intro: Welcome to Pediatric Voices, Duke Children's podcast about kids' healthcare. Now here's our host, Dr. Richard Chung.

Richard J. Chung, MD (Host): Hello, and welcome to Pediatric Voices, expert insights about timely topics in children's health, brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center. My name is Dr. Richard Chung, a physician at Duke Children's and a co-host of this show.

Today, we'll explore the topic of winter safety. We are recording this episode in the midst of the winter holiday season, with colder temperatures upon us and the potential for wintry weather in the coming weeks and months. And with wintertime comes some key considerations for keeping children and youth safe and healthy.

To help us understand winter safety better, I'll be speaking with Dr. Emily Greenwald. Dr. Greenwald is a Pediatric Emergency Medicine physician and a pediatrician who serves as the Medical Director of the Duke University Hospital Pediatric Emergency Department. Her academic work and clinical passion are focused on pediatric resuscitation and trauma. She is also our first repeat guest on the show. Welcome back, Emily.

Emily Greenwald, MD: Thanks. Thrilled to be here.

Host: So, Emily, as I just mentioned, you are back by popular demand. A few months ago, you spoke with my co host, Dr. Angelo Milazzo, about summer safety and offered some great tips for families around keeping kids and youth healthy and safe. Now, let's turn our attention to wintertime. First, Emily, what's it like in the emergency room these days, and what are the most common reasons you're seeing kids and youth coming in for care?

Emily Greenwald, MD: Yeah, great question. So, you know, one of the jokes that pediatricians have is that pediatrics is a winter sport. And what we mean by that is that we're much busier in the winter. And that's really due to all of the viruses that tend to circulate in the wintertime, especially respiratory viruses, and so, the coughs, the colds, the sniffles, the ear infections. All of those things, we see much more of that in the pediatric emergency department this time of year. We still see injuries and things that are potentially preventable due to safety concerns. But we also call the summer trauma season, meaning kids are out and about. They're much more active. There's a lot more going on outside, because of the nicer weather in the summer. And so, we tend to see more of those types of injuries in the summer.

Host: Yeah, that makes a lot of sense. And certainly in our clinics as well, we're seeing a lot of these respiratory illnesses. But as you mentioned, injuries also do happen during wintertime, even when it's cold out and people may not be out and about quite as much. Now, Emily, I'm no meteorologist, but I've actually heard tell that we may actually get some legitimate wintry weather here in North Carolina due to El Nino or other winter phenomenon. And, you know, certainly for our listeners who live beyond the triangle and even beyond North Carolina, perhaps winter safety is very much a pressing concern.

I think the other thing is that, you know, we in North Carolina aren't quite as familiar with ice and snow and such. And so even if we get relatively less of those things, we may be particularly vulnerable to injuries and other health impacts due to our inexperience handling those things. Now, I recall, Emily, that you grew up maybe in more of a wintry climate, is that right?

Emily Greenwald, MD: I did. I grew up in Ohio, but actually lived the last nine years in Colorado, in Denver, where we really had winter. And so when first thinking about this podcast, there were many more concerns in Denver, Colorado than maybe there are on a consistent basis here. But as you alluded to, there are many days where the weather gets quite cold here in winter and we are less experienced here. And so, I think there's a lot to talk about.

Host: And I can speak from personal experience that even a light dusting and even a thin layer of ice can be quite perilous when you're trying to walk down the sidewalk and you're inexperienced with such things. And so, why don't we kind of jump in and walk through some tips around colder temperatures and wintry weather? And so, let's start with the colder temperatures first. You know, what do you think about and how do you advise families around keeping infants and younger children safe in particular when it's quite cold outside?

Emily Greenwald, MD: Yeah. And I think that infants and younger children are the key here, because they can't always speak up about how cold they are, how they're feeling. Whereas a teenager knows and can complain or go back inside to get another layer, the younger children can't communicate that to you. And so, the best thing to do is to dress them in layers, having various layers that you can adjust once you get outside.

And then, also pay particular attention to them getting wet. And so if we do get the dusting of snow, you know, imagine that they have a pair of mittens on, and they're picking up the snow, and the next thing you know, the mittens are soaking wet. And then, the next thing you know, they really are at risk for very cold fingers, and if it's cold enough outside, even frostbite or hypothermia. So, dress in layers and stay dry are probably the top two tips here.

Host: Great tips and a good point about just the importance of communication and how that's different certainly for infants and younger kids who can't really give feedback to their parents or guardians around what they're experiencing. So, really great tip. Now, let's say that a young child is bundled up well and you're out and about as a family, other tips you want to talk about in terms of how to keep them safe?

Emily Greenwald, MD: Yeah. So, this is really a big one for pediatric emergency medicine where, despite the most careful driving, car crashes and car accidents happen. And while most parents are very good at having their children properly restrained in the right type of car seats, what some folks forget about or don't realize is that when it gets cold and we bundle up our children and they have a sort of puffy coat on or, you know, a thick, polar fleece sweatshirt, let's say, then they go to put the car seat on and the straps, and suddenly, they can't buckle them. And so, often the instinct then is to actually loosen the straps so that you can buckle. The problem is then that if you are in a car crash, the force of that car crash will actually smash that puffy jacket down to the extent that suddenly now the straps are way too loose. And so then, we see children coming out of the straps altogether.

And so, the safety message here is that really what you need to do is actually take off those puffy layers, those thick layers so that your car seat can fit the same way it should in summer. You should not be able to pinch the straps and get kind of a pinch of the material in between your finger. That's a nice test. And you can often, you know, put the coat on actually over the car street straps, kind of laying over the child if they're a child that can move it away from their face, et cetera. And then related, for the bucket-type car seats for infants, you know, you don't want to put a big coat over the child or a blanket over the child near their face because that's not safe if they fall asleep, et cetera. But what you can do is actually keep that bucket-type car seat in your home. And that way, it's warm for when you take it out to the car and the child isn't going to lose as much heat through just the surface of the car seat itself.

Host: Excellent. Really great tips and something that I personally hadn't really given much thought to, particularly around the fit of the car seat and what winter clothing and coats and such might do around the goodness of fit, and the effect of that car seat should a car accident happen. So, thank you those tips.

This also reminds me as we're talking about bundling up and the impacts of that on, particularly in infant safety. This reminds me of a podcast episode we did a couple months ago around infant sleep, actually, with Dr. Sophie Shaik and Kristina Nazareth-Pidgeon, two of our colleagues here at Duke. And I imagine that there's a lot of temptation among families to really bundle infants up in the crib, you know, in the bedroom during winter months. And so, are there any tips that you offer families around, safe sleep during the winter months?

Emily Greenwald, MD: Yeah, absolutely. So, not only do differences happen in terms of child sleep safety just because it's cold, but also many families travel during the holidays. And so, they may find themselves having their infant or young child sleeping in a different environment that can have different safety concerns.

And so, first of all, you know, your child should be warm when they're sleeping, absolutely. But still for infant sleep, they need to be sleeping on a surface that's flat on their backs and then without loose things. So, a blanket for an infant would be considered a loose thing, and there are products in the marketplace that are sort of like the kid's arm goes through a type of blanket and then it zips up almost shaped like a triangle over the infant and those are safe. Because they can't fall off and end up, you know, on top of the child's face. And so, looking at a product like that, raising the heat in your home slightly so that you don't need to be using unsafe products in the crib is another idea. But it can be really tempting to offer an extra blanket or a lot of bulky clothing. And really, that's just not safe.

Secondly, when you're traveling, you know, you need to plan for that safe sleep environment for your infant. If you're taking, for example, a foldable crib with you, make sure that you've got something warm enough for your child to sleep in. You know, it's not okay to just that one night sleep next to the parent in the bed with the comforter, because you've gone to a family member's house. That can be really dangerous and lead to tragedy that we all want to avoid.

Host: That's such a good point. Let's follow that thread a little bit. You know, during winter months, particularly the holiday season, many families might be traveling to other settings, maybe visiting relatives or staying elsewhere. What are some other considerations in addition to kind of the sleep environment for infants, other considerations to be thinking about when you go into other people's homes with young children in particular?

Emily Greenwald, MD: Yeah. And this is one that we think about and talk about a lot in the pediatric emergency department. And there's this idea that there are certain medications that many older people take for blood pressure or heart problems. And there's a category of medications that as pediatric emergency physicians, we say one pill can kill. And it's true that certain heart medications and blood pressure medications, if a young child who's, you know, seen a lot of new candy in the holiday season, suddenly sees a something that looks like a candy on the floor or even in a counter in a pill minder that's not secure, they may think that's candy and put even just one into their mouth. They may decide that it tastes bad. But if they swallow it, some of these medications can be very dangerous. And so, thinking when you go to other people's homes, asking, you know, do they have medications in the homes and are those medications secure? Because the family members may not have children themselves. And so, they may not need to secure these medications on a regular basis. But if you have young children that may get into these medications, it's a good idea to have the conversation before you go.

Host: Excellent point. And I imagine that there are a lot of different facets of different environments, different homes that may not be quite as baby proofed as your home environment. So, things like medicines lying around or other hazards perhaps that parents might be really attuned to in their home environment, but have difficulty fully controlling when they're out and about, I think, is probably common concern and not something that parents may have bandwidth to really think thoroughly about because traveling in and of itself is such a chaotic time during the holidays.

Emily Greenwald, MD: Yeah, that's absolutely true. I think a lot of the injuries we see happen exactly in that way, that there's some new exposure in a new environment and a holiday party going on. And, you know, a lot to take in and you're keeping track of your young child or toddler and, you know, the next thing you know, they've gone up to the interesting fireplace that's, you know, beautiful to all of us and very interesting to a young child. And, you know, it's protected with a nice glass shield that the child doesn't realize is hot and they put their hand on it and, you know, instantly get a burn, for example. We see quite a bit of that. And oftentimes it's not a fireplace within the home because then it's in an environment that the parent knows to be vigilant and to train their child and put safety mechanisms in place. It's rather in a different environment where there's a lot for the parents or guardians to take in to protect against every safety concern. And so, at least having heard about some of these on a podcast or otherwise can help bring it front of mind for these parties and other super great and fun things, but safety concerns also that happen during the holiday season.

Host: Excellent. Thank you for those tips, Emily. Let's turn our attention to what I alluded to before in my own personal experience with just kind of slipping and falling during winter weather and such. And so, as I alluded to, kids in North Carolina growing up here may have relatively less experience managing snow and ice. But if we should get that kind of weather, what are the types of injuries you're seeing that families should be aware of? And what are some tips in terms of just kind of avoiding even run-of-the-mill slips and falls?

Emily Greenwald, MD: Yeah, sometimes that's hard. I mean, you know, I have a six-year-old, and he goes at mach 10 all the time, and to tell him to slow down is really tricky, and he's been like that his whole life. And so, it's difficult. I think the kids will slip, they are closer to the ground, which helps, and they also don't tend to get fractures the same way, you know, an elderly person would. An 80-year-old who falls, they're much more likely to have a serious injury than a three or four-year-old. So, that's a good thing. But giving them a warning, holding their hand as you're walking. Being extra vigilant if you're carrying an infant and you're walking and you know that the conditions are treacherous, to just go slow, give yourself extra time in getting to wherever you're going, so that you can move slowly and not be in a rush.

Host: Excellent. What about when we're talking about winter sports? So, kind of more organized activities that are on purpose outside. And, you know, I'm thinking about not only younger kids, but also teenagers who may be even more adept, right? Because they've been perhaps training for particular winter activities. So, let's start with maybe ice skating as kind of a common example. I was actually recently traveling with family up in New England and we did some ice skating and I was struck by just the large percentage of people who chose to go out on the ice and yet looked really afraid and pained, right? You know, these people kind of gripping the sides of the rink. But that's a common experience, right? And it just brought out in the pediatrician part of me concerns for injury. And so, any tips around ice skating, whether kind of organized or maybe just as a recreational activity?

Emily Greenwald, MD: Yeah, 100%. So, I'm one of those people where I consider myself to be an athlete and I like to ski and things like that. And as soon as I get on the ice, ice skating, I look entirely terrified, because there's a lot of risk with ice skating. And the next thing you know, you can fall backwards and hit your head, for example. And we've seen some serious head injuries with ice skating. And so, I actually recently took my children to an ice skating rink nearby. And actually, they were the only children there wearing helmets. And I was really surprised to see that, and I think it's just not something that people think of. But I think especially if you're an inexperienced ice skater or you're inexperienced and there are people moving quickly who are experienced next to you, they could easily run into you. We see that a lot skiing in Colorado. Many of our most serious injuries actually were when a more experienced skier going very fast actually ran into a beginner skier that did something that was unpredictable that the experienced skier wasn't expecting. And the same thing can happen with ice skating. And so, wearing a helmet, being vigilant about is this skating rink so busy that I can actually stay away from people or do I need to wait for when some people come off the ice and then go, things like that. but you also have to be willing to accept inherent risk. I mean, no matter all the safety precautions you're taking, you cannot remove all the safety risk of ice skating or skiing, and these things are fun. And so, you have to balance that as a parent and also as a child.

Host: Great points. I think that balance is so key and is such a point of tension, I think for parents, who want their kids to really experience things and have fun, but then are also very attuned to concerns around safety. And how to strike that balance is, I think, really the essence of this conversation, right? Giving practical tips while also encouraging families to experience and make memories as they should.

And your point about just the difference in kind of skillset of people on the ice or on the slopes is such a good one, right? Because I think, you know, if you're a novice or if you're experienced, but then there are other people with very different skill sets who you don't know and can't necessarily predict the behavior of. It makes the environment that much more chaotic. It actually reminds me of kind of the roadways during winter time, right? It's one thing for you to drive safely and to know that you can do what you need to do to stay safe on the road, but you don't know the person next to you, or you don't know the person who's speeding past you in the left lane. And so, that's really kind of where a lot of that uncertainty and risk comes from in terms of safety concerns.

Emily Greenwald, MD: Absolutely.

Host: You know, one other activity, Emily, that comes to mind is the tried and true tradition of sledding, right? So whenever anything white falls from the sky, I think our kids are finding anything that they could sled down a hill with, whether it's an actual sled or just some other plastic surface of some sort. And so, are there any particular tips around sledding? Because that's not necessarily an organized sport, and yet it's such a common winter activity.

Emily Greenwald, MD: Yeah. I'm so glad you asked me about this, because actually this is one where, to your point, it is not an organized sport. You can do it many different places and there really are a ton of safety issues that a parent should keep in mind that a child likely will not think of regardless of their age. And sadly, I have seen a number of sledding true tragedies in my career that really probably could have been avoided.

And so, some things to think about. Don't go head first. Sit on your bottom and let your feet go first. That way, if you impact another child or an obstacle that's somewhere on the sledding hill, your feet will hit it first. And for obvious reasons, that generally turns out much better than your head hitting it first. I have my kids sled in helmets. I'm a pediatric emergency medicine physician. I have seen some of the worst of the worst injuries and know what can happen. But generally, a helmet also keeps your head warm. They have just as much fun. So, I would encourage that. Look for obstacles on the hill. If there's a tree, guaranteed your child will run into it. So, find a different hill that doesn't have a tree on the way down, because you can't really steer a sled. Many safety blogs talk about, you know, having a sled that you can steer, but my kids have had sleds that you can steer and trust me, they can't steer them . And some of the most fun sleds are the saucer type ones. So, it's just better that there's no obstacle that they can hit. And then finally, you should consider how your child is going to stop at the end of the hill. You know, is there a lake that they may end up sledding right into and not be able to actually stop with their feet in time? Is there some other danger kind of at the bottom of the hill? Because you'd be surprised they go down and then they keep going for a while, even as it starts to flatten out. And so, considering kind of what's there and how much of a flat runoff exists is a really good thing to think about. Actually, having moved here, my kids have been really excited to sled, because it's something we did a lot in Colorado and we have not had enough snow. But even during the summer, I've kind of identified in our neighborhood where the safest spots would be for the occasion that we do get some snow. I'll kind of, as a parent, know where to take them rather than trying to figure that out on the day that they're so excited. So even after listening to this podcast, like, notice as you go around your neighborhood today, where might be some of the safest spots to sled should we get that exciting occasion for your kids to experience that.

Host: Really good tips, Emily. And it strikes me that, obviously, none of this is rocket science, and yet It's so easy to forget and not think through, right? Because it's such an exciting moment when your kids are just like raring to get out because we don't get winter weather often. And so, it seems like this real opportune moment, but you do have to think things through, right? And I love your point that you can't steer a sled,. And you know, certainly from my own childhood experiences, I agree with that comment for sure. But the implications of that are just so many in terms of safety and really thinking that through in a thoughtful fashion. I think the other thing that strikes me in some of our neighborhoods here in North Carolina is that, there aren't ready made hills everywhere, right? And so, I see many kids sliding down side streets or even main thoroughfares, assuming that cars aren't going to be out and about after a winter storm. And yet, I imagine that there are some real risks associated with that.

Emily Greenwald, MD: Yeah, absolutely. That's terrifying. And so, yes, find that safe sledding hill that if you can walk to it, all the better, dragging your sleds behind that's in your neighborhood.

Host: Now, Emily, one other thing I wanted to ask you about as we move to a close here is actually the implications of ice storms related to our power infrastructure. So, I know we've all probably had experience with the tenuous electrical systems here in North Carolina when we do have severe weather. And so, If we should have an ice storm, if tree limbs and other things come down and power goes out, are there any safety considerations for families to think about when the power is out?

Emily Greenwald, MD: Absolutely. So, you know, we all know that most homes are heated with either a fuel burning-type furnace or an electric heat pump, and neither of those will work when the power goes out. Depending on how long your power is out and how cold it is outside, the inside of your home can get cold very quickly. And there are lots of homes in North Carolina that have families in them that have young children and infants are at highest risk certainly. And so, really the best thing to do is if you have an alternate place to go that does have power, whether it's a family member or friend's house, to stay warm with that young child or infant, because it is so challenging to layer them up safely as we've already talked about.

And then, it's good to have a go bag. I mean, Carolina does have ice storms and those limbs come down. And actually in my neighborhood, for whatever reason, every time we have big winds and a storm, the power goes out. I seem to have the lucky neighborhood for that. And so, we made a go bag as a family. We know where it is, it's got flashlights in it, it's got formula, it's got some extra batteries to keep the devices charged, and a few things that we need and can get to quickly so that if the power goes out, we're ready and not searching all over the house in the dark for these things.

And then finally, a couple other important things are that, I find that sometimes when the power goes out, folks get cold and then they start to think of solutions that they don't use often. And what I mean by that is suddenly they're using their fireplace or their wood-burning stove for the first time in years. And they haven't had the chimney inspected for safety or the wood-burning stove inspected for safety and a disaster can happen. And so if you have those things in your home and you think you may use them on occasion, it definitely is worth the upkeep of having them inspected and make sure that they're safe and ready to go if you should need to use them.

A couple more things related to this are some families have backup generators. They're expensive and expensive to run and so they tend to be fairly rare. But I have seen them operated too close to a window and they make exhaust just like a car does. And then, there's a dangerous gas in that exhaust called carbon monoxide. And it can come in through the window and it can make you very sick. So sick that if you don't recognize this, it can even lead to death. And so, making sure that that backup generator is outside the house and the fumes from it are not coming in.

And to further safeguard, every home in North Carolina should have at least one carbon monoxide detector. So again, that is to detect this gas that you can't see, you can't smell, but can be really deadly. So if you only have one, it should be installed in a grown up bedroom so that that grown up can be alarmed if the carbon monoxide level goes up and then get everyone out of the house and call 911 so the fire department can come and inspect your home and see if it really does have a dangerous carbon monoxide level. More than one is ideal in your home, but you should have at least one.

Host: Excellent. Thank you again, Emily, for sharing so much practical insight. It really strikes me just all of the knowledge you have and the practical tips that you've offered as an emergency medicine physician. You see everything, right? If it happens in the world, you've likely seen it. And I think that then brings forward your own collective wisdom, right? Over time, you've seen these things and can offer families advice around all of these different facets. And I imagine when we started the episode, listeners were thinking, you know, what happens during wintertime? Maybe, you know, slips and falls, but that's about it. But you've really shared with us just the diversity, I guess, of ways in which there could be potential health risks. And I appreciate just the very practical tips that you've offered. So, thank you, Emily.

Emily Greenwald, MD: Absolutely. I'm happy to be here. And these safety tips can help any child. It is well worth the time.

Host: Now, one more question for you, Emily. So, it strikes me that as an emergency medicine physician, you are one of the few doctors who don't want people to come see you, right? Because if they come to see you, it means something's happened, and it's probably unexpected and unplanned. It's probably quite severe. And so when they come in, in many instances, there have been opportunities to prevent, right, that haven't been in place. And so, no offense, Emily, but we don't want people to come to see you.

And so, just to put a finer point on it, what is your top piece of advice in general to keep kids safe, particularly what we talked about, balancing, giving kids the opportunity to be kids and experience things and have fun while also ensuring safety? What would be your final word to parents and families listening?

Emily Greenwald, MD: I have three young children of my own, and they take plenty of risks, and I let them do that. But the major thing I thought about this of what I do with my own children and what I would advise for other parents, and that is appropriate supervision. And that's because children just don't think of these safety risks and neither do teenagers for that matter. Appropriate supervision where you're watching, you're observing, you know what your teenager is doing. And if you're not going to be there, which is sometimes appropriate, you've talked to them in advance about what some of the risks are, and how they can help to lower those risks, for example.

So really, that's my answer, is appropriate supervision and knowing that, you know, sometimes accidents happen, absolutely. And that's what the emergency department is for, and we will be happy to take care of your child if an accident does happen. But we also want to help in sharing what we've seen to keep families safe.

Host: Wonderful. Thank you again, Dr. Emily Greenwald, for a wealth of wisdom to keep kids and youth safe during wintertime.

Pediatric Voices is produced by the team at DoctorPodcasting. The show has been developed by my co-hosts, Dr. Angelo Milazzo and me. Thanks to Dr. Ann Reed and the administrative team at Duke Children's, particularly Debbie Taylor and Courtney Sparrow for their support.

Find our show and hit the subscribe button wherever you find your favorite podcasts. And we want to hear from you. You can connect with us at dukechildrens.org, Facebook, X, and Instagram. Please send us your feedback about the show, including your suggestions for future topics. Thanks for being a part of the show. I look forward to talking with you again.