Sleep Apnea, Bounce Houses, Air Pollution – PediaCast 237

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Join Dr Mike in the PediaCast Studio as we kick off a new year of news parents can use, answers to listener questions, and interviews with pediatric experts. This week we cover the relationship between sleep-related breathing issues and behavioral problems, parents’ role in preventing alcohol and marijuana use, bounce house injuries, traffic-related air pollution and its relationship to autism, and the continuing problem of parents smoking with kids in the car.

Topics

• Sleep Apnea and Snoring

• Sleep-Disordered Breathing

• Sleep-Related Behavioral Problems

• Parents Role in Alcohol and Marijuana Use

• Bounce House Injuries

• Air Pollution and Autism

• Cigarette Smoke in Cars

Transcription

Announcer 1: This is PediaCast.

(Music)

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

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. I'd like to welcome everyone to the program. It is episode 237 for January 9th 2013 and we're calling this one Sleep Apnea, Bounce Houses and Air Pollution.

I like to welcome everyone to the program. It is 2013 and that means one thing – the Mayans were wrong. There's the surprise, right? I hope everyone had a fun and relaxing holiday season with your families. We certainly did in the Patrick house but now it's back to work, back to normalcy.

We do have some exciting changes to the show this year and some of them I can share with you now, some of them I can't quite share yet but I will be able to soon. The biggest change is just a little tweak to the format, which will help us usher in some of the bigger changes we have coming down the pike.

Now I know some people out there have a little bit of trouble with change and in fact I live with some of those people. But trust me this is going to be good. This is going to be good change. We're still going to have News Parents Can Use; we're still going to answer listener questions; we'll still have interviews with pediatric experts and ought to have a research round-up or two for good measure as well.

01:57

But we have some other projects coming down the road, which will definitely benefit all of you. So to make room for those we are switching our news and listener show to a news or listener show. So sometimes we're going to cover the news, sometimes we're going to answer your questions, but no more packing both of those things into a crazy long show.

Now having said that, those of you who've been with us since the beginning know that I do this from time to time. It's kind of like rearranging the living room. Little tweaks in the format and of course it seems like before I know it PediaCast is more of back into that long news and listener show. It's almost like that's what PediaCast wants to be.

So I'm not foolish enough to say that it won't happen again. But I'm really going to try to stick with it. So over the course of a month we'll have a news show, a listener show, an interview show and then the fourth week we'll either have another interview show or another news show or another listener show, kind of depending on the month or we'll throw in a research round-up.

So over the course of each month you're going to get news, listener questions and interviews. And again, I think we're really going to be able to stick with it this time, best laid plans and all, because of the other projects that we have in store for you.

Now I know the wait is difficult for news on those projects, but hold your horses. We'll spill the beans soon enough and you're going to like it. It's going to be really cool.

03:19

All right. Let's move on. What are we talking about today during this first show of 2013? Sleep-related breathing problems including sleep apnea and sleep-related behavioral problems like kids waking up in the middle of the night, having trouble going to bed or getting up early and just the behavioral sleep problems. What is their relationship to one another? We're going to discuss that.

Also parent's role in preventing alcohol and marijuana use in their kids despite two states giving a green light to recreational use of marijuana, which is still a bad idea for your kids. Of course I think in those states it's illegal for kids too, but marijuana and alcohol abuse bad ideas and you definitely don't want your kids get involve in those things.

We'll explain why and tell you how you can keep your kids from heading down the road to those problems. And they do cause mind altering problems even if in the case of marijuana it's not necessarily a chemical addiction but it can result in all sorts of badness in their adult lives.

Bounce houses are under fire and from my home institution here at Nationwide Children's Hospital. I'm going to weigh in on the bounce house controversy of 2012 with a bit of my own perspective and some sage advice, which is bound to get me in trouble, right?

Then we're going to tackle air pollution. There was a study not too long ago that showed traffic-related air pollution may play a role in autism and another study that looked at the prevalence of parents who smoke.

If they continue to light up in their homes and in their cars, we're going to tell you the numbers and we're going to admonish the parents who do it as well as the doctors who ignore the situation and thereby enable moms and dads who expose their children to poisonous and cancer-causing toxins while confined to the small interior of a car.

05:07

Can you tell I'm feeling a little feisty today? Before we get cracking on those news stories, I do want to remind that if there is a topic that you would like us to discuss, if you have a question for me that you'd like answered or a suggestion on a topic to interview a pediatric expert or want to point us to a news story, it's easy to do, just head over to pediacast.org and click on the Contact link.

You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

Also I want to remind you the information presented in every episode of 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, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

All right. We're going to take a quick break and we will be back with the News Parents Can Use, right after this.

[Music]

06:33

All right. So there are two categories of sleep disturbances that I mentioned in the introduction to the program, so the breathing-related issues like snoring and sleep apnea and then behavioral sleep problems like waking repeatedly, getting out of bed, not wanting to go to bed, rising early.

And in addition, poor sleep can be associated with daytime behavioral problems because lack of restful sleep can impact daytime wakefulness attention and mood. Now it makes sense that children with one of these problems might have an issue with the other problem.

For instance, it makes sense that kids with sleep apnea may wake frequently in the night, which leads to behavioral problems. That's an association that makes sense, right? And it's good news to [07:12] because if your child is having sleep-related behavioral problems caused by sleep apnea maybe if you address the sleep apnea you can improve their behavior. Again, it makes sense, but as it turns out doctors and parents have a disconnect when thinking about these issues in the examination room.

Researchers at the Albert Einstein College of Medicine in New York say children with one type of sleep problem are not routinely evaluated and treated for the other. The report published in the online edition of Behavioral Sleep Medicine suggests that pediatricians, pulmonary doctors, behavioral specialists and sleep medicine experts should work together in a multidisciplinary fashion when a sleep problem is suspected.

Senior author Dr. Karen Bonuck, Ph.D., says, "Our finding should raise awareness among parents and physicians that if a child is sleeping poorly they should delve deeper to see if there is an unrecognized respiratory-related sleep problem. And the best way to make sure this happens is by taking an inter-disciplinary approach to the care of these children."

Dr. Bonuck's team analyzed data from 11,000 children between the ages of 18 months and five years. They sent questionnaires to the parents asking if their child had snoring and apnea at 18 months, by the way, apnea means pauses in your breathing, so kind of like holding your breath.

So they sent questionnaires to the parents and they asked if their child had snoring or apnea at 18 months, 30 months, 42 months and 57 months of age. Parents were also asked if their child had any of the following behavioral problems such as refusal to go to bed, difficulty sleeping, waking after a few hours, multiple wakings in the night, getting up after being put to bed, nightmares and waking early in the morning.

08:51

Children with at least five of these problems were considered to have a clinically significant behavioral sleep problem. The prevalence of behavioral sleep problems range from 15 to 27% depending on the age of the child with a peak occurrence at 30 months of age.

Among those with behavioral sleep problems, 25 to 37% also had sleep-disordered breathing. And among those with sleep-disordered breathing, 25 to 37% also had behavioral sleep problems. The researchers point out their study does not specifically look at cause and effect and while it's unlikely that sleep behavioral problems cause sleep breathing problems, it is plausible to suggest that sleep breathing problems may result in sleep behavioral problems.

Dr. Bonuck sums up by saying, "It's important we pay attention to how our children are sleeping. There's ample evidence that anything that interrupts sleep can negatively affect the child's emotional, cognitive, behavioral and academic development. Fortunately, snoring and apnea are highly treatable and there are many effective interventions for behavioral sleep problems."

So this is an interesting study and I think the authors are right to point out that their study does not look at cause and effect. It's also possible that the issue is developmental. Maybe there's a brain wiring issue that results in both disordered breathing and behavioral problems associated with sleep.

In other words, if you help this kids breathe better at night maybe it wouldn't really affect their behavior after all. Maybe the problem isn't in the airway but rather at the brain level. And since most of our interventions are aimed at the airway, things like sleep positions, CPAP, tonsil and adenoid removal, since these things affect the airway and improve breathing maybe once you do them and improve the breathing the behavioral issues would actually remain.

10:35

So even though that you see them both together really the next step is to see if there is a cause and effect relationship. You find kids with both breathing and behavioral problems related to sleep, fix the breathing problem and then see if the behavioral problem improves, which is not something they did in this particular study.

Also, the study looked only at young children. What about school-age kids, especially those with behavioral and attention issues at school during the daytime? Could they have sleep-disordered breathing? And could fixing their sleep breathing problems improve their daytime behavior? So interesting questions for future studies.

One more point, when does the benefit of treating sleep-disordered breathing become worth the effort? If a child simply snores but they don't have any behavioral problems, does it matter that they snore? And if snoring and sleep apnea do cause behavioral problems, how bad do those behavioral problems need to be to warrant fixing the breathing, especially if you're trying to connect the child to a CPAP machine, which is blowing air in the kid's airway all night or even more concerning, a surgical procedure like a tonsillectomy, which could have serious risks associated with it?

11:43

In some situations the benefit may outweigh the risk and in others it may not. Which brings up a final point in my mind, since we're looking at young kids with this study, what is the long-term outcome of these children as they progress through the school years and into young adulthood?

Do young kids with sleep-disordered breathing go on to have a greater likelihood of sleep problems, whether it be breathing or behavioral, down the road? Or do many of them just outgrow it? Because that could make a difference in whether you intervene or not as well.

Now my guess is that young children with sleep problems becomes older children with sleep problems and if you deal with the sleep problems from an early age you might be able to intervene sooner in kids or we're going to otherwise end up with daytime and school problems down the road because of their sleep problems.

That would be my ultimate hypothesis. But while that makes sense just because something makes sense doesn't make it true. So in the coming years I think we'll see more research in this area. So what's the take home for parents?

Well if your child has sleep-related breathing problems think about their behavior and if they have sleep-related behavioral problems think about their breathing because the two issues might be related. And as always if you have a concern be sure to check in with your child's doctor.

13:00

All right. Let's move on to a teenage topic – alcohol and marijuana use, both of which are now legal in certain states. And again, did Washington and Colorado put a minimum age on legal marijuana use? I'm not quite sure. I'm sure listeners who live in those states may better know. If you do know write it in. I'll be interested to hear what you think. Not only on the minimum age but what you think about passing that in general.

Anyway, we are certainly not an advocate of mind-altering drug use whether legal or not here on PediaCast and especially for teenagers. So let's begin with the world view that teens regardless of their state of residence should not be using alcohol and marijuana. Can we all agree with that?

So if you agree with that world view and I hope you do, what role can parents play in preventing their teens from abusing these mind-altering and sometimes life-altering, I should add, substances?

Well according to researchers at North Carolina State University, Brigham Young University and Penn State, parental involvement is more important than school environment when it comes to preventing or limiting alcohol and marijuana use by children.

Dr. Toby Parcel, a professor of sociology at North Carolina State and co-author of the report, which was published online in the Journal of Drug Issues, he says, "Parents play an important role in shaping the decisions their children make when it comes to alcohol and marijuana. To be clear, school programs that address alcohol and marijuana use are definitely valuable, but the bonds parents form with their children are more important. Although he adds, "Ideally, we can have both."

14:35

Researchers evaluated data from 10,000 students and specifically examined each child's degree of social capital in their family and at school. Now, family social capital was defined as strong bonds between parents and children, open lines of communication and active engagement in a child’s life. While school social capital consisted of students involved in extracurricular activities, teacher morale and the ability of teachers to address individual student needs.

So what did they find? Well kids with the high level of family social capital and a low level of school social capital were the least likely to use alcohol or marijuana. And kids with the low level of family social capital and a high level of school social capital were the most likely.

Now you'll notice by the definition of school social capital these are good things, right? I mean, students involved in extracurricular activities, teacher morale, ability of teachers to address individual student needs, so these are all good things. So really the goal here isn't necessarily less school social capital, it's more family capital.

And if your child is involved in extracurriculars and attends a great school then family capital is even more important. So parents, regardless of your child's school experience, strengthen those bonds, open up those lines of communication and engage in the lives of your child.

By doing so, you may well save them from life-altering agonies of alcoholism and drug addiction down the road.

16:02

Our next story is a little closer to home, inflatable bouncer injuries. Researchers here at Nationwide Children's Hospital looked at injuries associated with inflatable bounce houses between 1995 and 2010. And they found a 15-fold increase in the number of these injuries treated in U.S. emergency departments.

In 2010, about 30 children each day, now across the entire country, mind you, were treated in U.S. emergency departments for injuries associated with inflatable bouncers. The study is published in the December 2012 print issue of the journal Pediatrics and reports the following breakdown of bouncer-related injuries in kids younger than 18 years of age — 28% of them had fractures, 27% had sprains and strains and 19% were injuries involving the head and neck.

With regard to mechanism, falls were the most common followed by stunts and collisions. Forty-four percent of the bounce houses were in a recreational setting and 38% were in a home setting.

Dr. Gary Smith, MD, DrPH, director of the Center for Injury Research and Policy at Nationwide Children's Hospital and a professor of Pediatrics at the Ohio State University College of Medicine, says, "The findings from this study show that there has been an alarming increase in the number of injuries from inflatable bouncers. It is time for us to take action to prevent these injuries. Ensuring that parents are aware of the potential risks, improving surveillance of the injuries and developing national safety guidelines and improving bouncer design are the first steps."

17:31

OK. There was actually some back lash to the release of this study in certain media and talk radio circles. And their problem with it went something like this, bounce houses people, OK, we're talking about bounce houses and 30 kids injured each day across the entire country. I mean, more kids are injured playing basketball each day in a handful of school districts, so really how big is this problem?

How many kids are injured going downstairs or stepping off curves for that matter? Do we need improved safety guidelines for basketball and stairs and curves, particularly at the government level, which is already way over its head in the red.

That's largely been the reaction. And I do understand and perhaps agree with that sentiment even though the study comes from my home institution. Look folks, there's risk in everything we do. Everything.

I don't know that a car isn't going to go left of center and then my life on my way home from work tonight and I certainly hope not. But that risk, that possibility is there. And you don't know how long you're going to live either. But do we ban cars because of that risk? No.

We can minimize the risk by wearing seatbelts and using car seats and staying alert when we drive, not texting when we drive. But we can't 100% eliminate the risk. The next thing that's considered kids like bounce houses.

You know what? I like bounce houses. Seriously, how many of us moms and dads watch our kids in the bounce house and think, "Man, if I could get in there I'd show those kids a thing or two." Now, how many of us would be injured in the process? Probably more of us than the kids, I imagine.

19:16

The point here is this, there is risk in bounce houses. Some kids, not many but a few, are injured every day. A very, very small number have become paralyzed or even died due to injuries in a bounce house. And to those parents dealing with that experience this is serious business, I understand that.

And it could happen to your child. It could happen to my child. It's not likely but it could. On the other hand, we hear about the health risks of obesity nearly every day. Kids watch too much TV, they aren't active enough. So jumping in a bounce house is better than sitting on their tush watching TV.

Now sure there are safer forms of physical activity. But when kids are spending their calories in a bounce house they are loving life in the process. So then where is our benefit versus risk meter in all of this?

For me, the benefit outweighs the risk for my kids. But you have to decide that for your own family and you have to be willing to live with the consequences. Now, there are some things you can do to minimize the risks of bounce houses because there are some potential problems.

Overcrowding. I don't want my child jumping in a crowded bounce house. The chance for collision or some other kids' crazy stunts is just too great. I don't want my child doing crazy stunts in the bounce house so that was going to require some supervision on my part, right?

I don't want my kids in there with bigger heavier kids who might hurt them and I don't want my kids in there with smaller lighter kids who they might hurt. Also, I don't want my kids bouncing in an enclosure that's not properly secured or when it's out in the open on a windy field.

We've all seen video footage on YouTube of bounce houses rolling across the field. Not a good thing. But you know, if it's not windy and they're secured then that minimizes the risk. Hopefully, this is common sense stuff.

Do we need government rules to enforce those kind of safety guidelines? Sigh. Maybe, which is a sad comment on the state of our common sense these days. So parents, as always, decide and thanks to our very own Nationwide Children's for raising awareness and quantifying the issue because that's important as we look at risks and benefits and make decisions.

21:26

All right. Let's move on to air pollution and autism, an unlikely pair to be sure, but two things which may in fact be related. Researchers from the University of Southern California and Children's Hospital Los Angeles report this in the Archives of General Psychiatry.

They say that exposure to traffic-related air pollution including nitrogen dioxide and particulate matter, exposure to these toxins during pregnancy and during a child's first year of life may be linked to a higher risk for autism.

Dr. Heather Volk and her team examined data from over 500 kids and found that those whose homes had the greatest levels of traffic-related air pollution inside the home had three times the risk of developing autism.

The team concludes by saying, "Research on the effects of exposure to pollutants and their interaction with the susceptibility factors may lead to the identification of the biologic pathways that are activated in autism and to improve prevention and therapeutic strategies. Although additional research to replicate these findings is needed, the public health implication of these findings is large because air pollution exposure is common and may have lasting neurological effects."

Now obviously, traffic-related air pollution is not the sole cause of autism, right? I mean, there are plenty of kids with autism living down on a farm and nestled in the woods. Of course these locations have toxins of their own to worry about, fertilizers and insecticides on the farm and I don't know ran off from the farms and poisonous mushrooms in the woods, I suppose.

Anyway, my point is autism is a complex process. And as we've discussed before on this show, it's likely caused by a combination of genetic and perhaps environmental factors. Only with this study, we're a little bit closer to removing the perhaps and saying, 'yeah, some environmental factors may play a role.'

And in this particular study one of those environmental factors could be increased exposure to traffic-related air pollution. Of course with a study like this you do have to look at who is exposed to increase traffic-related air pollution inside the home.

23:23

Are we talking about a particular socio-economic group? And could there be other confounding factors such as poor nutrition or exposure to other toxins in those same homes?

So it's not a perfect study, but I think the take home message for parents is this — if possible, pick a place to live that doesn't invite traffic-related air pollution inside your home for a number of health-related reasons.

Now, I do realize that there are many out there who may not have the luxury of this choice, which is a different problem. But if you do have the choice try to choose clean air and I think just as important is pursuing this. If traffic-related air pollution is to blame or at least partially to blame, we need to find out the biological pathways involved.

And discover what other toxins may play a role. Figure out how toxins contribute to the development of autism and how these factors interact with the genetic component of the problem. All that to say by understanding why autism happens would be in a better position to prevent it and treat it.

24:23

All right. Speaking of air pollution, this final story just really blows my mind. This is one of those crazy, crazy stories that just make you want to shake your head. Sigh. It's just senseless. OK. Let me just move on.

Already I'm just befuddled because I can't believe it. It just really makes me feel like all the education we try to do doesn't really matter. Investigators at MassGeneral Hospital for Children report in the December 2012 issue of the journal Pediatrics that 73% of parents who smoke continue to smoke inside their car while their children are inside.

Seventy-three percent smoke with their kids locked up in the car! It's great! Just lovely! And then these parents wonder why their child has a cough that just won't go away or is dealing with persistent asthma problems. OK. I added that editorial.

Here's what the researchers did. They hung out in the parking lots of 10 primary doctors' offices in eight states. They interviewed families as they exited the doctor's office and made their way to their cars. In all, investigators found 795 smoking parents and they asked them a set of questions.

Do you smoke inside your home? Now here's the good news, most of the parents said 'no, we maintain a smoke-free home.' The next question, do you maintain a smoke-free car? Most of the parents said 'no, we do smoke in our cars even when the kids are inside.' And in fact, 73% of them had done so recently.

The third question, has your doctor inquired about your smoking habits? Now, shame on the doctors here. Only 1 in 5 of the parents surveyed reported their child's doctor asking about cigarette smoke exposure.

So another sad commentary here, on the doctors this time. Cigarette smoke is an upper and lower respiratory tract irritant. It's also a known carcinogen, it causes cancer. And many parents strap their kids into a car seat, close the door, seal themselves in and light up. And then they wonder why their child has a runny nose and is coughing all the time. Trust me, it happens.

26:30

Unfortunately, doctors seldom ask about cigarette smoke exposure when seeing kids with these symptoms. So since providing take home message is important for this show, it's what I've been doing with each of these news stories, I'm going to give you two.

The take home for parents, don't smoke in your home and don't smoke in your car. Better yet, get help and stop smoking because you're killing yourself and you won't get as much time with your grandkids.

Doctors, take home for the doctors out there and the nurse practitioners, ask about smoking in the family. Not just in the home, but in the car as well, because smoking parents are still smoking in their cars to the tune of 73% of them.

And doctors, provide wise counsel and teaching on the dangers cigarette smoke poses to kids locked up in enclosed basis and forced to breathe those harmful fumes. Seriously, I can't believe 73% of smokers light up with their kids in the car.

Seventy-three percent despite all of our supposed educational efforts! It's just unbelievable.

All right. That wraps up our News Parents Can Use edition of PediaCast. Our first for 2013. I will be back with some final words and be sure to stick around because we're changing. This is something I didn't mention in the intro, it's a little bit of a tweak to the show. We are going to actually change course a little bit with the content of the show's outro.

So at the end of the show we're going to always have a final thought for you. In fact, I've tried this before as well and it's kind of fallen flat but we're going to try to stick with it this year. It's just like this is it. These are the New Year's resolutions for PediaCast, all right? Shorter shows, either news, listener or an interview or a research round-up and a final thought at the end of each show.

We're going to be back with the first one of those for 2013, right after this.

[Music]

28:47

All right. Another new feature of the show for 2013 and as I mentioned I've done this in the past from time to time but it always seems to fizzle out. But I'm going to try to make a better effort to stick with it. So I'm going to try to stick with exercise this year. I'm going to try to stick with some extra content at the end of the show.

We're going to include a helpful tip, a comment, an observation or otherwise piece of advice during the outro segment of each show. So today's final thought is this, if you have teenagers, take them out to dinner and catch the movie Lincoln.

And now I know it's Hollywood glamour and I'm sure Spielberg took some liberties but it's based on a highly respected Lincoln biography called Team of Rivals that has action and adventure. It keeps you on the edge of your seat, but more importantly, it contains a rich story of our past.

One that is often over simplified in textbooks and one that is important to remember and honor. So if you haven't seen Lincoln, you should. And if you have older children or teenagers at home, be sure to put a viewing of the new movie Lincoln on the agenda for your next family fun night. And that is my first final thought of 2013.

29:52

I'd like to thank all of you for listening to the show. And in particular, I'd like to welcome all of the new listeners. It seems like after the Holidays we always have an influx of new folks to the program as people get smart phones and new laptops and other iPads and find the world of podcasting. We always have an influx of listeners with the new gadgets and so I'd like to welcome all of you.

Also I want to remind you iTunes reviews are very helpful and in fact, if you have never reviewed PediaCast on iTunes I would just ask that you do so. I mean, you're getting all this great content for free, folks. It doesn't take you long, five minutes of your time just write us up a nice review over on iTunes.

It helps us to be in the spotlight in iTunes the more reviews that we have and perspective listeners who are thinking do I really want to waste some time and energy on PediaCast they read through those reviews and it just helps them make a decision. I know many of you out there listen to PediaCast because you read those reviews, so if you could give a little bit back just write a review on iTunes it would be appreciated.

Don't forget we are on Facebook, we're on Twitter, we're on Google+, we're on Pinterest. In Pinterest, we have a News Parents Can Use board. We also have a Show Episodes board and we have My Blog Post Board. Those are all over at Pinterest so you can search for PediaCast there.

Also don't forget to tell your family, friends, neighbors, co-workers and your child's doctor about PediaCast. Posters are available under the Resources tab at pediacast.org.

One last time, I want to remind you if you'd like to get a hold of me, just head over to pediacast.org, click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404- K-I-D-S.

And what would you contact us for? Well, if you have a topic idea for the show, a question for me that you'd like answered, a pediatric-related question. And in fact our next show is going to be full of answers to listener questions, that's the next one for next week. Also if you just have a news story that you want to point us to, those are the ways to contact us, pediacast.org, Contact link.

All right. Until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody!

[Music]

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