Jaundice, Pediatric Cancer, Skin Tags – PediaCast 101
- Pediatric Cancer
- Technical Issues With The Show And Feed
- Long Bone Fractures
- Skin Tags
- Risk Of Serious Jaundice Accurately Predicted By Simple Test
- Helping Siblings Cope With Cancer
- Sibling Support Program at Nationwide Children's Hospital
- Diagrams And X-Rays Of Salter-Harris Type Fractures
- X-Rays of Torus Fractures
- X-Rays of Toddler Fractures
- PediaScribe: Why Can't People Behave?
Announcer 1: Bandwidth for Pediacast is provided by Nationwide Children's Hospital, for every child, for every reason.
Announcer 2: Welcome to Pediacast, a pediatric podcast for parents. And now, direct from Birdhouse studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome to PediaCast. It is Episode 101. That's right. Like 101 dalmatians. Okay, I know that was just kind of silly but that's the Disney freak coming out of me.
It is Tuesday, January 15th, 2008, and we are calling this one Jaundice, Broken Bones, and Skin tags. I came across a review of Pediacast in the Tuscaloosa, Alabama newspaper. I can't remember what the name of the newspaper is, because that doesn't really matter. But in any case, the had a listing of what they considered to be the top 5 parenting podcasts, and yours truly was mentioned, although the reporter did say that our show is kind of dry and mentioned that my wife's blog is exciting and you definitely want to check that out. [Laughs] So, I thought I would respond to that with a show on broken bones and skin tags. Alright I know, sure, there's some dry stuff in pediatric medicine. You know, I'll give you that.
You know it just goes along with the territory. But skin tags, there is nothing dry about skin tags, folks. [Laughs] Alright. So I hope everyone had a great weekend. We did, we drove up to Cleveland and caught High School Musical on ice. That was fun. It was a good show. We bought the tickets – gosh, it's been like a year ago that we got the tickets, and somehow or another, we were able to get front row seats, and trust me, it's not because of the show, or from being a pediatrician in my office practice, it's just we got it on Ticket Master, we're at the right place at the right time. We got front row seats for an ice show. That's cold, folks. But it was fun, except that the guys behind Karen – which I was oblivious to this. Karen was sitting at one end of our row then the two kids were in between us, and I was at the other end. I had no idea any of this was going on, but apparently, the guys behind Karen were being pretty rude and talking the entire time, spilled beer on her coat at the High School Musical on ice show.
I mean it's a Disney show. It's a family show. And she gets alcohol spilled on her coat. So anyway, I'll let Karen tell the story and you can check it out in the Pediascribe blog because she tells a story much better than I do, plus she was there. [Laughs] It happened to her. So you definitely want to check that out.
Alright, so what we're going to talk about today; Jaundice, got a little update on that for you, Pediatric Cancer, actually helping siblings cope with cancer, not the child who has the cancer but sometimes the siblings in the same house get overlooked; we're gonig to talk about that. Also some technical issues with the show and the feed. A listener in Brazil brought up a point, and it's an important enough one, I wanted to share it with everyone. And then we're going to talk about long bone fractures and then wind things down with skin tags. Isn't that exciting?
Don't forget if there's a topic that you would like us to discuss here on PediaCast, it's easy to get ahold of us. Just go to Pediacast.org and click on the Contact link. You can also e-mail email@example.com. Or call the voice line at 347-404-KIDS, which is 5437, if you don't have alphabet numbers on — alphabet numbers [Laughs], yes, folks, I'm educated. Alphabet, you know, numbers — oh wait, I said that they're wrong again! I don't — ah my goodness. Yeah, I know that you know what it is, folks. It was a Monday at the office, it was crazy. You know what I'm trying to say here. 347-404-5437 if you don't have letters on your keypad. OK boy, if that reporter was listening now, she wouldn't call the show "dry," she would just call it "wacky."
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A simple test that can accurately identify which newborn babies are at risk for developing dangerous levels of jaundice, according to researchers at The Children's Hospital of Philadelphia.
Well, neonatal jaundice – a yellowing of the skin, caused by a build-up of the blood product bilirubin is common in newborns and usually disappears on its own, but it can progress to brain damage in a small fraction of cases.
The American Academy of Pediatrics currently recommends two options used alone or in combination, to assess an infant's risk of developing severe hyperbilirubinemia – just a fancy word for jaundice; high bilirubin levels, hyperbilirubinemia – jaundice. It's a predischarge measurement of the bilirubin level is one option and a screening checklist of risk factors such as intended method of feeding, siblings with history of jaundice, and race.
The Children's Hospital of Philadelphia researchers say the predischarged bilirubin measurement combined with the baby's gestational age is actually the most accurate method for predicting whether the infant is risk for jaundice.
Their findings are published in the January 2008 issue of the Journal of Pediatrics. The researchers studied outcomes for 823 newborns admitted to the Hospital of the University of Pennsylvania in Philadelphia between September 2004 and October 2005.
"The challenge facing every pediatrician who takes care of newborn babies is to identify those infants they send home who would develop a bilirubin level that could cause injury," said Dr. Ron Keren, a pediatrician at Children's Hospital of Philadelphia and lead author of the study.
"We found that by measuring the bilirubin in every baby, and combining that information with the baby's gestational age, you could accurately predict which infants are at very high risk and which ones are at very low risk. The screening method should allow pediatricians to determine which newborns should stay in the hospital for monitoring, which may go home and return the next day for another test, and which don't need any additional followup for jaundice at all."
"About 70 percent of babies fell into the low-risk category, while 13 percent were designated high risk and 17 percent were in the middle," said Keren.
It did a nice job of pulling out a very large group of babies you dont have to worry about and a small group of babies that need to be closely followed.
About four million babies are born in the U.S. each year. Of those, about 60 percent will develop jaundice in the first few days of life, but only about 1 in 100,000 will develop bilirubin levels that cause brain damage, known as Kernicterus.
The authors caution that the study has a few limitations, including a small sample size. Some infants in the study were treated with phototherapy, high levels of colored light used to break down the bilirubin, before they met the criteria. And finally, about half of the study participants were born to black mothers and the researchers' data indicate black infants are less prone to develop significant hyperbilirubinemia or jaundice.
Keren concluded that more research on risk-assessment strategies is needed to weigh the cost of implementing a universal screening program and its effectiveness for preventing severe hyperbilirubinemia against false test results, unnecessary testing and treatment, and delay in hospital discharge.
You know, I think this is a recent issue, I guess in the last 5 to 10 years because of the rush to discharge moms and babies from the hospital following delivery. I mean when all babies stayed 48 hours, it was much easier to monitor for jaundice, watch their weight gains, sort of help moms transition to caring for babies, especially first time moms, helping with breastfeeding issues as kids got started eating. And I think that few medical professionals would disagree that at least 48 hours in the hospital after a baby is born is ideal. But of course the insurance companies have other ideas and I mean you can't blame them when you look at it from their point of view, they have to foot the bill for the stay, and 48 hours for everyone becomes very expensive. Of course, now that they save money by kicking babies out less than 24 hours after they're born, do they pass that savings on to us, as consumers for these early discharges? No, of course not, but that's an issue for another day.
I'm in big enough trouble with the drug companies for my recent rants, so I don't need the insurance industry bringing down my tail too, at least for now. So, we'll just go ahead and move on.
Alright. It happens more than a thousand times a month, another family in the U.S. is told their child has some form of cancer. Those kids aren't the only ones who are affected. All too often, the brothers and sisters of those children can get lost in the diagnosis and their needs go unnoticed. Now, a unique program is helping to change that and it's become a model for others around the country.
It may look like a simple card game around the kitchen table, but to Paige and Kendel Meacham, it is much more. Spending time together like this was not easy when their brother, Chase, was being treated for cancer.
"I didn't really understand what was going on. All I know is my mom and dad were gone all the time and that was really hard," says Paige.
They might have felt somewhat forgotten, but they're certainly not alone. More than 12,000 families deal with a cancer diagnosis every year and most of the time the parents' reaction is similar.
"A child is diagnosed with cancer and the entire focus becomes that child, understandably so, and sometimes they forget the other [coughs] siblings at home," says Micah Skeens, Pediatric Nurse Practioner at Nationwide Children's Hospital.
That's why experts at Nationwide Children's have developed a unique program to help those families every step of the way. From teaching kids things like breathing techniques to better deal with anxiety, to assigning them homework to better relate to their families.
"We require that they go home in once every two weeks, they communicate with their parents so that they understand what their parents are going through and so their parents also understand what the siblings are going through," says Skeens.
By initiating those conversations, experts say siblings feel like their concers are being heard and their questions are being answered. And not just once, what makes this program unique is that it's ongoing. Kids are encouraged to be a part of the process right from the beginning and throughout.
"It just made them so much more comfortable coming out into the unit and high-fiving the nurses and just being a part of this journey that involved our whole family," says their mom, Kim Meacham.
Without programs like this, experts say siblings can become angry or withdrawn and often their grades will drop. This program at Nationwide Children's Hospital has been so successful it's been recognized as a model program by the National Sibling support organization called Super-Sibs.
So, what a great program idea. Kudos to Nationwide Children's Hospital, which just happens to be our bandwidth sponsor which by the way, I picked this news story to read before I realized that the hospital involved was Nationwide Children's. So this is not a hidden ad for our bandwidth sponsor. It just happened to be that way. So, kudos to Nationwide Children's Hospital. If you are affiliated with a pediatric cancer program or your family is dealing with a pediatric cancer, check out the show notes, we do have a link to the Sibling Support Program at Nationwide Children's.
And you know, maybe you can get in contact with them and find out more if you are interested in getting that kind of program. Start it at your hospital or if you're dealing with cancer in your family, I'm sure you know the HemOnc Department very well at your local children's hospital and you could let them know about this type of program.
Alright I apologize for the cough midstream there. You know, my cold – I'll give you a little update on that here real quick. It's definitely better. If I take a big deep breath in, it tickles the back of my throat and I still have that little cough. And by the way, I'm just over two weeks and definitely starting to feel better, not as much, congestion. My point is, colds last two weeks. [Laughs] You don't get better really quickly. So, just keep that in mind. You don't want to rush for the antibiotic. Alright, we're going to take a quick break and we will get back to some of your questions right after this.
Our first listener question, actually this is more of a comment than a question comes from Andre in Brazil.
Andre says, "Dear, Dr. Mike. I am a Brazilian pediatrician, and I enjoy very much your podcast. Your commentaries are, as you say fair and balanced. (Thanks) And you have a talent to communicating medical issues in simple terms. It's interesting to catch our similarities and differences. Medical sciences are much the same but culture is very different. I'd like to add that I was trying to download all the episodes in iTunes but I couldn't download the following and I tried many times." And he goes on to list a whole bunch of our episodes. And then he says, "God bless you, stay well and so on years, Andre."
I know this isn't really a pediatric question for me, but I'm including it for many reasons. First, it's just pretty darn cool to get an e-mail from a fellow pediatrician in Brazil. I mean, I know, just crazy, really. Second, if any of you out there are having trouble with downloads in iTunes, I would suggest you try unsubscribing, that's right – yes, unsubscribe, and then immediately, without pause, re-subscribe. Around Episode 50, our episode server changed.
So if your original subscription goes back to before the switch, when you click the "Get" button, it's possible that iTunes is looking for the episode on the old server. But if you unsubscribe and then re-subscribe, iTunes will read the feed and udpate the server information so that should fix the problem. Now I tried downloading all the shows that Andre mentioned and I didn't have any difficulty at all. Of course I am in the United States so maybe that's part of the issue. I'm not sure how localized versions of the iTunes directory handle these things. But if you're still having problems Andre, you could alternatively go to Pediacast.org, find the episode that you are interested in then just download the MP3 file from there and then import it into iTunes. I know that's kind of a long workaround. Or you can also listen to our player in the side bar, for some of you who are able to listen on a computer at home.
And if unsubscribing and re-subscribing doesn't fix the problem for you, Andre, or anyone else out there or if you are experiencing other technical issues, be sure to let me know because we certainly want access for everyone and we'll figure it out together. So, let me know how that goes.
OK a little cough break there.
Jessica, in Columbus, Ohio (very close to me) says, "Dr. Mike, it is suspected that my 17-month old son fractured his lower left leg in a playground incident. I say they suspected because the x-rays did not yield conclusive evidence of a fracture. The doctor said his bones are too soft to show a fracture well on an x-ray and that follow up x-rays are needed in 7 to 10 days to prove the existence of a fracture. Evidently the healing of the bone will show on the x-ray, but not the fracture. The doctor gave us the option of a splint, instead of a cast, which delighted me. My question is that I have read some things about breaks in young children and growth plate injury, what kind of question should I be asking my orthopedic doctor about the break? Lastly, is there anything special that a parent should know about a fracture in such a young child? Caring for them, long term impacts, etcetera. Thanks for your help. Love the show. Jessica."
Jessica, we could easily fill an hour discussing bone fractures in kids, but I won't do it, because that might get a little too dry. Severe fractures are always obvious on a on a chest x-ray, listen to me. Again, it's been a long day [Laughs] in the office, seeing over 40 sick kids, so you got to cut me a little slack here.
Severe fractures on x-rays are always going to be obvious, so if you have a fracture that goes completely through the bone, and the bone fragments are angulated or displaced as we call it, or they are overlapping, you're going to see it. The problem comes in if the fracture does not result in angulation, displacement or overlap.
In other words, if the bone anatomy is preserved, it can be difficult to pick up the fracture. And this is true even in older kids, teenagers and adults. I mean if everything is lined up correctly, you might miss the fracture. Now, if you look at an x-ray, and we're going to talk about the type of fractures you can see in long bones in kids, but if you look, and I have some links to x-rays so you have a chance to do this but when you look at an x-ray, you'll notice that our bones are not uniformly smooth. There are lines and shadows and to the untrained eye, you can imagine a fracture that's not really there. So you have to correlate the x-ray to the clinical exams. So if there is a little line where it hurts, then you worry. If there's not a line where it hurts, yeah you still have to worry about the possibility of a subtle fracture that's not showing up on that initial x-ray. Now you don't want to miss these subtle fractures because they need to be immobilized too at least with a splint and in the early stages. Otherwise the fracture might extend or progress and then healing can become compromised.
And also as that happens, blood vessels or nerves can become damaged as the bone breaks more. So it's important to immobilize these subtle ones, even you're better off mobilizing things that aren't really fractures and sort of overdoing it. And then, if there's a question about whether there really is a fracture there, you immobilize it and repeat the x-ray in a week or so. Now why repeat it?
Well, as the fracture heals, new bone is laid down around the fracture site and this will be seen on subsequent x-rays, especially when you compare them to the inital x-ray. So you will be able to see the difference seeing new bone being laid down and then you're better able to tell a week later whether there is really a fracture there or not. If in 7 to 10 days, the bone looks the exact same and the pain has subsided, it probably was never a fracture. Some special considerations in the long bones of kids, we're going to narrow this discussion to that; otherwise, I'll get out of hand.
In kids, especially in the long bones, you're right. The growth plate is an added issue and these really don't show up on the x-ray at all because they're is sort of a carti