Swimmer’s Ear and Premature Babies – PediaCast 467

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Show Notes

Description

• Dr Ben Kovalcik and Dr Erica Braswell visit the studio as we discuss care of the preterm infant. We explore unique concerns and needs of these babies, including medical complications and issues related to breathing, feeding, growth and development. Also covered: swimmer’s ear. We hope you can join us!

Topics

• Swimmer’s Ear
• Care of the Premature Baby

Guests

• Dr Ben Kovalcik
  Neonatology
  Nationwide Children’s Hospital

• Dr Erica Braswell
  Neonatology
  Nationwide Children’s Hospital

Links

• NICU Follow-Up Programs at Nationwide Children’s
• Newborn Care – PediaCast 441
• Bronchopulmonary Dysplasia
• Congenital CMV Infection – PediaCast CME 045
• RSV Bronchiolitis and Synagis – PediaCast 355
• RSV Bronchiolitis – PediaCast CME 021
• Neonatal Abstinence Syndrome (March of Dimes)
• Neonatal Abstinence Syndrome – PediaCast CME 042

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 1: 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 is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.

It's Episode 467 for July 23rd, 2020. We're calling this one "Swimmers Ear and Premature Babies".  I want to welcome all of you to the program.

So we are going to cover the care of premature babies today. And we have covered newborn care many times in this program, most recently last September. That was Episode 441 where we covered newborn care. 

0:01:15

And while the topics presented in that program pertain to all babies, whether they are born early, late, or on time, there are lots of special considerations and needs that are particular for premature babies. Premature babies have underdeveloped lungs. And breathing problems are common after they are born, which can end up leading to chronic, sometimes lifelong lung disease, which in turn can lead to heart problems, difficulty feeding, difficulties with growth and development in a cascading sort of fashion. 

So lung problems lead to heart problems. That can lead to difficult feeding. Then they have problems with growth and development. 

Of course, even without lung problems, there can be issues with feeding and growth and development. Premature babies can have vision and hearing problems, they're more prone to infections. Some are addicted to substances like opioids that their mother took during pregnancy. 

0:02:13

And many of these babies develop complications of their prematurity, things like brain bleeds and necrotizing enterocolitis or NEC, which is a life-threatening problem with the intestines. So all these to say, lots to consider and a lot of work and responsibility for the new parent who has a premature baby on top of the ordinary challenges of caring for a newborn at home. 

This week, we are going to explore the unique challenges of caring for premature babies. And to help us cover the topic, we have a couple of terrific guests joining us. Dr. Ben Kovalcik is a neonatology expert at Nationwide Children's Hospital, as is Dr. Erica Braswell, again, both of them with Nationwide Children's Hospital. 

I also want to talk a little bit about swimmer's ear today because it is summer. And there is not a lot that we can do because of the COVID-19 pandemic that is happening. And so a lot of kids are out there swimming, and especially in backyard pools because a lot of public pools are not currently open. So there's a lot of swimming going on because there aren't a lot of other activities. 

0:03:25

But not just swimming, kids are also playing in sprinklers, and slips-n-slides and the small inflatable backyards pools, all of those things. So swimmer's ear is common this time of year in the summer, and probably particularly so this year because of the pandemic and the lack of other things to do. 

So swimmer's ears, what exactly is it? It is also known as otitis externa. Now, otitis just means inflammation of the ear. Externa means the outer portion of the ear. And in this case, we're talking about the region in front of the ear drum or the ear canal, as opposed to otitis media which is inflammation of the middle portion of the ear. So that will be located behind the ear drum. 

0:04:14

And then, of course, there's also an inner ear. And that's actually a more inside the skull, the most internal portion of the ear. 

So here we're talking about in front of the ear drum, as opposed to middle ear infection which is behind the ear drum. And by the way, you can have both an outer and a middle ear infection. 

So when do you have ear pain, it's a good idea to see a provider who can look in there and get the right diagnosis so that you can get the correct treatment for the problem that's going on. 

So what causes this otitis externa or this inflammation or infection that is in the ear canal? Well, the most common thing that happens is that the skin breaks down when it's constantly wet. So when you're swimming, also long baths, even long showers, just if water's getting inside the ear canal for long periods of time and frequently. 

0:05:06

Think about what happens to the skin on your hands, for instance, when they're wet all the time. They get kind of pruny, right? Sort of soft wrinkly skin. And that happens inside your ear canal as well. 

But remember the surface of our skin is covered in normal bacteria that covers all of our skins. And if your skin gets sort of soft and wrinkly, it's easier for the bacteria that normally live on the surface of the skin to invade inside the skin and cause a skin infection. And so then, that results in swelling and tenderness of the skin from this bacterial infection, which was because the skin was sort of wrinkly and soft and broken down because it was constantly wet.

Now, there are other causes of what we would still call a swimmer's ear or otitis externa. For instance, if you do something else that breaks down the skin. So an example is scratching your ear canal with a fingernail or with end of a Q-Tip. 

0:06:02

So mechanical trauma can also lead to the same process. Really, the same mechanism, it's just that there's a mechanical scratch instead of soft wet skin. But then, the cascade is really the same, that the bacteria are able to invade and cause infection. 

So what symptoms do we see? The primary is going to be ear pain. You may also have itching or irritation. The pain can actually be severe. So you can't go on, "Well, if it's a real middle ear infection, deeper inside, it's going to hurt more." Not necessarily. 

The skin of the ear canal's very sensitive and so the pain can be on the severe side. Can be one or both ears, although it's more commonly going to happen in one ear. Whereas middle ear infection, especially in young kids, very often are both ears because of the... This is beyond the scope of this program, but just when you think about the way that the middle ear infection happens, which is from mouth bacteria going up the Eustachian tube and then getting into the middle ear space, that typically happens on both sides.

0:07:03

So it's very common to have ear infections in both ears, whereas the swimmer's ear often, it's just one ear. But you can get two. 

And then, moving to the outside of the ear, the tragus, which is kind of right in the center, that triangular portion of cartilage covered by skin that's right at the opening to the ear canal. Because that piece of the outer ear is connected to the ear canal, when you move that little triangular flap on the outside of everybody's ear, it often causes intense pain again because you're also moving the ear canal. 

Whereas, with middle ear infections, you're less likely to have pain when you move the tragus, which again is that triangular flap of skin on the outside of the ear that's connected to the opening to the ear canal. You may feel a fullness of the ear canal, like there's something in it and even diminish hearing as that swollen skin blocks soundwaves. 

So pain is primarily it, there are some nuances compared to a middle ear infection, but you can't diagnose it based on that set of symptoms. You really again need someone to look in there to tell you what's going on.

0:08:09

Now, in terms of treatment of swimmer's ear, it is important to distinguish otitis externa from a middle ear infection or otitis media, because they are treated differently. With middle ear infections, you typically need an antibiotic by mouth, unless in older kid, you may give it a day or two to see if it starts to get better on its own. But in general, you're going to use oral antibiotics for a middle ear infection. 

With the external ear infection or swimmer's ear, we can get by most of the time with a topical antibiotic. So antibiotic drops, and you can't use that for a middle ear infection because the ear drums block in the way. So those drops aren't going to get to where the infection is. But since with the swimmer's ear, the infection is the ear canal on the outside aspect, to the ear drum, then the topical antibiotic drops are going to help. 

There can be quite a bit of swelling. Sometimes, we'll do a combination drop that has an antibiotic and the steroid in it. The steroid helps to reduce swelling, although if there's a possibility of a middle ear infection along with the swimmer's ear, and especially if there is a rupture of the ear drum, then often we want to avoid using steroids and those getting into the middle ear, past the ear drum.

0:09:26

So again, a reason for someone to look in there and see exactly what's going on before you get prescribed treatment. 

Sometimes, you need what's called an ear wick to deliver the medicine past the swollen skin. That's just basically kind of like a really thin long piece of gauze that a medical provider will gently, it does hurt a little bit, will put into the ear canal. So that then when you put the drops in, they can travel along that piece of gauze and get down a little bit deeper in the ear, which can be important if the skin is really swollen which sometimes happens. And that makes it difficult for the drops to get in deeper. 

Now, if the ear's really swollen and the drops aren't going to work and it's just too painful to get an ear wick in or you're not able to get one in, then sometimes, we do need to use oral antibiotics even for swimmer's ear or an external ear infection. But those are rare cases and the most severe of cases.

0:10:25

And then, pain control's going to be very important. And usually, we can get by with ibuprofen or acetaminophen in terms of controlling that pain. And of course, always ask your child's medical provider for appropriate dosing for your child. And then, remember that you can have a middle ear infection with that swimmer's ear. And then, you are going to need oral antibiotic for sure if you have both of those present. 

And even though we treat with antibiotic, those only treat bacteria. It's also possible to get a fungal infection of the ear canal. So when the antibiotics are not working, you definitely want to be seen again to find out, well, maybe it's not bacteria, maybe it's a fungal infection and you need different medication. 

0:11:07

And then, of course, you can always watch for complications. The biggest thing here is going to be the spread of the infection to the cheek, to bones. So anytime your child's not getting better with the initial treatment, always be in touch with your provider to let them know, "Hey, things aren't getting better and we want to avoid complications, so we may need to have a recheck." 

Always good to prevent swimmer's ear and the easiest way to do that is by decreasing prolonged, frequent exposure to water. So decrease swimming and bathing time. If you still need to swim or you want to swim, and you're prone to swimmer's ear, ear plugs can be helpful at creating a barrier so that the pool water or the bath water does not go into the ear canal. So that can help you out to prevent.

Also, swimmer's cap can also do the same thing if it's fitted properly. And then, when we think about mechanical trauma, the way to prevent that is my grandma always said, "Don't put anything smaller than your elbow in your ear canal." So that would include fingers and Q-Tips, just don't put anything in there. If you're prone to ear wax, ask your medical provider how to deal with ear wax and again, still avoid fingers and Q-Tips in the ear. 

0:12:20

Also, a few drops of rubbing alcohol after swimming or bathing can help to displace the water and sort of dry it out in there a little quicker. And if you do have wax issue, you can mix the rubbing alcohol with half white vinegar which will help melt the ear wax. So that's a safe thing to do. But if there's severe pain, and there's a chance that you have a middle ear infection and a ruptured ear canal, you don't want to put any rubbing alcohol in the ear because we don't want that to get through any hole in the ear drum that might be there. 

So again, best practice, when you have ear pain, have someone take a look and find out exactly what is going on. That's going to be really important. 

All right, we are ready to move on to the care of premature babies. Before we get started with that, there are a couple of really quick reminders. 

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0:13:19

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Also, I want to remind you, the information presented in each and every one of our episodes is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call his or her healthcare provider. 

0:14:06

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

So, let's take a quick break. We'll get Dr. Ben and Dr. Erica connected to the studio and then we will be back to talk more about premature babies. That's coming up right after this.

[Music]

Dr. Mike Patrick: Dr. Ben Kovalcik is an associate professor of Pediatrics at the Ohio State University College of Medicine. And Dr. Erica Braswell is an associate professor of Pediatrics at Ohio State. They're also pediatricians with the Neonatology Program at Nationwide Children's Hospital where they provide care for premature babies. That's what we're here to talk about today, care of the premature baby. So let's give a warm PediaCast welcome to Dr. Ben Kovalcik and Dr. Erica Braswell. Thank you both so much for visiting us today. 

0:15:21

Dr. Erica Braswell: Thank you so much for having us. This is exciting for us to be here, to talk about what we do and share some information about the unit we get to take care of patients on. 

Dr. Ben Kovalcik: Yes, thank you very much, Mike. Very happy to be here. 

Dr. Mike Patrick: Yeah, really, thank you both for taking time out of your busy schedules to be here with us. So, Dr. Ben, what is meant by the term premature or preterm baby? At what point are you premature and at what point are you not premature? 

Dr. Ben Kovalcik: Well, very good question, very good place to start. We in the medical establishment have defined 37 weeks of gestation as being term. So really, anything less than 37 weeks, we consider preterm. So even if a baby is born at 36 and 6 and the next day, that baby would have been 37 weeks, we would consider that baby preterm. We consider that baby late preterm and it doesn't mean something somewhat different how early you are in gestation. 

0:16:19

Most mothers, mothers-to-be are going to receive a due date that really is 40 weeks. So even if you don't quite hit that day, there's a good chance that everything's perfectly fine, that they still what we consider term, because we got a good three-week window there where we really feel like babies are developed. And most of them do fine if they come at that time and there's really no issue. 

Dr. Mike Patrick: And so that 37 weeks is really the cut-off between preterm and full term. But as you said, there are then degrees of prematurity, right? So you can be moderate. You said, late preterm but there's also a moderate and very preterm or extremely preterm. And those are important things to consider, just how early you are because your risk of complications and a lengthy hospital course really correlate with more of that the earlier you are, right? 

0:17:08

Dr. Ben Kovalcik: That is absolutely correct, yes. We see babies that are born sometimes, even 25 weeks, anywhere along that spectrum, between 25 and 37, 25 or 40, et cetera. And again, that means something different. So the earlier you are, the more likely you are to have breathing issues, feeding issues, a longer stay, et cetera. 

Dr. Mike Patrick: Just so folks can wrap their brain around this, those really early premature babies as you mentioned, as early as 25 weeks gestation, they can be like 500 grams or less, right, for their birth weight? I mean, we're talking really tiny. 

Dr. Ben Kovalcik: Absolutely. It's really something. I think the first time, even when you're a medical student, et cetera, and you see babies like that, it really is somewhat jarring, somewhat shocking. Because they're so small, they can fit in your hand sometimes. Sometimes, their eyes aren't open, et cetera. 

0:18:02

Dr. Mike Patrick: And then when we see those kids as older kids, sometimes, I'm just floored by, like "This big kid that I'm seeing right now was a little 25-week premature baby. And here they are going to kindergarten." That's pretty amazing really, when we think about the care that they're able to receive these days. 

So what considerations and needs then are unique to these infants, Ben, as we compare them to full-term babies?

Dr. Ben Kovalcik: Well, essentially, there is no better, the womb is really the ideal place for a baby to grow, right? Obviously, that's the way the system is designed. However, if that isn't what happens, if they come out, if a baby comes early, then we have to do the best we can to try to mimic those conditions. 

Now, we're nowhere near as good as a mom's womb but we try to think of the same considerations. So the biggest one really would be breathing. I think that that's one of the main things. The earlier you are, the more likely you are to need a machine basically to breathe for you. So sometimes, we have to place a breathing tube and essentially breathe for a baby for quite some time until they're really ready to breathe on their own. 

0:19:17

If you're a little bit, say, not quite super early but you're kind of in that middle range, sometimes we just need to give a little bit of oxygen or a little bit of pressure, sometimes just through the nose to help to keep airways open or keep the smallest airways in the lungs open. Obviously, it varies how long that's necessary. 

Then we do have concerns about temperature, of course. Babies come out and they're small and early and they may not do the best job of regulating their own body temperature. So we really have to keep them as warm as we can and be very cognizant of their external environment and make sure that we keep them warm. That's when sometimes mom will see or parents will see babies in those boxes that we have. And the big thing that those boxes do is keep our babies in a good what we call thermo neutral environment. We put them in the best temperature that we can, essentially. 

0:20:12

And then, obviously, feeding and growth are huge, huge issues. It does take a while for these 500-gram babies to get bigger and be able to come out of the box and really learn to eat on their own, and essentially just start growing as we expect them to. 

One other big concern would be when babies are very early, sometimes, they're so immature that they honestly forget to breathe. And that's something that we call apnea. And a lot of babies can do that when they're young, very early. 

And then, sometimes, they kind of drop their heart rate, which we call Bradycardia. And sometimes, they even drop their oxygen levels, which we call a desat, desaturation. 

So sometimes, babies, they do well. They take a while, they're growing, they're doing everything that they can after a prolonged stay. But the last piece sometimes are those things that they need to remember to do, they need to remember to breathe, and keep their heart rate up, and they keep oxygen level up. 

So we're very aware of all of those things and work hard to monitor those for the preterm kids' sakes. 

0:21:19

Dr. Mike Patrick: Yeah, because you don't want those things happening at home for sure. Your parents, we want them to have peace of mind that their babies are sleeping so they can get some sleep, too, right? 

Dr. Ben Kovalcik: Oh, absolutely, yeah.

Dr. Mike Patrick: And then, are premature babies more at risk for infections? So is your immune system ready to work at this early age being born?

Dr. Ben Kovalcik: Yeah, absolutely. I mean, we have to be very cognizant of that, too. That's another reason that we are extremely diligent about wearing still a gloves. If we need to, we are cognizant of invasive things. So we don't want lines, meaning IVs or other kind of either devices in babies for a prolonged period of time. 

0:22:04

Now, sometimes that's necessary but we want them out as quickly as we can, because we don't want to have any excess risk for infection. 

Dr. Mike Patrick: And that's something that, really, there's been lot of changes even over the past ten years in terms of how these premature babies are taken care of as we learn. From one standpoint, you'll think "Oh, the longer that we have lines in place and we can give them medicine and we're able to resuscitate them with those lines if we need to." But then we also know getting things out as quickly as possible can speed up the process of you being able to go home. So this is continually a learning process, right, in terms of taking care of these babies? 

Dr. Ben Kovalcik: Absolutely, absolutely.

Dr. Mike Patrick: And I do want to mention to folks, we're talking about premature babies today, but all of the things that go along with normal newborn care also apply in many respects to premature babies. And we did a podcast on that, Episode 441, and I'm going to put a link to that in the show notes for this episode, 467, over at pediacast.org, so folks can find that very easily. 

0:23:05

So Dr. Erica, let's bring you in now, and kind of walk us through what the hospital care of premature babies looks like from the time that they're born until they go home. And I know that could be an hour-long answer, but sort of hit the highlights for us, what care of these babies looks like in the hospital. 

Dr. Erica Braswell: So every baby is a little bit different, but in a general speaking term, the first thing we're going to focus on is making sure that they are breathing well and they're keeping their heart rates up. So we're going to support that first. 

And then, the next step along those lines, we will support their nutrition to help them with their growth. Babies need to be able to regulate temperatures, be in an open crib. And the biggest thing is starting them in the process of learning to feed and tolerating internal feeds or feeds into their stomach instead of the IV nutrition that they get to start with. 

So that's one of the longest process in the premature baby's lifetime in the NICU or the hospital stay. It's really focusing on that last aspect of getting them all of their nutrition through their mouth. And that's so important because we need babies to keep growing for developmental reasons, for brain development. But we also need them to keep growing so that they can fight off infections. And once they go home, they get to stay home. 

0:24:25

So we do things like start the process of making sure they can tolerate safe sleep environment. So a lot of our premature babies, when we first have them, they sometimes sleep on their side or sleep on their back or sleep on their stomachs, but we always have them monitored. So prior to going home, we make sure all of our premature babies can tolerate the safe sleep environment, which means that they don't need any positioners to help make sure they maintain staying on their back and that they tolerate keeping their heart rate and they pulse sats or their oxygen saturation up. 

We also make sure most premature babies tolerate the position in the car seats puts them in. And that they're big enough to ride home safely in the car seat. We want to make sure that families know how to appropriately have their baby positioned in the car seat. Safety is a big concern for ours because these families have worked so hard and been through so much to have the patient in the NICU that we want to make sure that we support them in their transition to home. 

0:25:23

The big things families always want to know is "My baby was born prematurely but when does that mean they're going to get to go home from the hospital?" As parents, we don't like leaving our little ones behind and it's something we can't ever prepare families for, even when we know in advance that they're going to have a NICU stay. We can't prepare them for the stress and the hurt that it causes to be separated from their baby. 

So we can't ever give an answer. I tell people all the time, families all the time, I like to be bossy, but I'm not the boss when I walk in your patient's room and care for your patient. Your patient's are the boss. And they're the only ones that know the answer when they're going home. We can give you a general idea what your baby needs to do to go home. We do and a lot of times try to aim for saying, "Your due date is a reasonable expectation, but some babies go home before, and some babies go home after." 

0:26:15

Dr. Mike Patrick: And I love how you put that, that your baby is the boss of that, and each baby is a little bit different. And so, it can just be very difficult to predict. And you certainly don't want to push things and then have a child who now is going home too early and there are risks that are involved. 

And then, there's also risks to other babies in the NICU because once you leave the hospital, you're exposed to other organisms that you could potentially bring back into the hospital and cause a problem for those babies. So to some degree, it's not only for the baby but for the other babies that are there as well. 

What are some of the different levels of care? So we talked about the NICU, but there's also sort of care where kids are just feeding and growing, right? 

Dr. Erica Braswell: That's a great question. So in the NICU world, we talk about levels of care from 1 being kind of what we think of as just the newborn nursery, all the way up to Level 4, which is what you would see in a NICU like we have here at Nationwide Children's Hospital. 

0:27:15

We have actually four NICUs located on our campus. And our Acute NICU, which is our C4B unit, is a Level 4 NICU. And that's where the sickest of the sick babies, that was born extremely premature, that was born with congenital anomalies that need surgical or cardiac help and support.

Dr. Mike Patrick: And then you have less intensive care too, right? 

Dr. Erica Braswell: We do. We actually moved down to our C4C NICU is a little bit less acute patients, still patients sometimes need CPAP or pressure to help keep their lungs open. Sometimes, there's ventilator babies in there but not typically babies that need the machine to help them breathe. 

And then, we have a specialized unit here on Nationwide Children's Hospital main campus. It's our C4A NICU. And that specializes in babies that have bronchopulmonary dysplasia or the premature lung disease that babies can develop from being born prematurely and needing mechanical ventilation or support breathing. 

0:28:21

And then the unit where Dr. Ben and I get to work is know is A7B. It's actually more like a hospital floor. It is a NICU, it's within the NICU system. We are a low-equity NICU, so our ultimate goal is to take care of patients in the last part of the hospitalization to really their patient and their family transition to home. 

Dr. Mike Patrick: Yeah, very important. We keep talking about lung and breathing problems. So I think with every question that I pose to you guys, it's like breathing, breathing, breathing. Why are breathing problems so common in premature babies? 

Dr. Erica Braswell: So the environment that the womb provides with amniotic fluid, that environment really allows our babies' lungs to grow and to develop appropriately. It's actually, your lungs when you're inside moms, in utero growing, don't do anything. That job is done solely by the placenta. So that the lungs can have time to grow like the rest of the baby's organs. 

0:29:19

And premature babies, the more premature you're born, the less likely you have certain cells within the lungs that create a protein called surfactant. And that surfactant keeps these tiny air sacs open. And the best way to kind of explain this to families is think of a giant water balloon, with smaller and smaller and smaller water balloons, almost like it looks like a bag of grapes inside of  water balloon. 

Surfactant helps those really tiny grapes stay open. And that's where oxygen and carbon dioxide exchange happens. So without that protein to keep those air sacs open, the babies just can't oxygenate and/or ventilate, which means get rid of the carbon dioxide very well. 

0:30:03

Dr. Mike Patrick: Can babies be given that surfactant? 

Dr. Erica Braswell: We do. And it's been one of the biggest advances in the care of the premature infant, has been the development of their ability to give artificial surfactant to these patients. It does require a breathing tube to be put in to the baby. And then, it almost looks like a milky substance because it's a protein substance. And it's put into the breathing tube to get into the airways and coat the airways to help keep it open. But it is one of the biggest advancements in the care of our premature infants. 

Dr. Mike Patrick: And then, sometimes, and especially, if folks have had a premature baby, if mom is in labor and we know it's going to be born early, sometimes we give steroids to mom. Does that help to mature the lungs a little more quickly?

Dr. Erica Braswell: It is and that's really the biggest benefit of giving that steroids to moms prior to delivery. We typically like to make sure they've had two doses of steroids and it's typically given 24 hours from the first dose to the second dose. And we try to hold off deliver as much as we can for the benefit of the steroids. 

0:31:13

Unfortunately, we're not in control. The baby is the boss, even when the baby is growing inside moms. So we don't always get to get both of those doses in. So we try our best to do that to help with the lung maturation. 

Dr. Mike Patrick: And as Ben had mentioned, it's not only the lungs that are in issue but sometimes you forget to breathe when you're premature and then that's really more of a brain issue with the brain regulating breathing. And so you take both the lung issue and the brain immaturity together and it really can spell trouble. And that's why these kids need to be looked after so closely. 

Ben, what about long-term effects on the lungs then? Is being born early, does that cause a problem with the lungs more long-term? 

Dr. Ben Kovalcik: So sometimes, it can. I feel uniquely suited to speak of this. I work in our follow-up clinic following the babies that were admitted with the BPD or that chronic lung disease that Erica spoke of. I work in that clinic for five years. And I will tell you that the majority of kids that I saw actually did very well. 

0:32:18

Sometimes, kids would go home on oxygen and our job in that clinic was to get them off oxygen as quickly as we could. Again, another situation where the child is the boss. It just really depends on how things are going. 

The majority of patients I would tell my families, "You may be wondering what does this mean, but I'm anticipating that your child can run and play and participate in sports just like every other child as they get older." Now, there are certainly exceptions to that, that's extremely rare, luckily, with the advancements that again Erica mentioned. 

The one thing that I can say, there's a couple of things that I can say about that. What happens is there's some patches of lung when babies are born that really are pretty damaged and damaged pretty severely. And sometimes, we can't really fix those patches of lungs. However, what we can do is get the baby to grow. 

0:33:17

And so this is where everything is kind of related. We know that as babies get taller, so linear growth, that they grow more lung. So linear growth really corresponds with lung development. And we know that babies will basically grow a very healthy lung tissue around those areas of damaged lung tissue and hopefully lead to, again, a child that really doesn't feel any big detriment because of the fact that they were early, at least from a breathing standpoint. 

Sometimes, baby predispose to asthma, sometimes they'd have to carry around an inhaler, and it might not quite be asthma, but they need a little help keeping some airways open, et cetera. But again, for the most part, we see babies do well. 

Dr. Mike Patrick: And when they do have the damaged lung parts and sort of scar tissue in their lung, that kind of leads us to another term that you had mentioned earlier called bronchopulmonary dysplasia. And that's that condition where do you have some damaged lung that kind of follows you on as you grow and can cause problems down the road. 

0:34:17

We could spend an entire hour just talking about bronchopulmonary dysplasia. And so, if folks are interested in hearing more about chronic lung disease that some premature babies do have moving forward, there's a great article from the American Lung Association on bronchopulmonary dysplasia. I'm going to put a link to that in the show notes for this episode over at pediacast.org, Episode 467, so you can find that and learn a little bit more information about that particular disease process.

Erica, what about nutrition and feeding? So we talked that these kids have a lot of growing to do, lots of catch up. And what exactly are their needs compared to babies who are born on time in terms of nutrition. 

Dr. Erica Braswell: So to start with, in the early part of the baby that's born extremely preterm, their gut, their stomach, their intestines can't handle the absorption of the milk products to continue to grow and to meet their nutritional needs. If we start feeding an extremely premature baby too soon, we actually lead to worsening problems. 

0:35:21

So to start with, the first thing we do in those situations is use what we call TPN. So it's feeding through the vasculature. The next step is we do start slowly introducing very small amounts of feeds to extremely premature babies. We want to give them the chance to slowly build up their ability to meet their nutritional needs through their gut or their GI system. 

I will say that breastmilk is by far what is best for any babies. Mamas have spent their entire lives fighting infections and building up the immunity to fight those infections. Those proteins, what provides the immunity to fight infections, we call them antibodies, actually are passed through breastmilk and help these babies continue to be able to fight infections if they ever were to get exposed. 

0:36:12

So providing breastmilk is one of the best things that a new mom can do for her baby. It's not always the case, it doesn't work out for every mom. And so we do use some specialized formulas for our premature babies. A lot of times those formulas have more broken-down proteins than the formulas you can just buy off the shelf at the store. 

Very often, we need to take not only mom's breast milk but also our formulas and make them have a little more calories in them, a little more fad in them to help our babies grow. Like Dr. Ben was saying, we not only at the weight of the baby growing, but we also really want to promote that linear or the growth in their length to make sure that they're continuing to have good lung development. 

We also really monitor head circumference. Most of our babies are getting head circumferences and lengths once a week so we can really plot them out on a growth chart. Very similar to the growth charts that you'll see once you go to your primary care physicians or provider's office. 

0:37:11

But some of our growth charts are meant specifically to look at babies that were born prematurely, and to look at where they should have fallen as they were growing inside of the mom in utero and to adjust for their prematurity.

And so, the head circumference is so important because as the head grows, that means the brain is growing. And we're not born with the complete product of what we call myelin, which is a protein that lays down on top of our nerves and helps us make good connections from one nerve to the next, or from one synapse to the next. 

The way that I kind of explain this to families is it's almost like when you're driving on 270 right after the winter and there's lots of potholes, and you're hitting those potholes, and you're kind of jerking in the car. That's what a baby's brain kind of goes without their myelin. 

And myelin is laid down on our brains for the first, about two years of life. And so it's almost like right after they repaved 270 and you have a nice smooth drive. That's what myelin does. 

0:38:08

So babies jerk a little bit more than older kids and older people. We all still have remnants of that. We call it myoclonic jerks, like when you jerk yourself awake at night, and then you can't go back to sleep. But that's part of that immature nervous system remnant. 

So good nutrition is very important for both of those things, for your lungs to continue to developing and for your myelin that promotes neurodevelopmental growth.

And then again, like we said earlier, really good nutrition is what also helps build our immune systems and makes us strong enough that if we were exposed to an illness that we can fight it off. And we know that premature infants are more susceptible to certain illnesses. And so, we really want to make sure they're having that good nutrition to be able to fight off those illnesses once they go home from the hospital. 

So breast milk is best. You often need to increase calories. It takes a little bit of time to learn how to do this swallow-breathe, but ultimately our goal is for every baby to go home, taking all their nutrition by mouth. 

0:39:08

Dr. Mike Patrick: And this is really a plug also then, especially if this is important to clear up to two years of age, that your child, if they are premature, that they're being followed by someone who really has experience treating premature babies. And that could be in a specific neonatology clinic where a follow-up clinic, where you're following up with these kids. But in some areas, that may be your pediatrician who has experience in treating lots of premature babies, especially if you live in a more isolated rural area, your pediatrician may be used to dealing with that. 

But you definitely want someone who feels comfortable guiding you on that extra choleric need as long as it's needed, right? 

Dr. Erica Braswell: Yes, as long as it's needed. So we do have some wonderful developmental follow-up clinics that are provided through the Department of Neonatology here at Nationwide Children's Hospital. The primary resource that we want every family to use is their primary care doctor or primary care provider. That should be your first go-to with us supporting them.

0:40:10

Well visits for any patient, but especially our premature patients, are extremely important to keep track of their development, keep track of their growth, and keep track of their nutritional needs. 

Dr. Mike Patrick: Yeah, very important point. Ben, what is expected then in terms of growth and development for these premature babies as they move forward. I mean, there's delays, but do they catch up at some point?

Dr. Ben Kovalcik: Yeah, that's certainly the hope and that's something that we all work towards, is hopefully, our goal is when a child, even a premature child is two years old, they're doing everything and their own the same growth curb as every other two-year-old is doing. So really that's our sort of goal, that's our benchmark there. We'd like to see them around the age of two be sort of caught up. 

We recognize that there may be a period of increased growth. Catch-up growth is what we call it. I think you alluded to that statement or that label earlier, Mike. And that is what we would expect in the first two years. 

0:41:07

Now, we don't necessarily need to see a baby that was born extremely premature be all the way at the 97th percentile or even the 85th percentile, et cetera, we would be very happy as long as they're somewhere within what we call the average, between the 3rd and 97th percentile for babies by the age of two.

So we're extremely cognizant of that. We also would want them to be doing all the developmental things that babies are doing at that time as well. And, as Erica already mentioned and you already mentioned, we at Children's have wonderful resources to help families with that. Families are the number one drivers of that. 

Families are the ones that can really, with the right interaction, the right engagement, with the little bit of guidance from either us or some of the wonderful programs that Ohio has to offer, like Help Me Grow, et cetera. PCP, again, as Erica mentioned, absolutely crucial to really being the first step. And I'm sure they have recommendations and helpful hints and things for parents as well. 

0:42:10

So kind of with that team approach, we can all help kids to maximize their potential, be able to do the absolute most that they can do, despite having had a rough start. 

Dr. Mike Patrick: Absolutely. Erica, what about vision and hearing, any special concerns with premature babies there?

Dr. Erica Braswell: So there are, being born prematurely does protrude increased risk for both vision and hearing problems long-term. As far as  vision goes, the most common cause for vision problems in our premature baby population is what we call retinopathy of prematurity or ROP. That typically is thought to really affect those babies born before 31 weeks of gestational age. 

It can also affect babies that need intense oxygen support. We do know from years of looking at how to best  support the breathing of a baby that too much oxygen can be bad and harmful and most specifically harmful to the eyes. 

0:43:08

Specialized doctors that are called ophthalmologists or eye doctors, specifically eye doctors that are trained in pediatric ophthalmology will follow our babies starting in about four weeks of age and until their retinopathy of prematurity has resolved or cured itself. 

In worst case scenario, retinopathy of prematurity is caused because of the abnormal growth of the blood vessels that take care of or provide nutrients to the eyes. And when those blood vessels grow abnormally, if we don't intervene, then the worst-case scenario is we actually get what's called retinal detachment. And that's what can lead to the blindness that we do see but rarely in our babies born prematurely. 

We do follow these eye exams pretty closely here at Nationwide Children's Hospital for the first, once they're about four weeks of age and until they're about a year of age, they're followed closely. Some babies need them once a week. Some babies need them every two weeks. And then they do get spaced out, and eventually, they'll be told that at about a year of age, they need their final follow-up. 

0:44:10

Most ophthalmologist will also tell you to continue talking to your primary care provider, making sure that if you have any visions concerns, and that babies that are born prematurely do benefit from more frequent eye exams and yearly eye exams from an ophthalmologist. 

As far as other problems that we see with the eyes in babies that are born prematurely, sometimes we see a lazy eye and astigmatism. So the muscles of the eyes just doesn't work quite as well, and so one of your eyes kinds of shifts out. 

And then, there's also the increased chance of nystagmus, or what some people will call the dancing eyes. That one typically gets better, but it is something that needs to be monitored. Very often, babies that are born prematurely will benefit or will need glasses and can get benefits from glasses. 

Dr. Mike Patrick: Right. Another reason for the ophthalmologist really to be following up with these kids moving forward. 

0:45:06

Dr. Erica Braswell: Correct. As far as hearing goes, it is an increased risk if you're born prematurely, but more importantly, it's the infections that some moms can get exposed to. So those viral infections are the more common causes for hearing loss in our newborn patient populations. 

We specifically check all of our patients that get treatment within the Nationwide Children's Hospital NICU system for one of those viruses that's called cytomegalovirus or CMV.  So all of our patients are screened for that. And we do have a pathway of monitoring and helping provide treatment for those patients if we do find that. 

Every baby that is born and cared for in a hospital or birthing center is also given a hearing screen prior to discharge. We typically do it at about 24 hours of age in our patients that are born at term and go to what we think of as the mother-baby unit or follow a typical thing. 

0:46:02

In our premature population and within our NICU, we do kind of wait until they're further along in their growth before we do that hearing screen. We'd like to make sure that they're off oxygen and out of the incubator before we do those hearing screens. But every patient is screened for congenital hearing loss. 

Dr. Mike Patrick: Speaking of that particular infection, cytomegalovirus or congenital CMV infection, we did a PediaCast CME on that topic. So we do have a lot of pediatric providers who also listen to this program. And I would really encourage you to check that episode out because that's an instance where some of these kids, hearing loss can be prevented or at least lessened if you catch that infection early. 

And so we talked a lot about that. It's Episode 45 of PediaCast CME. And I'll put a link to that in the show notes for this episode, 467, over at pediacast.org. 

Ben, what about vaccines? Do premature babies get immunizations and are they given at the same time as term infants?

0:47:02

Dr. Ben Kovalcik: They absolutely do. I think the short answer regarding vaccines and babies, their safety, the schedule that they're given and whether they should get them, the short answer is yes, yes, and yes. Really YES with all caps and many exclamation points. 

Dr. Mike Patrick: You feel strongly about this, right? 

Dr. Ben Kovalcik: I think I'm not the only one, yes. 

Dr. Mike Patrick: Yes, you're right. 

Dr. Ben Kovalcik: I think that I can speak for most of my colleagues that we do feel that vaccination, of course, is safe. It's extremely important in not only premature babies, but all children. 

Dr. Mike Patrick: Absolutely, yes. 

Dr. Ben Kovalcik: And actually, we do give them based on the child's chronologic age. So we don't really need them to really catch up. So a premature baby that's born and is large enough and is two months old, we would start giving them the vaccination according to the same schedule as you would give a baby that was not premature. 

The one difference sometimes is the very first immunizations that some babies get at birth, we will hold off on depending on how little that baby is. And that's really the hepatitis B vaccine. But once we start giving that hepatitis B vaccine, we follow the same schedule for any other baby. 

0:48:14

Dr. Mike Patrick: So those are all active immunizations. There's also a passive immunization that's very important for some premature babies called Synagis. That's the brand name of it, but that's the term that most people recognize. And that's something where you're giving antibodies like on a monthly basis during RSV season. So as we head into fall and into the winter months, that can be protective for very premature babies. 

And again, we could spend an entire episode talking about bronchiolitis and preventing it with Synagis. There are a couple of episodes at PediaCast that we've done, one for parents, PediaCast 355, and another one for providers, PediaCast CME 21. I'll put links to both of those in the show notes for this episode over at pediacast.org, 467, so folks can find it. Very important topic, but sort of beyond the scope of what we're discussing today. 

0:49:07

And then, we hear about babies being born to moms who have been taking addictive substances and in particular, opioids. Erica, what special needs then do premature babies have who also are born to a mom who was taking some of these substances while they were growing inside? 

Dr. Erica Braswell: So those are patients that are born with neonatal abstinence syndrome, so just like when an adult abruptly stops taking caffeine and gets a headache or abruptly stops their opioid, they can have withdrawal symptoms. 

So when a baby is delivered, or when the baby is growing inside of mom in utero, that baby is exposed to the same substance that mom takes through the placenta. So that baby is exposed to the opioids or the addictive substances. And when the baby is born and no longer attached to the placenta, it's like an abrupt cessation in taking or being exposed to those substances. 

So they too can develop withdrawal symptoms. We see a lot of loose stools, poor feeding, very irritable babies that cry and have a particular type of cry. It's a more high-pitched cry. 

0:50:14

They can also have increased muscle tone and increased temperature, so similar symptoms that adults also see from withdrawal. We like to support those babies to the best of our ability in a non-pharmacologic way, so without medication if possible to support them through those withdrawals. 

So lots of holding, having moms or other support family members present to really bond and hold that baby is an excellent thing. We use quiet rooms, we use low lighting, we use low stimulation environment as much as we can. So Dr. Ben and I are fortunate that we work on a 16-bed unit that's all private rooms. And we do get to care for a lot of patients born with neonatal abstinence syndromes. 

0:51:01

When our non-pharmacological measures don't help, then we do need to start medication. The medication we typically use for opioid withdrawal here at Nationwide Children's Hospital is morphine. And we do that based on the patient's weight and it's a very low dose to start with. We can increase the dose if necessary, but we really want to maximize getting that baby into a more regulated state and really control those symptoms. 

In controlling those symptoms, we are helping their brain make new and better pathways and more normal connections within the brain. We're also improving their ability to bond with family members, improving their ability to eat as well and to grow. 

We do give our patients that have neonatal abstinence syndromes increased calories when they're needing medication treatment. And that's because due to their increased temperature and their increased respiratory rate and their increased muscle tone, they actually are burning more calories than what a baby that was not exposed is burning. And so they are supported with extra calories. 

0:52:03

We also have here at Nationwide Children's Hospital wonderful support staff who also provide an important role in these babies. We have music therapists that provide appropriate music and environmental sounds for these patients to help soothe them. 

We have massage therapists that are trained in medical massage for newborns. They actually provide education for families on how to appropriately massage and provide a deeper kind of stimulation to babies than just the typical padding or rubbing on a baby. 

We're supported by our occupational therapists and our physical therapists team and they both provide feeding support for these patients. And they provide positional support for these patients to help maximize our non-pharmacologic interventions to hopefully prevent us from having to start medication. Or as we're weaning medication, to help them ease through their withdrawal symptoms as best as we can.

0:53:00

One of our neonatal developmental follow-up clinics is actually a specialized clinic for patients that have neonatal abstinence syndrome. It's a great resource for pediatricians out in the community to know about in case they are taking care of these patients that didn't come through our hospital system, that there is a resource that they can use for guidance and help and developmental follow-ups for these patients. 

Dr. Mike Patrick: Again, very important topic that we could easily spend an hour talking about neonatal abstinence syndrome. I mean, we're going to put a resource from the March of Dimes on neonatal abstinence syndrome in the show notes for folks if you'd like to learn more.

And then, we did do a PediaCast CME for providers on this topic. And again, I'll put a link to that also in the show notes for this episode at pediacast.org, Episode 467. 

Dr. Ben Kovalcik: Ben, we kind of alluded to the fact that follow-up is really important for these babies, definitely in the medical home with their primary care physician is going to be very important. But some of these kids do have complex needs and you had mentioned that you had worked previously in a neonatal follow-up clinic. What kind of kids need to be seen in that sort of setting? 

0:54:10

Dr. Ben Kovalcik: Well, we have identified patients that are very high risk for developmental delays, et cetera. So depending on how early you are, you may end up needing to go for follow-up at the early developmental clinic. 

We have various other specialized clinics that are designed really to support babies with very specific needs. I think Eric is going to allude to some of these shortly. I think it can never stressed enough that the PCP is really probably going to be... The provider, the medical home, and the person that sees these patients still weigh more than any of our specialty clinics at Children's than anyone else. They're going to be really the first stop in where they're going to be giving the vaccines. They're going to be primarily following growth and development, et cetera. 

0:55:06

Now, we recognize that if babies need very specialized care, we will make that happen. So sometimes, babies leave our NICU and leave our unit, Erica's and mine where we work, with sometimes list of several follow-up appointments. 

If there's a cardiac defect, we will have you set up with a heart doctor, the cardiology doctors to follow. If there's a belly issue, we'll have you set up with the GI people, et cetera. The one thing that we do, like we don't do that lightly, we don't like when parents have to come and see ten subspecialists, but we recognize that, sometimes, that's necessary. 

I think everybody at Children's, we want to do what's best for every child and so we'll follow them until we don't need to. Hopefully, after several months to several years, those subspecialists just kind of fall away, those appointments become less and less, just like the schedule with your regular pediatrician. Babies are seen very frequently and then, kind of spaces out to like school physicals, et cetera. So it will be the same kind of anticipation, the same kind of schedule that we would hope that these babies would follow. 

0:56:22

Dr. Mike Patrick: You'd mentioned PCP which is primary care provider. And I think one of the take-home messages here, and again, we have a lot of parents, but a lot of providers who also listen to this podcast, is that there's no shame if you don't feel comfortable caring for a premature baby. 

If it's not something that you see very often in your practice, you may not feel comfortable with it. And certainly, the folks at Nationwide Children's and our NICU follow-up programs are happy to  help. And that may even just be a phone call like I'd ask a simple question. You guys are available and open to primary care providers who need your assistance, right? 

0:57:00

Dr. Ben Kovalcik: Oh, absolutely yeah. And I was going to say, sorry, Erica, that we also try to establish communication even at the time of discharge, especially from our unit. And especially for a kiddo that may have something that's a little more complicated or not as common as some other patients. 

So we can sometimes secure chat, it will be via computer. Certain primary care providers, every primary care provider should be given written summaries of our patients stays in the NICU. We try to make that as brief as possible because some other babies are here for a quite a while and it will be counterproductive to really send you 80 pages of notes. So we try to make it a summary as best as we can.

And then, of course, we can make phone calls, of course. If we need to, we can certainly reach out to PCPs before discharge or at the time of discharge and say "This child has this going on. Please be on the lookout and please free to call us if you have any other questions." 

0:58:03

Dr. Mike Patrick: And I'll put a link in the show notes to our NICU follow-up programs at Nationwide Children's. So if you are a parent or you are a provider and you like more information about the programs that we have for premature babies, you'll be able to find that easily with that link in the show notes over at pediacast.org.

Erica, you had mentioned particular clinics for kids with neonatal abstinence syndrome, but there's also other specialty NICU follow-up clinics. Tell us about some of those. 

Dr. Erica Braswell: So we actually have under the umbrella of the Neonatal Follow-up Clinics, we actually have four specialized clinics. So the first one, like we mentioned earlier, is our Neonatal Abstinence Syndrome Clinic. And that is specifically for patients that needed medication therapy to treat their withdrawal symptoms. 

And that follows patients typically starting at about two to four weeks from discharge and then on a regular schedule until they're about three years of age. That is really in the mindset of trying to really monitor their development and help meet the needs of their behavior that can develop because of the exposure in utero.

0:59:08

The next clinic that we have is our Early Developmental Clinic. And this is probably our biggest clinic because this is any baby that is born prior to 33 weeks gestational age gets followed up in this clinic. And this is really a full-service clinic, so you have the medical provider team, either a nurse practitioner or a physician or a physician's assistant that sees the patient. You have the occupational therapist, the physical therapist that are monitoring the development of the baby. You have our wonderful dietitian team that sees this baby to make sure their growth is appropriate. 

This is also where we make sure that things like Synagis are being talked about and that pediatricians or primary care providers have resources to get the Synagis paperwork done so that in the fall, those vaccines can be provided through the primary medical home for the patient.

And again, that one follows  babies until about three years of age. 

1:00:05

The next clinic that we have is our specialized Bronchopulmonary or BPD Clinic. And that's for babies that leave our hospital that were born prematurely and continue to need oxygen support. And again, it's all about monitoring how much oxygen they need and helping to make sure their lungs are continuing to have that good healthy growth and working on getting babies off oxygen.

There are also some medications, some inhalers that are used in these patients and sometimes other medications are needed. And this is the medical team that provides that care. And again, we always are focusing on the development and the nutrition and that can also be talked about at these type of clinics. 

And then the last clinic that we have is our Neonatal Complex Care Clinic. And this is for our patients that have a refer go in their premature course or babies that are born with certain congenital anomalies. If a baby needs ECMO during their hospital or their NICU stay, if baby is born with hypoxic injury, this is the clinic where they're followed up then. 

1:01:17

Dr. Mike Patrick: An ECMO is like a heart-lung bypass machine, right?

Dr. Erica Braswell: That's right. 

Dr. Mike Patrick: When their lungs are really not working well, and we need to oxygenate and pump the blood around. 

Yes, so really great programs, lots of resources. Again, I will put links to all of our NICU follow-up programs at Nationwide Children's Hospital in the show notes. And really, lots of other things, as I have mentioned, as we've gone along here -- our newborn care podcast that we've done in the past, more on bronchopulmonary dysplasia or BPD, congenital CMV, bronchiolitis and RSV disease, neonatal abstinence syndrome. If you're interested in hearing lots more expanded information on any of those topics, we do have resources for you that we will include in the show notes over at pediacast.org. 

So Dr. Ben Kovalcik and Dr. Erica Braswell, both with Neonatology at Nationwide Children's Hospital, really do appreciate you taking the time and visiting with us today. Thanks so much. 

Dr. Erica Braselwl: Thank you. 

Dr. Ben Kovalcik: Yes, thank you very much, anytime. 

1:02:14

[Music]

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. 

Also, thanks again to Dr. Ben Kovalcik and Dr. Erica Braswell, both with Neonatology at Nationwide Children's Hospital.

Don't forget, you can find us wherever podcasts are found. PediaCast is in the Apple and Google Podcast apps, iHeart Radio, Spotify, SoundCloud, and most podcast apps for iOS and Android. 

1:03:10

We also have that landing site, pediacast.org. You'll find our entire archive of past programs, also show notes for each of the episodes, a contact page, and our Terms of Use Agreement.

Don't forget to leave us a review wherever you listen to podcast. We always appreciate when you share your thoughts about the show.

And we love connecting with you on social media. You will find us on Facebook, Twitter, LinkedIn and Instagram. Simply search for PediaCast.

Don't forget, we also have a sibling podcast called PediaCast CME. That stands for Continuing Medical Education. It is similar to this program, we turn up the science a couple of notches and offer free Continuing Medical Education Credit for those who listen, which includes doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and even dentists. 

And since Nationwide Children's is jointly accredited by a many professional organizations, it's likely that we offer the exact form of Continuing Education credit you need to fulfill your state's Continuing Medication Education requirements even if you are a nurse, or a pharmacist, psychologist, social worker, dentist. We're accredited by all of those organizations and your credentialing bodies. 

1:04:23

Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME. 

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.