Ep. 161: Understanding CMV in Children: The Medical Picture (Part 1 of 2)

Cytomegalovirus (CMV) is one of the most common viruses, yet many people have never heard of it. CMV is a leading cause of non-genetic hearing loss in children. In part one of this two-part series, we take a medical look at CMV — what it is, how it affects developing babies and the latest advances in early screening, diagnosis and treatment.

Watch the episode on YouTube.

Featuring:
Cedric Von Pritchett, MD, Otolaryngologist, Nemours Children’s Hospital, Florida
William Parkes, MD, Otolaryngologist, Medical Director, Nemours Children's Hospital, Delaware
Salwa Sulieman, DO, Infectious Disease physician, Nemours Children's Hospital, Delaware
Kathryn (Kat) Tribulski, AuD, Audiologist, Nemours Children's Hospital, Delaware

Host/Producer: Carol Vassar

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

ANNOUNCER:

Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast produced by Nemours Children's Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.

Carol Vassar, podcast host/producer:

Each week, we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you are here, let's go.

MUSIC:

Let's go. Well beyond medicine.

Carol Vassar, podcast host/producer:

Today, we're talking about a virus that doesn't really have a high profile amongst folks, but it does affect children. It actually affects all of us at some point in our lives. For those who may not be familiar, it's called cytomegalovirus or CMV. Here to talk about that today, I have some of the experts, and we're going to talk about the hearing loss that's possible when someone has CMV, their fetus is affected, and that child does have hearing loss. With me right now, Dr. Cedric Pritchett. He is a pediatric otolaryngologist and head and neck surgeon. He's co-director of the Nemours Children's Ear Hearing and Communication Center and medical director of the Cochlear Implant Program for Nemours Children's Health.

Dr. William Parkes is also with us, also a pediatric otolaryngologist at Nemours Children's Health, medical director of the cochlear implant team. Dr. Salwa Sulieman is the pediatric infectious disease specialist or one of them at Nemours Children's Health. And finally, Kathryn Tribulski, or Kat as we know her. Dr. Tribulski is a pediatric audiologist. You're all with Nemours. So I want to explore this virus a little bit more. I was talking to some friends of mine, women who have had children, maybe even have grandchildren. And I said, "Do you know what this is? Have you ever heard of CMV or cytomegalovirus?" And they said, "No. What is it?" Dr. Sulieman, I'm going to ask you, what is CMV?

Dr. Salwa Sulieman, Nemours Children's Health:

Thanks for having me, Carol. CMV or cytomegalovirus is a virus that's sort of ubiquitous in the environment. It's everywhere. Many people have it and they're shedding it in their body fluids, their respiratory secretions. Most people have had it by the time they turn 21. Many, many people get this infection, but it has a very sort of wide range of symptoms. Most people are totally asymptomatic, have no idea they have it, which is one of the biggest problems with CMV. And then some people can get more severe infection. When we talk about specifically congenital CMV, that's an infection that can happen to babies when moms get infected during the pregnancy.

And when moms have never had CMV before, they have no memory to it. So their babies then have no memory to it. And when those babies get infected, they can have this syndrome called congenital CMV infection.

Carol Vassar, podcast host/producer:

And how does it affect these children? A lot of times they are, especially when infants are exposed in the womb; there are some severe consequences, aren't there?

Dr. Salwa Sulieman, Nemours Children's Health:

There definitely can be. So the majority of babies, probably around 50% that have congenital CMV are totally asymptomatic. But the other proportion of the babies that have some symptoms can really vary. The most severe of symptoms can be hearing loss, and that is probably the most important consequence or sequelae of congenital CMV. Some babies can be generally small, they can be born prematurely. They can have problems with their liver, sometimes problems with their blood counts. But generally, the biggest problem that we see and that we worry about is hearing loss.

Carol Vassar, podcast host/producer:

How common is it? You said that anyone over 21, most people over 21 have already had it. It's out there. We know it's out there. You can get it pretty young, you can get it in utero. So it's pretty common. How come we don't know much about it?

Dr. Salwa Sulieman, Nemours Children's Health:

Well, if you look at the numbers, only about 1% of the population has congenital CMV. So it's generally a small percentage, but if you look at that number in babies that are born each year in the United States, it's about 40,000 babies with congenital CMV infection. Now, only about 10% of those babies are going to have symptoms at the time that they're delivered. So there's another 90% of all of those babies that potentially have no idea that they have an infection, and then can go on to develop sequelae from this infection, such as hearing loss.

Carol Vassar, podcast host/producer:

So what should parents be looking for?

Dr. Salwa Sulieman, Nemours Children's Health:

Really, this is going to be more for us as care providers to really sink through and help identify those babies who may be at risk. So the problem here, the biggest challeng,e is that most of them are asymptomatic. But any baby that's born with any of the symptoms I described, most care providers are going to be looking for CMV around the time of delivery. The biggest intervention, which we're going to hopefully spend some more time on here, is talking about how we can identify babies that maybe have hearing loss early on and then get tested for CMV if the hearing loss is the only symptom of CMV that they have at delivery. And so that will hopefully help us a little bit in identifying those babies.

Carol Vassar, podcast host/producer:

So I'm going to turn to Dr. Pritchett, Dr. Parks. You are both otolaryngologists, and I've now said that three times correctly in this podcast. I think that's my limit. How are children diagnosed with hearing loss, just generally speaking? Dr. Pritchett.

Dr. Cedric Pritchett, Nemours Children's Health:

Thank you, Carol. Hi, great to be here. Hearing loss in the identification of children is one of the great accomplishments societies have achieved, right? Because we like to believe universally, children are screened for hearing loss, at least here in our country, from the time that they come out. And that's work that's been accomplished over the last 25 years. And so I'm not going to steal the thunder from Dr. Tribulski and describe how that happens because that's the space she lives in. But well over 98% of children who are born, by the time they go home, you'll know if they have passed their hearing test or not.

Because congenital CMV is something that has a predilection for affecting the hearing system, using that and eliminating that as a possible cause is important. We would say somewhere between perhaps 10 to 20% of children who have congenital hearing loss could have acquired that because of CMV. Now, the largest body of congenital hearing loss, of course, is genetic in nature, but congenital CMV is the most common non-genetic cause for babies who are identified with hearing loss in that first year of life.

Carol Vassar, podcast host/producer:

Dr. Parkes, when somebody is working with an infant, what do they do? Walk me through that. Maybe I've just had a baby. My baby is getting all those spot tests and other kinds of tests. What's the hearing test like, and are there protocols in place for that? At hospitals?

Dr. William Parkes, Nemours Children's Health:

There are, and this goes back to the late nineties in the United States, we have universal newborn hearing screening. So as Dr. Pritchett alluded to, the vast majority, not quite a hundred percent, nearly a hundred percent of babies have their hearing screened before they leave the birth hospital. And if they fail that screen, they'll be sent for formal diagnostic testing with audiology. And I think Dr. Tribulski talked in more detail about that. If you look at all those kids that fail the screen, most of them actually don't have permanent hearing loss. It's a screen, so some of them will actually end up having normal hearing for different reasons.

There could be technical issues with the test, or they could simply have some fluid in their ears that goes away soon after birth, and when they reach out, their hearing is normal. So it's a much smaller percentage of those kids that truly have permanent hearing loss, and it's the kids with the permanent hearing loss that we want to promptly identify, promptly treat to promote normal language development. There's a ton of science that informs us that if we allow for delays in diagnosis and subsequent delays in treating congenital hearing loss, so hearing loss present at birth or soon after birth, children are set up for lifelong language delays. And so the sooner we diagnose, the sooner we treat, the better the outcomes will be.

That's the importance of it, and that has long-term effects over the course of a child's entire life in terms of where they get to in school, where they get to beyond school, professionally and otherwise. And so it's just critically important. Kat, if you want to touch upon what it looks like after they fail the screen and get to you and where we go from there, I think that would be helpful.

Carol Vassar, podcast host/producer:

Please do.

Dr. Kathryn Tribulski, Nemours Children's Health:

There's actually, since the year 2000 was when universal newborn hearing screen has arisen, and there are some guidelines put forward by the Joint Commission of Infant Hearing, and that is that all babies in the United States are screened by one month of age, they're diagnosed by three months of age, and some form of treatment is enacted by six months of age. That's the goal. It doesn't happen necessarily all the time, but after a screening, when a baby does not pass, they come in to audiology and we do what is called a diagnostic ABR, which stands for Auditory Brainstem Response Test. The test is not invasive, even though it sounds kind of scary. And it involves several stickers or electroplacement on the infant's head and either some over-the-ear, in-the-ear headphones.

When you are in a still, relaxed state, we can actually pick up and evoked potential of hearing through presentation of those headphones and monitor the brain's response, and actually lower and raise the level to find the threshold of where you're hearing. It is not exact, but it does equate to if you were in a sound booth, raising your hand when you hear it. We don't expect those newborns to be able to do that quite yet. What we do is we elicit sounds essential for speech and language in various frequencies to determine what's the softest level we're seeing those responses. It can be a little bit time-consuming. It can be very stressful on the family. So we do try to set them up for success.

A sleeping baby is the best way to have the test because we are picking up on those electric potentials. Any changes in muscle movement from the baby moving around, eye movements, the feeding suck reflex can interfere with us measuring just specifically that auditory response. So a still, quiet baby is best. We're also able during that assessment to determine if there is an issue with hearing, is that something that might be more conductive or temporary in nature due to that fluid congestion, any built-up pressure in the ear? Or are we seeing more of a deficit on the auditory nerve or cochlea past that middle ear? So it kind of gives us a better idea of what we're looking at and to what severity.

Carol Vassar, podcast host/producer:

So you're seeing children as young as three months for that.

Dr. Kathryn Tribulski, Nemours Children's Health:

Even younger. The goal is for them to be diagnosed by three months, and depending on where you are in the country, you may not have access to a facility. And so that's where that comes into play. But you can do this test at a day of life. We don't necessarily always do that or recommend it because if they failed the screen, there are certain environmental factors like fluid, inflammation, that we want to see, is that going to resolve? Most families pursue this at a couple of weeks of life, but if there is a question or big concern, we can do it the day that you were born. It's just how reliable those results will be from other factors.

Carol Vassar, podcast host/producer:

And I suppose the answer to my question right now is going to depend on what the cause is, but what are some of the common treatments? What can be brought to bear when a child is found to have had hearing loss?

Dr. William Parkes, Nemours Children's Health:

These babies are screened in the hospital. They're referred to audiology. We want to test them soon, but maybe not too soon. And so it can be a couple of weeks, sometimes a few weeks, before they get their diagnostic testing. So after a baby is confirmed to have what looks to be a permanent hearing loss, they're going to be sent to us for the medical evaluation. So it's medical clearance if we think the treatment should be hearing aids, and then it's a medical workup to figure out the why of the hearing loss. And so by the time they get to us, in a lot of cases, babies are already one, two, even three months old, so they are a good bit older.

And the reason this is really relevant to today's topic is that when I get into the workup, sort of at the top of the differential or the genetic causes, because it's the most common explanation, but number two is CMV, and CMV is not going to affect a child's hearing after birth. So if they've been exposed after birth, it's not going to cause hearing loss. It's only exposure in utero that can do it. And so to confirm congenital infection, we have to test babies within 21 days of birth. So by the time they've gotten to me, if I ask that question, it's too late unless somebody else has already looked into it for various reasons.

And I think we'll kind of naturally get into how somebody may have already looked into it. But traditionally, they'd get to me, and it would be really hard for me to ever answer that question as to whether CMV possibly caused the hearing loss. I would do the rest of the workup, and if it's all negative, we'd be wondering, could this be CMV? Nowadays, we have more diagnostic capabilities and different screening strategies to improve our ability to figure this out. That remains challenging.

Carol Vassar, podcast host/producer:

Does the treatment change based on the cause? If you determine it to be CMV, is the treatment going to be different? Dr. Pritchett.

Dr. Cedric Pritchett, Nemours Children's Health:

The treatment options for hearing loss is a vast and fascinating topic of conversation. We could talk until the late evening hours on that, but basically, we're looking at whether or not that hearing loss is temporary or permanent, right? If it's due to fluid, that may be something that goes away over time, but if it is more permanent involving either the little bones of hearing that conduct the sound and amplify that or the nerve of hearing, which takes that converted electrical signal and sends it to the brain, then we have to talk about what we can do to help a child overcome that. When we think of treatment for hearing loss, in most cases, it's not going to be something that is directly restoring the natural hearing in a state that is perfectly normal for an individual who doesn't have a hearing loss.

But we do have approaches and techniques and strategies to augment and then sometimes replace the hearing that has been lost because the idea really is how do you get that energy to the brain that it can interpret and encode and use for meaningful communication strategies? Treatment in some cases could be hearing aids. That is one of the most commonly employed strategies early on when Dr. Tribulski referred to the 1, 3, 6, 6 months of age, we want to have that treatment in place where they're getting benefit from that. But in some cases, there may be surgical interventions when a child is older that can try to undo some of those things if the little hearing bones aren't quite working well, right?

Cochlear implantation is another strategy for children who have congenital deafness, and we insert a little electrode into the cochlea for that. What's also important is just helping children learn how to communicate with speech language therapy, because when you have that hearing deficit and that hearing difference, it's important to be given tools that you can grow into. Now, what's interesting is for the CMV conversation, depending on when you are identified and what is the collection of symptoms, the severity of losses that are there, there is very possibly an antiviral medicine that has been shown to help reduce the rate and the extent to which that hearing loss occurs.

And I know Dr. Sulieman is really familiar in this space, and I'm not going to take too much more time, but that's what has made CMV a unique and interesting entity because we have something that while it may not completely stop or reverse, it can certainly aid in retarding the loss of that hearing over time, and that's something special. Another more experimental conversation is gene therapy, but we're not going to go there. But I know for the CMV, what makes us excited is to think that there may be a group of children, if you can identify them early enough, you have a shot at doing something in addition to all of the other strategies that might preserve some of that natural hearing that they have.

Carol Vassar, podcast host/producer:

Dr. Sulieman, I want to hear more about that. I think Dr. Pritchett gave us a great overview, but I have never heard about this. Tell us more.

Dr. Salwa Sulieman, Nemours Children's Health:

It is amazing. We have an antiviral medication that we can give to babies that are born with what we call symptomatic congenital CMV infection. Our goal is to identify babies with congenital CMV infection and then try to put them into a category of asymptomatic versus symptomatic. So not every baby that has congenital CMV needs to be treated, but the ones who are symptomatic do. What does that mean? What does symptomatic mean? Well, it's changed even over time, but definitely, if you have any type of hearing loss, you're going to fall into the symptomatic category. Other things would include when they are born and they have abnormalities with their blood counts, their liver tests, or their brain, things like that.

We're definitely going to see that there could be a problem. But what I would really focus on here is that if there is isolated hearing loss and we can identify it quickly and we can identify that they have CMV, then we can start them on a medication called (val)ganciclovir. It's also a medication that other people take for various reasons, but it is very targeted at CMV. And if we can start it before 13 weeks of life, ideally within the first three weeks of life, but within 13 weeks of life, then we can treat these babies for a period of time, whether six weeks or six months. It's a long haul that has been shown to improve progression of hearing loss and neurodevelopmental outcomes.

And so that's really important to capture these babies early so we can start the medicine if they are symptomatic.

Carol Vassar, podcast host/producer:

Dr. Sulieman, a quick question about prevention, and I think pregnant women who've not had CMV are your target. You want to prevent them from getting it, passing it on to their children. How can that happen? Are there programs that are helping? Are there outreach initiatives that are focused on CMV? Can you tell us anything about that?

Dr. Salwa Sulieman, Nemours Children's Health:

Sure. So prevention is key with any infection. There's not a vaccine for CMV, so that's not something anyone can get, but we always encourage anyone who particularly is around young children. Children less than five, especially less than two, are just really good at shedding CMV in their body fluids, in their spit, in their snot, in their urine. If you are a healthcare worker, if you're a daycare worker, if you're an elementary school teacher, or a preschool teacher, or you just simply have kids at home, you can be exposed. So, washing your hands, try not to drink after other people.

Obviously, it's very hard in families, but the classic presentation of congenital CMV infection is with a mom who works with children, works with kids, and/or is a teacher, and really, that's where they get this exposure. So washing their hands is really good. I think there are definitely have been some outreach events that have happened within communities to try to explain some of this information, but the word's just starting to sort of get out there. But the biggest thing you can do is be particularly careful when you're pregnant or if you are sort of pregnancy-bearing age or childbearing age to be careful, especially around young kids.

Carol Vassar, podcast host/producer:

Dr. Parkes, when we were talking before we started recording, you alluded to the fact that single-sided hearing loss is a possibility. Talk a little bit about that and kind of the common questions that parents have around that particular issue.

Dr. William Parkes, Nemours Children's Health:

That's a great question or topic to bring up. We've said a couple of times that genetic differences are the most common explanation for hearing loss, and almost always they'll affect both ears, typically symmetrically. So you'll see a hearing loss in both ears, it looks about the same, meaning the same degree of severity, not all, but most of the time. CMV can do absolutely anything. So if babies are exposed in utero, they can be born with normal hearing and develop hearing loss later in life. It could be a month after birth, it could be a year or a few years after birth. As time goes on, the risk of developing late-onset hearing loss does decrease, but does persist for a number of years.

Children could be born deaf in both ears, no hearing whatsoever, hearing aids can't help, and we're pretty quickly bringing them through a cochlear implant evaluation, looking into a different strategy if hearing aids aren't going to help, and then anything in between. So a child can have severe hearing loss in one ear, a little bit of hearing loss in the other, or a profound total deafness in one ear and normal hearing in the other ear. Historically, what parents were told in this setting of single-sided deafness was, "Don't worry. It's great news that the other ear is fine. Speech and language development should be normal. This is really a non-issue. There's nothing that needs to be done about this."

Historically, as in decades ago, over the last couple of decades, there's been a lot more literature emerging about the impact of single-sided deafness over time. It is still true that most children will develop normal language even if you do nothing, but there are downstream issues because of that. The brain changes so the brain develops differently when you're only listening with one ear. When somebody's talking to your deaf side, it's hard because your head's in the way, so you're kind of turning to listen better. When there's noise around you, it's much harder to listen. The two ears work together to filter background noise and focus on what we're trying to listen to, and you lose that when you have single-sided deafness, and you can't localize sound.

If somebody's calling you from another room in the house, you don't know where they are, you can't see them, you just don't know where they are. So all that does lead to some frustrations over time, and so we're a little bit more apt to consider treatment for single-sided hearing issues. Now, single-sided deafness does remain somewhat controversial because in that case, if it's true deafness and a hearing aid is not going to work, then the move to consider present day is a cochlear implant. And so that's a pretty big surgery to put a child through, relatively low risk, but a big surgery nonetheless, with a big commitment afterwards to train a child to understand the new information that they're getting to their brain through an implant.

And so for a child who is expected to develop normal language, who may have some frustrations later in life that aren't at all visible during infancy, that's a tough decision for parents to wrestle with. Do we really want to be that aggressive? Surgery, implant, something that they'll have the rest of their life, some risks in surgery, after surgery, and then all of this therapy to get them to understand what they're hearing. Is it worth it? And I think it's emerging literature here too, so there's a lot to still be learned, but thus far, I think we feel most confident in pursuing this when we have an identifiable risk of the child developing hearing loss in their good ear.

So there are certain anatomic conditions that can do that, and CMV can do it. A lot of the time if a baby is deaf in only one ear and they have congenital CMV exposure, they will develop hearing loss in the other ear eventually, whether it's months or years later. The risk is variable of the literature, but it's upwards of 40 to 60%, 75% in some series. Because of that risk, I think we're more inclined to try to at least make families aware of this option to consider doing something like a cochlear implan,t so that if the hearing does decline in the good ear, they can then lean on the implant and then we have more modes of rehabilitating the other ear if it's affected later in life.

Carol Vassar, podcast host/producer:

It sounds like there's a lot for the parents to consider, a lot for parents and children and clinicians to do together to get the child to a place where they can hear and they can speak in manners that are somewhat on the level with their peers in school, and that kind of thing. That's where we are now, where we are headed in the future in terms of research, in terms of implementation, of additional treatments. Dr. Pritchett, I want to turn to you first and get a brief overview of that from each of you.

Dr. Cedric Pritchett, Nemours Children's Health:

Absolutely. I think the future holds promise. There's been a lot of work and a lot of money put into the CMV conversation, and while it's disappointing, we are only here, we can celebrate that we are here. Essentially, there is a universal acknowledgment that education is an important part, and that we are not doing a great job if most women who are of childbearing age have not heard of this. That's something we agree on that needs to change, and that's something we can do. Women know not to drink. They know not to change their cat litter box. They need to know not to kiss their baby on the lips and clean their plate afterwards because of the risk of that. The future state is going to be a significant growth in education and awareness.

Departments of health, healthcare practitioners, schools, everybody is on board with that. What we're also seeing, though, is some combination of different strategies to identify these children early. And we haven't figured it all out yet, but we do know the sooner we can identify these children who have congenital CMV, the better. Some states are testing all of their children. Some states are testing children who don't pass their newborn screening or have certain characteristics that would make us suspect congenital CMV is there may be prematurity or some jaundice, small heads, those kinds of things that are there. But we also have on the horizon the concept of vaccination, right?

And so vaccination has been huge. While we celebrate what has come from newborn hearing screening in most countries that practice that, vaccination is also game-changing. And there is a phase three trial that one of the commercial entities, biotechnological companies, is wrapping up, that show some promising data that we are able to look at reducing the likelihood that a woman who has not been exposed to CMV will not contract that virus, although she's around a high-risk environment for a defined period of time. And so thinking about how that could become another tool that's in our arsenal is exciting.

Then of course, when it comes to also can CMV's effects and consequences be ameliorated? That is also an area of opportunity. Children's brains and children's nervous systems are remarkably adaptive, and being able to support them with therapy, with intervention, with medicine, and seeing how they change is really exciting. So I think when we think of the future state, we're going to see more and more individuals, more and more professional organizations. Our organization, the American Academy of Otolaryngology Head and Neck Surgery, has been very forthright in their support of making CMV identification and treatment a priority.

Carol Vassar, podcast host/producer:

Kat, Dr. Pritchett gave us a very clear and complete way of looking at what he sees as the future state. What are your thoughts?

Dr. Kathryn Tribulski, Nemours Children's Health:

I think, honestly, the evolution of the schools of practice. As Dr. Parkes had mentioned, and Dr. Pritchett and Dr. Sulieman as well, the timing of this is really, really important. I know that I personally, as well as all of my colleagues, when we see that a baby has not passed the newborn hearing screen and we know this diagnostic assessment is coming, to actually go above and beyond and say, "Well, did they get a screening? Did that happen? Do I need to contact the pediatrician?" Those may not be innate things you think of, but to make sure those steps happen in a timely fashion.

My hope is that vaccines on the horizon may be a game changer in this, but in the meantime, to really expand our interpersonal development, to get pediatricians more aware, to get obstetricians more aware, to inform more families, education is really the best weapon we have against CMV at this time, and really all of our professional development and all of our healthcare workers to really help with that education and guidance to overcome this can be very, very beneficial.

Carol Vassar, podcast host/producer:

And grandmas to tell their birthing daughters. Dr. Parkes, anything to add?

Dr. William Parkes, Nemours Children's Health:

They summarized things beautifully, but it's stuff just like this, right? Getting on a podcast and disseminating information, it's lecturing medical students, and talking to residents, and just spreading knowledge everywhere we possibly can to improve awareness at a minimum, and eventually improve our ability to diagnose, and hopefully improve our ability to treat as well. And that's all contingent upon just the growing knowledge base through our science.

Carol Vassar, podcast host/producer:

Dr. William Parkes is an otolaryngologist with Nemours Children's Health. We also heard from otolaryngologist, Dr. Cedric Pritchett, audiologist, Dr. Kat Tribulski, and pediatric infectious disease specialist, Dr. Salwa Sulieman, all with Nemours, all talking about cytomegalovirus or CMV.

MUSIC :

Well beyond medicine.

Carol Vassar, podcast host/producer:

Now that we have the medical lay of the CMV land, we'll be talking in our next episode with two moms whose children have been affected by CMV. We'll also hear from policy experts about the efforts being made to create awareness and policy around this common yet potentially life-altering virus. Please join us. It's a big, wide podcast world out there, and we are so grateful that you have chosen to listen to Well Beyond Medicine today. Whether you are a first-time listener or a longtime friend, we encourage you to visit NemoursWellBeyond.org to listen to previous episodes, subscribe to the podcast, and subscribe to our monthly e-newsletter. That's NemoursWellBeyond.org.

You can also get the podcast on your favorite podcast app and smart speaker, as well as on the Nemours YouTube channel. Our production team for this episode includes Lauren Teta, Alex Wall, Susan Masucci, and Cheryl Munn. Video production by Brit Moore. Audio production by Steve Savino and yours truly. I'm Carol Vassar. Until next time, remember, we can change children's health for good, well beyond medicine.

MUSIC:

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