LYMPH NODES.

FREAK.

PARENTS.

OUT.

Let's check out some fast facts so that the next time you see a little lump in your kiddo's neck, or under the chin, or behind an ear, you take a deep breath and remember that a vast majority of the time, it's totally normal.

•  Lymph nodes are our friends.
• People often call them "glands" but they aren't really glands.
• There are hundreds in the body. Including hundreds in the head and neck. 
• They are "hotels" for your white blood cells: they temporarily house our immune cells to help us fight stuff!
• Sick? Got an infection somewhere? Even just a bug bite or a zit? Nearby lymph nodes may swell up for a bit.
• Some illnesses, like strep or mono, really commonly cause neck lymph nodes to become big. 
• Usually, lymph nodes are the size of a lima bean and are wiggly under the skin.
• Sometimes, they live in chains. Sometimes they're alone.
• Don't Google about lymph nodes. That's just a terrifying path I advise you not take. Ask your doctor lymph node questions. The Goog will just lead you astray.

What do I get asked about most as a pediatrician?

• You can ABSOLUTELY sometimes feel and see lymph nodes in your kid's neck. Kids, in general, are leaner than us, and many of the nodes are close to the surface. My 8 year old has three in his neck that I can see almost all the time when he turns his head. 
• Babies have lymph nodes in the back of their head/skull that are very easy to feel. 
• If an arm or a leg has an impressive bug bite, allergic reaction, rash, you name it - the lymph nodes that drain the area may get a little larger for a few weeks. So the groin lymph nodes (for the leg) and the armpit LNs (for the arm). 
• The general rule is, while lymph nodes may actually get large while your child is sick, they tend to shrink back to normal size in 2-3 weeks.

When do I worry?

• Sometimes, the lymph nodes themselves get infected. They can get red or pretty painful if this happens. We sometimes need to treat them with antibiotics. So, if LNs are red or very painful to touch, bring them in.
• Lymph nodes that remain enlarged after 2-3 weeks of an illness.
• Lymph nodes that are getting larger over time with no illness that seems to be causing it.
• If you notice more numbers of LNs in an area are getting large
• If a child is losing weight, is extremely lethargic (droopy and exhausted all the time), is having unexplained fevers for more than 5 days, or has soaking night sweats, come in.
•  Any trouble with swallowing or breathing

I think that's everything.

k bye.DA

Newborn Notes From a Pediatrician:

1. The hiccups are normal.
2. The sneezing is normal. It’s not allergies.
3. The booty is going to get red (baby's, not yours). This is from the constant wiping and moisture. If ulcers start to form, be more gentle with the wiping or even run that tushy under some warm water in the sink rather than wiping, and apply a barrier cream with each diaper change (Desitin, A&D, Boudreaux). Air dry booty often.
4. No amount of lotion will help that peeling, flakey skin in the first few weeks. They're like snakes - they shed that first layer after they're born.
5. No need for lotion, unless your pedi tells you so.
6. After they lay down for awhile, they often sound congested. This is usually because of reflux, which all infants experience at some point or another. I wrote a couple of articles on reflux you may find helpful: "Let's Learn About ... Infant Reflux" and "3 Important Questions Answered About Your Baby's Reflux Answered."
7. If you’ve chosen to breastfeed - congratulations on a great way to feed and nourish your child!
8. If you’ve chosen to formula feed - congratulations on a great way to feed and nourish your child!
9. Spitting up is normal now and then. Sometimes it comes out of the nose, yes. That’s okay. It’s just another hole in the head.
10. Putting the baby on a schedule is hard at first. They really need to eat as much as their brains are telling them to - and that often seems sporadic and chaotic, but it needs to happen. You can start some simple sleep training steps from day one, though. Start waking your baby at the same time every morning. And put her in the living room during the day for the first month - make sure there’s lots of light and noise in the area. Even if she’s sleeping through it, this will start to “set” the circadian rhythms - which tell her when to be awake and when to sleep. At the same time each night, turn lights low and put baby in a quiet room.
11. During the day, feed your baby at least every 3 hours. They’ll want to eat more often than that sometimes, and that’s okay. But if it’s been 3 hours, go ahead and wake her up. We want to get as many “daytime calories” in them as possible!
12. There is a very common, very gassy/grumpy phase they start around week 3. It is called the Period of PURPLE Crying. Often, during a certain part of the day (i.e., evening), they will cry, grunt, and generally look uncomfortable.You can read more about my thoughts on it here. 
13. Some babies poop with every feed. Some babies poop once a week. Both are normal.
14. It’s common for the hands and feet to be purple sometimes, especially if their leg is squeezed or they’re cold. This is called acrocyanosis and goes away with time. Always call us or an ambulance if you’re noticing any difficulty breathing, or if the tongue or gums look dusky or purple - this is different.
15. You don't have to clip the finger and toenails. You can peel or file them down.
16. Belly buttons are weird. Umbilical cords are weird. They ooze a little now and then and sometimes there’s a spot of blood on the diaper as they’re drying up and falling off. Let your pedi know if the skin around the cord is red and if that redness is spreading. Or if you feel like yellow goo oozing from it is excessive or soaks into clothes.

I know you feel alone, but know that you're not alone in your isolation these days, and there are still ways to connect. Create a safe "pod" of help and support and if you're my patient, know that I am in it with you.

It's OK to feel weird, and "off" those first few weeks or months - I did.

It's OK if you don't feel connected to your baby at first - I didn't. It was like a loud elephant was suddenly in the room.

If your feelings overwhelm you or worry you, PLEASE ask for help.

The picture you see above is of me and my first baby the night he was born. I was anxious, scared, exhausted, in pain, and I had no idea what I was in for.

Book smarts are nothing compared to experience, my friends. You will know more every minute, hour, and day.

Hugs,

Dr. Diane

Related Articles You May Be Interested In:

• During COVID-19 Pandemic, When Can You Have Visitors Over to Meet Your Newborn?
• Let's Learn About ... Infant Reflux
• 3 Important Questions About Your Baby's Reflux Answered
• Social Isolation and COVID-19 Causing More Anxiety for New Moms
• Should I Breastfeed During COVID-19 Pandemic?

As I say in this video – and I truly mean it – coming to see your Cook Children’s Pediatrician is safer, I believe, than going to the grocery store these days.

What can you expect when you come to see us?

Well:

• We ask that you call from your car before you come in. That way, there will be a room fresh, clean and ready for you
• You can complete your check-in paperwork on the MyChart app
• We ask that one guardian accompany one child for the visit
• Parent and child (if age 2 or older) should wear a mask
• You will be greeted and screened by a member of our staff when you arrive. We’ll take your temps and ask a few quick questions.
• Most days, the waiting room will be empty and you will not stop there.
• No more toys or books in the exam rooms
• All staff and providers will be wearing masks
• Super duper hospital-grade clean-down process in each room after each patient.

You know what’s a bummer? I can’t get or give my patented Dr. Diane hugs for awhile. Seriously – it’s so sad. But I await the day those hugs can come back.

Til then, we elbow-bump, my friends.

Stay healthy.

Dr. Diane

As Cook Children’s pediatricians, we are getting the forms daily. And the questions that come along with it.

“Can my kids go to summer camp this year?”

“Are we putting ourselves at risk by letting them go?”

While CLEARING your child for summer camp may be straight-forward for us, deciding whether or not they should attend camp this year can be a much more difficult question for families.

“Over time we will know more about the amount of disease in each community and the risk of being in a group setting at camp. At a minimum, camps have to maintain social distancing, wipe surfaces, enforce hand washing frequently, etcetera - and no high-risk children should attend,“ says Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s.

Some camps nationwide are choosing to hold smaller sessions, with fewer kids. Many are imposing daily temperature checks. Some are even requiring a camper be tested for the virus before starting. The American Camp Association has recently put out a lengthy guide for camps to help them comply with CDC recommendations.

Obviously, there’s no easy answer here. But here are some things to think about in making your decision (developed in part by the thoughtful physicians at Cook Children's Southwest Harris Parkway office):

1. How healthy is your child? Do they have any chronic health conditions that would put them at an increased risk of significant illness from coronavirus, such as diabetes, asthma or immune deficiency?

2. How healthy are your other household members? Is there anyone who your child has frequent contact with who is elderly or at increased risk of severe illness from coronavirus?

3. How important is this camp to your child? If it is something they feel ambivalent about, it is probably not worth the exposure. If they have been looking forward to it since last year, it may deserve a serious family discussion.

4. What safety measures is the camp taking? Is there a screening process? Are there attempts at some degree of distancing? What happens if someone gets sick during camp? It is very possible, if someone gets sick at the camp, everyone will be sent home. It’s for this reason if you do send your child, it’s best that your family plan to be available for an unexpected pick-up.

5. If your child gets sick at camp, it could potentially mean the child or family would need to be on home quarantine for two weeks. What impact would this have on your household?

As for my family? My kids are young, 4 and 6. We had plans to attend four daytime camps in Fort Worth, for 1-2 weeks each. We canceled those plans. My kids aren’t emotionally tied to the idea of camp, and while they’ll be a little disappointed, we will find other ways to get outdoors, plan some fun projects, and interact with other kids virtually (if you haven’t tried a Zoom dinner date with another chicken-nugget-eating family once a awhile…try it!).

Stay Safe,

Dr. Diane

Previously, I covered the bascis about infant reflux. If you missed that article, please click here. 

I have a few, more specific topics I promised I would go over in my previous post. 

Should We Try a Medication for My Baby’s Reflux?

This is a tough one for me to talk to parents about, because as a doctor, I really want to “fix” things for you.

I used to prescribe medications more frequently than I do now. This is because I have read recent large studies that make me worry about the future effects of these medications (see links below):

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528619/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137535/
• https://jamanetwork.com/journals/jamapediatrics/article-abstract/2676167

If we change the pH of the gut, what are we doing to the trillions of bacteria, the natural gut biome that lives inside?

Part of the job of this gut biome is to help our body learn “friend from foe,” and a large study recently found that children under 6 months who were put on medications like Prevacid, Nexium, and Zantac (there are many meds available) or any antibiotic were found to be more prone to food allergies and asthma later in life.

Is it worth the risk? In some cases, yes. Some babies are in pain daily. Some babies even lose weight because they are fighting meals to avoid the pain. If a baby is not in daily discomfort, however, I’ll often try to talk parents into trying other methods before medicating. And we talk often about weaning it off or stopping it after a few weeks.

What Is Cow Milk Protein Intolerance and How Does It Relate to Reflux?

Cow milk protein intolerance (CMPI, also known as cow milk protein allergy) happens when a child’s immune system reacts abnormally to proteins found in cow’s milk (either in formula or mom’s diet) and soy. It is NOT the same as lactose intolerance, and it leads to injury/inflammation of the stomach and intestines.

Symptoms of CMPI usually involve the GI tract, like vomiting, abdominal pain, blood in the stool, mucousy stool and diarrhea. Prolonged issues in infants could lead to wheezing, irritability and poor growth / failure to thrive and eczema. Frankly, these are sometimes my fussiest little patients, and they often cry more than most babies do.

CMPI and reflux come hand-in-hand in a lot of kids I see. I often find that eliminating dairy and soy in a mom’s diet will help the reflux as well. Sometimes, kids need to be on special hypoallergenic or amino acid formulas.

Do I Elevate My Baby At Night So They Won’t Spit Up?

I remember many a morning looking into my son’s bassinet and seeing him sleeping peacefully in a puddle of old vomit. The guilt would overwhelm me! And it happened a lot. It was hard not to want to do something different.

But no, we don’t want you to elevate your baby when they sleep. We want you to keep them flat on their backs because this is safest.

While it may seem like elevating the head off the crib makes sense, according to the American Academy of Pediatrics, “There is no evidence that healthy babies placed on their backs are more likely to have serious or fatal choking episodes than those placed on their stomachs. But there is strong evidence that babies placed on their stomachs are at higher risk for sudden infant death syndrome (SIDS).”

There is not a need to a wedge under the mattress, or elevate the head of the bed with blankets or pillows. Studies have actually shown this doesn’t actually help reflux symptoms, anyway.

I’m hopeful that the take-home point in this two part article about reflux is clear: reflux, to some extent, is a part of every baby’s life in the first year. And in MOST kids, it completely resolves by age 12 months. Talk with your pediatrician about how you can help your baby if some of the options we’ve talked about here don’t seem to help!

Hope this helps. Remember, if you still have questions about this topic to read my first article. 

Stay safe,

Dr. Diane

Normally, this is the time of year where I would write a heartfelt letter to moms for Mother’s Day. But given our unique, uh, pandemic situation … nothing is normal. So, instead, let me tell you what my heart feels.

Since mid-March, I have never felt so much like a doctor. And I have never felt so much like a mother. I have never felt – I mean really FELT, like deep in my core – those roles as much as I have these past 7 weeks.

Let’s evaluate my performance as both, shall we?

As a pediatrician, I encourage a thorough and varied education for kids and encourage parents to consistently uphold expectations.

(Yesterday, we literally couldn’t handle any homeschooling because my 6-year-old was having a tiny mental breakdown about his broken Lego set, my daughter threw her letter cards in the trash, and my qualifications as a home teacher are basically a solid nil. I propose giant pay hikes for all teachers ASAP.)

As a pediatrician, I stress the importance of a full night’s sleep. It’s so necessary to keep bedtime consistent to ensure children are getting enough!

(Says the lady who literally can’t understand how her 6-year-old can stay awake until 10 p.m. with enough energy to spare to run a small country - and I swear, child, if you get up out of bed one more time to tell me how your “eyes feel weird, not bad, just weird and I probably should watch some TV or eat something to help it oh and mommy did you know that a scorpion could probably beat a tarantula in an epic battle?” I will lose it.)

As a pediatrician, I ask you to consider socialization of your children, whether that be enrolling them in school, going on playdates, or simply a walk to the local library or park.

(OK well, yeah that’s a no right now.)

As a pediatrician, I ask you to get your children as much fresh air and exercise as possible. Minimum one hour a day!

(When it rains, when it’s too hot, when it’s too cold, or the wind isn’t right, or there is a breeze in the next state, or when just life happens - we are literal lumps. Couch lumps. Sometimes I can’t tell my daughter from a pillow. I literally lost her for 25 minutes the other day because she became a part of the couch.)

As a pediatrician, I tell you to offer your children three well-rounded meals daily. Offer 4-5 fruit or vegetable servings each day. A treat here and there is fine, of course!

(Last night, my kids ate frozen cheese pizza for the third night in a row. No fruit. No vegetable. Just pizza. And if they don’t get to pick out a piece of candy afterwards, God help us, it’s World War 3 in my household and if I hear any more screaming I may literally start bawling in the front yard so yeah, Twix bar? Sure, kid.)

As a pediatrician, I ask parents to set an example for their kids – your strength during these hard times is their strength!

(I have cried alone in my bathroom more times than I can count.)

As a pediatrician, I ask that you limit screen time for your children to less than two hours each day.

(Ask me to recite Olaf’s entire monologue from Frozen 2. Ask me. And prepare to be stunned as I have watched that movie now 54 times and now have it fully memorized. And if I desperately have to get work done? Let me tell you about my friends “Shark Boy and Lava Girl”.)

As a pediatrician, I want you to approach discipline wisely and effectively. Use positive reinforcement for the behaviors you want, and try varying methods to dissuade the behaviors you don’t want.

(Some days in my house, I yell more than I talk in a normal tone. Some days are really hard. Some days are really, really hard. I reach out to others for a break or for help on those really bad days. Click here to find resources to help you during this stressful time.)

I’m not divulging my shortcomings to you as a mother to prove anything to you other than… it’s OK, Mom. You’re human. Guess what? I am too. Just because I’m a pediatrician doesn’t mean I follow my own advice 24/7. And I certainly can’t do that during something as unprecedented as a silly little global pandemic.

Mothers, give yourself a little grace. We’ve never done this before – and no matter what that scientist or leader on television says – none of us know how long this will last. We can’t excel at all things on all days. We can only do our best as parents.

I’m here with you, and I see you trying really hard.

So if your family needs that second (or third) movie…do it. If you need time alone, it’s OK – you’re not a bad parent. If you need to just throw a frozen pizza on the table…I feel you, sister.

Use the extra time you’ve been given to soak in those children. Soak them in! Soak in their funny laugh at this age, and save all those drawings. Get in some giggles during that goofy TV show together. Watch their legs and hair curls grow longer on those walks.

Because things will get back to “normal” eventually, whatever that is for you – and those moments won’t be as visible or obvious. So soak it in! And fail sometimes with me. The beautiful part about motherhood is that if they consistently feel your love and protection, no mistake will be too great. And you can always start over tomorrow.

Here are the general rules:

1. Washing with soap and water for 20 seconds is the best method. The entire hand should be covered and scrubbed.
2. Alcohol based hand sanitizers are an alternative if they have 60% alcohol-but most are not recommended for use under 1 year.
3. Hands should be washed multiple times throughout the day but especially after having been around others, before and after feeding (bottle or solids), after the bathroom and if they are visible dirty.

Click here to learn more.

Know your babies' limits and plan ahead when making a trip outside so you can keep them well this winter.

Bundle Up

Before infants head outdoors, make sure they are wearing fresh diapers and are insulated against the cold and wet. 

"A good rule of thumb is to dress newborns in as many layers as you're wearing," said Diane Arnaout, M.D., FAAP, a Cook Children's pediatrician in Willow Park. "That includes covering their heads, hands and feet. Those areas can lose a lot of heat and be harder to keep warm."

As a mom of young children, Dr. Arnaout has first-hand experience in facing area winters with a newborn. She recomends using socks to keep tiny hands and feet warm, knit hats for infant heads and sunglasses to keep the bright winter sun out of little eyes.

Pay Attention

It's important to regularly check on newborns while you're together outdoors. Babies tend to fuss when they're uncomfortable, so if they are crying or restless while you're out and about, it may be time to move outside. 

To see if infants are getting too cold, check their ears, nose, hands and feet regularly. If your own nose or ears are cold or your lips and becoming chapped, odds and it's too cold outside for babies.

Blue skin, shivering and a cool chest and stomach are signs that children may be dangerously cold. If you see these signs, take action immediately to get kids out the cold. Seek immediate medical attention if you're not able to warm the body.

About the source

Dr. Diane Arnaout joined the Cook Children's Willow Park practice in 2011. Dr. Arnaout was born and raised in the Dallas-Fort Worth area. She served as a leader on the medical education committees during her internship and residency in pediatrics at the University of Texas Health Science Center in the Texas Medical Center at Houston, Texas.

When I first met little Pierce a few days after he came home from the Neonatal Intensive Care Unit, I noted two things: Pierce was a tough little guy, a real fighter, and his parents were two of the most caring, loving and excited first-time parents I had ever met.

So you can imagine my horror to learn that my new sweet little buddy had contracted the potentially deadly disease called whooping cough (pertussis) before he was even 7 weeks old.

Pierce was born 5 weeks early, was very small, and had respiratory distress at birth. After spending 18 days in the NICU, our little fighter was healthy enough to go home.

His parents worked really hard at getting enough calories in him daily, and I saw him in my office a lot to assure he was growing well and thriving. And he was.

A few days before Christmas, Pierce’s mom, Whitney, emailed me on our portal system to let me know he had some congestion, but seemed to be OK otherwise. Cool. No biggie! Baby’s first cold. Keep him drinking, watch for fevers, watch his breathing closely. Lots of kids have colds right now. Keep me updated.

A couple days later, he had a tiny temperature elevation to 99-100. Since he was born so early, and so small, I asked them to come in so I could check him. He looked great! So I sent them home.

Pierce’s cough was getting worse. Really junky. I checked on him again a few days later in my office. He seemed fine. We talked about what to watch for:

• A dusky color to gums and tongue.
• Chest muscles working hard to breathe.
• Not wanting to drink.
• Fever coming back.

Let me know if these things happen. I sent them home and asked them to email me updates over the next few days.

I didn’t like what I read in those updates in the next 24 hours.

“He’s starting to turn blue with this cough, Dr. Diane.”

“His cough is coming in huge fits, and it’s making him throw up.”

Pierce’s mom Whitney told me, “The moment we became super worried was when we started realizing how hard he was working to breathe. He was turning blue and dusky. He was choking. He was coughing until he would just gasp for air.”

They went to a Cook Children’s Urgent Care center that weekend, because things were getting worse. A nasal swab was done there for whooping cough, since his fits were getting so bad. The results would take a few days to come back.

But surely it wasn’t whooping cough, his parents (and I) thought! His parents had gotten their pertussis (Tdap) boosters when his mom was pregnant. And they’d asked all grandparents, aunts, uncles, and a cousin to all get their shots too. They wanted to protect their precious new baby from a known danger.

The day the whooping cough test came back positive on a Sunday, Pierce turned really blue with a coughing fit. The family went to the Cook Children’s ER immediately. I called the hospital doctor to let them know he was coming, and that I was worried about him. I sent in antibiotics for his family to take, with the hopes they wouldn’t catch it too. Pierce took antibiotics too, which made his pertussis not “spreadable,” but unfortunately this does not cure or even improve the illness once you’ve started coughing.

Whooping cough is a bacteria that we have a vaccine for. However, babies can’t get their first vaccine until they are about 2 months old. Infants are usually the hit the hardest by pertussis. They often have to be on ICU support, and 1% of infants who contract it will die.

Sweet Pierce was scheduled to get his whooping cough vaccine (Dtap) with me in my office the day after he was admitted to the hospital.

Pertussis is spread by microscopic droplets in the air. Someone coughing or sneezing near you can pass it to you. Or, just being in the same part of a room, breathing the same air, can pass the disease on to someone. It is HIGHLY contagious.

It starts with cold symptoms for 1-2 weeks. Then, the horrible coughing fits start. Adults and older kids can break ribs and pop lungs because they cough so hard. And it’s known as the “100 days cough” because it can last a long time.

Listen to Pierce’s cough in the video. You hear how he struggles to take in some breath between coughing fits? The “whoop” sound? This is how the disease got its name.

Our little hero spent a full week at Cook Children’s. He needed oxygen, fluids and supportive care. They assured he was able to drink and was breathing comfortably. They helped support him through the coughing fits and assured his oxygen levels never went too low.

“Cook Children’s was just as amazing as I knew it would be. I had heard from friends and family that the care they got there was truly the best, and we can agree with them now based on our experience,” Whitney said. “Everyone was so sweet and thoughtful. Some nurses and techs went above and beyond when they knew we were exhausted, rocking our baby so we could get some sleep. They didn’t just look after Pierce’s well-being, they looked after ours, too!”

We’re not sure how Pierce contracted whooping cough. It is such a contagious disease. It could have been at the grocery store as he napped. It could have been a well-meaning family member who hadn’t been vaccinated in a while. It could have been a bystander at the post office. Just waiting in line at a doctor’s office or sitting next to a table full of people at a restaurant can spread the disease.

Dr. Susie Whitworth, the director of the Infectious Disease clinic at Cook Children’s, told me “I wish the public understood how very safe the vaccine is, how very commonly we still see children with pertussis, and how infants still die of this vaccine-preventable disease. “

The most important thing YOU can do to protect babies like Pierce is to vaccinate yourself and those you love. The vaccine is 89% effective in children if they get all the boosters, but the effectiveness slowly wanes over time. This is why we give boosters to kids at age 4 and 11,  and why we recommend getting the vaccine at least every 10 years as an adult. So the MORE of us that get the vaccine, the LESS chance this disease can penetrate a community. And, if you’re vaccinated and do catch pertussis, several studies have shown the length and severity of illness is much less severe.

Pierce is now at home, and is feeling great. He survived a disease that so many infants do not. He came to my office a week after going home from the hospital and got his first set of vaccines. His parents told me, “We want to tell his story. We want people to understand what he’s been through. If it’s read by even one person who is on the fence about vaccines, and we change their mind, it will be so worth it.”

For More On This Topic:

• Immunization Schedule
• Calendario de vacunación
• Let's Learn ABout Whooping Cough
• Vaccines and Immunizations Information
• Pertussi (Whooping Cough)
• Is It Croup or Whoop?

So let’s talk about it, and what you can do to help it go away.

Baby eye tear ducts don’t work well sometimes.

Pull down your bottom eyelid and look in a mirror. See that little dot towards your nose? That’s part of the tear drainage system. Tears wash over our eyes daily then drain down that teeny tube into our nose.

Baby’s tubes just don’t work well sometimes, and get sticky, stuck, and blocked.

Parents often complain that one or both of their baby’s eyes are full of tears or have yellow crusts or drainage.

Tears (which are clear) almost always dry to a yellow color, by the way.

As long as the white part of the eye isn’t red or pink, it’s not pink eye (but if it is red or pink, see your pediatrician. Sometimes drops are needed).

This common problem is called nasolacrimal duct obstruction, and it’s nothing to worry about.

You often just have to wipe the tears/goo away, and with time, it’ll go away.

Sometimes we recommend a nasolacrimal massage. It’s also called the “Crigler massage.”

Take a warm washcloth and wrap it around your finger, like in my super-glamorous picture to the right.

Massage up and down a few times with the washcloth to help the duct open and the tear sac (inside the tissues in that area) loosen up. Do this maybe 1-2 times a day when the eye has been acting up.

The problem will often come and go a few times in a child’s first few months.

Very rarely, if it continues after 6-7 months of life, I’ll send kiddos to an ophthalmologist. There is an in-office procedure they can do that’ll fix the problem. I’d say maybe 1-2 out of 100 kids need this done.

Let’s talk about the satisfaction of avoiding the world’s most annoying bug (and most devastating disease vector).

So…what is the best mosquito repellent out there?

Answer: DEET. (But you’ve got options.)

I’ve said it before and I’ll say it again: DEET may not be the most natural thing on the planet, but you know what is natural? Disease. Like Dengue fever. Malaria. West Nile Virus. Chikungunya. Zika. All carried and passed by mosquitos. Super natural.

Few things I want you to know (all backed by evidence – see my links below if you wanna read more):

1. There is no product out there that is as effective or lasts as long as DEET when it comes to repelling mosquitos, chiggers, fleas, and ticks.
2. DEET comes in all kinds of concentrations – from 10% to over 75%.
3. DEET is safe. This has been proven time and again in numerous studies. It doesn't cause cancer.
4. However - it doesn’t mean that it can’t be sometimes irritating to our skin and airways, and you should be cautious with it. It can cause numb or burning lips, nausea, and headaches. But it causes more problems if ingested than just if on skin. And some people are allergic to DEET.
5. More on safety: There have only been roughly 20 cases in the world of severe DEET reactions, like a seizure or brain encephalopathy. They were due to massive ingestion of DEET (think a small kid drinking a large bottle of it).
6. DEET is safe to use as young as age 2 months. Yes, you read that correctly.
7. If your baby is 2 months or older, spray the DEET spray on your hands, and wipe it onto their body. Don’t put it on their hands or face. Use a DEET concentration somewhere between 10-30%.
8. 10% DEET lasts about 2 hours. 24% lasts about 5 hours. Sweat, rain, wiping, and swimming all make it not last as long.
9. If you need to put on both sunscreen and DEET, apply the sunscreen first, let it soak in for 15 minutes, then spray on the DEET.
10. What do I think you should use if DEET is not an option for you? Picaridin!
11. Picaridin is plant-based and almost as effective as DEET, but you need higher concentrations of it typically and it usually doesn’t last as long. Still though – a good option.
12. DEET is better than Picaridin when it comes to tick protection in particular, but both work.
13. Picaridin is often tolerated a little better by people (and clothing). It’s less stinky and not greasy, and it doesn’t irritate the skin as much.
14. Lemon Eucalyptus oil (PMD) is about one-half as effective as DEET in studies (for example, 30% lemon eucalyptus oil works about as well and as long as 15% DEET). Still more studies needed though. Don’t use this on hands or face of kiddos either; it can irritate the skin and eyes.
15. Citronella is meh.
16. The bracelets just don’t work. Don’t waste your money.
17.  Botanical oils (sandalwood, lemongrass, citronella, geranium, soybean oils) and essential oils are way inferior to DEET, Picaridin, and lemon eucalyptus. They are well tolerated with less irritation, but I don’t think I’d use these until more studies prove they work.
18. There are a lot of theories out there as to why some people get bitten more than others. Those theories include:

• Blood type
• The kinds of bacteria living on our skin
• Pregnancy
• The amount of carbon dioxide we exhale (my husband does think i'm full of hot air....)
• If you’ve recently had a beer (!!)

I use DEET on my kids and don't really think twice about it. I use somewhere between 10-20% and spray it on my hands, and then rub it on them. I avoid the hands and face. And we take a bath once we've come inside (less chance for skin irritation if it's not on the skin all night).

Hope this helps you navigate your fight against these beasts.

Dr. Diane

Below is the evidence I promised: 

• Efficacy of DEET and lemon eucalyptus compared to other products
• Efficacy of DEET
• DEET Safety in Infants and Lactating/Pregnant Women
• Applying DEET to skin does not harm fetuses
• PMD/Lemon Eucalyptus efficacy
• Picaridin efficacy
• Poor Efficacy of Citronella and most wearable bands
• Comprehensive look at plant-based insect repellents

The time has come. You and your kids spent time at the park on a beautiful spring afternoon. A few hours later, at home, the symptoms start (cue M. Night Shyamalan strange horror music). Or heck, for those really allergic, the symptoms began at the park!

• Itchy, watery eyes
• Congestion
• Draining, watery, itchy nose
• Sneezing
• Itchy roof of mouth (is this just me? Seriously? Anyone else get this?)
• Clearing the throat
• Coughing
• Complaining of a sore throat (this is due to drainage)

Congrats. See that bright green dust coating your trash cans and car? That’s pollen, and it’s now stuck to all the tiny hairs inside your nose, throat, and lung airways.

And the symptoms you’re having? That’s your body reacting to the certain pollens it doesn’t like.

Kids don’t really get seasonal (grass, plant and tree) allergies until at least age 2. I always tell parents, “your kiddo has to be EXPOSED to the planet’s seasons a few times before it can become allergic to them!”

Your child can become allergic to things like foods, pets, mold, and dust earlier than age 2 – because these are things they are exposed to daily in their home.

To help control your kid’s symptoms, there are a lot of over-the-counter medications you can try.

Listen – I’m a doc that usually says “less is more” when it comes to medication. But I do usually recommend daily meds for kids who suffer allergies, because I don’t want it to affect their happiness, or ability to get good exercise.

Start with a daily antihistamine – Allegra, Claritin, Xyzal, Zyrtec, Benadryl. If your child suffers from a lot of nasal problems like sneezing and congestion, add on a nasal steroid spray like Flonase or Nasacort.

There are also many types of antihistamine eye drops out there you can use daily to treat or prevent the itchy and watery eyes.

Here’s the thing – they’re often PREVENTATIVE. So, use them DAILY during the times of year you or your child suffer to PREVENT the symptoms from showing up.

You can dive further into treatment with your pediatrician – there are a few prescription options you can try to further help the problem.

If your child has asthma, it’s even more important to come up with a treatment plan with your pediatrician. These kids sometimes can have full-on asthma attacks this time of year if that’s a common trigger for them.

And do what an old, wise allergist once told me – “the minute you and your kids come in from playing outside, hold your heads over the sink, and spray nasal saline up in the nose to irrigate the nose and rinse out all the pollen!” You could also try this in the shower.

Makes sense to me! Try it! And good luck out there!

Lots of RSV. Last week of the 422 kids tested at Cook Children's, 137 had RSV and six had Flu A. 

So there's probably lots of coughing at your house as you prepare for your Thanksgiving travels. But keep this in mind: Coughing is good. GOOD! Here's why:

1. We need it! Coughing helps us to perform the "clean-up" process with each and every cold. If you don't cough, the mucus gets in the chest, and that's how pneumonia happens. So...most of the time, cough is Ok! And you can expect it for at least 7-10 days with colds.

2. Sometimes if kids have a hard cough, they gag and puke. While this is scary, it's OK and sometimes a normal part of the process. Always let us know if this seems to be worsening/happening more often though. Or if your kiddo has a new fever with it, or seems more fatigued.

3. Coughing with viral illnesses (colds) tends to happen more at night and first thing in the morning. This has to do with the physics of the postnasal drip when we lay down, and in the mornings we do a lot of hacking to clean up all the sludge that settled in the airways overnight.

4. Sometimes, people worry about "feeling the cough in the chest". This is often due to how air rolls over mucus in the nose and tree trunks that go to the lungs (bronchi) and doesn't necessarily mean anything is wrong. If your kiddo is happy and playful and otherwise well, let it be.

5. Don't be frustrated if your kiddo coughs up some wet stuff, and then swallows it. People try really hard to get their kids to spit it out - it's OK if they don't. We cough, swallow that mucus, and then poop it out. This is why many people get looser stools with colds (adults and kids). 

That is why when Cook Children's asked me to write something about what Star Wars means to me today, what with it being Star Wars Day (May the 4th Be With You), I may or may not have squealed and jumped up and down (while sitting in full Han Solo costume, of course)!

Star Wars was a fun movie series that I started watching in my teens. None of my friends were into it...my family didn't seem to care much about it...but I loved it! What a fun story about a galaxy far, far away!

It got my mind out of the stress of college and medical school. The characters were fun, hilarious, and sometimes complicated. The plot was always fast and the lines between good and evil were so clearly drawn (and yet...sometimes not so clear?)

Let's face it. Star Wars, like any well-made movie series, is a great way to escape.

Now that I have kids, Star Wars is even more fun. While they're still young and the movies may be still a little too scary for them, my son and I have racked up HOURS of conversations about why Darth Vader (um only the coolest guy ever to a 4-year-old) is on the Dark Side, who gets to own a lightsaber, and what kind of creature is Jabba the Hutt? Halloweens are full of fun costumes.

I have found that Star Wars has been such a fun connection to have with my patients, too! When a shy 5-year-old will not make eye contact with me all I have to do is pretend that tongue depressor is a lightsaber and....we're besties having a lightsaber fight!

And I publicly apologize to the mother of the 8-year-old last week who had to endure a conversation her son had with me about the shocking events of "The Last Jedi" for the entirety of his check-up 

And I'm not the only one! I've connected with so many other Cook Children's providers who are die-hard fans, too! NP Tara, Dr. Peak, Dr. Gray, Dr. Perry, I'm looking at you ...

And I mean, is there any better way to live your life than by the quotes of the Master Yoda? "The greatest teacher, failure is," is my new mantra.

Sure, in the end, it's just a dorky movie universe. But is there a more fun way to connect with people you might not otherwise connect with? Loving the same characters, the same story ... it's allowed me to grow close to others in so many ways.

May the Force Be With You!

Hugs,

Dr. Diane 

Both allergies and colds share a lot of similar symptoms:

• Sore throat
• Runny nose 
• Sneezing 
• Coughing 
• Feeling tired 
• Feeling achy

Honestly, it can be hard even for us to tell the difference when we examine kids.

HOWEVER, you don't get a fever with allergies. If you have a little fever (or a big fever), that's most likely a cold.

ALSO,  "itchiness" in general of nose and eyes, makes me think more allergies than cold.

AND, the time is important - Did  it come on really quickly? That's most likely a cold. Has it been going on for months with a slow onset? Most likely allergies.

Both allergies and colds can make you more susceptible to other problems like ear infections and sinus infections. That's why we say if your symptoms are lasting longer than 2 weeks, come in and see us so we can help.

"How do I know what to do?" Well, that depends on a lot of things.

Is your child under age 1? If so - this is more likely a cold than allergies (a child has to be alive longer than a year to develop allergies to their environment). Elevate the head of their crib. Stick a blanket under the mattress. Would you want to lay flat on your back with a bad cold? Suck out all that snot with a Nose Frida (dont knock it til you try it). Use saline drops. Tylenol (or ibuprofen if over 6 months) for the headaches and throat pain. Run a hot shower and sit in a steamy bathroom for a bit. And lots of lovins. There ain't much you can do for the tiny ones. They just have to push through it.

If they're over age 1 and they have what seems to be a cold, try some honey along with all of the above. It's been proven to help just as much as medication. There are some over-the-counter medications that have honey in them too. I wouldn't try cold medicines until they're at least 4. Studies don't even show that they help much.

If it's allergies - you have lots of over the counter options like Benadryl, Zyrtec, Claritin, and Allegra. Some nose sprays are also very helpful and we can prescribe those in the office. And there is a prescription medication called montelukast that I find can help some kids.

Also, a wise allergist once told me that if you rinse out your kid's nostrils when they come indoors, it helps a lot (it washes away all the allergens/pollens clinging to the hairs in the nose and really helps symptoms go away faster). You could also try nasal saline spray here and just have them hold their head over the sink.

Hugs!

Dr. Diane

Let me be real for a second – it’s been a pain in the you-know-what. We’re updating, changing, training, stressing. I may or may not have purchased more wine this month than usual.

Why are we doing this?

Because it’s better. It’s faster, more efficient, more organized, and SAFER than our old systems.

We are doing it because it will lead to better overall care for your child.

I’m actually really excited about it. As a pediatrician, my days revolve around a computer. Many of you may notice I always bring a computer into the room with me. I show you how your kiddo has grown. I take notes to remember important things you tell me. I look up what happened in the hospital when you went to the Cook Children’s ER. I read that consult note from when your child saw the ENT.

The way I do those things will be changing.

Things will be new and glitchy at first – just like any big change is -- but overall, the improvements in your child’s care will be awesome.

But… what does all of this mean for you and your children?

It means that, for a little while, you might experience a bit of a longer wait in the pediatrician’s waiting room, or urgent care, or ER as we learn to use the system.

You might experience slightly longer hold times on our phones while my staff is figuring out how best to schedule your kiddo’s appointment.

Our front desk people have to get used to the changes in booking appointments, changing charts, and updating your insurance information. Don’t worry, it’ll speed up with time.

Our nurses might need a little extra time to type in what medications your child is on, their medical history, and your concerns. Again – this’ll improve quickly.

It means that I, as your PCP, will be able to know every single thing that happened to your child in the hospital (as opposed to a tiny summary that doesn’t give me much information). Every single vital sign, oxygen reading, X-ray, lab result, consult note – I’ll have access to all of it! I may fumble around for the first few days when I try to show you things on my computer. Feel free to giggle at me.

It means that your child’s specialists and I will be able to communicate more effectively.

It means that YOU will have a new portal system called MyChart.

This thing is awesome!

• You’ll be able to look up your child’s vaccine records and print them, see summaries of all of our visits together, and ask me (and my staff) direct emailed questions!
• You can look up test results, see lab work, and find out when your next appointment is!
• Go to www.cookchildrens.org/mychart for more information - You can sign up now!
• It means that we will be SAFER – more safety checks on prescriptions, and constant updates to how we calculate and order things.
• It means it will be less of a hassle for us to get your child’s medical records from many hospitals around the country.

Bear with us, friends, as we embark on this new journey. I promise, it makes a difference in your child’s care.

And feel free to bring us some sympathy chocolate at the office on March 1st…. ;-)

We doctors call them "aphthous ulcers" because we cannot use names in medicine that are easily pronounceable. Come on.

My son Jack marched up to me this morning and announced, "Mama, there's a raisin in my nose!"

And that sucker was pushed in real deep. 

I didn't have any of my fancy extraction tools at home to get it out, so I'm gonna let you in on a little secret I learned about in residency: the "Mother's Kiss." Google it. It's great for getting out small things wedged up your kid's nose.

You close the "open" nostril and blow into your child's mouth. The pressure pops the object right out. It needs to be the "force of a sneeze"... whatever that means.

It worked beautifully for me today. I actually changed it up a bit and closed his mouth while I blew into his "open" nostril (I know...the things we do for our children). I was able to blow it out just enough to reach in and grab it.

Hope this helps you in your time of crisis 

Hugs,Dr. Diane

I should call this: "The Eustachian Tube - Dictator of Ear Happiness." More later on that.

Few things I want to put out there first:

1) There are two kinds of ear infections: middle ear infections (otitis media - the type you get tubes for) and otitis externa (outer ear infection, no tubes for this)

2) "Water in the ear" from a bath or pool typically does NOT cause middle ear infections! It CAN cause something called "otitis externa," or, "swimmer's ear," which is an ear canal/skin infection that may require ear drops to improve. I'm not going to talk about that kind of ear infection today. From here on out when I say "ear infection," I mean the middle-ear kind.

3) Ear infections are incredibly common. Do NOT freak out if your child gets one. Five out of six kids will have at least one by their third birthday (and most will have more than one).

4) A "red ear" does not mean a child has an ear infection.

5) A "baby messing with an ear" does not necessarily mean they have an ear infection.

6) A fever with your child's cold does not necessarily mean an ear infection is happening. The only way to know if your child has an ear infection is to have the ear drum examined by a medical provider.

Why do ear infections happen? Well....snot. And inflammation. Snot and inflammation from colds. Snot and inflammation from allergies. Snot and inflammation from just walking into the door of daycare or that play date.

The inflammation blocks a vital little guy called a eustachian tube. Look at the picture to the left. Find the eustachian tubes. See how they're a little exit canal for the inner part of the ear? They drain the ear. An infant's eustachian tube is smaller than an adults', and more horizontal. That causes problems. It just doesn't drain well.

It swells up, gets blocked off, and the snot in the middle ear has nowhere to go. Once the cold or allergies are better, it de-swells, opens up, and voila!, ear infection is gone. All the junk drains out. The baby's eustachian tube is different than an older kid's, or adult's. This fact along with the fact that babies and toddlers are snot machines and always putting things in their mouths - that's why they get more ear infections. We hope they "outgrow" this eustachian tube problem (and hands in mouth problem) by age 2-3.

It can take 3 weeks to 3 months for the fluid to drain out of the ear. And your kiddo may have an ear infection and you'd never know about it, and that's ok - because they usually get better on their own! Most ear infections are VIRAL! That means the fluid just has a virus in it, and it will all go away on its own thanks to our great immune systems.

When I look into a child's ear, I examine the ear drum to know if they have an infection or not. When there is no infection, an ear drum is translucent, kind of like a shower door. When it is infected, it is red, bulging out, and full of what looks like pus. Sometimes this is just viral fluid. But sometimes, while that eustachian tube is all swollen and blocked off, the liquid stuck in the inner ear gets bacteria in it. We can tell the difference by looking in there. And that is why some children need an antibiotic for some ear infections. To kill the bacteria while we wait for the eustachian tubes to un-swell.

So...who needs "tubes?"

There are a few things that cause kids to get lots of ear infections:

1. Being in a child care setting (lots of kids...lots of snot).

2. Secondhand tobacco smoke exposure (as if you needed another reason to quit).

3. Taking a bottle to bed (when the child lays down and drinks, the milk actually puddles in the area where the eustachian tube meets the nose/throat and causes swelling and bacteria to hang out back there - this habit also causes cavities - no bottles in bed, folks!!)

Some kids have really tiny eustachian tubes that stay really swollen all the time. If they're around other kids a lot, like day care, they get tons of colds each year, and that's normal. However their little eustachian tubes mostly stay swollen shut, sometimes for months at a time. And we see them in our office 1-2 times a month for repeated ear infections.

I guess a "rule" I follow is that if a child gets 5-6 bacterial ear infections in a year, or more than 3 months of constant fluid in the ear, I will send them to the Ear-Nose-Throat doctor to get tympanostomy tubes (or just "tubes", as most people know them) put in. This brilliant procedure creates a little "canal" for the fluid to escape from the inside of the ear. They fall out in about a year, when we hope they've "outgrown" the problem.

Sometimes, I send a kid to ENT if I've put them on 3 or more rounds of antibiotics and they're still having fevers and still in pain and I just can't get that dang fluid to go away. Who wants a kid on antibiotics for that long!? Another reason to see the ENT is if the fluid is making it hard for a child to hear. When a small child can't hear, they can't learn to speak. I've seen kiddos get ear tubes and within 1 week they are talking up a storm! It's amazing.

However, surgeries and anesthesia comes with risks. If you're worried your child has had too many ear infections, talk to us. We will let you know if we think it's time to see the ENT.

Wow...this was long. I hope it helped you learn something about one of the most common ailments we see in the office!

Tetanus is a nervous system disorder that causes severe muscle spasms. It is caused when a spore that is in the soil, known as Clostridium tetani, gets into damaged skin. It will not grow in healthy tissues, which is why things such as splinters and other puncture wounds, burns, and certain fractures put the body at risk for it. Once inside the body it produces a toxin that irreversibly attaches to the spinal cord and brain stem, and after a few days the symptoms begin.

I can’t imagine many diseases that would make me feel more helpless than if I watched my child in the grips of tetanus. It starts with restlessness, sweating, and rapid heartbeat. Later it progresses to the inability to open the mouth due to muscle spasms (lock jaw). They have episodes of intense and painful contraction of muscles and intense muscle spasms that can be triggered by stimuli such as physical touch, light, or sound. It would be so terrible to try to comfort my child and triggering an episode of them arching their back, clenching their hands, straightening their legs, and holding their breath. The worst part is that there is no change in their awareness, they know it is happening, and they know that it hurts.

The muscles surrounding the throat and lungs can even stiffen to the point that they may need help breathing as well. They are usually monitored in the intensive care unit due to this, and also for the need to control pain.

An intensive care doctor told us the story of a young unvaccinated child with tetanus: “She was walking outside with her parents in a large field, and cut her foot on something. Soon after, she started having muscle spasms in her calves. They got more and more intense, so her parents brought her to the hospital.” The child ended up needing intensive treatment, including numerous rounds of painful treatment injections. The parents finally realized how important vaccination was when she was transferred to the ICU because there was concern she would need assistance with her breathing.

How long can the symptoms last? A long time. The toxin attaches to the nerve and requires the new nerve growth until symptoms resolve, usually around 4-6 weeks. The main treatment is trying to control the pain, and ensuring they continue to breathe.

The bad news is that we can’t eliminate the element in the soil that causes tetanus, and we certainly can’t protect our children from open wounds.

But we CAN give them a vaccination that can prevent this terrible disorder!

Related stories:

• The Flu Can Kill
• It's only the flu that killed her
• Chicken pox: Why We Vaccinate

About the author

Sperry Binnicker is a nurse practitioner at Willow Park. Sperry joined Cook Children's in 2009 in the Pediatric Intensive Care Unit (PICU). In that role, she earned the Daisy Award, an award given to a nurse that is nominated and selected by the parents of patients for excellence in patient care. She continued her education while working full time and received her master’s degree from the University of Texas at Arlington in May of 2015.She is a Board Certified Pediatric Nurse Practitioner and a member of the National Association of Pediatric Nurse Practitioners. Learn more about the Willow Park staff here.

She is a sweet and happy baby who loves to babble ("mamama"... be still my heart!), pick up small toys and explore them slowly, play peek-a-boo, pick up her tiny foods with two fingers, point, laugh, and clap.

Things she cannot do? Crawl with her belly off the floor. Pull up to stand, or really put much weight on her legs at all. Shift from sitting to crawling to sitting again. Cruise along the furniture while holding onto it. She has delays in what we call “gross motor development” – the development of the “big movements.”

I see patients all the time at our Willow Park office that have gross motor delays, so I know not to worry. Lots of things can contribute to this. Sometimes it's just genetics. Sometimes it’s the baby's weight-to-height ratio. I notice that leaner, smaller kids tend to develop these movements faster, and bigger, longer kids sometimes need more time to build the strength to try these things. As you can see from the pictures, Abby has not missed any meals. There are exceptions to every rule of course, but I think this plays a role.

The baby’s temperament can also lead to delays. Some kids want to go go go...and some are completely fine with sitting still and working with what is in a close vicinity. Abby certainly fits into this latter scenario.

Of course there are numerous medical conditions that can cause motor delays. Always make sure, if your child has delays, to ask your pediatrician for a good neurological exam to check things like muscle tone.

Unfortunately, I believe what has played a big role in Abby’s delay is the amount of time she has spent in her favorite jumpers.

Baby jumpers, bouncers, exersaucers, and activity centers (they’re all basically the same thing) are stationary devices that allow a child to “stand” and bounce prior to developing those skills naturally. Kids love them because they’re fun and stimulating – most have toys and games attached – and they get to see more of the room and things going on around them, along with getting a chance to bounce up and down easily. Parents love them, because, let’s face it – they’re a quick and safe option for a break.

Baby walkers are similar – except they are on wheels so babies can bounce/pull themselves around the house. I have never owned one of these because they come with safety risks – children can fall down stairs, tip over, touch a hot stove, get pushed by siblings, pinch fingers, and slam into walls in these devices, and as fun as they seem, they’re not a good idea.

Around 4-5 months we started putting Abby in a jumper and she was thrilled! Finally she could be propped up and see everyone! She could control her body enough to bounce, and loved it. We were happy too, because we were constantly chasing her 2-year-old brother around, and it was nice to have a safe place to plop her down while that happened. Admittedly, it became a habit. When we’d read books, Abby would be propped up to be able to see the pictures. When we’d sing songs and play music with her big brother…Abby would get to howl and jump along in the bouncer. When we had to deal with the 2-year-old tantrums (and boy are those frequent)…in she went. Emptying groceries? Bouncer. Going to bathroom? Bouncer. Cooking dinner? Boom. Folding laundry? Ker-splat. She was probably in them a total of an hour to an hour and a half a day.

Looking back, she was in the bouncer way too much. Learn from my mistake, friends. Yes, pediatricians make mistakes.

Other doctors may think these things are harmless, but I respectfully disagree. Especially since I suspect my own child has likely been affected. Physical therapists have been warning parents for years about the problems with bouncers. And the more I’ve researched it, the more I’ve realized that too much time in these things can be detrimental to a child’s development.

I spoke with Gail Abaray, a pediatric physical therapist in Weatherford, who told me, "Bouncers don't allow infants to explore and move. They are limited in what they can do, and are stationary. And that pull to explore is so important. When they cruise the furniture, they learn about lateral movement, and how to turn their legs and feet. In a stationary bouncer, all of that coordination can't happen."

Look at the picture of Abby in her favorite bouncer. See how she’s on her tiptoes? This is typical and leads to the majority of the strength being recruited from her calves and thighs. What is not getting a workout is her hip, gluteal, pelvic and core muscles – and these are the ones that help children crawl and eventually walk.

Their hips are spread unnaturally wide by a piece of stiff fabric. They often lock their knees, especially the younger babies.

Babies cannot see their feet or the ground in these devices either – and thus cannot coordinate their body well in them.

Their upper bodies are also thrust forward – taking all the pressure/weight off their gluteal and hip muscles. The very muscles they need to strengthen.

The same things happen in walkers – babies are pulling themselves along while most of their weight is supported, and this works out and coordinates all the wrong muscles. They also can’t see the ground or their feet. “Walkers” are a true oxymoron here – they lead to delays in walking naturally.

So what do I recommend to parents now? Well…go buy a bouncer! They’re great! But – use them in moderation. Don’t put one in every room, like I did – it’ll only lead you to use them more. Use it only for very short periods of time – maybe 15 minutes here and there, once or twice a day – 20 or 30 minutes a day, max! Physical therapist Gail agrees: "I always tell parents not to feel guilty for using them. I did! But moderation is key!"

And avoid walkers in general. I am not convinced they’re safe or worth the money.

Don't feel guilty if you've put your baby in a bouncer - we all need breaks. And it's hard to deny they're so happy in them! But remember the big picture - kids need to learn to explore their environment on their own. It's vital to their development!

As for miss Abby-pants? Well, we got rid of all the bouncers and for the past month have set strict tummy time rules – she must work for toys on the floor for nearly the entire day, and must practice standing several times a day. She yells at me about it all day, but boy has this tough love helped. She has already shown vast improvements. She is now able to stand supporting herself on a piece of furniture, can quickly army crawl (using her arms mostly), and is starting to lift that big belly off the floor! We are also enlisting the help of a local pediatric physical therapist to help with some exercises and strategies. Slowly but surely, she’ll get there!

Hugs,

Dr. Diane

Constipation is the cause of alllllll the things. Just joking.

No, but really – it’s one of the most common things I see in my office at Willow Park, and it causes strange problems sometimes. Parents often don't believe me when I tell them it's constipation causing the problem. 

What is constipation? It doesn't necessarily mean your child isn't stooling daily. A kiddo can be constipated and poop many times a day. Constipation means hard, dry stools. They’re often painful to push out. And yes, most kids with constipation will go a few days between stools.

I really feel that constipation has become more prevalent over the years because of how our kids' diets have changed. In general, kids are eating less fresh fruits and veggies and depending more on packaged goods for snacks and meals. 

There are lots of medical causes for constipation as well. Did you know that hard poops can cause:

1. Stomach pain
2. Withholding of stool
3. Vomiting
4. Refusal to eat
5. New urinary accidents
6. Wetting the bed
7. Diarrhea
8. Poop accidents 
9. Blood in stools, blood in diaper
10. Fever (yes it can cause fever! mostly lowgrade)

Here's the deal - and let's get down and dirty about it. The things your kids eat affect the quality of their poop. If they eat and drink things that don't have much fiber (think cheese, yogurt, pastas, cookies, white bread, bananas, milk, goldfish crackers), their stools will be harder. 

Also, did you know our bodies absorb water out of our stools if we need it? So if your kiddo isn't drinking enough water, his body will just take it out of the poop, and it will become hard. 

The poop gathers at the “end of the tube” in a child’s body – the rectum and descending colon – and stretches everything out a lot. See the pic. This chronic distension leads to problems with the “valves” inside the rectum. Sometimes, this leads to leaking – soft stools can leak out without the child being able to control it. 

These big bulky stools can also push on neighboring organs, like the bladder, and even push urine out sometimes. And children with chronic constipation tend to develop poor control of their pelvic muscles and can lose control over their bladder, leading to leaking. One study showed that after being treated for constipation, 89% of 250 kids had complete resolution of their daytime wetting problems.

When the stools become hard, they hurt to push out. So kids don’t want to poop. So they hold it in. And the body slowly takes water out of it. And the stools get harder. And more difficult and painful to push out. Thus starts the painful cycle. 

Kids can get constipated anytime, but I find it’s most common 1) when babies start solid foods, 2) when kids start potty training, and 3) when kids start school.

So how do you fix the problem? Well, that depends on the severity of the problem and the age of the kiddo. But some general rules:

1. WATER. LOTS OF IT. Children and teens should drink at least 6 to 8 cups of water a day. 
2. Fresh fruits and veggies! I encourage kids to eat green veggies, prunes and other fruits (but not bananas), bran, whole grain bread. Sometimes those puree pouches with the kale, spinach, and broccoli are a good start for the picky kids.
3. Certain fruit juices – ok, we pediatricians are NOT big fans of juice. But I’ll make an exception in this case – go with prune, or pear.
4. Fiber supplements – flax seeds are great. Fiber gummies and cookies are good, too.
5. Behavioral and schedule changes – encourage a routine for “potty time”. 20-30 min after meals, have your kiddo sit on the toilet for 5 minutes. Encourage your child to listen to his body and stop playing when he feels the urge to “go” (and not hold it in). 
6. Do not punish your child, or get mad, if he has an accident (urine or stool) – remember, this isn’t under his control!
7. Avoid those foods I mentioned before for a few days – bananas, cheese, crackers, milk (if over age 1), breads, pastas.

If there is anything I can’t express enough to parents – it’s BE PATIENT! It takes many months for the intestines to stretch out and constipation to form in toddlers and children, and it takes many months (sometimes even years) to treat it. Sometimes we use safe laxatives or glycerin suppositories to help during the really rough patches – call or come visit us to talk more about that if you think its necessary. 

Hugs,Dr. Poop (er, Diane)

One way to narrow this down is asking, "What part of your head is hurting?" and "What does it feel like?" (Note! These are some very general guidelines and don't apply to all headaches. Most headache causes however can be found in one of these categories.)

Migraines are typically a one-sided severe, throbbing and intense pain occasionally accompanied by nausea/vomiting and sensitivity to light. Migraines have a genetic component though so we typically want to know about family history of headaches. They can be triggered by things such as: stress, hormones, dehydration, hunger, and lack of sleep.

What about neck/back of the head pain? Think about what is causing those muscles to pull and strain and cause you pain. Heavy backpacks are a BIG offender. Also, body positioning is huge. For example, staring down at the phone/iPad all day? (AKA every teenager). How about arms not on a level surface when studying? What happens is their shoulders are pulled up all day while they study, creating unnecessary tension and/or pain in the neck and shoulders. Oh, and don't forget heavy ponytails too!

Front of the head/forehead pain: Pain here can be caused by eye strain, so let's start by checking their vision. This type of pain can also be caused by allergies/sinus infections, especially if tender to the touch.

General causes of headaches: The number one reason I see headaches is dietary. Not drinking enough water and not having good protein for breakfast or before exercise is a large factor. This can also make them dizzy and feel faint.

Sleep!! I don't care what or how much you change in your life, if you don't sleep enough you are going to get headaches (I have tried to work around this rule- ya just can't). Most children need 9-11 hours of sleep, depending on their exact age.

Some red flags are: severe headache especially with fever or neck pain, headache that is progressively worsening and not responding to usual treatments, waking up in the middle of the night with a headache, early morning headache especially with vomiting, or any with neurological symptoms (not walking right, personality changes, weakness, decreased vision, etc).

Now, not every headache fits exactly into these categories. This is just a general outline to give you some things to take note of before the visit. I have also included a headache journal that, if you filled out before your visit, your provider would do a happy dance for you!!

We are always happy to talk about your headaches and want to do that. I want this to help make your visit and discussions with us more productive! It will be if we have already been taking note of these common types and offenders.

- Sperry, NP

About the author

Sperry Binnicker is a nurse practitioner at Willow Park. Sperry joined Cook Children's in 2009 in the Pediatric Intensive Care Unit (PICU). In that role, she earned the Daisy Award, an award given to a nurse that is nominated and selected by the parents of patients for excellence in patient care. She continued her education while working full time and received her master’s degree from the University of Texas at Arlington in May of 2015.She is a Board Certified Pediatric Nurse Practitioner and a member of the National Association of Pediatric Nurse Practitioners. Learn more about the Willow Park staff here.

Then, I was blessed to have a beautiful son...

….who decided that I needed to be re-taught a few things about children.

And by a few things, I mean everything.

Don’t get me wrong – you don’t have to be a parent to be an excellent doctor. I still dish out the same advice. The books and studies are spot-on and I’m going to give it to you straight. Breastfeeding does provide the best nutrition for babies. But I understand the pain you’re going through to meet that goal. And I understand the frustration of having a child who just won’t latch on. And I understand now why you look at me, with a crazy twitch in your eye, when I tell you to try an extra pumping session a day to build up your supply, mama. I hated that thing, too. Can anyone say “dairy cow”? And guess what – formula isn’t poisonous. I wasn’t physically able to meet my full breastfeeding goals with my kid – there’s no judgement here if you grab that can. And it’s okay if it makes your relationship with your child happier, healthier and more fulfilling.

Our car seat remains rear-facing at 18 months. It’s been proven to be five times safer than forward-facing. I’m sorry for my lecture during your little one’s checkup. And oh yes, I too want to rip my hair out when I can’t reach over far enough to give my kid that 400^th toy to keep them quiet on the trip to grandma’s.

“Crying it out” was a tough one for me. Pre-child, it was so easy to coach parents - encourage them to drop the constant rocking, the running into the nursery at all hours of the night, the fear of allowing their child to cry in order to learn put themselves to sleep. Then I went through it with my son. Let’s just say I give the same advice now (it really does work) …and recommend a glass of wine for every 15 minutes of crying. I probably cried more than my kid did. Motherhood helped me give this advice with a much softer tone. I get it, mom and dad. And I feel your pain (and exhaustion).

Pacifiers – I missed that thing so much. So, so much. Oh man I missed that thing when it had to go. I think I needed one myself when the time came to get rid of it.

As for the well-rounded, healthy meals I recommend offering your child throughout the day – I now understand why there are food shortages in some parts of the world. It’s because all that food is currently on the floor of my kitchen. Where my son threw it. I get it. And I’m here to help you find tricks to make things better. Tried and tested in my own home.

In all seriousness, motherhood has been the most exhausting, challenging, humbling thing I’ve ever experienced. But I can say without a doubt that it’s made me a better doctor for your child. Because helping you get through those everyday challenges is a huge part of what being a pediatrician is all about.

I recently polled some physician mom colleagues to get their take on how motherhood changed them:

• “I am that much more in awe of the composure, patience, faith, resolve my patients' families have, especially considering how chronically sick the kids are that I see, and how too not-infrequently, limited the treatments are. I see my son in every patient. Everything is different. Every heartache is my heartache. Each illness, each story seems to hit home that much harder. I am so so appreciative.”
• “I am much more empathetic and practical in some advice. I think that I am much more emotionally available post having kids and can understand a variety of stresses parents who go through NICU may encounter.”
• “You come to understand that "by the book" is not always what is possible in real life!”
• “I feel like when the kids have a tougher diagnosis - cancer- it hits closer to home and I hold my kids a bit tighter. Likewise, little pearls and tricks that I used help make it more of a village caring mentality for the family which has been lost over the last 30-40 years.”
• “My medical advice is not too different, but I understand the unspoken worry so much better now. So I try to address the emotional stuff first in ways that would not have occurred to me pre-kids. Now I'll directly say things like "you are a good mother even if you need to use formula," or "this lymphadenitis/rectal bleeding/etc is NOT cancer," or "they are not dangerous, but constant viral illnesses all winter TOTALLY SUCK.” I think it has made me a much better pediatrician.”
• “One of my favorite attendings in peds residency told me, as I was a mess after coming back from maternity leave with my first, that a little part of your heart will always be on the outside, dangling like a vulnerable little wisp in the wind that is parenting- and that little wisp makes you so much stronger and so much softer- all for the good....it's so true.”

Happy Mother’s Day, everyone!

"My mom used to say, 'When God closes a door, He always opens a window.' I have found that to be true many times in my life. My life as a pediatrician is a result of crawling through an open window when the door I thought I was supposed to walk through was closed to me."

Jason Terk, M.D., Keller, Keller Parkway

"Florinda Peak, the most amazing Mommy in the world, to 5 year old Dr Sandra Peak who did not want to practice reading… 'You have to learn how to read…because when you do the whole world opens up to you!'”

Sandra Peak, M.D., Lewisville

"The best advice my mother ever gave me was to give to others without expecting anything in return. (She also told me to never go outside with wet hair because I’d catch a cold, but medical school later disproved that. Sorry mom.)"

Diane Arnaout, M.D., Willow Park

"The best advice my mother ever gave me was, “never miss the chance to use a perfectly good bathroom” when you are out of the house."

Audrey Rogers, M.D., Fort Worth, Forest Park

Nicole Wineriter, M.D., Keller, HeritageTrace

"My mom told me to respect (be nice) to the nurses because they can either make or break your day."

Samuel Sheng, M.D., Arlington Neighborhood Clinic

"Encourage others. She always wrote notes to people for accomplishments, during sad times and just because."

Justin Smith, M.D., Lewisville

And finally, our favorite advice ...

"Marry Joan."

Tom Rogers, M.D., Forest Park. Dr. Rogers and his wife Joan have been married 59 years and today, she is a proud mother. "Joan worked to pay my way through medical school, gave me two great kids who are both pediatricians, and has allowed me to work without having to pay attention to small things like finances, maintenance of our house and yardwork. I couldn't be where I am today without her," Dr. Rogers said.

Happy Mother's Day from all of us at Cook Children's ...