Ep 184: Flat Feet, Smelly Feet, Ingrown Toenails, Toe-Walking and more--your common feet questions answered! with podiatrist Dr. Michael Zapf

In this episode, I’m joined by Dr. Michael Zapf, a podiatrist who’s been treating kids’ feet for nearly 40 years. We cover the most common foot concerns I hear from parents—how to tell what’s normal, when to worry, and what you can do to support healthy feet at home. In this episode you'll hear tips on ingrown toenails, shoes, feet hygiene, Severs disease, plantar warts, and more!

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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Transcript

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Hi everybody. Welcome back to your child is normal. I'm your host and pediatrician, Dr Jessica Hochman, so in today's episode, we're going to dive into an incredibly important and often overlooked part of your child's health, their feet. I'm joined by podiatrist, Dr Michael Zapf. He's a foot specialist with over 40 years of experience. We're going to talk about all of the foot related concerns that parents ask me about the most, like ingrown toenails, flat feet, in towing, toe walking, plantar warts, and even what to do about smelly, sweaty feet. Dr Zapp shares smart, practical tips that will help you know what you can manage at home and when it's time to see a specialist. And also, before we get started, if you could take the time to leave a five star review about this podcast. Wherever it is. You listen to podcasts, I would greatly appreciate it. Good reviews help other people find the show, and honestly, they make my day. Now on to the podcast. Dr Zapp, thank you so much for coming on my podcast. I'm so excited to talk to you. I have so many questions, believe it or not, related to the feat. Looking forward to being here and talking with you. Thank you for this opportunity. So So tell me about the work that you do, because I think feet are so important. When your feet are bothering you, it is really bothersome. It's really annoying because you have to walk in the day to day life. So I'm sure you see a lot of people that when they need to see you. They want to see you and get in quickly. So I'm curious, what are the most common issues that you take care of? Well, I went, I did recently because of this question, I did a little research on my patients, and the five most common things that I see are ingrown nails, flat feet with or without pain, severs disease in our young athletes, intoing and toe walking and plant our warts. So you want me to talk about some of these? I would love that. Actually, those are probably the questions that I get most often, come to think of it. So absolutely. So where do you want to start? Should we start should we start in that order? I'm going to start with ingrown nails I have, yeah, yes, that would be great to hear some guidance in terms of prevention and what to do once you have an ingrown nail. Right? Because we're, we're kind of a retail specialty. A lot of people come to us before they see their pediatrician, but a lot of times we get patients on referral from pediatricians or internists with ingrown nails. Kids, especially get them when I see them, they have often been on an antibiotic for a week or two, and the nails still persist. And from a podiatrist perspective, the problem really isn't an infection, it's this nail poking into the side of the toe that doesn't belong there. So from our perspective, the quickest way to get it past that is to remove the offending border of the nail. For older kids, put a little anesthesia in there and snip the edge of the nail. For the really little kids, it's almost easier just to spray it with a lot of cold Freezy spray and snip the edge. But once the nail is out of there, these kids are better the next day. In fact, they only have to remove the nail that you can't see, the part that's under the skin. My catch phrase is, the only thing you miss is the pain. You won't miss that edge of the nail. You need a band aid. You can go back to school. You can play soccer the next day. In fact, it's easier to play soccer or ballet the next day than it is to have the ingrown nail and afterwards. Do you recommend things like Epsom salt, soaks, hydrocortisone, any ointments that you recommend to aid in the healing process? Well, my post op care is to when they bathe their shower, to clean the nail. I often give them an ear bulb syringe, or if they're in the shower, they can have the shower water hit the nail and clean out all the debris, all the dried blood, the leaves and twigs, whatever is build up in there. And then you put a band aid on with an antibiotic solution. Mupirocin is my favorite. And then two more times during the day, they'll put a new band aid on with new mupirocin, and in 10 days, it's all healed. Amazing, amazing. And what about in terms of prevention? Is there anything that anyone can do to prevent ingrown toenails? I'm sure pressure of shoes and athletic activities contribute to the formation of them. Make sure the shoes have they haven't outgrown their shoes. We're going to talk about shoes later, but for as little as $10 you can buy a shoe measuring guide from Amazon, and maybe every three months, you should check and make sure that the foot hasn't outgrown the size of the shoe, because your whole toe can grow right into the side of the shoe, pushing the skin into the nail, causing an ingrown nail. And what about the way you actually cut the toenail? Does that matter as well? Most of the ingrown nails I see are down below any. Piece that you can cut on your own. And it's just that it's almost as if the nail is too wide for the toe. Certainly cut the nail straight across, but I I actually just sort of round the edge a little bit. If you cut it straight straight across, then there's this little gougy piece that, you know, catches on your saw, catches on your sheets. You got around it just a little bit. I'm not a straight across purist. That's good to know. That's good to know. More realistic. Now, the next that you mentioned flat feet, tell me about flat feet, because that is something that I get a lot of questions from parents about. When should parents worry? Is this something that naturally just occurs? Is there ever a problem having flat feet? Absolutely, there's sometimes a problem with flat feet. There's a easy way to tell whether the feet are flat. Have the child stand on the ground and see if you can put the eraser end of a pencil under the arch. So if the paint, if the pencil cannot go under the arch. It's probably a flat foot. Another way is to look at the heel, the foot from behind, and you should see one little toe, and if you see two toes, or three toes, probably that's a flat foot. Flat feet are unstable. Flat feet are hard to walk on. It's almost as if you're walking on ice a little bit. It's never good to have a flat foot, but if your foot is not too flat and you don't have complaints of pain, it can probably let that go. But if it looks flat at all, you should at least wear a good stable shoe, not a sandal, not a jelly and something that when you squeeze the heel of the shoe, it should be give you some resistance, nice and stiff, not, not like a skateboarding shoe. I'm sorry, these young kids love skateboarding shoes, the vans, you mean, and the I know my kids love those too, right? Unfortunately, skateboarding shoes with no support, I would say half of the kids have feet that can handle those the other half, it's probably going to well, at least not for sports. Maybe they can wear them casually, but when the feet are too flat, you'll see the kneecaps point towards each other, and when you put the feet in a corrected position, the kneecaps point more straight ahead. When you see the kneecaps pointing together from the feet, from the feet being flat, that leads to poor poor leg and hip alignment. It leads to poor jumping ability, poor endurance. These are the kids that when they're three years old, will want to be in a scroller at Disneyland after the first 30 minutes when all of their same age friends are running around being really active, kids with flat feet that have problems don't complain of pain. They just not as active. And so I always say, yes, we need poets and piano players too, but we should not have the feet make that decision. It should be the child's inclination to not be active. No, that's a great advice. It's true that if a child isn't naturally active, you have to think what's going on here, because that's definitely not the natural state of children. If your child isn't as active as its friends, if they complain of running, they don't want to run in school, and you see the kneecaps pointing towards each other. You can't put the pencil under the arch. You can see that too many toes, they will really do well with an orthotic. Before their age of nine or 10, we usually use a kid ethotic, a little pre made device that slips in the shoe. You can get those online. You can most every podiatrist sells them. A lot of pediatricians sell them, and it's kind of like a training device. So when they get to be nine or 10 and have a real heel to toe gate and you need to correct it with a real orthotic, they're already used to something in their shoe, and it's easier to get them accustomed to it. Do you have any particular brands that you recommend to families, or do you stay away from recommending brands? Well, for young children, stride, right? We box always very stable shoes. But if you go to the shoe store and you want the shoe that squeeze it, squeeze the heel, the more resistance it gives, the better it is for a kid with a flat foot. Now, is there any truth to children with flat feet that by by walking around barefoot, it may develop the muscles in the feet and that may be protective or helpful in some way, bare feet can be from for is walking around inside the house or outside when you you can police the grounds they're walking on, is a reasonably good thing. It helps build the muscles of the foot. The problem is we were never meant to walk on hard surfaces, like you're inside of your house or a playground. We were meant to walk on sand and. Grass and dirt, and our feet can really adapt to those surfaces. You took that same foot and put it on a really hard surface, and now the surface requires the foot to flatten to the foot surface. I mean, I think to be a lot fewer foot problems if we could put two inches or three inches of sand in every room in your house, and then you could let the foot do its natural motion. But to try and take this foot and put it on a hard surface, we're asking for trouble. That's really good to know, and it makes sense, because if anyone tries to walk barefoot on concrete, it just doesn't feel comfortable. It's really helpful, I think, for parents to hear what to look for, to be aware of Flat feet. And it's nice to know that there are things that we can do and looking for kid ethotics online. How helpful to know that parents can at least initiate treatment on on their own at home and and, you know, we'll talk a bit later about in towing and out towing, but we even can get kitty phthalics that have a angle of the front of the orthotic that can take an internal gait position and turn the foot out just because the way the kid ethotic or the orthotic is made, it's uncomfortable to walk with your foot internal. If you have severe in towing, sometimes the two feet will hit each other when you're running and playing. If you can turn them out, they run a lot better. That is a great tip to know. So let's talk about that while you brought up in towing, because this is a common, common question that they get from parents. They notice that when their kids are running, their toes point inwards. Sometimes they'll complain that their children tend to trip a lot when they're running. They seem clumsy. And most of the kids that I see, this is a condition that they outgrow naturally, but I would love to hear from you what things parents can do to help that condition and what to what to look for so that they can help their kids as they as they grow and become more sturdy on their feet, an exam for in towing. One of the simple things you can have the child do is just walk towards you, and either their kneecaps will point straight ahead or they'll be internal, and that tells you whether the problem is at the hip or whether the problem is below the knee. So if the child is walking in, then the kneecaps are straight ahead and the feet are turned in. Then it's either the leg bone, the tibia, or it's the foot itself being turned in. So first off, that's part of the exam anybody can do to see whether it's likely at the hip development through teenage years will externally rotate at the hip. Those kids are going to do okay, but they need to protect the foot from its flattening effect of this internal rotation of the leg. One thing I tell parents a lot about the rotation at the hip. We call it femoral anti version. A lot of those kids tend to be the W sitters, correct? They tend to naturally sit in that W position. That's another way to spot those kids that rotate at the hip. And for them skating, ice skating and inline skating. Ice Skating is very good, because you have to externally rotate your hip in order to skate. Stare straight. But yes, that's and when the kneecaps are pointing towards you, and it's the tibia, if it's severely unrotated. They've already been at the pediatric at the orthopedist office, and I also see them with a foot metabuses turn inward instead of straight, and that one needs an orthotic so that internal position doesn't flatten the foot severely. And I can unflatten the foot with an orthotic, and with the gate plate, I could even externally rotate it so they're walking straight. And you know, because of their deformity, they are, they are going to pronate. They are going to have that too many toe sign. They are going to be flat on the ground, you can't get the pencil in, they are going to have the kneecaps pointing towards each other. They're going to have a little more difficulty running and jumping. And we can prevent all that with a good orthotic. That's great to know. And again, the signs that parents can look for to know if their child, if their children, should see a podiatrist. Well, I would say number one, if they complain of pain, or if they have that endurance difficulty, they're just not playing like they're neighboring kids, and you see that the foot is flat and they're not doing what everybody else is doing, certainly bring them in for that. And second, if the parents have really terrible feet, and the kids look like they're going to have their parents feet. We can keep a lot of problems from happening. And so sometimes when we look at the kid, we go over, look at the parent, and say, you know, the the pronated pronating apple doesn't fall far from the pronating tree. You, it is so interesting how I see, you know, we know genetics are strong, but it's something that I definitely notice with the feet of children. When a child has something a little bit different with their foot, and a parent brings it to my attention, if you ask them, by any chance, does a parent or a relative in the family also have this issue with their feet very often? The answer is yes. So now tell me about Severs. You mentioned that that was another top reason that people come to see a podiatrist. Explain what Sievers is, what parents should look for, and how you go about treating the condition of Sievers. Right in Sievers, we'll do a quick picture of a foot here. Here's a foot back here is the heel bone. The heel bone that starts out as a block of cartilage, and it slowly fills in with bone here, and somewhere around eight, 910, your body has a second spot back here where it fills in with cartilage that's called not a growth plate, but it's an Apophis, and it's a second site of bone growth. And this little piece of bone gets its blood supply from the big piece of bone. And if a child is a year round athlete with three sports, they're going to break the little blood flow connections, and then it looks on an x ray like this little piece back here has died. It hasn't. It just gets white on an x ray and looks like it's dead. And when they first invented X rays, they said, Oh, that bone is dead. And so they call it an avascular necrosis, but it's not really dead bone, but if you rest it, you can re establish your blood flow connections, and then it doesn't hurt anymore. So Sievers disease is inflammation in the back of the heel on an athlete. When I went through podiatry school, there were still books that said it was a boy's disease, but now that girls are every bit as active as boys, it's it's equally shared. Any child who is too active is going to get inflammation in the back of their heel, and it really hurts. But in any event, zebras disease is painful. Inflammation of that hypothesis that often miss, often called a growth plate in the back of the heel. Really painful. I have seen it so painful in kids that touching it makes them cry. They have refused to go to school because they can't walk on it. It can be really painful. Now, two good pieces of news. It only lasts for 18 months, and it never causes long term problems, but it can cause short term problems when the kid is complaining. And I do reassure patients that, you know, even if it's like the playoff game, the last game of the season, the kid has to play soccer, it's really hurting if they let them play, and the kid plays and it hurts, they're not causing any long term damage. But I don't recommend that you make a child play when it hurts, and you can't tell by looking that it's hurting that day, so you have to take the kid's word, but even if the coach thinks, well, they're just trying to get out of running because it's hot. Sievers never happens to couch potatoes. It only happens to very active kids who really want to play. A lot of us pediatricians are taught to do the squeeze test, where we take our hands and squeeze the back of the heel, and if you see a child wince or show signs of pain or discomfort, it's almost Sievers until proven otherwise. Correct. So I what we do is I have them put ice packs on it four times a day. Especially, I tell the parents to bring an ice pack to practice. So on the way home, the child can be putting the ice pack on the heel. Ice is really good. They should never go barefoot. They should always wear a shoe which reduces the pull of both the plantar fascia and the Achilles tendon, and many times in orthotic can be helpful. I've seen parents use heel cups or heel pads that you can get online to help with Sievers. Have you found that to be helpful? Or is that something that you ever recommend? If it's helpful, of course, I think the way the heel cup works is it's 1/8 of an inch of heel lift. And I think that a quarter inch heel lift is probably better. You know, you got to put it in both shoes, but raising the heel of four inch is probably better. But if the eighth of an inch on the heel cup works fine, that's great to know. I'm sure it's disappointing for accomplished athletes know that they have to wait a while for Sievers to heal, potentially, but very helpful, very good point to know that eventually it will go away, that this is not something that they will have to deal with long term. No, I see a lot of plantar. Warts? Yeah. First off, most people don't know why they're called plantar warts. Yes. Why are they called plantar warts? Because it's if a wart was on the palm of your hand, it'd be called a Palmer wart. If it's on your face, it'd be a facial wart. Anatomically speaking, the bottom of the foot is called the plantar cervice of the foot. So if a wart is there, it's going to be a plantar wart. A callus is a plantar callus. You get a little piece of glass stuck there. It's a plantar wound. So plantar just means bottom of the foot. They're caused by a virus. Sometimes they are very hard to get rid of. No doctor, no pediatrician, dermatologist, podiatrist has ever made their entire reputation on how good they are at treating plantar warts. They always want to come back, and they're hard to get rid of, and you have to explain that ahead of time, because when your kids work, comes back, they gotta know it's not because you didn't do the right treatment. It's so true. I agree with you. I wish there was an easier way to treat warts, a lot of a lot of dermatologists and and pediatricians, because they used liquid nitrogen for the warts on the hand, they'll use the same words on the bottom of the foot, and it doesn't seem to work, because you can't freeze enough of the wart before it hurts so much that the child won't let you go any further. And and you it's, it's, it's really difficult to freeze in my office, I don't use liquid nitrogen. We do use, and I'm sure you use too an acid preparation. And you put the acid press preparation on daily. And then every two weeks, we use a scalpel blade to trim off all of the dead skin down to the wart. And you know you've gone far enough when you see little, tiny, pinpoint bleeding points. Warts have lots of blood vessels, but no nerves. If you carefully pair the wart down with your scalpel blade, it doesn't hurt the patient, but you stop when it gets the pinpoint bleeding. We do that every two weeks until it's gone. And the acid that you're referring to is that salicylic acid. Salicylic is one of the Yes, yeah. Now I have a secret remedy for that too. Worts only live in humans, and they're only in the skin, which is 98 degrees. If you can heat the wort to 105 to 109 degrees, I tell them to get a hot tub thermometer. They they're thermal liable, and you can start killing the warts with the heat. So I heat the wort, they put the acid on, let it dry, never drop, let it dry, and then every two weeks I trim it off, just so parents can know the salicylic acid. You can purchase it over the counter. If you've ever heard of compound W, or St John's Wort compound w is readily available, and you can use it at home and put it on your child's plantar wart and see how that goes. So if somebody comes to you to get their plantar wart treated, they can expect for you to recommend an acid preparation every day for two weeks, followed by paring it down with a scalpel to remove that excess skin layer on top of the wart, right? And we also have a 1064, laser, a very special laser we got it to treat fungal nails, but it works great by a different change of settings. For warts, you take the wart and you have one pulse, boom. It feels like a rubber band snapping on your skin. The wart forms its own little black blood blister that's painless that paired away in two weeks. And the big advantage here is you can go to the beach, you can get sand on it. There's no open wound, and it's it's very effective. Our 1064 laser is great for treating these little warts. I wish I saw you when I had my plantar wart. Every year I go on a backpacking trip with some girlfriends, and a few years ago, I had a terrible plantar wart that I tried treating on my own, admittedly, with the liquid nitrogen. And you're right, that skin around the plantar wart are really sensitive, and it was really tricky to remove the plantar wart. I should have just gone right to you one of my life regrets, yeah, the 1064, laser. Boom. It's like you don't need, you don't have to anesthetize it. Just laser it, and it goes away in two weeks. Wonderful. Okay, this is, these are great tips to know about. I also use blister beetle can throw and can throw. It is similar to the laser. It creates a blister, and it doesn't hurt in the office, but it hurts when the child gets home. But for a lot of people, when I use the salicylic acid, I put the salicylic acid on one drop, let it dry. One Drop let it dry. That's After heating the work to 105 208 then I do cover it with a band aid. You can use duct tape. I often will take a regular band aid and I take the sticky part of the band aid and put it right over the wart. But you can use duct tape too. I've also heard that the when the band aid comes off, it's removing the top layer of skin, which can also help get to the wart easier, excellent. Okay, this is great, I'm sure. And anyone who's listening, who's dealt with the war will really appreciate all of these wonderful tips. So thank you so much. Now, I get a lot of questions from parents about toes. Some toes curl, or their like, one toe will be over the other toe. Is this ever a problem? And when should they see a podiatrist? Of course, it could be a problem. Now, first thing you'll notice, a lot of kids will have one toe that's really elevated above everybody else, and when it's the second toe you want, you want to really get that toe down, because otherwise the big toe, the bunion toe, can move in place where that toe used to be. Many of these are going to be problems that will be corrected once the child is skeletally mature. You don't want to intervene unnecessarily in surgery until you know where all the little body parts are going to be, and as they grow, sometimes it changes. But yeah, I think you can leave the minor things alone. Quite often, the fourth toe gets curled under the third toe and causes pain because there's a blister that forms between the two toes. So you can tape that toe out so it doesn't cause problems. So we I use the tape to mitigate little problems and little aggravations until they're old enough to do something about it. Now, some other just common questions that I hear from parents about feet in general. When you see kids that have peeling skin on their feet, what are your go to? Recommendations? Usually it's caused by hyperhidrosis. That means sweaty feet, and sweaty feet causes the superficial layers of the skin to start peeling. And you can use a couple things. Use an antiperspirant material, not a deodorant, but an antiperspirant, like certain dry has a heavy duty anti per sprint, you can put it on the skin, and then moisture wicking socks are great. Now cotton is not good because the cotton sock absorbs moisture, and then for the rest of the day, it's acts like a wet wash cloth next to your foot. So there are socks like thorlow and Dry Max socks that with the moisture away and keep the skin very, very dry. And they even make some of those in pediatric sizes, and they're very helpful. An adult produces about half a pint of moisture a day in their feet, and that's divided between the two feet, that's a lot of moisture, and usually as you walk along, you squeeze the moisture out of your shoe, but the sock has to absorb all that. Once it absorbs it, it's done. It can't absorb more. So these types of socks that wick the moisture to the air are really helpful, and they're helpful for these little kids with this kind of peely, sometimes odory skin. Now, if, if stinky feet, a lot of young teenagers, boys, especially 1314, 15, the parents is like, it's just reached high heavens, and they'll use various kinds of athlete foot creams, even cortisone creams. Nothing helps. It's a particular bacteria, a type of coronary bacteria, that is really smelly, and if you use an antibiotic cream like your person on the foot, boom, the smell goes away. This is the best tip I get this question all the time, because when I examine patients for their physicals. Very often I look at their feet, and parents are embarrassed that their kids have such smelly feet. And I know it's normal, but I never knew there was something that we could treat it with. So that's very helpful. In our office, we have a Woods lamp, which is a certain wavelength of ultraviolet light. Many times if you shine it on the foot, you can see a beautiful, interesting coral, red fluorescence in a darker and that is this exact coronary bacteria. And it's a wonderful diagnosis, because you can show the parents look at this beautiful coral red between the toes, and then is your antibiotic cream, and it's gone, and you're a genius. Do you recommend using it until the smell goes away? Or Should parents be using it, you know, on a regular basis? What do you recommend? Surprisingly, these boys, it's often boys are more embarrassed about this than you think, and if they know that, by putting it on twice a day, they can get rid of that. Mail so that they're not going to be made fun of by their girlfriend. They'll use it 10 times a day and and whenever it comes back, you just use it that. That might be one of my favorite pieces of advice that I've heard yet on my on this podcast. So thank you very much. So and then, in general, do you have hygiene advice for patients that you see to take so they can take good care of their feet, just the general things that you would normally think about. Obviously, wash the feet every day, mild soap, but you got to wash between the toes, because if you use your wood lamp, you'll see that these anaerobic bacteria love to live between the toes, and so drive completely even between the toes. Again, cut the toenails across with a little rounding on the edge. You might want to get a separate toenail clipper for each kid in the family so everyone gets their own. You should change the socks every day, and I try not to wear the same shoe two days in a row, because every pair of shoes has a little different area where it rubs the foot. And if you wear the same shoe over and over again, you keep rubbing that same spot on the foot, and it starts to hurt so and you think of if you have two pair of shoes and you switch off, they're each going to last twice as long. For adults, you want to change it every quote, 400 miles. End quote. So if you walk three four miles a day, that's going to be every three months. But for kids, they're below six, you want to measure every three months. If they're above six, every six months, and make sure that the shoes are the right size. That's fantastic. My mother in law, who listens to this podcast sometimes, she teases gently her husband, who likes to change his shoes very often. So he will be very happy to hear you say that changing shoes is a recommended practice, coming straight from the mouth of a podiatrist. So I know he'll appreciate that advice. I also get a lot of questions from parents about kids that walk on their toes. I know for a lot of kids, it's normal, and some kids may benefit from seeing a podiatrist. Do you have general recommendations that you give to families when they first see you, when their children are when their children are toe walkers? Yeah, it's it's tricky kids with autism, other issues like that. Sometimes just, they just hate their feet touching the ground. Sometimes it's these sensory mortar things that I don't understand. But when I see a toe Walker, I try to see if I can't get the kid to walk on their heel either by thinking about it, but I also try and get them relaxed to see if they have enough ankle joint dorsiflexion to do it. So you know that there's some volitional toe walking going on. It's a tricky problem. If it's just a little bit of toe walking, I'll recommend that they get a heel, a heel lift, or wear shoes with a heel just to take the stress off the Achilles tendon. Physical therapists can do their spray and stretch and their activities. Yes, that's an that's very similar to the advice I give parents. I'll see if the child can voluntarily put their heel down, and if they can, that makes me feel relieved. If the heel cord really is very tight, then I will refer them immediately to physical therapy or pediatric orthopedics. Sometimes I'll recommend them to try high top shoes, because that will keep the heel down on the ground. But usually I find that it's genetic as well. If a child is a toe Walker, oftentimes there will be a parent that also walks on the toes from time to time. I guess my question always is, is it a problem to walk on the toes from time to time? Does that cause any damage to the feet? No, that you are aware of. I don't think so. That's good to hear. That's good to hear. Dr Zapf, I'm so grateful for you. Thank you so much for taking the time to come on the podcast. I really appreciate it. It's been a great pleasure. Thank you very much. Dr Hochman, thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr Jessica. See you next Monday. Bye.