Zinc, Eating Disorders, Nannies – PediaCast 216

Join Dr Mike as he covers pediatric news and answers listener questions. Topics this week include baby wipes, zinc’s role in fighting serious infections, afternoon snacks, predicting eating disorders, the effect of hot, humid air on asthma sufferers, ear tube surgery, sunburns and sunscreen, daycare vs nannies, and summer physicals. It’s all right here… on PediaCast!


  • Autism Speaks National Conference
  • Baby Wipes
  • Zinc and Serious Infections
  • Afternoon Snacks
  • Predicting Eating Disorders
  • Hot, Humid Air and Asthma
  • Ear Tube Surgery
  • Sunburns and Sunscreen
  • Daycare vs Nannies
  • Summer Physicals



    Announcer 1: This is PediaCast.


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

    Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast from the good folks at Nationwide Children's Hospital. This is Dr. Mike coming to you from the campus of that hospital. I'd like to welcome everyone to the show. It's episode 216, 2-1-6, for June 20th 2012. We're calling this one Zinc, Eating Disorders and Nannies.

    Of course we have lots more coming your way and we'll get to the entire lineup here in just a couple of minutes. First, I have quite a few housekeeping items for you today. Those of you who are longtime listeners know that when we do our News and Listeners shows, which this is one of them, we cover a little bit more in the intro and have some housekeeping items that we want to get out of the way, just some information I think would be helpful for parents out there that I want to cover. As opposed to the interview shows where we really try to jump right in to the interview, so just bear with me. There's some good information here.


    First off, the Autism Speaks National Conference for Families and Professionals is coming to Columbus. It is August 3rd and 4th of this year at the Hilton Columbus at Easton. And the conference partners include Autism Speaks, Nationwide Children's Hospital, Ohio State University's Wexner Medical Center, the Health Resources and Services Administration of the U.S. Department of Health and Human Services and the American Academy of Pediatrics.

    So, this is a big deal. It's a big national autism conference coming to Columbus August 3rd and 4th. There's a professional track of speakers and workshops for physicians, nurses, psychologists, educators, allied health workers and behavioral specialists and a family track for moms and dads and other relatives affected by autism and their loved ones. It's going to feature science sessions, practical workshops and topics include immune and metabolic dysfunction, gastrointestinal (GI) disorders, seizures, sleep issues, medical management, dealing with challenging behaviors, transition planning and coordinating care between doctors and other professional providers. So really lots of information packed into this thing.


    Keynote speakers include Dr. Ricki Robinson, M.D., a pediatrician and author of the book Autism Solutions and Dr. Peter Gerhardt, Ed.D., director of education at New York City's McCarton School.

    For more information, you can head to the conference info page at Autism Speaks and of course we'll put a link in the Show Notes to that site for you so you can get all the information that you need. And one more very exciting piece to this since Nationwide Children's is one of the conference sponsors, have access to some free vouchers for families who would like to attend the conference. So if you're interested in attending the family track and you'd like to attend for free let me know. Of course you still have to cover your transportation and hotel costs but we can get you into the conference free.

    So how do you do that? Well just use the Contact page at pediacast.org. Let me know of your interest and your contact information and we'll get back to you. Free voucher supplies are limited, so be sure to let me know as soon as possible.


    All right, moving on to the rest of our housekeeping items today, this is the big day! Patients are moving in to our new hospital building, so really excited about that. The new 65-bed emergency department opens its doors today to patients for the very first time. It's the largest pediatric expansion in the world ever with over 2 million square feet of new space and of course it's kid-friendly in so many ways with giant hand-carved animal friends made by Carousel Works. So 18 of them scattered around the hospital. These things are big.

    Carousel Works is the world's largest manufacturer of wooden carousels and they did really an amazing job with these. And they're not roped off for kids just to look at, kids can actually climb on these things and not only are they cute animals, but each animal has a job. So like the bunny is a gardener, the snail won the gold, silver and bronze medals that he has hanging around his neck. One of the animals is an astronomer, one's an explorer. They're really, really cute, hand-carved with wood and kids can climb on them and they're scattered throughout the hospital.

    Really cool thing and if you want to check out some of the work that the folks at Carousel Works do we'll put a link to their site in the Show Notes as well. Of course there's lots more than that, there are animal footprints on the floor that kids can follow, eye candy on the elevator ceilings, lighted up headboards, the kids can change what color it is then that color glows throughout the room and entertainment packages in every room. Large private rooms with rooms for the entire family, large siblings clubhouse where your brother or sister who's is sick in the hospital or for kid's who have a brother or sister that's sick in the hospital they can kind of hang out in the siblings clubhouse.


    I understand that they have two chefs from world renowned culinary schools, wood-fired pizza, a burrito bar, coffee house, ice cream parlor and an amazing magic forest that you just have to see to believe. And you can see all of that with pictures and videos if you just go to nationwidechildrens.org/grandopening you can see what the new hospital looks like. We're really proud and excited.

    We even have an hour-long video tour of the hospital that not only shows you the new facilities but also introduces you to community outreach projects, patients, families, staff and doctors who was aired on local TV here in Central Ohio but it's also available on the Internet from 10tv.com and we'll put a link in the Show Notes to that as well. And speaking of our staff and physicians, of course the facilities are amazing, but what's happening inside this hospital is what really counts.

    And for the first time in our history, Nationwide Children's Hospital made the U.S. News and World Report Honor Roll. It highlights the best of the best children's hospitals in the country. Basically, it's a top 10 list of children's hospitals as ranked by our peers. And we also nationally an all 10 pediatric specialties. So you can read more about that at U.S. News and World Report site and we'll have a link in the Show Notes. But we have a whole collection; we have a link garden in the Show Notes today.


    Of course we're proud of these accomplishments, our new facilities, the national rankings, but what it means for you the parent really is that when you bring your child to Nationwide Children's you can be sure that they're getting the best care available anywhere.

    All right. A couple other items before we move on to today's lineup, I recently wrote a guest blog post for iTriage. Now you may be asking yourself what is iTriage, well it's a crazy popular mobile app and website that empowers people to make better healthcare decisions. They can be found at itriagehealth.org, link in the Show Notes, in the link garden that we have growing. So what did I write about? Well, it's a topic we've covered here while back, "The Cinnamon Challenge", the hidden and possibly deadly dangers of eating a tablespoon of cinnamon. And if you'd like to read the blog post, we'll put a link to that; guess where, in the Show Notes.

    And stay tune for more of my blog posts coming to iTriage in the near future. Speaking of blogs, do you like how everything is just flowing from one topic to the next today? It's not always like that, folks. But today it is. Speaking of blogs, I want to do a quick shout out to a mommy blogger in California who shared PediaCast with her readers, Catherine over at Mommy Uncensored. She's raising three young kids and loves to write about her family and traveling and photography and shopping and organizing and baking and healthy eating and watching your kids grow. So be sure to check out Catherine and her family at mommyuncensored.com, link in the Show Notes.


    All right. So what are we talking about today? We do have a full show lined up for you. Baby wipes are gaining ground in the United Kingdom. Seriously, I didn't even know this was a debate, but I wanted to include it because we do have an international audience. I think this will really surprise a lot of folks in the United States but baby wipes are still considered a no-no in many circles in the United Kingdom and we're going to talk about why and why maybe in the near future using baby wipes could become a little bit more accepted. So we're going to discuss that.

    Also, zinc may play a role in fighting serious infections but before you run out and load your kids up on zinc, you want to hear the proper scenario for using it, so stay tune for that. Afternoon snacks, what's the best way to satisfy your kids when the afternoon munchies hit without filling them up with too many calories? Also predicting eating disorders in young girls, we'll look at the earliest warning signs so you can stay vigil and let you know what to do if worrisome signs appear.

    What's the effect of hot humid air for asthma sufferers? We know how cold dry air affects asthmatics, but what about summer weather? A first of its kind study has some answers. Then we'll get to some of your questions on ear tube surgery, sunburns and sunscreen and the day care versus nannies. And if that's not quite enough for you, we'll wrap things up with an important announcement and maybe a bit of opinion on summer physicals.

    So we have a big lineup for you, but before we get started, I want to remind you if there's a topic that you would like us to discuss, you have an idea or a question for me, 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 PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you 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 over at pediacast.org. So let's take a quick break and we will be back with News Parents Can Use, right after this.



    Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.

    We have an international flair to the news today and we're going to start in the United Kingdom. New researches found that a brand of baby wipes is just as safe and hydrating as using water alone on newborn skin suggesting official guidance may need updating. Now, many of you may be saying, whoa, slow down. You mean we aren't supposed to be using baby wipes on young infants? My doctor didn't warn me about that.

    Well, keep in mind we have an international flair to our news today and in the UK baby wipes are a no-no with British doctors advising against their use in young infants. Parents are told water and cotton cloth is best. Why? Because you get better skin hydration, fewer rashes and less infection according to the Brits. Of course U.S. parents are scratching their heads over this bit of news because here in the United States the use of baby wipes in young infants is routine. So American parents may be thinking hey, we deal with skin problems under the diaper all the time, maybe baby's bottoms are healthier on the other side of the pond, maybe British babies have fewer diaper area skin problems, maybe we should dump the wipes and use water and cotton cloth too.


    Well not so fast. A University of Manchester study published in BioMed Central's open access journal BMC Pediatrics compared Johnson's Baby Extra Sensitive Wipes against cotton wool and water on 280 newborn babies split into two groups over a three-year period.

    Despite advice from the UK's National Institute for Clinical Excellence (NICE) that mums should use water alone on newborns, the study found that the Johnson's wipes were as effective and as safe as water and they hydrated babies' skin just as well.

    Tina Lavender, Professor of Midwifery at the University's School of Nursing, Midwifery and Social Work and the study's lead author, says, "Baby wipes can be much more convenient for parents, especially when on the go, but current guidelines recommend using only water and cotton wool instead."

    "Our research, looking at one high street baby wipe, wanted to test whether the product was as safe and effective on newborn skin as water alone and to see if midwives could help give parents more options than current guidelines provide."

    All right now. Here comes the conflict of interest alert, the study, funded by Johnson & Johnson, makers of the tested wipes was carried out under strict, independent scientific protocols, including blind testing and peer review and it showed the company's product was as safe and effective as using water. In fact, there was a slight, though not statistically significant, reduction in the occurrence of diaper or as the Brits call it nappy rash when comparing baby wipes to water.

    Professor Lavender adds, "Parents can be confident that using this specific baby wipe, proven in the largest randomized clinical trial conducted in newborn bum cleansing, is equivalent to water alone. And our trial provides the strongest evidence available that we shouldn't base our practices on tradition alone and that National Institute for Clinical Excellence needs to look at its current guidelines."

    "For the first time, we have a robust, adequately-powered study that can be used in practice, the results of which should be adopted by our national guidelines. These results should provide healthcare professionals with much needed evidence-based information, giving them the option to support the skin-care cleansing regimen best suited to individual parents and their newborn babies."


    The findings of the study showed that Johnson's Baby Extra Sensitive Wipes were equivalent to water and cotton wool in terms of skin hydration. No significant differences were found in secondary outcomes except for maternal reported dermatitis or nappy rash, which again was slightly higher than the water and cotton wool group.

    A newborn skin is different than adult skin. Trans-epidermal water loss, which indicates the amount of water that escapes from the skin, is higher in newborns than in older babies. Consequently, the newborn skin barrier is less mature and likely to be more vulnerable to environmental threats. And trans-epidermal water loss does not decrease to mature levels until the first year of life.

    The study was conducted with 280 newborns from Central Manchester who were randomized into two groups, one group cleansed the nappy area with cotton wool and water, the other cleansed the nappy area with Johnson's Baby Extra Sensitive Wipes and throughout the trial moms were advised to bathed their newborns in water alone and not to use any other products on their baby's skin, except in the event of a nappy rash in which case they could use a cream provided by the researchers.


    The primary end point of the trial was that change in hydration between baseline and at four weeks. Hydration is a measure that shows how much water is contained in the skin, which is one of the characteristics of skin barrier integrity. Secondary end points were trans-epidermal water loss, skin pH, erythema (also known as redness), nappy rash, skin contamination with yeast and bacteria, clinical observations and maternal opinions based on diaries and structured questionnaires.

    Current UK guidelines vary in their advice and are challenged by the personal beliefs of many healthcare professionals. A 2006 National Institute for Health and Clinical Excellence guideline entitled "Routine Postnatal Care for Women and Their Babies" recommends that baby wipes should be avoided in the first six to eight weeks after birth. However, this guideline is not based on robust scientific evidence; it simply comes from the collective opinion of the expert guidelines group.

    So there you have it, British researchers challenging their national healthcare system to get with the program and embrace evidence-based recommendations. It would have been nice to have had the study funded by someone other than Johnson & Johnson, but it was well-designed and the results, for the most part, significant.


    All right. Continuing with our international flair, researchers in India have found that zinc supplementation, in addition to standard antibiotics, reduces the risk of treatment failure among young children with suspected serious bacterial infection by 40%. That's according to a study published in the Lancet. In 2010, nearly 66% of deaths in children under age 5 around the world were due to infections and of these deaths two of these occurred within the first month of life.

    Shinjini Bhatnagar from the Translational Health Science and Technology Institute in the All India Institute of Medical Sciences conducted the study and explains, "Zinc is an accessible, low-cost intervention that could add to the effect of antibiotic treatment and lead to substantial reductions in infant mortality, particularly in developing country where millions of children die from serious infections every year. And where second line antibiotics and appropriate intensive care might not be available."

    In order to evaluate how effective zinc is, in addition to standard antibiotic therapy for suspected serious bacterial infections such as meningitis, pneumonia and sepsis, the researchers enrolled children between 120 days of age and seven years of age who are undergoing antibiotic treatment for serious infections. All children were patients in one of three hospitals in New Delhi, India. The researchers randomly assigned the 352 infants to receive 10 mg of zinc each day orally and 348 infants to receive placebo, again, in addition to the medically appropriate first line antibiotic for their condition.

    Researchers then measured treatment failure, which they defined as a need for secondary antibiotic treatment within seven days, the need for treatment in an intensive care unit or death within 21 days from the onset of care. The researchers found that children were 40% less likely to experience treatment failure when given zinc along with the first line antibiotic rather that placebo. The authors conclude that zinc syrup or tablets are already available in the public and private healthcare systems for the treatment of acute diarrhea in many countries of low and middle income and the incremental costs to make this intervention available for young infants with probable serious bacterial infection would be small.


    In a joint comment, Dr. Christa Fischer Walker and Robert Black from John Hopkins Bloomberg School of Public Health in Baltimore, Maryland said, "This finding is important because case fatality is high in infants presenting with symptoms of probable serious bacterial infection. The exact mechanism for the effect of supplemental zinc is unknown and needs further investigation, but the clinical benefits in diarrhea and pneumonia in children younger than five years and now in probable serious infections in young infants suggest that therapeutic use of zinc could have wide spread application."

    Additionally, zinc would be beneficial for other serious bacterial infection such as those causing typhoid fever or meningitis. Now moms and dads, this does not mean that you should run out and buy zinc to keep your kids well or that you should give lots of extra zinc when your kids get sick. A healthy, well-balanced diet is your best bet with extra zinc supply by a multivitamin if your child's a picky eater. Too much of zinc remember can cause problems of its own.

    What we are talking about is giving zinc in the hospital setting as a supplement to appropriate antibiotic treatment, particularly in countries with less developed medical systems, poor access to second line antibiotics and ill-prepared pediatric intensive care. Could zinc supplementation become standard treatment for sick kids in the U.S. and other industrialized nations? Maybe, but further studies are needed to see if increased benefit holds true in an advance medical system and to make sure there aren't unforeseen complications or consequences.


    All right. Let's move on and just to warn you, we have another potential conflict of interest with our next story, so we want to make sure we identify the conflict and make sure the results still hold up to scientific scrutiny. And like our previous story about baby wipes, I believe this next research study is also significant despite the source of the project's funding.

    New research recently announced that the Canadian, notice we're continuing with our international flair, at the Canadian Nutrition Society's annual meeting in Vancouver, British Columbia, suggest eating raisins as an afternoon school snack or an after-school afternoon snack prevents excessive calorie intake and it increases satiety or a feeling of fullness as compared to other commonly consumed snacks.

    The study funded by a grant from, get this, the California Raisin Marketing Board, was conducted among 27 normal weight boys and girls ages 8-11 during a three-month time frame. Study participants were randomly assigned to eat raisins or other snacks including grapes, potato chips or chocolate chip cookies until they were comfortably full. Additionally, each child received the same standardized breakfast, morning snack and lunch on the test days.

    Subjective appetite was measured before and immediately after snack consumption at 15-minute intervals. Key study findings include food intake following raisin consumption was lower and feelings of fullness greater compared to the other snacks. When eating raisins children consume significantly fewer calories when compared to the other snacks in the study. Grape eaters, for instance, consumed 56% more calories than the raisin eaters; potato chip eaters consumed 70% more calories; and cookie eaters consumed 108% more calories.

    Kids who snacked on raisins also had a lower cumulative calorie intake when breakfast + morning snack + lunch + after school snack were taken into consideration with a 10-19% reduction of calories. And although all snacks reduced subjective appetite, desire to eat was lowest after consuming raisins.


    Lead researcher for the study, Dr. G. Harvey Anderson, Ph.D., Professor of Nutritional Sciences and Physiology at the University of Toronto, says, "To our knowledge, this is the first controlled study that looks at after-school snacking and satiety among children, we found consumption of raisins as a snack prevented excess of calorie intake, increased the feeling of fullness and thereby may help contribute to the maintenance of healthy weight in school-age children."

    So the take home here yes, the project was funded by the California Raisin Marketing Board, to raise my eyebrows at that, and there were only 26 kids in the study, you'd certainly like to see a little bit more in the participation level, but appropriate snacking and maintaining a healthy weight are big deals. So it seems like a good idea to me to at least give raisins a try. See if they satisfy your child's appetite after school, see if it helps them maintain a good weight.

    Personally, I'm not a big raisin fan and my kids aren't either. Ssshh… Don't tell the Raisin Board. So I supposed that's the biggest push back that you'll get. And I wonder how prunes or dried cherries would have fared. They kind of pitted the raisins against potato chips and cookies. Yeah, they did grapes, great. But other alternatives to raisins that could also be helpful that perhaps kids might like a little bit more.

    Hopefully the folks in Toronto would do a bigger study at some point, with more kids and more snack options to compare with one another. But in the meantime, give raisins a try.


    According to a new study conducted by researchers in the Division of Adolescent Medicine and Behavioral Medicine at Cincinnati Children's Hospital, doctors might be able to foresee which young girls have a chance of developing eating disorders later in life simply from the food they eat when they are young. The authors followed 800 girls, see that's a more appropriate number for a research study, they followed the eating behaviors of 800 girls between 1988 and 1999, starting when they were nine years with the goal of determining if what they chose to eat gave them a greater risk of having an eating disorder when they were older.

    The study analyzed the girls' fat, protein and carbohydrate consumption and then a few years later they screen the girls for common symptoms of eating disorders including unusual ways of eating, poor attitudes toward their bodies and obsession over being skinny. Researchers found the outcomes were different according to how old the girls were. Girls around 11 years of age who had high carbohydrate and fat consumption percentages were more likely to be unhappy with their bodies around the time they turn 14.

    On the other hand, 15-year old girls who had high carbohydrate consumption percentage but low fat consumption were found to have unusual ways of eating by the time they turned 19. The researchers discovered this was even more prevalent in girls who are perfectionists. Dr. Abbigail Tissot, PhD, associate director of the Division of Behavioral Medicine at Cincinnati Children's Hospital and lead researcher, commented, "We know that perfectionists are at high risk for eating disorders. They are so committed to perfectly conforming to an unhealthy and extreme idea of beauty that they get carried away. Unfortunately, these girls were committed to achieving thinness – no matter what it takes – are actually placing themselves at a higher risk for being overweight or obese later in life."


    Laurie Dunham, a registered dietitian at Cincinnati Children's said, "Eating disorders are notoriously difficult to treat, so prevention is critical. By assessing protein and fat consumption as early as age nine, we can detect which girls may go on to develop eating disorders and step in to help before things get out of control."

    Dr. Tissot adds, "The study is rare in that it's based on long-term observation of girls during their transition from pre-puberty through adolescence and into early adulthood. It tells us at what age we should be watching for these eating behaviors, giving parents and physicians useful tools for detecting girls at risk for future eating disorder symptoms."

    Another interesting note, the researchers found that girls who skip lunch end up consuming more daily calories than those who eat lunch. Dr. Tissot says, "Plenty of studies have been done on the effects of skipping breakfast. But a few until now have looked at the impact of skipping lunch."

    So that last finding is fairly convicting for me personally. I'm a notorious lunch skipper and my wife always tells me I'll probably eat more in the evening because I skip lunch and that I should just go ahead and eat lunch. Now, I'm thinking maybe she's right. So take homes from this story, watch your kid's carbohydrate and fat consumption during the pre-adolescent years, be especially vigilant if your child is a perfectionist and be on the lookout for unusual eating habits. Know what your daughter truly thinks about her body and make sure she's eating some lunch. And if you have any concerns that your child may have an eating disorder, talk to her or him about it and be sure to communicate your concerns to your child's healthcare provider.


    All right. One more news story for you and then we're going to move along to getting your questions answered this week. Summer is here and researchers from Nationwide Children's Hospital say they are closer to understanding why patients with mild asthma have difficulty breathing during hot, humid weather. The study which appears in the June issue of the American Journal of Respiratory and Critical Care Medicine, found that patients with mild asthma experience airway constriction and coughing when they inhale hot, humid air. Healthy volunteers without asthma do not experience this effect.

    Furthermore, when those with mild asthma inhale a specific asthma drug prior to breathing in the hot, humid air, airway constriction and cough were avoided. The specific asthma drug used in the study was ipratropium, also known as Atrovent. Ipratropium, when inhaled, prevents airway muscle contraction and increases airflow to the lungs. Its success in combating the air temperature response suggests that hot, humid air triggers asthma symptoms by activating airway sensory nerves that are sensitive to an increase in temperature.

    Dr. Don Hayes, MD, medical director of the Lung and Heart-Lung Transplant Program at Nationwide Children’s Hospital says, “We know breathing cold, dry air induces airway constriction in asthmatics, but until now the effect of hot, humid air had not been studied."

    Prior to joining the medical staff at Nationwide Children's, Dr. Hayes and his colleagues at the University of Kentucky Medical Center, enrolled six patients with mild asthma and six healthy controls in a study to assess their pulmonary reaction to hot, humid air. All participants were asked to breathe into a device designed to deliver air at pre-programmed temperatures and humidity levels. Investigators measured airway resistance of each participant before and after using the device for four-minute period. They also measured body temperature, heart rate, arterial blood pressure and oxygen saturation.

    Results showed a four-minute exposure to hot, humid air triggers an immediate increase in airway resistance in patients with mild asthma, but causes no significant response in healthy subjects. Breathing the hot, humid air also triggered significant coughing in those with asthma. However, When the six asthmatic participants used an ipratropium aerosol before the hot, humid air challenge, they did not experience airway constriction or cough.

    Dr. Hayes admits, “We don’t fully understand the mechanisms underlying these responses." He says a recent study from the University of Kentucky Medical Center found airway sensory nerves called C-fibers were activated when temperature inside the chest was elevated to about 102 degrees Fahrenheit. When C-fiber sensory nerves are stimulated, a number of pulmonary defense reflex responses can occur, including airway constriction and cough.


    This study is a good example of how we can translate findings from a research laboratory into better understanding and more in-depth knowledge about how to prevent and treat disease in patients. Dr. Hayes says further research is needed to completely understand how patients’ bodies react to hot and humid air and he's planning on conducting such studies here at Nationwide Children’s. Overall, he says his data provides evidence that supports the role that air temperatures and humidity play in worsening symptoms for asthma sufferers. And he says this research introduces a new role for an old asthma drug.

    So there you have it, if one or if you or one of your kid's have asthma and you'd notice that hot, humid days make the condition worse, now you have a little better idea of why. But before you start self-treating, before you go outside on a hot, humid day with an ipratropium or Atrovent, be sure to talk to your child's doctor. It is important to keep in mind that this study only looked at 12 patients. But more research is coming and when it does, we'll be sure to let you know.

    All right. So that concludes our News Parents Can Use this week. We're going to take a quick break and we'll be back to answer your questions right after this.



    OK. We are back and Dafna from Israel, continuing with our international flair today, Dafna in Israel says, "My daughter is 17 months old, she can say about four to five words but they're mostly animal sounds. She was recently diagnosed as having a hearing loss of 30-40 decibels because 'fluid in her ears'. Our doctor says there is a slight delay in language development based on what I described and that we should check her ear for fluid in two months and if the condition persists we could consider ear tube surgery. I understand that fluid in the ear is a condition that passes over time and the reason to do this surgery is to prevent delayed language development. My daughter is very communicative, healthy, energetic and seems to understand and remember things. I often say a word to her over and over again, for example ball, nose, ear, food and she does not repeat the words back. My questions are as followed: is there an alternative to ear tube surgery (according to our doctor there is not)? How serious is her language delay? How would you advise to find a good doctor in case she needs surgery? And is there any way that we can work with her given this condition to enhance language development such as singing or sign language? Thank you, Dafna in Israel.

    Well, thanks for your questions, Dafna. So to sum up, you have a 17-month old. She says four to five words, mostly animal sounds. She has fluid behind the eardrums and she also has some hearing loss, which you attribute to the fluid. So the questions become and I'm going to add some, why is the fluid there? How does the fluid cause hearing loss? Does she have a language delay? If so, how bad is it? Will getting the fluid out of her ears help her language delay? How do we get the fluid out? Who should get the fluid out? And is there anything else that you can do to help her language development?


    So this is a set of questions that many parents ask and we're going to tackle them one by one. Why is the fluid there? Well, usually it's leftover from an ear infection. It won't stay forever but it may stay many months and if she gets another infection it may stay longer.

    How does the fluid cause hearing loss? Well, remember proper hearing depends on sound waves causing air to move, the air moves the tympanic membrane or the eardrum, which moves some little bones in the middle ear space, which ends up stimulating the auditory nerve, which sends a signal to the brain, the brain interprets the signal and your child hears the sound. So if you have fluid in the middle ear space it dampens the movements of those little tiny bones, so stronger air movement or louder sounds are needed to move the bones and softer sounds don't move the bones as well, since the bones are surrounded by fluid instead of air and so we have a temporary hearing loss. And it's temporary because hearing should return to normal when the fluid is gone.

    Next, does she have a language delay? Well, I have a great link for you from the U.S. National Institutes of Health and specifically from the National Institute on Deafness and Other Communication Disorders. The link is to a Speech and Language Developmental Milestones checklist and of course we'll put that link in the Show Notes for you. According to this checklist, here's what one to two-year olds should be doing, so your 17-month old, these are the things she should be working and that she should have mastered by the time she's two years old. So you still have six months to go to work on this list. So what are they?


    She should know a few parts of the body and point to them when asked. She should be able to follow simple commands like roll the ball, where's your shoe. She should enjoy simple stories, songs and rhymes. She should be able to point to pictures when named in books, such as where's the dog, where's the truck? She should acquire new words on a regular basis and understand the meaning of those words and she should use some one or two-word sentences such as where kitty or go bye-bye or more cookie or no juice or just no. Lots of no's at this age, right?

    So you'll notice a couple of things about this checklist. First, it is heavily focused on receptive language. So, it's really focused on her being able to understand what you're saying and respond in an appropriate way to what you're saying. Now yes, we do want her to start using some words and maybe putting two words together, but you do have until she's two years old to do those things, which gives your daughter really seven more months to get there. So those are the things that you can be working on.

    Now something else we can do with this checklist is go back one step up on the checklist. So let's look at what kids should be doing when they're seven to twelve months of age because by 17 months your daughter should be doing all of these things. So you'd be concerned if there was a significant number of these that she wasn't able to do. So what are they?


    Playing peek-a-boo and pat-a-cake; turning and listening in the direction of sounds; listening when spoken to; understanding words for common items; responding to requests, so come here or do you want more? Babbles when using long and short group of words; babbles to get and keep attention. So your animal sounds sounds like babbling. They communicate using gestures such as waving or holding up their arms; and begin to imitate different speech sounds although not necessarily using words; and then by the time they have their first birthday, they usually have one or two words such as hi or dog or mama or dada.

    So take an honest look at the checklist, Dafna and I'll bet your child doesn't really have a language delay at all or if she does, it's very mild. But check it out and see. Here's the problem, the checklist tells us what is normal, right? But lots of kids out there aren't normal. In fact, their language development is advanced. And so the neighborhood kid is reciting whole nursery rhymes back at 18 months and your kid still grunt and then point at things. So you don't necessarily want to compare your kid to the neighbor kid. You want to compare your child to the what's normal checklist and I think when you do that you'll see that things really aren't so bad and you'll know what you need to work on.

    This checklist, by the way, goes from birth to age four and again you'll find a link to it in the Show Notes. I have a feeling this is going to be a popular one. So visit our link garden in the Show Notes today and you'll find a link to this checklist for Speech and Language Developmental Milestones.


    OK. So the next question, how bad is the language delay? Well, we kind of answered this one already; it depends on how you answer the questions in the seven to twelve-month checklist because the one to two-year old checklist is stuff you're still working on. It would be a delay if your child isn't doing the seven to twelve-month stuff at 17 months. So again, my guess there really isn't a delay at all or it's a mild one. But again, we have a need for more information so just take an honest look at that checklist and see if there is one.

    But let's say there is, even though there likely isn't. Let say that there is a mild delay or more than a mild delay. Next question is will getting fluid out of her ears help? Well, this is a little more difficult to answer and it's also a bit premature. The better next question is will getting the fluid out help the hearing loss? Let's not make the jump to whether it's going to help with the language delay if there is one. But will getting the fluid out of her ears help with that mild hearing loss that you're reporting.

    And the answer is yes, but only if the hearing loss was only there because of the fluid. So unless your child had a hearing test before the fluid was there, we are assuming that the hearing loss is 100% from the fluid. But maybe same hearing loss was present before the fluid was there, we don't know. But let's say the hearing loss really was only from the fluid and when we get the fluid out hearing returns to normal. If it doesn't, then we got to look for other sources of the hearing loss. But let's just assume that the mild hearing loss was from the fluid, OK, now we can say will getting the fluid out help? Yes. If hearing returns to normal, will language development improve?

    The answer to that is yes, as long as the language development delay really was because of the hearing loss. And here is where we can run into some trouble because it's not clear that mild hearing loss causes language delay at all. There are a lot kids with mild hearing loss who don't experience language delay and there are lots kids with no hearing loss who do experience language delay.


    Also, there was a study a few years ago that looked at a group of kids with chronic ear fluid who ended up getting ear tubes and another group of kids with chronic ear fluid who didn't get tubes, they just let the fluid go away on its own over the course of many months. Researchers followed them through preschool and completed language assessment before kindergarten and they found no difference between the two groups with regard to language delay.

    So at least for that study getting the tubes and draining the fluid didn't really seem to make a difference for those kids. So what do you do? Ultimately, that's a decision between you and your doctor and you have to weigh risk versus benefit. Surprise! For me, personally, here's how that boils down, but this is my opinion for my kid, OK? You and your doctor have to decide for your kid. For me, if my child was having recurrent acute ear infections with fever and puss and discomfort and if that was happening over and over and they've been on lots of antibiotics, sure, I'd send them for tubes. In fact, we did send my son for tubes and for that very reason and they helped. Their benefit outweighed their risk.

    Now, if my child has a mild hearing delay because of chronic fluid, what we call seros otitis, and I'm not really convinced that improving hearing is really going to make a big difference and I'm not sure the benefit of the tubes outweighs the risk of the surgery, then I'll probably wait awhile, which sounds like it could be where you are, Dafna, and this is the advice that sounds like your doc is giving you, to wait awhile and see. Sounds like good advice to me.

    Now, on the other hand, if my child has a significant hearing loss and serious language delay then sure get the fluid out and see if that makes a difference for him. Again, at that point, the potential benefit probably outweighs the risk.


    But there's also a good chance that there's another explanation for the significant hearing loss and significant language delay, so get the fluid out and get the tubes in but don't be surprised if it doesn't help because there may be some other problem that you'll need to explore.

    All right. Let's say that we did decide that we want to get the fluid out. How do we get the fluid out? Well ear tubes that's really the only way. If you try draining it without placing a tube it would like reaccumulate and there have been some studies that suggest the use of antihistamine medications like Benadryl or Zyrtec or Claritin or Allegra might help serious fluid in the middle ear space. But other studies have shown that these do not work so well and in my own personal clinical experience I have not found them to be so helpful at eliminating fluid in the middle ear space. But they are relatively benign medications and your doctor might try them before they recommended surgery but they're unlikely to help.

    OK. Who should help the tubes? Well, if you and your doctor decide to move forward with the tubes, I would trust your doctor's recommendation because here she knows the reputation of local doctors and has likely had good experiences with some and perhaps bad experiences with others. So if you trust your doctor with your child's health you can probably trust him to steer you in the right direction with regard to who should do it.

    For me, I would choose a pediatric ear, nose and throat specialist who has lots of experience putting in ear tubes and I'd do it in a facility with a good reputation for treating kids because you want the nurses and the anesthesia people to be comfortable with kid-sized emergencies should there be a complication with the procedure.

    And is there anything else that you can do to help her language development? Singing and starting to practice with some sign language those are great ideas. The best thing here in my opinion is use that checklist as a guide, work on the things in the age appropriate category, get down on the floor, read, sing, play games, keep in mind that kids are stubborn and just because they won't do something that you want them to do doesn't mean they can't do it, so you have to be a little bit sensitive to that as well. And keep in mind also that language development really varies widely from kid to kid even in the same family and mild language delays do not reflect how smart a kid is.

    On the other hand, significant language delays do need to be addressed because they can be caused by a host of issues including not only hearing loss but autism and other developmental issues. So, if significant language delays are occurring you definitely want hearing and ears checked and referrals to a speech therapist and a developmental pediatrician would also be in order. So I hope that helps, Dafna. Check out that checklist in the Show Notes and get cracking on the one to two-year old activities.


    All right. Let's move on to our next question, Stephanie, this one's a little closer to home, Stephanie in Monroe, Louisiana says, "Hi, Dr. Mike. I have a question about sunburns and skin. My almost four-year old has a somewhat darker complexion than I do, thanks to her father. OK, a much darker complexion than I do. She never seems to tan or sunburn during the summer. Her skin just gets a bit darker as the summer goes on. We recently went to an outdoor event in the Louisiana sun for about 90 minutes. I used SPF 50 on my own skin and still got a slight sunburn, my daughter refused to let me put anything on her, which is another issue altogether (those are Stephanie's words, not mine) and as it turns out she did not burn, instead she got a little more tan. My question is this, how is it that her skin is so resistant to the UV rays of the sun and is it safe to use a lower SPF on her, when she lets me put it on, or will that raise her risk of developing skin cancer later in life. Thanks so much. PediaCast is an excellent program. Keep up the great work! – Stephanie."

    Well thanks for the question, Stephanie. So here's the deal, if you want your child to wear sunscreen and you should and we'll talk about why that is in a minute, if you want her to wear sunscreen then you should put sunscreen on her when she goes outside, even if she doesn't want you to. You're the mom, she's the four-year old, you know what's best, she doesn't. And if you compromise now on things like sunscreen you really are opening the door for a whole lot of trouble down the road. Sure, some things are negotiable, I mean you want kids to make choices as they gain independence, but when their choices affect their health, you have to make those choices for them while you still can.

    So as I mentioned, yes, you should use sunscreen if she's going to be out in the sun for more than a few minutes, even if she has dark skin and seems to tan or get darker rather than burn. Why? Well to understand this, let's talk a minute about sun tans and sunburns. We know that UV light specifically causes DNA damage in our skin and if that damage occurs to certain portions of the DNA and that occurs down deep where skin pigment and new skin cells are being made, it can turn normal pigment-making cells and normal skin-making cells into cancer skills and that's going to result in things like melanoma, basal cell carcinoma, squamous cell carcinoma.


    So if a child gets tan or an African-American child or other dark complected individual gets darker, DNA damage is already occurring. They get tan or they get darker in response to this damage actually happening. Now to be fair, your body has a DNA repairing mechanism in place, so if the damage is mild your DNA gets repaired, your skin makes more melanin to absorb UV light energy and protect against further damage and you get darker.

    So how does melanin protect you? As I mentioned, it absorbs the energy from the UV light that means there's less UV light available to damage those sensitive cells, but no degree of melanin can absorb all of the UV energy. And this is why African-Americans and others with darker complexions and those who tan well are still at risk for skin cancer. Yes, they have better natural protection. Yes, their cancer rates are lower. But that protection is not 100% and their skin cancer rate is not zero, so it's still a concern.

    Now let's take this to the next step and talk about what happens during an actual sunburn. It's just interesting we haven't talked about this before in PediaCast. We've talked about sunscreen a lot. We've talked about what SPF means and proper application and what form of sunscreen you can use. And if you do a search on our website you can find shows from previous, previous summers that deal with that. But we've never really talked about the mechanics of a sunburn before.


    So let's do that. What happens is in response to widespread cellular damage from the UV light, so now we're talking about damage that exceeds the body's DNA repairing mechanism, the body responds by having an inflammatory response against the skin and areas of widespread DNA damage. So this actually helps prevent skin cancer by killing off any potential newly made cancer cells. The body first increases blood flow to the area, just like it would in any other inflammatory event, which is why you turn red first. Then the body begins to attack and kill the DNA damaged skin cells and that leads to pain, peeling of dead skin and in severe cases, blistering. Beneath the blisters, if it gets to that point, the body begins to make new skin, hopefully free from DNA damage. Now, because it's trying to make skin quickly to fix this are where the blisters are, normal skin production is revved up and instead of the skin taking its time in maturing in nice sheets of cells, it comes up and clumps, which is why you get significant flaking of the skin a week or so after the blisters rupture.

    So the burn is actually the body fighting itself in an effort to destroy DNA damaged cells, which in turn prevents skin cancer. But don't lose sight of the fact that damage has already occurred before you see a burn. The burn is in response to that damage. The tanning or the getting darker is a response to that damage. So your child and you can develop skin cancer even when sunburns are in a frequent occurrence because it only takes a small amount of DNA damage at just the right point in just the right cell and a momentary lapse in the body's anti-cancer protection system for cancer to develop.


    Now sure, frequent sunburns let you know that significant DNA damage is occurring frequently and so your risk is greater. But you know, often times the skin cancer will show up on these folks in a place that didn't burn all that frequently, so they'll have a history of recurrent shoulder and back burns but the skin cancer might show on their arm or their leg. So don't let lack of burning fool you, there's still risk at hand. So if your child is going to have more than momentary sun exposure, you should use sunscreen, period. Regardless of how well she tans, regardless of how dark her skin is and you not her should make that decision.

    Now, how strong of a sunscreen should you use? Well, to answer that, we're going to have to review the meaning of the SPF number, something we do at the beginning it seems of each new summer season, at least here in the northern hemisphere. Probably ought to do it at the beginning of winter too for folks in the southern hemisphere. SPF equals sun protection factor and the number tells how many times longer it takes your skin to burn with the product applied compared to the length of time without the product.

    Well, notice here there's still the potential for DNA damage and because once you start to burn the damage was there. But for example, if it normally takes your skin without any protection 10 minutes to burn, it'll take 20 minutes is you use an SPF of 2; a hundred minutes if you use an SPF of 10; 200 minutes if you use an SPF of 20 and 500 minutes if you use an SPF of 50. Now that number is assuming proper application and use conditions, you got to reapply it after swimming, that sort of thing.


    So if your child is well melanated to begin with and doesn't seem to get darker easily when they're out in the sun and they rarely burn, you may be able to get away with using a lower number, although you should never use a number lower than 15 and you should apply liberally and often.

    One other point I want to make, sunlight exposure allows the skin to make vitamin D and we know that low vitamin D levels can lead to rickets, which results in soft, weak bones and other problems. And there have been some reports of rickets in kids who use sunscreen and whose dietary intake of vitamin D is lacking. So sunlight is not all bad, but considering the fact it's easier to supplement vitamin D in the diet than it is to treat skin cancer.

    When you look at sunscreen from a risk versus benefit standpoint, I'd say the benefit outweighs the risk. But you do want to make sure your child's getting vitamin D in their diet. Fish high in omega-3 fatty acids also tend to be good sources of vitamin D as is vitamin D fortified milk and multivitamins. So, I hope that helps, Stephanie. Get that sunscreen on your daughter. She may not like it now but she'll thank you when she has healthier skin in her adult years.


    All right. One more question from our listener, this one comes from Jen in Fremont, California. "Hi, Dr. Mike. I first heard on PregTASTIC When we were expecting our first child. After our son arrived eight months ago, I transitioned to your show and I've been a listener ever since. A few weeks ago, we are trying to decide between nanny or day care for our child, Ky. We ended up hiring a nanny thinking that he might need more attention during this stage of his life than a typical day care can provide since he is still neither crawling or potty trained. So our plan for now is to send him to day care when he's between two and three years old and can begin interacting with other kids. But we're very interested as to what you think is the best approach and what maybe the optimal time to begin day care. Thanks so much for the great show. Best regards, Jen."

    Well thanks for the question, Jen. Unfortunately, there's not a one size fits all answer for your question because situations vary so widely from family to family. Let's start with laying down some pros and cons of day care versus nannies and let's just see where that takes us. Let me back up a bit. I also want to put in a plug for a parent, whether it be a mom or dad, staying home with young kids instead of using day cares and nannies. Now I realized this is not an option for many families today but as we begin to get into a discussion about day cares and nannies, I just want to be sure that we don't lose sight of the benefit of stay at home moms and stay at home dads.


    OK. So both parents are working and you need a surrogate parent for the day. What is the best option, day care or nanny? Let's take a look at the pros and cons of each. It's really sort of like looking at risk versus benefit when we talk about medical interventions but in this case you have to weigh the risks and benefits against the needs of your kids and the needs of your family and your finances and your beliefs about child rearing, so it can become quite complicated.

    But let's start with nannies. I always find, this is something I learned from my mother years ago, is write you list down, make a list of pros and cons and really try to brainstorm and think it out and write it down so that you can see it. So that's what I did here. Let's start with nannies, what are some pros? Well, one-on-one care, that's great. Yes, some flexibility with days and hours, I mean nannies can be there on weekends, they can be there in the evenings. A nanny could potentially be someone that your child already knows, a friend or family member that can provide some comfort. With a nanny your child's in a familiar surroundings, that provides some comfort. Field trips are more likely, like going to the park or the zoo. And the parent can really cater at the child's experience when there's a nanny. Also, they're going to have less exposure to illness.

    Now, what are some cons with a nanny? Well, they tend to be more expensive than day care, although not always. Day care prices certainly have rocketed in recent years. It has to be someone you trust. They don't come with regulations or inspections, so you really have to make sure that it's someone that you trust. There's less accountability, nobody's necessarily watching them unless you have a nanny cam, but even that it's not fool-proof. Parents may be tempted to work longer hours, you know day care sort of forces you to leave work, hey, I got pick my kid up by a certain time. That's not necessarily a bad thing. And so a parent may be tempted to work longer hours when there's a nanny in the house. So I'm going to put that in as a con. This will be for me. For older kids there's less chance for cooperative play and friendships beginning around age three or so. And also as a con, I'm going to put less exposure to illness. One of the things, kids who are in day care it's a pain because they get sick frequently but by the time they get to kindergarten they've been exposed to so many things and they've been sick so often, they have antibodies and immunity build up to those things and they tend to miss less school, whereas the kids who you've sort of sheltered and they haven't gotten sick a lot because they haven't been exposed to illness, they go off to kindergarten and they start getting sick all the time. So it kind of depends on how you look at it whether you want to put less exposure to illness in the pro category or the con category.


    All right. Let's talk about day care. What are some of the pros? Well, easy to find, there are more choices, tend to be more affordable in most cases. They do have regulations and inspections and you can find out the results of this, it's usually open information. The staff is likely to have some training in child development, but good nannies may have this too. And also day cares who really have lots of people trained in child development those may cost you more. There is more chance for cooperative play and friendships beginning around age three or so. And a pro or a con is more exposure to illness. Again, you can kind of decide that for yourself.

    What about the cons of day care? Well, there's less overall supervision because you've got one person looking over many kids. There's less flexibility with odd hours or shift work. Unfamiliar surroundings. Kids and adults they don't know these other kids, they don't know the adults that can be stressful for some younger kids. They tend to be confined to the day care so there's less opportunity for field trips, walks, trips to the park, to the zoo. And you have to play by someone else's rules. The day care may say hey, if they have a rash I don't want them here. Even if your doctor has a notice says the rashes aren't contagious, ultimately, you got to play by their rules. And so that can be a con for some people. And again the more exposure to illness could be a con.


    So, as we think about pros and cons of nannies versus day care, we say those things that I mentioned are pretty obvious, right? But when you take the time to make your pro and con list on paper, I mean really write it out, one thing or another may jump out at you that makes sense for your family situation. And you can lose that when you simply mull it over in your mind. So, I encourage you to write down the pros and cons like this, really with any big decision that you have to make in your life. Again, my mom taught me to do that long time ago and it's really been helpful in my life and of course I want to be helpful in yours.

    So Jen, once you made you pluses and minuses lists, you have to come up with the decision, which you have, and it sounds like a good decision for your family. Nanny now while your son is young and daycare later when you want him to start interacting with other kids probably around age three or so. I think that sounds great for you. Another family may come up with a different plan based on their unique circumstance and based on what parts of the pro and con list are most important to them and that's fine too.

    One more point I want to make, when you make a big decision, especially when there are pros and cons for each choice, it's human nature to have buyer's remorse. The other decision always looks better once you've made it. It's always sunnier and the grass is greener on the other side. If only you had gone the other way. Don't fall for that. You may be facing challenges because of the decision you made but if you had made the decision the other way, there still would have been challenges, just different ones. There are always challenges. Always.

    Of course if the challenge you're facing is significant, approaching disaster in your mind, unlikely but possible, you can always learn from the experience and go different route down the road. So I hope that helps, Jen. I don't feel like I presented a guideline like this is what everyone should do. Hopefully though I put some tools in your hand to help you with big decisions down the road.

    All right. We're going to take a quick break and we will be back to talk about summer time physicals and to wrap up the show, it's happening right after this.



    All right. We are back and I did want to give you a final thought about school physicals. They're common in the summer, often times you need them for the next school year for fall sports, for scouts, for summer camp and of course a lot of kids get their immunizations updated during the summer. And I remember during the 10 years that I spent in private pediatric practice, summer time was always a very busy time for school physicals. We used to add extra physical exam slots into our schedule and even so, sometimes families had to wait a little longer, especially if they didn't plan ahead, then maybe they wanted to wait because our schedule would get full.

    Of course today's families have a different choice that's often more convenient than their doctor's office. They can get right in, there's not much of a wait prior to the visit, they don't even need an appointment. What am I talking about? Well, I'm talking about urgent cares and drugstores and grocery store clinics that offer quick physicals, usually with a nurse practitioner. So here is my advice, don't do it. Your pediatrician's office is hands down the best place to go for your physical exam. Your pediatrician has trained for years to provide the best screening and care for your child. Your pediatrician sees lots of kids so they really get comfortable with what's normal and what's not normal. Your pediatrician is going to take the time to do a thorough exam, here she is more likely to identify the subtle beginnings of a problem; to screen your child's heart history and do a great a heart and lung exam; to look at your child's growth and nutrition; to screen for scoliosis and hernias; to talk about sensitive topics that are important during the teen years and to make sure that you are aware of the latest immunization and screening test recommendations.

    In short, your pediatrician's office or your family doctor's office is the only place that you should go for a physical. We are a children's hospitals with several urgent care facilities and we do not offer physicals at our urgent cares, why? Because your pediatrician or family doctor is the best man or woman for the job, period. Have I made my point? Are you listening?


    And a quick shout out to one of my colleagues, the good Dr. Stoner, who noticed that the local boy scout website was actually advertising scout physicals at a grocery store clinic. Unbelievable. Really. It's like taking your Mercedes to Bobby Joe's Oil and Lub. You can do it but you're going to get what you pay for.

    All right. That wraps up our show this week. I want to thank all of you for taking time out of your busy schedule to be a part of our program. I want to remind you that iTunes reviews are helpful. And if you're looking through some of the iTunes reviews that you find our helpful, make sure you click yes, those reviews are helpful. Because now when people go to iTunes the reviews are not separated out by the most recent. The default separation is what reviews have been most helpful. And so I would just encourage you if you find the review helpful, click that little yes button and say hey, yeah, I find this review helpful, so that we can stack that page with really the most helpful reviews.

    And so if you have a review that you read as helpful please just take five minutes, I'm asking for five minutes of your time. That may be more important right now than actually writing a review is just to look through some of the reviews, find the helpful ones and click yes, that way the good reviews are really there when people go to iTunes. And that's important because people read the iTunes reviews at least the first couple of pages of them to decide if they want take a chance on a show. And of course we want people to take a chance on PediaCast and you are our only mechanism to help us to do that.


    I did mention the mommy blog in the introduction to the show. If you have a mommy blog and you want to share PediaCast with your audience, then I'm happy to share your blog with my audience. So just let me know about that if you are interested.

    Also be sure to join our community by liking PediaCast on Facebook, following us on Twitter, tweeting with hashtag #pediacast and hanging out with us over on Google+. I have been saying make sure you swing by the Show Notes at pediacast.org to add your comment on today's show and I realized we added the script, transcribed script for each show, so that there's a transcription that you can go and actually read what I am saying right now online and I haven't had the chance to do this, but the person who's transcribing right now, right now you are transcribing my voice, I just want to say thanks, because that's really helpful to people who don't have time to listen to this and it's easier for them to read it and it's also helpful because it allows Google and other search engines to actually index the content of our audio program because we also have it in written format.

    The disadvantage of that is that the comments for each individual post fall below that transcription and that's a long way down, especially with the News and Listeners show that runs close to an hour. So, we have had some people do that and if you want to continue to do that, by all means we really appreciate your participation. But another way that you could do it is on our Facebook page. I do put a post out each time we'll release a PediaCast. It basically says this week on PediaCast and has a little summary of the show and a link to that episode. But that would also be a good place if you have comments about a particular show to leave those comments and they kind of get the discussion going.


    So if you're not on our Facebook page, I would ask that you just like us on Facebook and just start contributing that way if you do have a comment or a suggestion, if you like me want to be helpful to the rest of the audience you can do so on our Facebook page.

    Also, I want to remind it's important to let your child's doctor know about PediaCast. That's very important. The iTunes, liking the reviews, the ones are helpful and telling your doctor about PediaCast are really important. And so just next time you're in for a well check-up or a sick office visit say hey, we found this great evidence-based pediatric podcast aimed at parents but with enough information for pediatricians and family doctors and nurses and medical students and residents as well. And just let them know how to find us. We also have posters you can download and hang up wherever moms and dads hang-out. And you can find them at the Resources tab at pediacast.org


    All right. Well we do need to wrap things up. I just to warn you we are not going to have a show on July 4th week, so we're going to be skipping that week, I just wanted to give you heads up about that. If you would like to contact me and I read every contact that comes across, if you have a show suggestion or a topic idea or a comment or a question that you like me to answer, just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com, if you do that make sure you let us know your name and where you're from or you can call the voice line at 347-404-KIDS. 347-404-K-I-D-S and leave your message as an audio file just make sure, again, that you let us know who you are and where you're from.

    All right. Well, again thanks to everyone for making PediaCast a part of your day, we appreciated it. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.


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

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