School Performance, Brain Tumors, W-Sitting – PediaCast 340

Show Notes


  • Join Dr Mike in the PediaCast Studio for a Zika Virus update and more News Parents Can Use. This week we consider how parental depression, bed time, and text messaging affect school grades. Dr Jonathan Finlay and Dr Scott Coven stop by to discuss brain tumors, and we answer a listener question regarding the associations and possible dangers of “W-Sitting.” Be sure to tune in!


  • Zika Virus Update
  • Parental Depression & School Performance
  • Bed Time & Grades
  • Text Messages & Academics
  • Brain Tumors
  • HeadSmart
  • W-Sitting




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 on Columbus, Ohio. It is Episode 340 for March 2nd, 2016. We're calling this one "School Performance, Brain Tumors and W-Sitting". I want to welcome everyone to the program. We do have a full line-up for you today with more news parents can use, an interview with a couple of pediatric experts and an answer to a listener question on W-sitting. Now, you may be wondering what in the world is that. I'll describe it, explain it, let you know what the listener's concerns are and throw my two cents into the equation. So that's coming up a little bit later in the program. And I'll get to a rundown of all the all things that we're going to talk about. First though, a quick update on the Zika virus. I talked about this a couple episodes back. The Zika virus is a virus — in case you've been totally disconnected from the news — that is thought to be associated with microcephaly which is a type of birth defect where baby is born with an underdeveloped brain and a small head. And this is occurring in babies whose moms were infected with the Zika virus during pregnancy. The virus is spread by mosquito bite and there's a lot of it making its way around South America and the Caribbean. So much so, and causing enough concern that some countries — such as El Salvador for instance — they're advising women not to become pregnant at all for the next two years. And our own CDC here in the United States, the Centers for Disease Control and Prevention, they've issued regional travel warnings for pregnant women or those who plan to become pregnant saying you shouldn't go down to South America or the Caribbean or areas where Zika virus is active right now, if you're pregnant or have plans to become pregnant. But if you do go down there, they have some precautions that you should follow to avoid mosquito bites. 0:02:38 Much more on Zika virus and the CDC travel warning and their advice for folks who have to travel all back in Episode 338. But I did want to add a couple of quick updates from the CDC. Turns out the primary mosquito that carries Zika virus is only seen in the southernmost portions of the United States. However, a cousin of this mosquito, that one lives east of the Rockies, including here in Ohio and pretty much the entire United States east of the Rocky Mountains. And at this point, it's unknown if this cousin mosquito will become an important carrier of the disease. So more of that to come once we learn more. We really just don't know at this point. Most of the cases of Zika virus here in the United States, up to this point anyway, is occurring in folks who travel to South America or the Caribbean, caught the virus there by mosquito bite and then traveled back here to the United States. So person-to-person spread of Zika virus without a mosquito vector. Up until now, that's not been thought to be a significant characteristic of the Zika virus. However, the CDC is now reporting evidence of sexual transmission of Zika virus. You may have heard about this. So from one person to another, without the involvement of a mosquito through sexual contact. Now, a quick warning, we're going to talk about sex as it relates to the Zika virus for a couple of minutes here. So if you have little ears around, I'll give you a chance to decide what you want to do. Three, two, one. 0:04:18 OK, here we go. So if a male partner of a pregnant or soon-to-become pregnant mom travels to one of these countries where Zika is circulating, gets bitten by a mosquito, brings the disease back to the United States and transmits it to mom sexually, that could be a problem now, today, and across the entire United States. So, it is something that we need to think about. On the other hand, it doesn't seem like this is happening rampantly. It has occurred in a single case that we know about, up to this point, as of this recording. So we're not really quite sure what to make of that. The CDC has released some interim guidelines for the prevention of sexual transmission of Zika virus. And in those interim guidelines, they advise that men who reside in or had travelled to an area of active Zika virus transmission, who have a pregnant partner, should abstain from sexual activity, or they should consistently and correctly use condoms during sex for the duration of the pregnancy. Pregnant women should discuss their male partners potential exposures to mosquitoes and history of Zika-like illness with their healthcare provider and providers can consult the CDC's guidelines for evaluation and testing of pregnant women. I'll put a link to these guidelines, all these things we're talking about, in the Show Notes for this episode, number 340, over at The CDC goes on to say men who don't have a pregnant partner who reside in or have travelled to an area of active Zika virus transmission, who are concerned about sexual transmission of Zika virus, might consider abstaining from sexual activity or using condoms consistently and correctly during sex. Couples considering this personal decision should take several factors into account. Most infections are asymptomatic, and when illness does occur, it is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon. The risk for acquiring vector-borne Zika virus in areas of active transmission depends on the duration and extent of exposure to infected mosquitoes and the steps taken to prevent mosquito bites. After infection, Zika virus might persist in semen when it is no longer detectable in blood. 0:06:46 Zika virus testing has been recommended to establish a diagnosis of infection in some groups, such as pregnant women. At present, Zika virus testing for the assessment of risk for sexual transmission is of uncertain value, because current understanding of the incidence and duration of shedding of the virus in the male genitourinary tract is limited to one case report in which Zika virus persisted longer than in the blood. At this time, testing of men for the purpose of assessing risk for sexual transmission is not recommended. As we learn more about the incidence and duration of shedding in the semen from infected men and the utility and availability of testing in this context, recommendations to prevent sexual transmission of Zika virus will be updated. So again, this is all current as of this recording. It's important guidance from the CDC for anyone in the United States who's pregnant or may soon become pregnant and who travels or whose partner travels to regions where Zika virus is currently circulating. I'll put lots of links in the Show Notes — The Interim Guidelines for Prevention of Sexual Transmission of Zika Virus, Interim Guidelines for Providers Caring for Pregnant Women with Zika Exposure, the CDC travel health notices which will always have up to date regions of active circulation of the Zika virus. Also, the Zika virus alert page, the virus information page, the virus symptoms page, and mosquito bite and Zika virus prevention. All from the CDC, links to all of those things again over at in the Show Notes for this episode, 340. 0:08:26 All these because I want you, the PediaCast audience to be informed about Zika virus. You know, taking it seriously, giving what we know at this time and paying attention to it, but also not giving in to fear or unnecessary hype. Just the facts as we know them now, and with the understanding that the facts may change once we learn more, which after all is what science is all about. All right, so what else are we talking about today? As I mentioned, I do have a full line-up for you. In our News Parents Can Use segment, we're going to talk about school performance as it relates to academics or grades and the influencing effects of parental depression, bedtime and specifically what time is the best time especially for teenagers, and texting and instant messaging in the early evening and after the lights go out. Could these things have an effect on how well your child does in school as it relates to academics and grades? So we'll talk about that, detail the relationships and provide some practical advice as you think about your own kids. And then, in our interview segment this week, Dr. Jonathan Finlay and Dr. Scott Coven, both from the Neuro-Oncology Program here at Nationwide Children's, they're going to stop by and discuss the unspoken fear that many parents have when confronted with the child complaining of frequent headaches. Brain tumors, how common are they, what symptoms should really cause you to think about them? Is it just headache or is there something more? How are they diagnosed and treated? What's the long-term outlook for kids with brain tumors and what are the latest hot topics in brain tumor or in neuro-oncology research? We'll answer these questions and more with the pediatric experts. 0:10:11 Then, finally, in our listener segment, a mom writes in asking about children sitting in the W position. So I'll explain what that is. We'll consider possible associations and dangers and explore what you should do if your child likes to sit this way, with their legs in the shape of a W. We'll do it in an evidence-based way calling into question some of the warnings that are out there, if and when they aren't based in science and in evidence. So that's coming your way at the end of the program. Don't forget, if there's a topic that you would like us to talk about or you have a question for me or just want to suggest a topic or make a comment, any of those things, just head over to and click on the Contact link. You can also call the voice line and leave a message that way, 347-404-KIDS is the number. 347-404-K-I-D-S. Also, I want to remind you, the information presented in every episode of this podcast 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 Let's take a quick break and I will be back with news parents can use, an interview and a listener question. That's all coming up right after this. [Music] 0:12:16 Dr. Mike Patrick: A new study has found that when parents are diagnosed with depression, it can have a significant negative impact on their child's school performance. Researchers at Drexel University in Philadelphia — in cooperation with faculty from the Karolinska Institute in Stockholm, Sweden, and the University of Bristol in England — completed a cohort study of more than one million children born between 1984 and 1994 in Sweden. Their findings were recently reported in the Journal, JAMA Psychiatry. Using computerized data registers, the scientists linked the diagnosis of depression in moms and dads with their children's final grades at age 16, which is when compulsory schooling ends in Sweden. The research indicated that children whose mothers had been diagnosed with depression, their grades were 4.5 percentage points lower than peers whose mothers did not carry a diagnosis of depression. For children whose fathers were diagnosed with depression, the difference was similar. Their grades were 4.0 percentage points lower than peers with non-depressed dads. Put into other terms, when compared with a student who achieved a 90%, a student whose mother or father had been diagnosed with depression would be more likely to achieve a score in the 85% to 86% range. The magnitude of this effect was similar to the difference in school performance between children in low income versus high-income families, where low-income children perform 3.6 percentage points lower than high-income children. However , it wasn't as great as the difference between low versus high maternal education with children whose moms dropped out of high school performing 16.2 percentage points lower than children whose mothers completed college. Dr. Felice Le-Scherban, assistant professor in the Dornsife School of Public Health at Drexel University, says, "How well a student does in school has a large bearing on future job and income opportunities, which has heavy public health implications. On average, in the United States, an adult without a high school degree earns half as much as one of their peers with a college degree and also has a life expectancy that is about ten years lower." She adds, "Anything that creates an uneven playing field for children in terms of their education can potentially have strong implications for health inequities down the road." 0:14:32 Additionally, some gender differences were observed in the study. Although results were largely similar for depression in moms versus dads, further analysis found that episodes of depression in mothers when their children were 11 to 16 years old appear to have a larger effect on girls than boys. Girls scored 5.1 percentage points lower than their peers on final grades at 16 years old when that factor was taken into account. Boys, meanwhile, only scored 3.4 percentage points lower. Dr. Brian Lee, associate professor in the Dornsife School of Public Health at Drexel, says, "There were gender differences in the study's numbers, but we didn't want to lose focus of the problem parental depression as a whole." He adds, "Our study — as well as many others — supports that depression in mom or dad may independently and negatively influence child development. There are many notable sex differences in depression, but, rather than comparing moms and dads, we should recognize that parental depression can have adverse consequences not just for the parents but also for their children." The diagnosis of depression in a parent at any time during the child's first 16 years was determined to have some effect on the child's school performance. Even diagnosis of depression that came before the child's birth was linked to poor school performance. Researchers point out these findings could be attributed to parents and children sharing the same genes and the possibility of passing on a disposition for depression. In other words, perhaps depression in mom or dad leads to depression in their children, which results in lower school performance and that could be genetic effects and/or environmental effects. 0:16:08 So this is an important observation, the fact that parental depression effects the child school performance by means of environment or by genetics or in some combination of the two. Here is the practical point, if anyone in the family suffers from depression, whether it be mom, dad, child, make sure you seek help. Really try to get that depression under control. It's not a personality problem. Depression happens and it's chemically-mediated in the brain. Environment place a role. Genetics play a role. Biochemistry plays a role. As we've noted here, school performance is at stake when that has all sorts of ramifications down the road, but that's not the only thing at stake when we're talking about depression. There's also quality of life, work, hobbies, relationships, inside and outside of the home. Bottom-line, if you're a parent and you thought, "You know, I might be depressed," and if you've had that thought — you know who you are — if that describes you, consider this a gentle push to do something about it. Tell your spouse and/or other supportive person in your life, and be sure to tell your doctor. You owe it to yourself and your children. High school students going to bed between 10 and 11 p.m. on weekdays get better grades. There is a strong relationship between sleep problems and poor academic performance among adolescents . This according to a study recently published in the Journal of Sleep Research. Furthermore, the less sleep teenagers get, the worse their grades become. Dr. Mari Hysing, lead author of the paper and a professor of psychology at Uni Research in Bergen, Norway, says, "Our findings suggests that going to bed earlier, and encouraging similar bed and sleeping times during the week, are important for academic performance." The researchers analyzed data from a large population based study conducted in Norway in 2012, including 7,798 teenagers from Hordaland county. This survey is called youth@hordaland — a large and representative sample, which sounds like an apt description. 0:18:15 School performance was measured by grade point average, or GPA, and obtained from official administrative registries. The teens between 16 and 19 years of age who went to bed between 10 and 11 p.m. had the best grades on average. Going to bed much later on weekends compared with weekday bedtime was also associated with lower GPA. The study was a collaborative between investigators from Uni Research, the Norwegian Institute of Public Health, Orebro University and University of California at Berkeley. Investigators indicate the results underscore the importance of sleep for academic functioning. They go on to say that academic performance is an important marker for future work and health, and future studies should investigate further how the association between sleep and school impacts future educational status and work affiliation. After adjusting for socioeconomic status, short sleep duration and sleep deficit were the measures with highest odds of poor school performance. Researchers point out that when adjusting their numbers to take non-attendance into account, associations were somewhat reduced, but the link between sleep and GPA was still significant. So we'll add another factor that affects school performance, in addition to parental depression, which we just talked about. Sleep makes a difference, and according to this study, keeping a bedtime of 10 to 11 o'clock, somewhere around that range, appears to be best practice as well as not staying up until all hours of the night on weekends. We have one more item to consider as it relates to school performance and that is texting. This common activity may be to blame for falling grades and yawning in the classroom, so say researchers in Rutgers as published in the Journal of Child Neurology. 0:20:02 The study is the first of its kind to link nighttime instant messaging habits of American teenagers to sleep health and school performance. Dr. Xue Ming, lead author of the study and professor of neuroscience and neurology at Rutgers New Jersey Medical School, says, "We need to be aware that teenagers are using electronic devices excessively and have a unique physiology. They tend to go to sleep late and get up late. When we go against that natural rhythm, students become less efficient." The American Academy of Pediatrics reports that media use among children of all ages is increasing exponentially, while studies finding that children ages 8 to 18 use electronic devices approximately seven-and-a-half hours each day. Dr. Ming's research is part of a small but growing body of evidence on the negative effects of electronics on sleep and school performance. But few studies have focused specifically on texting and other forms of instant messages. Dr. Ming says, "During the last few years, I've noticed an increased use of smartphones by my patients with sleep problems. I wanted to isolate how messaging alone — especially after the lights go out — contributes to sleep-related problems and academic performance." To conduct her study, Ming distributed surveys to three New Jersey high schools — a suburban school, one in the inner city, and a private school. She evaluated 1,537 responses paying attention to grades, sex of the teen and duration of time spent messaging regardless of when the messaging took place before or after the lights out. She found that students who turned off their devices or who messaged for less than 30 minutes after lights out performed significantly better in school than those who messaged for more than 30 minutes after lights out. Students who texted longer in the dark also slept fewer hours and were sleepier during the day than those who stopped messaging when they went to bed. Texting before lights out did not affect academic performance. Before — so it's good to text before the lights go out, not after. 0:22:03 Dr. Mings says females reported more messaging overall and more daytime sleepiness, but they had better academic performance than males. She attributes this to the fact that the girls primarily texted before turning off the light. She adds, "The effects of blue light emitted from smartphones and tablets are intensified when viewed in a dark room. This short wavelength light can have a strong impact on daytime sleepiness symptoms since it can delay melatonin release, making it more difficult to fall asleep, even when seen through closed eyelids. Dr. Ming says, "When we turn the lights off, it should be to make a gradual transition from wakefulness to sleep. If a person keeps getting text messages with alerts and light emission, that can also disrupt the circadian rhythm. Rapid Eye Movement sleep is the period during sleep most important to learning, memory consolidation and social adjustment in adolescents. When falling asleep is delayed but waking time is not, REM sleep will be cut short, which can affect learning and memory." Dr. Ming also notes some benefits to early-evening media use, such as facilitating collaboration for school projects, providing resources for tutoring, increasing school readiness and possibly offering emotional support systems. She suggests that educators recognize the sleep needs of teenagers and incorporate sleep education into their curriculum. She says, "Sleep is not a luxury. It's a biological necessity. Adolescents are not receiving the optimal amount of sleep. They should be getting eight-and-a-half hours a night, and sleep deprivation is a strong argument in favor of later start times for high schools, like 9 a.m." So there you have it, three ways to improve school performance. Take depression seriously including depression in mom or dad, recognize it and get help. Number two, hit the sack by 10 or 11 p.m. Aim for eight and a half hours of sleep each night and don't stay up too much later on the weekends. And, three, send those texts and instant messages in the early evening at bedtime. Turn the lights out. Keep those electronic devices in the off position and get some shuteye. Your brain and your memory and everything you need to do and be the next day will thank you. 0:24:17 [Music] Dr. Mike Patrick: Dr. Jonathan Finlay is the medical director of Neuro-Oncology at Nationwide Children's Hospital and a professor of Pediatrics at the Ohio State University College of Medicine. He's an internationally recognized expert in pediatric brain tumors and has authored or co-authored over 200 peer-reviewed publications and over 80 review articles and book chapters. Prior to his time at Nationwide Children's, Dr. Finlay served as director of the Neural Tumors Program at Children's Hospital Los Angeles and Professor of Pediatrics, Neurology and Neurological Surgery at the Keck School of Medicine at the University of Southern California. He has also held faculty positions in Pediatric Oncology at Stanford University, the University of Wisconsin, the University of Pennsylvania, Cornell, and New York University. It is an honor and pleasure having Dr. Finlay on this program to talk about pediatric brain tumors. So, let's give a warm PediaCast welcome to Dr. Jonathan Finlay. Thanks for joining us today. Dr. Jonathan Finlay: Thank you for having me. It's a pleasure to be here. Good morning. Dr. Mike Patrick: We really appreciate you stopping by. We also have Dr. Scott Coven in the studio today. Dr. Coven is a Hematology, Oncology and Bone Marrow Transplant Fellow at Nationwide Children's. This means he's completed medical school and a pediatric residency and is now training to take care of kids with blood disorders and cancer, including those with brain tumors. So, a warm welcome to you as well. Dr. Scott Coven: Thank you as well for having me today. 0:26:04 Dr. Mike Patrick: So let's start with Dr. Finlay. How common are brain tumors in children and teenagers? Dr. Jonathan Finlay: Yes, well, it's not that they're at epidemic proportions, but to put a hard number on it, we reckon that in 2016, there will be 5,000 children and adolescents diagnosed with brain cancer in the United States. Now, to put that in perspective, brain cancer as a group, it's many different diagnosis, but brain cancer as a group represents the second most common type of cancer in children after the acute leukemias. The outcome for children with acute leukemias is absolutely fantastic in this day and age compared to what it was 40 years ago. And it is so good — and unfortunately, for brain tumors — it has outpaced dramatically the improvements in brain cancer. So what that means is that whilst brain cancer is the second most common type of cancer in children, nevertheless brain cancer is the most common cause of cancer-related death in children up to about 16 or 18 years of age in North America. Furthermore, it is in fact, the most common disease-related cause of death in children between 1 and 16 years of age. Dr. Mike Patrick: Can we make a difference in those numbers by diagnosing it earlier? Dr. Jonathan Finlay: We believe we can. About 60% of all brain tumors are actually low-grade gliomas. That doesn't make them benign or good for you. But, in those cases, the symptomatology can often take up to a year or two years before it comes to diagnosis, which impacts perhaps not so much on cure but on quality of life, and these are children that are going to live long lives. The concern is, with delayed diagnosis, the quality of life may be substantially and irrevocably damaged. For example, a child who might just have a little visual problem ends up being blind at the time of diagnosis. Or, rather than just a little bit of weakness in an arm or a leg, actually paralyzed at the time of diagnosis. So this is a significant problem for us. 0:28:22 Dr. Mike Patrick: As we think about epidemiology, is there a difference in boys versus girls with brain tumors or is it about the same? Dr. Jonathan Finlay: It's about the same but for a number of types of brain cancer, as with all the diseases, we see that girls tend to have a somewhat better outcome. We know that the females are the stronger sex and it probably relates to that. [Laughter] Dr. Mike Patrick: What about ethnic variations? Do you see that at all? Dr. Jonathan Finlay: Not so much in brain cancer. There are certain other childhood cancers where they seem to be less common in African-American for example, but we haven't really identified that — with the exception of a rare but highly treatable form of brain cancer called germ cell tumor arising in the brain, where we know that this far more common in North America amongst patients of East Asian origins. In fact, in areas of Southeast Asia, this type of otherwise rare germ cell tumor in the brain actually is the most common type of brain cancer in children and adolescents, and it's clearly related to certain genetic characteristics. Dr. Mike Patrick: Dr. Coven, what signs and symptoms would alert a parent that could be a possibility, that their child has a brain tumor? Dr. Scott Coven: The signs and symptoms can vary, especially by age, as we look at brain cancer over time. The most common symptoms you'll typically see are headache, nausea, vomiting, weakness, paralysis, visual disturbances, even seizures. Some other less common symptoms especially in the younger ages, you'll see GI issues. There'll be concerns from that standpoint. 0:30:08 And this is typical for what we're seeing over the past ten years when we've done our recent literature review here at Nationwide Children's. We're finding that our symptoms are pretty much consistent with what's been studied in the past. The difficulty with this is that nothing's really changed over the past 30 to 40 years. When we look at improvements in how we've been doing in brain cancer, the timeframe that it's taken from symptom onset to diagnosis in 1980s is the same as it is today and that's very disheartening. Dr. Mike Patrick: I think from a general pediatrician standpoint and from a parent standpoint, we see a lot of kids with headaches, and when headaches aren't going away, sometimes it's the unspoken fear in the room that the parent, they bring their child to the doctor because they think could they have a brain tumor that's causing these headaches that the child complains of so often? Is isolated headache without any neurological symptoms or any of the other symptoms that you talked about a concern for the possibility of a brain tumor? Dr. Scott Coven: Certainly, having a family history of migraine, having some of these other symptoms will certainly raise an awareness of potential brain tumor. Currently, we are working with the Headache Team through Neurology to streamline a pathway — especially in the ER and the general public in general pediatrician offices — about raising awareness of when we should be concerned, referrals to a neurology or the Neuro-Oncology team, or referrals for imaging studies. That's part of our hopeful program called HeadSmart that has been started in the United Kingdom. We hope that we can really enhance awareness of the general public here in Central Ohio and hopefully beyond that. Dr. Jonathan Finlay: It's important to remember that we're still talking about a relatively rare group of disorders. And our poor pediatrician in the community may see no more than four or five brain tumor, diagnose these children with brain tumors over the entire course of their practice. 0:32:14 On the other hand, headaches, they see a dime a dozen, day in and day out. Most of the time, it is sinusitis. Or there's a family history of migraine and everybody assumes that well, you just got dad or mom's inherited predisposition to migraine. In little children, we know lots of babies, do anything with them, any kind of ours that got that diarrhea or the GI upset. Dr. Mike Patrick: Yeah. Right. Dr. Jonathan Finlay: The number of infants, under the first six to nine months of age who eventually are found to have a brain tumor and had been worked up for gastrointestinal problem is really quite incredible. It's easy for us as neuro-oncologist to talk about this because, of course, by the time they get to me, they almost got a plaque around them next to saying, "Hi. I got a brain tumor." It really is difficult for the community physician, and of course, even more so for the poor family out there who have never even heard of this stuff. The real goal of our program that we're going to be talking about shortly is really to try and sensitize and help the community provide, be it a pediatrician, a family physician, a neurologist and orthopedic surgeon. As well as the families be sensitize, not only when they need to be concerned about the possibility of a brain tumor, but also when they don't need to be concerned, when they could be reassured. Because the last thing you want to see is hundreds and thousands of children all of a sudden getting ran off to get MRI scans of their brain for unwarranted reason. So, the issue is how long have the headaches been going on? What is the time of the day that they get the headaches? Is there vomiting associated with it? Are there any however subtle, focal, localized neurologic signs that go hand and hand with it? It takes first and foremost a good history on the part of the pediatrician and a good physical examination. 0:34:21 Dr. Mike Patrick: Now, some parents would say, well, why not just scan everyone, then we know for sure? What are some of the disadvantages or issues with scanning everybody with headache? Dr. Jonathan Finlay: Well, first and foremost is that healthcare cost would skyrocket unbelievably, but there are also medical concerns. So first of all, we want to avoid doing CT scans, which is often in the community the first thing you would get — a radiologic study of the head, a CAT scan. We know there are studies actually from Britain that show that children who get an inordinate of CAT scans for non-cancer related reasons half over their lifetime and increased incidents of getting cancer. Remember X-rays, they are carcinogenic and we want to limit for our children that exposure. Now, MRI is the preferable way. That's not X-rays. It's not carcinogenic but it's not always so easy to get a quick MRI scan performed. And, when we're talking about young children, in order to get a good quality MRI, you often have to use anesthesia. It's fine to say that only one in a thousand children under anesthesia had a complication, but it's one too many if it's your child. Dr. Mike Patrick: Yeah, yeah, exactly. Dr. Jonathan Finlay: Especially if it turns out to be completely unwarranted. Dr. Mike Patrick: Yes. So let's talk a little bit about delay of diagnosis with brain tumors. Just how big of a problem is this and what can we do about it? Dr. Scott Coven: Well, this goes back to some of the research we've done here looking at institutionally or worldwide. Like we talked about earlier, there's really been no improvements within the field of delays in diagnosis in the past 30 years. Some may say that, obviously, the overall survival may change if you have a patient with a delay in diagnosis. 0:36:19 But what we do know is that the quality of life and the quality of care that this children will have with the delay in diagnosis is astronomical. Children may have irreversible vision loss, paralysis, weakness, things that may have been prevented if the brain tumor was caught at an earlier time period. And, of course, what we're talking about here is low grade gliomas that comprise almost 60% of our brain cancer. These are very slow-growing tumors, typically have multiple symptoms before they're picked up. And typically, when they do present, have these irreversible changes. Dr. Mike Patrick: How long of a period of time are we talking about? What are sort of the average that someone would go from the onset of symptoms to actually being diagnosed with a brain tumor typically? Dr. Scott Coven: It's a great question. Back in the landmark studies in the 1980s., it was about six weeks. And our study that we have recently completed is exactly the same, six weeks. To compare, what we've done is look at leukemia patients. Back in the 1980s, their symptom onset to diagnosis was about 14 to 20 days. Recently, we completed a study looking at that as well. Exactly the same, 14 to 20 days. Dr. Jonathan Finlay: It's important to point out because somebody out there may hear, "Six weeks, that's not too bad. What's the problem with that?" But you have to look at a range, and particularly when you're looking at children, as I mentioned, 60% of our children with brain cancer have this lower grade, mostly low grade gliomas. The range goes up to an excess of a year or even longer than that. And it's that that we need to really be, that bringing back and cutting down on. And we had not shown any such ability to do that until the present time. Again, the longer delay in diagnosis translates to these children into poor quality of life. 0:38:31 Dr. Scott Coven: And going back to what the whole purpose of HeadSmart is, is that in the United Kingdom, when they first started this in the midst 2000s their symptom onset to diagnosis was about nine weeks. And now, over the past three years, four years since HeadSmart has been piloted in the United Kingdom, they've actually found that their time to diagnosis is just now about six and a half weeks. So you may not think two and a half weeks sounds like a lot, but to these parents of children who may have these irreversible changes, it's a huge difference. Dr. Jonathan Finlay: Once again, what our English colleagues have shown is that the tale of delayed diagnosis beyond six months, a year or even longer has dramatically disappeared. They really are preventing such incredibly long delays in diagnosis and accordingly anticipatal, their follow-up data will document if this is really true. But they anticipate that this will translate into better quality of life. Dr. Mike Patrick: The HeadSmart Program is an awareness program. I know there's a website associated with it. And we can put a link to that website in the Show Notes for this episode, 340 — 340 in the Show Notes over at just so folks can find it easily. But there's a lot of great information there, age-specific list of symptoms and brochures, things like primary care doctors could download and hand out, those kind of things. Dr. Scott Coven: And hopefully, in the coming months, instead of directing them to the HeadSmart United Kingdom website, we'll have our own and that's part of the program that we're trying to do over the next three to six months, which is get all the general pediatricians in the area resources that they contact with us if they have issues, concerns — when to image, when not to image, when to refer, when not to refer — brochures. Public speaking within the communities are all plans that we have over the next three to six months. 0:40:32 Dr. Mike Patrick: Yeah, beautiful. Dr. Jonathan Finlay: Initially, our focus really is in the Ohio — not just Central Ohio, but throughout the state — and actually regional adjacent states as well. It's absolutely clear that this is something that can be applied throughout the country. This issue with delayed diagnosis is not an Ohio problem. It is really a nationwide problem. Dr. Mike Patrick: Yeah. And I'm sure something that parents are very concerned about. And, of course, folks who are listening to this program, certainly, especially if their kids has had some of these symptoms that we've talked about. It's peace of mind too, whether their kids have these symptoms. Because sometimes parents will get the idea in their head that it could be a brain tumor but it doesn't match up with those symptoms. So not only in terms of helping diagnosis, it can also help with some reassurance to say, "No, that's not the set of symptoms that your child has." Dr. Jonathan Finlay: Absolutely. Dr. Mike Patrick: So, how are brain tumors diagnosed then? So we talk about imaging, CAT scan, MRIs. You see something there. How do you know that it's a brain tumor? Dr. Scott Coven: That's a great question. Like I said, imaging is typically the first step besides after having the symptoms. Typically, after that, we're really thankful here at Nationwide to have a multi-disciplinary approach. So, a lot of these patients, if they get sent from the emergency department or their general pediatrician, they normally first see Neuro-Surgery. If they get admitted to Nationwide Children's, typically they get admitted to Neuro-Surgery Service. And then, we are really lucky here to have some great neurosurgeons who communicate well with the whole team, so that the Neuro-Oncology team meets with the patient upfront. We have our own social workers and clinical team as well to really make sure that we're doing the best for the patient and taking good care. A lot of it goes back to just what we're seeing from the imaging studies, what we're seeing from the Neuro-Surgery team and how best we can help that patient get through those first few weeks. 0:42:30 Dr. Jonathan Finlay: It's also important to point out that the improvements in imaging — advanced magnetic resonance imaging studies such as we do here — now allow us actually before we even contemplate a biopsy, which obviously is the ultimate way to diagnose a specific type of brain tumor. But advanced imaging can actually help us very much determine how we're dealing with a low-grade lesion, how we're dealing with a more malignant lesion, and sometimes what type exactly of lesion are we dealing with. But often, the decision comes to do we do a biopsy? Do we do a resection? Sometimes, these things are picked up almost by accident and you see something is not always as if there's no symptoms or sign attached to it. Careful observation is often all that is needed. But usually, the issues evolve around do we get a tissue diagnosis? How do we get that done most safely and does it require resection? Again, this depends upon whereabouts the lesion is in the brain. Dr. Mike Patrick: I think some parents may have that question in their mind, malignant versus benign. What does these terms mean and what's the difference? Dr. Jonathan Finlay: I don't like the word benign. Benign comes from the a Latin word that means good. Nothing growing in your brain that shouldn't be there is good for you. I prefer, most of my colleagues agree, we talk about lesions that are either low-grade, that is very slowly growing, of low-growth, less likelihood — but not always — less likelihood of spreading to other parts of the brain and lesions that can often be managed simply by surgery or with other simple therapies. 0:44:18 Malignant is the opposite of that. That's why you have a highly proliferative, rapidly growing lesion that if not dealt with fairly promptly can result in significant damage and indeed death. Most of the malignant tumors tend to be diagnosed pretty quickly in this day and age. Although, I've certainly seen examples over the years, particularly in the very youngest of children and infants where gastrointestinal problems, as we talked about earlier, may be masking what's really going on. The failure to recognize a head that's growing somewhat larger than the rest of the child's body, I've seen remarkable diagnosis made by nurse practitioners who pointed out to the pediatrician, "There's something going on here. This kid's head growing more rapidly than it should be." And they've caught it that way. But I've also seen examples that this has been missed. Dr. Mike Patrick: That's one of the reasons that we check head circumference during well-child checkups. Dr. Jonathan Finlay: Exactly. It is so, so important. I cannot stress the importance of that, not just measuring it and comparing it and looking at the rate of growth compared to the linear growth. It's so important. Dr. Mike Patrick: In terms of treatment, so you talked about resection which would be taking the tumor out. What other forms of treatment are available for brain tumors? Dr. Scott Coven: We still know from research getting as good of a resection if possible upfront really determines how well a child will do long term. Some of the other things in treatment approaches that most parents will hear about is sometimes just observation alone. Some of these brain cancers obviously can be observed over time with monitoring of imaging studies. Some kids will do great. Obviously, some kids may require chemotherapy which is delivered through the blood vessels that go throughout the body. 0:46:27 And then, lastly most often radio therapy. And we have a good working relationship with OSU and The James who help us deliver radiation therapy to our children there in hope to decide on a plan and best treatment for our children. Dr. Mike Patrick: So each kid is going to be really unique. Dr. Jonathan Finlay: Really different. And it's not just tumor-related but very much age related. So that particularly in children under six to ten years of age, we work very hard even with the most malignant tumors to avoid radiation therapy if possible or at least minimize the use of radiation therapy. Because radiation therapy is not good for the developing brain. And that is an understatement. The younger you are, the more profound and irreversible will be the effect of radiation over the long term, in terms of intellectual functioning, memory and what have you. Also, radiation therapy is a double-edge sword. We know from experience with Hiroshima and Chernobyl that not only can it kill cancer but it also can cause cancer, and particularly in the youngest of children, So those are two very good reasons why we want to limit the use of radiation. This is something that here at Nationwide Children's Hospital, we're actually leading an international effort for children with the most common malignant brain tumors in the first decade of life, avoiding the use of radiation. Dr. Scott Coven: Of course, a subset that we didn't talk about is inoperable brain tumor because we do still have unfortunately patients that resection is not possible and treatment options in those case are typically limited. 0:48:11 Dr. Mike Patrick: Is that mostly based on the location of the tumor? Dr. Jonathan Finlay: Based on the location of the tumor but also the biology. Again, when we talk about brain cancer and how do they do, it's a little bit like saying how does a person with infection do? We got on one end of the spectrum is the common cold and at the other end of the spectrum are some of these weird African viruses that killed 95% of everybody who comes in contact with them. Brain cancer is a little like that. We have — it's not the same — some tumors where surgical resection is all that is needed. That reflects the location and the ease of the surgeon to be able to get there with impunity, but also the biology of the tumor. On the other hand, you can just travel two centimeters deeper and you're in the middle of the brain stem and you have a particular brain tumor which represents about 8% to 9% of our children with brain tumors and that tumor has remained incurable over the 14 years of my career in this field. And, hopefully, we're still trying to strive to improve that but nothing we've been able to do up to the present time has impacted at all above the diagnosis of such children with this diffused, intrinsic tumors within the pans, within the brainstem. And then, there's everything in between and we've made great strides in some of the malignant tumors with the use of intensive chemotherapy and limiting the doses of radiation therapy. So, we're improving outcome and quality of survival. I think that's so important to stress. It's not enough just to say we're curing this child or that child or the other child. It's a Pyrrhic victory unless we're able to allow such a child to grow up, sustain his place in the school place and then society at large and have a good quality of life. And that's what we strive for. 0:50:03 Dr. Mike Patrick: Absolutely. Speaking of new developments in striving, what are some of the hot topics right now in brain tumor research? Dr. Jonathan Finlay: Well, there are a number I could mention but I think what comes to mind immediately, is that a result of our increasing understanding of the biology of many different types of childhood brain tumors, we have learned the molecular level characteristics of certain of our tumors. Which, not only when we identify them help us prognosticate or predict who is going to do better, who is going to do worst, who needs more therapy, who needs less therapy. So we do not risk tailored therapy. But, even more than that, identifying particular molecular markers in a tumor that are not present in other normal cells of the body, and the development of drugs that target these molecular markers. We actually already have drugs that will target and treat certain of our aggressive brain tumors. This is the catch phrase that you hear in the news media these days, "personalized medicine". This is what we're talking about, targeted therapy. Another aspect of targeted therapy that we are particularly interested in and involved with her at Nationwide Children's is immunotherapy. That's where you teach the patient's own immune cells — that is the cells that normally are involved in fighting infection, haven't done a very good job so far at fighting cancer but have that potential with teaching them to do a better job of attacking specifically the cancer cells in their own body. Dr. Mike Patrick: Yeah, boy, it's so interesting. Dr. Coven, tell us a little more about how patients and families can find resources that they need to raise awareness about brain tumors. Maybe if they have other questions about brain tumors or the list of symptoms again. What are some of the best way to educate folks? 0:52:11 Dr. Scott Coven: Some of the us is using the website, the link that you talked about,, right now. It's the one that we're referring patients, parents and general providers to. And then, hopefully, over the next three or six months, working with our department here, transforming that into a program that will be more applicable to Central Ohio and then potentially to United States as a whole. This one include symptoms for age group, different types of brochures, posters. We're doing talks. We've talked to local charities here within the Central Ohio community to help raise awareness for children who already have brain cancer or families who may not know as much about brain tumors but still may be concerned about symptoms that their children are having. Dr. Mike Patrick: Not only is there information there for parents, there's also great learning opportunities for providers as well. I noticed there were some specific learning modules that were available at that site. Dr. Scott Coven: So that may not be the upfront development but part of the long-term plan is to develop a physician module or healthcare provider module, where we'll have probably some teaching cases. We plan maybe do a mobile application for a phone to really streamline the information to the provider quickly and to the family, so they can quickly access it, quickly decide how worried they should be, how worried they should not be. And ultimately, we want to make sure that we're getting the right information out there to everyone and obviously not increasing the amount of imaging studies we're doing with reducing cost still and, overall, making sure that we're raising awareness to the children and to these families. Dr. Mike Patrick: You could have a continuing Medical Education podcast as part of the website. You know, just saying. Dr. Scott Coven: That'd be great. Dr. Jonathan Finlay: That'd be great. Dr. Scott Coven: We love it. 0:54:19 Dr. Jonathan Finlay: Any opportunity. We're willing to travel anywhere throughout the Midwest and discuss all this. Dr. Mike Patrick: Dr. Finlay, tell us about the Neuro-Oncology Program here at Nationwide Children's. Dr. Jonathan Finlay: Well, I've moved here to Columbus, Ohio with my wife and three dogs about 19 months ago now. And as much as my wife and I really enjoyed Columbus, we really moved for Nationwide Children's Hospital presented for me a wonderful opportunity, given what I found to be the really visionary approach of the administrative and medical leadership of this hospital, the wealth of the community, the incredible support that exist for this hospital and the community. I'm pleased to say that over the last 19 months, all my anticipated expectations have been more that realized. I'm having a wonderful time here apart from anything else. But I've really been privilege to help in the building up of really a fantastic children's brain injury program, both in the educational terms and recruitment of the young faculty, in the recruitment of Fellows, like Dr. Coven here, into our work in terms of the clinical research that we're doing and the management of our children. It's been a wonderful experience. I think people are aware that Nationwide Children's Hospital is one of the most rapidly growing institutions, children's hospitals in America. And that growth is not just simply in size and numbers and size of buildings, but in terms of academic and clinical stage. I'm very proud of this program in our child with brain tumors is a part of that process. 0:56:03 Dr. Mike Patrick: Great. And we'll put a link also to the Neuro-Oncology Program here at Nationwide Children's, as well as the Head Start, HeadSmart — HeadSmart — Resource. Dr. Jonathan Finlay: HeadSmart. Not to be confused with Head Start which is our program for young children with brain tumors. Dr. Mike Patrick: Yeah, as a primary care pediatrician, HeadStart kind of rolls off my tongue. So HeadSmart and we'll put a link to that resource as well. Again, both of those things, that and the Neuro-Oncology Program at the website for this podcast, Show Notes for Episode 340. All right, well, I want to thank Dr. Jonathan Finlay and Dr. Scott Coven for stopping by and talking to us about brain tumors. Really appreciate it. Dr. Jonathan Finlay: It's a pleasure. Dr. Scott Coven: Thank you very much. [Music] Dr. Mike Patrick: We have a question this week from Elizabeth in Seattle. Elizabeth writes, "Hi, Dr. Mike. When my son receives speech therapy services, the special educator that work with the speech therapy made a comment that W-sitting was a problem and should be discouraged. My son did not W-sit but she made it clear to me that if he ever start to sit in that position, we should definitely discourage it. "The gal I know has a four-year-old child who routinely W-sits. I mentioned this to her in the past and when discussing it again today, she said she had ignored my previous comment because she doesn't think her child has a problem. What are your thoughts on W-sitting and is it really an issue? Should it be discouraged? Should it be at least be investigated if the children prefers this kind of sitting over others. "I'm going to stop bringing it up with this particular mother, but I like to know if it's worth bringing up to a different mom if her child sits like this on a regular basis. Thank you for your time and attention. Elizabeth." Well, thanks for the question, Elizabeth. Always appreciated. 0:58:14 So, let's begin with the definition. What exactly is W-sitting? It's a sitting position in which the legs are in the shape of a W. So they're spread apart, hips and knees are flexed and weight is distributed on the back of the thighs and in the inside surface of the lower leg. So the legs are kind of pulled back toward the child. If you look at your child from above, their legs are in the shape of a W with their feet at the top of each side of the letter. If you're having trouble picturing this, just do a quick Internet search for W-sitting. Pictures will appear ad it will all make sense. You've probably seen kids sitting in this position. It looks rather painful for adults unless gymnastics was in your recent past. But the kids who sit this way, they seem perfectly comfortable with it. They enjoy it. For some, it's their go-to position. So should W-sitting be discouraged? Is it harmful? And that's really at the heart of Elizabeth's question. I'm going to take an evidence-based approach as we consider answers which is something we always try to do here on PediaCast. At least that's our goal to the extent that it's possible. But I really want to point that out here because in this particular case, the answer that we arrive at when we look at the evidence may not be the answer that you find when you do a simple Internet search on the topic. You'll probably find lots of links to sites by those who discourage this practice, including many in the physical therapy community. And that's not really a surprise because as I research this question, it quickly became apparent that many physical therapy programs teach their trainees that W-sitting is bad. And because the learners heard this during their training, many practicing physical therapists today discourage W-sitting in children, and that is really borne out by doing an Internet search. You'll see that lots of physical therapists say don't do it. It's bad. 1:00:08 So what is it that physical therapists to-be learn about W-sitting? Why do they think it's bad? Well, the lesson that's presented is that sitting in a W configuration can lead to hip strain and possible hip dislocation. Also, muscle tightness in the thighs and lower legs, and it can aggravate already existing neuromuscular conditions such as low muscle tone. So why is this taught? Is it because there's a large body of evidence supporting these claims? Actually, no, there's not. And a quick search of W-sitting and other ways of describing that sitting position on PubMed or Google Scholar, those searches will largely come up empty. And yet, a regular Internet search on W-sitting reveals page after page after page of therapists warning against it. But, none of those pages that I looked at — and I looked at a lot of them– none of them that I could find back up this advice with any scientific evidence. So here’s no citation. There was no, "Hey, this study showed this." None of that sort of thing. So this leads to another question. If there is no evidence, why make the claim? Well, the reason I think is because physical therapists see this association on a fairly regular basis and they've seen it for a long time. Which is why the teaching has become ingrained in the training program. W-sitters who make their way into a physical therapist office, a good number of them have hip instability, muscle tone problems. And because this association is seen so often and has been seen for so long, even though it's not been rigorously studied, the association is probably true. Now, I've said this before, documented scientific evidence is not everything. It's important to be sure, but at the end of the day, truth is truth, whether it's been studied or not. And observational evidence from an experienced practitioner, that means something. But we also have to keep this in mind — an observed association does not prove cause. Does W-sitting cause hip instability and muscle tone problems? Or, does having pre-existing hip instability and muscle tone problems, does that lead to children preferring the W-sitting position because it's easy and comfortable for them to do? 1:02:30 So if you look at it that way, a couple of other questions come to mind. Number one, should W-sitters be screened for hip instability and muscle tone problems? Since we observed this association, whether it's causative in nature or not, should we at least screen? And, number two, when considering children with no hip instability and muscle tone problems, should they be discouraged from W-sitting because of concern that it may aggravate their condition? These are good questions. The first is pretty easy to answer. Sure, screen everybody who sits in a W-configuration for joint muscle and neurological problems. Actually, we as pediatric primary care providers, we should be screening all kids for these conditions. Not just the W-sitters, all children. And that's why we want to see kids every year as they develop. Does every W-sitter need to see a specialist or a physical therapist? In my mind, the answer to that question is no. Bring up your concern with your child's provider, absolutely do that. But if your child's exam is normal, and they're active and playful with no evidence of pain or disability and your provider is not concerned and your provider is saying sure, let him W-sit. I would agree with that. It certainly makes sense. On the other hand, if there is a concern with neuromuscular and or orthopedic development, then it's time to get a specialist involved and the right one is really going to depend on the signs and symptoms that you're seeing. Pretty common sense approach, I think, right? 1:04:01 Common sense is important here because for every W sitter who ends up in the physical therapist office with hip and muscle tone problems, how many W-sitters have never had any problem at all and don't end up in a specialist or physical therapist's office? We don't know the answer to that because that particular study has not been done. But I bet there are plenty of pediatric primary care providers out there who would say that their experiential evidence tells them it's a whole lot of kids that they've seen who W-sit and never have a problem. The next question that I pose isn't as easy to answer — children with known hip instability and muscle tone problems, should they be discourage from W-sitting because of concern it may aggravate their condition? Here is what I think having some research on this would really be helpful — because on the one hand, we don't want sitting position to aggravate an underlying condition, right? On the other hand, we don't want to take away a comfortable sitting position that a child has adapted because it's functional and comfortable despite their condition. So it's an important distinction. When we don't know for sure the right course of action, do you allow or discourage W-sitting in a child with a known neuromuscular or orthopedic problem. The answer to that question should really boil down to a case-by-case decision between a family and their child's providers including the physical therapist. So, bottom-line, Elizabeth, I think it's fine to mention the association to moms you meet, encourage them to have their child checked out by his or her primary care provider. But if the child's doctor is saying, their examination is normal, W-sitting is fine for this child, I'd have no problem going along with that recommendation. By the way, I'm going to include a link to a blog post in the Show Notes for this episode, 340, over at It's called W-Sitting: Problem or Solution? And it's written by a PhD professor of physical therapy, Dr. Kendra Gagnon at Rockhurst University in Kansas City. I think she's definitely a voice of reason when it comes to W-sitting. So if you like to read more about this issue, I'd encourage you to check out her post. Hope that helps, Elizabeth and as always, thanks for the question. 1:06:17 Don't forget, if you have a question like Elizabeth did, it's really easy to get in touch with me, just head over to, click on the Contact link and ask away. [Music] Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that. Also, thanks to our guest this week, Dr. Jonathan Finlay, the medical director of Neuro-Oncology for Nationwide Children's Hospital and Dr. Scott Coven, a Hematology, Oncology and Bone Marrow Transplant Fellow here at Nationwide Children's. We really do appreciate both of them stopping by to talk about brain tumors. Don't forget PediaCast is a production of Nationwide Children's Hospital. You can find us in all sorts of places. We're in iTunes, in the Kids and Family Section of their podcast directory. And if you have not left a review in iTunes, we'd really appreciate it if you have iTunes, if it's convenient and easy for you just to stop by there and leave a quick review of the program. It's always appreciated. We're also in most podcast apps for iOS and Android. If you can't find us in your favorite podcast app, let me know and I'll do my best to get the show added to their line-up. Just head to, click on the Contact link, and shoot me a line. Let me know that you need PediaCast in a particular app and we'll try to get it there. 1:08:04 We're also on iHeart Radio, where we not only have this program but also PediaBytes, B-Y-T-E-S. They're 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, You'll find hundreds of past episodes, Show Notes, transcripts, our terms of use and a handy contact page to ask questions and suggest show topics. We also have the voice line if you'd rather phone in your question or comment. That number is 347-404-KIDS. 347-404-5437. We're also on social media including Facebook, Twitter, Google+ and Pinterest with lots of great content you can share with your own online audience. Of course, we always appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids or those who take care of children, including your child's healthcare provider. In fact, next time you're in for sick office visit or a well check-up, sports physical, 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, so tons of content and deep enough to be useful and helpful but always in language parents can understand. And while you have your providers ear, please tell them we have a podcast for them as well — PediaCast CME. Similar to this program, we turn science up a couple of notches and provide free Category 1 Continuing Medical Education Credit for listening. Shows and details are available at We also have posters if you like to share the show the old-fashioned way and those are available under the Resources tab at Thanks 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. [Music] 1:10:06 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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