Peanut Butter, VapoRub, Wimpy Kids – PediaCast 141
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- Online Threats – Are Your Kids Safe When They Surf the Web?
- Peanut Butter and the Salmonella Outbreak
- VitaminWater Is the Subject of a Class-Action Law Suit
- Vick's VapoRub: Should You Use It?
- Respite Time for Parents With Medically-Fragile Kids
- New Autism DVD Teaches Kids To Recognize Human Emotion
- Diary of a Wimpy Kid: The Last Straw
- Eye Blinking In a Two-Year-Old
- Labial Adhesions and Fusion
- Diaper Rash
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 Summerland Studio, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone and welcome to PediaCast. It's episode 141 for Tuesday, January 27th, 2009. Peanut butter, Vapor Rub and Wimpy Kids. All right. My schedule has still been pretty dog on crazy as you can imagine. For those of you who are regular listeners of the show you'll know that we recently moved to another state, so we're in Florida now. And I've been keeping an eye on the weather back in Ohio. OK. It's funny because it's typical, they're under their third winter storm warning in the last four to six weeks, they're expecting nine inches of snow between now and Wednesday and it's sunny and 75 here.
Now if you like snow then great. But see the thing is, in Ohio where we lived we would get some snow once or twice a year and then it would just sort of stay cloudy and gray and cold and then the snow turns that icky gray mushy stuff. I guess if I live somewhere where you had a nice new coating of snow and you could ski that wasn't Central Ohio. I'm still a proud Buckeye, just living in Florida now.
But part of the craziness, too, is that we are building a new house and actually we closed this Friday. So in about three days we close on the new house and part of the new house is the brand spanking new Thornhill Studio and when we open that up I'll explain the name. But that's coming up and something to look forward to definitely on my end because right now as I've mentioned before I'm sort of crammed into the corner of a bedroom on some rickety bookcases, so the new studio would definitely be a nice change.
And once we're at the new studio we'll have the return of interviews and I have several of those lined up. Also we'll bring Karen back and do a show with her that was definitely popular in the past, so all that's coming up. But I do want to warn you, normally I would mention this at the end of the show and I still will, but I wanted to make you aware of it right here from the beginning in case you have to cut out on us early, the next show is going to be in two to three weeks. So you just got to give me some time; we got to get closed on the house; we have to move everything from our rental house to the new place and then I got to get the new studio set up; plus, I have a day job, actually it's an evening job.
But nonetheless, it's going to take me a little bit of time to get that all set up. But once we're settled in, interviews, return of Karen, weekly shows, it's all going to be coming your way soon. The end is in sight. But I did want to warn you that it may be two to three weeks before we get another show out and the reason again is because of the move.
OK. In the news, since the last time that we chatted we have a brand new president, so welcome, President Barack Hussein Obama. I did watch the inauguration and I have to tell you, I wish the new administration well, but we will keep our eye on policy as it relates to parents, children, family, healthcare for you and there's a lot on the horizon there. Not all the topics are medically specific, but they're still important to parents and kids so we will keep our eyes and ears open to all of those things.
And of course in the healthcare world, maybe not pediatrics specific, there is a lot of questions in the coming months or years where we have a nationalized health plan in the United States; if so, what form will it take? And we'll report the facts, I'll give you my opinion and we'll be sure to put in some opposing views on here as well. So there's going to be a lot of stuff to cover in the political world as it relates to parenting children and healthcare in the coming weeks, months and years.
And of course we'll also stick to our regular topics as well. For instance, this week we have lots of things on the palette here for you. Online threats — Are your kids safe when they surf the web? Also Peanut Butter and the Salmonella Outbreak. Vitamin Water is the subject of a class-action law suit, we'll tell you about that. Also Vicks Vaporub — Should you use it? There is a new study out concerning that product and we'll tell you about it. Respite time for parents with medically-fragile kids. Also a new autism DV that teaches kids to recognize human emotion. And there's a new book out, Diary of a Wimpy Kid: The Last Straw. The author of that, we got to try to get him on the show because that series has proven to be extremely popular, so we got to work on that when we get the new studio open. Also your questions, eye blinking in a two-year old, labial adhesions and fusion and also some questions on diaper rash. So that's all coming your way here very soon.
And don't forget if there is a topic that you would like us to discuss, it's really easy to get a hold of me, just go to pediacast.org and click on the Contact link. You can also email email@example.com, just let us know where you're from if you go that route; or you can call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S, which translates to 5437.
Also don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. 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.
And with that in mind, we'll be back with the News Parents Can Use, right after this short break.
All right, first up in our News Parents Can Use segment — Are your children safe on the internet? Well that depends, if you're worried about adult predators, the answer is yes, they're pretty safe. If your worry is peer bullying, they're not. That's the opinion of the Internet Safety Technical Task Force, a group created by the nation's state attorneys general, in charged with looking in to the problem of online sexual solicitation of children by adults. The task force led by the Berkman Center for Internet and Society at Harvard University met several times in 2008 and included dozens of law enforcement and childhood safety experts and the chief executives of online companies, such as Yahoo!, AOL, MySpace and Facebook. The conclusions of the task force were drawn up in a 278-page report which said (in many more words than I'm going to use) that there is not really a significant problem with adults sexually soliciting children online. In fact, peer bullies are a far common and serious Internet threat.
The report went on to say that most cases of online solicitation involved teens who are willing participants and already at risk because of poor home environments, substance abuse, depression and other social and psychological pathology. Of course these findings contradict the widely held belief that social networking sites like MySpace and Facebook are chock-full of adults whose sole purpose is to deceive and prey on children. And it runs counter to messages from the mainstream media, like NBC's To Catch A Predator series, which would have us believe the Internet is a dark and dangerous place for kids.
But one attorney general, Richard Blumenthal, of Connecticut criticized the report saying it downplayed the predator threat, relied on outdated research and failed to provide a specific plan for improving the safety of social networking. Mr. Blumenthal went on to say, "Children are solicited every day online, some fall prey and the results are tragic. That harsh reality defies the statistical academic research underlying this report."
John Cardillo, chief executive of Sentinel Tech Holding, which maintains a sex offender database and played a key role in the task force investigation disagrees with Blumenthal. He says, "The report shows that social networks are not these horribly bad neighborhoods on the Internet. Social networks are very much like real-world communities that are comprised mostly of good people who are there for the right reason.
Of course the key work here is "mostly". My opinion on this, well if social networking sites are very much like real-world communities, then you can expect some weirdoes in the crowd, right? OK, maybe not many, but it only takes one. So parents monitor your children's online habits; tell them about the potential dangers early on; teach them to remain on guard; instruct them to never give up personal information. These rules of online safety are like seatbelts and bike helmets, your kids probably won't be in a car crash or a bike wreck and chances are they'll never cross paths with an online sexual predator. But just in case, isn't it best to be prepared? That's the prudent thing to do.
Peanut butter, it's rich and creamy and nutty and it also appears to be the culprit behind the large outbreak of salmonella currently infecting hundreds of Americans throughout the United States. Until more is known, federal health authorities are urging consumers to avoid eating peanut butter flavored items, such as cookies, cakes, ice cream and snack crackers. The major national brands of jarred peanut butter however, are apparently safe that's according to Stephen Sundlof, head of the Food and Drug Administration's food safety center.
Why are they safe? Well because the contaminated peanut butter appears to have come from a product plant in Blakely, Georgia. The plant operated by a Virginia based Peanut Corporation of America sells peanut butter and peanut paste to institutions and food companies for use as recipe ingredients. They do not sell jars of peanut butter directly to consumers and they do not sell their product to Jif or Skippy or any other brand of jarred peanut butter.
The company has recalled 21 lots of peanut butter and peanut paste dating back to August 8th of last year because of possible salmonella contamination. At least 30 companies receive these lots including Kellogg's which has recalled 16 products including Keebler and Austin brand Peanut Butter Crackers, Famous Amos Peanut Butter Cookies and Keebler Soft Batch Homestyle Peanut Butter Cookies.
The Midwest supermarket chain Hy-Vee also received contaminated lots and are recalling bakery products in seven states. The current salmonella outbreak has affected over 500 people in 43 states and has resulted in 100 hospitalizations and 11 deaths and new cases are still being reported.
Salmonella is a bacteria and the most common source of food poisoning in the United States. It causes abdominal cramping, diarrhea, which is often bloody, and fever. Most cases resolve on their own without the need for antibiotics or IV fluids. However, it spreads very easily and may cause more severe disease in those with compromised immune systems, the very young and the elderly, in which case antibiotics and IV fluids may be needed.
If you're worried about the possibility of you or your children being affected by salmonella, be sure to let your doctor know right away.
Coca-Cola has misrepresented the nutritional content and health benefit of Vitamin Water — that's according to a class-action law suit. The Center for Sciences and the Public Interest filed against the soda company, on behalf of James Koh in the U.S. District Court for Northern California.
A spokesperson for Coca-Cola called the law suit frivolous. But is it? Koh, a resident of San Francisco, said, "When I bought Vitamin Water, frankly, I thought I doing myself a favor healthwise. I was attracted by the prospect of getting extra vitamins, but I had no idea I was actually getting almost a coke's worth of sugar and calories. There's no way I would have spent money on that, had I known."
Of course and maybe this is novel idea, if James Koh had read the label and compared it to a can of coke's label then he would have known because both beverage clearly and properly show the amounts of carbohydrates, calories and vitamins. Coca-Cola in their response to this suit pointed out this fact and added, "Consumers today are savvy, educated and looking for more from their beverage than just hydration."
And in the case of Vitamin Water, lots of consumers are looking to the tune of half a billion dollars in annual sales. The suit claims Coca-Cola racked up these numbers by promoting Vitamin Water as an alternative to soft drinks which is really it's nothing more than sugar water with a few added vitamins. The suit goes on to say, "The defendants have made millions at the expense of the public health and trust and continue to make millions through unfair, unlawful and fraudulent advertising and marketing practices."
Is anyone else bothered by this? OK, it's called Vitamin Water. It's water, they added some vitamins, do they have to put every ingredient in the title? I mean, does James Koh really want Coke to change the name to sugar-water-with-a-twist-of-vitamins? The lesson here folks is to be skeptical of marketing, read labels, educate yourself, make decisions and live with the consequences of those decisions — basic life lessons mom apparently never taught James Koh or the members of the Center for Sciences and the Public Interest. Maybe they should all sue their mothers instead of Coke.
Don't use Vicks VapoRub for children under two years of age, that's the warning from Dr. Bruce Rubin, a researcher at Wake Forest University Baptist Medical Center. His study, which appears in a January 2009 issue of the journal Chest, suggests Vicks Vaporub, a popular menthol compound used to relieve cough and congestion, may actually create respiratory distress in infants and small children.
Vicks Vaporub has been around for a long time. It was first introduced as Vicks Magic Croup Salve in 1905, but its big break came in 1918 during a deadly and widespread flu epidemic when sales increased from $900,000 a year to $2.9 million in a single flu season. And we're talking about 1918 dollars here.
Today, Procter & Gamble handles the marketing for Vicks Vaporub calling it "The only thing more powerful than a mother's touch." Unfortunately, it may be a bit too powerful. Dr. Rubin's study says, "Vicks Vaporub appears to stimulate mucus production and increase airway inflammation which can have severe consequences for infants and small children because of the already small diameter of their airway tubes."
It was emergency room doctors who first connected the dots when they noticed a common threat among infants presenting with respiratory distress, all of their parents had rubbed Vicks VapoRub under their noses. To establish a cause/effect relationship, researchers turned to ferrets. Yes, you heard me right. Ferrets. Well as it turns out, the ferret's anatomy and cellular composition in the respiratory tract is remarkably similar to humans, so say the researchers.
So the researchers obtained two groups of ferrets — one groups was healthy and the other had tracheal inflammation; in other words, they were ferrets with colds. They then rubbed Vicks Vaporub on the noses of all the ferrets and what did they find? Well Vicks Vaporub exposure led to increased mucus production, increase tracheal inflammation and decreased mucus clearing in all of the ferrets — the healthy ones and the ones with colds.
So it seems Vicks does make upper respiratory symptoms worse at least for ferrets who have the stuff rubbed on their noses. But does this really translate to respiratory distress in kids? That I think remains to be seen. Is this affect only when parents use Vicks Vaporub on the nose? What about under the nose? What about on the chest? What about on the soles of the feet as many grandparents say to do? And what about Vicks aroma in humidifiers and in bath water? Is the increase in mucus and inflammation a direct chemical effect? Is it mediated by the immune system? And do different people have different sensitivities?
All these are questions worth answering before we declare Vicks Vaporub an unconditional evil. In the meantime, it's probably wise to avoid it for now in the under two crowd, which you should be doing anyway because Vicks Vaporub label has long read, "Not for use in children under two."
Nearly 10% of parents caring for children with special needs say they need a break, but sadly, a quarter of them have nowhere to turn, so say researchers from the Wake Forest School of Medicine at Winston-Salem in an article published in the Archives of Pediatric and Adolescent Medicine.
The numbers come from a national survey of parents who have children with special needs. And the parents with the most difficult struggle aren't the ones you might think. Those with private health insurance are twice as likely to have unmet respite needs compared to those parents with government welfare type plans.
Why? Because Medicaid and Medicaid HMOs tend to cover respite care or parents covered by these plans fall under their protective umbrella of other social agencies, while those with private insurance are unable to secure affordable respite care assistance.
Another group with difficulty, those with children who are unstable with severe functional limitations, such as quadriplegic, those with significant brain injury and kids on ventilators. In other words, parents who most need a break find it hard twice as difficult to get help compared to parents with stable and more functional children.
The authors of the study state, "Respite care is an important issue in the care of children with special needs, particularly since more and more children with complex conditions survive and are cared for at home."
They call in further studies to assess the effectiveness of the Lifespan Respite Care Act of 2006, legislation passed by Congress to give caregivers from all socio-economic levels access to affordable and available respite care. And they conclude by saying, "There are powerful economic and social arguments for providing more respite care. Few safety nets exist to assist parents who suffer exhaustion, financial difficulties or face a lack of visiting nurse services."
A new DVD is available which aims to teach autistic children to recognize human emotions. Social interaction is difficult for kids with autism and a large part of that difficulty stems from their inability to recognize and respond to such feelings as happiness, anger and sadness in those around them.
The program is the brainchild of Simon Baron-Cohen at the Autism Research Centre at Cambridge University in the United Kingdom. He thought it odd that children with autism have so much trouble with understanding human emotion when they are so good with memory and attention to detail, maybe it's something that could be taught.
Enter he Transporters, an animated feature starring a cast of eight vehicles with human faces. These characters are track or river-based and include trains, trolley cars and ferry boats. If it sounds a little like the Thomas the Tank Engine there is a reason, Thomas has long been popular with autistic children because of his mechanical structure and predictable movements.
But can autistic kids really benefit from lessons on human emotion? To test that idea, researchers conducted a small study with 20 autistic kids ages four to seven. They watched the Transporters video for at least 15 minutes each day for a month. At the end of the study, all of the children had caught up with the non-autistic kids in their ability to identify human emotions.
Of course recognition of emotion does not equate behavioral change and Simon Baron-Cohen warns parents that his DVD is not a miracle cure. But he says, "If kids are given the opportunity to practice what they learn in a social setting, then real change is possible.
The British government financed the Trans porters project and following its 2007 United Kingdom debut, 40,000 families with autistic children received free copies. And the results? Well, there hasn't been a follow-up study but many parents report their kids want to watch the show hundreds of times each month and many moms and dads have reported "massive differences in the social behavior" of their autistic children.
The Transporters DVD is on sale for the first time this month in the United States. It sells for $57.50 and it includes interactive quizzes for kids and a booklet for parents and teachers. You can find the video at the transporters.com and of course we'll put a link there in the Show Notes.
Another popular product with kids is the Diary of a Wimpy Kid book series by author and cartoonist Jeff Kinney. Book three of his series s entitled Diary of a Wimpy Kid: The Last Straw and soon after its release earlier this month it shot up all the way to number five on amazon.com's most sold list.
The first two books, Diary of a Wimpy Kid and Diary of a Wimpy Kid: Rodrick Rules, were New York Times' bestsellers. The books involve a wimpy kid, Greg, and the plights of his home and school life through a book-long series of cartoon panels which have proved popular with young male readers.
In his latest installment, Greg's father attempts to toughen his son by signing the boy up for organized sports and other manly endeavors. Greg resists the efforts which leads his dad to threaten him with military academy leaving Greg no choice but to shape up or get shipped out.
The book includes everything kids come to expect from the Wimpy franchise including sissy taunts, teepeeing at grandmother's house, Greg answering his teacher with "me no speak English" and even a little bit of cross-dressing. Jeff Kinney laid the groundwork for his books online at funbrain.com, a site he started in 2004, which features cartoons, games and quizzes. That site has over 1,000 online pages and has been visited by 70 million readers and it's still going strong.
Kinney says he strives for real kid stuff. "I think everybody's childhood is absolutely filled with funny stories," he told the New York Times. "It's not the bombastic stuff about going down a hill at 90 miles an hour on your sled that's funny, it's the subtle stuff, like being dragged around on errands by your mother while you're wearing your Halloween costume."
He says his number one goal is authenticity so kids can't even sniff that it was written by an adult. And I'll put a link to the latest book in the Wimpy series in the Show Notes at pediacast.org.
All right, that wraps up our News Parents Can Use and we will take a quick break here and then be back to answer your questions, right after this.
OK. First up on our listener segment is Jobeth in Lexington, Michigan and Jobeth says, "Hi. I have a question for you. My two-and-a-half-year-old son keeps blinking his eyes when he is playing, watching television and so on. I was wondering what I should do and if it's related to a febrile seizure he had back in June of 2008. I try not to make a big deal about it to him but I'm worried. I hope you can help me. Thank you. – Jobeth"
So let's talk about eye blinking in a two-and-a-half-year-old. The problem here is that there are lots of possible causes and we'll touch on some of them. But the bottom line is, Jobeth, your child needs to see his pediatrician for this and probably deserves a referral to a pediatric ophthalmologist, not an optometrist, but a pediatric ophthalmologist with an M.D. or a D.O. initials after his name.
So there's a lot of possibilities here and keep in mind the child's age – two and a half years – and that's the reason I think you probably deserve a referral to a pediatric ophthalmologist. If this were an eight-year-old whose eye is blinking a lot then it's a little bit of a different story. But two-and-a-half-year-old who is blinking his eyes a lot there are some concerning things that this can be.
First, let me say it's highly unlikely that it's related to the febrile seizure. There is no brain pathology or eye pathology that would be associated with the febrile seizure unless it wasn't really a simple febrile seizure at all, but again, that's unlikely. So I don't think you have to worry about this being related to a febrile seizure that your child had last June.
So what are the possibilities? Well one would be a facial motor tick and this I would expect though more in an older child than a two-and-a-half-year-old, but it's still possible. We've talked a lot actually about ticks and tick disorders here recently, so if you look back through some of our older shows you'll find much more detailed information about motor ticks. But those are usually worse when a child is stressed, if you start talking about the tick or telling him to stop often times it comes out more. It's usually better when they're concentrating on something, their mind is on something else. And again, you'd expect this more in an older child. But can eye blinking show up as a motor tick in a two-and-a-half-year-old? It is possible. It's not highest on my list in the differential, but it's something that like I said is possible.
What about dry eye? When you are concentrating on something, whether it be really intensely playing with something, reading, watching TV, looking at computer screens, a lot of times with that concentration comes less blinking. And of course why do we blink? We blink in order to spread tears across the eye and to keep the surface of the eye moist.
And so if you have a child who is in the beginning really concentrating and not blinking, then as their eye becomes dry and a little itchy feeling they may start to blink more intentionally in an attempt to make their eye feel better. So if you notice that in the beginning when he's playing, watching TV, looking at books, he's not blinking and then a few minutes into doing that he's blinking a lot, it could just be that his eyes are getting dry because he's not blinking enough when he's concentrating.
But again, I think that also is less likely at this age, at two and a half. In an older kid, you would expect that a little bit more.
What about allergic conjunctivitis? This is basically watery, itchy eyes and so you blink a lot because of that feeling, especially in a two-and-a-half-year-old who might rub your eyes a lot as well. Is there exposure to cigarette smoke? Are there pets in the house? Do you have forced air furnace and do you change the filter?
All of these sort of things, but I wouldn't expect that to be so activity dependent. So if you're noticing it more when they're playing, when they're watching TV, then it's a little bit less likely to be an allergic conjunctivitis because that you would expect to be there no matter what your child is doing, whenever they're indoors or in whatever environment that has the offending agent.
But it's something to consider, allergic conjunctivitis and there are eye drops that can be used for that. And of course, more importantly, is to get whatever it is that's causing the irritation is to get that out of their environment.
What about an acuity problem? In other words, does your child need glasses? Squinting may indicate that or if he's up close to something that could do it. But it doesn't sound like he's really squinting if he's blinking and just blinking probably is not an issue with an acuity problem.
Now the thing that makes me the most concerned that would be in the differential diagnosis and actually it may be the more likely of all of these things that we've mentioned and that in a two-and-a-half-year-old and that would be something called amblyopia or strabismus. They're not quite the exact same thing. But if you have a child with strabismus, what that means is one eye is perhaps pulled in or pulled out a little bit more than the other eye is. And what happens then is that your eyes are not focusing together and so the child gets double vision. And this is sort of a prime age for this sort of thing to happen, so your child might be blinking in an attempt to focus.
Not so much an acuity problem, but more the double vision in trying to get the eyes to focus in both of them on the same thing. Now the problem with this is that the brain wants to see a clear picture and over time what can happen is the brain will start to ignore the eye that's not positioned correctly and that can lead to decrease in vision or blindness in the affected eye, which may be permanent blindness and become irreversible and then that is a condition that we call amblyopia, also called lazy eye. We talked about this before in past episodes as well.
So strabismus, which is the eye not being able to move or be lined up exactly with the good eye, the normal eye and that can cause a blurry picture which then the brain can ignore, which leads to lazy eye or amblyopia. So this is something, again, that I really think your child needs to see your pediatrician for, that's the bottom line. And probably, like I said with this age, deserves a referral to a pediatric ophthalmologist. Again, that's a medical doctor with an M.D. or a D.O. behind his name and one that specializes in seeing children, that's what I would do.
So there's a lot of things that could be, Jobeth, and in this sort of venue it's hard to say which of those things that it is.
OK, let's move on. Jessica in Columbus, Ohio. Hey! It's my old stomping grounds. And I'm sorry, Jessica, for what adventure you're having right now. No, not really. So Jessica says, "I know in the past you've talked about boys having foreskin adhesions involving the penis. But I don't remember a topic on little girls with fused labia, maybe because at the time I only had a boy. My daughter is two months old and at her check-up our doctor said she has mildly fused labia and I was instructed to put Vaseline around her vagina once per day to keep it from fusing further. I haven't heard of this before. Is it common? From searching the web I found that it usually separates at puberty with a rise in estrogen, but children with this condition can get urinary tract infections because urine gets left behind in the bladder each time she pees. How do I know if she gets a urinary tract infection? Any advice and/or information would be very helpful. I love the show. I've been listening for years and recommending it to all my friends. Thanks. – Jessica"
Well thank you, Jessica, for writing in. Actually, this is a common condition where the labia minora fused together. I think we have talked about this in the past, but it's been awhile, so let's go over it again. And it is sort of the equivalent to when little boys have the foreskin become adhered to the rim of the glands or the head of the penis and so this is another adhesion or fusion problem. And in this case, instead of it being the foreskin being stuck to the head of the penis, it's the labia minora being fused together.
But first, what is labia minora? There's basically two skinfolds that you encounter as you go from the outside to the inside down in the genital region of little girls. So the out one is called the labia majora and then if you pull that apart you see the labia minora and if you pull that apart then you're going to see the vagina and the urethral opening where they pee from. So there's basically two doors to get inside, the first being the labia majora, the second being the labia minora. So this is a problem with the labia minora becoming fused together.
So what do you do? Well, in my mind, first I would say if it's not causing a problem, don't fix it and some would disagree with that. This is one of those things where you get a group of 100 pediatricians in a room, ask them this question and you're going to get some different answers.
In my mind, if it's not causing a problem, don't worry about it because you're right when little girls go through puberty then it usually fixes itself. So if there's not a problem there, leave it alone. Now what problems are we talking about? So what kind of problems could occur? Well, one is that if that fuses together and then it pulls apart suddenly, that can lead to paid and bleeding. And if this recurs over and over in a specific child, then this is something you probably want to fix because you don't want them to have recurring episodes of pain and bleeding when the tissues that are stuck together pull apart.
So for example, if you have a girl who let's say she rides horses a lot and this is something that pulls apart, it's causing her pain and bleeding or if she does gymnastics or if, some girls are just prone to it; maybe they're more sort of a tomboy, they wrestle their brother. There are things that can happen that the legs get pulled apart and this spontaneously causes what's fused together to pull apart and it's painful and bleeding and so if this happens over and over again you may want to do something about it.
Also if the blockage where the labia minora is fused together gets too high and this is what your doctor was alluding to, you can get a partial blockage of the opening to the urethra. And so urine has a little bit of trouble getting out. And so when they go to the bathroom, keep in my mind we have to go and just take a couple of steps back here and we've talked about this before as well, but we have lots of new listeners so let's go over it again. Little girls are prone to urinary tract infection more so than boys for a couple of reasons, one is the urethra is short, I mean it's a short trip from the outside to the inside of the bladder; whereas in boys, you got the penis, the urethra not only goes to the penis it also loops down a little bit and then loops back up, so it's a much longer journey for bacteria to get inside the bladder in little boys compared to little girls.
Now one thing that protects girls from urinary tract infections is frequent peeing and emptying out the bladder. So if you have bacteria that made it from the skin up the urethra in to the bladder, it's OK as long as you're flushing that bacteria out on a regular basis and getting it all out. However, if the urethra is partially blocked and not all the urine can get out or a little girl would have to sit on the toilet longer, they'd have to really make sure that they've completely emptied their bladder. And if they have this partial blockage they may stop peeing prematurely then that doesn't seem to be a problem at all because if you empty the bladder but there's a third of the urine left in there, then you go from one-third back up to full and then she has to go to the bathroom again. You know what I'm saying here.
You might not think that there's any issue with this, but if you have this residual of urine that's just hanging out in the bladder over a long period of time then you can get a urinary tract infection. So if you have a girl who is fused down below and she's getting urinary tract infections then this would be a problem and you would want to try to keep her from getting fused so that this doesn't become an issue.
Now let me say this, most girls with labial adhesions don't get urinary tract infections. So then it becomes, do you treat this to prevent urinary tract infections, but what if the girl never would get a urinary tract infection? Why would you want to treat this? And we'll talk about why there are treatment issues. Why would you want to treat it if it's not causing a problem?
Because most girls are not going to get recurrent urinary tract infections with labial adhesions. Some of them do and it's going to be more likely in the girls whose fusion goes higher and starts to cover up the urethra.
Now the next thing that a lot of parents would worry about is what if it completely blocks off the urethra and now they can't pee at all? That's very dangerous. You get bladder distention, pain, they can back up in to the kidneys and cause kidney dysfunction and kidney failure.
Well the good news with that is that is extremely rare. And the reason it's rare is because the act of peeing keeps that area from fusing together completely up around the level of the urethra. Also, the labia minora sort of end right around that region and so even if it fused all the way up, there's still a little bit of space there where urine can leak up around the clitoris and then come down on the outside of the labia minora.
So it's really unlikely that this is going to completely obstruct the urethra. So the act of peeing keeps it open and sort of just the anatomy of it there is still a way for urine to get out. So total blockage would be extremely rare. I've never seen it. Never heard of it in any child in over 10 years of practice.
OK. So let's say that it is a problem. You do have a kid where it pulls apart and causes pain and some bleeding and this is happening recurrently or you have a girl who is having some urinary tract infections. What do you do? Well, let's look at what causes this because if you understand what causes it then you can understand what you need to do to help things along.
The epithelium, so the outermost layer of skin, at the level of the labia minora during childhood tends to be a sticky epithelium, so it's easy for it to stick together. When a child goes to puberty, that epithelium changes so it goes from being a sticky epithelium to more of a slippery epithelium. So the actual quality of that outermost skin changes from being sort of sticky to being slippery and it appears that estrogen, which there's a lot, more estrogen as go through puberty, mediates that change of the epithelium from being sticky to slippery.
And that's why if you don't do anything when kids go through puberty that tends to just all pull apart on its own. And the same thing is true for little boys who have foreskin adhesions. Again, the male hormones and testosterone tends to make that go from a sticky epithelium to a slippery epithelium and those adhesions come apart on their own and don't recur. The same thing is true for little girls.
So one thing that you can do is trick these cells into thinking it's time to change. So you subject them to estrogen and there is a cream that's used for that called Premarin Cream, that's one of the brand names. But it's basically a topical estrogen and so you rub that on the area that's fused together a couple of times a day for a week or two and the cells change from being a sticky to a slippery epithelium and so that helps it all to come apart on its own.
And the problem with this is that as soon as you stop doing this, the epithelium is going to change back to what it's supposed to be. So once again it becomes a sticky epithelium and then it's more likely that fusion is going to recur. And then this is where the daily Vaseline may help. Once you get it apart with the estrogen, then you want to stop the estrogen because you don't want to keep doing that and why do you not want to keep doing that? Because this estrogen is getting absorbed into the body and is going to have effects elsewhere that aren't supposed to be there because your child is not supposed to have estrogen in their system yet.
So this is not an ideal situation. You want to use it just as long as it takes to open things back up without the need to basically rip it apart. So you want to make that epithelium go from sticky to slippery so it falls apart and then you use the Vaseline on a daily basis to try to keep it apart.
Now the problem with this is that you're messing down there over and over and then it becomes more likely that you're going to introduce infection. It's just not ideal to be messing with the girl's genitals on a daily basis manually if you don't have to.
And that's why my thinking is if it's not causing a problem, if it's not pulling apart, it's not causing pain, it's not bleeding, they're not getting urinary tract infections then you leave it alone. Now some other doctors would disagree with that and so oh, there's a chance you're going to get a urinary tract infection and so we got to keep this open. But in my mind, most of the girls that you see who have this don't get urinary tract infections.
From a doctor's point of view, it may be that when they see girls with urinary tract infections they look and they see that there is a fused labia, so it becomes in your mind, hey, whenever they have a fused labia they get urinary tract infections because all of the girls with UTIs have this fused labia when a certain doctor looks.
But a more experienced pediatrician is going to know that during well check-ups there are lots of girls who are fused down there. If you don't mention it to the parents, they'd never really even know and these kids grow up to be fine with never having a urinary tract infection.
So just because you see that association a lot does not mean that all kids with fused labia are going to get the UTI. Same thing true with RSV and I'm going to bring this up as an example just because the time of the year that it is. Most babies who wheeze who have no family history of asthma and have cold symptoms they probably have RSV. That does mean that RSV makes all babies wheeze? No. There's a ton of babies out there who just have a cold that gets better in a week till a week and a half, they never wheeze with it and RSV was the culprit.
You just don't test those babies for RSV. So it just seems like RSV always causes wheezing. So it may seem like labial adhesions always cause urinary tract infections if the only time you look down there is when you have a girl with a UTI. But if you look at lots of well babies you'll find fused labia that never cause a problem and you never have to do anything for it at all.
So again, in my mind if it's not broken don't fix it, otherwise you run the risk of causing other issues.
OK, let's move on. Next up is Page in Boynton Beach, Florida and she says, "Hello, Dr. Mike. First off, you do a fantastic show so thank you very much." And thank you, Page, for the nice compliment. She says, "I hope you enjoy Florida as much as I do." Obviously we are. It's like 80 degrees today and sunny and it's January. It's crazy. So anyway, Page says, "I have a question about diaper rash. My son is almost four months old and he has a nasty diaper rash for the last two months on the sides of his testicles, underneath them and on his bottom. I've done a lot of reading, I've tried different creams, even one from his pediatrician. I used warm water and a cloth to clean him instead of wipes and give the area plenty of fresh air daily. He's exclusively breastfed. I read certain foods I eat can lead to rashes. However, it's only in the areas I mentioned above. I can't seem to make it any better. Do you have any suggestions? It sometimes bleeds and is very red. He's pediatrician is not concerned but I am. Should I switch to cloth diapers? I have switched disposable brands and that didn't help. I would appreciate any input or suggestions."
OK, Page, thanks for your question. Let's just run through diaper rash here really quick. We've done this before as well, but it has been awhile and I'll give you sort of the abbreviated version but with all the things that you really need to know.
First of all, diaper rash is in kids and Page, you said your son is almost four months old. So we're talking about a young baby here. What can cause a diaper rash? Well basically, let's break it down in to the three most common causes of diaper rash and this is going to be a rash that's just limited to the diaper area, it's not associated with a rash that's elsewhere on the body. So this is just in the diaper region.
First, let's break it down in to the three things that we can talk about here — yeast, bacteria and contact or irritation. So yeast is very common in babies. Yeast or fungus, we can use the same words here so yeast, fungus, it likes a warm moist environment to grow. It's everywhere. It's all over the place, on things, in your house. So it's easy to come in contact with yeast; it likes a warm moist environment which the diaper area certainly is.
Young infants also lack a lot of skin bacteria to provide competition to keep yeast from growing. So the normal bacteria that lives on our skin takes up space and so that is less space for yeast to grow. So in young infants though, their skin may not have a lot of bacteria yet so there's not as much competition and also infants get ear infections a lot, they are on an antibiotic for this or that, that kills their normal skin bacteria, which also provides space for the yeast to start growing.
So you have this situation where you have lots of yeast around, it likes a warm moist environment where there's not a lot of competition with bacteria and young baby skin in their diaper area is that perfect spot, especially in a baby who's been on antibiotics.
Also a lot of babies get yeast in the mouth as well for similar reasons, it's a warm moist environment, they don't have a lot of mouth bacteria yet or they may be on an antibiotic, which just killed their normal mouth bacteria. And this thrush which the yeast that causes that is usually one called candida, it can spread to the diaper area or from the diaper area to the mouth and so thrush and yeasty diaper rashes go hand-in-hand very often.
Now what does a yeast diaper rash look like? Well in the diaper area it's usually red in the creases with red dot or satellite lesions surrounding this redness in the creases. This is the classic description, not all kids follow the rule book and so it can have some different looks to it. It als may be present with a bacterial infection diaper rash or with a contact dermatitis diaper rash. It may be more complicated than that classic description, especially if there are other things going on like a contact dermatitis or a bacterial infection.
Yeast diaper rashes usually respond well to topical antifungal medications like Nystatin, Lotrimin, these kind of things. Oral antifungals also exist and those are like Diflucan, for instance, but that's more commonly needed for thrush that's not going away or recurrent. And usually the topical antifungals work pretty well for diaper rashes. And this is the sort of thing, again, you want your doctor to look at the rash or try to figure this out together and give you an idea of what sort of things to use. But if it's a yeast diaper rash, then there are creams that kill the yeast that may be helpful for you.
Now the next type is a bacterial infection. This can show up in the form of impetigo, cellulitis, pustules, boils, abscesses, you can get bullous impetigo with blisters. These are things that you shouldn't try to identify on your own. You want your doctor to look at the rash. If there's a bacterial component to the rash, your doctor is going to be able to tell you that and then treat it either topically with a medicine like Neosporin, you can use Bacitracin, Bactroban, other brands of Mupirocin. There are different topical antibiotics that can be used for bacterial infections in the diaper area. Or depending on the extent of the disease they may even need an antibiotic by mouth to take care of the problem.
The source of bacterial infection is typically skin bacteria or bacteria in the stool and bowel movements combined with broken down skin and that broken down skin may have come from yeast or a contact dermatitis. Again, these things are really intertwined. You have a yeast infection or you have a contact dermatitis, which we're going to talk about next, and that breaks down the skin and then normal skin bacteria is able to start infecting that area because you've lost your layer of protection on the outside surface of the skin or it can also come from the stool. So bacterial infections are also possible.
That leads us then to contact dermatitis. This is going to be the most common that we see. And this is probably what you're dealing with, Page, and I say that because if you saw your doctor and you tried some creams that your doctor prescribed and yet this rash has still been there for so many weeks and not necessarily getting worse but not getting better either, then contact is probably the issue because yeast and bacteria are pretty easy to identify and treat. It's the contact dermatitis as it become a little bit more difficult to get a handle on making them go away.
Now there are two different mechanisms by which you can have a contact dermatitis. One is through the immune system, so you are having an allergic reaction to something down there and your immune system is making you have the rash and then the second is direct damage so whatever is contacting the skin is actually breaking the skin down.
So let's first talk about immune mediated. This is the kind we typically see with disposable diapers and it's different by brand because whatever coating of chemical is on the diaper is going to be different from brand A to brand B. And I remember with my own kids, Pampers seem to always give my daughter the worst rashes and for my son if he didn't use Pampers he had a bad rash. So the brands do differ, it's going to differ from kid to kid depending on what they're sensitive to and what chemicals are on the outside of this diaper that's touching the skin.
So if it is the disposable diapers, going to cloth diapers might help you out. But there's no guarantee and it's only going to help if the problem was the diapers. Some creams can actually cause problems, so you'd use things like Desitin, A+D Ointment, Balmex and in most cases those are going to help. But in some kids there'll be an ingredient in the cream that actually their body doesn't like, it recognizes it as foreign, it makes antibodies against it and then this is what causes the rash.
And by the way, you can and we talked about this before, too, you can become sensitized to a particular chemical after you've used it for a while. So it could be that you use Desitin, it seems to be working, it's keeping rashes away and then suddenly you've got this terrible rash and Desitin no longer helps. Well it could be that Desitin and/or a component of it is now causing the rash because you've become sensitize to it even when before it seemed like it helped. So you may want to experiment with different creams to figure out if one of them is the offending thing.
So you through the diapers, switch to different diapers, you switch to different creams — Desitin, A+D, Balmex, all these to see if they're having a reaction to one or the other. So usually if it's an immune mediated, a contact dermatitis, it's going to be the diaper or cream or something that you're putting on that touches the skin.
Now for direct damage, the biggest culprit here is going to be poop. And the problem with the poop is the digestive enzymes that can still be in the stool. So you have a baby, who's making digestive enzymes to break down his food, typically, those aren't going to make it out into the poop because they get used up, unless they have an increased transit time in the intestine and then some of those digestive enzymes can make their way in to the stool, they touch the skin, they break down the skin just like they break down food, they break down the skin and then that causes the rash.
The other thing that we should mention here is that why is it that certain foods can make you get a diaper rash? If you're allergic to a food the rash is going to be everywhere, not just on the bottom. But some foods can make the poop loser, which makes the poop stickier, which makes the poop stick to the skin more, and so if there are digestive enzymes in the poop and it's touching the skin it's going to break it down.
If it's a more formed stool, like clay, you open it up and the turt is setting there, that doesn't coat the skin quite like lose, sticky stool does. So babies eat lots of fruits, things that typically you think of as making you have loser stool can give you a rash.
A mom will say, oh yeah, whenever I give him apple juice they get a bad rash. Well they're not allergic to apple juice, it's just that the apple juice has more sugars in it, they go straight through that cause an osmotic diarrhea. Again, I know I'm using some bigger terms here, but we've talked about all these things in the past so it shouldn't be new to you.
If you have sugars that aren't digested, they make their way into the large intestine by osmosis that draws more water in because of these undigested sugars. Prune juice can do it as well. That's great if you're constipated because you're loosening the stool, making it loser, but it also makes the stool loser, stickier, touches the skin more and those digestive enzymes can act on the skin and break the skin down.
So it's not that you're allergic to whatever food it is that gives you the diaper rash, it's that that food is changing the quality of the stool which makes it more likely that the poop is going to cause a problem. And I also should mention, too, there are some foods and medicines that can increase bowel transit time which makes it even more likely that digestive enzymes are going to appear in the stool.
For example, Zithromax and the Erythromycin group of antibiotics tend to increase stool or intestinal transit time, so that the digestive enzymes make it through faster and there's more of them in the poop. Also, antibiotics tend to work kind of like apple juice does in that some of the antibiotic is not absorbed, it makes its way to the large intestine and then you get an osmosis of water making a looser stool. And if you've had a kid on antibiotics you know they often times get loose stool or diarrhea with the antibiotic and some of that is because of osmosis. Also because you are killing the normal bacteria that live in the intestine which are important for digestion so that also plays a role.
So antibiotics, in addition to juices, may give your babies diaper rashes, but again, it's not the antibiotic causing the diaper rash; it's the antibiotic changing the character of the stool which makes it more likely to cause a contact dermatitis. I hope all these make sense.
OK. So where was I? How do you go about treating this? So do you avoid antibiotics? If you need an antibiotic, you need an antibiotic. You don't want to do it if they have a viral infection because then you can create problems and it's not helping at all. And one of the problems you can create is this diaper rash.
Do you want to avoid all foods that cause diaper rash? Not necessarily. You don't want your kids to have just juice, but you want him to have a variety of things and you don't want to have to say no fruits because they get a diaper rash with every fruit.
So what can you do? Well if you understand that the basic problem is the stool touching the skin and being in contact with the digestive enzymes, then it becomes apparent that you should use a barrier to keep the poop from touching the skin. And what we usually use for barriers are things like Desitin, A+D Ointment, Balmex. These things make a physical barrier so that the poop or the disposable diapers or whatever instead of touching the skin they come in contact with the cream. So that means in order to use those creams as a barrier you have to put them on thickly. You want to make so you can't see the skin, you're making a nice barrier so the poop touches the cream and you can use Desitin, A+D, Balmex.
Now there's also a component in many of these creams called zinc oxide, which helps to decrease inflammation which helps the redness go away when they have a diaper rash. It also makes it so that there's a better barrier, this is zinc oxide, it's a heavy metal, so you get a nice barrier with it.
But if your child is sensitive to one of these creams that you're using that could be causing the problem and it's not going to help. So you have to experiment a little bit here. Let's say you have a kid who's having this diaper rash because of poop irritation and it's not the Balmex, A+D, Desitin, it's not the ointment that you're putting on or the cream that you're putting on; so you want to put that on thickly so the poop doesn't touch the skin.
Another way to keep the diaper off of the skin is by after you catch them peeing or pooping and you clean them up then letting their bottom be exposed to air as long as you dare, you don't think they're going to go away. What does that do? Well it keeps the diaper from touching the skin for a longer period of time. It also helps to dry out the area so it's not so warm and moist, so that yeasts aren't as likely to grow. So there are lots of reasons to keep them open to air as long as possible.
But there comes a time when you're going to make a mess because they're going to go again. So you can't do that forever. If you could, they wouldn't be in diapers anymore, right? And that's one of the reasons why all these problems go away when you stop using diapers.
But in the meantime, when you have to do it there are some things you can do and one of those is to experiment with different diapers, experiment with different creams, use the cream thickly to create a barrier so that the poop and the diapers don't touch the skin so much and keep them open to air as long as you possibly dare.
There's one other little trick that I want to mention and I've used this one when all else fails and it works pretty well. And that is using something called, it's a combination product that you can actually make yourself, although the pharmacist may be able to make it a little bit easier for you and that's to take a base ointment and a good one to use is Aquaphor, so you just want it as the ointment and then you put in Maalox, the antacid.
At the children's hospital that I have been affiliated with in the past, they used to call this magic butt cream. And it's basically, equal parts of Aquaphor and Maalox. So you get a big jar, you put a smaller jar of Aquaphor in the bigger jar and then you put an equal amount by weight of Maalox, the antacid, and then you stir it all together to make your own cream. Again, the pharmacist can do this for you.
Now why does this help? Well those digestive enzymes in the poop need an acidic environment in order to work that's why you have stomach acid. So these digestive enzymes need an acidic environment. By providing an antacid it makes it so that PH of the poop rises so it makes it less acidic, more basic and the needs digestive enzymes are less likely to work.
So you can have the poop in the digestive enzymes touching the skin, but if the enzymes can't work they can't break down the skin and so that can help, too, by having an antacid in the diaper area and that's why Aquaphor-Maalox, that combination works wonders for a lot of rashes that nothing else seems to be working.
And that's why I think, Page, I think this is something you should consider because if you've already seen your doctor for the rash, you've tried to treat it as yeast, you've tried to treat it as bacteria, you've used different creams, you've tried different disposable diapers or maybe you haven't yet; let's say you tried cloth diapers but that still doesn't seem to help, you might want to try this Aquaphor-Maalox deal to see if it will help and you can ask your doctor to write a prescription for it then the pharmacist will make it up for you.
You probably will pay for it. Your insurance won't cover it because it's two over-the-counter products. But the pharmacist has the tools to make this mix better because if you try it at home the Maalox tends to set on top of the Aquaphor and not really make a nice cream. You have to really, really stir and stir and stir and the pharmacist may be able to do that easier for you. But it's equal parts by weight. So equal parts of Aquaphor and if you don't have any Aquaphor around you could use another cream. You just want something to put/mix the Maalox in with and mix those together in equal proportions.
Now again, I can't diagnose your child's rash, Page and say, oh yeah, it's contact dermatitis, do this. But these are all the different things that can do it and if you've tried everything else, you may want to give the Aquaphor-Maalox a try and ask your doctor about it.
Also, sometimes we do use some hydrocortisone cream. That's good when they have a contact dermatitis that's really red and itchy and bothering them. It can help calm the inflammation down. But it's just band-aid and whatever is causing the inflammation to begin with, as soon as you stop using the hydrocortisone cream is going to be there still to cause irritation and so you don't want to get in to the situation where you're using hydrocortisone cream every day, day-in and day-out to reduce the inflammation because the hydrocortisone does have other issues with it. It gets absorbed into the body, it can shut down your baby's own corticosteroid production can cause some skin changes, some pigment changes in the skin, some thinning of the skin.
There are other issues that can be associated with long-term steroid use. They're fine to use a couple of times a day for a few days when you have bad inflammation. But it's more important to figure out what's causing the inflammation or the contact dermatitis and dealing with that either by removing the offending thing or you can't really remove poop creating that barrier.
One thing I didn't mention that I should have much earlier on is make sure you change their diaper and that the babysitter or whoever is watching your child is changing their diaper quickly after they poop. Because again, if you're trying to minimize contact with these digestive enzymes and the stool with the skin, then you want to make sure you change their diaper in a timely fashion to also limit the amount of contact between the poop and the skin. That seems obvious but I didn't mention it. It's probably even more important than using a thick diaper. Change their diaper on a regular basis. You don't want them sitting in poop.
Sometimes I'm amazed; parents just can't understand why their child has this diaper rash that won't go away. Look, if you put on Depends for a couple of days and poop yourself and waited 10 minutes before you change, what do you think your butt would look like? OK.
So anyway, these are all things with diaper rash. Diaper rash can actually be a complex topic and this is another reason to go see your doctor, let him look at it. Is there a yeast component? Is there a bacterial component? Is there a contact component? Most of the time actually it's going to be a combination of things. Starts as yeast, then bacteria get involved or starts as a contact dermatitis then the bacteria get involved, or it's contact and yeast and the bacteria get involved and then you have to treat all three of those things in order to help it all go away.
OK. I've talked about diaper rash much longer than I had intended. I said, oh yeah, we're just going to do a quick talk about it. You get me talking on a topic and it all goes down from there. Well we have surpassed our one-hour sort of goal here and so let's go ahead and take a quick break and I'll be back to wrap up the show, right after this.
OK, we are back just to wrap things up really quickly. I want to thank Nationwide Children's Hospital for providing the bandwidth for our show today. Also Vlad at vladstudio.com for helping us out with the artwork at the website and then the feed.
Thanks mostly today to my family because we're in the middle of a move, we close in three days, we got to pack up this house, we've got all sort of things to do and yet they do give me the time that I need to get this podcast together because it does take many, many, many hours of preparation work to get one of these things together, not to mention recording and producing and uploading and all these things.
So thanks to my family because it's really taking a toll on my time. I love doing this but when you have to move you got stuff to do and so I've been neglecting that to some degree. I've been doing this at the expense of moving. So thanks to them.
And I do get a quite of number of emails thanking them and those are appreciated. I do appreciate it, they appreciate that. If this was my day job no reason to thank them, hey, it's paying the bills, you know. But this does not pay the bills and it's an addition to my day job, so thanks. Thanks, family.
Also of course, thanks to listeners like you. If you weren't here we couldn't be here doing this and so I really appreciate your time that you take away from your busy lives to include PediaCast in it.
Don't forget iTunes reviews are very helpful. If you haven't done one of those it doesn't take very long. We do have a poster page. If you like to design a poster for us, hey, send it in, we'd love it. We've got some, they're kind of lame. They need to be redone I think.
And of course, your word of mouth also helps so please continue, I hear this a lot now when people write in, they'll say, hey, we're telling everyone about the show. Please continue to do that because we don't have big advertising budget here. So how do parents know about us? Well they'd look through iTunes, but the biggest way, I think, is when someone says hey, have you checked out PediaCast. So your referrals are really the best way to do this.
If you have a blog and want to do a write-up on PediaCast, I would so appreciate that. And if you have a question for me that you would like me to answer or you want to quote, please email me at firstname.lastname@example.org, let me know you're going to do a blog post on PediaCast and I would be more than happy to answer some questions for you so that you can really personalize your post. That's really important to get the word out there about this show.
All right. Our next show will come from the new studio. As I mentioned before, it's going to take two or three weeks to get that all together. We are going to resume interviews. We have some great ones lined up. Karen is going to be back to do some shows together because I'll have a real studio and we'll have more than one microphone and it's going to be great, so we can look forward to that.
And until then, this is Dr. Mike saying stay safe, stay healthy and of course stay involved with your kids. So long everybody!