Ibuprofen Allergy, Fever Truths and Myths – PediaCast 421
- This week we answer a listener question about severe ibuprofen allergy (anaphylaxis) and examine truths and myths surrounding fever. We hope you can join us!
- Teething Necklaces
- Ibuprofen Allergy
- Febrile Seizures
- Communicating Medicine: Harnessing the Power of Social Media in Healthcare (Conference)
- A Brush with Anaphylaxis (Blog Post)
- Drug Allergies and the Importance of Getting Them Right – PediaCast CME 37 (Podcast)
- Seasonal Allergies – PediaCast CME 34 (Podcast)
Announcer 1: This is PediaCast.
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It is Episode 421 for January 16th, 2019. We're calling this one "Ibuprofen Allergy, Fever Truths and Myths"
I want to welcome everyone to the program.
It's our first episode of 2019 and right out of the gate I am starting the new year with a cold.
I feel, actually, I feel pretty good. A few days ago, not so much. But the voice just hasn't really recovered yet.
Hopefully, it won't be too much of a distraction because we have some great information to cover. And I really didn't want to postpone this episode because it's been since before the holidays since we last gathered together, and we've got another show next week, and after that, and after that. And really, we had great information got out.
So hopefully, my voice won't be too much of a distraction. I just may have to take more pauses and takes more sips of water than normal.
It is the beginning of the new year and it's a great time for resolutions. And that includes podcasts producers and show hosts.
So I did come up with a new year's resolution related to the podcast which I will share at the moment. I sort of do this every year, just sort of a good time to a make a little bit of an adjustment and how you're doing things especially when you have a podcast that's been going on as long as PediaCast has.
So I'll let you know what we have in store, kind of what my thoughts are for the coming year of the episodes.
First so, if you haven't heard, and especially if you have a young baby at home, last month, the FDA (Food and Drug Administration) put out an important alert recommending that parents not use teething necklaces for the babies who have teeth coming into the gums.
And I just wanted to make a comment on that.
A couple of issues with teething necklaces, you know one, anything that goes around your baby's neck could potentially be a strangulation hazard. You know, you don't want to think about that, even when you think well, you know, that they're wearing something but I'm watching them and so if they have a problem I could intervene very quickly.
But, you know, we can have distractions so easily and not really think about it. You know, the phone rings, someone's at the door, you look, you know, away for just a few seconds, that's all it takes. And if that necklace gets wrapped around their neck and cuts off their breathing, bad things can happen in a hurry.
Also, they can bite off pieces or pieces can fall off and they can choke. And the reason that the FDA put out this warning is because there have been instances of babies with bad outcomes because they either got strangulated by the necklace or they choked and either died or, you know, you can be neurologically devastated if your brain goes without oxygen for a little while.
So they did come out with that alert.
Now, there was some pushback that I noticed on social media. You know, some parents were saying, "Well, what about the necklaces that I wear?" Like the mom or the dad wears a necklace around their neck and holds the baby and then the baby can chew on the necklace right there in their arms.
You know, I would say that's safer than having the baby have their own necklace. I mean, that makes sense because it's a little harder to get distracted when the baby's in your arms and you're right there.
The question is though if something were to happen, would you know what to do? You know, if they did bite off a piece of it or a piece went into their mouth and they started to choke on, how comfortable are you that you could get that piece out of their mouth?
You know, sometimes, if it's just the right size and gets lodged in the airway, can be difficult even for emergency medical people to get that out of the airway and out of the mouth and you could have bad outcomes again.
So probably, not best practice to use teething necklaces. And that's why the FDA came out with their warning.
Also, you don't want to use numbing agents on the gums, especially those that contain Benzocaine and other anesthetic-type agents that numb, because these can cause a condition called "Methemoglobinemia" where the hemoglobin changes and responses to this chemical and doesn't carry oxygen as well, and that could also be dangerous and life-threatening.
So ibuprofen, if kids are older than 6 months, otherwise Tylenol, ask your doctor for the appropriate doses.
And then, cool is okay, you don't want to cause, you know, like frostbite. But if you have, you know, a popsicle, something that's, that chilled or cold on the gums can help, makes a little bit of a mess.
We used to take a washrag and put water, you know, get it wet with water, put that in the freezer, she gets those little ice crystals on there. And again, with close supervision, kind of let your child suck on that, can be cooling and a little bit of a texture feel on the gums.
And again, as long as you're right there with them making sure that they don't, you know, put the whole washcloth in their mouth. Or they start to get fussy because it's getting too cold, you want to pay attention to that as well.
Alright, let's move on.
I do want to thank the fine folks at the Children's Hospital at the University of Oklahoma in Oklahoma City for inviting me last week to present at their Grand Rounds. It was really exciting.
We talked about social media and medicine, we talked about the importance of social media engagement by medical professionals, the many barriers that keep doctors and nurses and all sorts of, you know, folks that work in medicine, from participating in social media. And I shared some practical tips for overcoming those barriers and outlined the many returns on the time investment when medical professionals engage.
It's important because there's so much myths and misconceptions out there, things that are based on stories and anecdotes that aren't necessarily, you know, really rooted in evidence, things that seeing like they're related but there's not really a cause-and-effect relationship, that's really an important thing to differentiate between.
And medical professionals are in a good, you know, a good position to share evidence-based information and, you know, the more of us that participate and engage and create digital content, the more likely it is that individual parents and consumers, medical consumers, are likely to come across good information.
So this is important, to get involved.
I also did an afternoon workshop on The Art of Digital Storytelling which is important as medical professionals seek to engage with creative content like blog posts, YouTube videos, podcasts, infographics and alike.
How can we be interesting and helpful online?
You know, and telling a passionate story and get folks' attention. We're all fulfilling all the other time commitments in our life.
So anyway, it was a lot of fun. Thanks again to all of you at the Children's Hospital in Oklahoma City for inviting and hosting me. Really appreciate it, it was a terrific meet, it was really a terrific meeting, so many of you.
And I hope our paths will cross again.
I mentioned all of this because we do a large number of pediatric providers in this audience, even though our target audience for the podcast is parents. And there's increasing interest from medical providers on getting involved and making a difference with social media and digital communications which is something I've been doing since 2016.
And it's just fun sharing my experiences and things learned, many times, the hard way with my medical colleagues. And I think, you know, as parents out there, when you do see your child's doctor or their other medical providers, you know, let it, encourage them. Say, you know, we see all the stuff, you know, that you educate us about and you know, we bring a page, "Did you see this on social media?"
You know, and you sort of start a stray on what the evidence shows, maybe you should get involved in a social media and contact creation because, again, the more doctors you do with, the better.
So, you know, in terms of how do they learn how to do it in an efficient and effective manner.
Actually, co-author of the book that will be coming out later this year called "Social Media for the Medical Professional." I'll share more information on that as the publication date approaches.
But there is another upcoming opportunity that I think providers would be very interested in.
We're going to present an all-day conference here at Nationwide Children's Hospital on Friday, June 14th, 2019. It's called "Communicating Medicine: Harnessing the Power of Social Media in Healthcare."
And it includes an afternoon of hands-on workshops where you can sharpen engagement, writing, and interviewing skills, and earn several hours of Category 1, Continuing Medical Education Credit.
Be sure to make a weekend of it.
You can also visit the world-famous Columbus Zoo, which is the Zoo that Jack Hanna built. We have a terrific Science Museum, COSI. The wonderful Franklin Park Conservatory and Botanical Gardens. We have art galleries in The Short North, German Village has lots to explore. And terrific mom-and-pop restaurants all over the place.
So please consider joining us in June, again for our conference "Communicating Medicine: Harnessing the Power of Social Media in Healthcare." And I'll include a link to the registration page in the show notes.
Let your providers know about it. Say "Hey! You know, I'd love it if you have a blog. And if you want to learn more about blog writing, check out this conference, you can earn Continuing Medical Education Credit."
Because this is an important thing that importance go for medical professionals to have. And again, I'll include a link to the registration page in the show notes for this Episode 421 over pediacast.org.
I mentioned new year's resolutions for the podcast, I do this every year as I looked toward the year ahead and think about "What we could do a little differently? What works? What's not working? How can we make the program better?"
And as I thought about this, the biggest thing I noticed is that many of the basic bread-and-butter pediatric topics, things like fever, and colds, and ear infections, skin rashes, head lice, scabies, croup, asthma, stomach bugs, ringworm, cold sores, infant teething.
You know, we've covered all of these things in the past but many of them, it was quite a while ago, and the shows are somewhat buried in the feed. And in some cases, you know, knowledge and recommendations change.
And so my new year's resolution for PediaCast this year is to cover many of these basic pediatric topics anew. After all, this is the stuff that parents come across and ask about all the time.
And so, I'm going to really try hard to keep the shows practical and useful this year and really focus on common every day pediatric and parenting stuff. We're going to start that turn right out of the gate with this episode as we answer a listener question about an allergy to ibuprofen and cover truths and myths related to fever.
And of course, I'd love your help in identifying other every day pediatric and parenting topics. You know, things that parents deal with all the time.
Just let me know, it's easy to get in touch. We do have a contact page over at pediacast.org that you can write in. We have a telephone line, 347-404-KIDS (347-404-5437) You can call and leave a message that way if you want to suggest a topic or you have a question.
And of course, we're on social media. Facebook, and Twitter, Instagram, those are three primary places where we are, just search for PediaCast and follow on and you can suggest topics in those places as well.
Before we get started with ibuprofen allergies and fever, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
So it's really important, if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.
So let's take a quick break and then I will be back to talk about ibuprofen allergies and fever. That's coming up right after this.
We are back and we're going to start things off with a listener question. This comes from Amanda in Richmond, Virginia.
"Dr. Mike, I really love your show. I discovered it a few years after my son was born and I'm so thankful for such great consistent information. Here's my question:
Just after my son's five-year birthday, he had some sort of allergic reaction. He'll complain of a headache, and I took his temperature, he had a 100.2-degree fever. So I gave him ibuprofen. He hadn't had anything to either drink. Within 20 minutes, his face and lips were swollen and he was struggling to breathe. We gave him Benadryl, called 911, and by the time paramedics arrived, his breathing had improved. They did not administer epinephrine. That night, we took him to a pediatric urgent care to check him out, and the doctor told us that reactions like this sometimes happen in kids and we should not worry about it. We went to our pediatrician the next day and he prescribed Prednisone and 72 hours on Benadryl and refer us to an allergist. Since then, we have seen two allergists, we did allergy test for food and environmental allergies and he did not have any reactions. Both allergists guessed that his reaction was to the ibuprofen even though he had ibuprofen many many times prior to this. He also sees a pulmonologist for mild asthma who agreed that the reaction was to the ibuprofen. I've been told there are no specific tests for NSAID allergies."
And I'll pause right there, NSAID stands for Nonsteroidal anti-inflammatory drugs, and ibuprofen belongs to this class of medications.
"So here's my question: I know NSAID allergies are very rare and part of me still wonders if the ibuprofen really caused the reaction. Is there anything else I can do to figure out the source of the allergy? It worries me to think he could have a life-threatening allergy to something unknown. Is there any truth to what the first doctor said? That sometimes kids have reactions without an allergy diagnosis?
Thanks for reading. I look forward to hearing your thoughts.
"P.S. To read a longer and more detailed version of what happened, here's a link to my blog about the incident."
And I'll put a link to her blog post, to Amanda's blog post in the show notes for this episode of 421. So if you want to read more about what happened to Amanda and her son and her families for what they went through, you can find that pretty easily over on the show notes.
So thanks for the question, Amanda. I really do appreciate you writing in.
So a few things to say about this, first, the medical term for a severe life-threatening allergic reaction is "Anaphylaxis" and this fall under the category of what we would call a Type 1 Hypersensitivity Reaction. Anaphylaxis is on the extreme end of these types of reactions.
But whether they're mild or extreme, they're caused by a common mechanism which is our body makes a type of antibody called "IgE"
And it makes this IgEs against particular allergens. So an allergen is just something for an, immerse the body that your immune system doesn't like and antibodies buying to the allergen and a reaction goes from there.
Now, these IgE antibodies are bound to mast cells, in body tissue, and on basophils in the blood. So these are cells that have the IgE antibody attached to them.
And when a particular allergen comes along, one that matches that particular IgE antibody, it binds to the antibody which has a trigger effect and that results in the mast cell or the basophil releasing its contents into that particular tissue or the bloodstream, in the case of basophils.
Now, each mast cell or basophil has hundreds of granules that can be released. And each granule contains more than 30 different chemicals. The most famous of which is histamine.
And these chemicals then cause the symptoms of an allergic reaction. Now, this is an immediate reaction. So it always happens soon after exposure.
There are other types of allergies and hypersensitivity reactions that are delayed. But this is one that happens immediately.
And the most common symptoms of these immediate reactions. You know, it really depends on the location where the chemicals are released. Itchy eyes, runny nose, itchy hives on the skin, are going to be common.
And Amanda mentioned Benadryl, and the reason of that helps in this situation as because it's an antihistamine. Meaning, it blocks the chemical histamine from causing these common symptoms, which is why we use antihistamines as one line of treatment for seasonal allergies, especially the antihistamines that are less likely to cause drowsiness, so things like Claritin, Zyrtec, Allegra, those sorts of things.
Now, what Amanda is talking about, sounds like a far-cry from watery, itchy eyes, and runny nose, or few hives scattered around the skin. And yet, the mechanism is very similar except in the case of seasonal allergies, the mast cells are releasing their chemicals only in the eyes and nose and upper respiratory tract, or in the case of hives in the skin.
Things get diced here when the antigen, whatever it is, travels to many places in the body. And when the allergic person has many mast cells and basophils, with many instances of a specific IgE attached.
And the chemicals inside these many cells are setting there, just waiting to be released.
So reaction to pollen, you know, tends to be limited to the eyes and the nose.
But foods and medicines, they travel through the bloodstream to distant places. And so, if you're a person with large numbers of a particular IgE antibody attached to a large number of mast cells and basophils, then they're going to release lots of those chemicals and in many more places when exposed to the offending allergen, which in this case, in the case of food and drugs, are going to be, you know, much more widespread in the body.
Now, the most common allergens that trigger, sort of diffused severe whole-body reactions, are going to be food, as I mentioned. And in particular, peanut, tree nut, shellfish, finned fish, milk, and egg, are the most common.
Insect venoms, especially of those of the order Hymenoptera, so wasp bees and ants. Those venoms can get in the bloodstream and cause anaphylaxis in addition to localized reactions.
And then medications, and antibiotics, and NSAIDs are actually among the most common of medications that can cause anaphylaxis.
So there's that word again, NSAIDs.
So yes, NSAIDs, including ibuprofen, can cause anaphylaxis. Other NSAIDs include aspirin which kids should not take unless directed by a doctor because of the risks of Reye's Syndrome which is a topic for another day.
Motrin and Advil are common brands of ibuprofen. Naproxen which goes by the brand name Naprosyn is also an NSAID.
Acetaminophen or the brand name Tylenol, that is a different type of fever reducer and pain medicine. It is not a nonsteroidal anti-inflammatory drug. So that one is not in the class of NSAIDs.
Now, the next question:
When does an allergic reaction become anaphylaxis?
Remember, we're talking about diffuse internal reactions, not localized reactions.
So, we have evidence of a reaction extending into the whole body. So it's not just the eyes, nose, and skin. But we also have involvement of the lower respiratory system. So wheezing, coughing, difficulty breathing. Maybe by coughing, not an occasional cough like a persistent cough, it's, you know, really troublesome. Maybe the GI tract, so you could have abdominal pain or vomiting. Or the cardiovascular system such as, you know, decreased blood pressure, hypotension which can lead to light-headedness and passing out. And of course, bad hypotension, really low blood pressure can lead to death. So this is serious business.
Now, Amanda's son had what sounds like the right symptoms. You know, swollen lips and face, difficulty breathing, that sounds like it goes along with anaphylaxis, and it happens shortly after taking ibuprofen with no other known exposures around that time. And that's why two allergists and a pulmonologist think ibuprofen lead to anaphylaxis in this particular case.
By the way, you're not born with these types of allergies. At some point, the body recognized an allergen as for and makes a bunch of IgE which sits on mast cells and basophils waiting for the next time that particular allergen comes along.
So it completely makes sense that a kid could have ibuprofen many many times. And then suddenly, seemingly out of the blue, have a life-threatening allergic reaction to it because the time before that, nothing happened, but the body said "I don't like this substance being here. I'm going to make a bunch of antibodies against it and set those on mast cells and basophils so that the next time you had that thing that you've had many times before, suddenly you do have a reaction to it and we could expect reactions to future exposure as well.
It is important to note, that is an important thing to note, that if you do have a severe allergic reaction that is likely that's going to happen every time you're presented with that allergen moving forward. In other words, Type 1 hypersensitivity reactions in anaphylaxis don't tend to come and go.
Now another nugget in Amanda's case is that Benadryl helped her son, which makes sense giving that antihistamine blocks histamine, which is released by those mast cells and basophils and caused the swollen itchy skin and lips. However, the big fear with anaphylaxis is low blood pressure and difficulty breathing and not getting oxygen in the blood which can quickly kill you. And Benadryl will not help the low blood pressure and difficulty breathing, you need epinephrine to reverse anaphylaxis and prevent death.
Hence, the EpiPen or the Epinephrine Auto-Injector, and that is really the one and only first-line treatment for anaphylaxis. That's what you need right away if you're having a severe, life-threatening allergic reaction.
And anyone who has a history of anaphylaxis should have an Epinephrine Auto-Injector, EpiPen's one of the brand names, with them at all times and know how to use it.
And I would say, also parents, friends, and loved ones should also know how to use that because it can truly be life-saving. So you want to make sure.
There are practice ones that your doctor can get a hold, of pharmacists can get a hold of it, doesn't actually have the needle but it works in the same way so you can get the mechanism of how to use it down and you always do identify.
So it's important to know how to do it. And even if you're not the one with anaphylaxis, if you are someone's friend, or their parent, their friend, their loved one, whatever.
So let's continue answering Amanda's question now that we've established a baseline of anaphylactic knowledge.
"Part of me still wonders if the ibuprofen really caused the reaction. Is there anything else I can do to figure out the source of the allergy? It worries me to think he could have a life-threatening allergy to something unknown. Is there any truth to what the first doctor said: Sometimes kids have reactions without an allergy diagnosis."
So these are terrific questions, Amanda.
Because NSAIDs are a big helpful class of medications, right? Many have all sorts of usefulness in treating fever, pain, inflammation, arthritis, and it'll be a shame to live your whole life avoiding them if you don't really have to.
Plus, if the reaction was to something else, you'd sure like to know what it was so you can avoid that thing in the future.
Now with regards to other possibilities, I mean, it sounds like the allergists eliminated other possibilities and they were no other known exposures in the immediate time period of the reaction which leaves the ibuprofen.
Although if you gave liquid ibuprofen to a five-year-old, I imagined that you did, you know, there are other chemicals in the liquid other than ibuprofen. There's flavorings, and dyes, and those sorts of things.
So although it be much more likely that you'd have an anaphylactic reaction with the ibuprofen than to those other things, if you just look at the numbers.
But, you know, it does make sense to sort of verify this. I do want to mention too that, this is quite different than I've been taking ibuprofen and I've had several doses of it and then I just got a regular-looking rash. Because when you're giving ibuprofen, oftentimes, you're doing it because the kid's sick. And they're sick because they have a virus and viruses do cause rashes.
So, you know, doctor who examines your child's skin and really gets the whole history of what this reaction look like and the timing would be able to tease out the difference between something like anaphylaxis and a rash that's caused by a virus and not the medication that you're taking.
So a lot of times, you know, fever reducers and antibiotics can get blamed from causing a reaction that's really caused by a virus.
So that's something else, just to keep in mind.
So, I'm sorry, getting back of on all these tensions, sorry. Talking about Amanda, in particular. So, what's sort of the next step? What can you do if you really want to verify that the ibuprofen is the problem and then to try to figure out, are there other NSAIDs that in the future, if ibuprofen is the problem, are there other choices and options that we have down the road?
And the answer in this situation is typically a drug challenge, where you give ibuprofen and you see what happens. Or you give other groups, I'm sorry, other drugs in that same category. So, other NSAIDs and see what happens.
THIS IS NOT SOMETHING YOU TRY AT HOME.
Okay, I want to repeat that.
THIS IS NOT SOMETHING YOU TRY AT HOME.
For obvious reasons, it's done in a controlled environment, such as an allergy clinic or a hospital room where trained people are ready to respond with epinephrine.
Small quantities of the drug, in question or given, very small, working up to the normal dose. And if the patient, you know, tolerates the medicine, great! It was not the culprit.
On the other hand, if a patient develops immediate symptoms, you know, you started low, then you know to avoid that drug in the future. And you're in the right place to get epinephrine, which is going to take care of those symptoms for you.
And again, in the case of ibuprofen drug allergies, there is some good news, NSAID allergies tend to be drug-specific. Meaning, those allergic to ibuprofen may be able to tolerate other NSAIDs such as naproxen and others. And subsequent drug challenges can sort out which ones are safe and which ones are not.
But again, this needs to be done by a medical professional who knows how to do this, and knows how to do it safely and is equipped to do a drug challenge.
Two more of pretty quick talking points:
One, Amanda asked us, are there any truth to what the first doctor said that sometimes kids have reactions without an allergy diagnosis?
True anaphylaxis involves an allergen, every single time, by the very nature of its definition and mechanism.
Do we always figure out what that allergen is?
Most of the time, we do, through skin testing or drug challenges, through the history. But it's possible than never figured it out for sure, I would not characterize that as common, but it exists in the room of possibility.
Speaking of possibilities, and please do not take this wrong, Amanda.
It is a bit unusual for true anaphylaxis to respond quickly to Benadryl alone. Which then begs a question, "If the reaction was not caused by ibuprofen, and nothing else has found, and it hasn't happened again, was this event really anaphylaxis at all?"
And, you know, there are other types of allergic reactions, which again are beyond the scope of this conversation. Although for those with further interest on this topic, we did do a PediaCast CME podcast called "Drug Allergies and the Importance of Getting Them Right," that's PediaCast CME Episode 37. And we did another one on "Seasonal Allergies," PediaCast CME Episode 34.
Both of those with an allergist, Dr. Dave Stukus. And we'll put links to both of those episodes in the show notes.
The target audience for those are medical providers. But, you know, if you're somewhat savvy and, you know, can pause and look up terms you might not understand. I think, they are appropriate for parents to listen to and learn.
Again, Episodes 34 and 37 on the CME programs.
So there are other types of allergic reactions as have eluded to, you know, again, viruses can cause hives and swelling by a different and non-life-threatening mechanism.
You know, Amanda's son was not a hundred percent well, to begin with. You know, you did take his temperature, there's a reason that you gave the ibuprofen.
And kids can do some funny things, you know. Especially if their face is a little swollen and itchy with hives, they can become anxious, they can hyperventilate, they can hold their breath when they get upset. Which, none of that is true anaphylaxis. But it sure could look like anaphylaxis to the untrained eye. But then, it would be, you know, would get better when they calm their breathing down.
I'm not saying that happened. I'm just saying, sometimes, our experience, the way we remember our experience does not line up with what really happened. You know, a common example of this are kids having seizures, you know, two minutes seems like an eternity when your child is having a seizure, and there's plenty of evidence that suggests parents tend to overestimate how long a seizure last by a fairly large degree, which is totally understandable, given the circumstance.
So the way that we, when we experience an event with our kids, sometimes the way we remember and let you describe the event doesn't match up with what really happened.
Again, I'm not saying this was not anaphylaxis in Amanda's case, but there are instances when we form opinions based on inaccurate or incomplete information.
Final talking point:
None of this discussion may actually pertain to Amanda's son's medical condition. We don't have enough information to make an accurate diagnosis to say "Yes, this was anaphylaxis." Or recommend any specific treatment plan. This is merely fun conjecture for educational purposes, thought-provoking conversation, based on Amanda's question.
And my intent, again, to provide educational information, not the diagnosis and treatment plan, especially pertaining to anaphylaxis and nonsteroidal anti-inflammatory drugs.
The best course of action for Amanda and her son is, of course, to follow the advice of the doctor they see in person, the one who can get the entire story, perform a physical examination, evaluate the results of all the tests and challenges, drug challenges performed, if there are. And make an informed recommendation based on the entirety of that information.
In other words, we don't practice medicine in this podcast.
However, I do want to thank Amanda very much for her question because it stimulated this hopefully enjoyable conversation and led, again hopefully, to a better understanding of anaphylaxis for everyone who is listening.
Finally, and I know I already said finally, so finally, finally…
How was that?
The most important take-home point:
If you have a history of anaphylaxis, keep an epinephrine auto-injector or an EpiPen with you at all times. Learn how to use it. Make sure your family, friends, co-workers, teachers, coaches, anyone you hang out with, make sure they know how to use it and then do not hesitate putting the epinephrine auto-injector to work and calling for emergency help if you suspect anaphylaxis might be occurring.
Don't wait for it to get worse. Use the epinephrine.
Thanks once again to Amanda for asking the question. I hope the response was helpful.
If you would like to ask a question of your own, it's really easy to do, just head over to pediacast.org, click on the contact link, and ask away. You can also call 347-404-KIDS, 347-404-5437 to ask a question. You can also suggest show topics through Facebook, Twitter, and Instagram as well.
Next stop, we are going to talk about fevers. And I think this is an important, an important conversation because a lot of parents have questions about fevers, there's a lot of misconceptions, there's a lot of truth about fever that you need to know.
And I just wanted this to be, sort of casual, like if you are just at a dinner party and your pediatrician friend was there, and you're like "Hey! What's the deal of fever?"
You know, what would I say to someone who just wanted to know about fever? You know, what are the myths? What are the truths?
And so, I wrote down some bullet points. And this is going to be a little more informal, I would say, than some of our other discussions here on PediaCast.
You know, the first thing is:
What is it that makes our body temperature what it is?
And, you know, we generate heat. And we generate heat because we are organisms, we are warm-blooded organisms. We make heat through chemical processes, through moving our muscles, there are chemical reactions taking place in our body that produce heat.
And to some degree, that can change depending on our state. So, you know, if you're running a marathon, your body temperature is going to go up because you're moving muscles, you're generating heat, and you're going to have some mechanisms that attempt to drive the temperature down through things like sweating, increasing your respiratory rate, because then you can blow off the heat, so to speak, your lungs react as a radiator renaissance and your skin acts as a radiator, and when you sweat, and you get wind blowing against the skin, it takes, it evaporates the water, it takes heat with it.
So we have mechanisms to drive our temperature up and to drive our temperature down. Which means, there must be a thermostat in our brain, and there is. It is located in the hypothalamus and it does serve to moderate temperature based on a set of conditions.
So first, we have to define, what is a normal core body temperature? By core body temperature, we mean, if you could a probe deep inside your body, because it's going to be a little different on the skin, but if you could put a probe deep in your body, what's normal?
And we come up with this number, it's just a nice number, probably average median number of 98.6 Fahrenheit which translates to 37 degrees Celsius.
But actually, normal temperature varies, you know, can vary from person to person. It can vary by age, by activity, by the time of day, infants tend to have higher core body temperatures than older children. Everyone's temperature is higher in the late afternoon to early evening.
So, you know, we do need a definition of what then we're going to call abnormal that we can just use across the board.
And so, what we've decided is that a fever is a core body temperature of 100.4 degrees Fahrenheit or higher which translate to 38 degrees Celsius. So nice little jump there.
So 37 degrees Celsius is normal, 38 degrees Celsius is a fever, 100.4 Fahrenheit. That is the definition of fever.
Now, I hear from a lot of folks, you know, their kids will be 99, and they will say, that's a fever for them. Because the normal temperature is less than 98.6. Their normal temperature is 97.
So when they're 99, we're going to call that a fever? No!
No, no, no, no!
That's a myth, that's not a fever. A fever, by definition, is 100.4 degrees Fahrenheit or higher.
We need a definition. We need a number that we're going to call a fever and we're not going to waiver from that.
So 99 is not a fever.
And, you know, for most folks who say "Well, my kid usually runs lower," I would challenge you, if you really believe that, make a diary and take the temperature every hour for a few days. Then you'll know what it really is.
But if you're basing that on, "Well, I think they're sick, and I take their temperature, it's really lower," most people aren't taking their temperature when they're feeling well.
So I'm not quite sure where that really comes from, how you know that you usually run lower. I'm just, I'm not quite convinced on that.
But anyway, 100.4 or higher, that's what we're going to call a fever. That's the definition.
Now, this is core body temperature, so, you know, that could be part of it, too. Maybe your child does usually run really lower. But the way that you're taking it is not really represented of what their core body temperature is, so that could be.
So, rectal temperature, well actually, if you would too, you know, flow to central line and get into the bloodstream, deep in the body, that's going to be really a good way of checking a core body temperature. But we're not going to do that, that's very invasive.
So rectal temperature is most representative of core body temperature. And we'll going to make really important decisions based on what that number is.
And the main thing that we're talking about here is in little babies, especially less than 28 days of age, were, if it's a 100.4 or higher, we're going to do a whole septic workup including spinal tap and blood cultures and urine catheters and they're going to get big gun antibiotics and they're going to get admitted to the hospital.
Meaning, we're making big decisions like that. Then rectal temperature's definitely the way to go because we want to be right.
But, you know, rectal temperature's not the most comfortable or easy thing to do and so there are alternatives.
And oral temperature under the tongue is, you know, sort of the gold stander of best of all alternatives. If you want the best alternative, probably oral under the tongue can be kind of hard to get that in kids sometimes, and it can take a little while, it's not an instant reading.
An auxiliary temperature under the armpit, that tends to run a little lower. You know, some would say "We'll add a degree to that." We would say "Just take the temperature, tell us what the number is and how you took it."
So, but an auxiliary, that's an alternative.
And ear scanner, so one that you put into the ear canal. In my experience, those tend to run a little bit on the high side whereas auxiliary tends to run on the low side, under the armpit.
There are forehead strips, some may better than others. They are somewhat sensitive to the ambient air temperature. So cold room versus hot room can make a little bit of a difference on what those read.
And temporal scanner, those are the ones that you kind of slide along the forehead and they, so sort of the same as the strip but it's more of a machine. Those are pretty good, but they do depend on the quality of and maker of the machine or cheaper models, or as more expensive models, and as usual, you get what you paid for.
But, you know, honestly, it's not always important to get what the exact number is. I mean, if your child's running high, and they don't feel well. Okay, they have a fever, I mean, that's all that you really need to say. You don't have to necessarily get the exact number.
And that, you know, so what if it's a dangerous number? We'll get to that. We'll get there.
So, getting it exactly right is really most important in babies. We're going to make significant and really young babies, we're going to make these significant decisions based on the number. And there, you really do want to get a rectal temperature.
Okay, so a few nuggets on taking a temperature.
Again, don't add or subtract the degree, just let the doctor know the reading you've got and how you took it.
Have a thermometer on hand, you know, don't wait for illness to strike. Have one there. And again, it doesn't matter if your child usually runs high or usually runs low. Use the definition, 100.4 degrees Fahrenheit equals a fever.
If it's a 100.2 and your child feels sick, they're still sick. Still, see someone. We're not going to call it a fever but that doesn't diminish the fact that your child doesn't feel well. and may need some help. But we're not going to call it a fever, because 100.4 or higher is a fever.
And this is an important nugget, feeling the skin warmth is not an accurate indicator. And this is because how warm a kid's skin feels is a perception and it's one based on the difference between your child's skin temperature and your skin temperature.
So if you are 97 degrees and your child is 99 degrees, they're going to feel warm. If your child is a 100 even and you're 98, your child's going to feel warm. If you're 97 and your child's 100.2, they may feel actually very hot but they don't have a fever because we, again, we have a number that we're going to use to make that definition.
So, you know, if you're worried they have a fever, it's best to take their temperature. Let your doctor know what number you've got and how you took it.
Fever height is generally a function of how well your body can make a fever and not necessarily how sick you are. You know, some organisms tend to cause very high fevers like the flu, like croup, there are a lot of viruses that can cause very high fevers and it's just, your body, the way that your immune system responds to that virus being present affects the hypothalamus in such a way that you drive the temperature up, pretty high. But it doesn't mean that you are very very sick.
On the other hand, you know, cancers can cause fevers that are not very high and that could be a life-threatening situation.
So we just want to know if the fever is present. You know, the degree of fever is interesting, if it's really high, it does maybe point us more on the direction that there could be something like the flu going on.
And if it's really high in a little baby, that is more concerning, especially the young infants, that there could be something more serious that's going on.
So again, this is all a by-product of the immune system in action. And, you know, from a, from an evolutionary or a design, whichever camp that you're in there, there's a reason that we get a fever when we don't feel well. There's a biological reason for that which we don't want necessarily understand completely whether it is that helps our immune system work better, maybe it inhibits the growth of bacteria or viruses.
We really don't know if there is a reason for a fever, but it makes sense that there probably is, given the fact that it is a universal finding among all human beings.
And there are some hypothesis that the immune system might work better. Higher temperature level, especially white blood cells, or again, bacteria or viruses have less activity, less, either less division or less invasiveness at a higher temperature.
The bottom line is, we don't know.
But on the other hand, one thing that we do know is that you feel pretty miserable when you have a fever. And so, that in of itself is really a good reason to treat the fever is for comfort.
And, you know, you do have increased need for fluid when you have a fever. Your metabolic rate is higher, you're sweating as you break the fever, you have elevated heart rate and respiratory rate in response to the fever. You know, which can make you feel uncomfortable.
And we do know, the immune system can still work at normal body temperatures. There is also no evidence that you're going to be sick longer if we treat the fever, and we want kids to be comfortable.
On the other hand, if your child has a fever but they're acting fine. You know, they're playful, they're eating and drinking, they don't, you know, they don't seem miserable. You don't necessarily have to treat the fever if they're feeling good.
So, you know, it's one of those things, really, we want to treat it mostly to keep kids comfortable. That's the important thing.
Now, you know, another nugget:
Fever, more common at night. People, you know, your kid seems fine during the day, and at nighttime, that fever spikes up.
Remember that your baseline temperatures tend to be higher already at night. So in the day, when your temperature's a little bit lower naturally, and then you had a fever, it doesn't go up quite as high, whereas at night if you're already your normal temperature at night, you know, is 99, then that's going to push it up a little bit higher.
So that's one reason.
Also, bed clothes or typically warm clothes, pajamas and bed covers and blankets, you know, so we are, we're covering up which allows the heat to stay in, that can drive the temperature up and we don't feel well.
And then body chemicals are responsive to our circadian rhythms. And so, probably, just the natural ebb and flow of chemicals in our body make fevers a little bit more likely at nighttime.
And I will say, too, that what I mentioned, how does the body cause a fever. You know, by increasing metabolic rate. It also does it by making you feel like you're chilly.
And so, there's a behavioral response, too, to creating a fever. And I told you, this was going to be a kind of myths, I know them all over the place here. But I think this was an important one to had, I just thought of, that when you, when the temperature's driving up and you feel chilly, you know, you get that extra blanket, you put a second blanket over you, you put a third blanket over you. And so, that's going to drive the temperature up.
So just by feeling chilly, by the hypothalamus telling your brain "Hey! You feel cold!" You're going to do some behavioral things. You know, turn up the heat which will help drive your body temperature up.
Okay, so let's say you do have a fever and, you know, you're not feeling well or your child's not feeling well with that fever, how do you treat it?
Best way to treat it is with fever-reducing medications. And the gold standards that we use here in the United States are going to be acetaminophen which is by the brand name of Tylenol. Ibuprofen, which goes by the brand name of Motrin, Advil, and others. You want to read the bottle label for doses. And pay attention to the concentration, especially if someone tells you what dose to give.
So this is one area that I think is important, where there is some confusion. And the folks who make acetaminophen have done a nice job of just standardizing the concentration at 160 milligrams for every 5 milliliters, which is a teaspoon.
So 160 milligrams, whether it's the infant version or the children's version, all of it is 160 milligrams in five milliliters And that's nice, the infant one will have the dropper and the children's one will have the cups. So the delivery mechanism that they give you is different. But the concentration's the same. So the volume, that a medical provider might tell you to give is going to be the same.
Ibuprofen, there is an infant version which is 50 milligrams in 1.25 milliliters. And then the children's version which is 100 milligrams in 5 milliliters.
You know, the standard, I think, that most medical professionals like to use is that 100 milligrams in 5 ml. Again, you can give that with a syringe, you don't have to give it with a cup. And it's going to be less concentrated which makes it taste a little bit better.
So the infant ones, you can give less volume but they're more concentrated, which makes them taste, not quite as good.
And I think it's best, I would love it if they would get rid of the 50 milligrams in 1.25 milliliters and just make it 100 milligrams in 5 milliliters across the board, kind of like Tylenol did, or the acetaminophens did this a few years ago, where they just went with one concentration. And I wish those makers of ibuprofen would do the same thing.
As we, in medicine, we based the dosing on the weight of a child in kilograms, sort of standard doses for ibuprofen is 10 milligrams per kilogram every 6 hours. And for Tylenol, 15 milligrams per kilogram every 4 hours.
But again, that's, as a medical professional, that's the formula we use to figure out the ideal dose. But it's fine to use what you see on the label for the dose, and then you're going to know you're using the right concentration. Because the label knows what concentration's in the bottle. And so you can just, and follow that.
Some folks will say alternate ibuprofen and Tylenol or acetaminophen. You know, if your doctor recommends that you do that, then you can give something every 3 hours because you're giving the same medication every six hours. And ibuprofen and acetaminophen work by different mechanisms, so that's not overdosing, it's fine to use the both of them. And if you alternate ever 3 hours, then your child can get something a little bit quicker.
Other ways to treat a fever, you know, remove layers of clothing. But you still want to keep your child comfortable. Don't do cool baths, no alcohol baths. You don't want your kids shivering down because they're cold, that's just going to become productive, their shivering's trying to draw their temperature up, your cold water starts driving their temperature down.
We're going after comfort here, folks. That's what we're really after.
Now, when do you worry? So when do you worry about a fever?
Babies less than a couple of months of age, definitely less than 2 days of age, then you're going with that 100.4 or higher, rectally, you need to see someone right away.
And babies, you know, from 1 month to 2 months, once they've had their first set of shots, we're a little bit less worried. But young babies, always call your medical provider when your baby has a fever regardless of how high it is. Just let them know.
You know, when fever lasts for a couple of days and there's no other symptoms present, just a fever, you know, it probably shows in a healthy, older kid, you know, it's fine to give it a couple of days and treat the fever.
But if they have other symptoms, other concerning like vomiting or funny-looking rash, you know, definitely have someone take a look at them. And if there's a fever for a couple of days with no other symptoms, probably have to be checked out, try to figure out what's causing that fever.
Fevers that lasts 5 days or more, even with other symptoms, even if you saw someone on the first or second day of fever, you know, once you get the five days of fever now, it still could be just a virus. But you do want to have someone check in it, just make sure you're not missing something. Make sure there's not something else going on.
Another worrisome thing is fever that goes away for a couple of days and then comes back, that may be an indication that there's now a secondary infection. So, the first fever could have been caused by the virus, that's causing runny nose and congestion, the fever goes away, stop runny nose and congestion. Couple days later, you get a new fever, well not, you have an ear infection on top of that or a pneumonia, sinus infection, you know, something else going on, that is, it's not really, the fever went away and came back, it's a new fever, maybe there's something new happening.
And so, that would be an indication to see someone sooner rather than later.
And then, any new unusual rashes, stiffed neck, severe headache, signs of dehydration, they're not drinking, they're vomiting, not urinating, you know, these would be all reasons to worry and see someone with those things are happening along with the fever.
Now the big question that lots of people have is:
What about seizures? So, do fever, high fever cause seizures?
And is this the reason that we want to treat fevers so that we don't cause brain damage and seizures.
Now, remember I said, the reason that we treat fever is to keep kids comfortable. And I'm sticking by that.
So in less a child has a history of recurrent febrile seizures, we would not treat a fever in order to prevent a seizure. And recurrent febrile seizures are a very rare thing, so we don't see that very often.
So let's talk about seizures that are associated with fever.
They are fairly common as it went off. So it's not common to have them recurrently, all of that does happen in some kids. But having a febrile seizure at least one during young childhood is common. And it is not generally dangerous. It does not cause brain damage, it does not result from brain damage. And there's some weak evidence to show that, and I say weak because these are hard things to study. But sort of working hypothesis, and there is some evidence, maybe not the strongest evidence, to say that what causes the febrile seizure is a rapid change in body temperature along with the genetic predisposition for this happening.
So if your genes are just right, and your DNA, and you go from being 98 degrees for a long period of time, and all of a sudden in a very short order, you go from 98 to 101, and it's a rapid rise, and the temperature were had been normal for a long period of time before that, and you have a genetic predisposition, that can cause you to have a whole-body seizure.
And it's kind of like the brain reboots. And it just fires everything when the temperature changes that quickly.
And so, for a lot of these kids, that's a first evidence, that they even have an illness. You know, they didn't have the fever before, they were cruised in a normal body temperature, they get that fever, and boom, they have this brief febrile seizure.
Most febrile seizures are simple. Febrile seizures, meaning that they last less than 5 minutes, it's just a single occurrence, and after the 5 minutes is over, then they're a little sleepy for maybe 20 minutes afterward, but they do respond and then life goes on, you know, you treat their fever and they're fine after that.
Now, a complex febrile seizure would be one that lasts more than 5 minutes. And it worries the company by worrisome symptoms like breathing difficulties, or it happens recurrently, especially during the same illness.
So they have febrile seizure, and then they have another one later that day, the next day, they have another febrile seizure, now we're talking more complex febrile seizure. And that can become worrisome. Fortunately, that is not the norm.
So those are unusual. Most febrile seizures are kind of a one-of-occurrence and what would we call a simple febrile seizure.
Now if you, does that mean you're going to have epilepsy?
There is a slight increase risk of epilepsy by age 7 in those who have febrile seizures compared to the general population. And it's not, probably in that case, the febrile seizure was an early manifestation of the child's eventual epilepsy. It's not that the febrile seizure caused the child to have epilepsy.
So fever is one of the things that we know can lower the seizure threshold. So those who have epilepsy may seize when they get sick, and fever may be one of the triggers for them having a seizure.
So fever, we do know lowers that seizure threshold. And so, if the kid has a tendency toward epilepsy, they may have febrile seizure. And then, by age 7, they do have full-blown epilepsy.
So you do have to take that in mind. And one of the reasons then, and associate with the complex febrile seizures is that more likely than they'll be the one to go on, they have epilepsy. And we don't know that for sure either.
And complex febrile seizure may need preventative medicines and again, there might be an increased risk of epilepsy in those kids, but that's not the normal.
So we're saying that febrile seizures are not, you know, dangerous. Typically lasts less than 5 minutes and then you go on about your life. But you'd still want to call your doctor. You know, if your child has a febrile seizure, you know, especially if it's the first episode, they've ever had one. Your doctor's probably going to say "Your child needs to be seen." Especially if it's their first one.
And that certainly makes sense, just to check them out, make sure that's not something else that could have caused that seizure, that there's not, you know, anything else going on.
Most of the time, if there's, you know, not. Someone will say "Hey, they have a virus." The fever caused their brief febrile seizure. Give the fever-reducing medicines. Just prevent another one from happening. And you go on about your day and they're not, again, not particularly dangerous.
Now, in terms of what are the chances of them having another one. Babies who have their first one when they're less than a year old have about 50% chance of having another one. If their first one is after a year of age, there's about a 30% chance of having another one.
And usually, by the time kids are going to kindergarten, they've outgrown these things. The brain stops responding to rapid changes and body temperature by this mechanism.
So again, and there's still that, there's a genetic predisposition here. So it does kind of tend to run on families. And the fear of a febrile seizure in an individual child, you know, it's so uncommon at that, it's not a reason to treat fevers.
Again, the reason to treat fevers is to keep kids comfortable.
Unless they have a history of complex recurrent febrile seizures. Then you may want to treat their fever to prevent that because, it's not necessary because they're dangerous. So if they last in more than 5 minutes or they have other symptoms associated with the seizure, that can start to get in the room of, could this be a dangerous thing for them.
You know, a lot to think about. And that's why medical professionals, all of these of what I'm saying, is why we don't get too excited about fevers. Because we see, you know, a lot of kids with fever. You know, one of our urgent care centers, we can see a hundred kids with a fever in an 8-hour shift. That's possible, especially in flu season.
And none of those hundred may have a febrile seizure, no, or maybe one.
So it's very rare, you know, with fever and certainly, again, not a reason to treat unless there's a history of complex febrile seizures.
So I hope that makes sense.
In terms of preventing fever, not a good way to do that. And, you know, other than giving the fever-reducing medicines, kind of preemptively. And you wouldn't do that unless your child has recurrent febrile seizures, complex ones. Or those with epilepsy who fevers are known to trigger their epilepsy, you know, then your doctor may recommend using fever-reducing medicines, you know, preventive action before you actually have a fever. And then you would just start using those at the first sign of illness if that's something that your regular doctor recommended.
So I hope that this has been helpful. Again, I wanted just to be casual conversation, here some bullet points on fevers have to take home. I think the biggest thing that I would say is that:
Fevers are your body's immune system at work. From a biological system standpoint, they obviously have a job, their universal experience with illness. And so, we shouldn't necessarily fear fever. We do treat it when kids are uncomfortable. And if you think your child has a fever, let your doctor know, let them know when other symptoms are present and they'll let you know when you need to worry.
So I think a lot of our jobs as pediatricians is often, you know, reassurance. And there are instances where we do, we are concerned about fever. But most of the time, most of the time we're not. So something to keep in mind. And I hope that helps.
We are back with just enough time to say thanks to all of you for taking time of your day in making PediaCast a part of it.
Thanks also for putting up with my voice today, it actually held out. I'm a little bit surprised, to be honest with you. But hopefully, it'll be better next week.
Next week we'll actually have a CME episode of the podcast. We're going to be talking about sports nutrition and low available energy, which is we called Female Athlete Triad. So we're going to talk about our sports medicine folks. You'll find that over pediacastcme.org or in Apple Podcast and Google Play or any podcast app. Wherever you find podcast, just look for PediaCast CME, that'll be next week.
And then, I will be back in 2 weeks with another episode of our PediaCast program for parents.
Don't forget, you can find us in all sorts of places. We are in the Apple Podcast app, iTunes, Google Play, iHeartRADIO, Spotify, most mobile podcast apps. Wherever you find podcast, you should be able to find us.
And of course, we have the landing site for this program, at pediacast.org. For the CME episodes which are aimed at providers, medical providers, that's pediacastcme.org.
We are also part of the Parents on Demand Network, at parentsondemand.com.
It's a collection of podcasts for moms and dads. And it includes PediaCast along with many other terrific podcasts for parents, including Soon to Be Parents.
And one of the shows in the Parents on Demand Network that highly recommended if you are expecting or you know someone who is expecting is the Preggie Pals Podcast with your hosts Sunny Gault, Annie Laird, and Stephanie Glover. If you're expecting a baby, or you know someone who is, a wonderful pregnancy podcast that you want to check out.
Recent episodes, just to give you some ideas of what they cover, Coping with Morning Sickness, Keeping Your Pregnancy Low Risk, Gender Prediction: Fact Vs. Fiction, The Truth About Gestational Diabetes, Preeclampsia: Symptoms and Treatment, Prenatal Anxiety and Depression, Prenatal Testing, Genetic Counseling.
So lots of terrific information for you there. They do interview lots of experts in maternity care.
And again, that the Preggie Pals Podcast and I'll put a link to it in the show notes for this Episode 421 over at pediacast.org.
Don't forget, reviews are always helpful. Wherever you listen, reviews are where it's at, right?
I mean, if you are going to go see a movie, or you're going to go out to a new restaurant, or you're going to try a new hotel, when you take a vacation, I mean, we read reviews of everything and make decisions based on what we read.
And so, if you do find PediaCast helpful, even if you don't find, leave a bad review if you have to.
You know, I read those and try to make some little changes to please everybody. But they are helpful, I think. And parents who come along after you and you're looking for a good podcast to listen to, reading your review may help them decide to give us a chance.
We'd also love hooking up with you on social media.
So we are on Facebook, Twitter, or on Instagram. Instagram tends to be a little more personal, you know, sort of my travels and what we're going, what our families doing, what we're up to.
So I would love to connect with you on Instagram. And if you like me on Instagram, I'll probably like you back, because I think that one, somebody just to see a community, what's going on on everybody's lives.
Facebook and Twitter is more pediatric news content. We let you know when new shows are out and promote some of our past episodes as well.
And then we really appreciate it when you tell others, not necessarily digitally, but face-to-face about the program. So your family, friends, neighbors, co-workers, babysitters, anyone who has kids or takes care of kids that could benefit from this podcast, please do let them know.
And that includes your child's pediatric healthcare provider. Please let them know about PediaCast so that they can share the show with their other families in their practice.
And of course, we have a lot of providers who listen to this program as well.
And while you have their ear, let them know we have a program for them. Again, that's the PediaCast CME, stands for Continuing Medical Education. It's similar to this program, we turn the science up a couple of notches, we offer free Category 1, an hour of free Category 1 Continuing Medical Education credit, for those who listen. And the shows and details are available at the landing site for that podcast, again, pediacastcme.org.
That one's also available in Apple Podcast, iTunes, Google Play, iHeartRADIO, Spotify, wherever you find podcast, simply search for PediaCast CME.
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 PediaCast.