Melatonin, Playing in Dirt, Tylenol-Asthma Link – PediaCast 144
- Hypoplastic Left Heart Syndrome
- Childhood Obesity
- Antipsychotic Drugs
- Playing In Dirt
- Tylenol and Asthma Link
- Fluoride Supplementation
- In Complex Heart Defect Environment Plays Role
- Study Challenges Using Eye Color To Assess Newborn Jaundice
- Link Between Infant Weight Gain And Childhood Obesity
- Decline In Antipsychotic Drug Prescriptions For Florida Children
- Fluoride Supplementation Chart From ADA
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Welcome to PediaCast, a pediatric podcast for parents. And now direct from Birdhouse Studios, here's your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast. It is episode 144, 144 for Monday, April 6, 2009. And I'm calling this one melatonin, playing in dirt and Tylenol asthma. There's been a little bit of a media to do about Tylenol and could it actually cause asthma. Been in some journals and the mainstream media has picked up on it so we're going to talk about that.
Of course, we have lots of other topics coming your way. Hypoplastic left heart syndrome, there's a new story about the cause of that. It's kind of interesting from a research study that was done recently. Also jaundice, childhood obesity, antipsychotic drugs, fluoride supplementation. See we've got a whole line up here and no political commentary. Not this week. We did get some more emails regarding it, but we're going to hold off. This is just going to be a-information-packed program this week. You have to wait till next week if you want controversy again.
And you'll notice I put titles back in and that was because of you. I've had some listener say, hey, where did the titles go? We really missed it. Part of it was laziness, not putting the titles in especially with changing to a new website and I had to reput everything in. And it was easier to do without titles but [sigh].
The titles… see my feeling on the titles of the show is that okay, I picked three topics and you glance through those and you think, oh, there's nothing I really want to listen to. But what if I didn't pick the right three? I mean because there's just so much information that we packed into one of these shows. I can't put every topic in the title. But I had enough people write in and say, hey, we missed the titles that I put them back in. So I can't be blamed for not listening to the audience. So titles are back and this one, Melatonin, Playing in Dirt, Tylenol Asthma for PediaCast 144.
Hey, it's springtime and the springtime, I look at it as a time for renewal and I'm not going to get to philosophical here on you. But I would encourage you, if you have not done this, is take time this spring to do something new.
It's so easy to get to the same old — same old and routines doing the same thing with your family. Make an effort this spring to broaden your horizons. Get a little bit more balance in your life, do some different things. Yeah, just an idea.
Alright, one of the new things that we have here at PediaCast that is a little bit different, compared to weeks and years past, is we now have a way for you to support the program because really, that's the best way to keep the show on us and to keep us being able to do exactly what you want us to do. Because if you control the purse strings, you control the show.
So we do have a donation page set up now because there's a lot of overhead cost associated with putting one of these podcasts together. And the sponsorship is few and far between for podcasts, any meaningful sponsorship. Because with just don't have a big enough audience. So we rely on your donations to help us along.
And I did want to read a message that I got last week from Suzanne in Sherman Oaks, California. Suzanne says, "Hi, Dr. Mike. As soon as I heard your request for a donation, I hopped right onto your side and made a one-time donation of $24. You are right in asking for financial support. Your family should not bear the financial burden for my benefit. I believe you are providing a valuable service to moms and dads and the information and the entertainment you provide is invaluable to me and my family and worth supporting with my dollars. I hope others share my feelings and act in the same way. Keep up the fantastic work and thanks to your family and for all you do and the passion that you put into the show. Thank you, thank you, thank you."
So thank you, Suzanne. And so those of you, if you haven't stopped by the website, just go to pediacast.org. You can click on Donate and there are several options there for you to help you support the program because we are here because of listeners like you and through your support we're able to keep this going.
Alright. I would like to remind you, if there's a topic that you would like us to discuss… oh by the way, we're going to the Skype line today. So a little bit later on in the show, we're going to have some of your questions actually that were called in, so we haven't done that in a few weeks. So we will be going to the Skype line.
That's one way that you can request information or if you have a question for us here at PediaCast, you can go to the Skype line. How do you do that? You just call (347) 404-KIDS. That's (347) 404-5437 and you can leave a voicemail with your question and we'll be able to get you on the program that way.
You can also contact us through pediacast.org. Just go there and click on the Contact link and you can get a hold of us that way or you can email email@example.com. If you do that or call the voice line, make sure you let us know where you're from. That's always interesting.
And don't forget 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 if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
Alright, we are back and before we head off in the news, there's one more thing I wanted to mention that I wanted to mention in the intro and I forgot.
And I usually mention this at the end of every show, but it's important enough that I wanted to put it at the beginning, at least this one time in case some of you don't make it all the way to the very end when we do the out throw segment. And that is if you enjoy PediaCast, in addition to donations, the other thing that we ask is if you could leave as a review in iTunes. We haven't had a new review in a while and I know a lot of you who are out there stumbled upon PediaCast because you were browsing through the iTunes store in the kids and family section and you found us that way. You read the reviews, there were lots of positive reviews so you gave us a try.
If you're one of those people, if you could contribute back by just taking, literally, it just takes a couple of minutes to leave a nice review on iTunes. And the more positive reviews that we get, that this help with exposure and keeping us on that very front page on iTunes. So if you haven't done that, please do so. If you have, thanks. Really appreciate it.
Alright, our News Parents Can Use is brought to you in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.
A congenital heart disease that often leads to death in newborns is significantly more common during the summer, leading researchers to believe the environment and not just genes that affect the heart may play a role in causing many epidemics of this disease. Cardiac surgeons from Cincinnati Children's Hospital Medical Center presented this research at the Annual American College of Cardiology Meeting in Orlando, Florida. The study is a finalist in the ACC's Best Poster Awards competition.
Hypoplastic left heart syndrome is one of the most complex cardiac defects seen in newborns and remains probably the most challenging to manage of all congenital heart defects. And a child with hypoplastic left heart syndrome, all of the structures on the left side of the heart, the side which receives oxygen-rich blood from the lungs and pumps it out to the body, are severely underdeveloped. This results in the left side of the heart being completely unable to support the circulation needed by the body's organs.
The most common treatment for hypoplastic left heart syndrome is staged reconstruction in which a series of operations, usually three, are performed to reconfigure the child's cardiovascular system to be as efficient as possible despite the lack of an adequate left ventricle.
Current management at major pediatric heart centers have resulted in survival rates of 75% or better. Cardiothoracic surgeons at Cincinnati Children's studied nearly 1,500 newborns from 38 children's hospitals in the United States who have left side and congenital heart disease and found a seasonal occurrence of hypoplastic left heart syndrome but no other left side of diseases over a 10-year period from 1996 to 2006. They also found seasonal differences each year with peak incidence between April and July and low points in January.
The researchers say strong seasonality is a clue. Environmental factors may play an important role in this disease as seen with common childhood illnesses like asthma and croup.
The study augment some prior epidemiologic studies and points the finger at the possibility of additional factors. It also opens the window for genetic studies to consider candidate genes not directly related to cardiac maldevelopment such as those involved in immune response, which really have not been considered in the past.
One potential environmental factor being studied by the researchers is recurrent maternal exposure to the common agent strep throat, which is also responsible for the devastating condition known as rheumatic heart disease.
Numerous studies have indicated the immune reaction against strep and pneumatic heart disease can lead to injury on the left side of the heart which is the side also affected in hypoplastic left heart syndrome. This preliminary study suggests many mothers whose newborns have left side of the heart injury also had a significant history of strep throat problems.
That's amazing to me. I mean ever since… when I was a resident, hypoplastic left heart syndrome was — back then, it was really a death sentence.
I mean it wasn't until the early to mid-'90s when survival rates began to drastically improved and recent innovations in surgical technique; a pharmaceutical agents used during and after surgery; and monitoring methods used during and after surgery have really improved in the last 10 years and so it's gone from being really, really low survival rates to survival rates of more than 75%.
And that's just really amazing to me, someone who remembers when hardly any of these kids survived. And actually, I have a really good friend from college who had a son that was born with this and who did die during the surgery to correct it. So I also know about this served on a personal levels as well.
But to think that strep throat might be involved in this is just… it just amazes me, really. It's an interesting finding with this the study. So it was a little bit of indulgence including this study on here as I found it so interesting.
Incidentally, surgeons at the medical College of Wisconsin post a survival rate of 93% in recent years which is simply incredible considering the complexity of this condition and its repair process.
Alright moving on. For hundreds of years, doctors, nurses and midwives have visually examined newborn babies for the yellowish skin tones that signify jaundice. The yellowness comes from a blood byproduct bilirubin and the child that develops high levels of bilirubin has a potentially serious condition called hyperbilirubinemia.
Now pediatric researchers say this long-standing practice of visual inspection is an unreliable method of predicting the baby's risk for hyperbilirubinemia. Only infants with the total absence of visible jaundice can confidently be expected to have very low risk.
Our study tells clinicians that our ability to estimate a baby's bilirubin level or predict the baby's risk of developing clinically significant hyperbilirubinemia by visually observing the extent of visual jaundice is inadequate and not very helpful, said study lead author, Dr. Ron Keren, a pediatrician in the Center for Pediatric Clinical Effectiveness at the Children's Hospital of Philadelphia.
The study appeared March 22nd in the online version of Archives of Diseases and Childhood, Fetal and Neonatal edition. Neonatal jaundice is very common, occurring in as many as 60% of newborns annually according to the American Academy of Pediatrics. It appears as a yellowish skin color, caused by excess bilirubin which is a byproduct of the normal breakdown of red blood cells.
In the vast majority of cases, jaundice disappears in 1 to 2 weeks as the baby's liver reduces bilirubin to normal levels, permitting the excess to be excreted.
But extremely high levels of bilirubin can cause kernicterus, a potentially life-threatening condition that can result in long-term brain damage, hearing loss and other neurological problems. Although extremely rare, kernicterus has been increasing in the US over the past two decades, leading some professional organizations to advocate universal bilirubin screening before newborns leave the hospitals.
The standard treatment for a significant hyperbilirubinemia is phototherapy, exposing the baby to ultraviolet lights that chemically change bilirubin under the skin to a harmless form.
The current study was the first systematic analysis of jaundice assessment as a predictor of significant hyperbilirubinemia risk. It was also the largest such study involving 522 term and late preterm newborns. Clinicians have long known that neonatal jaundice progresses from head to foot as shown by yellowing of the baby's skin.
In this study, conducted in the well-baby nursery of the Hospital of the University of Pennsylvania, nurses use a five-point scale to grade the farthest extent of jaundice along the newborn's body. The nurses who did the ratings did not know the actual bilirubin levels which were measured by other caregivers using a non-invasive device.
On analyzing the results, the researchers found that while there was some correlation between the extent of jaundice as rated by the nurses and the measured bilirubin levels, the extent of jaundice could not be used to estimate the bilirubin level or to accurately predict an infant's risk of developing significant hyperbilirubinemia, which was defined in this study as a bilirubin level for which phototherapy was recommended.
Furthermore, contrary to a common belief that it is harder to visually assess jaundice and dark-skinned infants, there was no significant difference in the results between black and white newborns. The correlation between the visually-assessed jaundice and bilirubin level was especially weak in late preterm infants, those at 35 to 38 weeks gestational age. This is important, said Keren, because late-term… a late preterm infants are at greater risk of developing significant hyperbilirubinemia.
The one exception to the poor predictive value of visual assessment came in the 91 infants or 17% of all those studied rated by the nurses as having a complete absence of jaundice. For those infants, the actual risk of developing significant hyperbilirubinemia was extremely low in less than 1%.
Even for these infants, Dr. Keren said, absence of visual jaundice may require a caveat. Less experienced observers may be less capable of accurately assessing a complete absence of jaundice. All in all, the benefit of objective results from universal bilirubin screening may outweigh the benefit of reduced cost in pursuing a selective screening approach.
Okay, I used some big words there and normally, with new stories, I do the story and give you my two cents worth. On this one, I do want to take this opportunity to talk just a little bit about jaundice because I think it's worthwhile.
Babies are born basically with too many red blood cells. And there… why? Well, there's this extra circulation that goes from the umbilical cord to the placenta. So you have this extra circulation so their blood is packed with more red blood cells. Once the lungs are used and the placenta is no longer where gas exchanges is occurring, the body does not need as many red blood cells. Because the lungs are more efficient, you don't need as many red blood cells to do the same job as you do when you're getting your gas exchange through the placenta.
So these extra red blood cells get broken down and bilirubin is a byproduct of this breakdown. Now as it turns out, there are two forms of bilirubin. One kind the body can get rid of easily and the other kind stays in the body longer. And the liver is what — I'm kind of oversimplifying things here a little bit, but you know, this is good enough to understand.
The liver changes the hard-to-get-rid-of kind to the easy-to-get-rid-of kind. However, if the amount of the hard-to-get-rid-of kind exceeds the liver's ability to convert it to the easy-to-get-rid-of kind, then bilirubin starts to build up in the blood and this is called hyperbilirubinemia. Hyper means too much bilirubin, emia means in the blood. So too much bilirubin in the blood is hyperbilirubinemia.
Now hyperbilirubinemia can lead to kernicterus, which is a central nervous system damage from high levels of bilirubin. So the bilirubin kind of spills into the nervous system cells and damages those cells and can cause brain damage and the auditory system with hearing is particularly at risk for this so that it can also cause hearing problems, which is part of the central nervous system.
Now something about breast milk appears to reduce the liver's ability to do its job which is why breast-fed babies get jaundice more often. And we don't know exactly what chemical is involved or why, but we do know that something about breast milk makes the liver not quite as able to do its job of turning that hard-to-get-rid-of kind of bilirubin to the easy-to-get-rid-of kind.
Now the good news with that is even when bilirubin goes really high, if the cause is just breastfeeding, kernicterus rarely develops. We don't really know why that is either. So there's still much about jaundice that we don't completely understand.
What do we do when it's there? Well, the first thing we do is phototherapy because ultraviolet light also converts the hard-to-get-rid-of kind of bilirubin to the easy-to-get-rid-of kind and at the level of the skin. So phototherapy helps in that way.
This should only be done under a doctor's directions. You don't want to take a jaundice baby and put them out in the sun because you'll worry about sunburns. So this has to be done the right way and your doctor is the person to oversee that.
Sometimes though, the amount of bilirubin is too high for that to effectively work and in that case, you have to do what's called an exchange transfusion where you take out the baby's bilirubin-soaked blood and replace it with bilirubin-free donor blood. So sometimes that has to happen too.
Now if you look at this, what are some of the things then that are more likely to cause hyperbilirubinemia and kernicterus? Well, now that we know the mechanism by which all these happens, it's easy to see. Anything that increases red blood cell breakdown, so blood type incompatibilities between mom and the baby. You can have a spherocytosis thalassemia, G6PD deficiency.
Okay, we're getting a little bit more complicated here, but there's a lot of disease processes where the result is an increased breakdown of red blood cells which then can lead to increased jaundice.
Also, anything that decreases the liver's ability to convert the forms of bilirubin which is another laundry list of problems that we won't get into. So we'll go ahead and move on. I just wanted to explain a little bit more about jaundice and what that's all about.
So let's go ahead and move on to our next story. As childhood obesity continues its 30-year advance from occasional curiosity to cultural epidemic, healthcare providers are struggling to find out why. And the reasons are many. Increasingly, sedentary environments for both adults and children, as well as cheap and ubiquitous processed foods no doubt play a role, but researchers are finding more evidence that the first clues for childhood obesity may begin as far back as early infancy.
A new study led by researchers in the Department of Ambulatory Care and Prevention at Harvard Medical School and Harvard Plymouth Healthcare, as well as Children's Hospital Boston, has found that rapid weight gain during the first six months of life may place a child at risk for obesity by age 3. There is increasing evidence that rapid changes in weight during infancy increased children's risk of later obesity, says lead author Dr. Elsie Taveras, Assistant Professor in the HMS Department of Ambulatory Care and Prevention and co-Director of the One-Step Ahead Clinic, a pediatric overweight prevention program at Children's Hospital Boston.
The mounting evidence suggests that infancy may be a critical period during which to prevent childhood obesity and its related consequences. These findings appear in the April edition of the journal Pediatrics.
Most prior studies examining the relationship between infant weight gain and later childhood obesity focus primarily on body weight. However, measures of the length, in addition to weight, together reflect body fatness better than weight alone.
In this study, Dr. Taveras and colleagues in the HMS Department of Ambulatory Care and Prevention examined how weight and body length or weight per length in infancy can influence later obesity. The team used self-reported data from Project Viva, an ongoing study of more than 2,000 pregnant women and their children. They isolated a subgroup of 559 of mother-child pairs and studied patterns of weight gain in infancy and their subsequent three-year effect.
In addition to looking at static weight and length measures, the team also looked at weight gain as a dynamic process measuring not only how much but how quickly an infant gained weight. The connection between rapid infant weight gain and later obesity was striking even after adjusting for factors such as premature babies or those underweight at birth.
Take for example two infants with the same birth weight who after six months weigh 16.9 pounds and 18.4 pounds, just a 1.5 pound difference. While according to the study, the healthier of these two infants… I'm sorry, the heavier, not healthier. The heavier of these two infants who were the same weight at birth, the one that weighed 1.5 pounds more at six months of age had a 40% higher risk of obesity at age three compared to the other child.
While this study confirms earlier ones examining the relationship between infancy and childhood weight, there are certain limitations. For example, the researchers weren't able to examine social and behavioral interactions around feeding between parents and infants. And while families in the study represented various ethnic backgrounds, they were fairly homogenous socioeconomically, so there may be some question regarding how widely the results can be generalized to other socioeconomic levels.
Still, when seen in the context of our research, the relationship between infant and childhood weight is compelling. There are still a lot more we need to understand about the mechanisms of how this all fits together, said Dr. Taveras. But this data clearly shows that the earliest interventions might actually have very long-term benefits.
Taveras also points out that these findings provide initial evidence that our cultural affirmation of infants who topped the growth charts and even our notions of appropriate weight gain during pregnancy may prove to be excessive.
At first, it may seem impossible that weight gain over just a few months early in infancy could have long-term health consequences, but it makes sense because so much of human development takes place during that period and even before birth, said Matthew Gillman, Director of the department's obesity prevention program. Now we need to find out how to modify weight gain in infancy in ways that balance the needs of the brain and the body.
I want to point out this was really a well-done study. This was a prospective study. So they took these kids right from birth and measured their birth weight, measure their weight at six months and then measured them at three years of age. And so this is really a well-done study. It's prospective in nature. They did talk about in the article the bad things about the study, the things that they didn't control for, the fact that it was all one socioeconomic level. So this is really well done.
And I want to point that out because a little bit later on in the show, we're going to talk about the Tylenol asthma link which was not such a great study. And just remember, this study that we just discussed when we're talking about that one because you'll definitely see a difference between the two. Little bit of a foreshadowing there.
Alright, moving along to our final news report. The Florida Medicaid Program last year began requiring physicians to receive approval before prescribing antipsychotic drugs to children younger than age six. And now the St. Petersburg Times reports that the number of prescriptions for children in that age group has dropped by nearly 75%, that's according to new data from the Florida Agency for Healthcare Administration.
In April of 2008, the state began requiring physicians to seek approval from the state before writing prescriptions for Risperdal, Abilify, Seroquel, Zyprexa and similar medications to children.
The new data compared the prescriptions for children younger than age six from May 2008 to December 2008 with the same period a year earlier. The data shows nearly 40% fewer physicians wrote prescriptions for the drugs. Their was a 40% decline in the number of preschool age children receiving the antipsychotics. Of preschoolers who received prior authorization for the drugs in 2008, more than half were diagnosed with autism and pervasive developmental disorder.
Risperdal was the most commonly prescribed, accounting for more than 70% of all prescriptions. The number of children prescribed more than one of the drugs dropped from 73 in 2007 to just 28 in 2008. And requests from doctors seeking to prescribe the drugs were altogether cut by two-thirds.
Dr. Helene Hubbard, a pediatrician who specializes in developmental problems said, "It's a terrible thing. My kids are suffering." But Dr. Robert Constantine of the University of South Florida said there's been no major outcry from doctors and ordinarily, we would have heard. According to the Times, the state still approves nearly three out of every four antipsychotic prescriptions for children, most of which are refills.
Sorry, I have to wet my whistle. [Clears throat] Okay. So what are my observations with this? These… see that's the problem with the show when it's a one-man thing. I mean I don't have these commercial breaks like these radio guys can do and then they sip on their water. This just goes on and on. That's one of the reasons for the music interludes but I got dry a little bit before that, so I apologize.
So what are my observations with this? Okay, these medicines, these antipsychotic medicines, I hate that word. But these basically slow kids down, making them easier to manage and improving the quality of life in the home. Some of these kids don't need that medicine. A lot of them do.
And in the past, it's been between the doctor and the parent to decide risk versus benefits, is this the kind of medicine that's going to benefit your child? Is it worth the risk? Is it going to improve the quality of life? And this sort of decision was made in the examination room between a doctor, a parent and if it's an older child, the child.
Now we are taking this decision out of the examination room and we are letting the government decide. And again, I said I wasn't going to get into the political scheme of things, but this is a problem, folks. I mean this is a problem.
Now the other thing that bothers me a little bit about this is the state is saying, hey, we approve three out of every four. And I suspect what happens is that the state… this is from their perspective, there's two reasons for them to do this. Number one, they want to save money. These medicines are expensive. And this is the Medicaid program so they're wanting to save money. So they put this roadblock in the way.
Number two, there's some controversy about whether these drugs should be used in young children or not. And so if there's an outcry by some organizations, legislators are more… the legislators are more likely to say okay, let's make it preapproved so doctors will think twice before doing it. So there's really sort of two reasons to put this preauthorization program in there. I think the major one is to save money.
Now the ones that get denied probably… the reviewer who decides this does not have the medical chart and looking at everything. They don't interview the child, all that they do is say okay, what's the diagnosis code and what have you done before? So I suspect that they look to see was this child tried on a stimulant medicines first, like Adderall, Concerta, those kind of things. Or did you just start with the Risperdal. And the kids who did not have any trial with any other agents were probably the ones that got rejected. So all the doctor would have to do is to put the kid on Adderall for months, say, they didn't work, we want to try Risperdal. And now it's going to go through.
So it's sort of bogus anyway the way that it's set up right now because doctors know why it got rejected and how to get it to go through. And I know this because I've been in the system practicing. I know how these sort of thing works. So now you have to ask yourself, if there's 75% less of them being written, that means that in 75% of the cases, either the kids didn't need the drug, which is unlikely. I mean I'm sure there's some of them didn't but I doubt that 75% of them were on the medicine inappropriately. That doesn't really make a lot of sense.
So that means that doctors weren't doing it because of the hassle that was involved. If I have to fill out a form or I need my nurse to fill out a form, then I'm already in a busy office. I've got… I'm trying to see as many patients as I can during the day so I can keep things afloat and keep people happy who would want to come in and see me.
And now my staff has to take time out of their day to be on the phone, to fill out forms, to fax this stuff in, to deal with the pharmacy who says hey, this needs a pre-authorization. And these things take up a lot of time.
Now if you're talking one, okay fine. But when you're talking that you have a big panel of patients and you're doing 10 of these a day, which is not unheard of… I mean you start to have to pay a person whose job it is to do all these pre-authorizations. I mean a full-time equivalent person in a practice to do all of this.
And so that jacks up the cost for the doctor and what does it really accomplishing for the state? What it does is it makes doctors not want to do it because they don't have the resources to do the pre-authorization process and the kids who need the medicines are the one who suffer.
And again, what this all boils down to is taking these kind of decisions out of the examination room and putting them in a government office where they aren't necessarily deciding yes or no, but they're deciding what hoops the doctor has to jump through to make this happen hoping that the doctor will pick not to jump through any hoops so that they can save money and not pay for the drug.
So this is all problems of our system that's only going to get worse with the socialized medicine. Okay, I'm sorry. I said no political commentary, but I just can't help myself.
Alright, that wraps up our News Parents Can Use and we will be back to answer your questions right after this break.
Okay, we are going to go to the Skype line right now.
Sandy: Hi, Dr. Mike. This is Sandy. I really enjoy your podcast. I'm from Indianapolis. I have a friend whose doctor has prescribed Melatonin for her son who's having trouble sleeping. I was wondering what this is and also, if it might help my son. He's three and a half and he has all that trouble sleeping. Either if I put him to bed too soon, he wakes up at 4 o'clock in the morning. If I put him to take a nap too late, then he's up until 4 o'clock in the morning. Thank you for your help. I'll talk to you later. Bye.
Dr. Mike Patrick: Okay, Sandy. I'm going to focus with my answer on melatonin. If you go back through… if you go to pediacast.org, click on search and look for sleep problems. You're going to find that we've talked about this many times.
So if you want more of a behavioral plan to help your three-year-old sleep better, we have discussed that many times in the past. So I really just want to focus on melatonin here because there has been a lot more use of it in terms of as a medicine to help kids sleep. So let's talk a little bit about what this is.
Melatonin is a naturally occurring hormone that's found in most animals. Not just mammals, just many animals. In fact, many plants also utilizes, particularly funguses. Are those plants? Maybe those aren't plants. Those are types of animals, aren't they? Yeah, I was a biology major, that was a long time ago, folks.
Okay, maybe not plants. Fungus… but fungal organisms, yeah, I guess those are animals aren't they. And I'm sorry. I just really made a fool of myself. So anyway, melatonin is in lots of animals, not just humans. And not just mammals either. And what does it do? Well, it plays a role in an organism circadian rhythm. So the daily rhythm, awake-sleep-type cycle, that sort of rhythm that we have that we call circadian rhythm. It's involved in that. And again it's secreted by the pineal gland in humans anyway and that is a midline deep brain structure.
What happens is that we think the retina gets stimulated by bright light and signals are sent to the pineal gland and that results in decreased melatonin production. And when no bright light signals are coming, then melatonin production increases.
So it's sort of a way for the rest of the body to know if it's light outside or dark outside. And then your body can adjust accordingly because your body is not directly connected up to your eyes, right? So the light comes in your eyes, stimulates the retina and then a signal gets sent to the pineal gland and that decreases melatonin production. So you get increased melatonin production when it's night outside.
Now let's talk about all the effects of melatonin. Let's talk about sleep first. Actually, as it turns out, melatonin is not a major regulator of sleep patterns, but it does appear to play a small role. Taking melatonin does not make you feel immediately sleepy. It's not like an anti-histamine where you get drowsy immediately after taking melatonin. It does not do that.
What it does seem to do though is to help with sleep rhythms. So it doesn't make you sleepy, but it does do other things to the body that lets your body know that it's time to sleep. For instance, it decreases your body temperature a little bit. It can make you feel fatigued, but not necessarily sleepy.
It has been shown to help because of this… because it helps with sleep rhythms, it has been shown to help — by studies, it's been shown to help elderly adults with insomnia. There's been studies that show elderly adults who can't sleep, you start taking melatonin at bedtime and after a while, it starts to help them with their insomnia. It doesn't help immediately.
It also seems to help those suffering from jetlag. What do you do there is you give the… you start the melatonin at the target location's bedtime. So you want to basically adjust the body's day and night cycle or wake-sleep cycle, then for the new location whenever it is that you're supposed to… even when it's supposed to be getting dark, you're supposed to be getting tired, you take the melatonin. And after a couple of days, it'll help you to readjust your circadian rhythm. Again, it doesn't make you sleepy immediately. It's important.
Also workers, shift workers who need to flip their awake-sleep cycles, like they'll work days for a couple of weeks and they'll work nights for a couple of weeks and days for a couple of weeks. By taking melatonin at the time when the new sleep time that after a couple of days, that may help when you do it that way.
So it does help with sleep rhythms, but it doesn't make you immediately drowsy, for instance, like an anti-histamine would. It also has… I mentioned that it lowers the body temperature. It induces fatigue but not sleepiness and decreases motor activity and it's thought that all of these things actually are what end up making you feel sleepy. Take all of those into account or all of those things happen and then you start to feel sleepy. So again, it's a little bit more complex than just to make you feel sleepy. It does some things that help with sleep-wake.
Now the problem with it though… because if that was it, if that's all that there was to it, yeah, fine, try it, not a big deal.
But — oh, I do want to mention one other nice thing it does. Melatonin does possess some antioxidant activities. So many health food supplements sort of market it for that purpose. So but… so this sort of thing looks great on the surface. I mean if that's all that there was to it, sure, it'd be beneficial to go ahead and do it.
But the problem is it's a hormone and melatonin has some other effects. And the biggest other effect is going to be on the reproductive system. It influences sex hormone production. And what's interesting is it's not necessarily the more melatonin that gets made, the more sex hormones get made. Because then you would think, okay, so at nighttime, the sex hormones get stimulated, hey, that's why people have sex at night, I guess.
Now it's not quite like that. The relative length of day versus night is a regulator of this. So when you get to the point in the year when the length of day versus the length of night ratio is a certain level, then the pineal gland is making a certain amount of melatonin and other areas of the brain respond to that amount of melatonin, not less, not more, that amount by gearing up the reproductive organs.
And so what this is thought to be involved in in other species is breeding seasons. So if a certain species has a breeding season in the spring, this is how that gets turned on and turned off. And then in fact, in sheep for instance, they normally breed only once a year, but you can give them melatonin in large amounts and stimulate a second breeding season in the same year. So it's kind of interesting that it has these effects, at least in other species.
Now in humans, one of the things that can happen is that you can start to get breast development, so gynecomastia we call it. You can get — you can start to have a risk for getting secondary sexual characteristics, so pubic hair in young kids. So there — it can sort of stimulate the sex hormones even in kids. So that's one of the things that can happen with it.
Now is it the risk of that happening to your child worth the benefit of their sleep cycle being better? They may be. And that's something that you have decide between you and your doctor.
There are also side effects that exist with melatonin. The most common of these are once they fall asleep, they may be prone to waking up and being disoriented, confused, sleepwalking. They may have vivid dreams, they can have nightmares. So these are things that are common.
Also, it can cause alterations and growth hormone production. And it's not really been well studied whether that is a good thing or a bad thing or whether it doesn't really affect — they've not taken a group of kids and given the melatonin and another group not and then finding out there growth velocities. They've not done that, but they do know that melatonin does have an effect on growth hormone production.
Also for some kids who get melatonin, they get GI symptoms, nausea, vomiting, cramping, that sort of thing. And then those are the most common side effects. Sort of medium, not as common, dizziness, irritability, headache, wide variations in blood pressure, increased cholesterol levels and increase blood sugar levels. And then rare, but not unheard of side effects and problems, you can have allergic reactions. There's some question of whether melatonin can cause an autoimmune. So your immune system, hepatitis. So it can cause liver inflammation brought on by your immune system, maybe.
There's also some indications it can cause blood clotting abnormalities, increased seizure risk and abnormal heart rates. So again, the question is does the benefit outweigh the risk or does the risk outweigh the benefit? And that's a decision between you and your doctor. And maybe, in the future, the government. So you just have to… you have to figure this out for yourself. I mean if your child's sleeping issues are really a problem and affecting the quality of life of your child, the quality of life of the parent, the quality of life the family, then it may be worth the risk.
But I think I would definitely try other things first. I would try, if it was up to me, I would try behavioral management first. Maybe even other classes of medication first, a lot of kids who are up at night have some ADHD problems. And if you can focus their energy during the day, then that may help them sleep better at night. There are ways to do that medically and non-medically.
So I mean you got a look at the whole picture. But I suppose if it's really a quality-of-life problem and nothing else has worked, then it may be worth taking those risks and side effects. Take a look at it that way.
Alright, let's go ahead and move on. We do have another Skype question. This one from Samantha.
Samantha: Hey, Dr. Mike. It's Samantha calling from Scottsdale, Arizona. I'm wondering on your new section if you could make a comment about a news article that showed up on CBS the other day about the fact that dirt is good for kids experts in fist.
They talked about the fact that everything we've done with antibacterial — everything is actually doing more harm to our kids than it's actually doing any benefit, as one who used to go out and digging the dirt myself. I think that this article is right up with all things wise and full of common sense. But I was just wondering what a professional thought. Thanks so much for your time. Thanks for everything you do. Love the podcast. Bye-bye."
Okay, thanks, Samantha. So playing in dirt, good or not good? First, let me say — I mean hygiene's important. And if you have a kid who has a rash or they have a scratch, they don't have complete dermal protection, you probably don't want to be playing in the dirt because there are bad things in dirt.
On the other hand, I understand what you're saying that it's good to get outside and play and it's playing in the dirt and end of itself bad. Probably not unless you live next to a toxic waste dump.
But again, there are microorganisms in the dirt. And if you have scratches and interruptions in the integrity of the skin, you probably don't want to be getting dirt in those — in those areas.
I think really, here there are two issues that this — that the story that you're talking about is looking at. It's not really so much playing in the dirt that's the issue. What the issue is is are kids getting enough antigen exposure when they're young.
And could it be that if they don't get lots of low-level chronic antigen exposure, that allergy and asthma may be more of an issue down the road for them? And then the other thing is microorganism exposure and are we killing off too many good bacteria? And these are really different issues. So let's take these issues separately.
First, in terms of antigen exposure. Antigen, remember, it's something that your body doesn't like. And when it enters the body, you have an immune response to the antigen and you get allergies.
So you get allergic rhinitis, your nose runs. You may get asthma symptoms. If it's in the skin, you get eczema. These are all — it's all immune system mediated in response to an antigen which is a foreign substance the body doesn't like and it's mounting an attack against. So if you have a peanut allergy, the peanut antigen is what your body doesn't like. Like a protein that's part of the peanut, okay.
We've talked about this before as it relates to environmental allergies that low-level chronic exposure of a substance leads to immune system tolerance. And this is the basis of allergy shots, right? I mean if you are taking allergy shots for a specific substance, you're injecting that substance into the body week after week after week in really, really low levels so that the body will start to tolerate that substance.
So if you don't allow kids to have low-level exposure to their environment over a long period of time, they don't build up tolerance and environmental allergens may pose more of an issue down the road. And hypothetically, this may lead to more cases of allergic rhinitis, asthma, eczema, this kind of auto… these kind of immune mediated illnesses.
We do know that these conditions are on the rise and we know that kids are exposed to these things less at low-level chronic — low-level chronically as compared to years past. I mean kids aren't playing outside as much. People aren't keeping their houses cleaner. There's better homes being built that keep dust out.
So I mean it's tough because on the one hand, it's good, I mean it's good for the older kids who would be allergic to the dust to not have that in your house. But if you're not expose to it in little bits when you're young, then you're more likely to have problems later on.
So I mean it's sort of — is sort of six and one-half less of another. I mean we got to the point where we've gotten so clean and dust-free and kids not being out playing in the dirt that, at some point, when they are exposed to those things, they have a problem. And that's I think why we're seeing more allergic rhinitis and asthma and eczema.
Okay, so there's something to be said for letting kids play outside, to be exposed to lots of things and do not keep your house 100% allergen-free. But on the other hand, as I mentioned, hygiene is important. Disease can be spread by exposure to pathologic microorganisms and unsanitary environments. So playing in the dirt may be okay, might even be get. But again, if you have a skin laceration or an abrasion or the dirt next to a sewage plan or dumpsite, you got to use some common sense with all this.
Now in terms of bacteria and the overuse of antibacterial agents, there are several issues involved here.
First of all, not all bacteria are bad, right? Some are good. The skin and the intestinal tract are full of good bacteria. And they're important for the health of the skin and the GI tract, sort of a symbiosis kind of relationship. There also there's placeholders because if you get rid of the normal good bacteria, then you've made room for worse things to grow such as the pathologic organisms, resistant organisms, MRSA, yeasts.
And this is why, incidentally, babies get diaper rash and thrush after an antibiotic because you've killed off all the normal good bacteria on the skin and now yeasts can come in and grow. In their mouth, that's thrush. In the diaper area, it's a diaper rash. And women get vaginal yeast infections after being on an antibiotic because you killed the normal good bacteria that live in the — in the vaginal area and now yeast can come in and grow.
So we know that bacteria's important. We know that there's good bacteria and we want to selectively kill the bad bacteria but not the good bacteria. Now with regard to resistance formation, bactericidal drugs in chemicals kill all bacteria no matter what.
So they don't really result in resistance because they kill everything. So the kind of — the cleaners like Lysol and the more industrial and healthcare strength cleaners that we use, they kill everything. So that's not necessarily a hazard-resistance. So when we used… when we say we shouldn't — we're using too many antibacterial things.
If it's bactericidal and it kills everything, that's really not a problem. I mean you don't want to spray it on your skin and kill off all your normal good bacteria, but I mean you're not spraying Lysol all over your skin anyway. And if you are, then you've got issues beyond might help.
So the cleaning agents is not really what the big problem is. The big problem is inappropriate use of antibiotics. And the reason that is because antibiotics selectively kill. They only kill some microorganisms.
So they kill some bacteria and they leave others behind because they work by a specific mechanism that kills a bacteria, a type of bacteria based on sort of what processes that bacteria has to have to live and thrive.
So it's really more of a — and that's why it's safe for you to take because whatever it is that the antibiotic is doing to that bacteria to kill it, it's not doing to your cells. Your cells can tolerate it.
I mean you wouldn't use a bactericidal-type agent if you had strep throat. You wouldn't spray Lysol on the back of your throat. Because, yeah, you'd kill the strep but you're going to kill your own cells too. So you use an antibiotic to selectively kill a bacteria… a bacterial organism based on the physiology of that particular organism and what you could interrupt — what process you could enter up to kill it that would not affect other bacteria.
So then the problem becomes though that bacteria are living things. They can mutate, they can change and they can figure… they can — if they mutate in such a way, you got to think about evolution here a little bit. If an organism changes in such a way to make it so that they can live even if whatever processes certain antibiotic disrupts, then they suddenly become resistant to that antibiotic because they've mutated in such a way to not need that — that pathway, that physiologic pathway that the certain antibiotic is interrupting anymore. And then they can grow and thrive and pass on their genes at which… so that their offspring are resistant to that antibiotic as well.
So inappropriate use of antibiotics is definitely a major problem because we're creating or helping to create resistant organisms by using them. So that is… so it's not so much anti-sanitary — using hand gel is fine. Okay you're killing off some normal good bacteria on the skin of your hands.
Fine, okay, you take that, that's not so good. But you're killing the pathologic things on your hands as well. And since your hands are going to be what's closest your mouth and where things can get in, it's probably okay to not have the goods skin bacteria in your hands, not to have any bacteria on your hands. I wouldn't lather down with it because you do want the goods skin bacteria on the rest of you.
Okay so there are pathologic organisms out there MRSA, salmonella, E. coli that we do want to — so it is a good idea to use hand sanitizers. Oh, why am I, I sound like a broken record here.
So I think it's important to recognize when people make sweeping statements like this news article that oh, we're killing too many bacteria. As long as you're killing all of them, it's not a problem. I mean you don't want to kill all bacteria in the world obviously because they're important. But I mean when you're spraying things down, you're trying to kill the bad stuff. You kill some of the good stuff too, fine.
And if you're killing everything, no matter what, it breaks apart the cell membrane and no organism can survive it, fine. But antibiotics, inappropriate use of antibiotics is definitely a problem. I think we all recognize that. I think the playing in the dirt thing was more of the low-level antigen exposure anyway.
Okay, so we only had two Skype — people have not been calling the Skype line. Is there a problem with the Skype line? Please let me know. Again, if you go the contact page of pediacast.org, because we have had issues with it in the past where we had to make some adjustments to get everything working again.
But those were the only two Skype messages that I've had recently. I do like doing the Skype once so please feel free to call. Again, that phone number is (347) 404-KIDS, (347) 404-5437. You can call that number and ask your question and it may actually get on the program a little bit quicker and easier than if you send it by email or do the Contact page at the website.
Also I really appreciate — I have not had other people, since last week, message me through Facebook. And I appreciate that because again, it's harder to keep track of all the messages if they're coming from different places. Okay, let's go ahead and move on.
Our next question comes from Crystal in Dubuque, Iowa. And Crystal says, "I recently discovered your podcast on Zune and I love listening to it on the way to work. I recently read in my Nursing 2009 magazine that there is a link between Tylenol and asthma. I was wondering if it's safe to give my 10-month old Tylenol before shots and to ease his teething. Thank you."
Okay, so this is the bad study that I was alluding to in the News section earlier on in the show. The Tylenol asthma link actually comes from data from an international study that recently looked at 200,000 children in 31 countries.
So it's a big study. It did look at lots of kids, but it was not a prospective study. It was a retrospective study, meaning that instead of planning the study and then moving forward as kids aged, they basically picked a point in time and look back which is fraught with issues.
So what did they do? Well, first let's talk about what the study did not do. So how would you design a prospective study to look at a link between Tylenol and asthma?
What you would do is you would take two big groups of kids, they're nearly identical. And you would take them from birth and you would say okay, one group is allowed to get Tylenol and the other group during the first year of life, will never get Tylenol. And then you follow both groups through childhood and look for emergence of asthma. Hey, that would be a pretty good study.
What this one did is they took kids with the history of asthma and kids without a history of asthma and then they asked their parents if they ever gave them Tylenol in the first year of life.
And what they found is the kids who had asthma were more likely to have parents that said yeah, I gave them Tylenol during the first year of life. Notice these types of studies are not the same thing. Okay, the retrospective study may show a link but it doesn't really really do a very good job at establishing cause because there's many valid explanations that could still explain this but exclude Tylenol as the cause.
For instance, remember asthma is linked to the immune system. So kids with asthma, maybe they produce higher fevers and so parents are more likely to give them Tylenol.
You know maybe the problem is that just if you are prone to asthma in your life, you're more prone to having higher fevers when you get sick. I mean some kids really don't get that febrile with viral illnesses. You can take one virus and give it to a kid and they're a 100.6. You give the same virus to another kid and they're 104.
So I mean we do know that there's a difference in how high temperatures individual kids make and so you could argue do the kids who make higher fevers more likely to get Tylenol and more likely to have asthma later on. But so there's the Tylenol-asthma link, but it's not a cause and effect.
Also, kids with frequent upper respiratory infections who then have fevers maybe they're more likely to develop reactive airway disease or asthma down the road. Or what about kids with allergic rhinitis who are given Tylenol inappropriately? I mean, they didn't ask the parents, hey, did you give Tylenol, did you do it right? I mean, maybe the kids had runny noses and the parents gave them Tylenol. There are a lot of parents who do that. Because they think Tylenol's for colds and they don't realize it's a fever reducer and a pain reducer, but it's not going to help a runny nose.
So there are kids out there who have allergic rhinitis, let's say. They have seasonal allergies even as infants and the parents give them Tylenol thinking that's going to help.
Well, those kids with seasonal allergy issues in the first year of life maybe they go on to have asthma in later childhood because allergies and asthma are all related. And so again, that's not telling us that Tylenol is what caused the problem and it's not a cause and effect.
So for now, based on this information, I would say Tylenol is safe when it's used for pain or fever. It's what it's supposed to be used for. And in the correct dose and with the correct dosing interval.
Teething pain, I think is a legitimate use, Crystal, If it's really teething pain, then the Tylenol should help. So if the child's fussy and they're definitely teething and you give them Tylenol at the appropriate dose at the appropriate dosing interval and they seem to be better after you give them the Tylenol, all's well and good. If you give them the Tylenol and it didn't seem to make a difference, then it probably wasn't teething pain. And I would stop it.
And I do have to question how much teething actually hurts. We've talked about this before. In older kids who have a new coming through, do they complain of pain? Not really. I mean, maybe sort of a ticklish feeling, but I'm not sure that teething really hurts.
Babies are fuzzy for lots of reasons and a tooth coming through, I'm not personally convinced that that causes pain. But that's another subject altogether. I mean if you find that your child's fussy and they're teething, you give them Tylenol, they seem better, fine.
Pre-shot, I'm not a fan of pre-shot Tylenol, as we discussed last week. I'm not going to say anything more about it, Crystal. If you didn't listen to Episode 143, last week we had a whole discussion on whether you should pre-dose your child with Tylenol before they get their shots. I'm not going to go through that again since we just went through it.
Okay we have one more question, we're right in an hour too so we're doing a little bit better on time this week. This last question comes from Jenelle in Niles, Michigan. And Jenelle says, "Hi, Dr. Mike. First, I wanted to say that I love your show. I've only heard a few shows, but I would definitely be a long-time listener.
My question is about fluoride. We recently moved out of our city and into a house with a well so our water does not have fluoride added, does not have fluoride added. I know it's important so I asked my son's pediatrician if he needed supplements when he went in for his 18-month checkup. She said no.
She recommended to let him swallow some regular toothpaste about a pea size once or twice a day. To me this seems very inexact. How do I know if my pea size is the same as hers? He may be getting too little or weigh too much and I wouldn't know. What is your opinion about this? Thanks so much and keep up the good work. Jenelle"
I normally don't criticize other doctors on this show, but in this case, I'm going to. I think your feelings are right on target, Janel. Your doctor's advice is not in line with recommendations from the American Dental Association and the American Academy of Pediatrics. The official recommendation would be this. Have your well water tested for fluoride in parts per million and your health department can do that. And you'll get a readout that tells your well water, what it is in parts per million.
Because some wells are naturally high in fluoride and you won't — you can use your well water and you won't need to supplement. And If you do supplement, your kid's going to get too much fluoride and then have fluorosis, the teeth which we've talked about before.
So fluoride supplementation is based on the parts per million of fluoride in your drinking water and you have to have your well tested to know for sure that there's no fluoride in it because some wells have naturally occurring fluoride and your child's age. And there's a chart that tells you what kind of supplement your child's — your child needs based on the parts per million of fluoride in the drinking water and your child's age.
And that chart, I'll put a link to it in the Show Notes. It's from the American Dental Association. It is their most recent chart and that's what you should do.
Now what I would do in terms of your doctor, here's what I would do. This is me personally. But I can be kind of a smart Alec. So you have to understand that.
You could take your water and get it tested. Take the report and the chart that I link you to to your doctor and tell your doctor, the American Dental Association recommends X amount for my child based on this readout of parts per million of my water and how old my child is so this is what I want.
And just mention the words standard of care when you do that. And I'll bet you to get the fluoride supplement that you need. Of course you'll also get a big red mark in your chart, right? I don't know if any of you are Seinfeld watchers. I mean, if you remember when Elaine kept being written down as a problem patient. You might run into that a little bit.
Here's another option. You could just not use your well water at all for your child's food and drink. You could just use it to wash dishes, bathe and do laundry and all that. But for ingestion, for food and drink, you could instead by fluoridated bottled water.
And that's what we did, actually. We lived in a house for about 10 years back in Ohio before we moved to Florida, they had a well. And we just didn't use the tap water all that often.
We get one of those big 5 gallon jugs, dispensers and had a service that brought us water. It really wasn't that expensive. I mean ended up being about put a $1 a gallon. And it was fluoridated so basically, had the right amount of fluoride in the water, so we didn't worry about supplementation.
So even if you had a well, that's also an option to just buy fluoridated bottled water and use that instead of your tap water for eating and drinking. And then your child gets plenty of fluoride and you can skip the whole confrontation thing. Unless you like confrontation, some people like that too.
Alright. So wow, one hour and 4 minutes. So we're right where we need to be. I'm going to take a quick break and then we'll be back and we'll wrap things up.
Alright. Thanks go out to Nationwide Children's Hospital for helping us out with the bandwidth the seat. Also, thanks to Vlad over at vladstudio.com. Really appreciate all his effort in terms of the artwork on the website. He's very gracious to allow us to use his art. Please visit him at vladstudio.com. You can buy posters and prints of his artwork. It'd be great for newborn nurseries and even older kid's rooms. So make sure you check him out.
Thanks also to Medical News today for helping us out with the News department. Thanks to my family, wife and kids, for allowing me to take the time that is needed to put these shows together because it does take a substantial amount of time. So thanks goes out to them.
And of course, thanks to listeners like you for taking the time to tune us in and contribute to the show with your donations and with your questions. Both of those things are extremely important to keep this thing going.
I mentioned last week and earlier on in this show, the overhead for this program has become very high. And that's because of all the downloads and all the bandwidth and it just takes money in order to keep doing this and so the support of listeners like you definitely helps to keep this running. And if you go to the Donation page at the website, just go to pediacast.org. Over on the left, you'll see a button that says Donate. Click on that and then there'll be several options recurring monthly subscriptions and also, we'll have one-time donations.
What I would suggest that everyone do is $2 a month. If you do $2 a month, we're talking $0.50 for each one of these shows. So I think you definitely get $0.50 worth of information — come on, folks, okay. With each one of these episodes, you get more. You get way more than $0.50 of product.
But if you do $0.50 per episode, so it's $2 a month, $24 if you do a one-time donation, that would be fabulous. Or you could do the $2 recurring donation. If you'd like to do more than that, if you think we're worth more than $0.50 an episode, by all means, we would welcome whatever donation that you can provide for us. And again, that's at the Donate button at pediacast.org.
Also, your questions are welcome. If you click on the Contact link or email firstname.lastname@example.org or call the Skype line (347) 404-KIDS, (347) 404-5437 and make sure your name and location if you wish to opine. It does sound like.
Okay. I think that's really about it. We need to wrap things up. Oh, iTunes reviews. I mentioned this earlier too. Please, if you have not done an iTunes review before, please take the time to do so. It doesn't take long, a couple of minutes and it really helps out a lot.
We also have a listener survey. If you've not done that, that's available at the website of pediacast.org. That also only takes a couple of minutes as well.
Alright, so I think we are ready to wrap things up. It's great being with you again. I'm really getting into the groove here of the weekly podcast again now that we have our new studio set up. So this should be a weekly occurrence. I'm going to try to get new shows out every Monday, so we'll see how it works and for how long.
And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long, everybody.