In the wake a baby is dead and her mom has been charged with her murder. In addition, the baby’s dad has been charged with aggravated battery and cruelty to a child for diluting their baby’s breast milk with water, then refusing to take the child for medical care.

By the time they did take her to the hospital, she was already dead.

Unfortunately, this is not uncommon. I remember a similar case from years ago in which a child’s family was desperate for money and thought they could use extra water to make their formula last longer. In a study from Clinical Pediatrics, up to 25 percent of families considered “food-insecure” admitted to using various methods to make their formula last longer.

The problem is that extra water is not safe for babies. It causes the sodium level in their blood to drop. Low sodium will lead to brain swelling which can cause poor feeding, lethargy, seizure and eventually death.

Giving free water to babies is not just an issue of formula stretching. Families commonly ask during the summer months if their babies need extra water due to the heat. The answer is NO!

Some reasons babies don’t need water:

• Breast milk and formula is mostly water (80-90 percent). Babies don’t get thirsty. Their diet is primarily liquid.
• Water does not have nutrition or electrolytes babies need. If a baby is going to be drinking something, why not make it be something that can help them grow?

Babies can safely start to drink some water after six months but they still don’t need a lot. They can get one to three ounces during their meals if parents want to introduce and practice with a sippy cup.

When parents report a croupy cough, it means different things. Some parents call bad/deep/dry/wet/rattly coughs croupy.

When I think of “croupy cough,” I mean “barky” like a dog or a seal. We are seeing quite a bit of croup this winter so I thought a quick update might be in order.

Age (When will my kid stop barking?)

The disease typically occurs between 6-36 months (can be as young as 3 mo but usually not older than 6 years).

Season (What time of year does my kid bark?)

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

Most ER admissions for croup occur between 10 p.m. - 4 a.m.. Unfortunately, things really can get worse at night.

Pathology (What makes my kid bark?)

Initially, the virus infects the nose and throat and then spreads downward causing swelling in the area just below the vocal cords. When looking with a camera at this area, there is a lot of swelling and redness (inflammation). The vocal cords themselves can also become swollen, causing them not to close as well. This is what can cause children to have a hoarse quality to their voices when they speak. The speed of the air as it travels through this area coupled with the swelling and inflammation causes the noisy breathing and barky cough.

Recurrence (Why does my kid get croup over and over again?)

Research has shown that some children are more prone to croup than others. I think that this has something to do with shape of the area around their vocal cords, consequently putting them more at risk for difficulty breathing and barky cough with any viral infection.

Treatments (What do I do for my little seal?)

All the treatments listed are intended to reduce the swelling in the vocal cords and below, helping your child to be more comfortable.

1. Warm steam – We used to put kids in croup tents where we pumped a humidifier in to get the humidity way up. To achieve the same affect, you can turn on the shower in the bathroom and just sit with the child. You can also run a humidifier in the child’s room.
2. Cold steam – Open the freezer door and put the child’s face in front of the steam the freezer emits.
3. Steroids – Giving the child steroids by mouth (or a shot in severe cases).
4. Racemic epinephrine – This is a specific breathing treatment that currently can only be given in the office or hospital.

Two take home tips:

1. The next time your child is barky, feel free to come in and tell us that your child is “croupy.” However, if your child isn’t sounding like a little seal, it’s helpful to try to find a different word to describe the sound of his or her cough, as there are many different causes for the different sounds of a cough.

2. If I start to explain this process to you in the office, stop me and say, “I got this. I read your blog about it.” Nothing would make me happier.

I've been interested in essential oils for a while now, beginning with a Facebook post where I sought out questions that might come up regarding essential oils and their use in children. Well, after much consideration, study and investigation, I think it’s time to release some of those results.

Whether you agree with my conclusions or not, I think you’ll find the information helpful and interesting…so here goes!

The slippery assumptions of oil supporters

We all have pre-conceived ideas about things. We can’t help ourselves. We were brought up in a particular culture or educated in a certain way or have friends that believe certain things. One of my primary goals as a person is to constantly challenge what to believe to see if there are holes in my thinking or understanding of things that are not logical.

I’m going to go ahead and put some of my pre-conceived notions and assumptions out there so that we can all be on the same page:

1.I have a strong trust in science, the scientific method and organized medicine. I can’t blindly follow any of those things, but I’m going to rely on them most of the time to make decisions for myself, my children and my patients. If the science proves that something works, I’m willing to use it or at least allow it to be used by my families.

2.I am very skeptical of anecdotal stories and advice. I often have to say, “I can’t contradict what you are saying, but it goes against what I know about this condition.”

3.I am generally very nervous about new treatments or new uses for old treatments. I often say, “I don’t want to be the first to try something nor the last. Somewhere in between is where I feel comfortable.” I want to weight risk vs benefit for everything.

4.I believe that the overwhelming percentage of parents (99.9999 percent) want the best for their child and would never intentionally harm their children in any way.

Because of these assumptions, I may evaluate oils in a different way than most people who use them do. I get that. But my patients who use them will tell you that when we talk about them, I am not judgmental (at least, I try not to be) and I am willing to listen to how they are using them as long as they will listen in return when I provide suggestions or push-back. (Most of them pretend to listen, at least, ha!)

I thought as we move through all the evidence about oils I have discovered, it would be helpful to challenge some statements made by my oily friends that imply false assumptions about me:

1.“I just don’t want to give them medicine for every little thing.”

That’s awesome, me neither. When patients leave my practice, it’s most commonly because I don’t give them a medicine or test that they want. The four most common examples are medicine for colds (cough and congestion), reflux, colic or antibiotics. If medications are not indicated for those conditions, I’m not going to be writing for them. If the decision is on the fence or unclear, I’ll engage the parents to help make a decision. The three little kids running around my house rarely get any medicine, especially for those symptoms for which I see oils being used. They rarely get medicine for fever or runny nose, never for cough and certainly never because their behavior is bad that day. Most of you probably don’t use oils for this-but some of you do…I’ve seen it. I’m not trying to single out a child with special needs or developmental problems, I’m more referencing a kid/parent who just aren’t quite getting along that day. In many of these cases, the use of oils is not in place of a medication, it is often additional to what I would do.

2.“You are a medical doctor so I’m sure you don’t like alternative medicine.”

Not exactly but this one is closer to true. Traditional medicine, to me, means tried, tested and proven. Alternative medicine might be old, might be tried but in my mind the definition means that it is unproven. In fact, through my studies the last few weeks, I have come across a couple of ideas that I am considering incorporating into my practice. But, at that point, if I begin to recommend it based on review of the scientific literature, is it alternative? Or, if the oils work like some claim they do, then eventually won’t we all be using them? Are they still alternative? This assumption is partially true but only because I want to be clear with my patients on what we absolutely know about oils, not what some have claimed.

3.Patients don’t tell me about their oils because they are scared of my reaction or assume I don’t want to know.

Incredibly wrong. I have to know what medication your child is on, period. If there is information about drug interactions or negative outcomes as a result of any medication use, I need to know who’s taking it so I can get in touch with people who are using them. We do the same thing for vaccines and everything else we use in the office so that if there is a recall or another issues, we can get the word out to our patients and tell them what to be on the lookout for.

Now we can move on to some research…

The Research on Essential Oils in Kids

These are the oils for which I found some research. I’m sure I left some off but I thought these were a representative list from a Facebook question I saw come across my timeline and would give us enough information to start the discussion.

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

I started by looking myself and then had our staff librarian follow up with a PubMed search. Because I knew that would not be enough for some, I also reviewed the following websites at the suggestion of the followers of my Facebook page (The Doc Smitty): aromaticscience.com, Dr. Robert Pappas Essential Oil University and airase.com (cost me $75). I also used the NIH Center for Complimentery and Integrative Health, the MedLine Encyclopedia & Natural Medicines Comprehensive Database and the Sloan Kettering Integrative Medicine Database.

First, I’ll summarize what we found from the more traditional medical research on each oil (PubMed, NIH Complimentary and Integrative Health, MedLine and Sloan Kettering):

Lavender

• One study shows use of lavender associated with decreased use of acetaminophen after children had their tonsils out but did not show decrease in pain intensity or nighttime awakenings. (48 patients)
• Several adult studies showing calming effect of lavender.
• Another very small study showed that lavender use in babies had a calming effect.
• These and other published research involve small sample sizes (less then 50 subjects) and often the study design is lacking or flawed in other ways.

Tea tree oil

• Some fair quality studies that included children showed some possible benefit for lice, acne and warts.
• A small study in adults showed possible improvement in toenail fungus.
• Many reports of side effects from accidental overdose are pretty common with tea tree oil (confusion, drowsiness and possibly coma). Just a reminder (just like other medicines, I’m not singling out oils) that we should keep these oils out of the reach of children. I have seen people make comments like, “These are natural so you can’t possible overdose on them.” This is simply not true.

Chamomile

• A review of the use of alternative methods for treating colic (including chamomile) was published in Pediatrics in 2011. The conclusion of the reviewers was that a further look into the issue was warranted.
• Colic studies are difficult because defining what is colic is difficult, if we can agree, deciding what constitutes improvement is even harder as most “cases” resolve on their own without treatment.

Peppermint Oil

• Some studies (some including children) have shown benefit for use in irritable bowel syndrome and recurrent abdominal pain.
• Other possible uses have been studied in adults (including headache), which has shown some promise but no definitive answers have been found at this point.

Eucalyptus

• Studies have shown that use of eucalyptus and lemon can work as an insect repellant although there have been case reports of toxicity from widespread application on the skin.
• There are multiple reports of severe toxicity after excess ingestion in children.
• Some studies have shown benefit for treating head lice.

We tried to research some other oils (thieves and frankincense) but found any evidence for their use in children to be lacking or unavailable.

Of note, you’ll see that there is no evidence for the use of these oils for some of the common uses I see them touted as being beneficial for: fever, cough, congestion, allergies, teething symptoms and (the one that makes me the most frustrated-see above) behavior problems.

Other Sources

At the suggestion of readers I also reviewed the literature from aromaticscience.com and discovered one article for which I had not previously found and only discovered 11 studies when searching for children.

I also reviewed Dr. Robert Pappas’ website but could not find further information about studies in children.

The gist of most of these websites is to list tons of articles of test tube and animal models with adult studies mixed in but they have very little to no information on children.

An example of this is the Facebook page of Scott Johnson who is “one of the world’s leading experts on evidence-based, therapeutic use of essential oils and natural products.” I looked back over 6 months of his postings on Facebook. There are roughly 2-3 posts per day. I found four posts related to children: one about probiotic use for colic, one about mother/baby skin-to-skin contact, one promoting increased physical activity in kids, and one about exercise during pregnancy promoting brain growth in children. None that truly show evidence of the efficacy or safety of the use of essential oils in kids.

Finally, I signed up for a website so that I could review a study that got a lot of buzz last year in the essential oil community. It was looking at the use of oils in autism spectrum disorder (ASD). You can read more about ASD in my post here. There are many issues with the study that limit its ability to be used as proof of effectiveness: the sample size is small (12) and there is no control group (even a group that used a different concoction of oils would be helpful). It’s not that this type of study should not prompt further thinking into the issue, it’s just that the number of children and parents who started using oils for autism based on it is inappropriate. For more traditional investigations into the use of medications for autism, this would be one of the most preliminary studies and would need to be followed up by significant further studies to test for effectiveness and safety of the regimen that was recommended. Why do I care so much? Because my parents of children with developmental concerns are desperate for something that might help. I’m desperate to have something more to offer them, but I am very protective of them when it comes to those who might take advantage of them.

Summary of Research

There’s just not much out there. What is out there is small studies or case reports and other poor study designs. This effectively turns their current use by consumers into the study of essential oils. The problems is that, with no oversight, no one is systematically watching for effectiveness or safety so we may not know until much later.

Effectiveness/General Use

Do they really work or is it a mind over matter thing?

I think that there are probably some uses for oils that will be studied and proven to work. I think these will be pretty rare and only a small fraction of the claims that are currently made.

So, is it mind of matter (placebo)? Here are some of the most common uses I see for oils in kids:

Teething - It’s not even clear what symptoms teething causes …fussiness, fever, runny nose, etc have all come into question. But, if you give an oil and a symptom goes away, does that mean the oil fixed it? Not likely.

Fever - Fevers come and go during the day with illness, even without medication.

Cough/congestion - The regimens I see where children have oils placed frequently basically make it impossible to know if they do anything for these symptoms. Cough/congestion will be worse at certain times of day and better at others treatment or no.

How close are we to having actual research on the use of oils?

I still think we are quite some time away. Those that are currently doing research are often biased, are not doing high-quality studies and are using small sample sizes.

Marketing

Why are they sold through multi-level marketing (MLM)?

It’s a fast way to get a product out there and make a lot of money. Since I’ve been on social media, I’ve seen several of these types of MLM ideas crop up. The difference with these is I have some specific knowledge about the conditions they are being used for and specific concerns about how their use could harm a population of people that I care very much about. I know very little about bags and good smelling wax that can be melted with a light-bulb so I haven’t gotten involved until now.

In many ways, it protects the big company because they are not the ones out there making claims about the oils and what they can do. That falls to their independent distributors. If someone were to have a bad outcome because of their use of essential oils, who is responsible? If I prescribe a medicine that someone is allergic to, that responsibility falls squarely on my shoulders, not the makers of amoxicillin. If I prescribe the wrong medicine for a kids asthma and something bad happens, that responsibility falls to me.

Are they an increasingly popular trend or just something I was not aware of?

I’m not sure but it certainly does feel like they are gaining in popularity. Social media makes it seem that way at least.

Do you believe the claim that certain brands of oils are superior to others?

I’m sure there are differences but since we don’t even know what they do for the most part, it’s hard to answer this question.

Philosophy/Opinion

Regarding writing about essential oils: Are you mad, man?

Yes, in fact, I think I must be.

What’s the number one reason you see parents using oils instead of medicine?

In general, people are becoming less trusting of experts and organized institutions. Medicine and doctors are no different. The gap between what a doctor knows and what patients know shrinks every day. People can find out information about their conditions and know basically the treatment options that exist. People are looking to live more natural lives and most who use them feel that oils fit within that idea. When you combine these two issues, right or wrong, essential oils seem to step in the gap.

What is a good way to communicate with your doctor about your use of essential oils (for specific conditions and generally)?

I think it’s important to be honest with you doctor about your use of essential oils. As new information is uncovered it would be important for your doctor to be able to show you new research etc, especially if something shows a particular oil to be unsafe. They can only do this if they know about your use of them. Also, as doctors are prescribing medications, we need to know anything you might be on that could cause a drug interaction.

What is your take on the potential political barriers to the study of essential oils given that they are not backed by super profitable pharmaceutical companies?

Young Living is a very profitable company. They are big and profitable and will only continue to be more profitable. There is no reason that they could not start testing their own products or set up independent testing.

After your research as a pediatrician, would you use them on your children?

People will read all of this information or even do further research and come to different conclusions from me but here are two reasons I won’t:

1. I do not treat my kids with unnecessary medications. Since they are recommended for symptoms and given with the hopes of reliving those symptoms, I consider these oils to be medication.

2. I believe that, due to the lack of good studies, the use of them in children should be considered experimental at this point.

Summary

• The use of essential oils seems to be growing.
• The evidence for their use in children is slim.
• Talk with your doctor about the products you are using so that they can be aware of potential safety issues and medication interactions. 

Previous articles on this topic:

• New York Times Report: Are Essential Oils Safe For Kids?
• Essential oils and their use on children
• How safe are essential oils for children?

RSV has arrived at Cook Children's.

Last week, 178 kids tested positive for RSV, compared to only two who tested positive for Influenza A.

RSV is a virus. It’s short for respiratory syncytial virus. It causes a disease in young children (especially those less than 2 years) called bronchiolitis. The RSV season usually begins around mid-August and runs through March.

Bronchiolitis is a disease of the lower respiratory tract which causes children to wheeze. They are wheezy because their small airways have swelling and junk (mucous and cells from the lining of the airway) in them.

The smaller airways are similar to the area where a child with asthma has issues (which is why they wheeze). The difference is that children with asthma have a squeezing down of the walls of the airway (which is what a breathing treatment reverses). This is why breathing treatments in children with bronchiolitis usually don’t work.

Bronchiolitis is not just caused by RSV. There is a long list of viruses that can cause the same symptoms:

• RSV
• Rhinovirus (usually a cause of the common cold)
• Parainfluenza
• Human metapneumovirus
• Influenza (Flu)
• Coronavirus
• Human bocavirus
• Human polyomavirus

Here are some answers to the most common questions I hear from parents:

What are the symptoms of bronchiolitis?

Typically the child starts with runny nose and cough. This will progressively worsen over a few days and possibly develop into difficulty breathing and difficulty with eating. The symptoms typically last a total of about 5-7 days with the worst day being the day in the middle. It is not uncommon for the cough and runny nose from bronchiolitis to last 2-3 weeks.

How do we treat bronchiolitis?

In most children, treatment is done at home and consists of sucking snot (click here for more advice on this) and counting wet diapers. This isn’t very fancy but, unfortunately, until someone invents TamiRSV we don’t have anything more specific. As far as wet diapers go…I am looking for a wet diaper about every 6 hours.

Who goes to the hospital?

Getting admitted for bronchiolitis is usually based on: dehydration, severe difficulty breathing or low oxygen levels.

Children who can’t eat because they are breathing fast and are puking because of all the mucous draining into their belly are at risk for dehydration. Unfortunately, the only way to fix this is to put them in the hospital for intravenous (IV) fluids until they are able to drink better.

A child who is having severe difficulty breathing also needs to be observed in the hospital. Unfortunately, babies with severe bronchiolitis can get tired from all the heavy breathing they are doing and this can progress to needing ICU care. It is best to have those babies who are breathing that hard in the hospital so that they can be monitored closely by people who know what they are looking for…

Babies with bronchiolitis often need extra help keeping their oxygen level up by getting extra oxygen. We monitor these babies closely and I put them on oxygen for severe difficulty breathing or if their oxygen level is less than 90 percent.

Summary

1. Bronchiolitis stinks, it makes kids sick and I don’t have much to offer.
2. Whether it’s RSV or not often doesn’t matter.
3. Watch for difficulty breathing and decreased wet diapers.

For more information on bronchiolitis and RSV, read this post from one of our hospitalists.

According to the National Conference of State Legislatures, Texas is among 18 states that allow families to opt out of vaccines for personal or moral beliefs. The Morning News reports that Plano, Fort Worth, Austin and Houston all ranked among the 15 U.S. metro areas with the most such conscientious exemptions for kindergartners. Each had more than 400 kindergartners exempted from vaccines.

Fifteen years ago, about 2,300 students opted out of at least one vaccine. Today, that number has grown to 56,737 kindergarten through 12th grade students.

This has many doctors, including myself, worried about more measles outbreaks in Texas.

"Populations who choose to not follow the recommended vaccine schedule for themselves and for their children are actually setting up the perfect conditions for the diseases they are unvaccinated for to erupt into an outbreak. It is really not a question of whether these outbreaks will occur but when," Jason Terk, M.D., a Cook Children's pediatrician in Keller.

News about vaccine preventable diseases is important for us to share, but it brings up many strong opinions.

Here’s how the debate usually goes:

“Please vaccinate your children.”

“If your child is vaccinated and vaccines are such a good thing, why do you care if my child gets vaccinated?”

Most people don’t have a good answer for it so it tends to be a good trump card.

So why do I care?

There are two reasons.

1. I care about your child. I firmly believe that vaccination is the right thing to do. I vaccinate my children on time and on purpose. I would not want any child to receive less care than I would provide my own children.

2. Vaccines sometimes do not provide complete protection. Most provide protection in the 90-percent plus area (some nearly 100, some lower). Because of this, even a vaccinated child can contract the disease. I will go into this in more detail below, but the more children who are vaccinated for a disease the less likely it is that any child will contract that disease. This occurs through a process known as community, or herd, immunity.

Many people will stop reading right here because they have already decided or have read somewhere that herd immunity is not a real thing. Here are some of the arguments against herd immunity I come across from time to time:

• It’s not based on a science, but on epidemiology. Epidemiology is the study of the way diseases spread. It is a very complicated field, involves tons of statistics and research and IS science. To say that it is not science is a false comparison.
• We still have outbreaks even in areas where there are high vaccination rates. This is most definitely true, but does not prove that herd immunity is not real.

How does it work?

Since it's most timely, let’s use measles as an example. First, you need to know some things about measles…

Measles has an attack rate of a susceptible individual at 75 percent. This means that 75 percent of people exposed to measles who are not protected will contract the disease. I’ll use 70 percent to keep my numbers round and err on the side of people who would disagree with me.

Measles vaccination has a 95-100 percent protection rate. Again, I will use 95 percent so that I am not cherry picking the best results to prove my point.

There are two scenarios below. The first scenario has a case of measles in a classroom where everyone else is vaccinated. The second scenario is a case of measles in a class with one child who is not vaccinated.

Scenario No.1:

Scenario No. 2:

In scenario No. 1, all the children are vaccinated which means they have a 5 percent chance of catching measles. If that child goes to another class or event where all children are vaccinated, each of those children have much less than a 5 percent chance because the child doesn’t likely have the disease and they only have a 5 percent chance of catching the disease even if he did.

In scenario No. 2, one child in the classroom is unvaccinated. He thus has a 75 percent chance of catching the disease. He’s going to go to other locations with other children, even if those children are all vaccinated, we have potentially opened up a whole second circle of exposed children. Not to mention that the children in the first class have now potentially been exposed twice.

So, in scenario No. 2:

• If I gave you a choice, would you want your child in group A or B?

• Does it matter if your child is vaccinated or not?

• What if you also have a baby in your house who cannot be vaccinated?

• What if you child is in class B, but has a disease for which they cannot receive the MMR vaccine?

The answer is no, none of these things matter. Logically, we should all want our child in room A because it decreases the odds of our child being exposed. Is it 100 percent? No, but it doesn’t matter. Are you more likely to be angry about a measles outbreak if your child cannot be vaccinated? Yes, and I understand that.

For one last thought, consider this … a  study in Pediatrics described geographic clusters of people who choose not to vaccinate at all or to under-vaccinate their children. I suspect that is true across our area as well, but I also suspect that there is clustering according to other factors as well: socioeconomic status, church/religious affiliation, etc. Populations where there are multiple families who choose not to vaccinate would be particularly susceptible in an outbreak situation. Let’s pray we don’t get there.

This is herd immunity and why the question, “If your child is vaccinated and they are such a good thing, why do you care if my child gets vaccinated?” doesn’t end the conversation.

The Dallas Morning News reports that person from another state who had mumps traveled to Dallas for the National Cheerleaders Association All-Star National Championship, which took place Feb. 23-25 at the Kay Bailey Hutchison Convention Center. 

At this point no Texas residents have developed mumps in connection with the case, but people are urged to watch for symptoms. 

This is another reminder about the value of vaccination in preventing what can be serious illness. Mumps cases decreased 99 percent after the introduction of a successful strategy for vaccination.

Here's a quick look at mumps cases over the years according to the CDC:

*Case count is preliminary and subject to change

** Cases as of Jan. 27, 2018 Case count is preliminary and subject to change

Most children transition out of their crib between 18 months and 3 years … sooner if they are climbing out, later if they are perfectly happy in the crib. There are some bad times to make the transition: surrounding a move (new rooms are already scary) and when potty training (one big change at a time).

Some children handle the transition with no problems, others might have more trouble.

Here are some types of children you might find a little more challenging and how you can help them:

1)The Manipulator/Negotiator

“One more story … one more stuffed animal … lay down for one more minute …”

Next thing you know, your bed time routine is two hours long and everyone is exhausted, plus you missed the window to vote for “The Voice.”

Set the expectations early. “We will read two stories; have two stuffed animals and two minutes of lay-down time.” When the bargaining starts, be firm and consistent and don’t give in.

2)The Screamer/Crier

The bedtime routine went smoothly, all was well but as you start to wrap up, you can see the anxiety building. As soon as you close the door … uncontrollable crying and screaming.

It is OK to go back in and reassure. Most of the time you can tell if they are truly scared. Stay a few minutes longer, and then try again. If this is every night, you might want to reconsider if this is truly a good time for the transition.

3)The Creeper/Sneaker

You hear little steps sneaking down the hallway or, you wake up in the morning with a child in your bed and wonder, “How did they get here?”

I recommend putting a child’s gate at the door of their room. Having a gate allows you to be in control of getting the child back to bed. You can walk to the gate and ask them to get back in bed without even going in their room. Make their room completely child proof so that if they get down and roam, they will be safe.

Hopefully your child’s transition to a toddler bed will be easy. If not, talk to your friends about how they did it or ask your pediatrician. They might have some helpful tips.

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in 2017.

Just in time for the holidays a reader wrote in with this question:

“My friend...was told by her grandson’s pediatrician that her grandchildren who are vaccinated should never be around any unvaccinated children. Well, the parents of her other grandchildren do not want to vaccinate their small children…As a result there are no more family gathering with all grandchildren. They have to spend holidays on separate days. My question is: Why would the pediatrician say this? If the children who are vaccinated and the children are not showing symptoms what’s the problem?”

This is definitely a sad and tricky situation and one that we should use extreme care when discussing.

One thing I will say is that no matter what one’s choice about vaccinating is, parents believe they are making the choice in the best interest of their child. Of course, I have strong opinions about how important it is, but this discussion is not for the faint of heart.

There are probably some doctors that would tell you it’s no big deal and you shouldn’t worry about it (I would disagree with them). There are other doctors that would say you should never have your child around children who are unvaccinated regardless of your child’s health (I recognize this is not reasonable in many situations).

Here are the questions to consider:

1. How old is the child? The younger the child, the more vulnerable they will be to infection. They cannot receive protection for chicken pox or measles before 1 year. Older children who are fully vaccinated have a significant amount of protection and they likely encounter an unvaccinated child at school every day.
2. Who isn’t vaccinated? This question is about family members which makes transmission of infectious diseases more likely than if you just walked by someone on the street and were not interacting with for longer periods of time.
3. Can you have an open conversation with those involved? The discussion is clearly more complicated than simple medical advice as it broaches on several tricky areas including family dynamics and vaccination.

The easy (get out of having to make a committed answer) is that there is no one answer to the question. The family should talk with their doctor about their specific concerns and make a decision with their counsel.

Should I stop the blog post there? Not so fast.

Instead, I want to give you a framework for having that discussion with your doctor.

What diseases should I be worried about?

I believe that all vaccines are important, period. But there are 3 diseases that jump to the top of my list when considering this issue:

1. Flu

Flu season is predictable in that it comes every single year at roughly the same time. It is unpredictable in that we never know how widespread it will be and how severe the cases will be when it does come around. Flu is particularly dangerous in babies and they cannot be vaccinated until they are 6 months old. Remember that the flu vaccine isn’t perfect, so I’m not saying that everything’s cool if we all have flu vaccines but it would seem logical to get as much protection surrounding the baby as possible.

2. Pertussis

Pertussis, or whooping cough, is still common and is a very serious disease for anyone who gets it. In children, teenagers and adults it tends to cause a very rough and painful cough that lasts for weeks to months. I know of adults who have had broken ribs because the coughing is so hard. The real danger for pertussis comes in small babies (less than 3-4 months). These babies commonly have spells of coughing that cause them to stop breathing; leading to ICU stays for intubation and unfortunately, death. Babies are vaccinated against pertussis at 2, 4 and 6 months which increases the number of children who are protected with each shot but they go on to get another vaccine at 4 and 11 years as well. So, when are they fully protected? It’s impossible to say. In addition, vaccines are not perfect so even vaccinated infants who are exposed could develop pertussis. Pertussis still occurs commonly in the United States and is generally carried by older children and adults who are coughing but do not know that they have pertussis. Just like flu, having the vaccine does not prevent disease 100% and I still feel that we need to do something better with the pertussis vaccine but again, it would seem logical to increase protection as much as possible.

3. Measles

Measles is another disease that still occurs in the United States. In 2014, there was a record number of 667 confirmed measles cases reported to the Center for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases (NCIRD). That’s the highest number of cases since measles elimination was documented in the U.S. in 2000. Measles can cause pneumonia and have a higher risk of hospitalization in children under 5. Children receive their first measles vaccine at 1 year of age, but they have no protection from measles until then.

What criteria should I use for being around others?

1. If your baby is under 6 months, use extreme caution. Many babies do not have full protection until after the 6 months shots. In addition, they cannot receive a flu vaccine until 6 months.
2. If your baby is under 1 year, I would also use caution. Your baby cannot be vaccinated against measles or chicken pox until 1 year.
3. After your child is vaccinated at 4 years, they have much of the protection that they need to protect themselves against the vaccine preventable diseases.
4. Babies or children who may not have a normal immune system-such as those with chronic illness or who were born premature deserve extra caution.
5. Anyone with symptoms of illness, especially fever, cough, congestion or rash, should not be around your baby or child regardless of your contacts’ vaccination status.

Can you get a definitive answer about when your baby can be around unvaccinated children? No, but you at least have some information to make an informed decision.

After you’ve discussed your plan with your pediatrician how do you handle the conversation with friends and family?

Here are some thoughts about some things you might say:

1. Our baby/child doesn’t have protection against many very dangerous diseases and we do not feel comfortable having her around people who could spread them to her.
2. Our baby/child has already been through so much, we can’t risk putting her through another medical problem. Especially something that we could have avoided.​
3. The doctor was emphatic that we cannot be out around anyone (especially someone who is not vaccinated or you could leave that out) until __________. (I’m fine with a family placing the “blame” completely on me.)

Ear pain can be caused by many different factors. Often kids just play with or point to their ears. If the child is otherwise cranky, sick or not sleeping well, parents will assume there is an ear infection. However, a study from 1998 showed that parents only identified 70 percent of their children with ear infections and when they suspected an ear infection, it was only present 50 percent of the time. (Translation-they could have just flipped a coin rather than trying to guess.)

This is why getting an antibiotic called in when your child has ear pain is a bad idea - whether it is from your doctor or from one of the new insurance nurse lines that many people are using. Every exposure to antibiotics is a potential risk for allergy or side effects. Unnecessary exposure is not worth it.

2. All ear infections have fever.

Studies are all over the place about what percentage of ear infections have fever. They generally fall between 1-2 out of 3. Regardless, that means a lot of kids with ear infections won’t have fever.

3. Having your child in the wind or under water causes ear infections.

The location of an ear infection is behind the ear drum way back in the inner ear. External exposure like wind and water don’t affect that area. Grandma will have to come up with another reason for their grandbaby to put on a hat when it is cold outside.

What are risk factors?

• Age (6 months-2 years)
• Family history
• Day care
• Not breastfeeding
• Smoke exposure
• Pacifier use (small effect)

4. You can’t go swimming if you have an ear infection.

Related to the previous myth, there is no reason to avoid swimming if you have an ear infection. Unless the ear drum has ruptured the space where the ear infection is located is walled off from the water. Don’t skip the swim party! If the child feels discomfort or pain while swimming, they can play in the shallow end or just have a snow-cone.

5. All ear infections need antibiotics.

Many children with ear infections will get better without antibiotic treatment. The latest treatment guidelines give the following advice for treating ear infections:

• Children of any age with severe pain, fever or ear drainage should receive antibiotics.
• Children 6 months-2 years with both ears infected should receive treatment.
• Children 6 months and up with 1 ear infected and with mild symptoms can be watched for 2-3 days to see if symptoms improve or worsen prior to starting antibiotics.

6. Amoxicillin is not strong enough for ear infections.

Many studies have looked to compare different antibiotic treatments for ear infections. The bottom line is this, there is nothing better at getting rid of infections than amoxicillin. Other antibiotics may work as well, but they are typically more broad spectrum - meaning they cover more different types of infections that those that typically cause ear infections. Because of this, we should reserve those antibiotics for those situations in which they are necessary. Amoxcillin is cheap, well tolerated by most kids and effective. Therefore, except in penicillin allergic patients, it should be used unless the child has been on the medication in the last 30 days.

7. If your child gets tubes, their ear infections are guaranteed to stop.

After a few ear infections, some parents are eager to move forward with placement of tubes. Tubes can be a life saver with kids who have had multiple ear infections and can prevent recurrence of ear infections, but they aren’t perfect. They are a surgical procedure and the inherent risk associated with anesthesia need to be fully explained to a parent. Continued ear infections occur in about 20 percent of children even after they have had tubes placed.

Every kid goes though it and yet, it’s universally misunderstood. Poor teething. It gets blamed for just about everything and probably causes very few symptoms.

I thought I would clear up some of these misconceptions and I asked Sheela Patel, D.D.S, a pediatric dentist at CookChildren’s to lend her expertise.

Teething Myth No. 1- Teething causes fever (or maybe you’ve heard it blamed for congestion, sleep disturbance, decreased appetite, diaper rash, diarrhea or vomiting).

It doesn’t. Right, Dr. Patel?

“Despite what you may have heard, teething doesn’t directly cause a high fever or even diarrhea,” Dr. Patel said. “Babies tend to put everything in their mouth in an effort to massage their gums, so they may pick up bacteria.”

Here are some symptoms that have been found to be statistically associated with teething:

• Mild temperature increase
• Sleep disturbance
• Salivation
• Rash
• Runny nose
• Appetite loss
• Irritability

You’re thinking, “See, I told you it does cause fever!”

Not so fast.

First of all, the temperature increase was noted to be 0.12 degrees Fahrenheit on the day that the tooth erupted. I’ll leave it up to you to decide if you think having a temperature of 98.6 vs. 98.72 actually makes a difference…

Second, the increase in temperature and the rest of the symptoms associated were found to be present on the day the tooth came and the day after. This was not a 2 week (or 2 month) process leading up to the teeth popping through.

The issue is that all kids teeth. In addition, all kids have occasional sleep disturbances, drool and have runny noses. Trying to determine if the teething causes these symptoms in a particular child is pretty difficult.

Teething Myth No. 2 - It’s too early for them to cut teeth.

The average age for the bottom middle teeth to come out is 4-6 months, but some children teeth before or after.

Some children are born with teeth, called natal teeth. If the teeth are stable in the mouth, nothing needs to be done. There may need to be some extra special care with breastfeeding moms to make sure their latch is not painful, especially during those early feeding days. If the teeth are wiggly, sometimes the pediatrician will pull it or recommend that you see a pediatric dentist to have it pulled.

Teeth can otherwise erupt any time after birth. But remember that the “symptoms of teething” that occur for two months before a tooth erupts are not likely due to teething at all.

Teething Myth No. 3 - They are too old to not have any teeth.

“He still doesn’t have any teeth.” I get this comment all the way from 6 months to 1 year. The right answer, “That’s OK.”

It is exceedingly rare for children to not have any teeth or to have teeth, but for them to never come out. A handful of babies don’t have teeth at their one year check-up but, I promise, they’re coming.

Teething Myth No. 4 - Teething must be treated.

The understanding of teething has changed a lot over time. Infant death used to be commonly associated with teething. Think about it, if a 6-12 month old child died for unexpected reasons, chances are they had a tooth coming in. Because of this, teething used to be treated with things as invasive as lancing the gums in order help them come through.

While we’ve come far enough to know that isn’t necessary. Parents still attribute a significant amount of normal fussiness or waking up at night to teething and treat based on this idea. What’s the problem? Everything we do has potential risks…from teething gels, to essential oils and even Tylenol^® or Motrin^®, while options, should be used with caution. (While I’m on my soapbox, just because something is the “natural” or “organic” variety, doesn’t mean it’s safe.)

For treatment of teething, Dr. Patel recommends that you “provide a firm rubber teething ring to chew on, but avoid the ones that are filled with liquid. Try giving your child a cool, wet washcloth to chew on. You can wet a washcloth, ring out the excess water and place it in the freezer. Make sure to wash it before each use. Give your child cool, softer foods such as applesauce or yogurt.”

Don’t let these common teething myths fool you. If your child has severe symptoms, don’t attribute them to teething. Don’t treat normal behavior with medication. Don’t assume that teething treatments are without risk.

About Sheela Patel, D.D.S

Dr. Patel is a dentist at Cook Children's Neighborhood Clinic on 2600 E. Berry Street in Fort Worth Texas, 76105. Dr. Patel received her dental degree in 2009 from University of Nebraska-Medical Center in Lincoln, Neb. She completed her pediatric residency in 2011 from the Baylor College of Dentistry in Dallas. Dr. Patel is board certified by the American Academy of Pediatric Dentistry. The Neighborhood Clinic offers a dental home for patients from 6-18 years of age the clinic and most CHIP, Medicaid, and commercial insurance plans are accepted. The staff speaks English and Spanish. To learn more, click here or call 817-347-4600.

That’s how I remembered this:

Blood, frogs, lice, flies, disease, boils, hail, locusts, darkness, death.

You might ask, why was I learning the order of the plagues? Obviously, for a bible quiz game we used to play in Sunday school. Because I’m ultra-competitive, even when it comes to Sunday school.

The recent weather in North Texas has many questioning if we are witnessing plagues or if the Apocalypse is upon us.

Fortunately, it looks like the worst of the drenching rain (and hopefully the flooding as well) are behind us. As the waters recede, the rising threat will be mosquitoes and mosquito borne illness.

What’s the big deal with standing water?

Standing water is the breeding ground for mosquitoes. There are four stages of life for mosquitoes. The adult flying stage is the only one that does not rely upon water for survival. The eggs, larva and pupal stages must live in standing water.

Any standing water - water in a bird bath, pond or standing water from improper drainage can be a place for mosquitoes to breed.

Why do mosquitoes bite?

Female mosquitoes bite because they need a source of protein before they can produce eggs. Otherwise, like males, they can feed on nectar or sap.

When females bite, their long mouthpart breaks through the skin and gets into the small blood vessels just underneath. They also inject a small amount of saliva into the wound to make entry easier and to keep the blood from clotting.

What harm do bites cause our children?

Local reaction - While not technically an allergy, some kids will have a large local reaction with swelling and redness at the site of mosquito bites. These can be itchy and cause distraction in school or lack of sleep when severe.

Local infection – It’s not uncommon to see local infection in kids who have scratched mosquito bites, leaving a gap in skin, which can lead to infection. If the swelling worsens after the first few days or if there is significant warmth from the site of the bites, you should see your pediatrician to see if antibiotics are necessary.

General infection - Because mosquitoes can carry diseases, bites from mosquitoes can transmit infection that can affect the entire body. Mosquito borne illnesses cause over one million deaths world wide, most commonly from malaria. Two other diseases that we have seen in Texas associated with mosquitos are West Nile Virus and Chikungunya.

Given the amount of rain and the season, mosquitoes will be inevitable this summer season. Read more here about the many different ways you can reduce your child’s risk of discomfort and serious illness: How to fight (and) win against mosquitoes.

Currently, I am the lone survivor of the war on Smith-Summertime-Flu-Like-Illness-2015.

You name the symptom and someone in my family has had it: fever, cough, runny nose, congestion, headache, sore throat, vomiting ... I could go on.

All of these symptoms are annoying. Running to grab the “puke bowl” when your 4 year old is “frowing up” is not my idea of a fun nor peaceful Wednesday evening. Trying to discern if his “headache” is really a headache, or fever or the early stages of some terrible bout with meningitis is not good for this pediatrician’s soul (nor his wife’s after she read this. It’s not meningitis, babe, I promise).

But the most annoying of all these symptoms for me is cough. When I have a cough, I generally try my best to keep it in for as long as I can, and let it go just before I feel like I’m going to drown in post-nasal drip. When my 6 year old has a cough, I’m pretty sure he feels like it is his duty to release that cough every five seconds. I think he does this just to remind me that he’s not feeling well and I haven’t given him anything to help.

Why don’t I give my kids cough medicines?

I don’t give cough medicine to my kids because they don’t work.

They really don’t.

Really.

The hard thing about this fact is that they were a staple of pediatric care for decades. Cough and cold medicines were first approved for use in children in 1976. There were no studies done to determine if they worked or what the appropriate dosing should be. I think the process back then went something like this:

“Why not give half the adult dose for children 5-12 and a quarter for the adult dose for children age 2-5?”

“Sounds good to me, let’s do this.” (Or maybe “Right on!” or “Groovy!” I don’t know, it was the 1970s.)

Since 1976 there have been several studies looking at the use of cough and cold medicines. The most recent review of the 25 best studies done stated this as a conclusion: “There is no good evidence for or against the effectiveness of OTC (over the counter) medicines for acute cough.”

I don’t give cough medicine to my kids because they can cause problems.

Side effects, even serious, even fatal ones, can occur as a result of giving kids (especially those under 6) cough medicines.

If you want to read some scary stories read these case reports from Pediatrics:

1. 3 year old ends up in ICU after becoming lethargic, having a slow heart rate, fast breathing and high blood pressure. Diagnosed with toxicity from Dimetapp (in this one we don’t know how much mom gave-could have been too much).

2. 3 year old being treated for pneumonia develops a fast heart rate, so fast that it start to interfere with the heart’s ability to work right. Parents were thinking they were giving Tylenol but ends up they were giving Tylenol Cold (acetaminophen, chlorpheniramine and dextromethorphan).

3. 9 month old boy is discharged from the ER with a diagnosis of pneumonia, doing well. Returns 12 hours later after being found cold, blue and not breathing. Unfortunately he dies after he is unable to be resuscitated. Toxicology on autopsy finds acetaminophen, pseudoephedrine, chlorpheniramine and dextromethorphan in the blood and heart tissue.

It is estimated that about 7.000 children are treated nationwide for toxicity related to cough and cold medicines and 64 percent of those are children under 6 years of age.

Everything in medicine is about weighing whether something works and if it could be harmful.

Cough medicines do not work and could cause harm, so my kids will pass.

P.S.

So will my patients because I don’t prescribe them either.

Last week, a Plano CPS agent responded to a different type of call after a Facebook post inviting parents to bring their children over to be exposed to chickenpox was reported

What is a pox party?

Pox parties were more common prior to the introduction of the chickenpox vaccine in 1995. The general feeling was that, if your child was going to get chickenpox at some point anyway, you might as well get it out of the way. It seemed like a rite of passage that everyone should go through. Because most people survived chickenpox with a few days of itchy annoying rash, there are some that ask me if the vaccine is necessary. “Wouldn’t it be better for us to just get the disease?”

Why do we vaccinate for chickenpox?

Most children with chickenpox develop fever, sore throat and loss of appetite which is followed by the classic rash. I was taught that the rash was like “dew drops on a rose petal” because of the clear, fluid-filled bumps that form on a red base. The rash would then crust over with the crusts lasting one or two weeks before falling off.

It was a memorable disease but not dangerous for most. I happen to remember riding around in the floorboard of my dad’s gas truck (it was a different time for lots of reasons) while I was recuperating, not able to go to school because our local farmer’s couldn’t wait for my rash to heal to have gas for their tractors.

Unfortunately, not all children with chickenpox have a simple course. Here is a list of possible complications that can arise from chickenpox:

1. Skin infections-These could be simple and treated with antibiotics but also can be deeper and involve muscle or other tissues. This would be more dangerous now that we see more antibiotic resistant bacteria.

2. Neurologic complications-Infection of the tissue around the brain could lead to confusion and infection of a particular part of the brain lead to a loss of coordination, both complications lead to hospitalization.

3. Less frequent complications-Pneumonia and hepatitis (liver infection) can also occur but do so less commonly.

Prior to the vaccination, there were 11,000 hospitalizations and 100 deaths from varicella yearly. About three children out of 1000 infected required hospitalization. Since 1996, hospitalizations and deaths have fallen significantly (70 and 88 percent).

Is there anything wrong with having a pox party?

As best as I can tell (I am not a lawyer), there is nothing illegal about throwing a pox party. One thing is clear, sending lollipops through the mail (even pox parties want to be the next Uber) to infect others is. There is also a picture that has been shared around the internet which reportedly quotes the mom from the Plano area pox party as saying, “I had to open my husband’s shingles blister and swab their mouths.” I have a feeling most of those out there who would throw or go to a pox party would consider this a little much.

Should CPS have been called?

I have to say when I first read this story; I thought that the call to CPS was a little overboard. CPS is busy as it is. Investigating pox parties is probably not the best use of their time. I have served on local CPS boards and the things that we talked about needed the full attention of a staff that was already stretched thin.

Secondly, the likelihood of serious harm resulting from contracting chickenpox is overall pretty low. Should CPS be called for every parenting infraction that minutely increases the risk of harm to children? No. That would mean I should report every family that turns their child’s car seat around at 21 months or that allows their baby to sleep on their stomachs. While I disagree with those decisions, I choose to educate as best as I can but don’t log on and report them to CPS.

My only pause in this case came from what I admit is a slippery slope argument but stick with me for just a second. What if one of these children ended up seriously harmed as a result of contracting chickenpox at this party?

Seeing children suffer from vaccine preventable diseases (pertussis is the most common which admittedly occurs in both vaccinated and unvaccinated babies) is hard. If I saw a child suffering from a complication of chickenpox only to discover that the child had contracted chickenpox intentionally at a pox party, this would be even harder.

How can we prevent against chickenpox?

The most effective and best way is through vaccination. Vaccination at age 1 and 4 years protects against 90 percent of chickenpox disease and 99 percent against severe disease. Rarely, children can get chickenpox after they have been vaccinated but the cases seem to be milder.

I hear statements like these:

1. “She must’ve been about 103 because she felt really hot.”

Touching a child to determine if you should check their temperature is valid, but skin temperature can vary based on what the child has been doing. If they feel hot after playing hard, being outside or waking up, give them a few minutes to cool off because you get too concerned.

2. “He had a 99 which is a fever for her because he usually runs around 97.”

Everyone’s temperature varies throughout the day, but we have to have a real cut-off for fever. You’ll see definitions vary but that cut off for me is 100.5 in children less than 3 months and 101.5 in children older than 3 months. (Remember that any child under 3 months that has a fever warrants a call in to your doctor right away.)

3. “He had a low-grade fever of 100.”

See above…it’s either fever or it’s not.

4. “I was worried because I know that fevers above 104 can cause brain damage.”

Temperatures that the body is generated because a child is sick are internally driven. The fever will stop rising at some point. Children are at risk for complications if their temperature rises because they are in a hot car or other external factors, but not because they are sick.”

5. “I knew something must be seriously wrong because his fever was so high.”

I think of fever like an on/off switch. A child has fever or they don’t. If they have a fever I need to look for the source, but the height of the fever does not indicate that something more dangerous is going on.

6. “I didn’t give him any medicine, because I wanted you to see how high the fever is.”

Nooooo ... If your child has fever and is uncomfortable, don’t leave them miserable until you come in to see me. I trust you if you say your child has a fever. If you’re worried I won’t trust you, take a picture of the thermometer.

7. “He was doing fine, then he had a fever of 102 and when I woke him up to give him some medicine, I couldn’t get him back to sleep.”

Another nooooooo ... never wake a sleeping baby to treat their fever. Never interrupt a playing baby to treat their fever. Treat fever based on the child’s comfort or to help them drink if they won’t. Otherwise, it’s fine to let the child have a fever.

I know it’s hard when your child is running fever. You feel worried and helpless.

Hopefully, dispelling some of these myths will help you treat your child with confidence.

* Read Dr. Smith's previous blog: "My child has a fever."

School physical season is one of my favorite times of the year for many reasons:

• It’s really fun to see kids grow up and get big over time.
• I love watching my patients’ personalities mature.
• I love that the visits become progressively more about my relationship with the child in addition to my relationship with their parents.
• For the most part everyone is healthy and happy.
• For most children, the promise of a new school year and new beginnings is exciting.

I have a few things on my agenda for each back-to-school checkup.

I want to talk about diet, exercise and sleep. I want to talk about how school went last year and what the plans are for the upcoming year.

But checkups are more than just about what I want. In order for the checkup to be a success, it must meet the goals of the child and parent. Parents are all over the place when it comes to their expectations for physicals.

Here are just a few examples:

1.“Let me get out my list.”

Whether your weapon of choice is a spiral-bound notebook or long thumb-scrolling iPhone lists, you know who you are. And frankly, I love you. Having a guide that directs the visit through any questions and concerns that you have is beyond helpful. It keeps me from having to talk about stuff that’s not important to you and wasting both of our time. So, bring it on, Listers, and I promise not to roll my eyes.

2.“I’m just here to get my form signed.”

No worries. That may be all you need and that’s great. In the meantime I can provide a quick screen for height, weight, body mass index, high blood pressure, heart murmurs, risk for sudden cardiac death, hearing and vision (and much more). I can also screen for drug/alcohol abuse, depression, attention problems and other school issues. “Here’s your form, thanks for coming in.”

But seriously, even in those children who come in with no apparent concerns or complaints, we do pick up health problems that need to be addressed to maximize your child’s ability to function well in school or compete at their best in their chosen activity.

3.“I’m not worried, but __________ wanted me to ask about __________.”

This is a tricky one. I’m totally cool with it, but it can be hard to get at exactly what the concerns is if that person isn’t there to ask questions. My advice … if that person is close enough to be providing this type of advice, they could probably come to the appointment. If the concern is coming from the child’s teacher, a quick note explaining what is going on can be really helpful.

Just don’t leave it up to chance that we can figure out what the problem is, especially if you don’t quite understand why they are concerned. Get specific information about the concern or have them come along.

I’m sure there are many more ways that parents think about their children’s checkup, but these are some common ones I notice.

No matter what, regular checkups are an important part of helping you maintain your child’s health. Good health increases their ability to be present for and to participate fully at school and extracurricular activities.

Which category do you fall in? Is there a different one you think I should include?

Sports EKGs are free through the month of August at specific locations in Arlington and Fort Worth. Cook Children's offers a $25 Sports EKG (electrocardiogram) screening test at our Cardiology offices in Mansfield, Southlake and Denton. Adding a sports EKG to your child’s physical can help detect most heart conditions that may lead to sudden cardiac arrest. Click to learn more. 

For school physicals, visit your local Cook Children's pediatrician. Click to find one near you. 

Well, it is not from teething but it could be from the treatment you are using for it.

Fever, congestion, diarrhea, fussiness, putting things in their mouth, not sleeping well, you name it and someone has attributed it to teething.

So how do you treat the pain associated with teething?

There are lots of products available most of which are not helpful and can be potentially harmful.

Avoid products with benzocaine and lidocaine (oragel and other gels). These have been known to cause a problem in babies called methemoglobinemia where your child will turn BLUE. I mean smurf crazy blue and is obviously a medical emergency. Also, avoid products with belladonna (teething tabs) as this has known to be poisonous and doesn’t have studies proving that it decreases pain anyway.

This quote comes from the healthychildren.org article on teething (click to see full article):

“To ease your baby’s discomfort, try gently rubbing or massaging the gums with one of your fingers. Teething rings are helpful, too, but they should be made of firm rubber. The teethers that you freeze tend to get too hard and can cause more harm than good.) Pain relievers and medications that you rub on the gums are not necessary or useful since they wash out of the baby’s mouth within minutes. Some medication you rub on your child’s gums can even be harmful if too much is used and the child swallows an excessive amount.”

So what symptoms really do come up before babies cut their teeth? When can we expect teeth to erupt? What can we do for our children when they are teething?

The best study I have found about teething was done in 2000 and included lots of kids and 475 tooth eruptions. Click here to see the study.

The symptoms that they found to be associated with teething were the following:

• Biting
• Drooling
• Gum-rubbing
• Sucking
• Irritability
• Wakefulness
• Ear-rubbing
• Facial rash
• Decreased appetite for solid foods
• Mild temperature elevation

The following symptoms were NOT associated with teething:

• Congestion
• sleep disturbance
• stool looseness or increased stool number
• Decreased appetite for liquids
• Cough
• Rashes other than facial rashes
• Fever over 102 degrees F
• Vomiting

I have seen some studies that will include congestion in the symptom list for teething. I think one of the main misconceptions is about fever. I commonly have parents ask if 102-103 temp could be caused by teething and the studies are pretty clear that if the fever is that high, it probably isn’t just teething.

If our children are particularly fussy from teething, we will occasionally use Tylenol^® and if more than 6 months old Motrin^® according to weight appropriate dosing sporadically for a day or 2 until symptoms subside.

The main thing is that you have to be flexible with your child and allow them a little extra grace for changes in sleep and feeding habits. Teething is normal and should be consider a normal developmental stage. It can be disruptive to schedules and the extra fussiness can make things stressful. Hang in there, this phase is temporary.

Related article:

4 teething myths every parent should know

Watch the video below for five key facts about diarrhea that every parent needs to know in only a minute. 

In today's video, Doc Smitty explains:

1. What are the common causes?
2. How long can it last?
3. When are the symptoms more than a stomach bug?
4. When do you call your pediatrician?
5. What are the biggest risks?

Learn the answers to these questions. It only takes a minute.

“Mom, my legs hurt.”

It wouldn’t be so concerning except that it’s happening four nights a week, for months. Right?

So, what do you do?

Watch The Doc Smitty in Cook Children's latest My Kid Minute video on growing pains:

To learn more about growing pains from The Doc Smitty, read his blog on the topic.

Here's why:

There has been an outbreak of severe flu among dogs in the Midwest. Cases of the H3N2 strain have now been seen in dogs in Texas.

Most dogs have cough, runny nose and fever, but it has been severe and resulted in death in some.

So you may be wondering, “Is my child at risk if our dog has this flu?”

The answer, according to the CDC:

“To date, there is no evidence of transmission of canine influenza viruses from dogs to people and there has not been a single reported case of human infection with a canine influenza virus.”

That’s fortunate, but what are some health dangers associated with pets?

Bites

I’ve seen too many severe dog bites in my training to not mention bites first. The most common statement I hear about the dogs who bite is, “We just never thought he/she would do that.”

Dogs can be a great addition to a family but use caution:

• Be careful of rough play. Even a playful snip can be dangerous if it happens near the eye or a fingertip.

• Stay away from dogs when they are likely to be defensive: when they are eating, sleeping or taking care of puppies.

• Stay away from unfamiliar dogs or dogs that seems scared or anxious.

Here are some more tips from the ASPCA on how to avoid dog bites.

Allergies/Asthma

This is actually one of the most common questions I get regarding animals. It’s very intuitive. People can be allergic to dogs and cats, so wouldn’t owning one increase my child’s risk for allergies?

I have seen several studies that suggest the exact opposite. Often by having animals in the house early, kids may have slightly decreased risk of developing allergies. That said, if your child has frequent allergy and asthma symptoms, it may be reasonable to attempt to isolate the animal from the child for a bit to see if symptoms improve.

Infections

Infectious diseases are transmitted through animals frequently; think about the number of diseases that tics and mosquitoes can carry. Although it can happen, they are less frequently transmitted from pets.

Here is a list of pets and some of the diseases they can transmit:

Cats

Cat-scratch fever:

This disease is caused by bacterial infection (Bartonella) of an open wound or a bite that results in the breaking of skin. It is more commonly transmitted by kittens than older cats. Symptoms of the infection in humans are fever, headache and fatigue. There is often a large and tender lymph node near the site of the bite.

Toxoplasma:

Toxoplasma is usually a foodborne illness, but can be transmitted from cat feces. In people with normal immune systems, there are often no symptoms of toxoplasmosis. Pregnant women (and fetuses) are especially susceptible and, for that reason, should not handle cat litter boxes.

Dogs

Hookworms:

Dogs infected with hookworms can have bloody stools; which in severe cases can lead to anemia. Humans are infected by walking barefoot on contaminated soil and develop an interesting rash which consists of red, squiggly lines where the larvae have migrated under the skin.

Reptiles

Salmonella:

Salmonella is one of the most common pet-associated infections. It is estimated that 70,000 people will contract salmonella from pet reptiles. Salmonella generally causes bloody stools but in children and in people with weakened immune systems can be serious. The CDC recommends that houses with children less than 5 and with any household members with weakened immune systems not own reptiles as pets.

Many Animals

Campylobacter:

Ingesting food contaminated with the bacteria transmits most infections of campylobacter, but cases can occur from the handling of dog or cat feces. The main symptom of campylobacter infections is diarrhea (which can be bloody) and usually lasts about one week.

Ringworm:

The fungus that causes can be transmitted from many different animals but most commonly occurs from puppies and kittens. The appearance of the rash on human skin is a circular rash with a raised edge. It can be difficult to distinguish from eczema which sometimes causes circular patches as well.

Pets can be great additions to your family and, in most cases, will not cause any harm to your children. Be aware of the specific risks associated with certain types of pets and take caution to protect your children when appropriate.

A disturbing trend on social media, the #kyliejennerchallenge, has left some teenagers in pain and not the look they were hoping for … to say the least.

So what is the challenge?”

“Kids suck into a container, often a shot glass, to increase blood flow to the lips, giving them a temporarily fuller, more pouty look,” said Justin Smith, M.D., a pediatrician and medical advisor for digital health at Cook Children’s.

Why should you tell your teenager not to do it? Dr. Smith has a few reasons:

• Pain
• Bruising
• Chapping/cracking – any cracking can lead to infection
• Cuts (some severe) from shattered glass

About the source

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Advocating for breastfeeding is a big part of a pediatrician’s job in the first few months of life. We state the benefits of breastfeeding. We encourage families who are struggling and provide help with troubleshooting issues. We point them towards lactation consultants and other resources that can help when things are not going well.

But, is there a point where “breast is not best?”

Does all the conversation about breastfeeding pressure moms to seek out breast milk from other sources when they choose not to breastfeed or when breastfeeding does not work for them?

The answer is: Yes.

Breast milk donation can be used to provide much needed breast milk to premature babies. Many of these babies would otherwise not receive breast milk. This provides an amazing service to a vulnerable population. I strongly encourage moms who are interested and have extra breast milk to look into donating their milk to one of these organizations.

There are other means of exchanging breast milk that I am not as excited about. Families can buy and sell breast milk online via websites that link buyers and sellers (often called “communities” or “societies”).

But, is this method of obtaining breast milk safe?

A recent study showed that out of 102 samples of breast milk bought online, 10 of those samples contained more than 10 percent cow’s milk. This shows that at least some sellers are mixing cow’s milk with their breast milk, most likely to increase volume and income from their breast milk sale.

Why is this dangerous?

It is dangerous because previous studies have shown that 20 percent of online breast milk buyers are buying milk because of a medical condition in their child - many of those are listed as formula intolerance. Introduction of cow’s milk into the breast milk increases the odds that these children could have a reaction or problem with the purchased milk especially if they have a true allergy to cow’s milk.

While this risk is not insignificant, I feel the danger is much greater. I believe that the real danger lies more in the motivation of the sellers. If they are willing to actively deceive buyers by adding cow’s milk, what else are they willing to lie about in order to find a buyer for their milk? Anyone ever thought of why we do not pay blood donors or allow for payment for organ donation? The motivations matter.

Here are some other potential issues with breast milk sold online that you should be aware of:

1. Storage and bacterial contamination

Safe storage of breast milk is not as simple as just throwing it into the freezer. Transportation of sold milk also creates another potential source for unsafe storage. The same group of researchers showed in a previous study that 74 percent of the milk they bought online contained enough bacteria to question their safety for infants.

2. Medications/drugs/alcohol

Many of the sellers’ listings make a point to say that the milk is free of substances or that the donor did not engage in risky behavior. In fact, sellers who made such claims (in addition to claims for clean handling and infectious disease screening) were 6 times more likely to sell their milk than those who did not make those claims. Does this encourage honesty?

3. Infectious diseases

You would hope that donors would be honest about their infectious disease history because many diseases can be transmitted via breast milk. Also, there are some transmitted diseases that the donor may not be aware of at the time they pumped the milk.

Of course, I advocate for breastfeeding for moms who can. But, let’s be real. Formulas have come a long way since the days where it was practically evaporated milk. So, let’s be realistic about the lengths we will go to in order to provide our child breast milk.

How do you know when it is something else or when it could be more dangerous?

A report last week from the CDC described a cluster of infections caused by shigella, a bacteria that can cause severe diarrhea.

Shigella is common, causing an estimated 500,000 cases of diarrhea in the United States annually. But this group of infections is unique because it has been found to be resistant to the most common type of antibiotic used in adults used for shigella. Most cases have been located on the East and West coast and many have been associated with travel outside the United States.

Fortunately, there were no cases of this more severe form of shigella reported in Texas so I feel that we are pretty low risk at this point. I did want to take a second to tell you about warning signs that might alert you that diarrhea might be more than a stomach bug.

Here are some symptoms that might alert you that should trigger a call to your doctor:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that last more than one week.
6. Let your doctor know if your child has traveled recently.

What are Salmonella and Shigella?

Two of the most common bacterial causes of infection are salmonella and shigella. They are both fairly frequent causes of severe diarrhea in children.

They can both be transmitted by contaminated food or water but can also be spread from person to person. Salmonella is more frequently caused by transmission from contaminated food, but also can be contracted from infected reptiles. Shigella is more frequently acquired from other children and is much more contagious than salmonella.

(Just to give you an idea, stool of a child infected with shigella contains 100,000,000 bacteria per gram of stool. Ingesting just 200 bacterial cells is enough to cause infection. Because of this, outbreaks of Shigella are common in child-care settings.)

The most common symptoms with both infections are diarrhea, abdominal pain and fever. With shigella, fever is often higher and children are more likely to have blood or mucous in their stools.

For either infection, your doctor can run stool studies to confirm the diagnosis. This may not be necessary if there are known cases that the child has been exposed to.

Both infections will typically go away on their own in seven days or less. Most healthy children do not require antibiotics. I do not routinely recommend anti-diarrheal medications in children because they can prolong symptoms with some infections.

If you suspect your child has one of these infections, consult with your doctor and keep them out of day care until we are sure they will not put other children are risk.

ADHD stands for attention deficit hyperactivity disorder.

There are three core symptoms of ADHD:

1. Inattention

2. Impulsivity

3. Hyperactivity

Inattention

Inattention can present itself in many ways. Some of the most common complaints that I hear about are daydreaming, forgetting assignments and inability to complete a short list of chores at home.

Often children who mostly have inattention do not become recognized until they are older because they are not the ones causing all kinds of problems in the kindergarten classroom. They will skirt by making OK grades and not getting in trouble until they get a little older and the requirements to sit still and complete assignments on their own increase.

Impulsivity

Do you know that split second where you think about telling someone off but you stop yourself? Or you think about driving 100 mph because you’re running late but don’t because you realize it will be dangerous? That split second is another thing that children with ADHD are lacking. They push right through that pause and act before thinking about the consequences of their action.

The best summary for this problem is that they lack the ability to determine if the upcoming action is: safe or appropriate for time and place.

Hyperactivity

The hyperactive symptoms are the ones that most people (even strangers) will notice about children with ADHD. They are not even necessarily bad kids, it’s simply that they have a significant struggle with staying seated, staying still when seated and not talking out of turn. These symptoms are usually noticed by 4 years of age and progressively worsen until about 7 years.

Learn more about hyperactivity and ADHD here.

ADHD subtypes

There are three major types of ADHD and they are characterized by which of the core symptoms your child demonstrates: mostly inattentive, mostly hyperactive-impulsive and combined.

Diagnosis

The diagnosis of ADHD can be made by multiple practitioners: pediatricians, psychologist, psychiatrists and some counselors are trained to diagnose ADHD. I prefer to make my own diagnosis in my clinic unless the case is particularly challenging or there is something complex about the presentation.

There are many different modalities that can be used to diagnose ADHD but it is mostly made by parental history, teacher’s reports and screening scales. I prefer to use the Vanderbilt scale but there are many other scales out there that can be used.

Diagnostic criteria

Diagnostic criteria for ADHD start at age 4 so younger children are generally not diagnosed with ADHD. This is due in part to the complexity of trying to decide what is normal and what is hyperactive or inattentive for a child younger than 3.

The following criteria are used:

1. Be present in more than one environment (home and school) - this is important because children who have issues only at home or only at school are usually having more of a problem with the structure at one place than actually having a tendency towards ADHD

2.  Be present for more than 6 months

3. Be present before age 7 - this is becoming more of a problem as adolescents and adults are becoming more aware of the problem but demonstrating that there were symptoms prior to age 7 can be difficult

4. The symptoms must impair function-see below

5.  Be excessive for the developmental level of the child - An active 2 year old is not hyperactive but normal.

Does it impair function?

My main point when I am discussing a child’s ADHD with the family is focused upon this aspect of the diagnosis and treatment. For most children, impairment of function means that they are not progressing through school appropriately, are in trouble at school regularly for hyperactive or impulsive behaviors or have difficulty performing regular function at the house because of their ADHD.

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer

If you want to start, visit Cook Children's guide to choosing a pediatrician. Then, go check out your doctor on healthgrades.com or vitals.com or any of the other rating sites you can find. What you’ll likely find is a sampling of a small handful of raters. These sites are a sample size and can be heavily skewed by one great (if you like your pediatrician, let people know) or one terrible one. 

So, where else can you go for advice?

Friends

Ask your friends who have kids what doctors they use. This especially works well if you have friends that are similar in belief systems, medical philosophy and personality. If they like their doctor and you’re similar to them, chances are you’ll like them too. Good old fashioned word of mouth (it’s actually more commonly via Facebook or what I like to call “word of mouse") is still probably the best way to learn about the doctors in your area.

Practice websites

Practice websites are helpful in determining the practical aspects of the practice you are considering. Look at office hours and availability of care after hours via phone, etc. If having a doctor that is up to date with latest medical knowledge and technology is important to you, make sure that their website looks professional and is updated. This is also a place where you can find a little bit about the doctor’s personality (from their bio) and see their picture but these often become pretty predictable. Everyone likes to spend time with their family and has a few particular interests in pediatrics like obesity or development. They also went to medical school and residency somewhere (in case you were wondering).

Ranking websites

There are several of these out there. Some of the most popular ones are healthgrades.com and vitals.com. I like vitals.com because it allows people to leave narrative comments and not just rate with stars. Some of those comments can really give some insight into what the doctor is like. These website are not without fault-because the number of reviewers is often small, they can be skewed heavily by someone who has a negative experience (this is a good reason to go over and rate your doctor that you like).

So, how do you know if your doctor is the best?

The right question is this: How do you know if your doctor is the best for you?

I think this comes down to two basic questions:

1. Can you ask your doctor any questions without fear of judgment or feeling silly?

2. Do you trust the doctor’s answers to your questions?

If you can answer a resound YES to both of these questions, then you are in the right place. If not, you should probably be looking elsewhere.

He’s not hurt and had a presumably bright future in the NFL.

Why did he retire?

In light of the recent focus on repetitive trauma, concussion and brain injury, he decided that it was in his best interest to stop playing football.

Consider it this way: After years of playing football, starting a very young age, succeeding in high school and later at the University of Wisconsin, he reached the pinnacle of his sport and decided it was better to walk away than to keep playing. Granted, he’s only one player and many, many more will continue to make the decision to go back to training camp in July.

Most football players will never reach that point where they’ll have to decide if the NFL is right for them. I played junior high football, but didn’t move on to high school. I like to tell myself that I was making sure I was protected from injury for tennis season (truth was, I was probably a little scared of being small and getting hit by bigger high school kids. Sorry for lying, Coach West).

If you look at the research,  it seems like cumulative trauma is the issue. The older and bigger you get and the longer you play, the number and the force of the traumas increase. The rules are changing in an attempt to make the sport safer. But, I’m sure many of you read this and worry about your young football players.

My sons haven’t asked to play football yet. At 5 and 3, I think the level of risk for concussion is higher when I pick them up and throw them as high as I can in the air barely grabbing them before they crash into the ground. But living in the middle of Texas, football countr,y and having an older son built like a perfect tight end and having little brother with a canon for an arm, I am sure that is a conversation we will have some day.

I wonder if someday we’ll look back on the days when football was played and think, “I can’t believe that they used to do that to themselves.” Or, will the sport look so different that we will barely recognize it?

What about you? Do you have concerns about your sons playing football?

Human papilloma virus is a cause of warts that affect the genital areas of males and females. They can also cause infection of the mouth and throat.

HPV is the most common sexually transmitted disease in the United States.

HPV does not show symptoms for many people who are infected but it can lead to cancer of the cervix or penis. Every year approximately 17,500 women and 9,300 men will be affected by cancers that are caused by HPV.

HPV Vaccination

Fortunately, we now have a vaccine that prevents HPV. It was licensed for use in 2006 and targets four strains of the virus: 6, 11, 16 and 18. Types 6 and 11 account for 90 percent of genital warts and types 16 and 18 lead to cervical cancer.

Any time something is “new,” rumors abound. I was privy to an online discussion about HPV on Facebook this week ... because it’s not the best venue for having these discussions I had to hold my fingers (tongue).

But, here are some of the myths I saw that I felt needed to be addressed, beginning with the HPV vaccine has been proven ineffective.This myth takes on a few different forms. I’ll address each one.

HPV Vaccine Myths

1. Myth: The HPV vaccine does not decrease the amount of HPV disease.

Truth: In the United States, the percentage of cases of HPV caused by those strains in the vaccine dropped by 56 percent after the introduction of the vaccine. Other studies in the UK and Australia showed decreases in the number of HPV cases after introduction of the vaccine. The vaccine prevents HPV disease.

2. Myth: The effectiveness of the vaccine wears off over time.

Truth: This study in Pediatrics showed that, at the end of eight years of surveillance, those who received the vaccine continued to have antibodies to the virus. There is no indication that will decrease over time but studies continue. Even if we found a fall-off, a booster could be used to prolong coverage and if we could get protection for any period of time it would decrease the rates of HPV and cervical cancer.

3. Myth: Even if it prevents HPV, the vaccination has never been shown to prevent cancer so why get it?

Truth: Despite the logical conclusion that decreasing HPV infection rates should decrease the rate of cervical cancer, some challenge the HPV vaccine by saying that it has never been shown to decrease the rate of cervical cancer. This study in Denmark showed a 40 percent decrease in atypical cells found on Pap smears (a precursor to cervical cancer). I believe that more studies like this will show even more proof that it is preventing cancer.

4. Myth: The HPV vaccine is not safe.

Truth: This is perhaps the most pervasive of all the different myths about HPV vaccine. News reports and anecdotal stories of teenagers who have received the vaccine and then experience weird, otherwise unexplainable symptoms can be quite compelling. The problem with relying on those stories is that, even before the HPV vaccine, teenagers had events or health outcomes that were unexplainable. Even those who choose not to be vaccinated today have some of the same symptoms. Wouldn’t it be nice if we had some way to determine if these events were caused by the vaccine or were merely coincidental?

Fortunately, we do. If we look at a large population of teenagers who received the vaccine and compare them to another population who did not, we can see if the vaccine increased the risk for bad outcomes or if there were events that would have occurred anyway.

Multiple studies have done this. One of my favorites is one that included almost 200,000 girls who received one or more doses of HPV vaccine. It showed a slight increase in passing out after the shot (we ask girls to sit for a while after receiving it) and skin infection, but no other increase health risks. Another included almost 1 million and showed no increase in autoimmune, neurologic or blood clotting disorders.

I am not concerned about the safety of these vaccines. I understand that, with anything new, parents are going to have concerns but as more and more data come in, the safety of HPV vaccine is confirmed. My kids will get it when they are the right age.

5. Myth: The HPV vaccine allows or causes teenagers to be promiscuous. (Related: We shouldn’t vaccinate because it protects promiscuous kids.)

Truth: This is the most infuriating myth for me regarding the HPV vaccination debate. It angers me because it preys upon the fear of some parents that their child might take sexual risk as a result of something the parents have done. If that is a concern, it might be justifiable if it were true ... BUT it’s not.

Studies have shown that girls who receive the vaccine are no more likely to engage in risky sexual behavior or to have more sexually transmitted diseases. Using that myth to scare other parents is inappropriate, just stop.

6. Myth: Because I’ve raised my child “right,” they won’t be at risk for HPV.

Truth: What? This line of thinking has so many holes.

First of all, you won’t always know about your child’s activities. Trust me, you won’t always know. You may think you know, but I’ve diagnosed a pregnancy in more than one girl who “never had sex.” Stuff happens.

Protect your child even if you’re sure they’d never have sex or won’t until they meet “the one.” Why? You can’t predict you child’s future partner’s sexual behavior. Maybe your children will grow up, meet the partner of their dreams and only have sex with that person for their whole life. But, maybe their partner’s history isn’t the same. Their partner could carry HPV, could give it to your child and leave them at risk for cervical or penile cancer. Why risk it? By withholding the shot, you are only putting your child at risk.

These are some of the common myths I’ve heard about HPV. I’m sure there are many more out there. But I urge you to go in with an open mind and talk with your doctor about your questions or concerns. We’d be happy to help!

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

Sorry that there’s no “all of the above.”

Around 25 percent of kids grind their teeth at some point. It most often occurs at night but can occur during the day (usually they are not conscious that they are doing it.) The most common ages are from 7-10 years and most grow out of it without any problems arising.

We don’t really know the cause of teeth grinding although it has been linked to stress and one study showed it to be more common in kids who talk in their sleep or wet the bed.

Most children do not have complications related to grinding their teeth. Some complications that have been reported are: jaw pain, headaches (more common in adults) and damage to teeth.

Treatment for teeth grinding can be very frustrating as there are no quick fixes. Since stress can be a related factor, try to have open dialogue with your children about factors that could be causing them stress. Mouth guards are not frequently used in children because they are not likely to help and making one to fit is difficult because children grow so quickly.

If the teeth grinding continues, talk with your pediatrician or dentist to see if there are new treatments available.

When people think of homelessness, they commonly think of someone living in a park or on the street with no structure to sleep under but the effects of homelessness are felt by many in less dire circumstances. There are various classifications of homelessness which include homelessness without shelter but also include the following:

1. Homelessness with shelter - Living in a supervised private or public shelter.
2. Imminent homelessness - A chance that the primary residence will be lost in 14 days.
3. Youth/family instability

In survey data from 2012, the Cook Children’s Center for Children’s Health show than 7.5 out of 1000 kids in Tarrant and the surrounding counties had spent the night in an emergency shelter or with family/friends due to homelessness. Because of the nature of the study, my suspicion is that this number is likely understated. Despite the fact that it is more common in low socioeconomic areas, it is not restricted there. An example of this might include a child who is kicked out of the home for various reasons.

What are the effects of homelessness youth and children?

1. 97 percent have moved more than once in the last year.
2. Interrupted or ineffective school participation
3. 22 percent have been witnesses to domestic violence
4. 50 percent of homeless teenagers have depression or anxiety
5. More likely to have severe asthma, malnutrition, ear infections, exposure to toxins
6. More likely to have mental health and substance abuse issues
7. More like to engage in dangerous sexual activity leading to STDs and unintended pregnancies
8. 7 times more likely to be victims of violent crime

All of these issues can be categorized under the heading “toxic stress.” Toxic stress occurs when a child experiences strong, frequent and prolonged adversity. Studies show that these experiences can have significant effects on the development of the brain and other organs which can lead to increased risk for negative mental and physical health outcomes. These problems can persist well into the adult years, even when the stressful situations have resolved.

What can you do?

1. Be aware - One of the biggest problems with addressing homelessness is that many people are not aware that it is even an issue in their area.
2. Donate time - There are many programs available in our area where you can serve as a mentor to children in schools. Children going through toxic stress benefit greatly from having an adult who spends time with them and with whom they can process their experiences.
3. Donate financial resources - Many homeless shelters struggle to survive financially. They have a hard time providing healthy nutritional options and, certain times of year, even enough beds to house all those in need.

Learn more about homeless in Tarrant County here. 

We have been trained to assume that chest pain is caused by the heart and an emergency, which is right in adults. But, one of the basic principles of pediatrics is that children are not “just little adults.”

Chest pain is a perfect example.

What are some common causes of chest pain in children?

1. Muscular or rib pain - This is the most common cause of chest pain in children. Pain can be caused by a bruise, muscle strain or after repetitive coughing.

2. Lungs - Asthma and pneumonia are two common lung causes of chest pain.

3. Stomach - Reflux can cause chest pain (think “heartburn”).

4. Psychological - Stress, anxiety and panic attacks frequently show up as chest pain.

If most chest pain in children is not an emergency, when does it become one?

1. The pain is severe, especially if it has the classic findings of heart pain (crushing pain, under the breastbone, moving to the left arm or up the jaw).

2. The pain is associated with difficulty breathing.

3. The pain has is associated with other symptoms (fever, nausea/vomiting for example).

What are some other findings that suggest the heart is the cause of chest pain?

1. The pain is associated with exercise or limits the child’s ability to exercise.

2. The child has lightheadedness, dizziness or faints with exercise.

3. There is a family history of heart problems or sudden death, especially if early in life.

If your child has any chest pain, a visit to your doctor is important so that they can ask you questions and perform an exam on your child to determine the cause and right treatment.

It’s the problem that many families have faced, but people rarely talk about. It can leaving you feeling like you are out on an island all by yourself.

Guess what? You’re not as alone as you think.

Here are the percentages of kids who are still wetting the bed at various ages:

• 5 years- 15 percent
• 7 years - 10 percent
• 10 years - 5 percent

Up until 10 years of age there is probably at least another boy or girl in your child’s class at school who is going through the same thing, it just doesn’t come up at the PTA meeting.

For the most part, the problem is just delayed maturation of a child’s ability to stay dry. This is evidenced by the fact that almost every case eventually resolves on its own without treatment. While the maturation may not happen fast enough for parents who are changing the sheets every morning (or even in the middle of the night), for most, it will happen.

If you want to blame someone for the problem, blame genetics.

There is often family history of delayed nighttime dryness. This is tricky to prove because this could be simply a result of the fact that it is so common. There have been some studies implicating genetics as a possible cause.

Some people will describe their children as “really deep sleepers,” but most kids are and it’s probably a bias based on the fact that most families with kids who are dry through the night don’t try to wake their kids up for anything.

So when should you call the doctor?

• The child is starting to wet after a period of being dry.
• The child has day-time accidents as well.
• The child has burning or pain with urination.
• The child is excessively thirsty and urinating frequently.
• The child has associated constipation.
• The child has other associated symptoms for which you are concerned.

There are some basic strategies to use in order to help your child stay dry:

• Limit or stop fluid intake after dinner.
• Have the child go to the bathroom regularly during the day and several times close to bed time.
• Children should not receive caffeinated or sugary beverages.
• Move toward underwear as soon as reasonable.

You can talk about further interventions with your pediatrician. Here's some advice I give parents:

Bedwetting alarms that wake children when they have wet the bed are the most consistently proven method to resolve bedwetting.

Medications for use with bedwetting can be used for temporary dryness, but have not shown to be effective for eliminating bedwetting long-term. Once you stop the medicine, it tends to come right back.

Most cases of bedwetting will resolve on their own, you should not blame yourself or your child. Punishment does not work!

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

My wife nudges me. It’s 2 a.m.

“Hey babe, did you hear that? Who is coughing? Can you go check on them? Take your stethoscope.”

That’s what an Emergency Room visit looks like in our house in the middle of the night. This time of year, many of you might wish you were married to a pediatrician … but, alas, Mrs. Doc Smitty is one of the few with that privilege.

We at Cook Children’s, and hospitals around the nation, have seen a significant rise in the use of our Emergency Departments and Urgent Care Centers over the past few weeks. Not only are we seeing more kids, many of those kids are more complex and more sick than we have seen in previous years. We are seeing RSV, flu, vomiting/diarrhea and just about every other pediatric illness you can imagine. It’s all going around.

Not only do we find ourselves servicing our local area, we are accepting transfers from most of North Texas in an effort to provide service to very ill patients who need the level of care that Cook Children’s can provide. This responsibility is based on Cook Children’s promise that every child’s life is sacred.

But that important commitment to helping so many children means helping a lot of kids. Here’s what we know that means to you.

We know that wait times are longer than usual right now.

We follow the trends in wait time closely – both at our medical center and in our region. All across Dallas-Fort Worth, hospitals are experiencing this surge in visits and we are hearing about increased wait times at emergency rooms throughout the area.

We are working to address this issue. We are increasing the number of providers ready to work in the ED. These are not our regular ED physicians but physicians who will be available to help out with patient surges after their “day jobs.” We are working to educate our families about other locations where they can receive care. Unfortunately, once a patient is checked in at the ED, we cannot ask that they leave to receive care elsewhere. Asking them to leave would be a violation of a law known as EMTALA.

Another issue we are facing is limited space. Hospital beds are filled with sick children that are not ready for discharge. This requires that children who need admission remain in our ED as they wait for a room in the hospital.

Space in the ED is already limited based on the fact that it was built to accommodate 45,000 visits per year but is currently seeing more than 120,000. Much of this problem will be addressed when our new Emergency Department opens, but, for now, we have to work to maximize the use of the space that we have.

Therefore, increasing providers will not cut your wait time down to zero but we will do our best to shorten it as much as possible.

You can help by utilizing our various other ways to care for your child’s medical issues addressed. Do not hear this as a lecture to not go to the ER; that is not the point of this post. We are working hard to provide other means that might help you by addressing the problem more quickly. Consider calling your Cook Children’s pediatrician. Even if they are not open, you can get advice from our outstanding pediatric nurses who can take your phone calls overnight. If your issue requires a visit but the ER seems like too much, check out one of the four Cook Children’s Urgent Care Centers throughout the Fort Worth area.

We know that waiting is terrible.

Doctors are some of the most impatient people I know. I don’t like to wait for anything. I get antsy and frustrated and become very difficult to deal with. If the radiology report or the lab result takes longer than expected, our anxiety level goes up. When we know our patients are suffering and we need those results to relieve suffering, we become even more frustrated. We hope you don’t sense our frustrations as frustrations with you. We just hate to see kids sick and to see more of them sick than usual makes us all sad.

You can hear the frustration in this brief interview with Corwin Wormink, M.D., Cook Children's Assistant Medical Director of Emergency Services.

We are working to address this issue. We are working to speed up all the processes associated with caring for your children so that our providers can be as efficient as possible. We are working to support providers (doctors, nurses and all other staff) so that they can be energized (physically and emotionally) to continue to provide excellent care for your child.

We know that waiting with a sick child is even worse.

We hate it that you are waiting hours to be seen in our ER. When our providers walk into the room and see that you’ve been waiting, our heart hurts about the time you’ve spent sitting in an uncomfortable chair trying to corral your sick child (often with their siblings). We know that you are worried about your child because he or she is sick. You’ve been scared to go to the bathroom, afraid you might miss your name being called out and that you are hungry and tired.

We are working to address this issue. We are looking to staff volunteers in the waiting rooms to help you get to where you need to be, to provide distractions for your children and to do anything they can to help you while you wait. We also are looking to increase our use of text and other notifications to update you on the status of your wait times, need for vital sign checks and other issues. Even when you are waiting, unable to be seen by a doctor, our triage nurses are checking and re-checking your child’s vital signs to make sure that your child’s medical condition is not changing, requiring them to be moved up in line to be seen sooner.

Your child is important to us.

Despite the fact that the numbers of children in the ED are high, we want to continue to provide the best care for your child. No matter how long your wait, we want you to feel like your concerns and questions have been addressed and that you have received the personal care your child deserves. If at any point, you do not feel like you have received that level of care, feel free to reach out to us at 682-885-6698.

You may not have a pediatrician lying next to you in bed for a quick ER check in the middle of the night but we do want you to know that we are here for your child in many other ways. Start by picking up the phone and calling your pediatrician or nurse triage line. If you decide your child needs to be seen, think about trying one of our Urgent Care Centers or in an emergency, our Emergency Department.

Our providers in each area are ready to provide the best care for your child.

Previous articles, related to this topic:

• Sicker kids means longer wait time in ED
• More flu, longer waits in the ED
• Emergency? 6 signs from an ER doc
• Cook Children's to build new South Tower on main campus
• Is it RSV?
• 8 flu myths I wish would go away

A recent study done in the adult oncology world and published in JAMA, found that doctors had a perception that patients were demanding extra treatment and testing. Review of the patient encounters showed that doctors perceived demands that did not actually occur. Many of the requests that did occur were medically appropriate.

In pediatrics, the most common issue where this comes to a head is the desire to give children antibiotics. It can also play out in other areas as well. Another common one that comes to mind is request for further testing for diagnosis.

Fortunately, in my experience, parents are becoming more informed about what situations require antibiotics and which illnesses will pass with a little time and TLC.

The problem is that many doctors have gotten into the unfortunate habit of wanting to provide what the parents are requesting without actually asking the parent what they expect. Doctors may perceive that parents want antibiotics or further testing when, in fact, they simply want reassurance that waiting is OK. This becomes a particular problem in urgent care or retail clinics where patient satisfaction plays a bigger role in getting patients to come back and see you.

So, how can you prevent this from happening to you?

Here are five casual statements that you might use the next time you visit the doctor to help them understand your expectations:

1. I’m pretty sure I’m just over concerned. I just wanted you to check things out so I can be sure.

2. I don’t really like to give my kids medicine but I wanted your opinion about what we should do next.

3. I’m totally OK with waiting, if that’s what you think is best.

4. What would you do if it were your child?

5. Are there other things we can try first or other options?

Your doctor should not feel threatened by these statements. If antibiotics are the only right choice, they should be able to explain the reasons why that is.

With each injury, parents commonly find themselves asking each other, “Do you think it’s broken?”

Broken bones are one of the most common types of injuries in children that need treatment.

They most commonly occur in the arms.

They can be the result of direct contact with something but are also common with falls where the child tries to catch themselves with their hands.

A common quote, “Well, he could move it so I know it wasn’t broken.”

If only it were that easy.

Here are some signs that your child might have a broken bone (we’ll start with the obvious and move to the less obvious):

• The bone is sticking out of the skin.
• The extremity is crooked.
• There is severe swelling or pain (if leg injury, is not able to put weight on it).
• The pain is not severe but does not steadily improve over a few days.

If you find yourself unsure or you have questions, give your Cook Children’s pediatrician a call. They can do an exam to determine if an x-ray is necessary and get your child the treatment they need.

So, you have a new baby. That means your automatic, "I worry about poop" button is switched into active mode. It seems that you can't have a new baby and not worry about their stool. Suddenly, it's the main topic of conversation at the dinner table, in bed before you go to sleep at night -- anywhere, anytime is the appropriate time to discuss pooping habits. (Just remember, your child might be discussing your pooping habits and diaper changes around a dinner table in the future.)

So, what is normal poop?

We generally state that babies should be having wet and dirty diapers about six to eight times per day in the first week. However, there can be a lot of variability in this. Babies can poop every time they feed or just once a week and still be normal. You should worry if the baby is having hard stools or has a lot of swelling of their belly.

Normal stool color and consistency also varies. The color can be all over the place.

Also, straining and turning red and pushing with all their strength is normal. They're learning what muscles to push with to get the stool out. Imagine if you didn't know and were just guessing how to poop. It wouldn't go so well.

There are many varieties of normal stool but if you are concerned about your newborn’s poop, call your pediatrician.

Newborn U

Having a new baby in the house is an exciting, and generally, very happy time. It can also be a time of worry and fear. Learn more at Dr. Smith's Newborn University.

Most of the time there’s nothing to be concerned about, but I want to give you the reason why they happen and what you should worry about.

In-toeing

The most common cause is that the lower leg bone tilts outward. This might not be noticed until the child starts to walk, when parents will only notice because the foot turns inward. In addition some of the bones might be slightly rotated because of a tight fit in the womb.

These causes rarely result in problems walking. The complaint of, “My 18 month old falls all the time” is really hard to evaluate. We can generally wait a little bit to see if things improve. As the child walks, things will generally, slowly straighten out. The changes are so painfully slow that you may not notice any difference. Take pictures or videos of your child walking as these can be helpful.

As always, bring any concerns to your pediatrician but here are some warning signs:

1. Does not resolve by age 3.
2. Has a limp or complains of pain.
3. Developmental delays (walking or other).
4. Problems seem to be getting worse, not better.

Bowlegged

Another common question (usually in the first year of life) is a child who is bowlegged. This can be noticed early on but, like in-toeing, is often identified after the child starts to walk. Because of the way that babies are squeezed into the uterus almost all have some degree of “bowleggedness” at birth. Usually both legs and both the upper and lower legs are affected. This will almost always start to improve as bones remodel when the child starts to walk.

Again, take any concerns to your pediatrician, but here are the warning sign for bowed legs:

1. Is not resolved by age 2.
2. One leg is more affected than the other.
3. Child’s length/height is not growing normally.
4. The knee seems to shift outward with walking.

Most of you can rest assured that your child’s pigeon toes or bowed legs are normal. If you have questions or concerns, contact your Cook Children’s pediatrician.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

In the year 2000, measles were declared eliminated from the United States. This occurred because there was a 12-month period where no measles cases were contracted here, making the disease no longer native to the United States.

I hear this question often in my office and its logical based on the fact that measles was eliminated:

“We haven’t seen outbreaks of these diseases for years. Do we really need to continue vaccinating for them?”

The answer is yes and it's exactly because of what we've seen in the past two weeks. Measles are only a plane ride away. We live in a society with global mobility. People fly in and out of countries where measles continue to be a huge problem and then fly back to the United States. Measles are highly contagious via droplets from coughs and sneezes. In addition, people are contagious before they start to show symptoms. (Contrast that with another infectious disease we dealt with recently (Ebola) that requires blood or body fluid contact and is not contagious until there are significant symptoms.)

Continued vaccination programs protect our citizens when they travel abroad. It protects our citizens when travelers return to the United States. It helps to control outbreaks when they do occur.

Another common questions centers around the severity of these diseases.

I pulled this quote from an interview with The Today Show in Australia and Dr. Sherri Tenpenny:

“I don’t believe that measles, mumps, rubella or chicken pox are routinely fatal illnesses. If you ask any person over the age of 50…they had all those illnesses when they were children and growing up.”

There are so many false assumptions mixed in with this statement:

1. You cannot ask a person in their 50s that died from one of these diseases how serious it is.

2. Even if not fatal, the complications associated with these diseases can be very serious.

3. This completely discredits the suffering of any family member of someone who experienced complications from these diseases.

Just look at the stats. In the United States, prior to the introduction of measles vaccine in 1963:

• 3-4 million people had measles each year
• 400-500 died
• 48,000 were hospitalized
• 4000 developed encephalitis (brain swelling)

These complications don’t happen as much in the United States, but do continue to occur in areas where vaccination rates are not as high. There were 145,700 measles deaths worldwide last year. This is a 75-percent drop since 2000 due to efforts to make vaccinations available to children all over the world.

Continuing to vaccinate for measles is important because measles are serious and only a flight away ... and lately, even in our own backyard. 

This is part 2 of Dr. Smith’s series on measles. For more information about measles vaccination and herd immunity, click here.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

They are not caused by holding (or kissing) frogs but, instead, are caused by viruses.

The virus that causes warts is contagious, but that does not necessarily mean that if your child touches a wart they will get one.

Warts will go away on their own without treatment (Say it with me now.). It never feels like that when it’s your own child, but I promise they will. It may take 6 months to 2 years but they will go away.

There are many strategies for taking care of warts at home. 

Over-the-counter (OTC) Meds

1. Bath or shower
2. Use an emery board to file the dead skin on the surface
3. Apply the topical wart remover
4. Cover the wart with a band-aid

Duct Tape

Place a strip (or ring if on the finger/toe) over the wart. This strategy may take weeks or months of coverage to work, but it does work (studies even show it)

Wart removal can be done, but I only recommend it for warts that are painful or in a location that makes activities (writing, etc) difficult. 

The most common types of removal are freezing and laser therapy.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

I resolved to quit doing them years ago. Which means I quit systematically breaking them years ago as well.

This doesn’t mean that I don’t work to improve myself; I just try to do it every day and not just on New Year’s Day. Bad habits are easy to form and hard to break. This is no different for parenting.

Here are some things I am working on:

Be purposeful

I have chosen two character traits I want my children to have: grit and integrity. I want my kids to try hard to overcome obstacles and I want to be honest, whole people, even when no one else is watching.

The best way to accomplish this is not to sit down when they are 12 and have a sit-down conversation that magically imparts them. The best way is to take every opportunity now to teach them in a developmentally appropriate way. I don’t swoop in to rescue them when they are having trouble with a puzzle and I make a point to call out (in a loving way-at least most of the time) the little white lies that toddlers and young children often tell.

Be patient

My mind runs 1000 miles a minute. I get from point A to point B really quickly. Why can’t my toddlers do that as well? I also don’t like to waste time doing anything…walking up or down the stairs with a 2 year old is the epitome of “wasted” time. “Daddy come? Daddy scoot?”

I have to remind myself that my goal for ultimate efficiency can harm my kids. If I quickly take the task from them, I am taking away an opportunity for them to learn or try something new. If I end up getting angry with them for this, I’ve doubly harmed them. Why would they ever want to try something new?

Be present

This is my biggest one. I have never been the dad who is gone all the time. I am fortunate that I don’t love golf and my job does not require frequent travel, so I’m home a lot. But just because I am home doesn’t mean I’m present.

The draw of Twitter, sporting events on TV and JackThreads is just as strong (and perhaps more dangerous) than golf ever could be. It doesn’t take long for the kids to notice that you’re not paying attention and their efforts to garner that attention will escalate until they get it.

Find a place for your phone that is not disruptive, turn off notifications for non-essential apps, whatever it takes, just be present.

We can all be better parents in one way or another.

I plan to work on being purposeful, patient and present.

What can you do to be a better parent today?

Oh, and if you do want to find something useful to do with your phone, while you are hanging out with your kids ...

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

This week presented an excellent opportunity for me to return the favor.

Our family chose to cancel our usual family Christmas. Not because the kids were bad and we’re not rewarding them. Not because we were frustrated with how commercialized it has become and are taking a stand. 

Actually, the rest of our extended family all got together and opened presents on the Sunday before Christmas as usual. We just didn’t go this year.

So, why didn’t we participate?

Flu.

Since I have been a practicing pediatrician, I have somehow avoided bringing the flu home. Whether it was luck or blessing or whatever you want to call it, we have been spared, until this year. My two boys have the flu.

So why didn’t we go?

Believe me, skipping the excitement and fun of watching our kids with their cousins is heartbreaking. This is the first year that all of our kids seem to know something is different about this time of year and Christmas at my grandmothers is always one of the highlights.

But, taking a risk with the rest of our family is not worth it and it should not be for you either. If your child is sick, find some other way to celebrate that doesn’t put others at risk. 

Think about those people who are most at risk from complications of the flu: children under 5 years (especially under 2, all the new babies out there), adults over 65 years (grandma and grandpa), pregnant women (your cousin’s first baby) and people with chronic medical conditions. These are just the types of people who it’s hard to stay away from at Christmastime.

We will make the best of today and pray that we are all better come Christmas Day. You should do the same.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Flu Myth #1

The flu shot can give you the flu.

Nope. Not true.

http://www.usatoday.com/story/news/health/2013/01/14/can-flu-vaccine-cause-the-flu/1833793/

Flu Myth #2

The only time I got the flu was the year I got the flu shot.

This may be true, but it’s completely coincidental. There’s no mechanism where the shot would make you more susceptible to getting the flu.

Flu Myth #3

The flu is annoying, but harmless.

This is true for many children, but we should watch for dehydration and difficulty breathing. Kids with asthma and other chronic medical conditions should be monitored closely.

Flu Myth #4

I had the “stomach flu.”

If you had vomiting and diarrhea only, you probably had another virus. Flu symptoms are fever, cough, congestion and body aches but rarely stomach problems.

Flu Myth #5

Because the flu shot is only covering 2 strains, you should skip it.

Getting coverage for 2 strains is better than 0.

http://www.checkupnewsroom.com/does-my-child-still-need-a-flu-shot/

Flu Myth #6

Over the counter cough and cold medicines help kids with the flu.

Cough and cold medicines do not work very well for anyone and can be harmful in kids. Just skip them. Run a humidifier and if over one year, give them some honey at bedtime.

Flu Myth #7

If you suspect your child has the flu, they need to see the doctor right away.

If they are drinking OK and staying hydrated, home care can be appropriate. Certainly call your doctor before going to the emergency room unless they have symptoms other than fever, cough and congestion.

http://www.checkupnewsroom.com/more-flu-longer-waits-in-the-ed/

Flu Myth #8

Every child who has the flu needs Tamiflu.

If your child is healthy (no asthma), the benefits of Tamiflu are minimal if anything, it is expensive and there are possible side effects. Consider these factors when and have a conversation with your doctor.

About the author

 is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Get to know Justin Smith, M.D.

Justin Smith, M.D., is a pediatrician in Trophy Club  and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. Dr. Smith is an experienced keynote speaker for a variety of topics including pediatric/parenting topics, healthcare social media and physician leadership. If you are interested in having Dr. Smith present to your conference or meeting, please contact him at thedocsmitty@cookchildrens.org.

He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” open now. Click to learn more. To make an appointment, call 817-347-8100.

Breaking news concerning the weirdest week in celebrity-infectious disease history:

Peyton Manning helped lead the Broncos to victory despite suffering from a flu-like illness.

Sidney Crosby and multiple other National Hockey League stars have been diagnosed with mumps.

Angelina Jolie missed press events for the release of Unbroken, a movie which she directed, because she was diagnosed with chicken pox.

Maybe it is not breaking news. In fact, I’m pretty confident that they will all recover without any issues. Most people with any of these three diseases do.

We so rarely see mumps and chicken pox that we often forget how people used to suffer severe consequences from these diseases.

Here’s a quick reminder of some of the problems people can have as a result of these infections:

Flu

We have talked a lot about flu and flu vaccination in the past few weeks. Most children with the flu will have fever, cough, congestion and body aches,but will recover without incident in three to five days.

What do we need to watch for?

The most common problems with flu are dehydration and wheezing or difficulty breathing (especially in children with asthma).

A couple of more rare complications:

Pneumonia - Children can have viral pneumonia or a “secondary” bacterial pneumonia after the flu. (Secondary means that it comes after and as a result of having the flu. Think of it like the flu made the lungs weaker and more likely to get a different kind of infection.)

Nervous system involvement - These are rare but can involve confusion (caused by encephalitis-which is inflammation of the lining of the brain) and weakness (Guillain-Barré syndrome).

Mumps

Most children with mumps have low grade fever, fatigue, headache and muscle soreness. These symptoms are followed quickly by the most characteristic sign of mumps which is swelling of a gland in the cheek, called the parotid gland. The infection is typically more severe in adults than children.

What do we need to watch for?

Orchitis - This is a mumps infection involving the testicles. It is the most common complication in adolescent and adult males and can lead to sterility. A similar infection can occur in girls in the ovaries but is less common.

Nervous system involvement-Infected persons can have meningitis which causes fever, headache and neck pain. In addition, prior to vaccination mumps was one of the most common causes of deafness in children.

Chicken Pox

Because most of us had chicken pox and only suffered fever and the characteristic red, itchy rash, it is sometimes difficult to understand why we are vaccinating against the virus. Fortunately, that is the case for most children who contract the disease.

What do we need to watch for?

Skin infections - Because staph skin infections are so common now (and often resistant to some antibiotics), I am glad that we have a vaccine to prevent chicken pox. Any open sore, especially one that children are scratching is prone to infection.

Best advice is to stay away from athletes and celebrities this holiday season.

Ultimately, just remember that these diseases can be serious even though these celebrities should be just fine.

The official name for this behavior is pica.

Every child does it to some degree so don’t assume that there’s something wrong with your child just because they like an occasional mud pie. Who doesn't, right?

Pica is most common in children 2-3 years.

Some things to think about (but usually aren’t the cause):

• Lack of nutrients (iron or zinc)
• Developmental problems (autism)
• Normality- Usually this is it!

Why we worry about it:

• Choking risk
• Lead poisoning - Paint (especially in old houses)
• Blocked intestine - Hair or cloth
• Tooth injury - Hard things (rocks)
• Grossness (That’s why parents worry about it, not me so much.)
• Poisoning - Remember 1-800-222-1222 for poison control

What you can do:

1. Tell your child what is OK to eat!

I must say 1,000 times per day to my 4 year old (yep, we all deal with the same problems, even pediatricians): “Food and drink are the only things that go in your mouth.”

2. Lock away dangerous items and things your child “craves.”

3. Offer your child a well-balanced diet

4.  Don’t stress, but monitor as closely as you can especially in those areas where you know you child is likely to start “snacking.”

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

I just got back from a vacation at an indoor water park; otherwise known as The Land of Five More Minutes. I could not walk around without hearing some child be told how much more time they had before they had to leave.

It’s no secret that children, especially young children, have a hard time with transitions.

One great way to ease these difficult times is to set them up with a defined period before their current activity is going to stop. Another is to set clear expectations for what is going to come next and your expectations for their behavior and attitude at the time of the transition.

The conversation might go like this: “We have five more minutes, then we are going to change clothes and go eat lunch, all with a happy attitude.”

I’m pretty sure grandparents think we’re crazy for walking around at the mercy of the timers on our phones all the time but it really can work well.

Here are some ways to fail at using your timer:

1. Bargain - Five more minutes turns into one more and one more until everyone is hangry (hungry and angry) and the whole point of the timer is defeated. Besides, think about the culture you are setting up for your child. Your word and your boundaries mean nothing because they know with enough fussing they will get their way.

2. Choose the wrong time - Thirty seconds isn’t enough. Ten minutes is too long. Somewhere in-between is just right.

3. Be inconsistent - If you only do a timer once a week, it is not going to work. Your children need to know what it looks like, how it works and know that you are going to stick with it no matter what.

You may feel like a timer is the most ridiculous thing you could ever imagine (especially if you don’t have kids, because I was a perfect parent before I had kids too). If you think it is silly, that’s fine, it’s just a suggestion.

If you are doing it all wrong, make those changes.

If your kid screams every time they are asked to stop an activity, give it a try, what can it hurt?

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Some good news this week about smoking rates: Gallup reported that smoking rates tied an all-time low with only 20% of adults reporting having smoked a cigarette in the last week.

Quitting smoking is one of the hardest things to do. I have seen motivated patients put them away, but come back to them when stress or cravings became too much. Your doctor (you know, the one for adults) can talk to you about all the health benefits for you and I recommend a conversation with them. However, I think one of the best motivators for quitting is your child’s health. Here are a few of the problems that secondhand smoke can cause for your child’s:

1. Increased risk for prematurity (smoking by pregnant moms)
2. Sudden Infant Death Syndrome (SIDS)
3. Increased upper respiratory infections
4. Worse asthma-wheezing is more common and more severe
5. Ear infections

As you can see the effects of secondhand smoke exposure have a wide variety, some more severe than others. Unfortunately, strategies like smoking outside and changing shirts are not as effective as quitting altogether.

Believe me, I am willing to do anything I can to help your child with asthma breathe easier. I will use all the medicines and treatments at my disposal and ultimately put them in the hospital for more help if needed. However, the best thing you can do to help is to quit smoking.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

I won’t be thankful that I can’t sleep in due to my 3-year-old alarm clock.

I will be thankful for extended breakfast with that 3 year old and big smiles for the blueberry bagel.

I won’t be thankful for traveling in a car with 3 children (under 5) who won’t sleep by my plans.

I will be thankful that when we get there they will be with family that loves them (and for the human hurdle):

I won’t be thankful for battles over eating new and different foods.

I will be thankful for three healthy children whose business and spunkiness brighten every day.

How can you survive this week?

• Be flexible.
• Allow a little extra screen time.
• Don’t stress if they don’t eat all their food.
• Remember that a few days off their nap schedule won’t ruin their chances at Harvard.
• What are you thankful for this week?

Parenting presents many challenges and sometimes it takes a little extra effort to remember those things that we can be thankful for.

Start with some simple things…

• Health - If you child is healthy, start with that. If your child is sick this holiday season, we pray for quick healing.
• Time - Extra time sometimes means extra conflict. Your kids don’t want perfection, they want you present, so just be present.
• Fun - With added stress due to family visits, it’s easy to lose the fun for your kids. Plan an activity for them, play a game or start in impromptu dance party.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Oh, there she is, over there checking out Facebook.

Are you nervous every time her kid climbs up the ladder he might fall down and injure himself?

She’s still playing Candy Crush. Ok, let me rescue her kid from the top of the slide.

There’s new evidence to suggest that there may be some truth to your concern.

A recent study from Yale Economics professor Craig Paulson showed that, from 2005-2012, unintentional injuries in children aged 0-5 increased. He was able to correlate the increase in injuries with the expansion of 3G cellular networks across the country. Many of these injuries occurred during times of parental supervision (not day care or with other caregivers). There was no similar increase in injuries of children aged 6-10.

This trend is the opposite of the overwhelming decrease in unintentional childhood injuries since the 1970s.

While there could be other explanations of this trend, clearly distracted parenting is becoming more of a problem in today’s world.

Here are some things to think about:

1. You will underestimate how long you will be looking at your screen. Even if you look away for one task, that task will take longer than you think and you are likely to get sidetracked by something else.
2. Injuries in children often take mere seconds to develop. There may be no build up from independent play to dangerous predicament in the time it takes to read and respond to a text.

In any situation, you should be aware of how much time you are spending with your smartphone.