PediaCast 162 * SimplyThick, MCDK, Homemade Baby Food
Welcome to this week's edition of PediaCast! Today Dr. Mike discusses parents with premature babies using SimplyThick, upcoming Tylenol label changes, ADHD medication and heart problems, MRSA and bed bugs, the HPV vaccine for boys, and Pediatricians' becoming involved in parental smoking. Nephrologist Dr. David S. Hains also joins Dr. Mike in the studio to discuss Multicystic Dysplastic Kidney.
- Parents with preemies using SimplyThick
- Acetaminophen (Tylenol) label changes on the horizon
- ADHD drugs and heart problems
- Fake antibiotics
- Bed bugs and MRSA
- HPV vaccine for boys
- Pediatricians' role in parental smoking
- Multicystic Dysplastic Kidney
- Dr David S. Hains, Pediatric Nephrologist
Nationwide Children’s Hospital
- US News – best children's hospitals rankings
- FDA advisory on SimplyThick
- management and etiology of the unilateral multicystic dysplastic kidney
- how breast milk protects newborns
- homemade baby food and nitrates (from drgreene.com)
Announcer: The bandwidth for PediaCast is provided by Nationwide Children's Hospital, for every child, for every reason.
Announcer: Welcome to PediaCast: a pediatric podcast for parents. And now, direct from BirdHouse Studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone and welcome to this week's edition of PediaCast: a pediatric podcast for moms and dads. It is Episode 162 for May 26, 2011, and we're calling this one Simply Thick, MCDK, which is a short way of saying Multicystic Dysplastic Kidney, but that's a mouthful and really long to put in the title of our podcast, and also, Homemade Baby Food.
So those are our main topics, but we have lots of others for you and we'll go through the whole rundown here in just a minute. First, you know, if I hadn't become a pediatrician, if you were to — let me put it this way, if you were to ask my family, OK, if your dad or your husband had not become a pediatrician, what one profession would he have wanted to do? And that would have been to basically be Jim Cantore. OK [Laughter].
I mean, I just love weather stuff and following tornados and hurricanes and, I don't know. I'm just fascinated by it. And so, typically, during hurricane season and now during, I guess, tornado season, I kind of have fun watching the news and seeing what was happening.
But this now is not fun; it is no longer fun. And when I see the pictures out of places like Joplin, Missouri, and Tuscaloosa, and Hackleburg, and the like, I mean, it is just heart wrenching and it's just horrible.
And I just want to say that here at PediaCast, I'm sure a lot of our audience echoes this that our thoughts and prayers are definitely with all of you whether in the places that I mentioned or elsewhere who have suffered physical loss, emotional loss, material loss because of these storms.
I just want to tell you we're with you and supporting you in every way that we can. And as a Pediatric podcast, I know there's a lot of kids who are suffering.
I mean, a lot of kids who have lost their homes and have been displaced, there's emotional trauma that goes along with it. And so, suddenly the job of the weatherman, it is not quite so glamorous. So, anyway, just I wanted to mention that.
What else has been going on? We saw Pirates IV when it came out. It's a good movie. I thought it was. The first one is still classic, but I thought it was on par if not slightly above Pirates II and III. I wish the whole 3D thing would go away. It's like every movie now you have to do in 3D. And from what I've read on this, they're actually filmed in 2D and then rendered later and it's a process that actually, apparently decreases the quality of the film so the colors aren't quite as bright. It's not as good of a picture.
And so, those of us who choose not to watch the 3D version of it still suffer because of the process that had to go on to change it.
Apparently – I shouldn't say apparently – I think that the whole reason for this is really money related. They can charge more for those 3D glasses and I don't think it costs them that much more to render it into 3D.
But, anyway, I'm just tired of it and I hate wearing those glasses when I'm at the movie theater and I don't think it adds anything. But that's my two cents and this is not a movie podcast so we better get kicking on the pediatric topics.
Before we go through our line up, I just want to mention one more thing. We're very proud about here at Nationwide Children's and that is the U.S. News Best Children's Hospitals, the rankings for 2011 and 2012 came out. And the Nationwide Children's, where we're based here, was nationally ranked in every single category.
So that includes cancer, cardiology, heart surgery, diabetes, endocrinology, gastroenterology, neonatology, nephrology, neurology, neurosurgery, orthopedics, pulmonology, and urology, all of these ologies.
Basically, every pediatric subspecialty that they rank, Nationwide Children's ranked nationally in every single one of those categories. So kudos and congrats to Nationwide Children's and, again, just another reason why I'm really happy that PediaCast was able to land here.
I want to mention emergency medicine was not included. They don't rank emergency medicine, but they should because we have the very best Emergency Medicine Department in the country maybe that's because I work there, but, OK, I'm just [Laughter].
You know I had to put that one in there. OK, so what are we going to talk about — oh, and by the way, I have a link in the show notes to the U.S. News Best Children's Hospitals ranking, so just check out the show notes at pediacast.org and you can find that out.
One more little teaser and it's going to be very brief. I'm going to talk in the outro, so at the end of the program, about an app for your iPhone where you can interact with PediaCast and that includes listening to episodes, basically having new episodes automatically come to your iPhone without the need to sync it with your computer and iTunes, and it also allows you to ask questions directly from the program.
So it's pretty cool, but I'm going to give you more information about that at the end of the program. Usually, we save that in the piece for thanking you and saying, "Hey, we'll see you next time," but we're actually going to have some useful information at this week. So stick around before the closing of the show and we'll give you more information about the new PediaCast app that's in the iTunes Store.
And it's not called PediaCast, by the way, so you really do have to stick around. OK, so what are we going to talk about? In our News section this week, stop using Simply Thick. Also Tylenol or acetaminophen is going to have some label changes coming soon most likely.
ADHD drugs and heart problems, also fake antibiotics. Even in America, you have to worry about fake antibiotics. Bed bugs and MRSA also known as Methicillin-Resistant Staphylococcus Aureus. We're going to talk about bed bugs and MRSA. HPV vaccine for boys and the pediatrician's role in parental smoking.
And then we actually are really excited. We have a studio guest who is going to join us after the news. Dr. David Hains is a pediatric nephrologist here at Nationwide Children's and he's going to stop by and talk with us about the multicystic dysplastic kidney, which sounds kind of dry. But, you know, here on PediaCast, we try to make every topic exciting and so I think you'll be interested to hear our interview with Dr. David Hains that's coming up.
And then also some listener questions. We're going to talk about breastfeeding immunity, homemade baby food, and baby tongues. So our Listeners segment is going to really focus on babies this week. So that's coming up.
Don't forget if there's a topic you would like us to talk about, it's really easy to get hold of us. Just go to pediacast.org and click on the Contact link. You can also email firstname.lastname@example.org. If you do that, make sure you let us know where you're from. And the third option is to call the voice line or the Skype line as we call it, 347-404-KIDS or 5437.
And by the way, that number is in the title of each podcast. If you were wondering what that long number is there, that is the phone number for the Skype line so you can call that and leave a message and that's another way that you can interact with the show and to get your question answered.
All right, don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
Dr. Mike Patrick: All right, we are back. The FDA is warning parents of premature babies to stop using a product called Simply Thick.
Simply Thick is a thickening agent used to make infant formula and breast milk thicker. Thicker milk or formula is helpful in the treatment of certain swallowing disorders that are common in premature infants, but it appears the remedy may be causing another problem; necrotizing enterocolitis also known as NEC.
The FDA is aware of 15 cases of this life-threatening intestinal disorder in premature babies where drinking formula or breast milk that has been thickened with Simply Thick. Necrotizing enterocolitis, it's a big word, what is it? It is the inflammation of the bowel wall thought to be related to infection which results in destruction and possible perforation of the intestine.
So the intestinal wall can get a hole in it and this can lead to bowel contents spilling into the abdominal cavity which in turn can cause sepsis and death. NEC is commonly seen in premature babies, but it usually occurs during the first few days of life when these infants are still in the newborn intensive care unit.
In this case, the necrotizing enterocolitis is occurring when the babies are older and have been discharged home. Reported cases have come from four different medical centers in different parts of the country, so the FDA does not feel that they are related to a specific infectious organism.
The only thing the babies have in common is that they were all born prior to 37 weeks gestation and they were all drinking Simply Thick thickened breast milk or formula. Simply Thick's chief ingredient is xanthan gum which is a complex carbohydrate that acts as a soluble food fiber that passes through the body without being digested.
The FDA is not blaming Simply Thick but says parents with babies born before 36 weeks gestation should stop using it until more is known. In the meantime, parents are encouraged to talk to their child's doctor about alternative thickening agents. And you can check the show notes, we have a link to that actual advisory from the FDA and also a nice article on necrotizing enterocolitis from Nationwide Children's. And you can find those in the show notes at pediacast.org.
Two FDA Advisory Committees are meeting this week to discuss fine-tuning dosing instructions on the labels of medicines containing acetaminophen, which is the fever reducer in Tylenol brand products. Currently, the labels only give dosing instructions for kids over two years of age, for the under-two crowd the label simply tells parents to ask their doctor.
The American Academy of Pediatrics and Drug Manufacturers would like the labels to give parents more specific instructions for babies and young toddlers. Dr. Daniel Frattarelli is a pediatrician in Dearborn, Michigan who claims — I'm sorry, he chairs the academy's drug committee and he plans to testify before a joint two-day meeting at the Non-Prescription Drugs Advisory Committee and the Pediatric Advisory Committee of the FDA.
He said, "If we give parents better information, they will be able to give enough medicine to work well and at the same time minimize the side effects."
He added, "Parents want to do the right thing for their children and we, as the medical community, have to give them that information so they are able to do it. Proper dosing of acetaminophen is important because overdoses can lead to liver damage and failure.
In 2010, the American Association of Poison Control Centers accounted over 7,000 dosing errors involving acetaminophen products that were made for children. McNeil Consumer Healthcare, makers of the Tylenol brand, said, "McNeil is committed to encouraging the appropriate and safe use of medicines in children including adding new dosing information on the over-the-counter pediatric acetaminophen label to assist caregivers and health care providers in appropriately dosing children, especially those six to 23 months of age."
Incidentally, drug labels of products containing the fever reducer, ibuprofen, which is the active ingredient in Advil and Motrin brands, are already included dosing information for children under two.
Children taking stimulant drugs to control ADHD symptoms appear to be at no greater risk of developing heart problems than kids not taking these medications. That's according to a recent study from the University of Pennsylvania School of Medicine and published this month in the online edition of the journal, Pediatrics.
Principal investigator, Dr. Sean Hennessy, an Assistant Professor of Epidemiology, said, "ADHD medications can increase heart rate and blood pressure which might be expected to increase the risk of cardiovascular outcomes. But this study comparing ADHD-medication users with non-users, found no difference in the rate of heart problems or deaths between the two groups."
He added that his finding should reassure parents that drugs such as Retalin and Adderall aren't associated with an increased risk of cardiovascular events. But not all doctors are buying into this reassurance. Dr. Steven Lipshultz, Professor and Chair of Pediatrics at the University of Miami, Miller School of Medicine, warns that this study did not take into account children with existing heart problems.
He said there's no way that in children with underlying heart disease that the drugs — he said — I'm sorry, I'll start over with that. He said that this in no way says that in children with underlying heart disease, the drugs are safe or not safe.
OK, look folks, I'm not a news professional so you have to give me a little bit of leeway. Another chink in the iron is the fact this study was funded by the Irish pharmaceutical giant, Shire, the makers of Vyvanse and Adderall XR both of which are ADHD stimulant medications. In 2007, the FDA directed Shire and other drug manufacturers to produce a medication guide that would alert doctors and parents to the possibility of ADHD stimulants increasing the risk of heart problems. That mandate remains and time will tell if this study provides enough evidence to change it. In the meantime, parents should continue to follow the advice of their child's doctor when it comes to considering the safety and efficacy of these medications.
So this is an example where even if it's a good study, just the fact that it was funded by people who would benefit from a positive outcome already just — it just puts a shadow of, hmm, onto it, you know what I'm saying?
So even though it's maybe a well-done study, boy, when you're doing this kind of things you really want to watch out for that kind of bias because it just really brings into question everything. So even when it's done well, it just has that air of you probably shouldn't be doing this.
Anyway, ADHD drugs, if your child has a pre-existing heart condition, the stimulant medications may be a problem for them so you definitely want to talk to your doctor about that. Of course, the kids we worry about are those who have an undiagnosed heart problem, they get put on stimulant drugs, and those are the ones in particular you worry about. So it's something to talk to your doctor.
OK. One more drug-related story; fake drugs with names that sound like antibiotics are turning up in some Texas pharmacies. They are marketed to the Spanish-speaking population and have led to several hospitalizations.
The FDA is warning consumers not to use products sold over-the-counter as dietary supplements that also claim to be antibiotic drugs. A statement from the agency says these illegal products are falsely promoted which claims to treat illnesses such as upper respiratory infection, sinusitis, pneumonia, bronchitis, and the common cold, these products may or may not contain antimicrobials and their use can delay treatment for serious illnesses.
The product carries labels that are similar to drugs sold in Mexico and are marketed specifically to the Hispanic community. It turns out the products do not appear to have any active drug ingredient and are not approved to treat any medical condition. They come in many formulations including capsules, ointment, and syrup, and they have names like Amoxilina, Ampitrexyl, and Citricillin.
FDA officials learned about these products when the hospital in Austin reported treating several patients whose parents mistakenly believed they had been treating their children with an antibiotic. Marv Shepard, the Head of the Partnership for Safe Medicine, said, "The maker of these products have no scruples and they are preying upon the parents of children to make a quick buck. They use deception and jeopardize the health of children. This type of fraudulent marketing is unacceptable and despicable."
Strong language. "The FDA is investigating the origin, distribution, labeling, and advertising of the products and they have urged stores to remove the products from their shelves." You know, in Mexico, antibiotics can actually, you can just walk into a pharmacy and buy antibiotics. You don't actually have to have a prescription.
And so, I think that's one of the reasons the Spanish-speaking population in Southern Texas is falling for this because where they come from, it was not a problem to walk in the store and just buy Amoxicillin off the counter. And so, when they see a product that says Amoxilina on it, they just assume that it has Amoxicillin in it.
But those of us who grew up and know sort of the ways of this country, no, you can't just walk into a drug store and get Amoxicillin; you've got to have a prescription for it. So they really are preying upon folks who don't really know our system.
OK. Let's turn our attention now to bed bugs. We've all heard about or experienced firsthand the resurgence of these pests in North America and Western Europe, and as if their mere presence wasn't bad enough, it turns out the critters may transmit methicillin-resistant Staphylococcus aureus, also known as MRSA, and they may also transmit vancomycin-resistant Enterococcus. That's the finding of Canadian researchers and published in the June issue of the journal, Emerging Infectious Diseases, published by the U.S. Centers for Disease Control and Prevention.
A CDC news release said these findings suggest that bugs may act as a hidden environmental reservoir that promotes the spread of MRSA in overcrowded and impoverished communities.
The researchers say further studies are needed to characterize the association between staph infections in bed bugs, bed bug carriage of MRSA, and their portal of entry provided through feeding suggest a possible potential mechanism for passive transmission of bacteria during a blood meal. Because of the insect's ability to compromise the skin integrity of its host and the propensity for staph to invade damaged skin, bed bugs may serve to amplify MRSA infections in impoverished urban communities.
All right, who feels itchy now?
Dr. Mike Patrick: HPV vaccine for boys, U.S. girls have received Gardasil for a number of years. It's a vaccine that protects against human papillomavirus which is the cause of 70% of all cases of cervical cancer. A recent study in Austria showed that nearly one-third of males also harbor the virus in their foreskins. And with American males who keep their foreskins after birth, rising from 44% to 67% in recent years, there is increasing risk that uncircumcised men might pass the virus to unprotected women.
The study author say their data supports vaccinating boys as well as girls. Fred Wyand, a spokesman for the American Social Health Association's HPV Resource Center, agrees. He says the research leads us to look at vaccines as part of a risk-reduction strategy in both men and women. The American Academy of Pediatrics and the Centers for Disease Control have not yet recommended the HPV vaccine for boys, but that's something they might consider in the future.
And finally, adult physicians are calling on pediatricians to help curb smoking in parents. Dr. Shawn Ralston, an Associate Professor of Medicine at the University of Texas Health Science Center in San Antonio, he spoke on the topic last week at the Georgia Health Sciences University.
Addressing a large group of pediatricians and medical students, he said, "You as pediatricians have access to smokers that no other arm of the healthcare system has access to."
It's true, the majority of parents are healthy young adults who spend more of their time in the pediatrician's office than seeing their own doctor. Dr. Ralston acknowledged pediatricians routinely discuss the effects of smoke exposure on children, but he urged the doctors to go a step further by giving parents the tools and counseling help that they need to stop.
OK. Dr. Ralston, your theory sounds like a good one. Really, it does. But keep in mind the pool of pediatricians in this country is shrinking. Pediatrician offices are busy, busy places because there isn't enough of us to go around. Pediatricians are also some of the lowest-paid doctors out there which is a reason that our work force is shrinking, and another reason that we have to stay busy, you need to see lots of kids to pay the bills.
So if you are suggesting referring parents somewhere for help, fine, we can and should do that, but to provide lengthy counseling, which is really what they need to be successful, or to prescribe medications for adults who aren't our patients, well, the reality is you probably need a better plan.
OK, maybe that's just me being cynical. I understand his point, really, I do, but the reality is pediatricians may see lots of healthy adults in the office but in many cases, we simply don't have the infrastructure and place to do what Dr. Ralston is asking us to do.
All right, that wraps up our News Parents Can Use and we're going to take a short break. And as I said we have a guest in the studio today. Dr. David Hains is going to stop by. He is a pediatric nephrologist or kidney doctor here in Nationwide Children's and we're going to be talking about multicystic dysplastic kidney. And he'll be joining us right after this.
Dr. Mike Patrick: All right. Welcome back to PediaCast. This is Dr. Mike coming to you from the campus of Nationwide Children's. And I'm joined in the studio today by Dr. David Hains. Dr. Hains is a pediatric and nephrologist, and that's a fancy way of saying kidney doctor. He's an Assistant Professor of Pediatrics at the Ohio State University and a Principal Investigator for the Center for Clinical and Translational Research here at Nationwide Children's. So welcome to PediaCast, Dr. Hains.
Dr. David Hains: Thanks for having me.
Dr. Mike Patrick: Yeah, absolutely. Now, before we get started with our topic today, which is multicystic dysplastic kidney, which is a mouthful, but we'll break it down and get to exactly what that is, before we get to that I noticed in the course of doing the show prep that you went to Butler University in Indiana for undergrad and Indiana University School of Medicine.
Dr. David Hains: True.
Dr. Mike Patrick: Yeah. So before we get started, I have an important question for you regarding the State of Indiana, and I'm sure thousands of listeners out there really want to know the answer to this question. What exactly is a Hoosier?
Dr. David Hains: I think if you ask different people from Indiana, they'll give you different answers.
Dr. Mike Patrick: Is that right?
Dr. David Hains: Yeah.
Dr. Mike Patrick: I Wikipedia-ed it and there were a bunch of different ideas and reasons, so I didn't know if there was one true answer that…
Dr. David Hains: I don't think so.
Dr. Mike Patrick: No. It's just a folklore.
Dr. David Hains: Yeah.
Dr. Mike Patrick: Right. All right. Well, we aren't here to talk about Indiana. I just I had to know. But what we are going to talk about today is multicystic dysplastic kidney, and the inspiration for this topic comes from one of our listeners. Danielle, in Cologne, Germany, said, "Hi, Dr. Mike. My four-year-old son has multicystic dysplastic kidney. His left kidney never developed and he has seen a specialist since birth. Our specialist says we have nothing to worry about and there is nothing special that we need to do except to monitor the cyst and make sure they eventually shrink and disappear.
My son also has high-functioning autism. Of course, as one of your recent podcasts pointed out, when you look online you can find so much scary information or misinformation. So my question is can you please discuss multicystic kidney disease and that do you have any links to it or know of any links between it and autism?
Also, I want to try an Omega-3, B12, Zinc, and Magnesium supplement for the autism, but I'm worried about how his good kidney will react to them. Any information you could share will be helpful. Thank you for your show and the wonderful information you provide. I always look forward to listening to the new podcasts on my long commute."
OK. So thanks for your question, Danielle. Let's talk about multicystic dysplastic kidney and I guess a good place to start is could you define for our listeners what exactly is a multicystic dysplastic kidney?
Dr. David Hains: Yeah. That's a good question. It's actually a very common-occurring phenomenon, and basically what happens is the kidneys, as they're forming in the womb around five or six weeks gestation, just don't get put together correctly.
So, one, that's part of the reason why we have two is that is a very complicated process making a kidney. And so, if something goes wrong what ends up happening is you have this dysplastic or abnormal bunch of tissue that can form cysts, form scars, form other things, and really essentially is non-functioning. So it's something that one arise somewhere along the line during development and that's why we have another good kidney to carry us along.
Dr. Mike Patrick: Right. And this is typically just one kidney that's involved. What would happen if they happen with both kidneys?
Dr. David Hains: So because the kidney is a non-functioning kidney, you have to have at least one kidney in order to make amniotic fluid. The kidneys make amniotic fluid. The amniotic fluid then helps your lungs develop.
So any children that would have two multicystic dysplastic kidneys wouldn't have good lung development and probably would have a lot of really rough time early on in their prenatal course.
Dr. Mike Patrick: So amniotic fluid is urine?
Dr. David Hains: Yeah, it is.
Dr. Mike Patrick: Yeah.
Dr. Mike Patrick: I realized that. And not only that, so you have to actually have urine, basically, or the amniotic fluid into the lungs for proper development.
Dr. David Hains: Absolutely.
Dr. Mike Patrick: That's interesting. Now, I'm just curious, since there's one kidney that had — this happened to it, so it became dysplastic, full of cysts, irregular scar tissue, doesn't work right, so that doesn't necessarily happen to the second kidney, but is there a high risk of there being some problem with that other kidney?
Dr. David Hains: A lot of times, whenever you see a multicystic dysplastic kidney, it's associated with a familial form of different developmental abnormalities. Most of the time it's just a single occurrence in the one kidney, but what we do see is 10% to 15% at a time, people with multicystic dysplastic kidney on one side may have some dysplasia or some abnormal elements in the other kidney.
Dr. Mike Patrick: Sure.
Dr. David Hains: And that really just needs to be diagnosed with ultrasound or something like that.
Dr. Mike Patrick: And follow it along just to make sure that one kidney, that it doesn't going to have issues or problems associated with it.
Dr. David Hains: Absolutely.
Dr. Mike Patrick: How common is this problem?
Dr. David Hains: It's actually really common. It doesn't usually cause problems and so you don't hear about it.
Dr. Mike Patrick: Right.
Dr. David Hains: There aren't walks for multicystic dysplastic kidneys. Because generally, what happens is most people don't even know about it that they have a kidney that's not working and their other kidney is working just fine. So people feel fine and unless you go looking, you won't necessarily find it. So I think the cited incidents when you look at different studies is somewhere around 1 out of 3,500 live births.
Dr. Mike Patrick: OK. And male and female are equally affected with that as well.
Dr. David Hains: Yup.
Dr. Mike Patrick: OK. So how does this end up, I guess, in a simple way, how does this happen? I mean, is it something that you inherit that one kidney goes bad or is there something that happens during development and is there anything we can point to that causes it?
Dr. David Hains: So there are some known genetic causes. Those are very, very rare. They happen in families and we don't look for those causes. Usually, this is just sporadic occurrence and really how it happens is it's a very complex set of steps that have to occur for a kidney to form correctly.
And if one of those steps is off, I mean, you're talking hundreds of thousands of steps, if one of those steps goes off early on, it doesn't happen the way it's supposed to, this is what ends up happening.
Dr. Mike Patrick: Got you. I guess you could call it a hiccup in kidney development.
Dr. David Hains: That's exactly what…
Dr. Mike Patrick: I mean, just one step happens and we don't know exactly know why.
You do hear about infectious agents, having sort of a causative action in birth defects.
Dr. David Hains: Some medicines.
Dr. Mike Patrick: Medicines, chemicals, exposures in your environment. So are those kind of things, could those come into play or we just really don't know?
Dr. David Hains: Yeah. So there is a study looking at amniotic fluid in mothers that subsequently gave birth to children with multicystic dysplastic kidneys in. I believe it's 1% to 3% had a viral infection in their amniotic fluid. Now, does that mean that that's what caused it or is that just a sporadic occurrence?
Dr. Mike Patrick: Yeah, you just see that.
Dr. David Hains: A coincidence.
Dr. Mike Patrick: Yeah, yeah.
Dr. David Hains: That could be it. There were some mothers that were studied that also had epilepsy that were on anti-epileptics during their pregnancy and there was higher percentage than you expect in those mothers multicystic dysplastic kidneys in their children. So some people think that some anti-epileptic medications may be linked as well.
Dr. Mike Patrick: Right. It's really tough for moms who are pregnant because you don't know what to avoid, what not to avoid, and, I mean…
Dr. David Hains: Absolutely.
Dr. Mike Patrick: But I guess if you're going to have something that has to go wrong during development, at least it's an organ system where you have a duplication. So I guess there's a little bit of good news there.
Dr. David Hains: Exactly.
Dr. Mike Patrick: OK. So this is usually, it doesn't have any symptoms with regard to the diseased kidney. I mean, is there any symptoms at all? I guess not, right?
Dr. David Hains: Generally, no. Usually, what this is picked up as is either, a, it's found prenatally now that we're — we've gotten really good at doing prenatal ultrasounds. So in the last few decades, we've started actually picking it up more and more often just because our prenatal ultrasounds are so good.
The other way it can be picked up is it can feel as a belly mass during early childhood exams and it's painful. And usually, during a newborn exam it can be picked up as a mass.
Dr. Mike Patrick: And then there's a — you know, we talked about the differential diagnosis as doctors. And to parents, this just means if you found something on ultrasound before a kid is born or the doctor felt a mass, I mean, there's a big differential for what an abdominal mass could be. So how do you — is it just ultrasound? Is that the only thing that you do to evaluate these kids once they do have a mass there and is that the definitive way to diagnose it?
Dr. David Hains: Yes, so in a skilled pediatric center, ultrasound is usually the test of choice. You have to get really good pictures of the kidney itself because certain types of obstructions or blockages during development can lead to the same kind of picture on an ultrasound.
And so, there are certain tests you can order to make sure this isn't a blocked kidney as opposed to just a non-functioning or a multicystic dysplastic kidney.
Dr. Mike Patrick: Yeah. What kind of test?
Dr. David Hains: There's a test called the MAG3 Scan. It's a nuclear medicine test where you can see if the kidney picks up any tracer. We can inject the kidney with a tracer, the kidney should pee it out if it's a functioning kidney. So if it's blocked, it's going to try peeing it out but pee against kind of a blocked portion as opposed to a multicystic dysplastic kidney that's not going to pick up the tracer at all because it's not really even a kidney. It's the dysplastic thing, abnormal tissue that doesn't really work at all.
Dr. Mike Patrick: Now, I would suspect that there are parents out there whose children have this that will be concerned, well, could this be a tumor rather than a dysplastic kidney and does my child have cancer. Is there a way that you differentiate between just a malformed kidney versus a cancer?
Dr. David Hains: Absolutely. So just ultrasound pictures these are going to look very, very different. A cancerous or abnormal mass, that's worrisome for cancer. It's going to look very, very different than a multicystic dysplastic kidney which is essentially a big bag of cyst and water.
Dr. Mike Patrick: OK. One thing that I had a question about is, is that cystic structure pretty stable in the abdomen? Is there ever an issue of it sort of folding in on itself and cutting off its own blood supply and causing an acute abdominal episode or is there just not much blood supply to it so that strangulation type thing doesn't really happen? I mean, is that an issue?
Dr. David Hains: Yes. So this is basically dysplastic tissue, so it doesn't have organized blood vessels. This is really — and it does just like all scars on our body, over time it really kind of contracts down to nothing.
Dr. Mike Patrick: And this is what Danielle was talking about. Her doctor telling her we're going to follow this along but our expectation would be for this just to regress and go away.
Dr. David Hains: Absolutely. And so, most of the people walking around with a single kidney, if you meet somebody and say, "You know, my grandma had a single kidney. Usually, it started off — she had — grandma had two kidneys. One of them was a multicystic dysplastic kidney that shrunk away to nothing and the normal kidney is still there." And so, later on in life some people would pick up just that single kidney but it actually started this way.
Dr. Mike Patrick: Great. So long-term prognosis with this is really good.
Dr. David Hains: Absolutely.
Dr. Mike Patrick: Great. Now, we want to kind of contrast this with another disease which I know there are lots of people out there who've heard about, called polycystic kidney disease. Can you just give us a little bit of an idea how that disease is different than multicystic dysplastic kidney?
Dr. David Hains: Absolutely. So these are two things that we see quite often as pediatric nephrologist. It's probably not a lot of things that people hear about all that often. Multicystic dysplastic kidney disease again is a dysplastic or abnormally formed kidney that started when the kidney was being put together.
Polycystic kidney disease is something completely different. You have a normal kidney that then develops cyst over time. There's two forms; there's autosomal recessive that affects children early on in life and they don't really even have cysts. So it looks very, very different than a multicystic dysplastic kidney.
Then there's an adult form and generally, we don't see cyst early on in life. You get those later in life in your 30s and 40s. So some people we worry that when they get on the Internet, is this multicystic dysplastic kidney really polycystic kidney disease. And the reason why you should worry is polycystic kidney disease gets worse over time, multicystic dysplastic kidney is just an abnormally formed kidney.
It's not going to get worse. It's not going to cause any problems. And these are two conditions that are very easy for us to really tease out and tell the difference between early on in life.
Dr. Mike Patrick: Sure. And polycystic kidney disease is going to be associated then with hypertension or high blood pressure or it can be, and then renal insufficiency or the kidney not working properly and possibly kidney failure and then dialysis. So if a parent had a child who's diagnosed with multicystic dysplastic kidney and they got the two confused, and they've looked up on the Internet polycystic kidney disease, are going to be in for more of a shock and there's more complications and problems that can develop with that.
Dr. David Hains: Absolutely.
Dr. Mike Patrick: So, right. And then to address sort of our listener's specific question about multicystic kidney disease or — I'm sorry, see, I get the two confused even just saying it; multicystic dysplastic kidney. Do you know of any connection between autism and that disorder?
Dr. David Hains: I did a literature search to even look deeper because I didn't know of anything and there actually isn't any literature out there with the terms autism and multicystic dysplastic kidneys.
Dr. Mike Patrick: And I did the same thing and I couldn't find anything. My thought was with polycystic kidney disease, as I understand it, it can be multi — organ systems can be involved. You can have cyst in the liver and pancreas as well and perhaps, there is some association with some mental retardation as I came across, so there can be some central nervous system issue. So maybe that's what someone had told her about or that there —
Dr. David Hains: It could be.
Dr. Mike Patrick: It could be. But I don't know. I don't know for sure.
Dr. David Hains: Yeah, I don't think there is anything that's known and there aren't any strong association yet between the two.
Dr. Mike Patrick: And of course, with autism incidents sometimes it's being reported to be as high as 1 in every 150 kids and in this being 1 in every 3,500 kids you're going to have a lot of kids who have a multicystic dysplastic kidney who also have autism, but it doesn't necessarily mean that one caused the other.
Dr. David Hains: Absolutely.
Dr. Mike Patrick: They're just both there in the same person. And then she wanted to start Omega-3, B12, Zinc, and Magnesium supplements, and I know that neither you or I are behavioral pediatricians or autism specialists.
And we're certainly aren't here to recommend or say you shouldn't do that but just from a kidney standpoint, if that's something that someone wanted to do, is there a concern with having one functioning kidney? Does it really take the place of two kidneys or is it like having half the renal or kidney effect, so to speak?
Dr. David Hains: Yeah. Even though you only have half the kidney in terms of number of filters and number of blood vessels, that kidney grows to take over the work load of two kidneys. So you actually end up at the end of the day with a much bigger kidney than you would have had if you had two kidneys.
So from that standpoint, most people have normal kidney function by our tests. So things like limiting medications that might be harmful if you had kidney failure or kidney insufficiency, aren't as worrisome in this state in people with multicystic dysplastic kidneys because that kidney really generally works fairly well.
Dr. Mike Patrick: Yeah.
Dr. David Hains: In terms of — I can't speak to the safety or efficacy of any of those medicines, so I know that various dietary supplements if up to the recommended daily allowance, is probably fine and those especially in any patient with multicystic dysplastic kidney.
Dr. Mike Patrick: So the bottom line is they have a normal kidney function, but of course whether Omega-3, B12, Zinc, and Magnesium are really going to help with autism is beyond the scope of this discussion.
All right, well, thanks a lot. Dr. Hains wrote a review article regarding the management and ideology of the unilateral multicystic dysplastic kidney. It was published a couple of years ago in the journal, Pediatric Nephrology, and we'll put a link to that article in the show notes at pediacast.org.
The abstract can be found in PubMed so people can read the abstract. From there, you can link to the full article and you may need to pony up a few dollars to do that since it's a published work. Or if you use an academic library, a lot of times you can log in there if you have a university or college near you and see the full text of that without needing to pay anything extra.
OK. So we're left with one more question and it's a question we ask everyone who stops by PediaCast Studio. Here, we encourage moms and dads to spend quality time with their kids and sometimes that may seem difficult to do, especially on a rainy day which we've had a lot of here lately in Ohio.
And one thing that I loved as a kid was playing board games with my family. So my question to you is what is your favorite board game either now or when you were a kid or card game? And we're kind of keeping a list at pediacast.org of favorite board games, so what do you think?
Dr. David Hains: I still love playing Risk. My family used to play lots of Risk.
Dr. Mike Patrick: You know, my kids love that game and they always ask me to play but it takes so long.
Dr. David Hains: It does.
Dr. Mike Patrick: I mean, it's like hours. And then in fact, my kids just played it a couple of weeks ago and they had the whole thing set up and it got a bit too late and they had to go to bed. And they left it out and, of course, our cat ruined it.
Dr. Mike Patrick: It's not a good way to cover it up. So Risk, OK, great. Great classic game. All right. So a big thank you to Dr. Hains for stopping by the PediaCast Studio and educating us on the details of the multicystic dysplastic kidney.
Remember, if you have a topic you'd like to talk to us or like us to talk about on PediaCast, it's easy to get in touch with us. Just go to pediacast.org and click on the Contact page. You can also email email@example.com or you can call the Skype line and leave us a message at 347-404-KIDS. And with that we'll put a wrap on our interview with Dr. David Hains. Thanks again for stopping by.
Dr. David Hains: Thanks for having me.
Dr. Mike Patrick: All right, we are back and we're going to do our Listener segment. You notice we have a little bit of a different order starting this week. We're going to be doing the news and then our interview which we're calling the Featured segment and then we'll wrap things up each week with our Listener segment.
So first up this week is Christie from Austin, Texas and Christie in Austin says, "Hi, Dr. Mike. When I, the breastfeeding mom, am exposed to a bug that I have previously developed antibodies to, does my baby get enough antibodies to prevent contracting the bug? Does he make antibodies too or just float by on mine?
When he encounters the same bug later in life, will he have immunity to it? Does baby get my antibodies to bugs we're not encountering? Is he, for instance, immune to the flu from 2002 that I got? They say that breast-fed babies get sick less often and when they get sick, it's not as bad. Immunity-wise, how can a baby get a bug not as bad? Does that just mean the bug doesn't get to run the course? In other words, it's cut off mid-way?"
All right. Well, excellent, excellent question, Christie, and let's talk about this. Basically, the breast milk — well, actually, let's take a step even back before that. Your immune system works in a couple of ways. One way is that when an organism enters the body that's a foreign organism, it's not supposed to be there, your body makes antibodies against them so that then the next time that that organism comes along you have antibodies that are ready to fight it off.
Although it's not quite that simple, you don't always have all of the antibodies floating around. You have sort of a low level of them and then you have some memory cells that thin when they come into contact with this organism that says, "Hey, I remember this organism. We can make antibodies against it, so let's do that."
And so, your body starts to make antibodies against that organism. And so, that process can happen pretty quickly so that the second or third time that you're exposed to that organism, your body starts to make antibodies within a couple of days and you fight it off and so you're sick for a couple of days and it's kind of mild.
Whereas the first time that you're exposed to something, it's a longer-duration illness, and that's why kids, younger kids, get sick more often and their illnesses tend to last longer, have higher fevers because they're just fighting these things off for the first time. They don't have that memory system in the play shed.
OK. So what is it that when you breastfeed your baby, what are they getting? Well, they're not getting that whole memory, let's gear up and really make a ton of antibodies kind of system. They're just getting that low level of antibodies that we always have kind of floating around in our systems because of previous illnesses that we've been exposed to.
So when they drink the breast milk, they're getting these antibodies so they do have some protection but it's still not as good of protection as once they get the illness for themselves and make antibodies against it. You know, that whole memory system in place, that's a better protection.
So what you have is kids who are breastfeeding — let's first compare them to kids who aren't breastfeeding. If your child is breastfeeding and are getting these antibodies and a particular virus — and by the way, they get all the antibodies. So, yes, when you were exposed to the flu in 2002, if you still have some flu antibodies floating around those do go through the breast milk and so the baby is going to have some immunity against the flu from 2002.
But remember, again, they're only getting a few of these antibodies. They're not getting that whole memory cell kind of system. So it does protect them compared to a baby who's not breastfeeding and is not getting any of those antibodies.
Does that then blunt their own exposure to these, to viruses so that they make their own memory system in a less strong fashion? I think so. I think the advantage, what I'm saying here [Laughter] the advantage of breastfeeding is you've got this low level antibodies to help if an organism comes along to help fight it off in a better way than if you're not breastfeeding and your baby is not getting those antibodies.
Now, on the downside, and I think that this is what Christie is asking, does that mean that when that organism comes along and antibodies from the breast milk fight it off, does that mean the baby has a less strong reaction for its own future protection?
And the answer to that is, yes, because you're fighting it off faster and so the baby's own immune system is not — doesn't get geared up to have to fight the fight. Now, you could say then in terms of the baby's long-term immunity is it better to not breastfeed as long so that they don't have those antibodies so that they can make a stronger reaction?
Yes, but the flip side of that is that babies also have a tendency to get overwhelmingly sick and their immune system may not protect them quite as well as a little bit later in life. So even though they may get better immunity because they don't have your antibodies running around in their system, the flip side of that is that they might get sicker and because of them being a baby, that being sicker is more likely to lead to them really being sick and having to be in the hospital or having bad outcomes because of an illness.
Again, it's risk versus benefit and the benefit of having those antibodies there when babies are most prone to bad infection is worth the con of not forming a strong of an immunity for later. So, certainly, it's helpful but it does kind of interfere a little bit with the body's own immune process in making those memory cells for the future.
So I hope that answers your question. Breastfeeding is definitely great, do it as long as you possibly can, and those antibodies in the baby are a good thing, even though it may blunt their own immunity and then when they're in school age they may get a little bit sicker. But then they're building their immunity for their teenage and adult years. And when they're school age they're bigger and not as prone to serious illness, so it's OK that they don't have mom's antibodies working for them anymore.
OK. By the way, I do have a link in the show notes if you want more information on this. I found a really good article written by a physician and, yeah, I read through it. It's really well done. It's from a site called breastfeedingonline.com, and the article is called, "How Breast Milk Protects Newborns". And we'll put a link to that in the show notes which you can find over at pediacast.org.
All right. Next up is Melissa in Belleville, Illinois. And Melissa says, "I'd love to hear your thoughts on homemade baby food. I've looked into it online and there doesn't appear to be any cons other than maybe needing to be careful about sulfate amounts in some veggies. What is the nutritional difference between homemade and canned baby food? Any important tips for making my own? Thanks for your podcast, it's a great resource."
Well, thanks for your question, Melissa. So let's talk of homemade baby food. First, I think the biggest concept here is a carrot is a carrot is a carrot.
So whether you're feeding your child carrots that you've made at home or whether you're feeding your child carrots that are in jarred food, it's still a carrot. And so, really we have to ask what is the difference between a jarred food and the food that you might make at home, and is that difference something that is significant and are there risks involved?
So the first way in which the jarred carrot is going to — and I'm just using carrot as an example, so you can extrapolate this out to any other baby food you like. The jarred carrot is going to be pureed for proper consistency but that's something you can do at home. I mean, you can open up a jar and kind of get a feel for the thickness and use a food processor and make your carrots that same thickness.
So that's not something you have to rely on the baby food companies to do for you. It's something you can do at home. There's no magic behind that. The jarred carrots are going to have preservatives in it so that they have a long shelf life so that they can stay in the grocery store and be safe for use long after they've been placed in there.
So you obviously aren't going to put preservatives in your carrots and that's not a bad thing. That just means that they're not going to have a long shelf life, but that's OK because you're going to make the carrots and feed them to the baby and not save them for long periods of time.
So really the only difference is that they're made of certain consistencies so your baby doesn't choke on them and then they have the preservatives in them. Now, you talked about the sulfates and really, I think what you're talking about is nitrates. And sulfates can be an issue but that's typically — what we're really more worried about are nitrates.
And nitrate exposure in vegetables can lead to a rare condition called methemoglobinemia. And if you just listened to our last show, PediaCast 161, you know that nitrates in teething gel can cause this rare condition called methemoglobinemia. And I'm not going to go into all the details of that disease because we did that in our last episode. So if you just click back an episode, you can hear all about that.
Well, now the baby food companies will tell you that they screen their vegetables for nitrates so that you don't have to worry about your baby getting methemoglobinemia from eating their food. In doing that, they insinuate that if you just puree up your own carrots that you're going to put your baby at risk for getting methemoglobinemia.
So the next question becomes how real is this danger? Well, with teething gel, it's a very real danger, but that has a lot more nitrates in it than vegetables do. And that we have seen an increased rate of methemoglobinemia in babies who get teething gel which is why the FDA issued a warning telling parents with young infants at home you shouldn't use the teething gel because there's enough nitrates in it to cause methemoglobinemia and that really does happen.
But what about the actual cases of methemoglobinemia in kids because of homemade baby food?
OK. It's a risk but how big exactly is that risk? Well, I'll let you decide. Guess how many documented cases we have in all of the medical literature of babies getting methemoglobinemia from homemade baby food. Take a guess. The answer is one. That's it; one kid.
It was reported in 1973 and it was a very young baby who drank way too much carrot juice. So it can happen and in the reported medical literature, it has happened once. So if we're looking at risk versus benefit, what's the benefit of homemade food? Well, there's a cost benefit, there's a freshness benefit, there's a no-preservatives benefit. I'm guessing there's probably a better tasting benefit.
And then in terms of risks or cons, there's the con of time it takes you to do it, of the fact that you cant' store it up and use it later, that you have to actually make it and use it as you go along. And then there is this risk of one reported case of methemoglobinemia. So I'll let you decide the risk benefit analysis on that.
For me, when our kids were little we used jar food but that was because of the convenience and storage issues. That is just us being lazy. It wasn't because I personally was afraid of methemoglobinemia. Now, if you make your own baby food and your child is case report 2, please don't come crying to me about it. It's a risk. OK? It's a risk.
Is it a bigger risk than driving your baby around in a car at 70 miles per hour? Again, you have to decide. But let me add this, the official American Academy of Pediatrics guidelines on nitrates in homemade baby food says this, "A homemade prepared infant food from vegetables such as spinach, beets, green beans, squash, and carrots should be avoided until infants are three months old or older."
Why three months? Because if the baby is younger than that, they have the highest risk of nitrate-induced methemoglobinemia. Also, Dr. Alan Greene, he has a great site called drgreene.com, put an E at the end of green, drgreene.com.
He has a nice article on homemade baby food and nitrates if you want to read more about it. And I'll put a link to that in the show notes over at pediacast.org.
All right. And finally, we have Anna in Toronto, Canada. Anna says, "Hi, Dr. Mike. First of all, congratulations on the changes to your show. It must be very exciting to be recording with Nationwide Children's Hospital." It is. "I have an eight-month-old daughter. For the last three months she has a black tongue. Her tongue looks like the ones you see online for black hairy tongue. Although we do not smoke and of course she does not smoke, she's eight months old." Good.
"Hers is not really black but brown. I have seen one doctor and a dentist. Nobody is concerned but nobody really knows what it is. I have an appointment for another doctor this week. I just wonder if I should worry about this. She has been all right otherwise. Thank you for your show, it is wonderful."
Thanks for writing in, Anna. By now, you've probably seen that third doctor for this and if that third doctor joined the other two and said there's nothing to worry about, then as apparent, I think it's time to believe the professionals and not worry about it anymore. But that's me, there's some people who are still going to worry and ask the fourth and fifth and sixth person.
I can't comment on your child. And I laugh at this, but other doctors will know what I'm talking about. You see a kid and you've had two or three other doctors tell him one thing and the parents are — they're expecting that you're going to say something different when we all know what we're talking about with some of these things.
You know, obviously, you hear about the case where the doctors all had it wrong for years and then someone finally figured it out, but those are by far in a way the exception and not the rule.
All right. So I can't comment on your child's brown tongue because I can't see it and if I told you what I thought of what it was in your child, obviously I'll be practicing medicine over the Internet which is never a good thing as we all know and we have to be careful not to do.
But I can talk about tongue color in general. Tongues normally, you're born with a tongue that's pink. It has pink or red. It has taste buds on it. Those are the little bumps. Sometimes those bumps are arranged in funny patterns and when that happens some of the bumps are bigger than others and it gives patterns on it. We call it a geographic tongue. That's just a genetic thing.
But a lot of times, tongues are also sticky. And not sticky like if you put your finger on it, but there's a surface tension that food can stick to and medicines as well. So it doesn't feel sticky but there is adhesion that happens. And then you add these taste buds which are little bumps all over the place and it's really easy for food to adhere and get caught between these taste buds, and some kids' tongues are better doing that than others.
So a lot of times you'll see a baby with a white tongue and it's just their milk. It's just a coating of milk that is adhered to the surface of the tongue and kind of caught between the bumps.
Now, another thing that can make the tongue white is thrush which is caused by a yeast organism. And thrush when it's on the tongue has a very distinctive look to it and there's typically other signs of thrush in the mouth, particularly on the inside of the cheeks near where your lips are. You'll see some spotty white stuff there.
So if you have a kid who has evidence of thrush in other places in their mouth and their tongue has a specific look to it, then that whiteness may be thrush and they would need treatment for that. But pediatricians know what this looks like. I mean, we see thrush a lot in kids. So if you're pediatrician is telling you this does not look like thrush, it's probably not thrush and it's most likely going to be milk that's causing the white color.
OK, but what about — and let me mention this too. The reason that babies get thrush, might as well, I love doing the teaching thing.
The reason babies get thrush is because yeast organisms are everywhere that's why your bread gets moldy. And babies don't have a lot of bacteria in their mouth naturally, and so it's a warm moist place and yeast can grow. As they get a little bit older, their mouth starts to get colonized with normal good bacteria and there's no room for the yeast to grow and so that's why older kids don't get thrushes often as young babies do.
And if you take an antibiotic, let's say, for an ear infection, you'll kill off some of those normal bacteria and then it's a little more like leading the older babies can get thrush if they've been on antibiotics and that's the reason why.
All right. So what about brown? You know, brown is most likely brown because it's a mixture of a whole bunch of different colors. So probably if I see a kid with a brown looking coating on their tongue, it's probably their food. It's that adherent surface, food getting stuck between the taste buds, and when you have a bunch of different colors together, it's brown.
All right. So thanks for the question, Anna. I hope that helps. Again, I'm not saying that your child's brown tongue is caused by food, but I'm just saying that it is a common cause of a brown tongue. But you should probably go with the advice of the three doctors that you've talked to.
All right. So we are [Laughter] that wraps up our Listener segment. I do want to mention if there is a question that you have or comment that you have, all are welcome, you can get a hold of us at the website. Just go to pediacast.org and click on the Contact link. You can also email us by emailing firstname.lastname@example.org. If you go that route, again, make sure that you just put on there where you're from. We appreciate knowing that. And of course you can call the voice line or the Skype line at 347-404-KIDS, that's 347-404-KIDS.
All right, I told you in the very beginning that we're going to talk about a product that you can get for your iPhone that features PediaCast. And we will be back with the outro of our show and we'll talk about that right after this.
Dr. Mike Patrick: All right. As always, things go out to Nationwide Children's Vladstudio who helps us out with some of the artwork in the site. You can visit him at vladstudio.com. And of course, listeners like you who contribute to the show and ask questions and get involved, we really appreciate that.
There is a new way that you can get involved with PediaCast and that is with a free application that you can find in the iTunes Store in the App Store called Podcast Box and this is a product from the folks at Wizzard Media.
Wizzard Media really helps and supports a bunch of different podcasts, PediaCasts among them. And basically what this app does is it allows you to subscribe to podcasts. Now, they do charge $1.99 for each show.
So if you want to interact with PediaCast through the Podcast Box, it'll cost you $1.99. It's a one-time fee. And when you click – I did it myself – when you click that you want to buy it, it'll say, "Do you want to purchase one show of PediaCast?" And you click, Yes. It is not $1.99 per episode. Show means the entire show of PediaCast and includes all new episodes that come out.
So don't let that fool you. I was a little concerned about that terminology when I saw it, but it's $1.99. The application itself is free. It has all of the Wizzard-related podcasts that are a part of their network, so to speak.
Now, PediaCast is a product of Nationwide Children's but we have sort of like, I should say an affiliation with Wizzard Media. They helped us design this process. There's also an Android app that you can use as well.
So this is called Podcast Box. You download it to interact with PediaCast. It's $1.99, one-time fee. And that money, we're not making a ton of money off this. There is a developmental fee that goes in the making of these things. And so, it just hopes to offset that.
And what that let you do is listen to every episode in the feed and new episodes will automatically come down to your iPhone. You don't have to wait until you actually physically connect with iTunes. It will just happen, the feed is there over the cell network. And then you can also link directly to our website and submit questions or comments directly from the application. So it's a pretty cool thing.
Now, I want to be transparent here. There are other apps out there that will allow you to do a similar thing.
But those all have costs associated with them as well. They tend to be — there are several of them that are out there. You can do a search for podcast download apps and there is a bunch of them. But they all have a cost associated with those as well. And you can't email directly from the app, which I think is pretty cool.
And the other thing is with those particular applications, you do have to know the RSS Feeds to input those in rather than it being in a directory. So it's just another option that's out there I wanted you to know about. And, again, if you go to the App Store on your iPhone, just look up Podcast Box and you'll see us there. So we're excited about it to be able to be in an app on the iTunes Store. So take advantage of that if you so choose.
All right. I want to remind you that reviews in iTunes are helpful as are comments and shout-outs in your blogs and Facebook and Twitter. We really appreciate all those. And when you go in to see your doctor the next time, just mention, drop our name.
Please be a name dropper for PediaCast because we really strive to be a great resource that's evidence-based that you can trust on the Internet. So please talk us up. We really appreciate that.
And, again, if you have comments or a question for us, pediacast.org, Contact link, email@example.com or the voice line at 347-404-KIDS. All right. I've talked enough today. I think we have definitely gone over an hour.
And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long everybody.