Sick Kids & Child Care, Neck Injuries – PediaCast 353

Show Notes


  • We have two interviews for you this week. Dr Andy Hashikawa joins us for a discussion on sick kids and child care. Where can providers and parents find guidelines on keeping kids home? And how well do child care centers follow these guidelines? We’ll take a look. Dr Julie Leonard also stops by for a discussion on pediatric cervical spine injuries. We hope you can join us!


  • Sick Kids
  • Child Care
  • Exclusion Guidelines
  • Neck Injuries
  • Cervical Spine Injuries




Announcer 1: This is PediaCast.

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

Dr. Mike Patrick: Hello everyone, and welcome once again 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 353 for September 14th, 2016. We're calling this one "Sick Kids in Childcare and Neck Injuries". I want to welcome everyone to the program.  

So I have a couple of great interviews for you this week and I think you get a pretty good feel for the topics at hand, given the title of today's episode, Sick Kids In Childcare and Neck Injuries. Now, you may be wondering how are these topics related and why are we  covering them now? 

Well, first, they aren't really related but they do tend to affect parents at both ends of the age spectrum. So, in that way, we have a little bit of something for everyone this week. It's the parents of younger kids who are typically struggling with the question of sick kids in childcare. And it tends to be the parents of school-aged children and teenagers who are more worried about neck injuries. Although, of course, kids of all ages get sick, attend childcare, school and also injure their necks. So, again, we really do cater to all parents with our topics this week.

Now, the why now question is a little bit more interesting. You know, school's back in session, which means kids are getting sick from other kids in the classroom. They bring the germs home. They share them with younger siblings who take the disease to childcare and share with the other kids there. And then, they take the germs home and share them with the older siblings, and they take the disease to school. And we have a big giant cycle here. You get the picture. 

Of course, moms and dads are affected, too, from childcare and classroom illness because parents take the disease that they catch at home from their kids to work and share it with their co-workers.


So the bottom-line is we all get a little more sick this time of the year. It never fails. And it doesn't really matter what the weather outside is like because temperature does not drive illness patterns. Childcare and school attendance does drive it. With all the kids in close, close quarters sharing their microorganisms, you can't get away from it. 

So that begs the question, when should you keep sick kids away from childcare and the classroom? Should they stay home with any illness? That seems a bit impractical. After all, most illnesses are minor and short-lived. And the way our immune system works, getting minor illnesses isn't necessarily bad because it revs up the immune system so that you have protection against that illness the next time it comes along. And in subsequent time, you don't get quite as sick from the organism. It happens all the time. 

And if your kids aren't exposed to these stuff in childcare or the classroom, they'll surely pick it up at the grocery store, at the library, at the sports gym, your place of worship, your church. And with this much illness, it goes around on any given day, if you excluded kids with any ill symptoms, there are times when you'd likely exclude half of the class or more on any given day, which interferes with learning and moms and dads going to work and making a living. 

So, we don't necessarily want to exclude everybody. We have to pick and choose so that we don't spread dangerous diseases. That's the idea behind guidelines for when to exclude kids from childcare. Well, as it turns out, some childcare centers go a little over the top with their exclusion policies. 


So, we have a guest joining us today who's done a good bit of research on childcare exclusion guidelines — which kid should and should not stay home from childcare in the classroom, and then how well or how poorly individual childcare providers follow these guidelines. So we'll explore his research and the topic in much more detail. That's coming up with an interview with Dr. Andy Hashikawa from the University of Michigan. 

And then, we're going to cover neck injuries after that. This is another good topic anytime of the year but especially in the early Fall as school sports gets back in swing. So we'll talk about the different types of neck injuries, the symptoms of each, which ones you should worry about, who needs an ambulance ride and an emergency department visit, an X-rays or CT scan or an MRI. Why are children more prone to neck injuries compared with adults? How are neck injuries treated? And what are the latest hot research topics surrounding pediatric neck injuries? 

And we have a great guest for this one as well. Dr. Julie Leonard is a nationally known expert on childhood cervical spine injuries. She's published a plethora of scientific papers on the subject. So, she'll stop by to share her knowledge. 

Before we get started with our guests today, I do want to remind you, if you have a topic that you'd like us to talk about, suggestion for the show, a question for me, it's really easy to get in touch. Just head over to and click on the Contact link. I do read each and every one of those that come through and we'll try to get your topic or your question on the program. 

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 


Let's take a quick break. And, I will be back to talk about sick kids in childcare and neck injuries. It's coming up right after this. 


Dr. Mike Patrick: Dr. Andy Hashikawa is a pediatric emergency medicine physician at CS Mott Children's Hospital in Ann Arbor, Michigan, and an assistant professor of Emergency Medicine at the University of Michigan Medical School. One of Dr. Hashikawa's research interests is sick kids in childcare, more specifically who should attend childcare with their illness and who should stay home. He's also interested in who makes these decisions and the consequences these decisions bring. 

It's an important topic, one that many parents and childcare workers wrestle with frequently. So let's give a warm PediaCast welcome to Dr. Andy Hashikawa. Thanks for joining us today. 

Dr. Andy Hashikawa: Thanks for having me, Mike. 

Dr. Mike Patrick: Yeah, really appreciate you stopping by. I think we have to define right at the beginning, 'childcare exclusion' what is meant by that term? 

Dr. Andy Hashikawa: That's a great question. So, the term childcare exclusion really refers to when any sick child is kept out of childcare. So this can occur when a child becomes sick at childcare and then are sent or excluded home. Or when a parent happens to drop him off at childcare and the childcare staff quickly figures out they might be ill or sick and then are sent home. And finally, it occurs sometimes when the parent reports or calls in, "My child isn't feeling that well," and then the childcare says "Yeah, it's probably best that they stay home." So, that's usually what we mean by childcare exclusions related to illness. 


Dr. Mike Patrick: And in terms of policy, this is typically set at the local levels. Is that correct? 

Dr. Andy Hashikawa: Yeah, that's completely correct. This can vary state by state, county by county, and at the local public health department. So it can vary quite significantly. And these exclusions are sometimes really necessary to keep other children safe. For instance, if you have chicken pox or if a child is having bloody diarrhea, it's really important that some of these exclusions take place to prevent the spread of illness to other children.

Dr. Mike Patrick: Yeah, absolutely. Now, there must be some sort of guideline that even though the policies are set locally, just national guidelines that then local officials can look to as they make these decisions. 

Dr. Andy Hashikawa: Yes, there are actually. They've existed for a number of years, over 20 years, and they're from the American Academy of Pediatrics. They worked alongside the American Public Health Association. And these are really national guidelines for childcare providers and preschool teachers. And there are specific guidelines about which sick children should be excluded from childcare. 

If you look at the guidelines, they all boil down to at least a couple of different principles and questions that a childcare provider should ask. The first is, does the child's illness keep him from comfortably participating in activities? So for instance, if you have a child with a fever and he's clearly not feeling well, just laying down, won't do anything, that might be a situation where child really feels unwell and should be sent home. 

The second question that we also like to ask is does the sick child need more care than the staff at the childcare can safely provide without really affecting the health and safety of other children? So, for instance, if all your care and resources are focused on a child who's having lots and lots of diarrhea, who's watching the other kids? Are they safe? So, all the principles really boils down to those two kind of principles.


Dr. Mike Patrick:  And the guidelines themselves really look at specific body systems and different symptoms that kids can have and give you an idea. So if you have a kid who does seem well enough to participate and the staff has enough manpower to take care of that kid along with all the other children, then just from a symptom standpoint, you can look up these guidelines and see if it's something that would be necessary to keep the child home or go ahead and send them. 

Dr. Andy Hashikawa: That's absolutely correct. So, for instance, you have child who has a low-grade fever, but he's actually doing well, running around. There's no changes in his behavior and it really doesn't bring a lot of resources into play, this child, for sure, could potentially stay in childcare without being sent home for just a low-grade fever. 

Dr. Mike Patrick: And these guidelines, for those who are interested are in a product called Caring for Our Children, National Health and Safety Performance Standards. And then, there are guidelines for early care and education programs. And it's in the third edition. So it's a mouthful. But to make it easy for folks to find, we'll put a link to it in the Show Notes for this episode, 353, over at That will take folks directly to the document, so they can look it up on their own. 

Now, walking us a step further then, what is an unnecessary exclusion? 

Dr. Andy Hashikawa: Unnecessary exclusion really refers to the term when children with colds that aren't really causing a lot of symptoms are sent home when they really don't need to be and they actually could stay in childcare. We know that a lot of the illnesses which occur frequently when a child is in child care are really not harmful. They're caused by cold viruses. And in fact, the virus is actually spread a lot of times before the child is sick. 


So, having the child go home just to prevent spread is really no longer recommended because a lot of these cold viruses are spread way before the child becomes sick. So it's really more about making sure the child is comfortable, that there are resources at childcare and not so much about sending the child home with a cold to prevent illness because we know that's no longer the case. So, if a child were to be sent home just to prevent spread, that might be considered an unnecessary exclusion. 

Dr. Mike Patrick: Let's go through some examples of situations where some kids are sent home versus could stay. Let's talk about misconceptions that are out there. 

So the first one, you kind of hit upon a cold. So viral upper, respiratory illness, kid has a runny nose, congestion maybe a sore throat, might have an ear infection could even have croup. But again, as long as there's not a high fever and they're comfortable, and you have the ability to care for them, that's not necessarily an exclusion, right?

Dr. Andy Hashikawa: That's completely correct. Again, the vast majority of all sicknesses, illnesses in child care are really caused by viruses, really not harmful to the child or to other people. And actually, as your immune system is learning, it actually makes your immune system stronger. So, that's a time when a child could be safely kept at childcare. 

There's also a lot of other misconceptions. For instance, awhile ago, a lot of these viral or colds were treated to antibiotics. We realize now that antibiotics really don't do anything for viruses. For example, pink eye for a long time was thought to be mostly a bacterial infection, but research really has shown that they tend to be more of a cold of the eye. They are caused by a cold virus. So the majority of the time, physicians really no longer recommend treatment with antibiotics. And actually we treat it as a cold of the eye. 


So these children, for instance, with a little pink to the eye, redness to the eye but are otherwise acting fine really don't need to be sent home to go to the doctor's office to get antibiotics. These children can continue to stay in childcare. 

Dr. Mike Patrick: So that's another one of the misconceptions that anyone with eye symptoms of any sort should stay out of childcare until their eye symptoms are gone. That's not necessarily the case, at least according to the national guidelines. 

Dr. Andy Hashikawa: That's correct. Oftentimes, if we were to exclude children with a cold, that could result in several days of being gone and for a parent, that's going to be really rough. So, there's no evidence to suggest that's beneficial. The majority of the time, they just do fine. Again, a lot of this is already spread before they have the symptoms. So it's absolutely appropriate that a child, if they're feeling well, can stay in childcare. 

Dr. Mike Patrick: Now, what about vomiting and diarrhea? 

Dr. Andy Hashikawa: That's a great question. Often, we see kids either spit up once after they'd have something once after they had that really doesn't agree with them or have a loose stool. Usually, those kids are actually fine to stay as long as they don't have a fever that goes along with it. But oftentimes, we do recommend if there's a trend that they're having multiple episodes or the diarrhea is leaking through the diaper — it's a trend — and that usually requires more resources there at the childcare. So those are the children where you'd say probably should be at home. 

The other one will be if they have bloody diarrhea. That's one that we definitely feel that should be sent home. But the most part, just one kind of spitting up no longer is an emergent exclusion to home or the doctor's office. 


Dr. Mike Patrick: A lot of these stomach viruses that cause what we call gastroenteritis, the vomiting may last a day or two, but then the diarrhea can last for several days. But as you say, even when they're in that sort of diarrhea phase, as long as they don't have a fever and you can control where the poop is going. So they're potty trained or it's contained in the diaper and you're using good hand washing technique so you don't spread it, then you don't have to wait for the diarrhea to be completely gone before they go back. 

Dr. Andy Hashikawa: That's absolutely correct. Some of the diarrhea can last a long time as we know. Keeping this children out for sometimes a week or a week and a half at a time would really not be appropriate. And again, the evidence will suggest that these kids are completely safe to return to childcare. 

Dr. Mike Patrick: What about fever? Should fever in and of itself exclude kids from going? 

Dr. Andy Hashikawa: So that's a great question. Fever usually in and of itself, as long as the child is acting well and has no other major symptoms really doesn't exclude the child. The only exception to that will be a really young infant and that will be clearly defined. But kids' temperature can also change dramatically by even running around. We know that. So just because they feel warm or they have a low-grade fever, as long as they're acting well and it doesn't require extra resources, really the child can safely stay in childcare. 

Dr. Mike Patrick: Another common one is ringworm. So, kids get a lesion on their skin or on their scalp caused by a fungus or yeast. And then, they're sent home until they need a note from the doctor before they can come back saying that they're not contagious anymore. What about that?


Dr. Andy Hashikawa: So, yeah, that's an interesting one, because ringworm in and of itself sounds horrible. But we know that it's something that's very common. And usually, by the time parents or providers see ringworm, it's been there for weeks. We just didn't know about it. So, having a child immediately sent home that minute, that hour, so that they don't prevent spread really is not helpful at all. 

And the end of the day, it should be treated by an anti-fungal agent. But once treatment begin, they can return immediately to their childcare center or preschool. There's no need for the rash to completely disappear which would take weeks. 

Dr. Mike Patrick: Right. Absolutely.

Dr. Andy Hashikawa: So, if we were to wait for it to resolve, they would be out of the preschool for weeks. Again, it's no longer considered an emergency where they have to be excluded and parents have to come in during the middle of the day to get them home or their doctor's office. This can be taken care of at the end of the day. 

Dr. Mike Patrick:  There are a lot of other questions that parents may have about things such as impetigo, lice, scabies, molluscum contagiosum, thrush in babies' mouths. And again, for folks who want specific recommendations for specific sets of symptoms or diseases, do check out the guidelines, the national guidelines from the American Academy of Pediatrics and the American Public Health Association. And again, you can find the link for that in the Show Notes for this episode, 353.

Now these are national guidelines, but we also mentioned that the actual policies are at a local level. And so one of the studies that you were involved with back in 2010 looked at how exclusion recommendations compared to actual childcare practice. So tell us a little bit about that study. 


Dr. Andy Hashikawa: What we did was we surveyed over 300 childcare directors and kind of used hypothetical cases of children who really are well, have some minor symptoms of illness and asked them, "Would you exclude this child? Or, would it be okay for them to stay?" And if you take all the cases overall, almost 60% of the children would have been sent home unnecessarily or what we call unnecessary exclusion. 

And if you break it down, the biggest one was actually for ringworm. Almost 85% of them would have been unnecessarily sent home followed by a symptom of diarrhea, pink eye and fever, almost 60%. So this is a state that actually did have some guidelines that working still with the American Academy of Pediatrics, but we found that most  of the providers actually really were not in line with a lot of these recommendations and actually sending them home unnecessarily. 

Dr. Mike Patrick: Why do you think there's a gap between the national recommendations and actual practice at the local childcare level? 

Dr. Andy Hashikawa: Yeah, Mike, that's a great question. I think there's been a significant variability in how these guidelines are stated. For instance, many of them aren't very detailed, difficult to access. The second thing, just because having guidelines doesn't mean they're disseminated very well. There really hasn't been a lot of training for childcare providers. They're kind of been on their own. So knowledge about these guidelines are actually pretty low even though they were available at the local and state level. 


And a lot of these, it's knowledge that's handed down from their parents, and they're kind of almost what we call winging it and they're deciding case by case. So I think because of the variability, really training that's available, this is why I think the gap exists between recommendations and practice. 

Dr. Mike Patrick: Now, why do you think it's important to address this gap? This is another study that you were involved with in 2014 that just sort of looked at what the results of this gap then cause. 

Dr. Andy Hashikawa: I think based on our study, we did a national survey of parents who had a child in childcare setting. We kind of asked them what happens when you have a sick child that can't attend childcare? And it really showed that there were significant concerns from parents about loss of pay or job, or not being able to get a paycheck. 

There is also a significant burden on them trying to get them back to childcare as soon as possible, and this meant trying to get an appointment with the doctor. And we all know sometimes it's really hard to get an appointment with the doctor that same day or the next morning. So, many of these parents were having to seek care either in the emergency department or the urgent care, just to be able to get a doctor's note or say they can return to childcare.

And this can really affect the workforce, businesses, both poor and minority families. As we know, the United States is one of the few countries that really lacks substantial paid sick leaves especially when the child is sick, so it can definitely affect millions of parents nationally, especially those that don't have paid sick leaves. It can impact them significantly. 


Dr. Mike Patrick: Sure. And it drives up the cost of medical care, just as a society, as a whole if the sole reason that you're going to take your kid… And I hear this fairly often from parents. Like, "We're only here because we the note to get back. He may even be feeling better at this point but we need that note." And that really drives up the cost of the healthcare for everybody.

Dr. Andy Hashikawa: Yeah, many of the ED visits actually are for really non-urgent issues. And then, definitely, that increases the care of the medical cost for everyone. And also, there's been evidence that there's a lot of unnecessary antibiotics use where either parents or childcare providers are requesting antibiotics just so they can get back into childcare. And we know the problem with unnecessary antibiotics. It increases resistance. It's very costly and really not oftentimes safe for children when they really don't need antibiotics. 

Dr. Mike Patrick: Yeah. And not only the cost in terms of dollars but even wait time. When your kid does have significant issue, you may wait a little longer because of the parents who were there just to get the note. 

Dr. Andy Hashikawa: Exactly. That's how I actually got interested in this area. I was a medical student and I was working a shift in the ER. And it was 2 AM, and there was a couple of kids with a pink eye. And they looked really well, and I just finally asked, "You know, if I may ask, what brings you in at 2 AM to the emergency department having waited several hours just to see us?" And they said, "Well, it's really an emergency for me, because I know my kids are fine, but I need either an antibiotic or I need a work note, so I can get to work tomorrow." Yeah, so that's how I really got interested in this area, both in the childcare and the illnesses that occur. 

Dr. Mike Patrick: Well, interesting stuff. We're going to put links to both of these studies. The 2010 one that looked at actual practice of childcare providers compared to the national guidelines, and then sort of the after-effect of this gap, the 2014 study. And we'll put links to the PubMed abstract. And then folks can go from there to get the actual article if they want to read more. And we'll put that in the Show Notes again for this episode, 353, over at 


So, what do you think the role is then in terms of trying to close this gap between national guidelines and actual practice? What can pediatric providers and health officials do to help close this gap? 

Dr. Andy Hashikawa: I think one is, pediatric providers, really, when they're providing these anticipatory guidance… Especially for new parents, I think many new parents are really unaware that when their child attends childcare, they're going to be sick more often. And that's just because their immune systems are developing. Kids have no personal space. They sneeze all over and drool all over each other. It's inevitable that they are going to have more episodes of illness. Now, they're going to be healthier later on when they start kindergarten but during that first year of childcare, it can be pretty troublesome for parents. 

So, you know, having a pediatric fright is one, upfront tell them, "Hey, you're going to have a kid that's probably sick more often with cold." So just even having that ahead of time. 

Second, going through when they should think about a child needing to stay, a child needing to stay at home, and the fact that most of these illnesses really don't require antibiotics. They are treated just anticipatory guidance and with Tylenol and anti-fever medicines and usually with rash, but they really don't need antibiotics. 

And then, finally, having them plan ahead. So, there are times when a child going to have to stay at home because they really don't feel well. And so, planning ahead and having back up childcare would really be important, so they don't run into emergencies. 

Dr. Mike Patrick: Yeah, absolutely. And since a lot of these policies are set at the local level. I guess health officials and pediatric providers just armed with the knowledge that these guidelines exist could just raise awareness in their own community and with local childcare providers, that "Hey, these are what the guideline show." Because, they may not have heard this before. 


Dr. Andy Hashikawa: I absolutely agree. I think knowledge is power and usually, what I tell parents is "Hey, ask your childcare provider what their policies on illness are before it happens. Ask them are they using the American Academy of Pediatrics guidelines?" I also like to ask parents, "Hey, does your childcare provider actually get training for illnesses? How do they determine whether a child can stay or go?" So, having the parents ask these questions ahead of time really can help in terms of selecting what type of childcare they might want to take them to, and really making the childcare provider more aware that these American Academy of Pediatrics guidelines do exist. 

Dr. Mike Patrick: And I hope we have lots of childcare workers and even childcare administrators who listen to this program. What is their role in closing this gap? 

Dr. Andy Hashikawa: I think the number one thing is training. So, now, finally for the first time or the past several years, there's actually really good training available from the American Academy of Pediatrics. And I do want to let the childcare providers know that the AAP has really developed a new what we call VEEC. It's a Virtual Early Education Center that puts together all the health and safety training for childcare providers. It's a free a website and it has a lot of really good resources that are available. 

PediaLink also has free training for childcare providers that they can take for credit. It's on infectious diseases and childcare. So that's something we also recommend.


And finally, there's a new Managing Infectious Disease in Childcare and Schools, the fourth edition, that will be coming at the end of September and that will have all updated pictures, guidelines and training that they can receive. 

Dr. Mike Patrick: Yeah, that's fantastic. And we'll get those links in the Show Notes so folks can find those resources easily. Again,, Episode 353. 

Then, finally, there's a role that parents play. And this is, well, because I think to some degree at the local level… And again, this is not based on research, just really more observation and anecdotal stories, but I think that at the daycare itself, there's probably some pressure that when sick kids are there, that other parents don't want their child to get sick and then they put pressure on the daycare, like, "Hey, why do you have these kids here?" Even though, they may not be knowledgeable that this is not really a dangerous situation. Does that make sense? 

Dr. Andy Hashikawa: That does make sense. So one of the things that has been going on nationally is the concept that the childcare center or the daycare really is an important part of the medical home. Meaning, there should be good communication between the childcare, the parent and the physicians. So more and more, I have seen childcare centers or daycares have this in-home sessions where a childcare health consultant or a pediatrician or a pediatric resident will come in and do a session both for childcare providers and parents, where they can understand why the guidelines are set the way they are and what some of the common symptoms that are allowed in childcare. 

So I think good communication is really important between all three, and then there's a lot more information resources that are available that childcare providers can send to parents, and that parents can give to childcare providers if they are unaware of the guidelines. So, I think more and more realizing that childcare is such an important part of the child's health in the medical home. 


Dr. Mike Patrick: Great. Great stuff and lots of fantastic information for providers, parents and childcare workers. And again, we'll put links to all these resources including the national guidelines in the Show Notes for this episode, 353, over at 

So Dr. Andy Hashikawa, pediatric emergency medicine physician at CS Mott Children's Hospital and University of Michigan Medical School, really appreciate you joining us today. 

Dr. Andy Hashikawa: Thank you so much for having me, Mike. 


Dr. Mike Patrick: Dr. Julie Leonard is a pediatric emergency medicine physician at Nationwide Children's Hospital and an associate professor of pediatrics at the Ohio State University College of Medicine. Her top research interests and she has published many papers on the topic is cervical spine injuries in kids. 

There are many questions surrounding neck injuries in children — who is at heightened risk of serious injuries? How should these kids be evaluated? Where they should they be seen? How should they get there? Also important, what imaging studies, if any, do they need and how should they be treated? 

Parents and coaches, emergency responders, primary care doctors, urgent care providers and emergency department physicians all think about these questions. And Dr. Leonard joins me in the studio to help answer them. 

So let's give a warm PediaCast welcome to Dr. Julie Leonard. Thanks for stopping by today. 


Dr. Julie Leonard: Thanks for having me, Mike. 

Dr. Mike Patrick: Yeah, really appreciate you taking time out of your day. Let's begin just with an explanation of why is it that pediatric neck injuries are such a concern. 

Dr. Julie Leonard: Well, it's an uncommon event that when it occurs it can have serious consequences, be associated with injuries to the spinal cord. And so, long-term morbidity or deficits. 

Dr. Mike Patrick: So, you can have quadriplegia, if you break your neck and have a spinal cord injury. 

Dr. Julie Leonard: Correct.

Dr. Mike Patrick: So, pretty serious potential there from injuries. 

Dr. Julie Leonard: Correct.

Dr. Mike Patrick: And then, there's also another reason from a health standpoint is that some kids may get an excessive workup. And so, you get radiation exposure that you might not need. You wouldn't want to X-ray everybody with a neck discomfort, right? 

Dr. Julie Leonard: Correct. I think that's the balancing act is figuring out when both parents and as clinicians that we should be worried for the spine injury. Obviously, we want to pick up on those kids that have injuries that we can prevent the potential for them having any kind of neurologic deficit. But on the other hand, the vast majority of children don't have injuries, and we really want to minimize the amount of testing that we do for those children particularly the use of radiographic studies and testing such as computed tomography or CT scan. Those CT scans as we well know are associated with a lot of radiation and in children, that creates a lifetime risk for radiation induce tumors.

Dr. Mike Patrick: Sure. And MRIs don't have radiation exposure but they're very expensive but not as much availability, so they may end getting X-rays anyway. 

Dr. Julie Leonard: Correct. People think the MRI as something that is benign, but in fact for small children who would need to lay still there's the risk of sedation that's needed actually to be able to perform the study. So, there is also risk associated with the MRI. And many believe that an MRI alone isn't complete evaluation for injury. 


Dr. Mike Patrick: So neck injuries are fairly common. We see kids in emergency department or urgent cares and I'm sure there's a lot of primary care providers out there who also see kids complaining of neck pain after an injury. But life-altering cervical spine injuries with spinal cord impairment and problems are pretty rare, correct? 

Dr. Julie Leonard: Yes. For every hundred injuries, injured children that we evaluate in the emergency department, far less than one of those children are going to have some injury that could potentially lead to neurologic deficit. So it's very uncommon. Feared but uncommon. 

Dr. Mike Patrick: Yeah. But if your child is that one, then it's very important and a very big deal and that's why we want to catch all of these without on the other hand, over-evaluating. 

Dr. Julie Leonard: Correct. 

Dr. Mike Patrick: Now, in terms of risk, children and particularly, younger than about eight years of age are at a higher risk for neck injuries compared with older kids and adults. Why is that? 

Dr. Julie Leonard: In reality, actually, if you think about who's at greatest risk, you're at greater risk for a cervical spine injury as you get older. And it has to do more with the kind of activities that you're involved in. As you get older, you're more likely to be driving a car. You're more likely to be in work environments where there's the high level fall. You're out in the environment and unsupervised. So, older people have a higher rate of cervical spine injury. 

However, children that are less than eight years of age have a higher risk of having an injury that's in the upper part of their cervical spine and the types of injuries that are more likely to lead to things like quadriplegia or paraplegia. 


Dr. Mike Patrick: And why is that that eight year old… 

Dr. Julie Leonard: Why that threshold? 

Dr. Mike Patrick: Yeah. 

Dr. Julie Leonard: It has to do with the development of the cervical spine. And when the cervical starts to fuse and kind of take on the proportions of an adult cervical spine, we also believe that it has to do with the size of the head relative to the body. So, head-first impacts are a big risk factor for cervical spine injury. In fact, diving injuries and diving mechanism is the biggest risk factor for having a cervical spine injury. And children that are less than eight have very large heads and they may often lead with their heads. And so, we think it's multifactorial. 

Dr. Mike Patrick: Sure. You kind of compare a larger head, more mass moving the neck and the fact that the neck moves more easily because it's less rigid. And also, there are a little underdevelopment of the muscles that also hold it. 

Dr. Julie Leonard: Support it. 

Dr. Mike Patrick: Right. Yeah. And then, are there also some medical conditions that can be at an increased risks for neck injuries? 

Dr. Julie Leonard: Sure. Our parents of children with special needs are pretty aware of these risks. But probably the biggest risk population is our patient with trisomy 21 or Down syndrome. And it has to do with again how their cervical spines develop and make them more likely to have injuries. But there are other conditions as well, particularly conditions that affect bone development or ligament development in children. 


Dr. Mike Patrick: And then you have mentioned another risk factor just being the mechanism of injury. So severe blunt trauma, fall from a height, falling out of a tree, diving into a pool, motor vehicle accidents, just sort of high energy type injuries, you're more likely to have significant cervical spine injury. 

Dr. Julie Leonard: The high energy injury part is tricky. So there's really two components, how you land (what part of your body strikes first) and then the other component is the biomechanical forces. We see the leading cause of cervical spine injury in the civilian population is going to be motor vehicle collisions. And those individuals that aren't wearing their seatbelts or wearing them inappropriately and are ejected head first out of the car or crashes where the car was rolling over. You know, high energy. 

And the second group is really activities that people are engaged in, that can predispose them to that head-first impact. So we do actually see a lot of injuries in sports and backyard, just recreational activities, like playing on the trampoline, wrestling on the backyard, climbing the tree. 

So those tend to be the two classes that are most common in terms of mechanisms. 

Dr. Mike Patrick: Right. Another important point I think for first responders and coaches and parents, that sometimes there can be other injuries that distract from the neck injury. So if there's a high energy impact and the kids has a broken leg, that may be causing them more discomfort but we still want to protect their neck if there's significant trauma. 

Dr. Julie Leonard: Right. That's actually where our recent work is starting to shift how we view that. So, work that we had done among 17 collaborating centers in the United States. We actually found that outside of high energy type of mechanisms, if you have an injury in, say, a leg where you're playing football and you've been tackled and you put your arms out, it's actually protective of having a cervical spine injury. Because you've broken that fall and the leading impact has been somewhere else. 


So it's a bit tricky. There are regions of the body that are most highly correlated with having a cervical spine injury or actually head injuries, especially severe head injuries. So those children up to one and four can actually have also a sort of spine injury if they have a severe head injury. 

And then, if you have chest injuries and back injuries. So if you think about it, just in a practical sense, it's kind of an adjacent area to the neck that can potentially lead to forces that transmit also to the neck. And so, this idea that a child's crying about their leg and they're going to forget about their neck pain is starting to be debunked a little bit, where we're looking more a very neck-specific complaints and then regional injuries that can be correlated or related to also having a cervical spine injury. 

Dr. Mike Patrick: That's very good to know. It makes it even more important that the child gets the right evaluation at the scene especially when there's significant trauma or high-energy mechanism of injury. 

Dr. Julie Leonard: Correct. 

Dr. Mike Patrick: Now, so we mentioned that most kids with neck pain following an injury do not have bone or spinal cord injury. So, if less than 1 out of 100, let's say, what type of neck injuries are more common? What really is happening to most of these kids? 

Dr. Julie Leonard: The head and neck are supported by very large strap muscles in the neck. And those big muscles are obviously, just like any other muscle in your body prone to being strained. So the vast majority of these children that are complaining of neck pain are going to be found to have a strain of their muscles as opposed to actually having an injury to their spine. 


Dr. Mike Patrick: Yeah. So from an exam standpoint, so the more the soft tissue, muscles, ligaments, how does that injury look different on a physical exam compared to a cervical spine or potential spinal cord injury? 

Dr. Julie Leonard: A lot of it has to do with the history. So often, muscles strains, the pain isn't necessarily immediate, though sometimes it can be immediate if it's a serious strain. It's more of delayed onset where you've kind of twisted your neck and over the course of a couple of hours are starting to get stiff and it's starting to be painful. 

The location of the pain is important. It tends to be over the lateral sides of the neck, or below your ears and between your shoulders, the big muscle that you can feel going down there. As opposed to it being right in the center of the back of your neck where your spine runs. 

So location. Of course, pain with movement. As you get stiff, it's interesting because oftentimes, gentle movement with the muscle strain actually can make it feel a little bit better. When you have a spine injury, it can be excruciating to try to turn your heads. So if you're having limited neck mobility, that's very important feature as well. 

I think the other thing is that the cardinal signs of a neurologic injury. So a child that's complaining of weakness anywhere or numbness or tingling in their extremities that is persisting, really, that's an ominous sign and needs evaluation. 


Dr. Mike Patrick: Is this something that parents and coaches could distinguish between on the sports field? What should parents and coaches do when a neck injury occurs? 

Dr. Julie Leonard: So, it's interesting because anytime you see on TV and in the movies, when you kind of watch ambulance care for injured patients, you'll see them strapping patients down to kind of this rigid long board and putting a collar in place. And really, again, this is an area that's changing. It's shifting. We really believe that those kinds of protections and protective devices are only really warranted in a small subset of patients. It's better to allow patient, if their neck is stiff and sore, to assume a position of comfort. We're not forcing them to lay in a place that makes it worse or putting on a device that makes it worse. 

And so, really, we are encouraging people to restrict that kind of pre-hospital intervention to those patients that are unconscious, can't walk or move. So, for the vast majority of people who are just complaining of neck pain, it's completely appropriate to allow them to either go with their parents to be evaluated by a physician or in the ambulance but not necessarily with those devices in place. 

Dr. Mike Patrick: And I imagine you still think about mechanism of injury. So if you did have a child who dove into a swimming pool or was rejected from a car, high energy, head-first kind of stuff, those kids you probably do want to overdo it compared to getting hit on the football field. 

Dr. Julie Leonard: Correct.


Dr. Mike Patrick: So then, how do you decide who needs medical evaluations? One step further than just we're trying to see — are we concerned — which ones actually need to be seen in a medical facility? 

Dr. Julie Leonard: So in part, this is work that is conducted by the CDC, where they have field triage guidelines in terms of which children really need to be seen in emergency department and those that don't. The first layer as you're pointing out is these mechanisms that are significant. So, when you talk about motor vehicle collisions, we're not just talking about you're in the parking lot and you have this minor rear-end motor vehicle collision. We're talking about motor vehicle collisions where somebody else in your car may be seriously injured or died. You were, the patient, was ejected or thrown out of the car. The car has substantial damage to it, and that's beyond just airbags deploying. It's the passenger compartment which was protecting them has been intruded or invaded, meaning the frame of the car has been collapsed. 

So those are the CDCs markers for what a severe motor vehicle collision is. And those patients really should seek medical evaluation. And then, again, you brought up the diving mechanism. Again, that really is a mechanism that's highly associated with cervical spine injuries. So if you have a child that's, for instance, they dove into a swimming pool and hit their head on the bottom of the swimming pool or on the diving board, those are children that definitely warrant being evaluated and seen in a healthcare facility. 

And then, you get into the kind of complaints that people have after injury. So, again, serious head injury needs to be evaluated. So, children that after have a loss of consciousness or are unconsciousness, those children really warrant being evaluated. Or they have other signs of substantial injury to their head. So those children need to be seen. 


And then, children that have the neck complaints, as we talked about. And then, finally, you have this subcategory of patients that have either heightened risk for injury. As we mentioned, kids that are predisposed to having cervical spine injuries or they do have some co-morbid injury to the chest where you think the force of that injury was enough that maybe they also injured their adjacent neck area. 
So those are kind of the classes of patients we'd like to have a medical evaluation for. 

And as you went through that spectrum, you kind of started with the most severe, when you're looking at mechanism of injury, neurological deficit there would also account. And so, those kinds of folks you want to call 911 and have emergency medical response. But the other ones, you may be able to go, drive your kid to an emergency room, go to an urgent care. Call your primary care provider to get some advice on what you should do and how you should get there. 

Dr. Julie Leonard: Absolutely.  

Dr. Mike Patrick: And once a child does show up in the medical facility with a neck injury, what can parents expect in terms of the exam and who's going to get imaging and who isn't? That sort of thing. 

Dr. Julie Leonard: Well, a lot of it depends on piecing together of the history and then the physical exam. So, plain films, just a regular old X-ray of the cervical spine for spine injury is very actually sensitive for spine injuries. And so, most pediatric emergency physicians are going to rely on that as their screening tool for a cervical spine injury. 


But there, again, is that subclass of patients, that really we have a heightened concern for them. So patients that are showing at the emergency department and they're unconsciousness or their mental status is not normal. They're not thinking normally. They're a group of patients that we're likely to pursue a CT scan on but that's going to be a small subset of patients we see. The vast majority are more likely going to just, if they have one of those risk factors, do screening plain X-rays. 

Dr. Mike Patrick: One scenario that comes up frequently that I think providers out there can identify with and I think parents can as well is the kid who has mechanism of injury that's not high energy, high impact, and they do have midline posterior. So in the back of the neck pain, as you're moving down the spine, they saw "Ouch" at a certain spot. And you give them some ibuprofen to help with the pain and you get the plain X-rays and those are normal, but they continue to complain of pain when you push in that spot. What do you do for those kids in terms of further evaluation? 

Dr. Julie Leonard: So you get the plain X-rays and they're normal. 

Dr. Mike Patrick: Right, yeah. Neurological exam is normal.


Dr. Julie Leonard: Everything is normal. 

Dr. Mike Patrick: But the pain is still there. 

Dr. Julie Leonard: But the pain still there. So, those are a group of children that we'll ask to come back in about two weeks for another evaluation. So, by getting the plain X-rays, we're screening for most injuries that are significant. But you could have a subtle ligamentous tear. Just like you tear ligaments in your knees, there are ligaments that stabilize the spine. And you could have subtle tear that what we'll see is at two weeks, they'll probably have persistent paint symptoms. But we'll also be able to do some additional testing that would allow us to know that those ligaments had been disrupted. 


But when we look at that, those kids that we send home that have that persistent tenderness in the back of their neck, the vast majority of those children, 99% of them actually, the pain resolves and there's no injury. 

Dr. Mike Patrick: Is it recommended that those kids go home in a collar while you're waiting for that two-week period?

Dr. Julie Leonard: So you're bringing up a point of controversy right now in our field and a hot area of research interest. 

Dr. Mike Patrick: And it's okay to say we don't know what the right answer is. 

Dr. Julie Leonard: Yeah. In the adult population, many, many people end up with what we call wry neck or whiplash or they have muscles strains. And in the adult world, they test more aggressively, and they also are moving towards not sending adults home in collars. 

On the other hand, in children, we haven't quite got there yet. And it's an area that we're starting to debate a little bit. You brought up ibuprofen and as an emergency physician, that's often my litmus test. If something gets betters, if the pain gets better with ibuprofen, just like with a virus, all of a sudden, the child looks a ton better, feels better with ibuprofen, to me that's always a measure that it's not something that's significant. 

So we'll often will give ibuprofen in the emergency department. Take them out of a collar if they were placed in one, let them move their neck around a little bit. And if they're feeling better, we will discharge them without the collar. But if we can't get the pain under control, most of us will still send them in a protective collar.

Dr. Mike Patrick: But there's active research to really figure out from an evidence-based standpoint what the best way to proceed is. And that's the beauty of medicine, the day that we ask these question and we look to try to figure out what the right answer is, but there's this period of time where we're investigating that we don't know quite yet. And so, tend to err more on the side of caution until we know. 


Dr. Julie Leonard: Yeah, correct.

Dr. Mike Patrick: So the vast majority of these neck injury that are ligamentous or muscle strain, how do we treat those and how long does the symptom usually end up lasting? 

Dr. Julie Leonard: So, in children, muscle strains usually actually resolve pretty quickly particularly if the force that cause it was not at the level of the motor vehicle collision, that they were just horsing and wrestled and twisted their neck. That is usually a one-week kind of process in terms of resolution. 

Dr. Mike Patrick: Yeah, just like the muscle strain anyplace else in the body.

Dr. Julie Leonard: And the guidance really around muscle strain is that not moving actually perpetuates, that you become stiff. And so gentle movements actually tends to help those injuries over time. Rust the first day or so, but then pretty quickly, having some gentle movement helps it resolve. They'll be a few particularly older teens that may last longer and be more in the two-week range. 

Dr. Mike Patrick: So just like muscle strain anywhere, rest, ibuprofen, maybe an ice pack, that sort of stuff. Then the rare kid would need a muscle relaxant or something like that. 

Dr. Julie Leonard: It's pretty uncommon in pediatrics for us to rely on muscle relaxants. 

Dr. Mike Patrick: Absolutely. In terms of prevention, what can parents and kids and teenagers do to prevent neck injuries from occurring in the first place? 

Dr. Julie Leonard: Well, one is to be very cognizant of that head-first impact. Again, with the work that we've done, where we've looked at a large population of children that had cervical spine injuries, there were certain categories of recreational activities that put you at increased risks relative to other recreational activities. 


So one big area was backyard horseplay and recreational activities and play equipment and trampoline, where a child's not being supervised and they get into flipping off of things and diving off of things and going head first. So I think very early on, teaching your children that feet first is the best way to go.

Dr. Mike Patrick: That can be a particular problem on trampolines. 

Dr. Julie Leonard: Correct. Where they're trying to flip further or actually fall off the side. But we see it with, as you mentioned, the tree climbing or monkey bars where you're climbing and going over the top of them. We see it a lot in backyard horse play or wrestling or at home wrestling where kids are piled, driving each other into the ground. 

So that brings me to the organized sports that tend to have a kind of higher rate of cervical spine injuries relative to other sports. And we see football and wrestling and cheerleading, interestingly. And of course, those are the sports that you'll lead with your head often and again put you at that increased risk. 

Dr. Mike Patrick: Absolutely. And diving into a pool, we've mentioned that several times hearing this. I think we mentioned it several times during our water safety podcast that we did a few weeks ago, too. 

Dr. Julie Leonard: Feet first. 

Dr. Mike Patrick: Yeah, yeah, definitely. What are some hot topics in neck injury research? And, first, I do want to mention, there's this thing out there called PECARN, which stands for the Pediatric Emergency Care Applied Research Network. Tell us a little bit about that. What is PECARN? 


Dr. Julie Leonard: PECARN is a federally funded network of emergency departments that collaborate in clinical research. One of the areas of research interest for the network is care of traumatic injuries. And so, we have a cervical spine injury study group, where we're actively investigating neck injuries in children. This research collaborative has been highly successful in changing injury care. For instance, decreasing our use of CTs for evaluating children with minor head injuries as an example. 

So it's got the power of being representative of children across the United States and enables us to look at rare things like cervical spine injury. 

Dr. Mike Patrick: Yeah, what are some of the studies that you've been involved with? And in brief, some of these, I did get the links to the abstracts on PubMed and we're going to put those in the Show Notes for this episode, 353, over So people who are interested in more of the details could find those if they wanted. But just so, what are some of the topics of the research with neck injuries that you've been involved with? 

Dr. Julie Leonard: So, you're going to make me get a little wonky here for a science wonky. So, we've actually outlined a process of research to be able to answer kind of all the questions that we're talking about. Our very first study, again, we had 17 medical centers and we looked at 540 children with cervical spine injury. And from that work, we were able to identify these risk factors that we've been talking that should raise somebody's index of suspicion for injury. 

But it also has the power for enabling us to look at other things, like what is the kind of pattern of epidemiology of injury. So that's where we were able to look at that less than eight and over eight and who's more likely to have a more severe spine injury that's going to be associated with neurologic deficits. 


But it also empowered us to look at things like what kinds of activities when we look at those children that are engaging in sports and recreation, which of those activities are the ones that are more risky. But moving forward, the way that we did our work is now, we're following kids prospectively. So we've just completed a study that involved four of our centers, where we're looking at children as they come in and are being evaluated for traumatic injuries and for neck pain and seeing which of those children ultimately have injury. And really starting to fine tune a risk assessment tool that will allow us to, as clinicians, say "Okay, these are the children that need to be tested. And these are the children that don't." And it fine tune how we test. 

Dr. Mike Patrick: And then, that makes you feel more comfortable as a physician in an emergency department or an urgent care center, that you have some evidence on who really don't need to get X-rays on or send home in a collar. And so, everybody gets better care in terms of… You're more likely to pick the ones who really need it get it. 

Dr. Julie Leonard: Correct. That's the power of these network and this large studies, is that it enables us to get the number of children enrolled in this prospective cohorts or large populations that we follow over time. So that we can develop tools that clinicians can use to guide their decision-making in an evidence-based fashion. 

Dr. Mike Patrick: Yeah, absolutely. 

Dr. Julie Leonard: So, it's one of the things I'd encourage parents out there. It's the kind of research… Everybody gets really worried about putting their child in a research study, but prospective cohorts are so informative to our public health. And they're really low-risk to the child. We're mostly following these families just by looking at their medical records, not by actually asking them to come back or doing things that are very invasive. 


Dr. Mike Patrick: Do you find that parent with kids in an emergency department, when they're approached about being involved in one of these studies, are they pretty amenable to it? 

Dr. Julie Leonard: Well, you know, it's interesting. PECARN has had great success actually in recruiting families into studies. So, in our cohort studies, about 80% of families that are approached are given the option to opt out of it. They'll stay and be involved in the cohort. We conduct other higher-risk studies, and again, we're pretty successful in talking families through that concept of research. About 50% of families ultimately will enroll their child in something that is other than just an observational study. 

Dr. Mike Patrick: So moms and dads out there, if you're in an emergency department and approached about being part of a research study, no arm twisting, but it really does help the care of all kids moving forward. 

Dr. Julie Leonard: It is. It's just so important to our health system and bettering it. 

Dr. Mike Patrick: Yeah, absolutely. Well, Dr. Julie Leonard, pediatric emergency medicine physician here at Nationwide Children's Hospital and the Ohio State University College of Medicine, really appreciate you stopping by and talking to us today. 

Dr. Julie Leonard: Yeah, thank you. 



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 again to Dr. Andy Hashikawa, pediatric emergency medicine physician at CS Mott Children's Hospital and the University of Michigan Medical School, and Dr. Julie Leonard, pediatric emergency medicine here at Nationwide Children's Hospital and the Ohio State University College of Medicine. 

It's all the time we have today. PediaCast is a production of Nationwide Children's Hospital.

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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.

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