Author Archives: Firas

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Pediatric Podcasts

So I drive to work every day for about 40 minutes one way. I thought the best way to make use of this time is to listen to some pediatric podcasts to refresh my knowledge and also get updates. I previously posted about this but most of those listed in my 2008 post are no longer active so here’s my current experience with what I found. Please let me know if you know some other good pediatric podcasts so that I update this post.

Pediatric Podcasts

Image courtesy of

Here’s the list

  • Peds RAP This is a fun modern delightful pediatric education and they invite experts. The free account allows you access to a single chapter per month and the full subscription is for $395 per year for physicians. This is a really fun informal conversation about very relevant pediatric topics. There is sound effects during the podcasts, there are jokes, and you will be smiling if not laughing all the way when you listen to this podcast. This is sort of like how you talk with your buddy pediatrician in the elevator about interesting recent pediatric news and articles. The hosts are Soloman Behar MD from CHLA and Mizuho Spangler DO and the podcast offer full 3.5 hours accredited CME per month. You cannot download the full episodes in iTunes you have to download their free app. This is undoubtedly the best pediatric podcast available.
  • Pediacast and Pediacast CME  by Dr. Mike Patrick from Ohio State University college of medicine broadcast live from Nationwide Children’s. Pediacast is geared for parents but it’s also really useful for pediatricians while Pediacast CME is for specifically designed for pediatric providers and CME credit is available. Both podcasts have their own separate websites (see links above). There is show notes with details and outlines and links to resources. You can download the podcast free on most platforms including iTunes. This is totally free and even there is no commercials during breaks. This is core general pediatrics and things that are really asked by our parents, highly relevant to our daily practice. Dr. Mike usually takes a considerable amount of time explaining and dissecting but that’s probably needed if we remember that the show is listened by parents. Very parent-friendly style.
  • PREP Audio This has retired since December 2014. It was an excellent one hour update and an interview with a specialist in the topic discussed. Really wished AAP brings this back.
  • ReachMD This is not pediatric specific. However, you can pick on demand topics that are related to pediatrics. The iPhone app is easy to use. You can also choose to stream live radio with continuous topics (they are often repeated over the course of 24 hours time). This podcast is free.

Alternating Tylenol with Motrin for fever

I’ve got many parents asking me if it’s OK to alternate Tylenol with Motrin and so I thought let me post about it.


Tylenol – image courtesy of

First few basic facts; Tylenol is the most common brand name for the generic name of the medicine which is Acetaminophen. Motrin and Advil are common brand names for the medicine Ibuprofen. Ibuprofen should not be prescribed for infants younger than six months.

Tylenol can be given every 4-6 hours. Motrin can be given every 6-8 hours. Tylenol and Motrin have different mechanisms of action and different toxicity profiles so they are OK to be given to the same child for the same illness (fever). Fever is defined by a body temperature that is 100.4 F or more.

Fever Medicine

Fever medicine – image courtesy of

You can alternate Tylenol with Motrin every 3-4 hours. The interval should never be less than three hours in between.

So if you give Tylenol at 6 AM you can then give Motrin at 9 AM then Tylenol at noon then Motrin at 3 PM and so on.

Brief Resolved Unexplained Event (BRUE) Instead of ALTE

We have been dealing with the term Apparent Life Threatening Event (ALTE) for decades. The AAP recently released new guidelines addressing this condition for the first time and have appropriately replaced the term ALTE with BRUE (Brief Resolved Unexplained Event) accurately reflecting the clinical situation.

ALTE renamed BRUE

These infants and small children often end up admitted to the hospital for overnight observation and cardiorespiratory monitoring. This is because there was a lack of national guidelines and pediatricians (including experienced and seasoned pediatricians) cannot be 100% confident that there isn’t a serious condition. Even the Nelson Textbook of Pediatrics does not have a chapter named ALTE and messages are confusing to say the least. Nevertheless, most of the times ALTE patients get discharged next day with no specific underlying pathology. This of course is a waste of resources and put families at unnecessary anxiety. Even the term itself (apparent life threatening) scares families and underscores the possibility of a serious underlying condition.

Research have found that most of these events resolve with no further consequences or complications and there is no statistically significant link to SIDS. Specially when major causes are ruled out (cardiac disease, epilepsy, child abuse, congenital malformations, sepsis, and respiratory apnea). Gastroesophageal reflux remains one of the most likely causes but that is not life-threatening unless associated with aspiration pneumonia and significant respiratory compromise.

Thank you AAP for saving us and now we can confidently tell these worried parents (Do Not Worry).

Hand Foot Mouth Disease versus Herpangina

My daughter goes to daycare where several other kids were told they have Hand Foot Mouth Disease (HFMD) and within few days my daughter has got this oral enanthem

Hand Foot Mouth Disease

We can see there is a big ulcer on the side of the tongue but also several white coated flat vesicles on the hard and soft palate posteriorly. The image does not show the uvula and posterior pharygneal wall but there were lesions there too.

Why we looked into the mouth? she was pointing to mouth hurting. This is the typical presentation in verbal children but in non-verbal children the presentation is typically refusal to eat and drink.

At the time of the picture there was no skin rash (no exanthem) and therefore I was thinking she most likely having herpangina. But within few hours she started to have tiny red pink papules on the dorsum of her feet which later evolved to more vesicular and at that point we realized that just like the other children in daycare she has HFMD.

But I was asking myself. Does it really matter clinically to differentiate HFMD from herpangina? They are both caused by Coxsackievirus Type A and sometimes Type B or echo virus. They both have similar rate of complications (HFMD little higher rate). They are both managed with supportive treatment and there is no specific antiviral treatment in either case.

The lesson for pediatricians here is that we tend to think herpangina when we see only enanthem but here is a proof that HFMD can start with the oral enanthem and then after a day or two you will see the hands and feet rash, in fact in some cases it’s only the oral lesions and there won’t be any exanthem and in other cases you will see only exanthem with no enanthem.

One of the parents told me (Hand Foot Mouth Disease! The name is kind of scary name of a disease in cattle, can you guys please change the name?) Since then I started telling my patients and families it’s a Coxsackievirus infection and this would serve two benefits (avoid labeling herpangina versus HFMD and avoiding the scary name) 😉

Would love to see your comments on this post.

Pediatric Physical Examination

Pediatric Physical Examination is an excellent book for those who are just learning the pediatric exam but it’s also a perfect refresher for seasoned pediatricians.

Pediatric Physical Examination

This is a complete and thorough journey through each and every system of the pediatric physical examination. Lots of photographs and illustrations will make you comfortable with the pediatric physical exam. Colored tables and pediatric pearls for important information to stand out. For infants and young children it emphesizes the less-invasive to more-invasive approach instead of the head-to-toe approach used in older children and adult exam.

One of the pearls for example that I really liked is the pull the tragus instead of the ear pinna for straightening the auditory canal, really useful trick that I tried on my patients and it works.

Highly recommended specially for medical students and pediatric residents. I think this book should be the recommended curriculum book in each med school.

Facebook Suggesting Friends by Location Proximity!

If you said OK to your mobile Facebook app to follow your location by activating “Nearby Friends” feature then you may get this.

Yesterday, I met a person whom I’ve never seen in my life before. I had dinner with that person along with other friends and family members. That person Android phone and my iPhone came close together for about two hours. Then I returned home and opened my Facebook app. Guess what the first person suggested to be added as a friend was the person I just met! We have only one mutual friend on Facebook.

Facebook is now following your location and can suggest friends as they come closer to you in location. Amazing!


An Experience with Southwest Airlines

We always fly Southwest Airlines. It’s convenient, they have flights almost to every state, and they are frequently cheaper than other airlines specially if you count the free two bags with each ticket.

Southwest Airlines Feedback Card

However, this time we had a terrible experience with them. We flew from Oakland to BWI a single non-stop flight. When we checked in at the gate in Oakland they missed scanning my daughter’s boarding pass at the gate door and therefore the crew at the plane was announcing her name and checking if she has boarded or not. We walked down the isle and told them that here she is with us and they said OK will check her in.

When we arrived to BWI, I received an email that my daughter’s ticket was cancelled because she did not fly! I immediately called them and the person on the line said OK we will fix it.

When we were checking in for our return flight from BWI back to Oakland, the Southwest Airline agent said that my daughter does not have a ticket and we did not pay for her! It took us about 30 minutes explaining and they finally apologized and let my daughter fly with us.

Reflecting on this experience I think that Southwest Airlines has some deep problems need to be fixed. The error has passed unchecked three times, at the gate when we first flew from Oakland, then my telephone call with them, and finally the ridiculous experience during checking in for the return flight.

New Changes in NRP

The new 7th edition of the NRP (Neonatal Resuscitation Program) has a significant change over the previous recommendations.

The new book has been released and you can Order it from Amazon.

NRP Book

NRP Book

Now. We don’t need to routinely intubate non-vigorous newborns with meconium-stained fluid. Previously we used to intubate such newborns before we do stimulation (the fear was stimulating them to breathe would make them aspirate more meconium into the lungs) and do tracheal suctioning.

However, I think the word “routinely” is important here. Yes, no need to do that routinely but if the newborn is sick and not ventilating adequately we still have to do tracheal intubation and tracheal suctioning and follows the regular NRP algorithms.

Roth IRA versus Roth 401K

I recently had trouble understanding the difference between the regular Roth IRA and the company-sponsored Roth 401(k). So thought I share the knowledge with  you;


  • Both of them are after-tax investment. You pay tax upfront and then the money will grow tax-free. When you withdraw at retirement you don’t pay taxes.


  • Roth IRA has income limit of $183,000 (house-hold) or $116,000 (if single). If you make that much you cannot invest in Roth IRA. While in Roth 401K you can invest no matter how high is your income, there is no income limit which is obviously a great choice for high earners.
  • Contribution limit is also different. For Roth IRA, the maximum you can put is $5,500 per year. While in Roth 401K, you can put a maximum of $17,500 (or $23,000 if over 50 years old), just like the traditional tax-deferred 401K limits.

Clearly Roth 401K is the best option for employed individuals with high income.