Child⁠ ⁠Neurologist⁠, Jamie Palaganas, M.D.

0:00 Hi, it's Doctor Robert Seikard with Episode #15 of Doctor Podcasts. And I'm really pleased to have a pediatric neurologist here today, Doctor Jamie Palaganis and Dr. Palaganis, as you can see from here is an assistant professor of a Clinical Pediatrics at Weil Cornell Medical Center, one of the top medical centers in the country. And Doctor Peleganis and I will speak about the pediatric neurology, which is a very interesting topic, especially these days. So we've all heard that there are neurologists, those are doctors who basically specialize in the brain.

0:38 Why is pediatric neurology a separate specialty just from a regular neurologist? Right. So it's often a conversation that kids are not just little adults. So it's not that it's the same software, the same hardware, the same systems, all functioning in just a smaller body, but there's a lot more complexity to that. So from a Physiology perspective, you're changing as you're developing from infancy all the way through, you know, you're all of your organs sort of mature and kind of adapt and change how they function.

1:10 And your brain is absolutely no different. And so we also not only talk about like the brain function or your spine or your muscles, but also as your you're developing, are you hitting your milestones on time? Are you walking on time, talking on time? And if there's something that doesn't fit along the typical trajectory, why is that? Where is that coming from? So development factors in not just physical developments and skill development, but even emotional and psychological developments along the way too.

1:39 So it's really a very different sort of paradigm than just in adults, which is has its own level of complexities because the brain is changing in yet a different sort of way. But this is in the early stages and the early developments of the brain, even prenatally all of those complexities are really coming out in those first years of life through school age. Once you get to adolescence, then it starts to ease into more, more like adult neurology. But even in there, there are some intricacies that we have to keep in take into account.

2:08 Well, that's interesting. At what age does a child's brain become an adult brain? Does that vary from person to person? Because I know some 40 year olds. Who you? Know still are little kids, but from a functional and biochemical basis, When? When does that occur? Yeah, that's a really good question and it isn't really set in stone. So you know for as a pediatric neurologist typically we will see patients up till depending on the practice 18 or 2122 and we know that myelination of the brain kind of continues into your early 20s.

2:42 So you could say that functionally it's fully mature around then, but that doesn't mean that you can't see an adult neurologist once you're an older teen by then things are more sort of set in sort of the Physiology and the function and structure. And then older age and adults is a different sort of Physiology and changes that happen. So it's not really something that's set in stone. It kind of depends on what the issue is. And also certain things you know are weight based in Pediatrics. So if we're doing medications or a lot of different factors that of ways we evaluate people, we're taking into account your size.

3:19 So once you reach adult size, there are some things that become more adult practice. That being said, I'm a very small adult, but I still count as an adult. So you can't just say, oh, when you're a 70K adult because a lot of us don't reach that size. Or you can have a child who's much younger who reaches adult size, and you don't necessarily treat them as an adult just because their weight falls into an adult weight. What about the brain size? The actual volume of the brain? When when does that reach the adult stage where it doesn't change much anymore?

3:51 Yeah. So your head circumference continues to grow from into late school age. And so like there's a mnemonic that we used to remember what the 50th percentile for head circumference is. And you know, we track head circumference growth to make sure that you're growing appropriately through the first couple years of life. After that, we don't really track it all that regularly unless there's something that's dramatically changing. So you know, after the first 2-3 years if you're growing normally we stop formally tracking it, but your head size sort of becomes near adult dish in like your 910 year old area.

4:29 So the size matures at that point, but the functional level changes into your early to mid 20s. Yeah, and functionally, I think you. Even in medical school, you're still maturing your brain. Yeah. And well, I would say that, you know, plasticity is obviously a big topic in neuroscience. And so there's maturing in the structural sense of there's still myelination that's happening. So insulation that's forming in your brain is still occurring well until your your early adult. Wiring inside the brain.

5:01 Hard wiring still. Is still evolving, but even then, beyond there, it doesn't matter if that is all done per SE. There's still you can still learn new things, you can still adapt differently. So it's not that the function is really set in stone in the same way that it might be in other parts. Everyone says that children are able to pick up languages much easier and quicker than adults. Why is that? A complicated question, but when you're so when you think about learning language in the early stages of development, the first year of life is pretty much all motor skills.

5:40 So even though kids start to develop sounds and start to develop words in that first year of life, they're able to do that because they've learned the oral motor skills to do so. So you know, that's why you start non specifically with like Mama Dada, which may be for a specific person or may just be babbling. And then as they get older it becomes more specific. And those are kind of ubiquitous across cultures and languages, is that you start with similar sounds because they're easy enough to form.

6:09 And so because at that point you now have developed the skills to kind of make your mouth and your voice do certain things if as you're exposed to it, you start to embed those different skills. So hence people who have different sound qualities will develop the language skills they need for whatever language it is, but then have a different hard time when they're learning a new language older on, because they're the muscle, the motor patterning that they've learned. It's different. And so it's it's more that that's just what the brain is doing at that time.

6:41 So once you get past about a year, you know language starts to pick up your gross motor skills. A lot of them are already fully in place. So you know walking is a year to 15, OK, up to 18 months to start to walk. Things like that are now have already done a bulk of their developments. You know, fine motor skills are continuing to develop, but like you have the building blocks there and then you start to get into these higher level skills like learning language. So once you have the motor skills then you start to your brain sort of shifts attention to what do I do with these skills and language is the next thing that gets picked up.

7:17 So if they're exposed early, there may be a delay if there's multiple languages. And I always encourage people that it used to be said to limit the language that a child is exposed to, but if they're slow at it in the beginning, that's fine. They're going to come up learning 2 languages, 3 languages, whatever it is, and they'll tease it out over time. Which is great took because to be a native speaker versus learning it later in life is so different, but it will sometimes cause an apparent delay because there's just a lot of information that the brain is trying to.

7:48 Tease a lot of processing, Yeah, interesting. So pediatric neurality, very complex specialty. Tell us about the training. How many years of training and what kind of training did you do to become a pediatric neurologist? Yeah. So child neurology or pediatric neurology, there is a little bit of a unique training field. So when you apply and this is kind of all changed over the last 20 years or so, but there's a couple different paths to doing it. But generally speaking, most people do a five year residency in child neurology, which is 2 years of general Pediatrics training where you're with all the the general Pediatrics residents.

8:27 And then three years of neurology training, which during the three years you have to do an entire year of adult neurology. And then across the other two years of your training, you're exposed to all your different child neurology. So typically after you do 2 years, years of general Pediatrics, you're then totally changing gears and you spend most of your third year in adult neurology. You do still do some pediatric neurology in there, but you have to shift gears a lot and remember you're adult internal medicine which is terrifying, not going to lie.

8:59 And then you do a lot of inpatient adult neurology. You do some child neurology and then over the next PGY four and five years, you do more and more child neurology. Some people can do one year of Pediatrics and one year of adult medicine and some people do one year of Pediatrics and a year of neuroscience research. So there's a lot of different paths you can do and it's very unique because you're kind of part of a lot of different programs while you're during your one single training. Program. So it's an extra five to seven years past medical School of Training.

9:33 So it's five years if you do straight child neurology, some people do the full three years of Pediatrics and then realize they want to do neurology and then they do the three years of neurology. And then if you do fellowship, fellowship can be anywhere from a year to three extra, depending on what it is that you're going into. But then you're ready to retire, right? It's a long, long path, but so many of the residencies and and pathways certainly are now well. It's very complex subject, so you need all that training.

10:02 So one of the one of the common symptoms that I see in patients I'm an ophthalmologist is children and adults come in with headaches and the headaches take on various forms and shapes, various symptoms. I assume that's one of the common symptoms that you see in in children. Parents bring them in for headaches. Can you tell us how you figure out if a headache is significant or it's not, and how you work it up and what you do about it? Yeah. So I would say that headaches are probably if not the most common complaint to come to child neurology, maybe top two.

10:39 So question of top two being like, could this have been a seizure? And then headaches are often really up there and headaches can be so scary for people because they're concerned. What if it could be? Really the big thing that everyone always worries about is, is it a brain tumor? Right. The reality is it's actually very rare for headache to be the primary presenting symptom of a brain tumor. Yes, it can be, but it's unlikely that that alone is going to be what's going on. And so there's a lot of different features we look for that would be red flag features to say this warrants imaging or this warrants more work up or this seems more concerning.

11:20 And when I'm asking, certain things I think are really important when you're talking to a child who has headaches. So now you can have a teenager who has a headache and who can very easily explain to you what they experience when they experience it. Where it gets more challenging is in the younger kids because they may not have the vocabulary for it. They may just kind of show you or like hold their head or want to go lay down and it's not very, very clear cuts. And So what becomes extra challenging in those younger age to tease some of that out is by that point, by the time they come to see you as a neurologist, often, you know, they've seen the pediatrician, their parents have tried to ask questions about it and they're at an age where there's sponges, right?

12:05 So they're picking up on all these questions that are being asked, but they may or may not actually fully understand or know how to answer them. Like, what does it feel like? Is it banging? Is it squeezing? They may not fully know what it is that they're trying to describe, right? And so you look for a lot of things. Just like super simple red flags would be things that every time they go to bed at night and they lay down flat, they get a headache. As soon as they sit up, it goes away. OK, Does it happen when they lay down during the day?

12:32 Yes. That would be a red flag. If the headache only happens when you're laying down, that's concerning a lot of times, Headaches. It may be increased brain pressure. Exactly. So something that would increase your pressure would become more prominent when you're laying down. Now, that doesn't mean that if you have a headache one time, because after you went to bed, that showed the brain tumor, which is where the concern pops up a lot is it happened at night, at bedtime, but that doesn't necessarily mean it's in the right pattern.

13:00 So even if a child goes to bed and sometimes has a headache, like while they're trying to go to sleep, while they're laying down, but you say, oh, well, then I went in, they had some water and then they lay down and they go to sleep and they're fine. And they wake up in the morning and there's no headache. That's far less concerning than saying, oh, they can't go back to sleep because their head is hurting every time they lay down, right? So you have to look for kind of the intricate patterns about it.

13:24 Is there vomiting? That happens at night? But really, it's more than just the head pain, It's what else is happening with the head pain? Is it always in the same spot? Does it seem to move around? Do they have vision changes that happen, you know, looking for signs for migraine? Do they have sensory symptoms? What else happens with the headache? And when there's something more malicious brewing that's causing the headache, often there are other features that are actually there too, and those actually are what usually come up even more than the headache.

13:53 The headache is kind of like an indolent, slower presenting symptom, but something else will happen. Like they're less strong on one side or they're bumping into things or their face seems less weaker. They're not talking right. You know, other things that are of concern. And then you also happen to notice, Oh yeah, they've been complaining that the back of their head's hurting or that they can't. They feel, don't feel comfortable laying down, and then you start to tease it out. So, you know, it can be very challenging, but more than 50% of kids, I think, see doctors for their headaches, and those are just the ones that go to the doctor.

14:28 There's still others who, you know, don't even mention it to the doctor because they get headaches here and there. So headaches, even in children, are really common. And that's something that sometimes is surprising to people if they're not someone who, you know, grew up experiencing headaches. That headaches can occur even in young kids, and sometimes it's just harder to kind of tease out the severity of it. So you ask a lot of questions to try to figure out if it's significant or not. Then you examine the patients and see if they have any abnormal neurologic findings.

14:59 Right. And so in in kids, one thing that's always I find really important in interviewing children about their headaches is trying to get the child to answer before you let the parent jump in and not be. It's not because we're trying to cut you off, I promise. But it's important to try to get as much alterated answers from them, because kids actually sometimes are super descriptive and insightful. Sometimes people will ask a child to draw a picture of what their headache feels like, because they actually can do that better than they can put it into words.

15:29 And so you can get so much information if you let the kid do the first round. And so I'll usually say to a parent that I promise I'll let you clarify, but I would really like the chance to ask, even though they're five years old or four years old, you know what's going on? Tell me what happens. And sometimes you're surprised by the things that they come out with because they're given the chance to talk about it. And that actually can give a lot more clarity as you start to put the full picture together.

15:56 And examining kids in child neurology is often a lot of observation. So sometimes, you know, you're dealing with children who are terrified of doctors. They're afraid that they're going to get stuck with needles. I spend most of my time, even if I'm talking to the parent, I'll make eye contact. But then I'm staring at the kid, basically, and watching them play around the room. I don't expect them nor want them necessarily to sit perfectly still, especially if they're a toddler and they're exploring, because that actually gives me so much detail about their exam that that is so much more important than me physically examining them and tapping on their reflexes and things of that nature.

16:31 The formal exam kind of helps to clarify any concerns that I do pick up on just by watching. Right. And if you're suspicious of anything, then you would send them for imaging like an MRI scan, things like that. Right, so we do, we try not to use CAT scans at all for kids unless it's an emergent situation in the ER. Radiation. Because of the radiation, and certainly that's become a growing concern over the years. Mris are not negligible, though. I think that's an important thing. Everybody always wants the MRI when you know their kid has a headache.

17:02 And I totally understand that because of this fear that everybody has about headaches. Could they be coming from something? And a lot of us have had family members who have had a brain tumor or an aneurysm or something along the way. But for a child, you also have to factor in all the stress that comes with an MRI. They have to be sedated depending on their age. Or you're trying to tell. Maybe they're an anxious child and you're trying to tell them they're OK, but then they have to have this scary test where they're in a tube and it's making a lot of noises at them or they have to go to the hospital and have sedation.

17:35 And so there's a lot of factors that go into weighing whether or not you do the imaging. You know, if there are certain red flags, of course you're going to do it, but sometimes it's going to be more watch and wait, Let's try some conservative things. There's nothing red flag, no red flag features that are popping up that make me super concerned. Let's see how this goes before we carry through with that, because sometimes afterwards you realize that that events of doing a study or doing lab where it can be so stressful for the child and we don't think about that at that moment and so we wanna factor that in, in our decision making.

18:08 Right. Another thing I see occasionally is kids who have ticks where they blink a lot. Yes, that's what I see, cuz they're coming to me as an eye doctor. But you must see lots of other ticks. Can you tell us what a tick is and what causes it? And how you figure it out and how you manage that? Yeah, so ticks are super, super common and actually a lot of people have a little tick or stereotypy is is another word for something very similar and just don't even realize that they do. So basically so stereotypy is considered like you starting before the age of three and ticks are after that.

18:45 Part of the reason for the differentiation is ticks. You have a premonitory urge so you have a feeling of you need to do something. So kids will say, my eyes are itchy, right? So if they're doing an eye blinking tick, they'll say my eyes are itchy so they blink a lot or my neck hurts so I do this or had a a scratchy throat so I cleared my throat. That's the sensation that's making them do this movement or make the sound whatever it is. And it's basically just extra energy that has to come out. So you know we were talking a little bit before we started about the the pandemic and one thing that came out in huge volumes were ticks.

19:28 So kids went from being in school and being very active and running around to now they were home full time, not able to get all their energy out. And there was a lot of kids presenting for neurology consultation because of new onset ticks. So it's really kind of like extra energy, which in a child is very normal and it's got to come out somewhere. So it's not a problem with the brain itself. And like I said, many people do have little ones that they may or may not notice. So eye blinking is common, throat clearing, sniffing, things of that nature.

20:02 And often they start because there was something that made them do that say they did have allergies. And their eyes really were itchy and so they started blinking. But then again, given the age and the developmental way that the brain is changing, it becomes a habit. And it's not a volitional thing. It's just becomes like a little circuit that their brain likes to go back to. And so when it's not occupied doing something else or when they're anxious, it comes out more and so. So ticks are, you know, if you look around a room of like school, age, children, it would be very easy if you're looking for it very closely, to pick up on a lot of things.

20:38 And I think it's very important to normalize it. They can be very alarming when you start to see them and often they'll come on really fast and then they gradually die down and then something new may pop up and then that goes away and it's this waxing. How long do they typically last the the tick? Yeah, it's super variable. So you can have ones that are there just a couple of days. Not unusual for them to get worse or to start during an illness. And so an illness is a stress on the body and that kind of unmasks ticks.

21:08 It doesn't necessarily 'cause it. It's probably somebody who is likely to have a tick and they just come out, you know, under the setting of being sleep deprived or having a fever or something of that nature. And then it'll gradually get better. So a lot of kids will have ticks that are there for several months and they'll get better and then sometimes they'll go away completely, but then come back a year later. Is it better to tell the child that they're doing it and to stop, or to just ignore it?

21:36 Right. So I So in general, you do want to ignore them because the more you draw attention to them, the more likely they are to happen. So I'll usually counsel families that when we're starting a a visit about ticks, you might have a real bad day with your ticks because we're going to spend an hour talking about ticks. So now if the kid is doing it more and more you might see that later on today. It's just because we kind of we triggered that. But it's you know, the it's they they come on and last for like several months at a time and then resolve.

22:11 But there's so many different factors of like how you want to address it. So the reason for ignoring the ticks is actually more because you don't want to draw negative attention to it. So the harm, there is no inherent harm in ticks much of the time. Sure, there are rare circumstances where ticks can be such extreme muscle movements that they can be damaging or harmful. But a lot of the times they're more bothersome to other people than they are to the child's. And a lot of times the kid doesn't even notice that they're doing them.

22:42 And so if you're drawing attention to it by saying like why are you doing that? Stop doing that which is natural. You know, if it's something that seems like a brand new and kind of irritating to be watching more as an adult than as a child, that creates some self esteem, concern and negative attention to it that we want to limit because it can. That can have downstream sorts of effects. So that's the reason for ignoring it. It won't make it go away, but it might help it from becoming, from, from the downstream concerns that come from from it.

23:15 And the other thing is people, I I do often recommend that parents talk to their teachers about it. Or you can ask the child a little bit about it and say, hey, I notice you're blinking your eyes a lot. What what's going on is, are they OK? And you can ask certain questions to kind of make sure. So I will ask a child, you know, why are you doing that? You know, is there a feeling that you get, does it feel better after you've done it and look, kind of make sure and confirm that this is just a tick.

23:44 And the kid says it's just a tick. Sometimes the kid will actually say that. Sometimes. Sometimes they'll say, I don't know, it doesn't bother me. I just do it. It feels good when I do it, OK. And that's that's kind of all you need to confirm that it's a tick and it's not something more dangerous and then you let it be. And then I always say to them too, does anybody, I'll ask, you know, does anyone else say anything to you about it? Have the teachers asked of you about it, Have other kids at school?

24:11 And I think a big concern parents have is bullying. You know, our Tourette's syndrome used to be so much more in the media, but I'm sure it's still out there now. And what can be, you know, kids can be picked on for things like that. Truth is, so many kids do have their own little quirks and do their own little things that it's not actually as big an issue a lot of the time, not not 100% of the time that actually it isn't that much of A concern. So I do recommend that you tell the teacher about it, so the teacher doesn't necessarily draw negative attention to it, but can note it and see if it's better or worse or what's going on, and then just let it go.

24:47 What's difference between a tick and a seizure? And what's the difference between seizures and epilepsy? And is there a difference? Yes. So excellent question. So when we see something that looks like a tick, one of the first questions is, is it a tick or which can be very easy to answer depending on the child or could it be a seizure. So ticks are like extra energy that comes out. They do look stereotyped, they do look the same, but within that there's some variability. So it's not as much of like a short circuit like if you video a tic, it'll look very similar time to time, but there might be some variation.

25:26 If you're talking about something that's concerning for a seizure seizures, think of them as a short circuit. They tend to happen the same way every time that they're going to happen. Not every time, but a lot of the times when they happen, they will look the same, like think that you could practically superimpose the videos and see the same pattern happen at the same time. That's not 100%, but it's a simple way to sort of start the conversation. And tics, you can often interrupt. So you know, if a child's blinking a lot and you tap them and you get their attention and say stop it, they can stop it.

25:59 If a child is blinking because they're having a seizure, you tapping them and calling your name isn't going to stop. It won't work. So you can't interrupt A seizure. Seizures tends to be there are a lot of different types of seizures. But the first things we'll ask are, were the movements rhythmic? Were they suppressible? And so if you can intervene on something, so someone's having a shaking movement and I put my hand on it and it stops. My concern for seizure is low. If it doesn't stop and it stays in the same rhythm, the same frequency, you know, yes, I can damp it because if I push I can stop it from happening as much, but you can still feel it.

26:37 That's much more concerning for something like a seizure. And so your ability to intervene on it is really crucial. Can you get their attention while it's happening? If I put my hand on it, does it change direction? Because seizures don't change direction. They're simple motor movements typically, And so those are the types of things we look for. Does it look the same every time? Can you interrupt it? Can you change it? And is there awareness of what's happening and can child recall it Now what are seizures versus epilepsy?

27:05 Epilepsy is just the tendency for seizures. So there's a couple ways you can have the diagnosis of epilepsy. One is you had two unprovoked seizures, kind of regardless of what your EEG your brain wave test shows. Or you can have a seizure and an abnormal EEG that shows the potential for seizure and that's how you kind of reach that criteria. So the. EEG is measuring the brain waves by attaching electrodes to the scalp. Right. So like an EKG shows your electrical rhythm in your heart, and EEG does the same thing for your brain.

27:39 But like your heart, you know, we do a bunch of stickers. We do a lot more when we're doing it for your head. And then we look at different parts of the brain and we can see if there's certain areas that look like they have irritability and that potential to have a seizure. We say like sparks do there, do we see sparks? And then a seizure would be like a fire, like the sparks all came together and started firing at the same time. And once you establish the seizure, then you need the imaging and then the child needs to go on medications for that, right?

28:11 Right, right. So after you come up with a diagnosis of, you're pretty sure it's a seizure. So you know, sometimes things, a weird thing will happen once and you don't know was it a seizure and you get the EEG and EE, GS kind of non specific. It sometimes takes time to really be sure. And then there's a lot of joint decision making. You know, you have to discuss with the family, with the child, risks, benefits of using medication. Sometimes people will really want something after a single event, sometimes people will not want something after several events.

28:44 And so you just kind of have to work with the family and see what are their concerns, what are our concerns and come up with a decision together. Another topic that's been in the news a lot in recent years is concussions. In the old days, concussions where, Oh yeah, you got hit in the head, you were dizzy for a while and forget it. Now there's a huge emphasis on concussions because they can lead to other problems down the road. So tell us about the importance of concussions, especially in children.

29:13 Yeah, so concussions are a really interesting topic and I think they have gotten a lot of press and certainly you know the downstream effects of repeated concussions, the big repeated concussions and CTE and all of the movies and media press that came out about it over the last years has been important in raising awareness. In some ways. I think sometimes the this pendulum has swung a little far that we're a little over concerned. You know, normal bumps on the head don't need to necessarily have a full concussion protocol in place because I certainly can remember back being a child and falling off my bike or bumping my head pretty good and not wanting to tell mom or dad that my head was killing me.

29:55 But because I wanted to go back out and play with my friends. So, you know, I think there's there's, you still need to allow for some normalcy in kids are going to fall. Toddlers are going to bump their knees and then they're going to fall down and bump their head. And if they bounce back up, they cry and then they go back to what they were doing. That's OK. But in kids, you know, concussion can be challenging sometimes because, especially in younger children, again, they they may just want to go back to playing.

30:26 They may not complain of a headache per SE, They may just seem kind of whiny or off. A lot of factors come into play, and where it gets so challenging is it's not a perfect science. So you can see somebody take a really bad hit, say like even a young kid. I remember watching a video that a patient showed me of a he was in a hockey game and he took a horrible hit into the boards. But he came to me for concussion clearance. He never had a symptom, never had a headache, never had neck pain like he swore up and down his family was.

30:56 Like, no, he's been 100% normal, but it looked so bad. Nobody wants him to play until he sees a neurologist and gets clearance. And so I understand that and I I saw the hit, it was significant, but that didn't cause any problems. But then the same kid can have something much more minor happen. And there must be something about the physics that we don't see of it, how you were braced, something where you can have headaches and insomnia and mood lability that pop up in the day or the day couple first, couple days afterwards and then you know may impact your overall functioning.

31:30 So it's a little bit hard to definitively diagnose concussion sometimes because sometimes what you expect to lead to problems doesn't and sometimes hits that you don't expect you don't. What? What is a concussion? Actually, I think a lot of people don't understand what what it is. Yeah. So a concussion is, you know, you have a close head injury, so your head gets hit or takes an impact in some way. Now an important clarification on that though is you can get a concussion without directly striking your head.

31:59 So it is like in the whiplash type of injury. So you know, think about it, a car accident or something. Yes, your head may hit the back, but say you're doing something else, your water skiing or you're skiing and you don't necessarily land in a way that your head hits the ground. You hand land on your side, but your head still kind of whips forward and back. It's that coup Contra coup. So your head moves forward, your head moves back, your brain shakes inside your head and basically gets jostled.

32:28 So your internal brain, which is kind of soft tissue, bumps again, bumps against a hard skull, the bone. Right. So your brain is encased in fluid. There's fluid in the center of your brain called the ventricles. And then around your brain and around your spine you have the same fluid. So that's your cerebral spinal fluid and it's a shock absorber, but it's not going to be perfect. So if you have a high acceleration deceleration, you can have some you know that shaking that happens in there can cause more typically like in a mild head injury, it's it causes a concussion, which is not something that you're going to see on an MRI or a CAT scan or any sort of imaging.

33:12 It's more at the kind of the software gets jostled around and you get some bugs in there that need to be worked their way out versus there is not bleeding in the brain, there's not bruising in the brain on the more severe levels of concussions then you're talking about. You can see it on imaging where there's bleeding or there's bruising, things of that nature, but run-of-the-mill concussion that a lot of kids will sustain during their lifetime or people will sustain during their lifetime or not ones that you're going to pick up on imaging.

33:40 There are new blood tests that they can use to diagnose concussion if there's been brain injury. So there's a lot of research going on about biomarkers for concussion right now.

33:53 I wouldn't those are not ready to be used in real time quite yet. There's for multiple factors of cost and turn around time of those studies but also sensitivity and specificity of it I think isn't quite where we would just send it from the emergency room or from the clinic. That would be nice down the line. But again I think the there's a lot of complexity to it too because there are different people and their sensitivity to having a concussion can be higher than others. So, you know, some kids may not have have a concussion from the same strike as another child who has a severe concussion.

34:27 And there's intangibles that are are hard to track. So even if there is a lab test, I think the clinical picture is a really big part of that too, because if the clinical picture says they have a concussion, but the lab test says it's not still going to kind of treat it the same way. So when my kids were young, I was obsessive compulsive about avoiding injury. I made them wear helmets when I played baseball. They always made fun of me and I told him not to head the soccer ball too hard. What? What's the thought on that now?

34:59 Should kids be heading soccer balls? That is one of the like specific questions that I think is always a little bit hard. I think the I personally in the different neurologists are gonna have different stance on this. There are going to be risks to any sports that have high impact collision, right. So whether that's soccer, football, cheerleading, boxing, any of these things have high risk, but you also have high risk of something happening. Unfortunately on a day-to-day basis, you know the chance of you going out and having a car accident or or falling off your bike that you do every something that you do everyday still exists.

35:37 So it's very much a personal risk benefit of participating in those sports. If you're going to be in a sport that is high risk, then I think there are things that you can do to try. First of all, awareness of like if you do fall and you feel dizzy, headachy just out of sorts and foggy sit out and wait it out, Let's see. And then you can kind of determine after the fact, do I need to do something more about this? Do I need to be worked up by a doctor, depending on the severity of it. But in terms of like if you're playing football or if you're playing soccer and you want, you're getting to the level of competitiveness where that becomes a thing to head the ball or where you're going to have tackle football and is no longer touch football, making sure that the strength training is on point.

36:22 So how do you brace? You strengthen the neck muscles, You know, different things are really important for that. It's not going to be a preventative that's going to, you know, magically stop you from ever getting a concussion. But if you do not have the strength to sustain an impact like that, it's certainly going to make it more likely. So depending on you know, wearing a helmet is super important. Depending on the sport, what kind of neck, Gears of football they might have high necks or things of that nature.

36:53 To help with stability is important, but also making sure that the training is supporting those sorts of uses. So something like a header if you don't have built up neck strength could be very risky especially you know somebody who's loosely put together say they're hyper mobile. I would say that that would be a time where a counsel maybe you don't want to be doing that. So if you've confirmed the diagnosis of concussion in the child, what's the treatment for that? Right. So over the last probably 10 years at this point, not if not more.

37:25 You know, the treatment used to be go sit in a dark room and don't do anything, don't talk to anybody, don't do work, don't exercise until you feel better and then go back to your activities slowly. What we've learned is that actually prolongs the recovery and it's actually better to reintegrate earlier in the process. So one to three days of rest depending on the severity of what's going on. And then even if you still have symptoms, we're talking about mild concussions here, not ones where you're in the hospital, right?

37:56 So these mild concussions, even after a few days of of rest, even if your headaches are still there, you still feeling dizzy, you start gradually going back to your normal activities. You go for a very short walk, you do a few minutes of homework, you do a few minutes of screen time and you kind of see, can I tolerate it? And if you can tolerate it, the next day you do a little bit more and the next day you do a little bit more. And then if one day you overshoot, you backtrack a little bit. But it's a gradual reintegration that for some kids can be back, they can be back within a matter of days.

38:29 For some kids, it takes a lot longer. And so it's it's much more about mobilizing early, which is kind of a trend in a lot of things, right? A lot of surgeries even get up and get moving right right away afterwards, which is counter to what we used to do for a lot of a lot of different recovery options. So similar for concussions. Yeah, One of my adult patients recently told them they had a bad concussion cart. They were told not to watch TV, not to read, not to use their computer. It's like what's left?

39:00 Yeah, and it's and you. There's a role for it for like a day to three days. But beyond that, and in kids, I think what's really important is actually if you tell a kid that they can't do any of these things and they're feeling fine, they're actually more stressed out because they're not going to school. You know, if you've got a kid who's a good student, they're not going to school, they're stressing out about missing school, Maybe they just want to go play with their friends and they're not able to do those things, then it almost seems like they're getting worse because they're just are pent up and they're now they're angry and they're upset and they're frustrated.

39:33 So it is. There's a balance in there in trying to kind of make sure that you're not causing harm by depriving. But then also we do know that it is important to start to mobilize. Even if you're not feeling 100%, it's OK You know, there should be conversations with parents or with school or coaches about no, they can't do everything right now or they'll be sitting in class, but they may not be performing the way they normally do. That's OK, like that's expected right now. And then kind of work with them in a gradual fashion.

40:02 One of the things I get asked by parents a lot is are computers. IPads. Phones harmful to the eyes. There's actually no evidence that they're harmful, although there are some studies that show it may cause near sightedness to get worse. But what about the brain do Do computers? iPads. Phones, All this electronic gadgetry? Is that harmful to the brain? So the screen use itself, I don't think we have any data that the screen use itself is the problem, it's what is on the screen, right. So it's more what are they being exposed to so that we know that there are dopamine surges you get from just scrolling through your Instagram or your Facebook or your Tiktok or whatever like that that happens on on all of our devices.

40:48 So, you know, if it's educational content, sure, that's fine. But it's, you know, I think there's a a limit that you should have on using a screen for anybody. And when I tell people the American Academy of Pediatrics had used to have like our time limits, they recommended for different ages. And now for school age and above, it's more like a reasonable amount of time. They don't quantify because school uses screens. So you can't, you can't say in the same way before we used computers all day to, you know, limit it to a few hours a week or something like that.

41:22 So it's the content really. The content is. What's wrong with repeated dopamine surges if it feels good? Right. So repeated dopamine surges is what you get from whether it's taking drugs or something like adrenaline rush from something exciting you do going on a roller coaster. And it's obviously not to the same degree when you're scrolling through a social media feed, but it's still that same process, so you can be addicted to your device. Right. So let's backtrack a little. Can you tell us what dopamine is?

41:57 Cuz some people might not. Know. Yeah. So dopamine is a neurotransmitter that's produced in the brain that is associated with pleasure. And so has a lot of complexity, how that feeds into emotion and different things, but it gives you a good feeling. And so anything that makes you have that like real little rush of adrenaline probably also has a little bit of a a dopamine boost in there. And so it's not something I think people thought a ton about back when we first started using a lot of social media and a lot of or even just sitting on YouTube.

42:31 But that's become very evidence that that's part of why it's become so addictive and so hard to pull kids away from video games. So it used to be video games, and now it's like social media. Then there's also the content on social media. And again, remember, kids are sponges. And so depending on what they're seeing, they're soaking up different things that they may not be exposed to otherwise, whether it's language, whether it's violence, whether it's extreme, whatever. And those are things that you can only do so much to guard against.

43:04 It doesn't matter how many parental controls are out there. I think that's another downstream thing of it. The other thing that I comment on a lot, and I'm I I think I'm the only person I know who comments on this part. But when you're spending a ton of time using a screen, what is our posture? We're sitting at this. Shoulders are rounded, we're slouched, our head is tucked and it's terrible posture and, you know, everybody's mom yells at them to sit up straight. But it actually is a huge factor for how you're feeling is if you're if you're creating muscle memory for poor body positioning that creates asymmetries in your strengths.

43:45 It creates weaknesses that make it harder to do other activities and can be really a contributing factor to things like I'm getting a headache after I stare at a screen a lot. Well, how are you using your screen? What are you watching, what are you doing and where are you sitting when you use it? And how long do you stay there? Because if you're sucked in and you're desk scrolling, then you might stay in a position a lot longer than you need. To So it seems like if you get addicted to these repeated dopamine surges, it interferes with functioning in school and activities with friends and going outdoors and sports.

44:22 And eventually that's all you want to do. It certainly can be like that. And I think, you know, we a lot of people struggle with trying to get their kids off their devices and that's been for quite a while now. I feel like it's become even more prominent and might be actually backing off a little now because I think there's more awareness. The way I usually counsel about it is, you know, I don't think you have to stay off screens 100% of the time. If you can keep your kid off the screen, awesome, good for you.

44:47 But I don't think you, you have to feel bad if your kid is using the screen for some of the time. In terms of limits, I think it's how much time are they spending on a screen versus doing other things. Try to make it at least equal that they're doing things that are off the screen and interacting with people. That's the other part is the social development can be stunted if you're not using true social development skills in terms of interpersonal interactions. If you're only interacting through social media, that's a different sort of way of learning how to respond to people in real time and things of that nature.

45:23 One of the things you talk about a lot is the challenges of of diagnosing neurologic conditions and then managing them, not not only the medication but the social and developmental factors. Can you tell us about that? Yeah, So, So I think part of what makes child neurology so interesting to me is all the intricacies that you're talking about. So you know, what may seem like chronic headaches when they walk in the door, you may tease out over time and actually find out, well, they're actually not really having headaches, but they're really anxious about something in their life.

46:01 And so you need to dig beyond just the medical questioning, and you need to know a little bit more about what's going on in different aspects of their life. So when I'm interviewing kids and their families, the questions aren't just about the physical symptoms. It's also tell me a little bit about their personality. How would you describe yourself? What's the way that you kind of, you know, are you a type, A personality and a perfectionist? Are you pretty laid back? You know, how do you handle different stresses, things of that nature?

46:34 Because all of that factors in. If you're somebody who is very anxious about health and you develop a headache and then you start thinking about the headache, you can start to notice other things in your body and become much more aware of sensations that maybe we're always there but you just didn't notice. And so you want to make sure that you're you're keeping an eye out for what is the pattern? And does the pattern for me as a neurologist make bells go off about a certain problem or is it that there is a problem and then there's stuff that kind of gets involved because you know, of concern about whatever the the initial symptom was.

47:12 And you know, like I said before diagnosing children can be challenging because the child themselves has a hard time describing and a parent can do an excellent job but they're still not in the kids head. So it's hard to fully tease out the the details of what's going. On So you're not only a neurologist, you're also a psychiatrist for the child and the parents, right? Well, no, I'm not a psychiatrist, but there is a lot of psychology in neurology and I think that's something that I did not quite realize when I started my training.

47:41 So by background, I was a psychology major in college, but then discovered neuroscience and took pretty much all neuroscience classes to check my boxes and was neuro all the way after that. And then as I went through my training, I realized how much the psychology was so important to the neurology because they're in so intricately intertwined. So the mind's body connection is a very big deal. If you're anybody who gets headaches or has a nervous stomach or has gotten butterflies in the stomach, all of those things are the way that your body can be showing you that maybe there's some stress going on and it doesn't always happen in the acute moment of stress.

48:25 Sometimes it happens after the stress is over or it can happen just kind of random seem seemingly randomly. And I think it's important to realize that in any medical condition, just not just neurology but the mind does have a factor on it, on how you're feeling overall and can be a really important thing to kind of tease out but also make sure you're treating at the same time. You can't treat a person just in their physical body because their physical body impacts their their psychological being and vice versa, so.

48:56 So speaking about the mind body connection people are proud of, the audience is wondering what is this picture back here? It's a brain and a yoga pose. So I understand besides the pediatric neurology, you're also a yoga instructor, right? Yes. Can you tell us about that and that how that fits into pediatric or child neurology? Yes. So you know, this is something that is pretty unique to me. I know some other neurologists with similar sorts of stories, but I was always somebody who use who use exercise as a stress outlet.

49:34 And what exercise I've done has shifted many times throughout the years. But yoga became a a very important mainstay for me as I started in practice as an attending. And the stress was more than it was surprising, the change in the stress from having been a trainee to becoming and attending. And so I became very passionate about, well, the yoga had been so helpful to me, I wanted to learn about how I could use it to help. My colleagues were also stressed out. And so I went to yoga teacher training thinking I was going to learn how to put together a class and how to teach people to do the poses.

50:08 But it was actually so, so much more than that. Like the first day of teacher training, I did a 200 hour, three-week program, so an intensive 3 week training program. And the first day was, you know we talk about different sort of philosophy behind yoga and things of that nature. And the first like lesson of the day was don't take things so personally. And I got a page from patient relations and I was like because those were things that just crushed me. Anytime, you know, you get that phone number and you have to call back and what did I do?

50:38 Did I do something wrong? And you take it personally because as doctors we tend to be somewhat type A. Even if you're the most chill doctor, you're still Type A. And you know, you take things very hard and learning how much it was. Once I actually started to try to practice that, to not take it personally and realize there was like I could always learn something about a situation that was negative and come away stronger from it. But he didn't have to let it crush me because it really wasn't my fault.

51:08 So you know, I've got in a complaints because somebody couldn't get in touch with me because I was on vacation and there was someone else covering. I was like, OK, well that's not, I can't take that personally. I, you know, I I'm allowed to take a day, I'm at yoga, teacher training. I'm not on vacation. But I had someone else covering my pager and that was the call that I got that day. And normally I would have dwelled on it and thought about like what do I do to prevent this in the future. And I said.

51:33 Don't take vacation. You can't leave the answer. It can't be don't take vacation days. And was more the realization of there's only so much I can do and I can counsel patients, Hey, there are going to be days that I'm not the one who returns the call. And I can put that in part of my discussion process and set expectations. But that's where my culpability ends in this. And so there's only so much that I need to take personally on that. And that revolutionized things for me like that one simple message was is very hard to do in practice, but it also actually comes around to a lot of the things I'm talking about that are amplified by stress.

52:11 It's the same thing because if you, if you start to dwell on it and you, your symptoms get worse. If you think about, Oh my God, I had a headache. I don't want to get another one tomorrow. I have a test. What am I going to do? Guess what? You get a headache. Tomorrow. So how does yoga help you deal with with these stresses? Right. So yoga is about, it's not just the physical poses, it's about using your breath and have having a different philosophy of just moving through and kind of adapting to the position and being uncomfortable, being uncomfortable.

52:43 So people will talk about I can't do yoga, I'm not flexible and I'm not flexible, but being in an uncomfortable position and kind of learning how to adjust your body in just tiny little minute ways or breathe in little different ways can help you to withstand the discomfort. And so it actually becomes more comfortable over time. And that's a very it's analogous physically and psychologically that becoming comfortable with being uncomfortable actually can help you. So being neurology, you know these are conditions that are so terrifying to people because they threaten not just your physical being but also who you are.

53:22 You know you everybody thinks of their mind and their brain as being like make you you, right. And so if you feel like you have this new diagnosis or this new condition and it changes who you are, then that's extra traumatizing and extra stressful. And yoga and the kind of philosophy and the the thinking about like how you move through things differently can actually really help the way that you can work your way through it. So it's psychology. It's just fun in a different way. But you doing things like yoga, breathing can be very helpful for stress management, for helping with relaxation, which can be helpful for things like headaches or difficulty with sleep.

54:01 And then again, the the body mechanics are actually so important. So sometimes people will come in, you know, with pain that isn't orthopaedic or isn't there, they have headaches or they have joint pain. And it's not owned by any single specialty because it's soft tissue or myofascial. And like looking at the body mechanics of how people move, it ties in really nicely with neurology, where we know how all the muscles work and how they're innervated and where, which part of your brain is doing it.

54:31 But how you can kind of retrain your brain to position yourself a little differently, to move a little differently to alleviate some of that pain can be really helpful. So I use different yoga postures or strategies and philosophy in a lot of my counseling of patients. So you actually tell patients about this and how it can help them get through some of their problems? Yeah. And obviously that's met with different levels of acceptance. You know, when I was a teenager, if you told me to go do yoga, I would have rolled my eyes and punched the door on the way out of the room, like I would have said, no, I'm not doing that.

55:04 It's ridiculous. But you know, I try to sort of I changed the story or the change the way that it comes across depending on the audience and and who you know, what are their interests, what are their ways that we can work some of these types of practices into their day-to-day. Right. And I understand you were also a personal trainer before you. You did this, right? Tell us about that. Yeah, in medical school I did. I was a personal trainer at a local gym. So I had class in the morning and then I'd work at the gym in the evening, and I actually would have patients that would then find me at the gym, you know, from different rotations.

55:43 And so there was a nice little circuit there. I put the personal training on hold during residency. I wasn't working out either because there was no time for anything. But then I refounded over the last several years and started actively working as a personal trainer again. And it goes again with the whole idea of understanding how your movements factor in so much for certain different conditions. So even if it's fatigue or dizziness, there are different ways of like working on conditioning skills or body movements and body mechanics that can really help kind of drive improvement of quality of life on a day-to-day basis.

56:24 I'm not saying it fixes or cures things, but it can certainly make you feel better. And endorphins and a dopamine surge from an A workout is preferable than to a dopamine surge just from looking at your phone. So I like to kind of try to use those holistic methods. So I've heard that sleep is very important. Sounds like you're not getting any sleep. I try. I'm a world class insomniac. Oh really? But yes, I do sleep better if I meditate beforehand. So again, not a thing that a lot of my patients are going to try because it sounds hokey, But how?

56:59 Many hours of sleep should children get a night? More than most of them probably do so, and I can't sort cite the exact age hours on there, but generally speaking, in the first few years of life, kids are sleeping tons and should be sleeping tons. Once you're in school age, you know kids are still needing often 10 plus hours of sleep and even into late adolescence, recommendations are for more than the five to six hours of sleep that a lot of teenagers are getting. So you know, trying to get teenagers to get at least 8 hours is great.

57:36 Some of them need more than that. Is there good data and evidence that the sleep decrease is actually harmful to the brain? So that's a a very good question. In childhood, I don't know so much. I mean we know that obviously if you're not getting good sleep and you are falling asleep during the day, sure that's impacting your your functioning, right? Like if you're that kid who needs mom to come in 15 times and wake you up and you miss the bus every day, that's that's a factor. But beyond that the impact, I don't know.

58:11 You know, we know now that amounts of REM sleep can certainly predispose you to certain adult neurologic conditions, whether Parkinson's or Alzheimer's or different parts of your sleep or factors for that. We don't know. The same for like in children. But that being said, I think sleep is a very, very individualized sort of thing. There are recommendations, but there are some people, adults and children, who will do great on a certain amount of sleep and for somebody else that they feel awful if they get 8 hours, you know, maybe they need 10, maybe they actually do better with five to six and actually function better.

58:46 I think it's a it's an interesting area to kind of get more research down the line of just kind of what are, what are the cut offs for for people of what's normal. Yeah, seems to be very variable. I know some people who tell me they only sleep 4 hours every night and they're fine and then other people need 8 or 9 so. Yep. And I think that's OK. I think just acknowledging where you are in that spectrum and where your kid is too. So you know you can have two kids in the same household and one needs 12 hours of sleep and the other one and they're about the same age and the other one I need 7 and it seems.

59:20 So is there something wrong with one versus the other? And there doesn't necessarily have to be and it's you just need to kind of see like the whole picture again, is it impacting, is there a cognitive decline that's happening because of it? Are they are their grades not as good or whatever else is happening? To look at other indicators, right, how is child neurology evolving and and what do you see in the next five years, 10 years? So child neurology is definitely a field that is very rapidly changing genetics.

59:51 And I know you talked to Doctor Chung about genetics recently. Genetics has very much revolutionized a lot of things, a lot of things where we couldn't make diagnosis or didn't have treatments for. So let's say SMA Spinal muscular atrophy, which is a condition that basically creates weak muscles. And so depending on the severity of it, some children may never be able to sit up if they have a severe version, if it's an infant onset. But now we actually can identify it by genetics and we can, because of that, we now have treatments that can actually change their entire prognosis.

1:00:33 And that's happening in a lot of things. There's a lot of precision medicine that is coming from a within the neurology realm. So as we learn more about genetics, there's a lot more research ongoing about specific treatments for very niche genetic disorders, a lot of studies being done on rare conditions trying to target the specific gene that we have learned a lot about. And so that's the direction that we're really evolving towards. Is this more the age of precision medicine and not necessarily just trying to have to treat widely what we're looking at?

1:01:07 So that's an exciting, an exciting area of developments, very challenging to keep up with because there is always something new, but it's leading the way in whether it's certain neuromuscular disorders or epilepsies to better understand them, but also to have more treatments available. And I understand your practice has evolved also. Can you tell us a little bit about that and what, what do you think will be the future of that? Yeah. So I have a a bit of a unique path. I started out in neurology thinking I wanted to be a neuro oncologist and was dead set on that for a very long time.

1:01:46 And then through my training, realized how much I really loved the inpatients and the I I liked making a difference very quickly and in the most stressful situations. I like the diagnostic challenges and things of that nature. So I actually did became a neural hospitalist. So I focus on acute inpatient neurology. So most of my time in the hospital was spent as an attending on the inpatient services, the consulting services on the floor or on the ICU or on the Pediatrics floor or on my own general child neurology team.

1:02:21 So these were kids who were hospitalized. They were in the hospital. Right. So both in the emergency room, so when they're getting into the hospital and whether or not they need to be admitted and then once they were actually admitted to the hospital, regardless of what service they are on. So whether it was an infant who was just born and in the neonatal ICU or somebody who came in and was admitted to the neurology service with new onset seizures or something like that, all the different ways that you can enter into the hospital.

1:02:50 That was my my area of specialty and so I did that for the last nine years or so. And with that I would also focus a lot on the transition. So from going from inpatient to outpatient and then trying to keep you outpatient and not let you bounce back to the hospital, not, not, you know there are conditions where we can't prevent it. You know, we try our best to manage the symptoms. So things like multiple sclerosis or epilepsy, but sometimes you get a flare and you have to come back in. But sometimes if we have a really good treatment plan place or we have a good follow up plan in place, we're able to manage things as an outpatient And that's important for a lot of reasons.

1:03:30 It's important for overall well-being, obviously trying to limit how severe things are that you need to come back, but also for even for the family in terms of days loss of work for the kids, days lost at school, things like that. The intangibles that you don't necessarily think about while you're rounding day-to-day. So that was a lot of my emphasis was trying to work on smoothing the transition to outpatients and then helping with plans to try to manage things and keep things outpatients with that.

1:04:02 There's also been a lot of times where I spend a lot of time triaging over the phone with pediatricians or other doctors, other referring providers, about somebody who came in with the new neurologic concern and how soon do they need to be seen? Do they need to go to the emergency room? Can I manage this just here in my office or do I need to send them to you, things like that. And there's a big bottleneck in getting into child neurology or pediatric neurology across the country is there's not as many of us as there need to be.

1:04:34 And so it can be very challenging to get a timely appointment and the emergency room is not always a great place to try to get that opinion. You know, a lot of times it's really not the great place to greatest place to get a what could be an outpatient consultation. And so given my my all my focus on acute neurology and really honing my skills of how to help with that triage process, which I really do enjoy, I've transitioned to more of a concierge style. So I'm starting my own concierge child neurology practice where part of the service is obviously to patients and directly seeing patients and trying to get them in in a timely manner.

1:05:14 But also working with practices to be able to have somebody to run a case by to talk to and help triage. What do we do? How do I get them through until they can be seen, Excuse me until they can be seen by you? Or how do I? Do they need imaging or work up? And can they be seen in less than three months which is often the wait list? It's so many places 3. Months. Wow. Or longer depending on where or what sub specialty you need. And it's it's a little bit of a dramatic shift from being that inpatient focus.

1:05:47 But my hope is to really help people who are trying to get in urgently for these new onset issues. Whether, you know, headaches that come out of the blue ticks, seizures, things of that nature that require somebody to not just jump in for the safety and the health of the child, but also to help the whole family kind of cope and deal with what is going on. And what do we do. Because it's a it's a big process for everybody to kind of have to transition through. And having too long to sit there worrying and not being able to ask all the questions is really stressful.

1:06:21 So my hope is to sort of streamline that process for As for as many patients as I can can help and then have more direct access to, you know, somebody to kind of talk through. And then as problems arise, they can get in touch with me more personally and directly. And then you know, close, very careful focus on closed loop communication with their care team. So that's parents, that's teachers. If needed, they're pediatricians or whoever else is on their medical team. Because I think that's something that gets lost a lot in the shuffle is we mean, we mean well.

1:06:54 But there are times your practice is just so busy, you don't have the time to reach out and call every referring provider and say, hey, I saw your kid, here's what's going on. And my hope is to be able to kind of hold on to that by providing this style of care. That's very interesting and and fascinating. I learned a lot today about child neurology and many other things as well. So I want to thank you, Jamie, very much today for taking the time to come here and and talk about child neurology. It was very interesting.

1:07:28 Thank you very much. Thank you very much. All right.