Poison Ivy, Tick Bites, Sunburn – PediaCast 322

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Show Notes

DESCRIPTION
Join Dr Mike in the PediaCast Studio for three important summertime topics: poison ivy, tick bites and sunburns. We dive into the science of each and cover treatment options and prevention strategies. Also covered: quality family time, adult learning theory and active play in daycare. Be sure to tune in!

TOPICS
Quality Family Time
Adult Learning Theory
Poison Ivy
Poison Oak
Poison Sumac
Tick Bites
Rocky Mountain Spotted Fever
Lyme Disease
Sunburn
Sunscreen
Active Play in Daycare

LINKS
Rocky Mountain Spotted Fever (CDC)
Lyme Disease (CDC)
Insect Repellents / DEET (AAP)
Sun Safety Guidelines (AAP)
Active Play Opportunities at Child Care

Transcription

Announcer 1: This is PediaCast. 

[Music]

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 to PediaCast. It's 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 322 for June 24th, 2015. We're calling this one Poison Ivy, Tick Bites and Sunburn. 

I want to welcome everyone to the show. 

So we're going to go a little off our usual course today. Those of you who are regular listeners of the show, you know what our usual course is. We either cover news parents can use, or we answer listener questions, or we interview pediatric experts like we did last week. Today, though, I wanted to provide something useful for summer, since we are definitely in the thick of it now, with the Fourth of July just around the corner. 

So I wanted a useful summer show, and I got to thinking, what am I seeing this time of the year when I'm seeing patients? What problems are the kids having? What are families asking about? The ones I see face to face, because even though you aren't asking those questions… The ones that you guys have been writing in, it has of late have been on the more esoteric side — things like erythema multiforme and electromagnetic waves come to mind — which is fine, don't get me wrong about that. I love answering those questions, but there are also the common everyday questions. 
And even though you aren't specifically asking, they are questions I'm sure many of you are thinking about. It's what I like the call the bread and butter of pediatric questions, the ones we know we're going to encounter often, sometimes daily, and they change depending on the time of the year. 

0:02:06 

So what are those questions in the summer? Well, I can come up with a pretty big list and really fill up several shows, not just one. But I didn't want to overdo it either, so I came up with three things I've been seeing a lot and answering questions about as I take care of kids in real life this time of the year. 

So the first is poison ivy. That's hitting it pretty big right now. Now, you might not have poison ivy in the region where you live, but you probably have poison something. Maybe it's poison oak or poison sumac. Maybe what you call poison ivy is a different plant from the one I call poison ivy, but they all have something in common, and that's an oil called urushiol, which results in a pretty itchy rash for lots of people.

So poison ivy and its related plants, that's topic number one. We'll cover what they look like, where they're found, how they cause the rash they cause, what you can do for it, how to prevent it, all those kinds of things. 

And then, topic number two will be tick bites. Those always seem to be a concern for families. Sometimes, it's a legitimate concern. Other times it's not really a worry at all. So we'll talk about types of ticks, how to remove them, complications of tick bites, things to watch for. And we'll mention the diseases that ticks can transmit including Rocky Mountain spotted fever and Lyme disease. We're not going to cover those with tons of detail, but we will fill you in on regions where there are concern and associated symptoms. 

And then, an all time summer favorite — in terms of a topic, not so much when you have one — and that is sunburn. We'll cover that in quite a bit of detail. Because I really think the science of sunburns is fascinating. So we'll talk about what is taking place beneath the surface, and we'll cover treatment and prevention as well, which will give us the opportunity to talk about sunscreen. So stay tune for that. 

And then, at the end of the show, I have a final word. We haven't done one of those in awhile on active play in child care centers. How much physical activity are kids getting? Is it enough and if it's not, what can you do about it? 

0:04:10

Active play is important and we covered some of the reasons why in our last episode when the good folks from the Ohio Chapter of the American Academy of Pediatrics stopped by to tell us about their Good4Growth program. 

A couple of other items before we get started. Another concept that we talked about last week was spending quality time with your kids, because that's part of providing a caring, supportive, nurturing environment. I wanted to tell you a quick story of some quality time my wife and I recently spent with our kids. And I want to share it not because it's something I think you should do. But my point is that sometimes these things happen in ways you don't always expect — ways that may not seem nurturing or beneficial at the time, but when you reflect back, it's like wow. 

I also realized that what constitutes a wow for my family is probably not the same thing that constitute a wow in your family, I get that, which is why I'm not asking you to do this. Our family's a little strange, I have to tell you. So just keep that in mind and that will put things into perspective. And I'm sure your family's a little strange too in one way or another. 

So this is just an example. Back in 2003, my daughter would have been eight and my son was six, and the Ohio State Buckeyes… Following the Buckeyes has always been a pretty big thing in our house, and so when the Ohio State football team won the national championship back in… That was 2002 season, so this is early 2003 when this happened. 

So, you know, the whole family would dress in Buckeye gears and we follow the games, and the trophy — so that crystal football that was back in the BCS era — Ohio State got that, and they kind of took it on a road show, so people could come and get their picture taken with the crystal football. And it was at Circuit City, which doesn't even exist anymore. 

0:06:09

So we went there, and they have for sale… Because we're waiting in line. We're looking at the display ads, and they do a good marketing job with what you're passing as you're waiting to see the crystal football. Well, one of the movies that was set in there was s Jurassic Park, the original Jurassic Park movie. Now, again, my kids are eight and six. So I think my wife was thinking people get eaten by dinosaurs, probably not the best movie for your six-year-old son. But I persevered and we did end up watching Jurassic Park, when my kids were six and eight, which gives you an opportunity to nurture, right? I mean when the dinosaurs are chasing people and eating people, your six-year-old cuddles in a little closer, and you're able to nurture. 

But, actually, they enjoyed it. We watched it on multiple occasions as kids like to watch the same movies over and over. And so, we're interested in this. Jurassic Park 2 and 3 seemed like a good ideas but the plotline wasn't as good. It was very hard for them to live up to the original. 

My son, in particular and he's 18 now, but over the last several years… Every now and then, we watch Jurassic Park still. A couple of years ago, I think it came out on the big screen in IMAX 3D. The original movie did, and we went and saw it. But my son has really been watching the development of Jurassic World over the past several years, and he knew the ins and outs of the script rewrites. He thought it was coming out at one point, and then they mothballed it again. 

They had announced who they thought was going to be in it, but then they retracted that. And so, he's really been watching the development of Jurassic World over the course of the last several years and also watching who's going to be cast in it. So, it's something he's really interested in. That all stems back to our little trip to Circuit City to see the football championship trophy. 

0:08:08

Well, as you know, Chris Pratt is one of the stars of the show, and he was recently in the movie Guardians of the Galaxy, which my kids just love because 80s music is another big thing in our house. So Guardians of the Galaxy was a big hit, another one that we've watched several times. And so, the fact that Chris Pratt was also going to be in Jurassic World was really excited for my son. 

So needless to say, when Jurassic World was coming out, he was really excited about the show. He let me know when the release date, that we were going to the midnight showing. I needed to request a night off at work, which I did. So it was really going to be this family time together to watch Jurassic World, and we were excited about it. 

Now, I have to tell you, I did not have high hopes that this would be a very good movie. It's a tough original to beat. But my wife and I were excited because our kids were excited. Well, as it turns out, we loved it. It was just a fantastic movie. I really think it did live up to the original. 

And the whole way home, we're having that back-and-forth, what did you think of this? Wasn't that great? How about the way they did this or that? Wasn't it cool how they snuck in parts of the old movie into this one? And then we get home and the conversation continues really for a very long time. And we're revisiting those memories of heading out on a snowy day to see the trophy, buying that first Jurassic Park movie when they were so young. Watching it with them, even though they were very frightened by it. 

So my point here is, well, at first it was just some plain old family fun which is always good, but it was family fun that at many points along the way involves some serious screen time where there wasn't much communicating going on, where we're actually watching the movies. But how that screen time sparked interest in research — my son researching the scripts and the casting and keeping an eye on it. 

0:10:01

And creativity, they got these Jurassic Park Lego sets. My kids are 18 and 20, and they're down putting Legos together of Jurassic Park and interacting and playing together even as teenagers. And all along the way, there's lots of conversations going along. 

So as humans, we have this tendency, I think to sort of toggle between extremes. Screen time is no good. We need to limit it because we stare like zombies and we don't communicate with one another. Which, in many cases, is true, and you can't spend too much time watching TV and engage with your smart phone. But screen time can also be a catalyst for something bigger, something that's healthy and useful. 

So anyway, I just wanted to share because there's some perspective in there that doesn't play out well in research studies looking at screen time. And I wanted to share because there's something in your life that your family recently rallied around that brought back old memories that you shared together. In our case, both of those things, we really rallied around something fun and shared memories. 

If not, find something like that to rally around. Even if it's a bit odd, like watching dinosaurs eat people, because a caring, supportive, nurturing environment is not always cookies and flowers. What is it for you and your family? 

Important things to consider — I know the intro's running a little bit long this week — one more item of business, and it's another way we're going to change things up a little bit this week. I know, I know we are really little going off the beaten path here today. So I was sitting in grand rounds this morning. Every Thursday morning here at the hospital, we have grand rounds. Most pediatric institutions have this.

And today's speaker was Dr. John Mahan who appeared recently on our PediaCast CME, where we do Category 1 CME for provider. He did a talk on there on difficult learners. He is the director of our residency training program. His talk today was on adult learning theory which is important in medical education. And it's important here too because that's what really PediaCast is all about, is medical education for families and for parents. So adult learning theory is an important thing. 

0:12:10

There was this long list of learning concepts that he encouraged us to incorporate in our teaching. And he asked us just to incorporate four of them. So I'm going to actually incorporate four of these adult learning theory concepts into the podcast today. And who knows, if they turn out well, maybe we'll keep doing them. 

Number one is don't be boring. So hopefully, we're not going to be boring as we talk about poison ivy, tick bites and sun burn.

Also, change it up every ten minutes or so. So our attention span, I'm already 12 minutes into this program, and so your attention is probably wavering, and I need to leave the introduction and get on to our first topic. 

And the third thing was music can help with learning. And so, we've always done the musical interludes. I think we're going to also do little 30 seconds of music. I'm going to try to keep the topics to about ten minutes — although sunburn I can tell you is going to go over because talking about sunburn and sunscreen gets a little lengthy — but maybe halfway through, put a little musical interlude in just to help refocus after that ten-minute period. 

So I'm going to make an extra effort not to be boring. We have three main topics today. I'm going to try to keep them to ten minutes each — although sunburn will go over a little — and I'm going to add that 30 seconds of music between the topics, so we can regroup and refocus for the next educational offering. 

Now, you may be saying that' sonly three things. What's the fourth? Well, you have to help me out with that one. It turns out learning is best achieve with carbohydrates on board, and when you take a nap after the learning activity. So break out the Snickers bar or a handful of grapes if you're like my friend, Alex, and not a big chocolate fan and then, take a nap after the show is finished. That sounds wonderful. 

Apparently, LBJ, President Johnson back in the 60s changed into his pajamas in the White House and took a 30-minute nap every afternoon. Then, he got up and was productive until late in the evening. See, the interesting things you learn in grand rounds. So napping is important, too. 

0:14:04

All right, so we'll give it a go and I expect to hear feedback on what you think of the format. 

Real quick, it's easy to get in touch with me. Just head to the Contact link at PediaCast.org and leave a comment or suggest a topic, or ask a question. Also, I want to remind you, the information presented in PediaCast 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, be sure to 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. 

All right, let's take a quick break. We'll come back and talk about poison ivy right after this. 

[Music]

Dr. Mike Patrick: All right, we're going to talk about poison ivy, and I say poison ivy because I'm in Ohio, in the Midwest. And that is the summertime problem plant for many folks in this part of the country. If you live west of the Rockies, poison oak is more likely to be your problem. And if you live in the southeastern United States, you're probably more familiar with poison sumac. 

So our discussion will be relevant to many families in all parts of the United States. You'll just hear me refer to poison ivy more often throughout our conversation because that's the plant I'm personally trying to avoid when I'm and about and is the plant my patients are getting into when they come see me with that characteristic summertime itchy rash. 

So let's talk about the plants themselves first, and then we'll get to the rash. Poison ivy, poison oak and poison sumac are all toxodendron plants. Their species, Toxicodendron species in the family of plants is known as Anacardiaceae. One thing that all of these have in common, all of these Toxicodendron plants, is an oily organic compound inside their leaves called urushiol. And that's spelled U-R-U-S-H-I-O-L. 

Now, the plants and leaves look different from one another, when you compare poison ivy with poison oak and poison sumac, but they all have in common this oil inside their leaves. 

0:16:42

So what do they look like? Well, poison ivy, its scientific name is Toxicodendron radicans, and that's the one that's predominantly here in Ohio, in the Midwest. But also, every state east of the Rocky Mountains has some of these plants. So it's pretty widespread. And if you live in the states where it resides, be sure to look up images of it on the Web. Know what it looks like so you can avoid. And your kids should know what it looks like too so they can avoid it. 

It's a stout weedy vine with leaves of three. So the leaves are compounds leaves with three leaflets each, which is the reason for the old adage, Leaves of three, let them be. And it grows up trees and along fence lines, but really it can grow any place where you see tall grasses and weeds.

Poison oak, its scientific name is Toxicodendron acuminatum. Again, this one is predominantly west of the Rocky Mountains. It's more shrublike than poison ivy with leaves that resemble those of an oak tree, which is how it gets its common name. Like poison ivy, if you live in an area where poison oak also lives, you and the rest of the family should know what it looks like so that you can avoid it.

And then, we have poison sumac. Its scientific name is Toxicodendron vernix, and this is primarily seen in swampy areas of the southeastern United States, although it also grows in pockets of the East Coast and the Midwest. It's a little bit of a taller plant. It grows up to 30 feet high and its leaves have 7 to 13 leaflets each.

0:18:13

So it looks quite a bit different than a classic poison ivy and poison oak. Now, I say classic because just to make things more confusing, there's also a plant out West, Toxicodendron rydbergii, which is known locally as poison ivy. So we do have a type of poison ivy west of the Rockies, although it looks different than the eastern variety. 

And we also have a plant that grows on the East Coast, Toxicodendron pubescens. It's known locally as poison oak. So we do have a type of poison oak east of the Rockies although it looks different than the western variety. 

So here's the bottom-line, you want to know what versions of the poison plants in the Toxicodendron species live in your neck of the weeds.

[Laughter]

Dr. Mike Patrick: In your neck of the weeds… And you want to know what they look like. That was actually in the script. I actually know it woods, but it came out weeds, I think that's funny. 

You want to know what they look like, and if you're not sure, ask your friends and neighbors or go to your local botany club or your doctor. Google what plants look like. Just remember what they look like and avoid them. That's the important thing. 

Let's move on from the plant to the oil, because it's the oil that is the underlying problem, and it's an oil that all of these plants share, and again the name is urushiol. It's a yellowish oil inside the leaves, which means if you touch the outside of an intact leaf, it's not a problem. However, many leaves, in fact, most of the leaves are not really perfectly intact. They may be broken, maybe because you rub up against them. For other reasons, they could have insect bites on them and that allows the oil to sip on the surface where it can be touched by human hands. And the oil then acts as an allergen and revs up the immune system, which is ultimately responsible for the rash. 

0:20:01

Now, some interesting things about urushiol. Lots of people are allergic to it, but not everybody. In fact, you probably know someone who has said, Ah, I'm around poison ivy all the time, and I never get it. But those people can become sensitized at anytime, and then they will start having a problem with it. 

So in other words, your body may be fine with it for awhile, and then one day, your immune system decides it isn't fine with it anymore. The next thing you know, exposure leads to a rash, just like it does in everybody else. 

So you should never feel like you are immune to this reaction because it can start at any time at any age. So even if you've never had a reaction, you should still know what the poison plants in your area look like, where they grow and how to avoid them, because they could become a problem for you. 

Another interesting thing about urushiol, only primates appear to be allergic. So only you and your pet monkey need to worry about it. Dogs, cats, sheep, cattle, any other mammal other than primates don't seem to have a problem with it at all. However, they can get the oil on their fur, and if you come along and touch the dog or the cat or sheep or cattle or whatever, you can get a poison rash without ever coming into contact with the plant. 

You can also come into contact with the oil if you're exposed to unwashed clothing, gloves, garden tools. Even from last season, the oil remains potent in terms of its ability to cause an allergic reaction regardless of where it's located or how old it is. 

So you know, we often see this in the clinic where kids come in with the rashes. Sure, it looks like poison ivy, but they have no history of plant exposure, but animals, old clothes, gloves, tools, those are other potential sources of contact with the oil that you have to consider. 

OK, so let's talk about what happens when urushiol connects with humans and other primate skin. Well, within about 30 minutes — definitely no more than 60 minutes — it forms a permanent bond with the skin. And yeah, you heard me right. It's a permanent bond. 

0:22:11

This has several implications. First, once it's on the skin and bound tight, it doesn't spread. However, if you keep coming into contact with the oil in a form not bound to human skin like the plant itself, that you keep coming into contact with, or an animal or clothes or garden tools, then you can get the rash in new locations. 

Also, certain areas of the skin may be more sensitive and break out sooner than others, and areas with more exposure may break out sooner than areas of less exposure, which gives the impression that the rash is spreading even though it really isn't.

There is an exception to this, if you take a bath within 30 to 60 minutes of contact, before the oil has formed a permanent connection with your skin, then it is possible for the oil to float to the top of the water and spread all over your body. So if you know you've been exposed to a poison plant, don't take a bath immediately following the exposure. Sure, wash the area with plenty of soap and water, take a shower, that's fine, but not a bath, for obvious reasons. But again, once you're 30 to 60 minutes out from exposure, the oil bonds permanently and washing, even with soap and water, is unlikely to be helpful. 

All right, so we have the oil bound permanently to the skin. What's next? Well, either your immune system reacts or it doesn't. And just because it hasn't in the past doesn't mean it won't this time. Also, once you do start reacting, you probably always will with future exposure. 

The reaction itself is pretty classic and once you have it, you'll recognize future outbreaks on yourself and others. It usually starts out as itchy bumps. They develop into patches. You may have some vesicles which can pop and ooze. The ooze, by the way, does not contain the oil and won't spread the rash. The broken skin may lead to bacterial infection, so you want to watch out for that. Soft tissue swelling is also possible especially on the face and the genital region. 

0:24:09

And then, the skin dries up but the itch remains and bumps and vesicles can return and flare until eventually, after two to three weeks, the old skin with urushiol bound to it finally sloughs off, as all skin tends to do in its natural life cycle. A new skin without the oil bound to it takes its place. 

So the bottom-line here, once the oil is bound to the skin, 30 to 60 minutes following exposure, it's with you for two to three weeks no matter what you do. And if you're going to react, that's how long you can expect the rash to last. 

Now, I do want to inject some good news here. We can treat the symptoms by helping the immune system to calm down and accept the presence of the oil. Now, we do that with things like oral antihistamines like Benadryl, topical steroids like 1% hydrocortisone cream, and there are stronger ones available by prescription.

Sometimes, especially if the rash is severe or widespread or on the face or groin region, which can swell greatly, then systemic or oral steroids like prednisone may be helpful. But you have to do these things for awhile, like two to three weeks, because if you stop, the rash will probably flare again until you've made new skin. 

So unlike asthma where you can take an oral steroid for five days and be done with it, you're more likely to need a longer dose of oral steroid, or to use the topical steroid longer. If you're doing oral steroid for two to three weeks, then we do recommend a taper where the dose is gradually lowered over that time if oral steroids are needed. If you're using the topical cream, you'll probably need to use it again, two to three weeks rather than just a few days. 

Now, as always, we don't dispense medical advice here. If you have an itchy rash, talk to your doctor or your child's doctor and make sure it really is from a poison plant and not something else. Also, you want to make sure the skin is not infected with bacteria and follow your doctor's advice for treatment. We just talk general ideas here. What you or your child needs might be a little different. 

0:26:07

So that's poison ivy, and poison oak, and poison sumac in a nutshell. Again, you want to be aware of the specific poison plants in your area, what they look like and how to avoid them. 

I almost forgot, if you're doing work that prevents you from avoiding them completely, from avoiding poison plants. So you're doing yard work or there's something where you really just cannot avoid being in contact with the poison ivy, of course, wear protective clothing, cover your skin, wash the clothing after exposure. 

But there's also a chemical called Bentoquatam which is an over-the-counter product like Ivy Block , and it prevents skin exposure by providing a physical barrier against urushiol oil, but you have to use before the exposure. Ivy Block doesn't help after exposure. You want to put it on beforehand because it acts as a physical barrier if clothing is just not possible. 

It's only approved for ages six and up, and you do want to follow the directions carefully. It's not something I'd use all the time, just when you might be doing yard work or another activity which makes avoidance difficult and exposure likely. In most situations, it's not necessary, better to just avoid the plant altogether, but I realized sometimes you can't, and the products like Ivy Block are an option when you need it. 

All right, let's take that quick music break, and I'll come back and we'll talk tick bites. 

[Music]

0:28:05

Dr. Mike Patrick: OK, we're all refocused. We're going to change the topic to tick bites. Ticks are small arachnids. So they're more closely related to spiders than bugs. They're in the order Parasitiformes. They're ectoparasites, meaning they latch on to the surface of a host, and they obtain nutrition by feeding on the blood of the host, which is typically a mammal or a bird, but sometimes a reptile or amphibian.

Because they feast on blood, they can transmit certain diseases from one animal to another, and that's one of the reasons that tick bites are feared, because you've heard this. And when you or your child are beaten by a tick, there is concern that they might get a disease transmitted to them, and that's why you go see the doctor. And this is another one of those concerns frequently fielded by doctors because there is this concern out there that tick bites can be a particular problem.

This is another one of those instances where discussing the topic in one area of the United States is going to be different than talking about it in another area, depending on the types of ticks that live in your area and the prevalence of disease that those ticks might transmit. 

So if your child has a tick bite, in some areas, it may be a real issue. In other areas, it might not really be much of an issue at all. And you may not know in what areas there is an issue, and in what areas there isn't so much of an issue. And so, by all means, when your child has a tick bite, if you have any concerns, call your doctor and they can fill you in on the details that you need to know, and to reassure you when that is all that's warranted as well. 

There is some general and common things that we can talk about with regard to ticks in any region that you might live. First, you want to look for them on your child's skin if ticks are in your area. Around these parts, we see ticks in tall grasses and wooded areas because that's where the ticks like to hang out looking for hosts. So when you or your child come in from being in tall grasses or wooded areas, you want to look for ticks attached to the skin, because unless you look for them, you might not find them.

0:30:26

Here in Ohio, the most common tick is the dog tick, the American dog tick. They're pretty large ticks and easy to see when you search for them, although they can be difficult sometimes to see in the scalp. They're about the diameter of a number two pencil eraser. And then, they get larger when they're engorged with blood. So they're pretty large tick. 

Now, contrast that with the deer tick which is not so common here in Ohio. It's more likely to be found east of here and the upper Midwest. And the deer tick is more like a sesame seed size before it feast and usually no bigger than a number two pencil eraser when it's engorged. Now, the sizes of these ticks do vary, and it's really more helpful to know which ticks populate your area, and again, the incidents of disease that might be associated with them. 

So the first common thing that we can say about ticks is you need to look for them on your child's skin, and yours too, by examining from head to toe, including under the clothes because ticks can crawl before latching on. The scalp is a common location and maybe one of the hardest places to find and see them there. 

Now, with regard to the private area, the groin — and I feel like I have to say this — kids can get ticks attached in the private region because the ticks can crawl, and they can get up under the clothes fairly easily. 

So it is a good idea that kids are aware and know what ticks look like, so they can examine themselves especially after they've been playing in an area with a high risk of ticks. If you're a mom or dad, look on those areas in your young kids. But, you want to be sensitive too especially if your child's older. Or your mom's boyfriend or a grandparent may not be appropriate for you to examine their private area, and I don't want anyone saying Dr. Mike told me to do it. 

Use your judgment, know the risk in your area with regard to ticks. Examine, but also teach your child how to self-examine if and when it's appropriate. 

0:32:17

OK, so you find the tick. What do you do? Well, if possible, you want to remove the tick intact, without leaving pieces parts of the tick in the skin. Now, if you do leave part of the tick in the skin, it's not the end of the world, but if you can remove it intact, that's your best bet. 

So how do you do that? Well, first, no burning with the match. The heat might make the tick release and fall off. But I cringe every time I hear that suggested. You may burn your child's skin. The heat may not remove the tick. You're not trying to burn the tick. Just don't do it. Not a good idea. 

Here's what you want to do. You want to get as best as you can between the tick's body and your child's skin. And they do make tools for this, which slide in pretty easily between the tick in your child skin. You can find them online and outdoorsy-type stores. If you don't have one of those special tick removal tools, you can also use a pair of tweezers, but you really want to try to get between the tick's body and your child's skin, not squeezing the tick itself. And then, once you're in between the skin and the tick, you want to apply a constant, steady, upward pressure until the tick releases and pops off. 

Again, you don't want to squeeze the tick's body too hard. You really want to get between the tick and the skin and pull upward. You don't want to wiggle it from side to side. You don't want to pull it with a sharp pole, because then you're more likely to leave some of the tick pieces parts behind. So slow, steady upward pressure until it releases and pops off, that's what you're after. 

Then, you can drop the tick in a little cup of rubbing alcohol to kill it, or throw it outside if everyone else in the family will hate you for killing it in alcohol. Sometimes, that becomes a family issue, and I'm all about maintaining a good quality of life in the home. So ,if you need to toss the tick outside, fine, do that, or kill it in a cup of alcohol. 

Then, you want to wash this kid with soap and water, dry it, and apply some over-the-counter antibiotic ointment, like Neosporin, for example, to the attachment point in an effort to prevent skin infection. 

0:34:21

Now what if you can't get every little pieces part of the tick out because you didn't do it with a 100% fabulous technique and you leave some behind? Or you just absolutely cannot bring yourself to try and nobody else is available to do it. Then, call your doctor. Get their advice, go to an urgent care with experience in kids, let them do the job for you. Don't be embarrassed. We do it all the time in the summer months.

So that's tick removal. And it's common to ticks regardless of the type of tick or where you live. 

What if you do leave part of it behind? Well, get out what you can with a tweezers. Don't tear your kids skin apart. If you can get every little piece out, and you're child's not in any discomfort, just wash the skin well. Apply antibiotic ointment and keep watch. Most of the time, those little itty bitty parts will fall out on their own. But if your child's in discomfort or any sign of infection occurs, which we'll get into in a minute, then you want to have your child seen. 

Even if you're just worried about it, there's no discomfort , there's no sign of infection, but you're just worried that part of that tick is still in there. It's never wrong to call your doctor or head to an urgent care with pediatric experience. That's what we're here for, and sometimes we'll say You did good job. We can't get it out anymore than you did. But at least you don't have to worry about it anymore. And sometimes, that's just what you need — peace of mind, right? 

The other common topic that we can talk about with ticks, regardless of the type of tick or your region of residence is skin infection, which I alluded to a moment ago. And this is different than disease transmission. When the tick attaches, it punctures through the skin, and we all have bacteria on the surface of our skin, and when the tick punches through, it takes some of that surface bacteria with it and embeds the bacteria into the skin, which is the point of washing with soap and water and applying an antibiotic ointment after removing the tick. 

0:36:17

Now, most of the time, this won't really be a problem. Your body's immune system will do its job and keep a skin infection from occurring, but you do want to watch for a skin infection. So if you see evolving redness surrounding the attachment site, or swelling, tenderness, recurrent bleeding or drainage, or if your child has fever or vomiting, you want to call your doctor and have your child seen right away, if any of those signs of skin infection are occurring. 

OK, so what about disease transmission which is what everybody is really worried about anyway. Well, first let me say, the overwhelming majority of tick bites are not associated with disease transmission. But sometimes they are. And how often that sometimes occurs is a function of the species of tick and the region you were located in when the tick exposure occurred. 

Your doctor should know the risks in your area, and if you were traveling when the tick exposure occurred, your doctor should be able to find out the type and degree of risk that you had based on where you had traveled from. So your doctor is really an excellent first resource if you have a concern. 

Here in the United States, the two most common diseases transmitted by ticks are Rocky Mountain spotted fever and Lyme disease. Now, I'm not going to cover these disease in detail. We'll leave that to future episodes of the program, if there appears to be interest. I will include links in the Show Notes over at PediaCast.org for this episode, 322, for resources on both diseases from the CDC, the Centers for Disease Control and Prevention if you're interested or concerned. 

I will say this Rocky Mountain spotted fever is transmitted by the larger ticks and these include the American dog tick, the Rocky Mountain wood tick, and the brown dog tick. Symptoms may include fever, headache, abdominal pain, vomiting, muscle pain and a distinctive rash, although the rash is not always present. 

0:38:07

Lyme disease is transmitted by a smaller tick, the deer tick, also known as the black-legged tick or the bear tick, depending on your region. Symptoms may include fever, headache, fatigue, joint pain, nervous system abnormalities and a distinctive rash, which is different than the distinctive rash of Rocky Mountain spotted fever. And like Rocky Mountain spotted fever, the rash is not always present. 

Suffice it to say, if you have any concerning symptoms in the weeks following a tick bite, you should talk to your doctor. It doesn't mean that the tick bite is responsible or even related to your symptoms, but it is a piece of data your doctor should know. 

What about prophylaxis for Lyme disease following a tick bite? So you have a tick bite, you need a medicine to prevent Lyme disease. Again, the right answer here will depend on the type of tick and the prevalence of Lyme disease in your region. And again, if you have specific concerns, talk to your doctor since we really can't cover every possible situation on this podcast. And truth be told, the answer may be different from one region to another, from one doctor to another, from one family to another. 

It's one of those instances that things are complicated by the fact that you have to start pulling risks and benefits into the equation, and you really do want a doctor coming alongside you in real time, not on the screen or a speaker to walk that path with you. 

What about preventing tick bites? Well, you want to be aware of where they live. And again, primarily tall grasses in wooded areas, but really, you can get one from the solitary in your backyard or the grass against your shed. So be on the lookout, especially if you're in an area known to have ticks.

If you're heading to a high-risk area, think about wearing a hat because they often fall from trees and long sleeves and long pants. But remember, they can crawl up your clothes from the grass so when you go inside, if you're in a high-risk area for ticks, strip down and look. That's the only way to be sure. Lovely, right? 

0:40:01

Insect repellants are another strategy and a good idea if you're spending time on a high-risk area, especially if tick-transmitted diseases are known to be in your region. Products with DEET and products with higher DEET concentrations work longer. For example, one study show that 10% DEET gives you about two hours of protections;24% DEET gives you about five hours of protection, and concentrations above 30% don't seem to offer any longer protection. So it's not beneficial to do concentration higher than 30%.

DEET can have some toxic effects in humans, so talk to your doctor. Apply your usual risk-benefit filter when making a decision. The American Academy of Pediatrics recommends no more than 30% DEET concentration in children and no insect repellant should be used in children younger than two months of age. 

You should follow all package directions. Still wear protective clothing — hat, long sleeves and pants. Check for ticks when you're done in the area and be sure to wash the repellant off with soap and water when you go inside. 

There is a great article on insect repellants including the use of products containing DEET from the American Academy of Pediatrics at their HealthyChildren.org website, and I'll include a link to it in the Show Notes for this episode, 322, over at PediaCast.org. 

Insect repellants are not a replacement for wearing proper clothes. You should still check and remove attached ticks. Don't let insect repellants give you a false sense of security, but at the same time, they can be a helpful addition to your prevention strategy. 

So that's tick bites in a nutshell. Let's take another quick break. We'll refocus and we'll talk sunburn and sunscreen after this. 

[Music]

0:42:14

Dr. Mike Patrick: You know, another nice thing is I get a little sip of water between topics, which is nice. So we might have to keep doing this. We'll see. We'll see if it works, see if you're paying attention longer. 

So sunburn, I'm going to take a close look at that. Not because it's something that kids and adults frequently get in the summer which it is, and not because it can be associated with skin cancer, which it can. And not because it's easy to prevent, which it is. I don't want to talk about sunburn because of those things even though they are important, but really they're things you already know. 

Sure, we all need a reminder from time to time, especially as the summer months get into full swing. And yes, I'll provide reminders of these things more than once as we talk, but the real reason I want to cover sunburns today, is because number one, I find the science behind sunburns pretty interesting, and I think you will, too. It turns out the mechanism by which sunburns occur isn't quite as cut and dry as you might think. 

And number two, there are some misconceptions out there on the best ways to treat sunburn.

And number three, it will give us chance to talk about sunscreen. That's one of the topics I like covering every summer, because following winter, at least here in Ohio, we all forget the basics like, When do I need sunscreen on my kids? What kind should I use? Lotion, roll-ons, sprays, which one? What does SPF mean? How high of a number do we need? How often do we reapply it? And what about babies who apparently are too young for sunscreen? 

So we'll answer those questions as we've done nearly every summer, since PediaCast started, going back to 2006, but they're important things to cover. And some of it, like what exactly is the SPF calculating, seems I have to look it up and double check myself every time we talk about it, because we go so long between mentions. I don't even think about sunscreen in the winter months. 

0:44:00

And yes, that's an important part of being a doctor. We can't know everything about everything all the time. Much more important is knowing what we don't know, and how to find the right answer. 

All right, so let's talk about the science behind the sunburn. Ultraviolet energy or UV rays is the culprit behind sunburns. It's present in sunlight and tanning beds. This part you probably know, it penetrates the skin and damages the DNA of cells in the skin and down deep at the base level or basal level of the skin. 

There are several types of skin cells that are involved here. There's ones down deep known as the epidermal stem cells, and there are the cells that make new skin cells. So they migrate upwards and then slough off. Or they make cells and do that. They stay down there at the bottom. Their job is making the new skin cells. 

Then, there are those that make pigment-producing cells. Those are called the melanocyte stem cells. And then there are those that migrate up and actually make the skin pigment. Those are the melanocytes. And it's these pigment cells which make the pigment melanin and that determines how dark our skin is at baseline. So darker-skinned folks have more melanocytes and are making more melanin, have more melanin component in their skin than fair-skinned folks do. 

Now, the melanin is important because it absorbs UV energy and that protects those skin-making cells and melanocyte-making cells down deep in the basal layer or the skin, down at the bottom. 

So why do we want to keep the skin-making cells protected from UV rays? Well, as we said, UV energy disrupts the cell's DNA, and since these cells are constantly making new cells, they're actively using the DNA as a code, so if the UV energy disrupts the normal code, the cells can't work correctly. 

Now, fortunately, the cell does contain mechanisms to fix the code. That's pretty cool. We could spend an hour just talking about how that works, but we won't, it's pretty technical. However, the DNA-fixing mechanism does have a finite capability. They can only do so much. Add to this fact that the disruption of the DNA code at just the right spot can turn the cell into a cancer cell, so it just starts reproducing itself. 

0:46:23

Of course, there are also mechanisms in place that can get rid of individual cancer cells, but it only takes one cell on one occurrence of aiding all these mechanisms to result in skin cancer. And that's how things like melanomas and basal cell carcinomas and squamous cell carcinomas, that's how these things come to life. Now, sometimes these cancers are treatable. In fact, a lot of times they are. But sometimes, they kill people. So it's an important process and one we have to take pretty seriously. 

So let's focus in on a couple of those protective mechanisms. The first is an increase in melanocyte and melanin production. So if we start getting DNA-damaged, the skin starts making more pigment to absorb more of the UV energy, and that's why your skin gets darker when you spend time in the sun. And that's true for those of us who are far-skinned to baseline, and it's also true for those who are darker-skinned to baseline. 

So the suntan or just you getting darker in the sun is one of the body's responses to DNA damage that is already being done. It's a great system but it is limited by our genetics as some of us can only make so much pigment, and we are at greater risk of developing skin cancer than those whose genetics allow them to make more pigment. 

However, and this is an important point, no matter how dark your skin is at baseline, if you're getting darker, DNA damage is already taking place, and it only takes one cell getting through our defenses to result in skin cancer. 

So many think that tans are great, including myself and probably lots of you. Let's keep in mind what a tan really is. It's a protective mechanism in response to DNA damage that is already occurring and putting us at risk for developing cancer. I know it's not what you want to hear, but it's the truth. 

0:48:11

OK, so what about sunburns? Well, as it turns out, the sunburn is another protective mechanism. You see when the DNA damage is great — so we've had lots of UV exposure down at the basal level, and we are in danger of completely overwhelming our DNA fixing capacity, which means that the cells can't work right and the chances of skin cancer cell rising to life is greater — in that case our skin cells are programmed to die in a process known as apoptosis. 

As part of that cell-death process, the immune system kicks in and increases blood flow to the area, which is why the skin first turns red. So that red that you see with the sunburn is actually inflammation and your skin feels warm because of the increased blood flow. And you need that increased blood flow, so that inflammatory cells can come in and clean up the mess to prevent you from getting skin cancer and to get rid of those cells that aren't going to work right because the DNA damage is just too great. 

So it's a pretty cool mechanism. It's one that can save your life by preventing skin cancer, but it's also a painful process, and it's one that's better avoided in the first place. 

So the dead skin peels off and depending on the degree of cell death and the amount of inflammation, the process may also result in blistering, which the blisters can enrapture and ooze, and you know the drill. And then, finally, cells down deep really rev up making new skin cells, but they're making them so fast and with such intensity that the new cells come up in clumps rather than fine sheets. And that's why for a few days to a couple of weeks following a sunburn, your new skin is flaky and fragile. 

So that's the sunburn process. It's really an induced mechanism that maintains proper skin function by destroying cells whose DNA has become seriously messed up, and in doing this, it also helps prevent skin cancer. 

0:50:09

But this also means that every time you get a sunburn, you have seriously damaged your DNA. And remember, it only takes one cell getting through the defenses to end up causing skin cancer down the road. So again, we want to take this seriously. 

All right, so let's move on away from the pathophysiology of sunburn and on to treatment and prevention. 

Let's do treatment first. There really are three primary goals with treatment. The first is pain control. And, of course, Tylenol or acetaminophen versus ibuprofen or the Motrins and the Advils , those are the mainstays here. Most of us prefer ibuprofen over Tylenol or acetaminophen because it has an anti-inflammatory effect. And remember, with sunburn there's inflammation, and so when we're helping with those symptoms, an anti-inflammatory is helpful.

There are also topical agents available that soothe the skin. For example, products with aloe vera, also menthol and camphor. There are spray-on numbing agents available. Sometimes this help, sometimes they don't. 

Your best bet, especially if you have a young child who has a sunburn is to call your child's doctor. If the sunburn is extensive, your child should be seen. If it's mild sunburn, your doctor can hook you up with a pain control plan that's appropriate for your child's age, weight, and medical history. So ask your doctor even if it's just Tylenol or ibuprofen, talk to your doctor about what the right dose is, and how often and all that. 

The second goal after pain control is to protect the new skin that's being made. And there is some evidence that aloe vera not only soothes but also protects the new skin. Staying hydrated is important. And this should be obvious but keeping the new skin out of the sun is also important. Stay indoors or seek serious shade. If you must venture into direct sunlight, keep the healing skin covered. And if that's not absolutely not possible, at very least, use liberal amounts of a high SPF sunscreen — and we'll talk more about sunscreen in a moment — but that really should be a last resort. It's better to provide a physical barrier that keeps the UV energy away from the healing skin. 

0:52:13

And then, third goal is infection prevention. Sunburn represents a disruption of skin, and one of the skin's chief job is keeping infection out. We all have bacteria on the surface of our skin, and they can become a problem when the skin is disrupted as with sunburn. So you want to keep the healing burn clean. You can wash it gently with mild soap and water a couple of times a day. Pat the area, dry gently, and apply a thin layer of over-the-counter topical antibiotic ointment for a few days, especially if they are broken and oozing blisters but it may be helpful for milder degrees of sunburn as well. 

And then, you want to watch for signs of skin infection and have your child seen right away if any of those occur — things like increasing redness, swelling or tenderness when you think the skin should be getting better, drainage from the burned skin other than that brief clear drainage when a blister ruptures. And then also, fever, that can be another sign of infection. 

One more thing I want to make really clear. We're talking about home treatment of sunburns, but if there are extensive burns at any age, or if your child is very young, or if you have any concerns at all, talk to your child's doctor. Have them look at. Better to have your provider say, You know, it's just a mild sunburn, not much else we need to do, rather than Why in the world did you wait so long to come in? So if you think about talking to your doctor about it, just do it. 

OK, let's talk prevention. Your best defense is to avoid too much UV exposure. So how much is too much? Well, that depends, if our goal is to prevent sunburns, which is a good goal to have, then you want to avoid the amount of UV exposure that causes your skin to burn. 

I know that seems pretty obvious, but my point here is, that we do have to take a balanced approach and also not be afraid of the sun. There are benefits to kids playing outside and families spending time together in the sunshine. The skin makes vitamin D with sunlight exposure, that's a good thing. But Vitamin D can also be supplemented, and we know if you're getting tanned or burned, DNA damage is already occurring, and even though we have DNA fixing and other protective mechanisms in place, it only takes one occurrence, one cell. 

0:54:26

So what do you do? Well, overall, with regards to sun exposure, that's where our benefit-risk meter comes back into play. But I think one thing we can all agree on, we want to avoid sunburns right. The only benefit they bring is protection, but let's face it, if the protection we need is that extreme, it's better to prevent that thing our body is protecting us from, right? And so, if your child will be spending enough time in the sun that burning is possibility, then you want to protect the skin. 

Now, how long of a time is that? I don't know for you and your kids. I don't really know your kids well enough to know how long that is. I know how long it is for me. I know how long it is for my kids. But we all have a different amount of natural protection to begin with, so you have to know you and your family and how long your family can tolerate some sun exposure before burning. Because again, that's what we're talking about preventing, is sunburns. 

Sure, I can say, slather on the sunscreen every time you step outside. For some out there, that's closer to the truth of what you need. But for others, there is some overkill with that statement. I think most of you out there understand what I mean by that. Or at least I hope you do. If not, fine, slather on the sunscreen every time you step, even if you're just running to the car, and we'll all be happy. 

Oh, wait. Before you slather on the sunscreen, can you go outside and physically protect your skin from the sun without using sunscreen, by seeking shade and covering the skin with clothes? Sometimes, we overlook that strategy and go straight to the sunscreen. But that strategy is an important one, so while we're going to spend a few minutes talking about sunscreen, don't underestimate the importance of a physical barrier like shade and clothing. And that's particularly important for those in whom a sunburn can be quite dangerous like young babies and the elderly and those with some medical conditions or who are on certain medications. 

0:56:20

In fact, that's one of the reasons we say don't use sunscreen for young babies, especially those who are less than six months of age, because we don't want you to have a false sense of security and protection. It's better to keep them in the shade than relying on sunscreen because they burn easily, and sunburns and babies can be really serious resulting in significant dehydration, and serious infection is possible. 

Is sunscreen absolutely wrong to use in all babies less than six months of age? No, there are times when you should use it, especially on unprotected skin that you simply cannot keep out of the sun, like the face. But don't rely on it working. That's really the point. 

So protecting the skin from prolonged direct sunlight exposure, that's a fine strategy. But it's not always possible. It's not always desirable depending on what you're up to on any given day, what activities you have planned and our tolerance of risk. It's at this time that sunscreens can come into play. 

So sunscreen works by two mechanisms. First, it creates a physical barrier that reflects or scatters UV rays. So fewer of the rays enter the skin. And this is accomplished with ingredients like zinc oxide or titanium dioxide. 

Second, it provides an ingredient that absorbs UV radiation. One example of this is Octyl methoxycinnamate or OMC, but there are others. The issue with these chemicals is that they have a limited capacity for absorbing the energy. In other words, they get used up. They only work so long, and that's where this concept of SPF or sun protection factor comes into play. 

0:58:03

The SPF number tells you how many times longer it takes your skin to burn with the product applied — and you burn because the absorbing ingredient has been used up, so it's not protecting you anymore — compared to the length of time you would burn without using the product at all.

So if it normally takes your skin ten minutes to burn depending how easily you burn and what time of day and direct sunlight and all that, let's just say that it takes ten minutes for you to burn, then if you're using an SPF of two, it will take 20 minutes. If you're using an SPF of 10, it will be a hundred minutes, SPF of 20, 200 minutes, SPF of 30, 300 minutes. You get the drill here — 50, 500 minutes — if you burn normally in ten minutes without using anything. 

OK, great. So if I use an SPF of 30, I can spend 300 minutes in the sun. Well, not so fast. This number assumes that the product stays perfectly applied to your skin the entire time, which in real like is probably not the case, especially if you're swimming or rolling around in the sand or taking clothes on and off, or sweating, or if the product was not applied with an adequate amount to begin with. 

So this introduces two more concepts. First, you want good coverage. If you can do that with roll-ons and sprays, fine. But it's probably easier to feel confident that your coverage is adequate if you use a lotion. Yes, it takes longer. Your hands might get messy and greasy, but like all things, easy isn't often better. So I like sticking with a lotion, but if other products are working for you and your family and your kids aren't getting sunburns, then great. 

The second concept is frequent reapplication, especially after swimming or taking clothes on or off, rolling in the sand or working up a sweat. Don't wait 300 minutes. Don't wait until you start burning, reapply often.

How much SPF do you need? Well, it depends. How important is it that you don't get burned? In other words, go as high as you can for the young, elderly and others at risk, but don't count on that high level to mean that you shouldn't reapply it often and that you shouldn't put a lot on, because you should, especially for those at highest risk. 

1:00:17

What time of day are you going out? The midday sun when it's right overhead. That's when the UV energy striking your skin will be at its highest, so you might want more protection during that part of the day. 

And what is your baseline protection? For fair-skinned folks, it's not much, so it makes sense to use a higher number. 

Here is what I would not base your SPF on. I would not base it on how long you'll be out in the sun, even though that sort of the whole concept behind the SPF number. Don't trust that any sunscreen, regardless of the number will last as long as you think it will. Apply lots of it, and reapply often. 

Are you sensing a trend here on my recommendation? And if you're a fair-skinned and/or burn easily, or if burning is particularly high risk for you because you're very young or elderly or have other conditions, then go for the higher numbers. 

The prevailing minds on sun safety say, at the minimum, you don't want to go any lower than 15, and anything over 50 probably doesn't really offer any additional protection. So no sense paying lots more for something over 50, and lower than 15 is close to using nothing at all. So 15 to 50 is the range that you're looking for. 

The HealthyChildren website from the American Academy of Pediatrics has a great sun safety resource with some other tips. For instance, don't forget about hats and sunglasses and be sure to stay hydrated when you're out in the sun. They have a great list of recommendations that you can print, hang on the fridge and glance at before you head out for the day, and I'll include a link to it in the Show Notes over at PediaCast.org, in the Show Notes for this episode, 322.

All right, we've gone a little over. Let's take a quick break, and I'll be back with a final word on child activity in day care centers right after this. 

[Music]

1:02:30

Dr. Mike Patrick: Physical activity is important for young children's health and development, yet most three to five-year-olds are not getting the two hours per day of recommended physical activity. A study in the June, 2015 edition of the journal, Pediatrics, entitled Active Play Opportunities at Child Care finds kids simply are not given enough opportunities for active play. 

For the study, researchers observed 98 children from 10 child care centers in the Seattle area. All of the centers had scheduled at least 60 minutes per day of outdoor playtime, and they all had outdoor play areas as well as indoor space for physical activity. Researchers categorized children's activity levels throughout the day, and the children wore accelerometer. So that must have been fun. 

In the study, children average 48 minutes per day of active play opportunities and only 33 minutes per day of actual outdoor time, and children had less than 10 minutes per day of teacher-led physical activities. For 88% of the time children were in the center, they were not given opportunity for active play, which explains the finding that children were sedentary 70% of the time. Now, children were more likely to be active when outdoors and engaged in free play, rather than inside or involved in teacher-led activities, indoors or outdoors. 

Study authors conclude that children should have more opportunities for active play during preschool and possible strategies include increasing outdoor time, more child-initiated and teacher-lead active play, and flexibility and nap time for older preschoolers.

1:04:04

If you're interested in hearing more about this study, I'll put a link to the abstract in the Show Notes for this episode, 322, over at PediaCast.org. 

And if you're interested in how much active time your child is getting at day care, put an accelerometer on them. 

[Laughter]

Dr. Mike Patrick: Can you imagine? Day care workers all over are rolling their eyes right now. Great, parents are going to start sending with accelerometer and I'm going to have to answer for the low readings. 

I don't even know where you buy an accelerometer. Amazon I guess or a sporting goods store, I don't know. Or maybe your preschooler has smart phone access an accelerometer if you download the right app.

Seriously, don't send your kind to day care with an accelerometer. But you can and should talk to your child and the day care staff about how much opportunity they're getting for outdoor free play, and how is outdoor free play in child-initiated and teacher-led physical activity, how are these things valued compared to the educational programming?

That's a criteria worth thinking about when choosing the place your child will be spending so much of their time. Preschool enrichment and educational activities are important, and I'm sure we can dig up studies that show this is true. But creative free play is important as well, and are we robbing one experience to overdue the other. 

If this is of interest to you, ask about it. Point your day care's leaders in the direction of the article and again, I'll have a link in the Show Notes. If they won't listen, and you think this is a problem, find a day care center that does place an equal priority on allowing kids to run and play. And then, consider voting with your feet because day care centers need paying customers, and they're more likely to listen to the parents who pays the bills than researchers speaking through well-designed studies published in peer-reviewed journals. 

At the end of the day, you're the parent and you do have the opportunity to make a change. My two cents anyway, which sometimes gets me in trouble. 

Anyway, I want to thank all of your for taking time out of your day to make PediaCast a part of it. Don't forget, if you are in the Central Ohio area, Nationwide Children's Hospital offers urgent care services at seven convenient locations, including our downtown Main Campus, Dublin, Hilliard, Marysville, Westerville, East Broad and Canal Winchester. You can find exact locations, hours and approximate wait times on our website at nationwidechildrens.org/urgentcare. 

1:06:23

You can also find urgent care locations and wait times in our hospital's mobile app, which is called MyChildren's and available for iPhone and Android. 

Of course, you should always with your regular doctor before going to any urgent care. Just to make sure it's the right thing to do, given your child's problem and situation. And if you're child has a serious or life-threatening condition, head to your nearest emergency department, or if needed, call 911.

That's all the time we have today. PediaCast is a production of Nationwide Children's Hospital. Don't forget, you can find PediaCast in all sorts of places. We're in iTunes and most podcasting apps for iPhone and Android, including the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher and TuneIn. 

We're also on iHeart Radio, where we not only have this program, but also PediaBytes, B-Y-T-E-S. Those are shorter clips from this show, and they can be weaved together with other content providers to make your own custom talk radio station.

And then, there's the landing site, PediaCast.org, where you'll find an archive featuring hundreds of past episodes, transcripts of each program, in case reading suits your taste, and a handy contact page to ask questions and suggest show topics.

We also have a voice line if you'd rather phone in your question or comment. And our number is 347-404-KIDS. 347-404-5437 if you need the digits. 

We're also on Facebook, Twitter, Google Plus and Pinterest with lots of great content you can share with your own online audience.  

And, of course, we always appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids and those who take care of children, including your child's healthcare provider. Next time you're in for a sick office visit or a well-check up or sports physical, or a medicine recheck, whatever the occasion, let them know you found an evidence-based pediatric podcast for moms and dads. We've been around for nearly a decade, with lots of great content, deep enough to be helpful, but in language parents can understand.
 
1:08:10

And, while you have your providers' ear, let them know we have a podcast for them as well, PediaCast CME. Similar to this program, but we turned up the science a couple notches and provide free Category 1 CME Credit for listening. Shows and details are available at PediaCastCME.org. 

All right, it's goodbye for now. And until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody. 

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