality of the current education system will require increasing instructional time, improving teacher training, expanding school monitoring and creating programs tailored for children who have missed instruction for as long as three years because of this crisis.

Investigators say infrastructure and transportation systems will also need to be improved to accommodate the refugee children into the education system.

The report offers recommendations to host country officials, United Nations agencies and donors about how to improve quality and access to education for the Syrian refugee children under increasingly strained budgets. It also outlines the societal implications of how refugee children are integrated into host country education systems.

Dr. Shelly Culbertson, lead author of the report and a policy analyst at RAND, which is an independent non-profit research organization, says, “Establishing education for a large number of refugees is a complex task that requires a combination of short-term solutions, long-term planning and evidence upon to which base future decisions. The existence of so many refugees is changing the demographics of the host countries and creating significant challenges for both the refugees and their host countries. ”


According to the United Nation’s High Commission for Refugees, the ongoing civil war in Syria has created the greatest refugee crisis the world has seen since the end of World War II. Only half of Syrian refugee children are accessing education with nearly 700,000 children not attending any formal education in Turkey, Lebanon and Jordan.

Classes are overcrowded and instructional time has been shortened because of double shifts created to handle the influx of students. Teachers are inexperience in handling difficult classroom conditions that include traumatized students, some of whom have missed years of education.

Louay Constant, another of the study’s co-authors and a policy researcher at RAND says, “Family poverty and policies that prohibit adult refugees from working had left some households desperate to find ways to earn a living. Some households are taking drastic measures by allowing, or compelling in some cases, children to work in exploitative conditions when they should be in school.

“Ten percent of Syrian children in Jordan are involved in child labor. Moreover, an increase of incidences of early marriage of girls is to some extent attributed to the desperate financial situation faced by many of these refugee households.”

It could be decades until many refugees return to their homes, if ever, making it critical for host countries to create sustainable plans for the education of Syrian refugee children while maintaining quality education for their own citizens, this according to the researchers.

So lots of serious stuff to chew on this week as we begin a new year of PediaCast. Again, my goal here was one of awareness and evidence-based resource sharing for pediatric providers around the world who like it or not are asked to take care of urgently displaced children.



Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really appreciate that. Let us know what you think of the new format.

Also, thank to Dr. Lara McKenzie, principal investigator with the Center for Injury Research and Policy at Nationwide Children’s Hospital.

Don’t forget, PediaCast is a production of Nationwide Children’s Hospital.

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And, while you have your providers’ ear, please tell them we have a podcast for them as well, PediaCast CME. Similar to this program, we turn up the science a couple of notches and provide free Category 1 Continuing Medical Education Credit for listening. Shows and details are available at

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


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

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