PediaCast 155 * Energy Drinks, Teen Sleep, Forearm Fractures

This week Dr. Mike explores the topics of energy and sugar-sweetened drinks, as well as forearm fractures.  He will also answer questions regarding third-hand smoke exposure, bath time for kids, and teenagers experiencing sleeping problems.


  • Energy Drinks

  • Sugar-Sweetened Drinks

  • Third-Hand Smoke

  • Bath Time

  • Teen Sleeping

  • Distal Radial Fractures




Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital for every child, for every reason.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from BirdHouse Studios, here's your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. It is Episode 155 for February 22nd, 2011 and we are calling this one 'Energy Drinks, Teen Sleep, and Forearm Fractures'.

Of course, we'll talk about lots more than just those topics. We'll do some news, we'll get into some listener questions, and then we're actually going to do a Research Roundup. We haven't done one of those in a while, and actually, that's the one we're going to kind of focus on forearm fractures because there's a new study that shows maybe not all of them need to be casted, maybe just a splint is OK. So we're going to talk about that.


Before we get into the meat of the program, I just wanted to let you know something a little bit new. We are now on Twitter. It's true, we're on Twitter. This may be a surprise to a lot of you. I mean, here we are, on the cutting edge of new media, been doing a podcast since 2006, and we've just not really joined the Twitter crowd.

But we're there now, so if you look us up on Twitter, we're pediacast. That's our handle. Just do a search for 'pediacast' and follow us there. No one's really found us yet. We just have a couple followers. So you could be one of the first. Just go to Twitter and search for 'pediacast'.


We've been on Facebook for quite some time. We have a large following there. So if you aren't part of our Facebook page, just go to and you can find us.

We also have an Android app in the Android store, so if you have a mobile device running Android, you can find us there. Hopefully we'll have one for the i-devices, iPods and iPhones and such, coming soon. We're not there yet. We've submitted our application to the Apple store, had to make some adjustments, resubmitted, so hopefully here soon we'll have something for you in the iTunes store.

In the meantime, there are several apps that allow you to subscribe to RSS feeds, or even to search for podcasts, and then they use the cellular network or your Wi-Fi network to download the latest episodes. I think that's a great idea because as soon as the episode is available, it will just automatically download to your device. There are several apps that do this. The advantage is, if you're not dependent upon tethering your device to your computer, before the latest episode of PediaCast shows up, it just sort of gets pushed to your mobile device.


So you may want to look those up in the iTunes app store. Just look up 'podcast' and 'RSS feed' and you will find several choices. I've used a couple of them. I'm not going to endorse a specific one. But it's a nice option to get the information and the show directly to you without having to download it or actually having to tether to your computer.

One other thing I wanted to mention before we get started is, here at Nationwide Children's Hospital we have a new campaign going on called Miracles at Play. You can find out more at, but let me tell you exactly what this is because it's something where you actually, the listener, can make a difference in a kid's life with this.

The Miracle challenge, which is part of the Miracles at Play campaign, is an effort to raise money to help with the hospital and with research, and there's a company here in Columbus, Ohio called Wolfe Associates and basically they're going to donate $1 to Nationwide Children's Hospital for each person who becomes a fan of Nationwide Children's Hospital on Facebook or follows Nationwide Children's Hospital on Twitter.


Another way that you can help us earn a dollar is by registering your email at, and this is a particularly good option if you are a local to the area, in Ohio, and you want to find out exactly what's going on as it happens at Nationwide Children's. They're not going to spam your inbox, I can guarantee that, but you'll get occasional emails with what's up and what's happening. So if you're in the area, that's a good option.

But you don't have to give your email. You can just become a fan on Facebook or follow us on Twitter. Again, that's Nationwide Children's Hospital's Facebook and Twitter, and then the Wolfe Associates would donate $1, it's really easy, up to a total of $100,000.


Now you would think that this would be an easy thing to do, but these are new Facebook followers and new followers on Twitter. So if you were a follower before this started, those don't count. So really, any new ones. So if you are out there and have not been a fan of Nationwide Children's Hospital or are not their follower on Twitter, please do that. It really doesn't take you long, and when you do it, it's a dollar up to $100,000.

You may be saying, 'Well, why do I want to help financially a children's hospital that is hundreds or even thousands of miles away?' The reason is because Nationwide Children's Hospital is a very large tertiary or goes beyond being just a regional children's hospital.

Really, we treat lots of folks from around the world who fly into Columbus to get their treatment here because basically run the gamut of all the sub-specialists, some of the best in the world, and lots of people come from far and wide, and also because lots and lots of research happens here, and that research impacts the lives of kids everywhere.


So for more information, just go to, and there will be a link in the show notes, or just go to Facebook or Twitter, do a search for 'Nationwide Children's Hospital' and become a fan or 'like' or follow or whatever the terminology is, depending on whether you're on Facebook or Twitter, and that will help us earn $1 up to $100,000.

OK, so what are we talking about today? Energy drinks, as I mentioned. Also, sugar-sweetened drinks. Mountain bike injuries.

We had a listener call in, or actually write in. We're going to talk about that, too, in a couple of minutes because our Skype line is back up and running. Third-hand smoke exposure, that was the question, also another one on bath time, when can kids start taking baths by themselves, and another question on teenagers and sleep, what's enough, what's not enough, and what if your teenager is tired all day because they're not sleeping well, what can you do about it.


And then finally, in our Research Roundup, again, we're going to talk about distal radial fractures. Do you cast them, or is just a splint OK? We'll talk about that.

If there's a question or a comment that you have, all you have to do is go to, click on the Contact link, and you can get a hold of us that way. Or you can also email If you go that route, make sure you let us know where you're writing from so we can let everyone else know as well.

And then again, our Skype line is back open. It is 347-404-KIDS. That's 347, 404, K-I-D-S. You can call and leave a message, and that's another way that you can ask a question here at PediaCast.

All right, let's get a move on. Before we get started, we have to do our disclaimer. The information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. 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.


Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at

And with all that in mind, we will be back with News Parents Can Use right after this.


Dr. Mike Patrick: Our News Parents Can Use is brought to you in conjunction with news partner Medical News Today, the largest independent health and medical news website. You can visit them online at

Energy drinks may be unsafe for some children, especially those with diabetes, seizures, heart abnormalities, or mood and behavior disorders, according to a report by researchers at the University of Miami Miller School of Medicine and recently published in the journal "Pediatrics".


However, the beverage industry fiercely disputes this. Senior author of the report, Dr. Steven Lipschultz, said, "Until we know more about the effects of energy drinks on the health of children and teenagers, they should be discouraged from drinking them on a routine basis." He added, "We wanted to raise awareness about the risks. Our systematic review suggests these drinks have no benefit and should not be a part of the diet of children and teens."

For the report, Lipschultz and colleagues reviewed the current published literature on energy drinks and concluded they have no health benefit for children and that many of the ingredients are understudied and not regulated.

They are concerned about these unknowns as well as reports of toxicity potential related to energy drink consumption, for instance, where poison centers have received calls about caffeine overdose in children. They may even put some kids who consume energy drinks at risk of serious adverse health effects. They called for more research to understand the effect of energy risks in at-risk groups.


The researchers added that regulation of marketing and sales of energy drink should be based on appropriate research and the surveillance of toxicity related to energy drink consumption that it should be improved. For instance, the current system in the U.S. does not separately record if a caffeine overdose was due to consuming energy drinks or for some other reason.

In the meantime, pediatricians should be aware of the possible effects of energy drinks in children and teenagers, particularly in the more vulnerable groups, and to screen for heavy use both alone and with alcohol and to educate families and youngsters at risk for energy drink overdose which can lead to seizures, stroke, and even sudden death, according to the authors.

For their systematic review, Lipschultz and colleagues searched PubMed, the online database of biomedical journal citations and abstracts, and Google using keywords like 'energy drink', 'sports drink', 'ADHD', 'diabetes', 'poison control center', 'children', 'adolescents', 'caffeine' and 'taurine' to find articles related to energy drinks. They also read the product information the energy drink manufacturers put on their website.


So what did they find? Well, they found that children, adolescents and young adults account for half of the energy drink market. According to self-report surveys, between 30% and 50% of teenagers and young adults consume energy drinks.

Energy drinks frequently contain high levels of stimulants such as caffeine and taurine and safe consumption levels have not been established for most adolescents. There have been reports of energy drinks linked to serious adverse effects, particularly in children, adolescents and young adults who have seizures, heart abnormalities, diabetes, mood and behavior disorders, and those who are on certain medications.

Of the 5,448 caffeine overdoses reported in 2007 in the U.S., 46% of them were in young people under the age of 19. Several countries and American states have debated whether to restrict the sales of advertising of energy drinks.


Well, now this report has infuriated the beverage industry, who have labeled it 'bad science' intended to scare and create buzz. A statement issued by the American Beverage Association said there is, quote, "a lot of misinformation circulating about energy drinks, especially about the amount of caffeine they contain and whether or not the products are regulated by the U.S. Food and Drug Administration."

They stressed that energy drinks and their ingredients, whether categorized as a conventional food or as a dietary supplement, are regulated by the FDA, and that caffeine, the core ingredient whose use has been improved both by the FDA and more than 40 countries around the world, is one of the most thoroughly-tested ingredients in the food supply today.

They urge consumers to note that energy drinks contain about half the caffeine in a cup of a coffee typically bought at a coffeehouse, and thus young adults are consuming twice as much caffeine this way as they are from a similar-sized energy drink.

They also dispute the point made in the report that children and teens are large consumers of energy drinks, citing data from a well-known government study, the National Health and Nutrition Examination Survey, which they say shows the caffeine consumed from energy drinks for those under the age of 18 is less than the caffeine derived from all other sources including softdrinks, coffee, and tea.


The American Beverage Association says this survey also shows that caffeine children and teens get from energy drinks is equivalent to each child and teen drinking less than one can of energy drink per day and that total caffeine consumption from energy drinks among preteens is nearly zero.

OK, I have to pause here. We don't care, American Beverage Association, that each child in America drinks less than one energy drink per day. What we want to know is this: looking only at the population of children and teens who actually consume energy drinks, how much on average do these kids drink? That's what we want to know, right? At least give us a figure that means something.

The American Beverage Association advises consumers to stay informed about the products they consume, to read product labels and the voluntary advisory statements that many companies put on them.


Now they don't deny that caffeine may have adverse effects and they confirm that energy drinks contain a good dose of the stimulant, so anyone who is sensitive to caffeine should apply the same common sense approach to consuming energy drinks as they would to drinking coffee.

Lead author of the "Pediatrics" article Sara Seifert, a third-year medical student, explained why they conducted the review and published their survey. She says, "Numerous reports are appearing in the popular media and there are a handful of case reports in the scientific literature that associate energy drinks with serious adverse events. Additionally, many schools, states and countries have started regulating or banning energy drink content or sales to children, adolescents, and young adults. In the face of such reports, it seems prudent to investigate the validity of such claims."

So how much caffeine is in each ounce of energy drink and how does that compare to softdrinks, coffee and tea? Well, it's not a secret, so I looked up some of this information. Let's go through it very quickly. And I don't want to overwhelm you with numbers.


How much caffeine is in softdrinks? Let's start there. Well, Mountain Dew has the most with 50 of the mainstream ones, the ones I looked up. It has the most at 54 milligrams in a 12-ounce can. Dr. Pepper came in next with 43 milligrams, Pepsi at 37 milligrams, Coke at 35 milligrams. Barq's Root Beer just has 23 milligrams. Mug Root Beer, Sprite and 7-Up all have zero caffeine.

OK, let's compare that to coffee drinks. Now, remember, it makes no difference if your coffee is black or if you're putting cream or sugar in it in terms of caffeine and whether if it's a coffee drink with milk in it, whether that's low-fat milk or regular milk, 2% milk, whole milk, whatever. Caffeine-wise, it's all going to be the same.

Generic brewed coffee, it's going to depend on what kind of beans are used, but for an eight-ounce cup, it's going to be somewhere around 95 to 200 milligrams. So that's quite a bit more than the 54 milligrams that are in Mountain Dew. Almost twice as much in one cup of coffee.


Starbucks Vanilla Latte, Grande size, has 150 milligrams of caffeine and a Starbucks' one-ounce espresso, again depending on the beans, is going to have between 60 and 75 milligrams.

OK, how about tea? Well, tea depends on if it's a black tea or more of a green tea. Black tea, again depending on the variety, is going to be somewhere between 40 and 120 milligrams per eight-ounce serving, and green tea is going to be about a milligram per ounce, so an eight-ounce serving would have about eight milligrams of caffeine in it.

OK, let's compare that now to energy drinks. Energy drinks, if you look at them, there's a variety in terms of how much caffeine.


For AMP, which comes in an eight-ounce can, there's about 74 milligrams, so a little bit more than a can of softdrink but not quite as much as you'd find in coffee or a Starbucks latte. A Full Throttle is a 16-ounce can and it has 144 milligrams. So it does have more. It's approaching coffee with Full Throttle.

Red Bull, that comes in an 8.3-ounce can and that has 76 milligrams of caffeine in it, so that one, again, is more than a can of soda but not quite as much as coffee. Monster Energy is up to 160 milligrams in a 16-ounce can and Rockstar is 80 milligrams in an eight-ounce can.

The bottom line here is, if you look at Mountain Dew as sort of our standard high-caffeine soda, it's about 54 milligrams, in a coffee we're talking about double that, around 100, some varieties of coffee may be as high as 200 milligrams, Starbucks Vanilla Latte is about 150 milligrams of caffeine, and the highest caffeine is Monster Energy which in a 16-ounce can has 160 milligrams of caffeine.


So a can of energy drink has about as much or maybe a little less caffeine than a Grande Vanilla Latte at Starbucks. Now the question is this: Is that a dangerous amount of caffeine? For some kids the answer is no, and for some kids the answer is yes. The kids that we worry about most are those with heart disease, diabetes, seizure disorders, certain behavioral problems such as ADHD, but it may be a problem for other children out there as well and the verdict is really still out.

So I understand part of the American Beverage Association's position. They're saying, 'If you're going to pick on us, you better also pick on Starbucks.' Right? I get that. But what the ABA also has to realize is that caffeine really can be harmful to many kids, and sometimes even deadly, and that's something they should care about. That fact should be important to them.


Now, in the end, we need more research to guide our recommendations concerning all caffeinated beverages, not just energy drinks, and until then parents should watch their child's intake of caffeine, especially if your child has a high-risk condition. And, as always, talk to your doctor.

All right, let's move on.

Mountain biking, also known as off-road biking, is a great way to stay physically active while enjoying nature and exploring the outdoors. The good news is that mountain biking-related injuries have decreased.

A new study conducted by researchers at the Center for Injury Research and Policy of the Research Institute at Nationwide Children's Hospital found the number of mountain bike-related injuries decreased 56% over the 14-year study period, which was from 1994 to 2007, going from a high of more than 23,000 injuries in 1995 to just over 10,000 injuries in 2007.


"The largest decline we found in mountain bike-related injuries is likely due to a combination of factors," said Dr. Laura McKenzie, principal investigator at the Center for Injury Research and Policy at Nationwide Children's Hospital.

While some of the decline may be explained by a decrease in the number of people riding mountain bikes, there have also been a number of improvements to the bicycle design such as disk brakes and dual suspension systems that give the rider greater control of the bike and may help to reduce the incidence of injuries.

According to the study, appearing in the February 2011 issue of "The American Journal of Sports Medicine", the most frequent diagnoses were fractures, soft tissue injuries and lacerations, while the most commonly injured body parts were the upper extremities, shoulder and clavicle, and the lower extremities.

Falls or being thrown off the bike were the most common mechanisms of injury. Several differences in injury patterns were found among sub-groups while the majority of injuries overall were sustained by boys and men. Girls and women were more likely to sustain an injury severe enough to require hospitalization. In addition, bikers aged 14 to 19 years sustained twice as many traumatic brain injuries than bikers of other ages.


"While the number of mountain bike-related injuries has decreased, they continue to be a concern," said Dr. McKenzie. "The gender and age differences we found represent opportunities to further reduce injuries through focused prevention and an increased use of protective equipment."

This is the first study to examine a nationally representative sample of mountain bike-related injuries treated in U.S. emergency departments. Further research is necessary to thoroughly understand mountain bike-related injuries and the role injury prevention can play in reducing them.

Data for this study was collected from the National Electronic Injury Surveillance System, which is operated by the U.S. Consumer Product Safety Commission. This data provides information on the consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the United States.


Finally, some very big news that's very close to home. According to the American Academy of Pediatrics, sweetened drinks are the primary source of added sugar in the daily diet of children. Each 12-ounce serving of a carbonated sweetened softdrink contains the equivalent of 10 teaspoons of sugar and 150 calories. A child who consumes one can of regular soda needs to walk 45 minutes just to burn it off.

Well, Nationwide Children's Hospital is addressing the epidemic of childhood obesity and promoting the value of health and well-being for patients, families and staff members. Last month, Nationwide Children's joined just a handful of other healthcare institutions by eliminating all sugar-sweetened drinks from its campus. This new policy applies to hospital cafeterias, gift shops, vending machines, patient room service, and onsite catering.

Based on Nationwide Children's regular soda sales alone, patients, staff and visitors were consuming nearly 43,000 pounds of excess sugar in these drinks each year. "That's equivalent to the weight of 21 Volkswagen Beetles," said Dr. Kelly Kelleher, Director of the Center for Innovation in Pediatric Practice and Vice-President of Health Services Research at the Research Institute at Nationwide Children's Hospital. "That is just unacceptable, and if we wanted to walk the walk, we needed to do something about it."


Waters, low-fat milk, pure fruit juices and diet sodas are all healthier alternatives to sugar-sweetened drinks. Nationwide Children's is expanding its selection of these healthier drink options and in addition will decrease the cost of bottled water for sale in its cafeteria and food court.

The hospital has always been at the forefront in the fight to combat pediatric obesity. Nationwide Children's has shown this through many clinical and educational programs, and just recently by championing the landmark Healthy Choices for Healthy Children anti-obesity legislation in Ohio earlier this year.

During the last few years, the hospital has made other healthy changes to its campus including eliminating deep-fat fryers from room service food preparation and offering healthier baked versions of items like french fries and chicken nuggets, baking french fries instead of frying them actually saves 240 calories per serving, reworking the ingredients of popular food items like spaghetti with meat sauce to make them healthier. For instance, making chicken salad with white mayonnaise saves 190 calories and not adding butter to cooked vegetables saves 123 calories.


They are also offering a healthier selection on the cafeteria menu which contain less than 600 calories, less then 30% of calories from fat and less than 600 milligrams of sodium.

They're posting nutrition information in the cafeteria, food court, gift shops and on the hospital's Intranet. They are also reducing the size of many snacks and drinks sold in the hospital's gift shops, expanding the healthier snack option like trail mix and having educational signage and handouts on how to save calories and make healthy choices.

Not only are sweetened beverages not so for good for child's diet, but they also have an effect on the health of their teeth. "At Nationwide Children's, we have one of the largest pediatric dentistry programs, and oral health is severely affected by the acids and sugars in many of these beverages," said Dr. Kelleher, who is also a faculty member at the Ohio State University College of Medicine. "Cutting back or eliminating sugared drinks from a child's diet will greatly improve the health of their teeth."


Now, sugar-free doesn't mean caffeine-free and there will still be caffeinated drink options at the hospital. Staff and patient families will still be able to bring in their own sugar-sweetened beverages; however, they will not be able to purchase them on campus. Physicians, residents and nurses will still have the option to order sugar-sweetened drinks for patients in special circumstances.

OK, I have to confess that as I worked on the script for this particular show, sitting on the campus of Nationwide Children's Hospital, I realized I was drinking a sugar-sweetened beverage. Now, I didn't buy it here. I smuggled it or brought it into the Nationwide Children's Hospital campus. So what's my point? Well, even doctors don't always follow this recommendation. Should I cut back on sugar-sweetened drinks? Absolutely yes. And you should, too. So let's make that pact together. And kudos to Nationwide Children's for taking the step.


So why do I even have this story in here? It's not just a pat on the back for what we're doing here at Nationwide Children's, but what about your school? Go to a school board meeting and use us as an example, and I'll have a link to the news story at Make a difference in your community and fight for removing sugar-sweetened drinks.

When I was in school, you couldn't get a Coke in school. You had to get a milk or maybe you could get a juice, and you could certainly drink water, but there was never the choice of a sugar-sweetened soda in school. Moms and dads, think back to when you were in school. Was there, and should there have been, and should there be now? So just get involved in your community and make a difference.

All right, that wraps up our News Parents Can Use. We are going to be back with our listeners' segment right after this.



Dr. Mike Patrick: All right. First up in our listeners' segment is Carol in Chicago. Carol says, "Hi, Dr. Mike. I am a long-time listener to your podcast and a big fan. I am a mother of seven kids ranging in age from nine to 27 and also grandma to three. I never fail to learn something new when listening to you."

"Today, though, I need some advice. My youngest daughter has Down syndrome and rides the special needs bus. This year, she has a new driver who is obviously a heavy smoker, and when I put her on or get her off the bus, I can smell it. When I can't smell the smoke, it's because she's used something to cover it up."


"My daughter has asthma that has landed her in the hospital more than a few times, including having to be live-flighted. Her triggers are viral infections, pollen in the Spring, and cigarette smoke. I contend if I can smell it, she shouldn't be on that bus. What do you have to say about this?"

"I did see an article in the "Pediatrics" journal dated January 2009, but can't read it without a membership. Are there studies out there proving third-smoke can make you ill? I really don't care to try it and see. I don't feel I need to risk her health just to prove one of us is right."

"Right now I am driving her back and forth to school. I think the school district should be able to only place non-smokers as drivers on the special education bus. They are on that bus because they have special needs such as health issues. Am I wrong to be very upset by this? Thanks for the question, Carol."

Well, Carol, no, I don't think you are wrong about being upset about this. I'd be upset, too. And really, I don't care if it's a special needs bus or the regular bus, and I don't even think your child's asthma makes a difference with this issue. Kids shouldn't be trapped in a bus that smells like cigarette smoke, period, even if they don't have special needs and even if they're healthy, in my humble opinion.


Now, having said that, the question still remains, does third-hand smoke exposure cause worsening control of asthma?

Well, first, what is third-hand smoke exposure? This is smoke particles that cling to fabrics, carpets, hair, clothes. So if you smell a smoker who isn't smoking, you've been exposed to third-hand smoke.

Now we know that second-hand smoke exposure is bad for asthma, and many studies in children and adults show exposure to someone actively smoking causes a decrease in asthma control and an increase in asthma symptoms. But what does the literature say about third-hand smoke exposure? Does it have the same effect? Well, as it turns out, the verdict really is still out on that one.

Now, the study you're referring to was published in January 2009 in the journal "Pediatrics" and it was simply a survey to see if parents believed being in a room where someone had smoked the day before was bad for their children's health.


The researchers asked 2,000 people this question in a random phone survey, and they actually asked a few questions. 'Is second-hand smoke exposure bad for kids?' and 95% of non-smokers said yes and 84% of smokers agreed. Then they asked, 'Is third-hand smoke exposure bad for kids?' third-hand smoke exposure where you just smell it. Sixty-five percent of non-smokers said yes and 43% of smokers agreed. And then finally they asked, 'Do you ban smoking in your house?' and 88% of non-smokers said yes and 27% of smokers said yes.

Now, when researchers drilled through the data, they wanted to see if there was an association between thinking second-hand and third-hand smoke is bad and actually banning smoking in the home. What they found was that there was no statistically significant relationship between thinking second-hand smoke is bad and whether you ban smoking in your house or not.


But there was a statistically significant relationship between thinking third-hand smoke is bad and banning smoking in your home. So the authors concluded, if you can convince parents that third-hand smoke exposure is bad for kids, then perhaps you can increase the number of parents who actually ban smoking in their house.

Now, this is a far cry from actually showing that third-hand smoke exposure is bad. So the next question becomes, how do you convince parents that third-hand smoke is bad? Is there a study that shows this connection? Unfortunately, the answer to that is no. Is there a study, though, that shows third-hand smoke is safe? Well, no, there is not. So that's why I say the verdict is still out.

Now, part of the problem with doing a study on third-hand smoke exposure is you'd have to find a large group of kids who were only exposed to third-hand smoke. Otherwise, if they were also exposed to second-hand smoke on a routine basis, it might mess your results up.


So you'd have to find a group that was never exposed to third-hand smoke, that would be your control group, and then your experimental group would be kids who were exposed to only third-hand smoke and not first- or second-hand smoke. And that's difficult to do because most kids who are exposed to third-hand smoke are also exposed to lots of second-hand smoke, even if parents say they aren't smoking in front of their kids. So you know this to be true, right?

Also, it's difficult to quantify third-hand smoke. How do you measure it? Do you just go by how bad the smell is? What about differences in people's smelling abilities? What if you have a super sniffer and you can smell just one particle per million of smoke. How do you measure those particles? How much exposure is too much? And how do you make thousands of kids have the same exposure level?

So it's an interesting question. I'm not saying a well-done study in a large pediatric population on third-hand smoke exposure couldn't be done. It could. I'm just saying it hasn't been done yet, and it would be a difficult one to pull off. But who knows? Maybe someone's working on it right now.


Back to Carol. The January 2009 study you referred to really isn't going to help you get the bus driver reassigned or fired. So I'd go back to my original argument: No kid, special needs or not, asthma or not, no kid should be trapped on a bus that reeks of smoke, or cheap perfume for that matter. Would they tolerate an alcohol smell even if the driver is blood-testable sober every time? How about marijuana smell?

Really, I think kids deserve a smell-free ride to and from school, at least to the extent that you can control it, and if the driver is the source of a bad smell, that is an issue you can control at the school.

So I'd be the squeaky wheel. I'd say something to the bus driver, to the transportation supervisor, to the school principal, to the district superintendent, to the school board if you needed to, day in, day out, as many times as it takes to get your voice heard and to be that squeaky wheel. That's how I'd deal with the problem. Again, my two cents. Your mileage may differ a little bit.


Let's move on to bath time. Jamie in Fleming Island, Florida says, "I have a question and would love to get your point of view. At what age should a child completely bathe themselves? I have a five-year-old and a four-year-old."

"Thanks so much. Love your podcast. It's always full of great information and a great resource to have around."

All right, Jamie, thanks for your question. Two issues here. First, safety, and function.

Safety. They say you can drown in a puddle, right? How much water does it take to block the airway? Not much. Do four- and five-year-olds horseplay in the tub? Yes. Could they slip? Yes. Could they crack their heads? Yes. Could they drown? Yes. Could a six-year-old? Yes. Could a seven-year-old, a 10-year-old, a 13-year-old, a 16-year-old? OK, maybe I'm pushing it now, but the point is, bathing can be dangerous, and I'd be a fool to say, 'Well, at age this or that, your child is safe.' Really, it depends on your child's temperament, their maturity, their activity level, and your own risk comfort level.


Personally, I'd be in the bathroom with them until they are blank years old and then close by with the door open after that. See? This is what the lawyers do to us poor doctors. I can't do it, Jamie. I can't do it. From a safety standpoint, you simply must use your judgement. I'm not going to be able to tell you how old your kids need to be to bathe from a safety standpoint by themselves.

What age were my kids when they did it by themselves? I'm not going to tell you. I'm just not going to do it. [Laughter] Really, they say there's no stupid questions, and this is not a stupid question, Jamie, but there are potential stupid answers, and for a doctor to say, 'All kids, once they reach the age of this or that, it's safe for them to take a bath by themselves' would be a foolish thing to do.


So, really, you just have to use your judgement as a parent on when they can bathe by themselves. But I sure would be close by and listening attentively whenever you make the decision that it's fine for you to leave being at their side when they're bathing.

Now the other issue with this is, what about function. In other words, when will they actually be able to do the job well and get themselves clean? Never mind that you are hovering over the tub to make sure they're safe. When can they do the job right?

Again, it depends on your kid. Here I feel a little more comfortable giving a bit more of a definitive answer. A two-year-old's probably not going to be able to do it. Three-year-old, probably not. Four, yeah, maybe four-year-olds would be able to clean themselves and do a good job. Five, probably a lot more, as long as they don't get too distracted. Six, I think many six-year-olds probably could do a good job. By age seven, sure. I think most seven-year-olds would be able to do it.


So I think, Jamie, your kids being four and five, you're right at that cusp of when they probably could do it. It really just depends on their own skill set, their own attention span, their own ability. But from a safety standpoint, again, you really have to use your judgement on that.

All right. And you know what? It's not just the bathing thing. Pediatricians get asked these kind of questions all the time. Everyday across America and around the world, parents are asking their doctors this kind of stuff, and we do our best to give you a good answer, but when it comes to safety issues, you really have to be careful.

I mean, there are trustworthy five-year-olds and there are accident-prone 12-year-olds, not just with bathing but really with anything. You know your child best. There are risks in every decision we make as parents, and you can't escape those risks by asking another person, even a doctor, to make those decisions for you.

All right, let's move on to a question that I can actually answer a little bit more concretely, and that's teenage sleeping.


Theresa in Vancouver, Washington says, "My oldest son, 13, has been complaining about being tired all the time. I have read a lot about teens and lack of sleep, but those articles don't seem to answer my question. Most articles say teens aren't getting enough sleep, but my son goes to bed around 8 or 8:30 on his own accord and sleeps until 6:30. His alarm goes off at 6. But he says he is tired and doesn't even hear the alarm."

"We have tried many times over the last few weeks, but I wonder if it could simply be that he is growing. I know babies sleep right before a growth spurt; is this the same for older children? My son is quite tall. He is 13 and almost six feet. Last year he grew about three inches, and I wouldn't be surprised if he has grown more this year."

"We have tried eating some protein and carbs before bed, lavender essential oils to relax, breathing to de-stress, excluded all light from the room, and he doesn't have anything electronic in his room at night. He doesn't feel like he wakes up at night, he doesn't feel like he gets enough sleep. Any ideas?"


"By the way, love your show. I'm tickled you're back and have sure missed you. Theresa."

My usual advice for sleep problems in teens you've pretty much already addressed, Theresa: having routine, avoiding caffeine, soothing pre-bedtime activities, no electronics in the room. It sounds like you're doing all the right things, and it also sounds to me like getting to sleep or staying sleep really isn't the issue.

I mean, you basically have a kid, Theresa, who gets to sleep fine, they stay asleep well, they're just really tired in the morning and really tired all the time, and you're asking, could it be growing that causes this? Well, there's no good evidence that growing does much of anything other than making you taller. So I would definitely talk to your doctor about this one.

Questions that come to my mind, how tired is your son once he's actually awake? I understand it can be hard to get up in the morning, and some people just have a harder time getting up than others, but are they tired for more than an hour after they get up? Is the tiredness lasting all day? Is the tiredness interfering with his school work? Is it interfering with his ability to stay awake in class? How are his grades? Is he getting trouble at school?


These are the kind of questions you have to ask to know, is this something that's an issue that you need to do something about. Because if it's just he has a hard time getting up, but once he's been up 10 minutes we're good to go, that's one thing, but if he's falling asleep in class, getting in trouble in school or having bad grades, then that's something different. And there are real and sometimes serious medical conditions that can make you tired all the time. So definitely see and talk to your doctor about this one.

Now here's a few things that do come to my mind in kids who are tired who are tired all day, especially if they're having school problems, whether it be academic or behavioral, because of it.


The biggest one would probably be obstructive sleep apnea. You can have kids who, they fall asleep fine, to their mind they're staying awake fine, but they are waking up frequently in the middle of the night, but not all the way awake to know that they're awake. But they have some sleep apnea that's waking them up and then oftentimes they have a little obstruction of their airway, they're snoring.

But it goes beyond just making a noise. They're actually dropping their oxygen saturation which briefly wakes them up enough to readjust their airway. They basically move to open up the airway. But they may not know that that's happening, so you can have a kid who's waking up multiple times during the middle of the night and never know that they're waking up, and it's obstructive sleep apnea that's doing it.

Oftentimes with those kids, you take out their tonsils and adenoids and the sleep apnea goes away, they get a better night's sleep and the behavioral and academic problems at school get better. We've talked about this before.

There's a real easy way to diagnose obstructive sleep apnea and that's to have your kid see a sleep specialist who has a sleep lab, usually at a pediatric hospital, and they're able to hook your kiddo up to monitors and machines and basically watch them when they sleep to see if they are having episodes of obstructive sleep apnea.


So that would probably be one of the top things on my list. But there's lots of other things, too, and some of them can be serious medical conditions.

The other thing I would, maybe even before you do the sleep study, and that's, are you really sure that your kid is telling you the truth?

Now, I'm not saying that your kid is lying, but there are kids out there who sneak electronic devices into their bedroom and are up late at night or getting up in the middle of the night to text their friends, to be on Facebook, to play games.

So you do want to make sure that your kiddo really is telling you the truth and they really are getting to sleep easily. To their mind, staying asleep, they're just tired in the morning and they're not smuggling electronics into their room, like I smuggled a sugar-sweetened beverage onto the campus of Nationwide Children's Hospital. So you do want to make sure that that's not happening.


Now, I believe you and your kiddo. It sounds like you're doing all the right things. But I would talk to your doctor, especially to address the issue of obstructive sleep apnea.

But as I said before, there are other possibilities, and some of them are serious. The list of things that can cause chronic fatigue, which is really what you're getting into if your child's sleepy all the time, the list of things that can cause that is very long and includes things like depression, iron-deficiency anemia, certain viral infections, for instance Epstein-Barr virus comes to mind, thyroid problems, autoimmune diseases, and really the list goes on. So definitely get with your doctor on this one.

All right, thanks again for the question, Theresa.

Remember, if you have a question or comment for us here at PediaCast, it's very easy to get in touch with us. Again, just go to and click on the Contact page, and then you can also email


All right, we'll be back to add an item to our Research Roundup right after this.


Dr. Mike Patrick: All right. We are back and we welcome you back to the program.

We're going to do an in-depth segment. We haven't actually looked at a research article in one of these in-depth segments in a while, so we're going to do that today. In particular, or specifically, we're going to talk about distal radius fractures. Do you cast them or is it OK just to put a splint on them?


Now, this is something that a lot of parents know about. One of the more common fractures in kids is a distal radius fracture. So this is the forearm, and it's the thumb side of the forearm, and it usually happens when a kid falls down with an outstretched arm and they'll get a distal radius fracture. So this is kind of a high up wrist fracture or a low forearm fracture that we're talking about here.

The question becomes, traditionally, these have been casted, but would it still heal OK with a few complications if you just used a splint instead of a cast?

Well, this was the question for the researchers. The institution was The Hospital for Sick Children in Toronto. This is the question that the folks at The Hospital for Sick Children in Toronto asked. In particular, the authors were Dr. Boutis, Willan, and Babyn, and this was a research study that was published in the "Canadian Medical Association Journal" in October 2010.


So the question, among children with minimally angulated fractures of the distal radius, does splinting compared to casting result in similar physical function at six weeks? That was the question.

So if you have a kid with an isolated fracture to the hand end of the radius, which is the forearm bone closer to the thumb, if you have an isolated fracture and it's minimally angulated, so just picture in your mind a bone with a fracture through it, if the bone is aligned well, so at the fracture site there is no angulation of the bones, there's no angle there, it's just a nice, straight fracture, could you splint it instead of casting it, and would that result in similar physical function, could they use their arm, does it heal as well, at six weeks if you compare splint versus casting?


They actually conducted this study between April 2007 and September 2009. They enrolled kids who were ages five to 12. All of the kids still had open growth plates, so they were still growing, they all had distal radius fractures, and these were all fractures that just went straight across the bone. They didn't involve the growth plate, they weren't angulated, they weren't displaced, the bone looked good. It was in good alignment.

They excluded kids whose fractures were more than five days old or if there was growth plate involvement or what we call a 'buckle fracture' which is more of a dent in the bone rather than a fracture that goes through the bone. So they included kids who all had very similar fractures.

The participants were randomized into two groups. One group got splinted; this was the experimental group. One group had a cast. The traditional cast was put on. This would be the control group. And then they did follow-ups scheduled at one week after injury, four weeks after injury, and at these two visits, they assessed for pain, fracture angulation, to make sure there still wasn't an angulation in the fracture, and to make sure that they were using their cast or their splint in a proper fashion, that things were going well.


And then they followed up everyone at six weeks, and at the six-week checkup, they assessed for physical function, which is our primary outcome, using the performance version of the Activities Scale for Kids, which was performed by a research physiotherapist. And then at three months after the injury, they did a final telephone interview.

By the way, all the people who did these follow-up visits and follow-up telephone interviews, the outcome assessors, were blinded to each child's group assignment. So when they did follow-up, they had the person who was evaluating them, they had the kid's cast taken off or their splint taken off, and they did their examination, looked at the follow-up x-rays. So the person who was actually doing the exam did not know which group the kid was in, and then when that person was out of the room, finally they would put either the splint or the cast back on.


They had altogether 100 children enrolled in the study, 50 in each group. Four were removed from the splint group due to diagnostic errors. So the initial film showed maybe there was a fracture there, but then on follow-up, the x-ray was normal. So the person who initially diagnosed the fracture mistook a little line or something in the bone for a fracture, which really did not end up being a fracture. Which happens. I mean, you'd rather over-call fractures than miss some. Because of that, in the end, the cast group had 50 kids and the splint group had 46 kids.

All but four were followed up at the six-week check, and 100% were contacted by phone at the three-month check.

What were the results? Well, there was no significant difference between the two groups with regard to the performance version of the Activities Scale for Kids. So there was no difference at all between the two groups. That's great. There was also no difference detected from mean fracture angulation, for range of motion, and for pain indexing.


Three children in each group required immobilization for six weeks due to progression of angulation to 25 degrees. So altogether, there were six kids who had to be immobilized a little bit longer because their angulation did progress to 25 degrees of angulation.

None of the children in either of the groups required surgical intervention by the three-month assessment, and there were no serious adverse events reported for either group.

Now, another important thing is there was no statistically significant difference between the two groups with regard to minor complications such as itching and irritation. However, in the cast group, three required cast replacement, and one of those was converted to a splint due to discomfort. In the splint group, one child had a rash from the splint and converted to a cast at the one-week visit.


So the cast group, now, basically with each of these groups, they just asked them, 'Would you have preferred the other thing?' Would the grass have been greener?

Of the cast group, 60% of parents and 68% of children said they would have preferred a splint. So the people who had the cast really didn't like the cast and said, 'Having looked back, I really don't like this cast. I wish they had just given me the splint.' Sixty percent of parents said that and 68% of children in the cast group.

Well, what about the splint group? How many of them said at the end, 'I wish I had had a cast.' Well, it was only 5% of the parents and 12% of the kids who said they would've preferred a cast. That would've been my kids, by the way. They would've preferred the cast. They would've been like, 'Man, I broke a bone and I got gypped. I didn't get the cast.'


But the point here is, the cast group wish they had had a splint, and you have to make some assumptions there, well, was there something about the cast that wasn't so great after all that made you say, 'I really wish I would've had a splint instead,' and maybe that something that wasn't there with the splint group, since so few of them said, 'I really wish I had had a cast instead.'

Basically, what's the conclusion here? Well, the authors conclude that a prefabricated splint is as effective as a cast in the treatment of minimally angulated fractures of the distal radius, and those splints appear to be preferable to patients and their parents.

So what does this mean for you, the parent?

Well, if your child has a fracture of the distal radius, which is, again, forearm, thumb side, down close to the wrist, these are common fractures, so lots of parents listening to this program already have a child who's had a fracture there or you will experience this at some time in the coming years, so if your child has a fracture of the distal radius and they meet the criteria of being between the ages of five and 12, still having open growth plates, so they're still growing, that it's just a transverse fracture that's less than five days old with minimal displacement, minimal angulation, and it doesn't involve the growth plate, then ask about the possibility of a splint instead of a cast.


You can say, 'Look, a well-designed study showed that a splint is preferable to a cast in the opinion of parents and children and that there's no difference with regard to pain, progression of angulation, or a functional outcome.'

If your orthopedic surgeon wants to see the study for him or herself, we'll have a link to you in the show notes for a PDF that has the full study text, and that's available at Just tell them to go to, click on the Show Notes, and find the show notes for Episode 155. There will be a link there, again, to a PDF that has the entire research study.

All right, well, that concludes our Research Roundup on PediaCast. We'll be back and we'll wrap up the show. We'll round it up, too. We'll wrap it, round it, whatever, right after this.



Dr. Mike Patrick: All right. I did a little bit of a better job today meeting our time constraints, so we're just under an hour. Whoo! Did it.

Thanks go out to Nationwide Children's Hospital, as always. Also, Medical News Today, VladStudio who helps with the artwork at our site, Wizard Media who helps with our Android app, and, of course, to listeners like you.

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Again, they're not going to spam you, you're not going to hear from them every week, just something occasionally they're going to send you out information about the hospital and the programs that are going on here, the research that's being done, that sort of thing.

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Until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!


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