Pilonidal Disease, Infant Walkers, Teen Suicide – PediaCast 416

Show Notes


  • Dr Peter Minneci visits the studio as we explore the symptoms, treatment and prevention of pilonidal disease. Also considered this week: MiraLAX and infant-walker safety, texting while driving and teenage suicide. We hope you can join us!


  • Pilonidal Disease
  • MiraLAX Safety
  • Infant-Walker Safety
  • Texting while Driving
  • Teenage Suicide




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome. Once again the PediaCast, it is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital, we're in Columbus, Ohio. It is episode 416 for October 2nd, 2018. We're calling this one, Pilonidal Disease, Infant Walkers and Teen Suicide. Want to welcome you to the program.
Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome. Once again the PediaCast, it is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital, we're in Columbus, Ohio. It is episode 416 for October 2nd, 2018. We're calling this one, Pilonidal Disease, Infant Walkers and Teen Suicide. Want to welcome you to the program.

We have an information packed show for you this week with terrific topics for parents with kids of all ages, from infants to teenagers; this you could tell from the title of today's program. We are covering Pilonidal disease, more on exactly what that is in a couple of minutes. We're also going to explore the safety of MiraLax, which a lot of kids sometimes take on a daily basis over a long period of time for constipation. And adults take it too, so many parents will be interested in this topic for their own health. But we're going to talk about the safety of MiraLax because there has been some reports about possibility MiraLax not being safe and with so many people taking it, there is a new study out that does speak to the safety factors of MiraLax, so I think a lot of folks will be interested in that. So stick around.

We're also going to cover safety considerations as they relate to infant walkers. You've heard pediatricians talk about the dangers of infant walkers for many years. And yet, there's still a lot of infant walker injuries that occur. To the tune about two thousand kids every year and about third of them are very serious injuries involving the head and the neck. And so, this is still a problem and just want to talk a little more about the numbers and why is it that pediatricians do not like infant walkers. So, more on that coming your way.


Then two topics that pertain to teenagers: texting while driving and then very important topic, teen suicide and how to prevent it. So lots coming your way. Before we get started, and we talk about what exactly Pilonidal disease is, you may notice especially to those who listen regularly, my voice sounds a little different today. I've got a cough drop in my mouth otherwise every time I talk, the coughing comes. I've been sick for about a week and a half with what is probably, a neural virus disease. Begin with a runny nose, congestion, not a high fever but you know, feeling chills and sore throat. It's no surprise because in addition to PediaCast, I also work in urgent care centers, in our emergency departments here at the hospital and I'm around sick kids. My wife is a pediatric nurse, she's around sick kids a lot, and she had the same illness couple of weeks ago. So it's no surprise that I caught it.

And after the runny nose and congestion, there came my laryngitis. In fact, I have to cancel last week's CME episode on sports nutrition. Don't worry, we'll get it rescheduled soon. And then at the tail-end of last week, I got a little conjunctivitis. So in my case, a pink eye which always makes my ophthalmologist nervous because of my history of glaucoma and the surgeries that I've had. So I've been using eye drops to prevent a bacterial infection on top of the viral one. So bottom line, I've been a mess, folks. It's a risk you take when you work with lots of kids especially as the school year gets started.


And anyone who works with children, whether it's in the medical field or in education in school knows that when you get a bunch of kids sharing their germs in the classroom, adult illness oftentimes follows. But I will tell you this and this is really the whole point of sharing this story with you. I think that it's really good for doctors and nurses and other in health professions did get sick now and then. It really helps with understanding what our patients are going through. It helps with empathy. I think it helps us to be better providers. So you know, I don't want to get sick often. But when I do, it sort of like a reboot and I always find myself to be a better, more compassionate doctor toward my patients after the experience.

I think the same thing is probably true for educators. You know, when you get sick yourself and you see kids who then come to school, and they're not feeling well, or they have several absences, you do develop I think more empathy when you've experienced those illnesses more recently yourself. So, embrace the illness. I guess that's the point. And emerge from it to be a better provider or educator than you were before the illness because we all know, kids get this stuff very often because their immune system is in training, and they catch every virus that comes along. So they make memory and not get sick as often as adults.

Alright, so you've heard the word Pilonidal disease a few times already in our podcast. What in the world is that? Well, it's a condition that is more common than you think. People just don't like to talk about it in mixed company. It's a skin infection that often occurs between the middle fold of the buttocks what we would call, intergluteal fold. It's the region, sort of the sacrum and the coccyx in the fold between the buttocks. It's a sensitive area, both in terms of pain and privacy. Which means there's often a delay in the diagnosis, especially the first time it occurs. And Pilonidal disease can be quite painful.


Antibiotics at least when used alone, aren't so effective especially as the infection progresses. And if it's not treated properly, re-occurrences is common and complications can occur. So, we're going to cover the nuts and bolts of Pilonidal disease, what causes it, what signs and symptoms should we watch for? When to see a doctor, which doctor should you see for this, what kind of doctor? How is it best treated, what are the potential complications and how can you prevent it? All good questions and to help me with the answers, I have a pediatric surgeon joining me in the studio, Dr. Peter Minneci. He's an expert on the successful management of Pilonidal disease, we'll talk to him in a few minutes.

First I would like to remind you, PediaCast is on social media, and we just love it when you connect with us there. We're primarily on Facebook and Twitter and then those places where we'd like to share our current episodes with so you would know exactly what's coming up this week on the program. Also, some of our past shows and episodes that we think might be helpful for you. And then other pediatric and parenting content from other places that we curate and share on Facebook and Twitter, so please look us up there, PediaCast and connect with us.

We're also on Instagram. Now, Instagram is more of a personal look kind of into the studio, kind of sharing what my family is up to, my personal life and love it when you connect with us there, and we reciprocate and would love to follow you as well and see what's going on in your family. We're also on some other places in social media, not as quite as active there for example, LinkedIn. If you look for Dr. Michael Patrick, I'm there on LinkedIn. And sometimes, we put some stuff on Pinterest, kind of following away from that a little bit because we haven't got much traffic from Pinterest. But you know if you'd loved us on Pinterest and don't find us anymore, shoot me a message through the contact page and maybe we'll try to be more active in that place. Just really trying to go with where folks are. If there's some other social media channels you think we should be involved in, I know there are many. Let me know. And we'll experiment and explore.


I mentioned the contact link, that is over at pediacast.org. There's the contact page, I do read each and every one of those that come through. So, if you have a topic suggestion for PediaCast or if you have a question that you'd like us to answer, simply head over to pediacast.org and click on the contact link. Also, want to remind you the information presented in every episode of the program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

So if you do have a concern about your child's health, make sure you 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 pediacast.org. So let's take a quick break and then I will be back to talk more about Pilonidal disease, MiraLax, infant walkers, texting and driving among teenagers, and teen suicide. It's all coming up right after this.


Dr. Mike Patrick: Dr. Peter Minneci is a pediatric surgeon at Nationwide Children's Hospital and an associate professor of surgery at the Ohio State University College of Medicine. He co-directs our hospital's Center for Surgical Outcomes Research and will talk more about the nature of that center, what they do, why it's important in many ways that they are improving surgical outcomes for kids. We'll talk about that in a little while. First though, Dr. Minneci has an interest in helping teens and young adults suffering from Pilonidal disease. That's what he's here to talk about, so let's give a warm PediaCast welcome to Dr. Peter Minneci. Thanks so much for stopping by today.


Dr. Peter Minneci: Thanks for having me.

Dr. Mike Patrick: So, let's begin with just a brief definition. What exactly is it that we mean by Pilonidal disease?

Dr. Peter Minneci: Okay. So, Pilonidal disease is an infection between the buttocks essentially. So, in the sacral area sometimes it's called the gluteal cleft. Essentially, patients will get an infection in that area and once that happens, they are usually termed with having Pilonidal disease.

Dr. Mike Patrick: Yup. So it's a skin infection near the tailbone, sort of the top-ish area of where the buttock cheeks come together.

Dr. Peter Minneci: Yes, right sort of at the base of the sacrum near the coccyx if people know what that bone is and where that is. It typically presents with pain that's usually the initial symptom because it's obviously not an area where you can see. So the initial presenting symptom is oftentimes pain and then someone looks at the area and realize that it's infected.

Dr. Mike Patrick: Sure. And how does this happen? How does this area of skin become infected?

Dr. Peter Minneci: So, it typically is a disease that starts in adolescence. So when you hit adolescence and your hormones start changing and you start to produce hair, more sweat and more oils, the area begins to grow hair. And what happens is the hair follicles themselves can become clogged and then the bacteria that normally live on your skin will be trapped essentially under the skin and will start an infection.

Dr. Mike Patrick: And is this common occurrence?

Dr. Peter Minneci: So it is relatively common. It affects about 1% of the population overall. It does affect boys just a little bit more than girls about 1 and a half to 1 ratio. And it most commonly presents in adolescence and young adults. So really, teenagers up through about mid-20s is going to be the time when people first get diagnosed with this disease.


Dr. Mike Patrick: Yeah, so as you start to gain a little more weight, you're going to start to have coarse hair that's growing and starting to make oils that certainly the prime time for this. And then as I was researching this, I found an interesting that can occur at other locations sort of by a similar mechanism, and in particular between the fingers. This is in the adult world but barbers, dog groomers and sheep shearers, sometimes you'll see a similar situation when you think about the mechanism, it sort of makes sense.

Dr. Peter Minneci: Yeah, it's the rough hair and the broken hair and the struck edges of those hairs getting to those cracks, and then they sit there and you just by moving. Or in the case of the buttocks area, just sitting put pressure on them. And then they crack the skin.

Dr. Mike Patrick: Yeah and I read it sometimes you see it more in the bus drivers, people with occupations where they have to sit for long hours of time and there's wiggling and moving. And so, that friction can help the process along.

Dr. Peter Minneci: Yeah, so the biggest risk factors are going to be essentially, the age. And then the type of hair that you have. So, if you have more hair or if you have coarse hair, that's more likely. Obesity, because it just allows the area to be a little bit deeper. So the deepness of your gluteal cleft is also a risk factor. And then jobs or in case of students, where you sit for more than six hours a day, that whole idea of pressure and causing friction comes into play.

Dr. Mike Patrick: Yeah, so this is a good reason for teenagers to take a break from playing video games and to be active not only for the rest of their cardiovascular health but also, to try to prevent Pilonidal disease.

Dr. Peter Minneci: Oh absolutely. So for patients with cardiovascular disease, we'd recommend sitting as little as possible.

Dr. Mike Patrick: Yup. So what signs and symptoms go along with this? What would kind of clue someone in that Pilonidal disease may be occurring?

Dr. Peter Minneci: So typically, you're not going to know that you have a Pilonidial sinus. So when an area in the skin that's developed or opening in the skin in that area that has developed overtime unless someone looks. So, the most common presenting symptom is that it's going to be pain, since it does oftentimes in teenagers and it is a sensitive area, they may not immediately seek someone's vision to look at it. And so, you start with pain. And typically, they may notice some drainage, so if they're wiping they may see yellow fluid or what looks like pus if they know what that is on the toilet paper or on their finger if they were to wipe that area. And typically, the area of the pain becomes more and more, and then they usually have someone to look at it. And so, if a parent was looking at it or a friend, you would usually see redness in the area. You might see pus and sort of hair within the pus and you oftentimes will see within the painful area openings of the skin which we would call, Pilonidal sinuses.


Dr. Mike Patrick: And this is something that can sort of present a little bit advance because people may put off having someone to take a look at they're a bit uncomfortable in that location.

Dr. Peter Minneci: Yeah, oftentimes we'll see kids who show up, and they might be football players, and they kind of tackled and kind of ignored the pain and then it just doesn't go away. And then the issue would not looking at right away. If you pick up pain as the first sign, oftentimes you may have an infection and you may be a little successful treating with just antibiotics. But most of the time, it's going to present and the infection has grown a little bit and oftentimes already have an abscess and then the pain becomes severely worse at that point because you have pus and the pressure and then you usually need some sort of drainage procedure.

Dr. Mike Patrick: And for parents who as we've talked about this warning signs and risk factors. If you have a child at home who has some of those risk factors that maybe a good idea just to ask them or to say in the future “Hey, if you do have a pain in that location. You're kind of at risk for this because of your body type hair, whether you sit a lot or not and ask them about it.”

Dr. Peter Minneci: Yeah, I think symptoms are the key things. So ask them about it makes the most sense. If they can look in the area and if you were to see a Pilonidal sinus, then we would recommend that you institute kind of the preventive measures we've talked to patients for recurrent disease and those are going to be sort of types of things we think about sweaty hair areas, which is keeping them dry as clean as possible and hair removal if you already have an episode of this disease.


Dr. Mike Patrick: And how is this diagnosed? Is it always just a clinical diagnosis, you know for sure that that's what it is. Especially, once a medical provider can take a look at that area, it's going to be pretty obvious or are there other things that can appear in the same way and is there something that you need to do to make a diagnosis?

Dr. Peter Minneci: So most of the time it's going to be based on history and then exam, actually looking at the area and see what it looks like. You know almost all patients, you are going to see a sinus and if presenting with an acute infection then it will have all the signs and telltales of infections. So, redness and tenderness or in this case, fluctual abscess or draining pus through one of the wounds. There are some patients who will present where you don't sort of see at the surface yet, and one of the reasons is that the sinus or pits, some people actually call it, they actually tunnel the skin.

And there can be some inflammation starting deeper down, so closer to the actual bone level. And so, in those cases when the clinical exam isn't clear when someone is having pain, then an ultrasound can be helpful because you can actually see inflammation in the area and subcutaneous tissues. In that case, if you actually catch it that early, oftentimes antibiotics will just treat it.

Dr. Mike Patrick: Because you don't want to try to drain something when there's nothing to drain. I mean, that just puts a lot of folks through a lot of discomfort and it's not necessary. So, when you do have questions about it, an ultrasound might be helpful.

Dr. Peter Minneci: Oh, absolutely.

Dr. Mike Patrick: And then once you make a diagnosis of Pilonidal cyst or Pilonidal disease, how do you go about treating that?

Dr. Peter Minneci: So most of the time again, patients are going to come and present with an acute infection. And so, you need to deal with that first. So, depending on what it looks like. If there's no obvious fluid collection, you would start antibiotics for sure. And then if there's a fluid collection consistent with an abscess, then you would most likely end up with a drainage procedure and that can be done in a variety of settings. So, some patients will actually present to our clinics, they've been referred to from their primary care doc, who's taken a look at them, diagnosed it and sent it to us. So, sometimes if it's small enough, you can do it in a clinic or an urgent care with some local anesthetic. Oftentimes, they are large enough and painful enough that will take a quick trip to either sedation or the operating room for either a heavy sedation or a quick journal anesthetic to allow for adequate drainage.


Dr. Mike Patrick: Particularly sensitive area anyway, so not necessarily the most enjoyable experience of getting one of those drained. Especially, if it's very large and then you may be talking about putting packing in it, something that if it's large enough?

Dr. Peter Minneci: Yeah. So, depends on where it's drained and who drains it. You always want to open it and get the pus out and then the question is, what to do it afterwards? So, if you get it drained in adults you oftentimes will get packing. Whether they will take a piece of gauze and moisten it and slide it into the opened area and have that, have you changed that or have someone help you change that two or three times a day until it heals from the inside out.

Dr. Mike Patrick: Otherwise, the opening or the incision might close up and you just get a re-accumulation of the pus. So, that kind of helps up keep the hole open, so to speak. So, stuff get drained until it begins to heal.

Dr. Peter Minneci: Right. So, the idea behind the packing is exactly as you've said it. The cavity opened to allow the infection to drain out. And then as the body cleans itself up, it's time to heal itself from the bottom up. With the packing only going in as far as it easily goes in. The problem with packing is it's extraordinarily painful. And so, at least at pediatric session we have a few other things that we've tried and most of the time, if you were treated here, we will put in a temporary drain. Which is basically usually a suture with a dissolvable suturer. So that essentially the drain will stay in for three or four days and then the stitch dissolves and the drain will slide out. And then what we'll have you do is basically sit in the bathtub. And so, the drain is tending the wound open and you sitting in the tub two or three times a day for those three days basically washes around the drain passively, cleaning it out effectively simulating what packing would do and obviously, it's much less painful. Now, it will work 98% of the time.

Dr. Mike Patrick: Yeah and hopefully, the adult world is paying attention to that because it's not like adults want to be uncomfortable. So hopefully, that practice will start becoming popular in the adult world as well.


Dr. Peter Minneci: We would hope. I've talked to many adults about this, and they're all fascinated about it but I have not seen a major change practice.

Dr. Mike Patrick: It's going to take patients demanding, “Hey try something different.” And then recurrent, so once this is healed up, the risk factors are still there. And so, this can become a recurrent problem, correct?

Dr. Peter Minneci: Yeah. So, there's two forms on sort of, recurrent disease and chronic disease. They are related but they are slightly different. Oftentimes, patient will present they'll have initial episode. They'll be treated, and they'll get the abscess drained and then it will seal. And then, we would recommend preventative measures to try and prevent a recurrence. And recurrence waits range from anywhere from depending on the study you read anywhere from 15% to 50%.

Dr. Mike Patrick: Yeah, so pretty high.

Dr. Peter Minneci: Yeah. And so, the only changeable things that you can do is keep the area clean and dry, and try and remove the hair as best you can. So, what the recommendations are if you can, to either shave the area or to use depilatory creams like a Nair, or if you have the resources for potentially laser hair removal to the area to try and decrease the amount of hair that gets into the gluteal cleft, which will then hopefully decrease your risk of recurrence. And then from a hygiene standpoint, if you're a teenager who sits a lot, try to have breaks from when you're sitting. If you're an athlete, or you're just exercising regularly, try not to stay sweaty afterwards. Try and get the areas cleaned and dry as possible. And one of the things I'll tell patients I see on the office who are on sports teams, is even if you don't have time to shower, just run into the locker room and try to change into a dry pair of underwear, because then the area will be dry.

Dr. Mike Patrick: Yeah, it can make a big difference. And in terms of preventing recurrence, these are really the same ideas for preventing it from happening the first time too, if you are from the group that has risk factors.


Dr. Peter Minneci: Yes. The biggest issue about having it happening the first time is most people don't know that they have ready developed Pilonidal sinus. And so, it would really require someone looking in the area which, if parents are paying attention to it and are willing to look, then it's not a bad thing to do. But it's a hard thing as a teenager, especially the boys.

Dr. Mike Patrick: Yeah and especially with the sensitivity of sexual stuff. You know, you don't want people looking in that area but it needs to be with a trusted adult and especially if you're having symptoms, to get that trusted adult to take a peek for you or a medical provider. You know, make an appointment and go and see your doctor.

Dr. Peter Minneci: One of the biggest things about this disease is for the patient who do develop chronic disease and recurrent disease, it is emotionally hard. Because it's not something people want to talk about and it is a sensitive area. And when you have a chronic wound, you can smell. And it's not good for high school or college or any of those things. So it does carry an emotional piece to it that if we can figure out ways to decrease the recurrences, it's going to help a lot of kids.

Dr. Mike Patrick: Yeah, and part of that is raising awareness about the problem and what the symptoms are to look for. In terms of the surgical management of this, it's one thing to open the wound and drain it. Is there come a time when the sinus itself needs to be cut out?

Dr. Peter Minneci: Yes, so the thought process on that has changed slowly overtime. One of the biggest things is that, surgical options that we have none are great. When I offer patients surgery, I'd like to be able to say I have a 90 something percent chance of occur and with Pilonidal disease I don't necessarily have that. So, the initial treatment usually always get the infection under control. And then if you are someone who dissolves recurrent disease, which could either be recurrent infections or draining sinuses. So, once you've had an infection, the area never actually heals all the way back up and it does not infected anymore but it's constantly draining fluid, which is typically a little bit smelly and potentially cloudy in nature. So, it's staining your clothes, it becomes more of a nuisance.


So, for those patients, there are several surgical options. One is to do nothing and try and just keep the hair out of the area and give it time and see if it will heal. If you have recurrent infections, then the risk of surgery starts to make sense. So, the biggest problem with surgery is, most surgery if you're going to try to cure the disease, you have to basically excise or cut out the entire area. So, that surgery is a relatively large surgery and it has a long recovery period. Typically, about a month to six weeks, and the wounds is typically closed in some way and the problem is that the wound issues because it is an area that is under a lot of tension, there's not a lot of extra skin in that area. It has a high chance of breaking down. And so, the wound complication rate approaches 20-30%. So we oftentimes don't think about surgery, until we get to at least the second infection because about a third of patients will have a second recurrence since then at that point to those patients that start to make sense at the risk of surgery will makes sense.

Dr. Mike Patrick: Yeah. So, it's really better to be on top of this and identify it as early as possible, get the infection under control, try to prevent it rather than to let it get to the point where you have the sinus tracks and you might need something that's much more extensive like this.

Dr. Peter Minneci: Yeah. Our goal is to try and improve hygiene care and decrease recurrence. And that's the angle I think we've taken within our center to try and minimize the burden of this disease. And then there are some people now who are working on less morbid, smaller procedures which can get the recurrence rate down because the recurrence with it at large excision is high.

Dr. Mike Patrick: Yeah. In addition to recurrence as sort of a complication of this, I'd come across some information about an increase risk of squamous cell carcinoma, which is a type of skin cancer. Is that a real risk with recurrent chronic disease?

Dr. Peter Minneci: It's small for the most part. For most patients who have it, they don't usually have enough infections but so squamous cell carcinoma is going to be a risk factor for any chronically draining sinus. And so, if you are someone who has chronically draining sinus, you will need to kind of pat the area and check. But then, in those cases you are usually going to be followed by a physician and usually a surgeon, who's going to be taking a look at the area. The bright side I guess of this disease is that, it oftentimes burns out. So, by the time you become a late twenty-year old, it will oftentimes go away.


Dr. Mike Patrick: Yeah. And is it just because those risk factors decrease to some degree? I mean you're not quite as oily as when you were a teenager, the hair kind of softens a little bit.

Dr. Peter Minneci: Exactly. The hair softens, you're not making new hair follicles. So the burden of hair is no longer growing and then the amount of oil production and secretion is no longer up-rises, it's coming down.

Dr. Mike Patrick: There are other structures in the area such as bone and bowel, do they ever become a complicating factors in these infections?

Dr. Peter Minneci: So, you'll almost never get deep enough infections that it's almost always contained to the skin and the subcutaneous tissues because the bone is built in a fashion and the bowels deeper. You can have issues with the anus itself, if you undergo resection and the resection is taking too close to the anus because it's the most inferior aspect of your gluteal cleft is going to be your anus. And so, if the surgeon ends up taking more skin to try and remove infected tissue, and it ends up approaching on the anus, you can then start to have some issues. It's pretty rare but it's something we keep in mind.

Dr. Mike Patrick: Yeah. Here at Nationwide Children's, if someone has Pilonidal disease, or if they need to see a surgery or it's a chronic issue, what surgical management of this? How do they get sort of plugged in, which clinic should they go to?

Dr. Peter Minneci: So most of the times, we start at the pediatric surgery clinic. And so, if they've seen an ER or urgent or primary care's office or referral to pediatric surgeries is typically the best place to start. And then once they're assessed depending on their disease and what their bottom looks like, whether they should have surgery? Those discussions will be have and what the risk and benefits are. Most of the treatments that we're going to offer here are either going to be drainage for an acute infection, excision with either a primary closure, we try to close the skin. There are some surgeons who will do with leaving an open wound and putting a vac on. So it's a vacuum assisted essentially it's a sponge that gets hooked up to a vacuum that sucks fluid out. And so, you have an open wound that slowly closes overtime. So that typically will 6-10 weeks to close, and it requires a vac change or dressing change 2-3 times a week.


It comes a lot of social issues that I think people aren't aware of and need to be made aware of when they start to make those decisions. And then for patients who truly have recurrent disease, and if they have a primary excision or if they want to go for something that's a little bit more aggressive, you can oftentimes refer them to plastic surgeons to do a surgical resection with a flap closure. So, rather than closing in the mid-line, and sort of creating the gluteal cleft which anatomically will look normal, purposely shifting the suture line off to one side or the other. It does have a low recurrence rate but it does anatomically alter what the bottom looks like and that there is no mid-line anymore.

Dr. Mike Patrick: Yeah and folks probably won't necessarily like that depending on who you are.

Dr. Peter Minneci: Yes. So, we try to avoid that again.

Dr. Mike Patrick: Yeah. But the pediatric surgery clinic would be a great place to start and I'll put a link to the pediatric surgery here at Nationwide Children's in the show notes for this episode 416 over at pediacast.org. Depending on your insurance, you might need your primary care doctor to refer you or in other cases, folks would maybe able to just make an appointment on their own depending.

Dr. Peter Minneci: Yeah.

Dr. Mike Patrick: That's great. And then at the beginning of our time together, we've talked about the Center for Surgical Outcomes Research here at Nationwide Children's. What exactly is that?

Dr. Peter Minneci: So that is a research center within our hospital and it was started by myself and Dr. Deans when we came here about 8 years ago. It's a joint effort between the department of surgery and the research institute here at the hospital. And our mission is to improve the quality of care of surgical patients and specifically trying to decrease pain and suffering, which relates to all types of things that we do. And so, that center has a couple of major missions and one is that we help all surgeons complete clinical projects. They have a clinical research question, we help them to develop a project that maybe answered. And then it houses our own personal research programs. And so, Dr. Deans and I are very passionate about trying to make the lives of patients with Pilonidal disease better. Very frustrated from treating this disease for over the years.


And so, we've built a research program around it, really characterized, a little bit the epidemiology a little bit better. What the treatment of this hospital, what the outcomes are, and we are now in the process of trying to do a prospective trial of laser hair removal. So one of the issues with laser hair removal, although it's recommended by multiple society guidelines, including the American College of Colorectal Surgeons, it's laser hair removal. Which is, permanent hair removal is not covered by most insurances. And the major reason for that is there's never really been a well-designed study that shows it works. And so, we've designed that study, and we're in the process of doing that and are actively recruiting patients, basically any patient who has a Pilonidal disease between the age of 12 and 21 years is welcome to join our study.

Dr. Mike Patrick: Yeah. It's one of those things where the insurance companies don't necessarily want to pay for something until you can show that it's actually going to save the money by not having to treat all of this recurrent Pilonidal disease.

Dr. Peter Minneci: Yeah. The biggest issue I think is laser hair removal will cost someone around a thousand dollars. So, it would cost insurance companies probably about the same. The biggest issue is that if you do shaving or depilatory creams, they would probably work as well. But it's compliance. I mean if you're a 16-year old or an 18-year old, now you're 21. Maybe you had let your parents do it by the time you go to college, they're not there anymore. So your ability to maintain the hair removal is very difficult. Whereas, if you undergo laser hair removal, it's near permanent hair removal. And if it does grow back, it grows back very slowly and very small amounts. So, it allows you for the hygiene benefit with just a very limited amount of time.


Dr. Mike Patrick: Yeah. That totally makes sense. And another example with the sort of things that you do would be the idea behind using a drain, instead of using the packing. And again, because you're not looking at it necessarily which one works better, but which one improves the lives of the patients who were suffering with this disease.

Dr. Peter Minneci: Yeah. That is one of the things and one of the first projects we did when we first got here, is we were doing these types of drains for all kinds of abscesses versus packing that other people were doing. And we did a quality improvement initiative when we came here and now most of our partners would treat most of our abscess with these types of drains that will fall out on their own. Which cause much more comfortable, less pain and it actually cause less scarring.

Dr. Mike Patrick: That's great work. We really appreciate you stopping by, we will have some links for you in the show notes over at episode 416 at pediacast.org. We'll have a link to Center for Surgical Outcomes Research at Nationwide Children's, if you'd like to learn more about their work. Also, pediatric surgery here at the hospital. And then, we'll also having a link to what we would call, Helping Hand on Pilonidal Disease. It's just a written document that talks about this and easy to share links. So if you know friends or family who are suffering from this, just some more information about Pilonidal disease for them. Of course, share the podcast with them. But if you would rather share a link with the written document, we have that as well. So, Dr. Peter Minneci, Pediatric Surgeon here at Nationwide Children's Hospital, once again, thanks so much for stopping by.

Dr. Peter Minneci: Thanks for having me.



Dr. Mike Patrick: Polyethylene Glycol, also known as PEG 3350, which is commonly sold as MiraLax, is an over-the-counter stool softener frequently given to children to treat constipation. However, some parents have raised concern about the active ingredient, Polyethylene Glycol, and there have been primary reports about behavioral changes in their children after taking the medication. In response to these concerns and claims, the US Food and Drug Administration requested research in to whether PEG 3350 contributes to neuropsychiatric events on children. On concern about PEG 3350, is that it might contain trace amounts of potentially neurotoxic compounds, such as Ethylene Glycol, Diethylene Glycol, and Triethylene Glycol.

So, I want to pause here to make an important point. Just because Ethylene Glycol, Diethylene Glycol, and Triethylene Glycol, just because those are known to have toxic effects in the body, and in particular on the nervous system, it does not mean that Polyethylene Glycol is dangerous automatically just because of the name. So, they sound alike but remember that each of these compounds has a unique chemical structure and different chemicals with different structures have different effects on the body. This is why mercury in vaccines wasn't really a problem. The mercury that was used in multi dose vials in vaccines back a few years ago, was there as a preservative in the form of Thimerosal, which is an Ethylmercury. The dangerous form of mercury is actually which is actually, Methylmercury, which even though sounds like Ethylmercury, it's not the same thing. One is dangerous, the other is not. And because they have different chemical properties, they look different and behave differently.


And because parent didn't really understand the difference, there was a huge outcry. You know, there's mercury in vaccines! And parent were declining vaccines because of this, so many manufacturers took it out. Not because Thimerosal is dangerous but because parents feared it, and they weren't getting their children immunized. The result was a preservative-free single dose packaging, which creates more ways and has a shorter shelf life. But that's a small price to pay for calming the fears that arise when folks don't really understand the science. Sort of the same thing here, Polyethylene Glycol is not the same as Ethylene Glycol, Diethylene Glycol, or Triethylene Glycol. If it were, we would certainly not be giving it to children. But parents fear these names, spreads concerns like wildfire in social media and now we need another study to prove that MiraLax does not increase exposure to dangerous chemicals.

Again, small price to pay to calm the fear that arises when folks don't quite understand the science. So as it turns out, researchers here at Nationwide Children's Hospital heeded this call to action from the US Food and Drug Administration and embarked on a new study, which is recently published in the Journal of Pediatrics to evaluate levels of the dangerous chemicals in the blood of children taking PEG 3350 again, also known as MiraLax. As well as the levels in the blood of untreated children. So, children who were not taking MiraLax for constipation. So what did they find?

Well, investigators say that there were very low levels of these three dangerous chemicals in both treated and untreated children. These low baseline levels of Ethylene Glycol, Triethylene Glycol, those two did not differ between the two groups between treated with MiraLax and untreated. While Diethylene Glycol levels were actually lower in children receiving therapy with MiraLax or PEG 3350 compared with the untreated controls. The fact that all three compounds were found in the blood of all the children, whether they were taking MiraLax or not, indicates that all children are exposed to these compounds routinely.


Dr. Kent Williams, lead author of the study and the Gastroneurologist at Nationwide Children's says even the adults working in the lab had detectable levels of all three chemicals in their blood. So, where does this exposure come from? I mean if it's in the blood of both treated and untreated, it's unlikely to be coming from MiraLax. Otherwise, you would think that the treated group would have more of those chemicals in their bloods. Well, it turns out the FDA has approved certain polymers to be used as food additives, as well as ingredients in commercial products such as lotions, creams and make up. So, there is some exposure of these. The more dangerous compound compared to the Polyethylene Glycol, which is in MiraLax, just that we get from our environment. Most importantly, researchers found that chronic use of PEG 3350, so long-term use of MiraLax does not result in sustained elevation of the dangerous compounds in the blood.

Yes, they're there. They're in everybody. But those taking MiraLax did not have more of them. In fact, the greatest levels of Ethylene Glycol and Diethylene Glycol measured after MiraLax treatment would lower than with the greatest levels of these compounds measured in untreated control samples. We don't really know why that is, we don't know why it would be lower in kids that get MiraLax. It doesn't mean that we should give MiraLax to everybody to lower those levels. But also keep in mind the way that MiraLax works, it doesn't get absorbed into the body very well. In fact, it acts as undigested molecules that get down into the large intestine and then that draws the water into the large intestine through osmosis, and that's how MiraLax works.


So, this medicine for the most part, is not getting into the bloodstream to begin with. They just go straight through and kind of pulls water with it in order to act as a stool softener. Dr. Williams says, in fact one control child's level of ethylene glycol is almost 2x higher than the highest concentration of ethylene glycol found in children treated with MiraLax 3350. It's obviously that one controlled child was being exposed in some other way. Investigators conclude that potential toxic side effects of PEG 3350 or MiraLax which contains very small trace amounts of ethylene glycol and other compounds. Potential side effects from MiraLax are extremely unlikely, and the reports of behavioral issues are probably not due to taking the stool softener but rather, behavioral changes that tend to occur in association with constipation in general. Behavioral problems are common in children with constipation and include, because you don't feel well.

And it include aggression, depression, anxiety and increased emotional reactivity. Dr. Williams says what I tell parents is that, potential side effects of MiraLax are very unlikely but the complications of uncontrolled constipation can be quite severe. Although infant walkers provide no benefit to children, and pose significant injury risk, many parents are still using them in US homes. It's according to a new study from researchers in the Center for Injury Research and Policy at Nationwide Children's Hospital, which examines characteristics of infant walker-related injuries and evaluated the effect of the 2010 Federal Mandatory Safety Standard on these injuries. The study published in the Journal of Pediatrics found at more than 230,000 children younger than 15 months were treated in hospital emergency departments in the United States for infant walker-related injuries from 1990-2014.


The number of infant walker-related injuries decreased dramatically during the study period, dropping from 20,650 in 1990 to 2,001 in 2014. The overall reduction in injuries was primarily due to a decline in infants falling down the stairs in these walkers. The decrease in the stair falls was due to impart due to implementation of safety standards that required changes in the way infant walkers are designed. In 1997, a voluntary safety standard was adopted. They required infant walkers to be wider than a standard doorway, or to have a mechanism that would cause it to stop if one of more of the wheels dropped over the edge of the step.

Then in June 2010, the Consumer Product Safety Commission issued a mandatory safety standard that included more stringent requirements for infant walker design, a standardized method to prevent stair falls and the addition of a parking brake. So, parents could make it stationary whenever they wanted. These mandatory safety standards made it easier for the commission to stop non-complying infant walkers that entry points to the US before they entered the marketplace. And by the way, this was important because all 10 infant walkers that were recalled between 2001 and 2010, so they were found to be unsafe and recalled. All of them were imported products. So by making these safety standards mandatory, they could check walkers as they came into the country, and they refuse entry if they didn't meet these safety standards. The greatest decrease in injuries occurred during the early years of the study. However, there was an additional 23% drop in injuries in the 4 years after the federal mandatory safety standard went into effect in 2010, compared to the 4 years prior to the mandate.


Researchers conclude that this reduction can be attributable to the new standard, as well as other factors such as decreased infant walker use. So, our message was getting out there that they're not safe, please stop using them. It was an important message for pediatricians and continues to be an important message for pediatricians to give to parents. And also, fewer older infant walkers that didn't meet the safety standards. The older versions and models, fewer of those in homes. Dr. Gary Smith, Senior Author of the study and Director of the Center for Injury Research and Policy at Nationwide Children's says, the good news is that the number of infant walker-related injuries has continued to decrease substantially during the past 25 years. However, it is important for families to understand that these products are still causing serious injuries to young children. You know, the tune of just over 2,000 injuries a year. And they should not be used. Now most of the injuries, 91% were on the head or neck. And those can be very serious injuries. And about 30% of the injuries were concussions or closed head injuries or skull fractures. So a third of the injuries are very severe.

The three leading causes of injuries were again, falls downstairs, falls out of the infant walker and injuries that occurred because the infant walker gave the child access to something they wouldn't normally be able to reach. And of course, this was mostly burns from hot objects. Dr. Smith says, infant walkers give quick mobility up to 4 feet per second to young children before they are developmentally ready for such speed. Despite the decrease in injuries over the years, there are still too many serious injuries occurring related to this product. Because of this, we support the American Academy of Pediatrics call for a ban on the manufacturer sale and importation of infant walkers in the United States. At the very least parents, just stop using these please! The most recent numbers again show just over 2000 infant walker-related injuries each year in the United States. It's third of them very serious. Now, it is down from a 20,000 injuries in 1990. But 2000 is still too many. Especially, when you consider this tend to be serious injuries, and they're totally preventable by not owning, using or gifting an infant walker. So please, moms and dads, just stop using them.


So, what about alternatives? Well, I love the idea of an infant walking with you, the parent. You know, those the harnesses that you see whether it's on your back or on your front, of course you want to be very careful still going up and downstairs. We see a lot of parents slip and fall with the kid in one of those carriers, that can be very dangerous too. But carry your kids around, and it's always fun too because then you can talk to them and talk about what you're seeing, what you're doing. The more you talk to your kids, the more likely it is that they're going to start getting a hang of language. So, that's important. You know, there's always the stationary ones that don't move around. Kind of look like an infant walker, but they stay in one place and have some fun things to do.

You know, short periods of time and those are okay. Short period of time in an infant swing, not safe to let your child sleep unattended. You're not there, and there's sleeping in an infant swing. That's not safe. You know, safe sleep especially when kids are not being constantly watched is going to be in a crib, on their back and alone. The ABCs alone, on their back in their crib. In their backwards, but you know what I'm talking about. The CBAs, the ABCs of safe sleep, not in infant swings. But I digress. So, lots of other ways that you can have your kids be sort of entertained while you're getting things done. But be there with them, that's the important thing. And again, the other important thing is just stop using those infant walkers.

Cellphone use while driving has been estimated to increase crash risk by 2 to 9 times depending on the study. And texting while driving, may it be especially risky because it involves three types of driver distraction. Visual, you know your eyes are off the road; manual, you know at least one hand is off the wheel; and cognitive, attention is being diverted away from driving. A new study led by the Center for Injury Research and Policy at Nationwide Children's Hospital examined individual and state-level factors associated with texting while driving among teenagers.


The study done in conjunction with researchers from the Center for Disease Control and Prevention or CDC and the Ohio State University, looked at the risk youth behaviors survey data from 35 states. The study published in the journal of adolescent health found in nearly 2 in 5 teen drivers, ages 14 years and older, had texted while driving at least once in the month prior to the survey despite the fact that 34 of the 35 states in the study banned text messaging for drivers 21 years and younger.

Texting while driving prevalence varied by state, from 26% in Maryland to 64% in South Dakota. More teens texted while driving in states that had a lower minimum learners permit age, and in states where a larger percentage of students drove. White teens were more likely to text while driving than students of all other races and ethnicities. And texting while driving prevalence doubled between ages 15 and 16 years, and it continued to increase substantially for ages 17 years and up. Dr. Motao Zhu, the study's lead author and principal investigator in the Center for Injury Research and Policy at Nationwide Children's says, the increase in texting while driving at the age when teens can legally begin unsupervised driving was not surprising. Graduated driver at licensing laws could have an impact on texting while driving behaviors since the earlier the teens start driving, the earlier they start texting while driving.


The five states where more than 50% of teens drivers reported texting while driving allowed a learner's permit at 15 years of age or younger. Teens who engage in other risky driving behaviors are also more likely to text while driving. Teen drivers who did not regularly wear seat belts were 21% more likely to text while driving compared to frequent seat belt users. And teens who were reported drinking and driving were almost twice as likely to text while driving compared to those who did not. Dr. Ruth Schultz, a former epidemiologist with the CDC's division of unintentional injury prevention says, risky driving behavior is known to be much less common when there is an adult in the car. And the association between age and texting while driving highlights the need for parents to pay attention to their child's driving, pay attention to their child's texting while they're driving throughout their teen years, not just when their children or learning to drive. The data from the study is likely an underestimate of teen drivers cellphone use.

The survey question asked specifically about texting and emailing while driving and therefore, does not measure the full range of ways that teens use their cellphones behind the wheel, including answering or placing a phone call, accessing social media that may not have been considered texting. Playing music and using other apps, it's also possible the students who took the survey considered reading a text or email to be different from writing or sending a message. And some may not have considered texting while their vehicle is stopped at a light as texting while driving. These possibilities could lead to underreporting of the behavior. Parents can help limit their teens texting while driving by doing the following: Number one, be a good role model. Teens are more likely to use their cellphones while driving if they see their parents doing it, if having your cellphone on and within reach while driving is tempting, put it on silent so you won't hear notifications. Try putting it in the trunk or backseat compartment or locking it in the glove box, you can't reach it while driving. If you cannot or do not want to put your cellphone away completely, ask a passenger to make an answered calls, reading your replied texts or look at the calendar as you make plans.


Be patient if you know your teen is driving, wait until he arrives before you text or call. Teens report that they are more likely to respond to a call or text while driving if it's from a parent, a close friend or a boyfriend or girlfriend. Set clear rules about prohibiting all cellphone use while driving, make sure to communicate those rules clearly and enforce them and model them yourself. Continue to monitor new drivers, keep riding with your teen after he gets his license, compliment your teen safe driving behaviors and remind him of the rules when he makes poor decisions. Also, take advantage of built-in features. Many phones have a driving mode.

You can turn on the disable texting, calling or other functions while in motion. Consider having your teen use this mode or installing an app, some of which will send immediate notifications to parents with a similar purpose. So bottom line here is I think we all have the idea that texting while driving is dangerous. We can understand that that's true. And our teens our doing it, and many of us are doing it. And it's just time to stop. So, please put your phones away, just drive. When you drive, concentrate on driving and communicate when you're done driving and help our kids to do the same.

As kids head back to school this year, many of them will be struggling. According to National Statistics, we lose more than 2,00 children and teens per year to suicide. Experts say, parents who check in regularly with their child could have a life-saving conversation. Dr. John Ackerman, Clinical Psychologist in Suicide Prevention Coordinator for the Center for Suicide Prevention and Research at Nationwide Children's Hospital, says that the conversation about depression or suicide is going to be difficult. But you can have it without putting a young person at risk. And it can be very helpful, having this discussion can be incredibly relieving for young people. It is a powerful opportunity to understand that being emotionally open, especially about thoughts to suicide can lead to healing and connection, rather than shame and isolation.


According to suicide prevention experts, asking your child directly about suicidal thoughts is usually the best thing a parent can do to help your child open up about their emotions. Even if your child is not struggling with suicide or depression, parents can model for their child that it is good to talk about serious emotional concerns with trusted adults and important to reach out to friends to have these conversations as well. Dr. Ackerman says, if your child's friend tells them that they're feeling suicidal, your child should tell their friend that they care about them and acknowledge that they are hurting. After their friend knows they're being listened to and supported, the next step is to ask specifically if they're thinking about suicide or have tried to kill themselves. This should be done of course, in a compassionate way and free of judgment.

If they say yes or even I'm not sure, a trusted adult should be told right away and never leave someone alone if they're showing warning signs of suicide. Dr. Ackerman adds, this is a conversation that saves lives. His goal is to identify kids before they have a crisis, or go years without treatment. Statistics from the National Institute of Mental Health indicate that half of all mental health issues start by age 14. And he also has some tips for parents, families and teachers. First, do not wait for a crisis. A good opportunity to talk about suicide or mental health issues is when things are going well. Check in regularly and ask your child directly how they're doing. And if they ever have thoughts about ending their life, look for changes in mood or behavior that might be a warning sign that something is wrong. For example, if your child seems really down. Here she stops doing things they normally enjoy or you notice significant change in their eating or their sleeping.


Dr. Ackerman says, it is not hopeless and there are lots of ways that love ones can help youth get support when they need it. This involves timely treatment, building connections, helping other people know what to say when a family member or a friend is struggling and having a safety plan in place to help get through a crisis. If you or someone you know is thinking about suicide, contact the National Suicide Prevention Lifeline at 1-800-273-TALK, that's 1-800-273-8255 or contact the crisis text line by texting 'START' to 741-741. And I'll put this important resources in the show notes for episode 416 over pediacast.org.


We are back with just enough time to say thanks once again to all of you, for taking time out of your day and making PediaCast a part of it. I really do appreciate that. Also, thanks to our guest this week, Dr. Peter Minneci, Pediatric Surgeon here at Nationwide Children's. Really do appreciate him taking time and sharing his expertise with us on Pilonidal disease. Don't forget you can find PediaCast in all sorts of places. We are on Apple Podcast App, also on iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps. And then there's the landing site, pediacast.org where you'll find our entire archive of past programs there. Also, show notes for each episode, written transcripts of the episodes, our terms of use agreement and the contact page, so you can suggest topics or ask questions of your own.


We're also a part of the Parents On Demand Network, or the POD network at parentsondemand.com. It's a collection of podcasts for moms and dads. The collection includes PediaCast along with many other terrific podcast for parents, including if you have twins at home, or you're expecting twins. Or you know someone who's expecting twins. Be sure to check out the Double Happiness Multiplied Podcast. This is your complete guide to enjoying a multiple pregnancy and building a happy healthy family life. Each episode features opinion from multiple birth experts and parents who share their experience of having twins, triplets and quadruplets.

Some recent topics: seven common complications of a multiple pregnancy, how to prepare for the birth of your twins, what to expect if your twins are born prematurely, spending time with a NICU with other kids at home and how to keep your relationship on track while having multiples. So, great stuff especially if you have twins or more on the way, or in a NICU or at home or if you know someone in one of those situations. So again, Double Happiness Multiplied Podcast. I'll put a link to it in the show notes for this episode 416 over at pediacast.org

Don't forget reviews are always helpful wherever it is that you listen. If they have a review mechanism for podcasts, please consider just taking a few minutes out of your day and putting in a review for PediaCast and the other podcast that you listen to as well. Folks really rely on those interviews when they're deciding on what programs they want to spend time with as they listen to podcast. So, those reviews are definitely helpful. And then one last plug for social media, please do like us and follow us on Facebook and Twitter. We keep you up to date on what we're talking about in the current shows, as well as some past programs we think you might be interested in. We also try to share other pediatric and parenting content that we think would be helpful. And then Instagram.


Look for PediaCast on Instagram. Really more personal look into the studio, look into my family life and what we're doing, what's going on. And really enjoy connecting with the listeners there and finding out what's going on in your families as well. And then of course, be sure to tell your friends and family, neighbors, coworkers, babysitters, anyone who has kids or takes care of kids about PediaCast. Those personal recommendations are so important. And that does include your child's pediatric healthcare provider.

Please do let them know about this program, so they can share the resource with other families. And while you have their ear, let them know we also have a program for them. PediaCast CME. Similar to this program, we do turn up the science a couple notches and offer free category one continuing medical education credit for those who listen. Shows and details are available at the landing site for that program, which is pediacastcme.org. That show is also in Apple Podcast, iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps. Simply search for PediaCast CME. Thanks again for stopping by. And until next time, this is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long everybody!


Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

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