Since he was 2 years old, Gaites Fisher has had trouble breathing. In addition to severe asthma, Gaites has a condition in which his right aortic arch compresses his trachea, making it difficult for him to breathe. His mom, Angelaka Johnson, tried everything to help; she bought an air purifier, tried to track what triggered his attacks and researched endlessly for solutions to his asthma attacks.

But despite her best efforts, Gaites still ended up being hospitalized six times between the ages of 2 and 5. Allergies or a cold would sometimes trigger the attacks, and she would quickly find child care for her other two children and rush Gaites to the hospital.

“(I felt) like I failed as a mom because I couldn't get his asthma under control. And I didn't know how to help him more,” she said. “And I always felt so defeated having to go to the hospital, knowing we’ll probably end up staying overnight.”

In June 2025, after another hospital stay at Cook Children’s, Angelaka got a phone call about a program that aimed to help her and her son with his asthma.

“I didn’t know what to expect. I thought we would just be on the phone and she would give me info that I already had; that it would be more redundant,’ she said. “And it ended up being a lot more helpful than that.”

The Cook Children's Healthy Homes Program, which celebrated its 10-year anniversary in January, provides free resources, support and education for families and children with severe asthma. Since its inception in 2016, staff have served 1,556 children across the eight-county service area. The goal of the program is to identify and manage the source of kids’ asthma - like dust, dander or mold - and keep families from getting to the point where they need emergency care.

Marquietta Jones was formerly a Healthy Homes program coordinator for eight years and was recently promoted to care coordination supervisor.

She explained how families are brought into the program. Community health workers reach out to families who have had multiple asthma-related emergency department or urgent care visits in the previous six months. The staff reach out to the family and schedule either an over-the-phone or in-person assessment and questionnaire about their home environment and asthma history.

Over three months, families get free one-on-one support by a community health worker to identify home environmental triggers, secure supplies and services and, if needed, obtain referrals to social and medical support.

Angelaka says she was a little skeptical when Community Health Worker Cristina Cantu took her through the assessment, but she quickly realized Healthy Homes didn’t just talk about resources and support; they followed through.

“Usually when you do these things where people say they aren’t going to charge you, they make you jump through hoops to get the things you need, or it wasn’t the things you need. Where in this case, they kind of over delivered. I was surprised,” she said.

The most common triggers for asthma are respiratory infections, weather changes, pollen and dust, but it can be difficult to narrow down what factors in a home exacerbate those triggers. For example, dirty A/C vents, dusty ceiling fans and leaky sinks are all commonly overlooked household issues that can make asthma worse. A large part of the Healthy Homes program is educating families on how to identify and clean those problem areas.

Angelaka had done plenty of research on her own about how to help her son’s asthma, but he still often had flare-ups that sometimes led to hospital visits. The mother of three is a full-time graduate school student, and Gaites’ asthma and hospitalization were hard for the entire family.

To help with Gaites’ breathing, Angelaka bought an air purifier, cleaned the house frequently, monitored his time outside when the weather changed and tried to track his triggers. So when Cantu from Healthy Homes called to talk to her about asthma, Angelaka wondered what the community health worker could tell her that she hadn’t already looked into herself.

But Cantu did not just dump information on Angelaka; she asked her questions. Through the program’s opening assessment, Cantu and Angelaka were able to figure out what she was already doing and what other resources could help further. Then, Healthy Homes provided those resources.

For example, Cantu taught Angelaka how to make her own cleaning solution that seems to be healthier for Gaites. Angelaka used to clean with a standard, store-bought cleaner and assumed any kind of dust removal was helpful for her son. But when she switched to the other cleaner made with Castille soap, vinegar, baking soda and hot water, she noticed he seemed to be coughing less.

Similarly, Angelaka didn’t realize that not all air purifiers clean the air in the way her son needs; Jones recommended an air purifier that has both a carbon and a HEPA filter. Healthy Homes gave Angelaka this more powerful air purifier, which she said has made the biggest change.

“I can’t explain enough the difference the air purifier makes,” she said. “It has definitely made a difference to me. When he’s in here, he’s playing, he’s not coughing, not sneezing. When he comes in from playing in the backyard, the air is clean in here.”

The Healthy Homes’ website includes a plethora of information and tips on identifying and managing asthma triggers. 

Perhaps most importantly, Cantu gave Angelaka emotional support. Gaites is on the autism spectrum, and Cantu showed Angelaka a Facebook group for moms of children with autism. She checks in with the family about once a week and sends Angelaka info on community resources. She and Angelaka created a binder with all of Gaites’ medical information, triggers, and emergency plans that Angelaka gave to family members, babysitters and Gaites’ school.

The binder of emergency information has made Angelaka more confident that Gaites’ teachers or school nurses will be able to help him if he has a flare up. That sense of security has made it easier for her to focus in classes, because she’s not constantly worried about him.

“When you’ve exhausted all your other resources that you may know on your own to do, it's good to have a program like this that helps you find resources…so that you can be more proactive instead of reactive with those asthma symptoms,” Angelaka said.

Healthy Homes is intentional about providing that all-encompassing support for families, Jones said. Aside from providing families with supplies, the program can provide resources for financial support and other basic needs. Community health workers give parents information about all kinds of community resources, not just those related to asthma. And with monthly check-ins throughout the three-month program, community health workers help families feel less isolated.

Beyond the initial improvement in child’s asthma, community health workers want families to be empowered to continue that care for the rest of their lives.

“We encourage our parents to be advocates for their child,” Jones said. “We want to be able to empower those parents to find ways to eliminate those triggers and to make sure everyone that's in contact with that child is on one accord.”

About 9% of the children in Cook Children’s eight-county service area have asthma. While serious, asthma is manageable.

For families who don’t qualify for the full program, Healthy Homes mails out information that includes a link to the Healthy Homes website. The website has videos on common asthma triggers and medication methods, as well as downloadable booklets available in nine languages.

For families like Angelaka's, the Healthy Homes program can mean all the difference for kids with asthma. On average, families who go through the Healthy Homes program have a 75% decrease in the number of emergency room visits, according to Healthy Homes’ data. In the six months since Gaites completed the program, he has not been to the emergency room at all.

This is a change, his mom said, from the two visits per year he has had since he was 2 years old.

Angelaka said she’s glad that Gaites and his siblings can focus on just being kids instead of worrying about being sick.

“Because he likes to run, he likes to run and he likes to jump. And that means a lot to me for him to just be happy and to just play without worrying,” she said.

If your child has asthma, you can check out Healthy Homes website for resources on identifying and managing asthma triggers.

Michael Ramirez’s asthma has landed him in urgent care multiple times after asthma attacks that scared him and his mother. Recently, he visited Cook Children’s new clinic focused on helping kids with asthma: the Nelson Ku High Risk Asthma Clinic.

The clinic is named in honor Nelson Ku, an 11-year-old who died after an asthma attack in February 2024. Nelson’s parents, Peter and Beth Ku, are working with Cook Children’s to educate families, schools and sports organizations about the serious health impacts of asthma and the tools available to intervene when a child experiences an attack.

The clinic addresses the needs of high-risk asthma patients, both in a one-on-one clinical setting and through community education.

Kate DeVore, LCSW, Case Management Social Work Team Lead, was one of the social workers who introduced an initial quality improvement project that came before the high risk asthma clinic. Three years ago, she and her colleague Sarah Pitman, LMSW, started to identify barriers to care among kids who sought emergency care for asthma attacks. The goal was to reduce hospitalizations by helping patients and families manage their asthma.

“Sometimes a patient is in the hospital a lot because they have bad asthma, but sometimes it's because they don’t have access to their medications for a variety of reasons, or they don’t understand why they need their medications or how to use them correctly,” DeVore said.

Karen Schultz, M.D., medical director of Pulmonary Services at Cook Children’s, proposed a multidisciplinary program operating out of the multi-disciplinary clinic space on the third floor of the Dodson Specialty Clinics Building.

Patients are referred to the program if they meet the criteria to be considered “high-risk;” by having a certain number of visits to urgent care or the emergency room, hospitalizations or PICU admissions due to asthma.

Michael’s Urgent Care visits are why a doctor referred him to the clinic. When he and his grandmother, Yolanda Ramirez, arrived at the clinic, they met with the team of pulmonology clinicians and hospitalists. As the six-year-old played with plastic dinosaurs (his favorite is the Pterodactyl), Michael was evaluated by the team.

First, the respiratory therapist took Michael for a pulmonary function test, followed by an evaluation by Sara Gill, RN, who is the program coordinator. Miriam Alexander, M.D., a hospitalist, saw Michael next, followed by Child Life Specialist Abigail Hoekstra, who brought along “Asthma Abby,” a doll who helps the team demonstrate asthma symptoms. DeVore wrapped up the clinic time with a biopsychosocial assessment.

Together, the team seeks to figure out why a patient’s attacks are happening, how to better manage their asthma symptoms and possibly prevent future attacks.

Michael’s grandma said the visit was helpful in learning more about his triggers and his medication needs. For example, Michael will now take his inhaler every day instead of only when it seems like he needs it. They also plan to make sure the school has a spacer he can use with the inhaler. She also appreciated that the team gave her printouts of a lot of the information, so she can share it with Michael’s mom, who had to be out of town for the appointment.

Michael’s mom also has asthma, and Yolanda said it would have made all the difference to have the same resources for her daughter that her grandson now has. When her daughter first started having respiratory issues as a young girl, Yolanda did not realize it was asthma. It took a few months for her to realize what was going on and get the treatment she needed.

For his part, Michael said he listened to the doctors and that what they told him will help him with his asthma.

“Everybody was talking with him,” Yolanda said. “He’ll start asking a bunch of questions, sometimes random, but they’re listening to him.”

So far, the clinic is only open on Fridays, but that may change in the future. It has been open since May 2025 and the team has seen 88 kids so far. The team hopes that each family takes away a better understanding of their asthma triggers, care and management.

“Asthma is on such a spectrum,” said Gill, who herself has asthma. “It can be very manageable but it can also be so severe. A lot of people don’t take it that seriously until they’re hospitalized. I would like to be able to get a lot more education out there and get it to the point that they are taking it more seriously and have the education they need to stay out of the hospital.”

The clinic’s reach also stretches far beyond the hospital walls. Patients and families have access to Cook Children’s Healthy Homes Asthma Disease Management Program, which sends community health workers into patients’ homes to manage triggers.

A large portion of the program is focused on creating more partnerships with community groups and schools. The Nelson Ku High Risk Asthma Program will join existing programs, like Asthma 411, and the School Nurse Symposium in June, as well as pursue new collaborations.

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A Breath of Fresh Air: Cook Children’s Healthy Homes Program Transforms Lives of Children with Asthma

Nelson Ku didn’t just attend school, he starred in it. The hallways and classrooms of Fort Worth’s All Saint’s Episcopal School were center stage for his uncanny ability to make his friends and classmates laugh. Nelson was known as a smile maker and deeply loved for it.

“Nelson loved going to school because of his love for his classmates,” said Nelson’s father, Peter Ku, D.D.S., a long-time Fort Worth dentist and a member of the Board of Trustees for Cook Children’s Health Care System. “He loved hanging out with them. His love for his friends is why he enjoyed so much being silly and trying to make others laugh.”

So when an asthma attack during Lacrosse practice took his life in February 2024, it devastated the All Saint’s community and left Nelson’s father, mother, Beth, and big brother, Marshall, reeling from their loss. Nelson was just 11 years old when he died.

“That morning I woke up and got ready to go to the office, kissed him in the back of the head and said, ‘Nelson, I love you.’ And he said, ‘Dad, I love you too,’” Dr. Ku said. “I never imagined I’d get a phone call at 4 that evening and never hear him again.”

It’s a call that no parent can fathom, and many question how anyone could go on after. Yet, while still walking through their own deep sorrow, the Ku family is finding comfort and purpose in their faith in Christ and in bringing awareness to the complications of asthma.

Finding Purpose in Tragedy

Dr. Ku and his wife, Beth, believe proper training and education, coupled with the use of rescue tools, could have made a difference in Nelson’s life that day. In hopes of saving others, they are working with Cook Children’s to educate families, schools and sports organizations about the serious health impacts of asthma and the tools available to intervene when a child experiences an attack. The couple hopes asthma rescue medications and resources will one day be as standard in schools, on practice fields and at every sporting event as automatic external defibrillators (AEDs) are today.

In June, Cook Children’s officially launched a new program to help children and families better manage asthma and its hidden threats. It’s known as the Nelson Ku High-Risk Asthma Program. The goal of the program is to identify and address the barriers to asthma care and symptom control of children who often seek care for the condition in the emergency department. The program aims to give them the education and tools they need to reduce the severity of their attacks and the need for hospitalization.

“We're glad to be able to recognize Nelson, but we don't want it to 100% be about him,” Dr. Ku said. “We want his story to make a difference. We want his story to inspire others to say, ‘Hey, asthma is important. We're going to do whatever we can to better protect our kids when it comes to this stuff.’ We’re trying to do things that make a difference.”

The Ku family wants parents, educators and coaches to know that asthma is a serious condition that cannot be taken for granted.

“I would imagine death from asthma isn't one of the higher children's fatality statistics, but at the end of the day, one life being lost to asthma is too many, which is, in my opinion, very controllable,” Dr. Ku said. “I love that the high-risk clinic allows those kids who really struggle with it to be able to find some hope in it.”

A Life Well Lived

In his 11 years, Nelson lived a lot of life.

When he wasn’t making his friends laugh, he did his best to pester his big brother, as most little brothers do. Although separated by a significant age gap, Dr. Ku says the brothers were “two peas in a pod.” They often spent time together down by the creek on the family’s property.

Marshall has a special memory of helping his little brother collect creek water to view under his new microscope, evidence of Nelson’s inquisitive nature and affinity for science.

“His favorite subject was science,” Dr. Ku said. “His science teacher told us that he would go to her classroom after school and when he had breaks to sit down with her and ask questions regarding things from outer space to creation to the human anatomy.”

In addition to collecting smiles from his friends, Nelson curated an impressive assortment of stuffed animals, including a life-sized plush black cat that became his favorite of all. Dr. Ku estimates he had about 15 piled high on his bed and would nestle into them every night.

“We would call it his nest,” Dr. Ku said. “He would put all his stuffed animals around and just kind of scrunch in the middle of all that, plus have covers on him. Looking back, it just showed his innocence, and I love that about him.”

Like it was for Nelson, that sweet collection of stuffed animals is now a source of comfort for his parents, reminding them of their son’s quirky nature, and in true Nelson fashion, bringing a smile to their faces.

The Nelson Ku High-Risk Asthma Clinic, named in honor of their beloved son, brings them a sense of solace, too.

“It means a lot to be able to find purpose,” Dr. Ku said. “I don't know how families do it if they aren't able to find how to utilize a tragic event to make a difference. It brings healing and it brings comfort and, honestly, in my opinion, it brings significance to nothing.”

RELATED STORIES:
A Breath of Fresh Air: Cook Children’s Healthy Homes Program Transforms Lives of Children with Asthma
Nelson Ku High Risk Asthma Clinic Provides Hope and Help to Families

What is the Healthy Homes Asthma Program?

The Cook Children’s Healthy Homes Asthma Program, created in 2016, has helped thousands of families across the eight-county service area identify and minimize asthma triggers in the home. The goal is to manage the source of kids’ asthma -- like dust, dander or mold -- and keep families from getting to the point where they need emergency care. 

Weather changes, pollen and dust are the most common triggers the team identifies. The team will walk families through specific areas in the home that can become hot spots (like bedding, window blinds and ceiling fans) and how to manage them. Marquietta Jones, the program coordinator who has been a CHW for six years, is a big proponent of getting the kids involved in that cleaning process. 

The program is not just a conversation about cleaning, though. Healthy Homes provides education, coordination with community services and long-term planning to empower families to tackle their child’s asthma head-on. 

“Our families not only get the education, but they get it while walking hand-in-hand with the community health worker -- someone who is by their side to help them parse through the tons of information we’re inundated with and figure out which pieces are most applicable to them, putting it into practice.” Courtney Barnard, director of the Healthy Homes Program, said. “That’s where we see the success: in that the families walk away not only knowing more, but feeling confident that they can continue this beyond their time in the program.” 

The program begins when CHWs reach out to families who have had two or more emergency department visits or three or more urgent care visits in the past 12 months for asthma. The staff explain the program and schedule a home assessment. During the over-the-phone or in-home assessment, the CHW reviews the child’s asthma history and explores triggers that may be present in the home environment. 

Over three months, families get free one-on-one support by a CHW to identify home environmental triggers, secure supplies and services and, if needed, obtain referrals to social and medical supports. 

Families receive supplies like air purifiers, vacuum cleaners, mattress encasements, cleaning supplies and more. The team provides air duct cleaning, pest control and carpet cleaning free of charge for families. Through one-on-one coaching, families can talk through questions they should ask their doctor, how their child can be active safely and medication needs. 

One popular tool the team created is the action plan binder, which families say they use for years after leaving the program, said RoseMary Ragon, another CHW with Healthy Homes. The binder includes all the child’s medical information and a plan that lays out what to do for each stage of asthma symptoms. 

The team provides referrals to local social services, as well. Cristina Cantu, another CHW with Healthy Homes, said the team listens to the needs of the families that go beyond managing their asthma. 

“Our goal is to improve the overall health and wellbeing of the child by helping families address all the other needs they may have, like medical and dental providers, food, utility assistance, and counseling,” Cantu said. 

‘’It's About Having the Education"

Since 2018, Healthy Homes has enrolled 700 kids in the program and another 715 children who did not qualify for the full program have been provided with education and follow-up services. 

The data behind Healthy Homes is evidence of its success: families in the program saw an 85% decline in emergency room visits in the 12 months after enrollment. But the full impact of the program is even more apparent in family’s survey responses, which usually mention their CHW by name. 

One person wrote that their son was in the hospital at least every three months, and sometimes four times a month, for asthma attacks. But the CHW on their case helped them clean the air ducts, gave them an air purifier and cleaning soap that helped control his asthma. 

“[My CHW] and this program was such a blessing to my family…” they wrote. “My son hasn’t been to the hospital since with asthma related problems. Thank you sooooo much for the help and guidance.” 

“Mold and dust removal was the best thing,” another participant wrote in their survey. “[My CHW] was such a big help and she really went above and beyond informing me of all the asthma triggers. She is very well informed and that is what really helps, having the right people that want to help and not just doing a job. Thank you for all your staff members.” 

Jones said she loves those “aha” moments where a family discovers something simple, like changing a child’s clothes after they play outside, that makes a huge difference for their child’s asthma. 

“It’s about having the education, if you don’t know, you don’t know. It's not a curable disease, but it's manageable,” Jones said. “It can be something simple and they’re like ‘I didn’t think about that.’” 

Jones, Ragon, Cantu and Valcourt all emphasized the bond they form with their families, and the glow they feel when families become empowered in tackling their child’s asthma. 

“When your child has asthma, you have that overwhelming feeling, like ‘oh my gosh, what do I do?” Valcourt said. “To me, the biggest thing I take away from it is knowing that after they leave the program, most of the families say, now I can manage the treatment in the home.” 

For families who don’t qualify for the full program, the program provides education that can be just as life changing. The website has videos on common asthma triggers and medication methods, as well as downloadable booklets available in nine languages. The CHWs walk families through all of that information. 

Ragon said families have revisited the videos for years because of how useful they are.

“I get a lot of feedback on that video; Families who have had a child with asthma for years will say, ‘I learned new things from this,’ and keep referring back to it, just like that (Action Plan) binder,” she said. “And they can always give us a call."

Next Steps 

The Healthy Homes Program is also looking beyond care in family’s homes. The goal is to educate school nurses, P.E. teachers, coaches, teachers and others about asthma and how to keep kids safe while being physically active. 

“Asthma is not a death sentence, there is so much people can do to help,” Barnard said. “We want parents to feel empowered that they have a lot of options that they can do to help their child. And we want to make sure they know what those are and how to do it.” 

Overall, the team hopes people leave the program with an understanding of managing asthma triggers, a good plan with their physician, an Asthma Action Plan and, most importantly, knowledge and confidence. 

Jordan Walker Ross’ childhood was filled with regular visits to Cook Children’s Medical Center – Fort Worth.

If that name sounds familiar, there's a good reason. You’ve likely watched him make theatrical magic as he morphs himself into characters spanning multiple genres, from the disciple known as Little James in the faith-based drama “The Chosen,” to Mikel, the resilient cowboy in the TV Western “1883.”

Jordan comes by his acting chops naturally. He is the grandson of Emmy-award-winning actor Barry Corbin, best known for his role as rough-around-the-edges town developer Maurice Minnifield in “Northern Exposure.” You’ve also seen Corbin in “Urban Cowboy,” “War Games,” “Yellowstone” and “Lonesome Dove,” to name a few of his many stage, television and film hits.

“He’s following along in my footsteps. Lord, help him,” Corbin said. “I always tell people if you find something else that you’d be happy at, go do that, because it’s a lot easier. But he chose to go the hard way and I’m proud of him.”

Jordan’s journey from his home in Texas to Hollywood success hasn’t been easy. He had big hurdles to climb long before his first acting audition.

Born seven weeks early on February 8,1990, Jordan estimates he spent at least four weeks out of every year as an inpatient at Cook Children’s for treatment of severe asthma, likely the result of his underdeveloped lungs from prematurity. Jordan also has cerebral palsy and severe scoliosis.

His first admission to Cook Children’s came when he was 3 for a serious bout of meningitis, which his younger sister also contracted.

“They were just babies and in two separate hospital rooms,” said Shannon Ross, Jordan’s mother. “So I would put on all of the gear and go into Jordan’s room and check on him and play with him for a little while. Then, I would go into another room where I would get sanitized and put on a new gown and go see my daughter.”

The Ross siblings recovered from their shared illness, but that hospital stay marked the beginning of a relationship that would carry Jordan into adulthood.

“It was just part of the routine,” Jordan said. “I would have an asthma attack and my nebulizer or inhalers wouldn’t help so it was like, okay, cool, we’re going to Cook Children’s. It was like a second home to me.”

Magical Connection

It was at Cook Children’s that Jordan says he first experienced a similar magic to what he now creates on screen. The type of magic where everyone understands the special role they play in a common goal.

What is that common goal? Connection.

In Hollywood, it’s about connecting with the audience through storytelling. At Cook Children’s, it’s about connecting with children and their families through kindness, generosity, respect, collaboration, safety and imagination.

“The environment at Cook Children’s is just magical,” Jordan said. “That’s a perfect word for it because even from the outside with the blue peaks and the bushes trimmed in different animal shapes, they’ve done such a good job making it feel like such a fun, happy and magical place, even though you are there for sometimes scary things.”

For Shannon, the most memorable magic happened when Jordan was able to venture outside of his hospital room and explore spaces throughout the medical center while riding in a little red wagon. 

“The kids loved riding around in the wagons,” she said. “You put their IV on the IV pole on the back and you could just go all over the place. You go down to the lobby and they’d have people coming in to sing or do magic tricks. And then there’s the store. It was like going to Toys R Us. It was just the neatest thing in the world.”

Everything for the Child

Jordan’s visits to Cook Children’s were often a family affair that included his mother and grandfather.

Like many of the characters he’s played, Corbin was a stalwart presence at his grandson’s side. He’d often sit outside Jordan’s hospital room and read the newspaper. Far enough to stay out of the way but close enough to keep watch over Jordan and his mom. Their constant presence, Jordan says, was a source of comfort and security.

So when Jordan had a severe asthma attack and found himself inside the emergency room of a Los Angeles hospital two days after his 18th birthday while working in California, Corbin and Shannon rushed from their homes in Texas to his side. Despite Jordan having asked the staff to call his mom and breathlessly repeating her number to them just before being intubated due to an extremely low blood oxygenation level, the staff initially declined to give Shannon information about her son’s condition, citing his status as a legal adult. After working through the red tape, Shannon and Corbin were eventually reunited with Jordan. They found him lying on a stretcher in the hallway of the emergency department days after his admission. He was alone and connected to a ventilator.

It was a stark contrast from the safe, family centered, everything-for-the-child approach to care that Jordan and his family say they were accustomed to at Cook Children’s, and it took them all by surprise.

“Cook Children’s is an anomaly,” Shannon said. “It’s not like other hospitals because it was able to make a really negative and scary experience a positive one. You almost forget you’re in the hospital and that is huge for a parent, kid or grandparent. I never realized that until years later when Jordan aged out of Cook Children’s and went to an adult hospital and that changed everything.”

Shannon had Jordan transferred to another LA-area hospital as soon as possible. She also reached out to his long-time Cook Children’s pulmonologist who cleared the way for Jordan to be flown back to Texas and admitted to Cook Children’s when he was stable enough to make the trip.

“Coming back from LA, when I saw the blue peaks at Cook Children’s, it was just the biggest relief,” Jordan said.

Dynamic Duo

Now, for the first time, Jordan and Corbin are sharing the screen as co-stars, recounting their Cook Children’s story. Although far from the lights of Hollywood, it was a job they were both more than willing to do having experienced Cook Children’s care and kindness first-hand.

“The doctors and nurses at Cook Children’s have a personal relationship with each patient. It’s their mission to treat your child like it is their child,” Corbin said. “Jordan is a naturally empathetic person. You don’t learn that. It’s something you have or you don’t have. He had it to start with, but I think his experiences at Cook Children’s enhanced that and made it stronger. A lot of that empathy has to do with his treatment at Cook Children’s.”

That connection Jordan felt as a child under Cook Children’s signature blue peaks continues now that he has three children of his own. When they are sick, he and his wife turn to Cook Children’s for their kids’ health care needs. Jordan says their periodic visits are a full circle moment for him. The nostalgia he feels reminds him that, just like he was all those years ago, his children are in good hands.

“I remember our first trip there with my kids was like going back to my childhood home,” Jordan said. “A huge chunk of my formative years was spent there. Getting to go back and see it all again from the perspective of a father was really special, and it was nice to see it hadn’t changed. The care and environment are still the same.”

Breathing in secondhand smoke isn’t healthy for children, whether the smoke comes from tobacco or marijuana.

Many of the same toxins and irritants in tobacco smoke are also present in marijuana smoke, according to the American Lung Association. Children who are exposed – at home, in the car or in other places – are indirectly inhaling any particles the smoke contains. No amount of secondhand smoke is safe.

What concerns doctors about secondhand smoke? “It can lead to chronic cough, mucus production and infection,” said Alice Phillips, M.D. at Cook Children’s Pediatrics Cityview. “If the child has asthma, it could trigger an asthma attack.”

It’s an increasingly common experience for Dr. Phillips to smell marijuana when patients and their families come to appointments. She detects the marijuana scent on parents and caregivers, as well as in the clothing of young children.

“In the past, I might have noticed one to two times per month, but now it is multiple times per week or even per day,” she said.

Daniel Guzman, M.D. encounters the marijuana odor on three or four patient families every shift he works in the Cook Children’s Emergency Department (ED). Dr. Guzman said he initiates conversations with those families, particularly if the child came to the ED with breathing problems. He points out his purpose is to share the medical perspective -- not invade anyone’s privacy.

“If they’re coming in for asthma issues, then I always have that conversation about smoke, whether it’s cigarette smoke or marijuana smoke that affects the lungs. We know short term that it can lead to more chronic asthma-like issues and other respiratory problems for these children,” Dr. Guzman said.

Education

Secondhand smoke falls in the category of preventable injuries that Dr. Guzman works to reduce through education. Maintaining a smoke-free environment can be compared to proactive safety measures like car seats, gun locks and lifejackets that are meant to keep children safe.

“That’s where the grassroots of all this starts. You make a change in one person, it can have a significant downstream effect, which can be life-changing,” he said. “It’s just a matter of continuing to have that conversation.”

As part of the routine exams with her teenage patients, Dr. Phillips discusses the risks of smoking, vaping and drug experimentation. Because recreational marijuana is illegal in Texas, the scent can pose a tricky situation in the pediatrician’s office. Parents aren’t always completely open when Dr. Phillips brings up the topic. She tries to communicate in ways that stick to the facts, avoid judgment, and demonstrate concern.

“I am the kids’ doctor but also their advocate,” Dr. Phillips said. “As doctors, we must walk the delicate tightrope of partnering with parents in the care for the kids.”

The American Lung Association advises:

• No one should be around secondhand marijuana smoke.
• Anyone exposed to secondhand marijuana smoke can have detectable levels of tetrahydrocannabinol (THC) in their systems. THC is the psychoactive or mind-altering “high” ingredient in marijuana. 
• Don’t allow smoking at any time or place children are present.

Dr. Phillips points out that children look to the adults in their lives for guidance.

“Little eyes are always watching,” she said. “Just like we need to eat our vegetables to encourage good eating habits, we need to stay away from things which might be harmful to ourselves or potentially encourage the same habit in our kids.”

By Michelle Bailey, M.D.

I’m writing this from home, dressed in three layers and with all unnecessary electrical items turned off. I’m anxious about when the power may go in and out, and if the water will continue dripping from the faucets. During extreme weather, with doctor’s offices closed, it may be worrisome to think about what you would do if your child is sick.

Right now with the power on, I am available, as are many other Cook Children’s Pediatric and Urgent Care clinics, to do telemedicine Zoom or phone visits. But if a medication is necessary, you’d still be responsible for going into a pharmacy to pick it up. Under some extreme circumstances, there are a few things you can find in your medicine cabinet to use in a pinch. Of course, follow any doctor recommended advice and call 911 if your child is having a medical emergency that needs immediate assistance.

The following is simply what can be done - if absolutely necessary - in extreme circumstances: 

• Heating formula or breastmilk bottles: While it’s nice to have a bottle warmer, if the power is out, it is not necessary. Your baby can and will drink milk even if it is cold. So go ahead and offer pumped breastmilk from the fridge, or mix formula powder with room temperature nursery water or even bottled water from the fridge. Room temperature breastmilk or formula should be consumed within 1-2 hours.

• Vomiting: The main goal is to keep your child hydrated. If you have powdered electrolyte solution on hand, such as Pedialyte powder packs, use this. Otherwise, offer frequent sips of water. Motion sickness medication and antihistamines, such as Dramamine and Benadryl, can also offer some relief to nausea and vomiting.

• Fever: If your child’s temperature is above 100.4F, use a weight-based dose of fever reducing medication. If you are out of medication, use natural ways to reduce temperature such as removing a layer of clothing, place cool wet rags to the forehead, armpits and back, and offer sips of cold water, popsicles or even yogurt. There is no “brain boiling” temperature, but you will want to keep your child comfortable by lowering their fever. Remember, fever is an actual thermometer measured temperature of above 100.4F, not just how warm your child feels.

• Wheezing, coughing, fast or difficulty breathing: If your child is in respiratory distress, call for an ambulance. If they are having a worsening cough or wheezing and you have a nebulizer and albuterol medication at home, start using it as directed on the prescription. It is always helpful for your child with asthma or wheezing to have a backup albuterol inhaler and spacer, in the event power goes out and you cannot use the nebulizer machine. If it has been awhile since you put together the nebulizer and tubing, here is a refresher video, click on the “using a nebulizer” tab: https://cookchildrens.org/pediatrics/McKinney/Pages/video-library.aspx. And in the most extreme of circumstances, if your child is wheezing or having trouble breathing and you are out of nebulizer medication, and/or or power is out, and you don’t have the albuterol inhaler, and you can’t drive to the emergency room, and 911 says they are 30 minutes away…. you get it, worst of worst scenarios, then offer your child some coffee or other highly caffeinated beverage. Caffeine is a weak bronchodilator, which can reduce respiratory muscle fatigue and can improve lung function for up to two hours. This is not to say coffee or soda is a replacement for your child’s prescribed inhaler, but it can make a difference when minutes matter during an impossibly unprecedented situation.

Again, call your child's pediatrician FIRST and speak to the doctor or nurse before trying any of the above. Please stay safe and stay warm!

Moderate to severe asthma is a possible risk factor for severe COVID-19 disease according to the Centers for Disease Control and Prevention. But a COVID-19 infection can cause a flare up of even mild asthma. COVID-19 is a respiratory virus and contracting an infection with any respiratory virus can trigger an asthma flare-up. In fact, the most common cause of an asthma flare-up in children is a viral respiratory infection.

What does my child with asthma need to do to stay healthy during COVID-19?

The single most important thing a child with asthma can do to stay healthy during COVID-19 is to control their asthma. Here is a list of some important ways to keep your child with asthma healthy:

1. Control their asthma.
2. Wash hands frequently with soap and warm water for 20 seconds, especially before eating or drinking or touching any part of their face.
3. Avoid being around people who are sick.
4. Maintain a social distance of 6 feet outside the home.
5. Wear a face mask in public (if the child is older than 2 years of age and is able to remove the mask by themselves).
6. Absolutely no smoking or vaping inside or around a child with asthma. Now is a great time to try quitting by calling 1-800-QUITNOW!

In addition, make sure to track when the asthma medications need to be refilled so the child does not run out, as this can trigger an asthma flare-up. And keep an extra supply of the child’s quick relief medication (usually albuterol or levalbuterol) at home in addition to the one they are using.

What is “asthma control”?

Children with controlled asthma are less likely to develop an asthma flare-up when they are exposed to one of their triggers, like a viral respiratory infection. Asthma control also means almost no day-to-day asthma symptoms. The symptoms of asthma are wheezing, coughing, chest tightness and shortness of breath. Asthma is UNCONTROLLED if any of those asthma symptoms are:

1. present during the day more than just two days per week
2. OR cause any night waking
3. OR cause any physical activity limitation
4. OR require more than to quick-relief treatments per week
5. OR require systemic steroids (like oral prednisolone or prednisone) more than once in the last 12 months

The best way to control asthma is to avoid or minimize exposure to asthma triggers and take daily maintenance asthma medication (typically an inhaled steroid) as prescribed. Asthma maintenance medication should almost always be taken every day, even when the child with asthma “feels fine.” Not all children with asthma need daily maintenance medications. But, if a child’s asthma symptoms are uncontrolled, they might benefit from daily asthma maintenance medication. Now is a great time to assess your child's asthma symptoms to determine if the current plan is controlling their asthma. If the asthma isn’t controlled, call your asthma doctor to review the plan and adjust if needed.

What if my child with asthma says they “can’t breathe” or is scared while wearing the face mask?

Wearing a face mask is important for everyone going out in public at this time and is especially important for children with asthma. Many young children can be resistant to wearing them at first but with persistence and patience, this can usually be overcome. Here are a few ideas to help make masks seem less scary from the American Academy of Pediatrics:

1. Look in the mirror with the face coverings on and talk about it.
2. Put a cloth face covering on a favorite stuffed animal.
3. Decorate them so they're more personalized and fun.
4. Show your child pictures of other children wearing them.
5. Draw one on their favorite book character.
6. Practice wearing the face covering at home to help your child get used to it.

Regarding a child with asthma saying that they “can’t breathe” while wearing a face mask, it is important to make a distinction between the feeling of being short of breath and a true difficulty breathing causing a drop in the oxygen level in the blood. Only patients with very severe lung disease or who have very weak breathing muscles would have their blood oxygen levels decreased simply by wearing a face mask. If needed, this could be tested with a pulse oximeter at most physician offices. If the feeling of being short of breath is present but their blood oxygen level is normal, then it is safe for them to wear a face mask.

For more information on children and face masks from the American Academy of Pediatrics

Are steroids safe to give to treat asthma during the pandemic?

Inhaled steroids have been the daily asthma maintenance medication of choice for decades now and continue to be very safe, very effective, and very necessary for patients with persistent asthma during in the COVID-19 pandemic. A child with asthma should NEVER stop their daily inhaled steroids unless instructed to by their asthma doctor.

Systemic steroids are related to inhaled steroids but instead are much stronger and given by mouth (or injection) for short periods of time (less than 10 days) to treat asthma flare-ups. Systemic steroids can be safely given for asthma flare-up, if needed, even if that flare-up is triggered by a COVID-19 infection.

Are nebulizers safe during the pandemic?

COVID-19 (like all respiratory viruses) spreads by aerosols created when an infected person coughs or sneezes. An aerosol is a super-fine mist that floats in the air. Another person can then catch COVID-19 by breathing in these infectious aerosols. COVID-19 can also be spread if these aerosols settle on surfaces that are then touched by someone else who then touches their face. In addition to coughing or sneezing, anything that generates aerosols can spread a virus. This includes laughing, singing, loud talking and nebulization.

Nebulizers are devices for administering certain kinds of asthma medication. Nebulizers work by turning a liquid medication into an aerosol that is then breathed in by the patient. If a person infected with COVID-19 (even if they have no symptoms) uses a nebulizer, the virus can become aerosolized and pose a risk of infection to anyone nearby. Fortunately, most nebulized asthma medications can be changed to medication given by inhalers. Inhalers can be used with a mask attached to a tube (such as a spacer or valved holding chamber) in even the youngest asthmatics and cannot create infectious aerosols the way a nebulizer does. Discuss with your asthma doctor if changing from nebulizers to inhalers is right for your child.

How do I tell the difference between COVID-19 and asthma?

COVID-19 symptoms can appear two to 14 days after someone comes into contact with an infected person. COVID-19 symptoms can include fever, chills, cough, shortness of breath, trouble breathing, feeling tired and weak, muscle or body aches, headache, new loss of taste or smell, sore throat, stuffy or runny nose, diarrhea, nausea or vomiting, pinkeye, painful blue or purple lesions on toes and even hives or rashes. Many of these symptoms overlap with those of asthma, allergies, the flu or other viral respiratory infections (“colds”). Because of this overlap, being tested is the only way to know for certain if a child’s symptoms are due to COVID-19.

For more information, The Asthma and Allergy Network has a helpful chart comparing the symptoms of COVID-19, the cold, flu, allergies and asthma

What do I do if my child gets sick with asthma during the COVID-19 pandemic?

The possibility that a child with asthma’s active symptoms could be due COVID-19 infection does not change the initial treatment. I tell my patients that an asthma flare-up due to COVID-19 is still an asthma flare-up. If a child has asthma and develops any coughing, any wheezing, any shortness of breathing, any trouble breathing or any chest tightness, they should start their asthma action plan immediately.

The most common first step in an asthma plan is to treat these symptoms with their quick relief medication (usually albuterol or levalbuterol). If these symptoms do not respond or get worse, the child’s asthma doctor should be consulted immediately for additional guidance.

 When should I take my child with asthma to the doctor?

Most asthma flare-ups can be safely and effectively managed at home by following your asthma action plan and consulting your child’s asthma doctor by phone if needed. But, if the plan is not working or symptoms worsen, a change in the treatment plan or closer monitoring might be needed. Call your child’s asthma doctor if any of the following symptoms occur:

• worsening cough or wheeze
• new chest pain or back pain
• decreased ability to do usual physical activities​
• symptoms not responding to albuterol plan (but otherwise not in distress)
• needing albuterol more frequently than every 4 hours (but otherwise not in distress)
• not improving significantly after 2-3 days of increasing albuterol

Asthma flare-ups can become a life threatening emergency. If your child shows any of the following warning signs, their asthma flare-up has become a life threatening emergency. Start the emergency plan part their asthma action plan (often called “the red zone”) and call 911 or go to the nearest emergency room immediately if your child:

• can't catch their breath,
• can’t speak in full sentences
• can’t walk because of breathing difficulties
• sucking in (retractions) under the ribs or at base of neck
• abnormal movement of the belly while breathing (belly breathing)
• turning a bluish or grayish color around their mouth or fingernails
• making grunting noises
• head bobbing with each breath
• not responding to albuterol treatments
• feeling drowsy or confused

When should I take my child with asthma get tested for COVID-19?

The CDC website has a Coronavirus Self-Checker – an excellent and easy to use assessment tool to you decide if a child (older than 2 years) or adult needs to seek testing or medical care due to COVID-19. The online and mobile-friendly tool asks a series of questions, and based on your responses, provides recommended actions and resources.

If my child with asthma gets sick, when can we be around other people again?

If a child has an asthma flare-up during the COVID-19 pandemic, it is important to stay home and away from other people. Staying away from others helps stop the spread of COVID-19. You can be around others after 10 days since symptoms first appeared and at least 24 hours with no fever without the use of fever-reducing medications

For more information about COVID-19 and children with asthma from the American Academy of Pediatrics, click here.

https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Caring-for-Children-with-Asthma-During-COVID-19.aspx

For more information about COVID-19: cdc.gov

References

** Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2020. Ginaasthma.org

*** https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

Being a pediatrician is a special job. You get involved in not only a child’s life, but become a part of the entire family. I was diagnosed with asthma at the age of 4, and this is the reason I became a pediatrician. My pediatrician growing up was so wonderful and caring of both myself and my parents, I wanted to be just like her, providing compassionate care to children.

Our delightful environment in North Texas tends to allow for year ‘round allergies, which can exacerbate asthma and wheezing.

So when should you take your child to the doctor to check their cough or wheezing?

The answer is, any time you are concerned and your normal medications aren’t enough. Some asthma is seasonal when allergens are worse in the air, some asthma is activity-induced, and your child will require an as-needed emergency inhaler called Albuterol. When Albuterol is needed more than once or twice a week for cough, wheezing, or difficulty breathing, it’s time to talk to your pediatrician about starting an inhaled steroid maintenance inhaler.

This is taken every day, and the inhaled steroid lessens the likelihood you’ll need to use the emergency inhaler. There is also a commonly prescribed chewable or swallowed pill called Singulair that is helpful in keeping allergies and asthma symptoms better controlled. When your child has worsening night time cough, trouble keeping up with peers during physical activity, or wheezing, it’s time to schedule an appointment with the pediatrician to discuss increasing or changing medications.

During an acute asthma exacerbation from whatever cause (viral illness, change in seasons, allergy flare, etc), the doctor will often prescribe a short course of oral steroids, around the clock albuterol nebulizer treatments or inhaler use, and perhaps a round of antibiotics if they are deemed necessary. It is critical to take all medications as prescribed. Just because your child feels “better”, doesn’t mean that it is time to stop daily asthma medications. They are better because the medications are working, and stopping any maintenance medicines can cause irreparable damage to their lungs. Let’s keep our children at their best by coming to the doctor at the first sign of respiratory distress, and quickly managing asthma and wheezing.

When is it asthma, and when is it something else?

It's hard to think about right now, but it only a couple of months we will see cooler weather and winter will be here before you know it. Winter season brings on LOTS of cold viruses, all 847 of them, and several can cause wheezing or trouble breathing, also known as reactive airway disease.

Especially known is the dreaded RSV, but other viruses can affect the lungs too, and require extra support from nebulizer treatments to even oxygen given in the hospital. Some children are highly susceptible to every common cold virus spiraling into a reactive airway disease/ asthma/ wheezing episode, and require a doctor visit every 1-2 weeks it can seem. So when it is just “asthma”, and when should the pediatrician and parent confirm it’s not something worse?

When something doesn’t feel right, come in and talk to your doctor. It may be nothing. It may be just another cold and cough virus. But maybe, and it’s a very small chance, but maybe it is something more. And you as the parent deserve to be listened to, to have your concerns validated and heard. And we as the Pediatrician, promise to do right by your child and not only treat in the moment, but plan for further investigation if necessary. Don’t ever feel awkward or hesitant coming in to the office to check the cough or snotty nose virus; I’d rather reassure you that it’s a simple virus and not something more.

Listen to your gut, and I’ll listen with my ears and my heart.

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

Does your child have to limit playing or sports because they are short of breath?

Does your child also have runny nose and watery eyes on a regular basis?

Does your child also have eczema or super dry skin?

Then they may have asthma.

Asthma is the leading cause of emergency room visits and missed school days. It is repeated episodes of wheezing and cough even without illness. During the winter months as kids seem to come home with a new set of cold like symptoms every week, many parents wonder if their children have asthma. So first things first.

Having a cold due to a viral infection, including RSV and Influenza, does not predispose them to developing asthma. However, if you have asthma that is poorly treated or unrecognized, those viral infections will always seem to be worse. They may be more symptomatic with cough and shortness of breath. They may awaken at night more frequently than other children.

The difficulty is sorting out children, especially six and younger, who have repeated viral infections versus asthma that is exacerbated by an illness. If your child has watery eyes or runny nose, eczema, nightly cough and repeated episodes of wheezing even when not appearing to have an illness then they may have asthma.

While no one wants their child to have any illness, the good news is that there are medications available to insure that children with asthma have no limitations in their activities, sleep soundly at night and rarely have to go to the emergency room. I tell my patients with asthma that whatever they choose to do: play soccer, run track, etc. that by working together we can usually develop a strategy that will not limit their potential to succeed. For some it is recognizing symptoms of asthma and beginning treatment quickly. For others it is a daily preventive medication to lessen symptoms.

More than anything, if you are worried, ask your pediatrician. We are experts in treating asthma and want to help. Asthma is one of the most common diseases referred to a pulmonologist by a primary care doctor. For more advanced care for kids with asthma, your pediatrician can also help refer you to a Cook Children's pulmonologist. 

For more information on Asthma:

• Asthma
• Asthma Educational Resources
• Pulmonology at Cook Children's
• What Is An Asthma Emergency
• Playing Sports With Asthma
• Can My Child Die From Asthma?

Sounds fun, right?

But the U.S. Food and Drug Administration has sent out an alert of the “potential for serious injury from eating, drinking, or handling products prepared by adding liquid nitrogen at the point of sale, immediately before consumption.”

If you aren’t familiar with the product’s names, you’ve probably seen them at malls, food courts, kiosks, state or local fairs, and other food retailers. They are food and drinks prepared by adding liquid nitrogen immediately before consumption. The products may include liquid nitrogen-infused colorful cereal or cheese puffs that releases a misty or smoke-like vapor.

The concern is that the liquid nitrogen, although non-toxic, can cause severe damage to skin and internal organs if mishandled or accidently ingested due to the extremely low temperatures it can maintain. The alert from the FDA advises consumers to avoid eating, drinking or handling foods prepared using liquid nitrogen at point of sale and immediately before consumption, due to injury.

A particular worry is for people asthma patients. The FDA says “inhaling the vapor released by a food or drink prepared by adding liquid nitrogen immediately before consumption may also cause breathing difficulty.”

The FDA stated that the organization is aware of severe – and in some cases, life-threatening – injuries, such as damage to skin and internal organs caused by liquid nitrogen still present in the food or drink.

Karen Schultz, M.D., medical director of Pulmonology at Cook Children’s, said this warning is definitely a concern for young asthma patients.

“Inhaling cold air is a known trigger for asthma and, in fact, is used to help determine if someone has asthma (called a ‘cold air challenge’)," Dr. Schultz said.

Worsening signs of asthma include breathing that is hard and fast, trouble talking or walking, inability to work or play, constant coughing, or a color change in the lips and/or nail beds. At this point, rescue medications should be given and the family should seek immediate care.

"General signs of initial worsening of asthma include some difficulty breathing, coughing and wheezing, problems working or playing, or waking up at night coughing," Dr. Schultz said. "At this point families should start using their rescue medications as instructed by their physician. Families should call their physician if their child has required three extra treatments in a 24 hour periods or they need them more frequently than every four hours."

Consumers who have experienced an injury because of handling or eating products prepared with liquid nitrogen at the point of sale, immediately before consumption, should consult their healthcare professional. Consumers should also consider reporting their injury to MedWatch. The FDA encourages consumers with questions about food safety to Submit An Inquiry, or to visit www.fda.gov/fcic for additional information.

* Photo Courtesy of the Food and Drug Administration. Read Alert from FDA.

Related Articles

• Cook Children's Pulmonology
• Appointments and Referrals
• Asthma Information
• What Is an Asthma Emergency?
• Innovative Program Keeps Kids with Asthma in Class and out of the ER
• 'My Child Can't Play Sports. He Has Asthma.'

The recalled bottles have the following lot numbers: MON17384, expiration 12/31/2019 – by Camber Pharmaceuticals, Inc., Piscataway, N.J. Sealed bottles labeled as montelukast sodium tablets, 10 milligram, 30-count bottle from Camber were found to instead contain 90 tablets of Losartan Potassium Tablets, 50 mg.

"Losartan is often used alone or in combination with other medications to treat high blood pressure," the FDA wrote in its press release. "Losartan is also used to decrease the risk of stroke in people who have high blood pressure and a heart condition called left ventricular hypertrophy (enlargement of the walls of the left side of the heart)."

Patients who have the recalled bottles should contact their health care provider or pharmacist immediately, the FDA said.

"This tablet mix-up may pose a safety risk as taking losartan tablets when not prescribed has the potential to cause renal dysfunction, elevated potassium levels and low blood pressure," the FDA wrote in its press release. "This risk is especially high for pregnant women taking the allergy and asthma medication montelukast because losartan, which is indicated to treat high blood pressure, could harm or kill the fetus. The FDA recommends that consumers who have this recalled product should contact their health care provider or pharmacist immediately."

This recall is not related to the recent valsartan recalls that were due to an impurity, N-nitrosodimethylamine (NDMA).

Along with the treatment of asthma, Montelukast is also used to prevent bronchospasm (breathing difficulties) during exercise and to treat the symptoms of seasonal and perennial allergic rhinits.

Read the full statement from the FDA here.

I read the paper during my lunch hour this week. It seems to be a decent study (sometimes studies aren’t that good. Remember that the next time you see an inflammatory headline and try to always read the study, or at least the fine print, for yourself!)

The researchers claim that children who are given antacids or antibiotics in the first six months of life are more prone to “allergic conditions” – like allergies, eczema, asthma, food/medicine allergies, and so on.

The study looked at over 790,000 kids in the Military Health System database from 2001 to 2013. It was a pretty big study.

What it concluded was that if a child got an antacid medication (like Ranitidine or Lansoprazole, amongst others) or an antibiotic (Amoxicillin, Augmentin, Bactrim), the kiddo had a higher chance for those problems listed above.

Antacids in the first 6 months doubled the chance of food allergy. Antibiotics doubled the chance of asthma.

The general thought is that antacid medications and antibiotics mess with our “gut biome.” Those are the living organisms in our gut that help us digest food and help our immune system to know friend from foe.

We want lots of different “good gut bugs” living in there to help us out. When you use antacids or antibiotics early in life, the theory is that this diversity is reduced.

As a mom, I asked myself, “Did those two months my son was on ranitidine cause him to have his awful cantaloupe allergy?” The guilty feelings were already sinking in.

Stop right there! Let’s not feel guilty about this. We are always learning and medicine is always changing. Let’s move forward. Yes this study seems solid, but what questions can we ask about their study methods?

Maybe we’d have more knowledge of a true connection if each individual medication was studied, instead of all of them lumped together?

Maybe kids who deal with reflux or infections as babies are just more prone to allergies and illness in general later on in life?

Are military families living in or with environmental conditions which may predispose the kiddos to allergic conditions?

I don’t know the answers to these questions. But boy, is this article making me think!

Like any “big discovery,” do we need more studies on this same topic to reduce any bias and truly know if there is a connection between these medications and allergies? Absolutely. We’ve done similar studies on animals in the past, but now it’s time to do more studies on humans.

For me, as a pediatrician, I’m going to walk through these risks with my patients a little more thoroughly.

Children with reflux suffer. I watched it happen in my own kid. Do some of them need the antacids to survive? Absolutely (some kids lose weight with reflux). Will I try to talk parents of children with more “mild” cases of reflux out of it? Probably.

Children with bacterial infections need antibiotics. Will I make sure to be certain to use the “least strong” antibiotic I can muster so as not to kill off too many of the important gut biome? Absolutely.

This article will no doubt cause some strong opinions. If, in the end, we are using less medication to treat our children’s mild infant illness, I think it will be better for everyone. I look forward to reading more research on this in the future!

Commonly recommended ways to prevent constipation are to drink water, exercise, and eat fruits, vegetables and fiber-rich foods. Yet even when we use these techniques, our children still sometimes get constipated. Whether its contributing to stomach ache, delayed toilet training, bedwetting, or missed school, constipation is no laughing matter.

“But my child poops every day! My child can’t be constipated!”

Even if your child stools every day, he or she may be constipated. Think about your office desk; you may clear papers off regularly, but if you are not clearing as many papers as are building up, you will soon have a messy desk. Children may poop every day and still not be fully emptying their intestines. When constipation develops, the extra stool causes the intestines to stretch. Once this happens, the intestines may not be able to move as well, which leads to more constipation, and it becomes a vicious cycle. In infants constipation can be particularly hard to recognize because in this age group it is can be normal to have less than one stool per day.  Parents should look for a change in the frequency of stools along with firm stools when considering constipation. 

“What now?”

The good news is that constipation can often be treated with dietary changes. The key to making the treatment stick is continuing it long enough. If you stop too soon, the intestines have not had time to heal, and the constipation returns. As a physician who often sees this condition, I recommend treating constipation for as long as it has been a problem. For example, if constipation has been an ongoing problem for one month, treatment typically lasts at least one month. Treatment also depends on your child’s age.

• For infants over the age of two months, ask your pediatrician about giving small amounts of prune juice or pear juice.
• For a toddler, in addition to pear, apple, or prune juice, consider adding high fiber foods such as pears, peaches, and whole-grain cereals to his or her diet.
• School age children or teenagers can learn about which foods will help improve their symptoms and can then get involved in choosing foods that are fiber-rich and appealing to them.
• In cases that do not respond to dietary changes or are more severe, your pediatrician may recommend a medication to help treat the problem.

Contact your child’s doctor if you have any questions or concerns about your child and constipation.

"One of the triggers of asthma symptoms are respiratory viruses and we are seeing a large number of those driving people to access Emergency Care," said Corwin Warmink, M.D., medical director of Emergency Services at Cook Children's.

Karen Schultz, M.D., medical director of Pulmonary Services, advises parents of children who have asthma to make sure they have an asthma action plan. An asthma action plan should be provided by the outpatient physician who cares for the child's asthma or, if admitted to the medical center, will be provided by the discharging nurse at Cook Children's.

The written plan helps patients develop with their doctor the methods to help control their asthma. The plan looks at the daily treatment of the patient, including medication to take and how to control asthma long term and how to handle worsening asthma, or attacks.

"General signs of initial worsening of asthma include some difficulty breathing, coughing and wheezing, problems working or playing, or waking up at night coughing," Dr. Schultz said. "At this point families should start using their rescue medications as instructed by their physician. Families should call their physician if their child has required three extra treatments in a 24 hour periods or they need them more frequently than every four hours."

Worsening signs of asthma include breathing that is hard and fast, trouble talking or walking, inability to work or play, constant coughing, or a color change in the lips and/or nail beds. At this point, rescue medications should be given and the family should seek immediate care.

To learn more about asthma, Dr. Schultz answered a few of our questions:

1.What is asthma?

Asthma is an inflammatory process that happens in the lungs that causes swelling and increased mucus down in your lungs so it makes it harder to breathe.

2.When do asthma flare ups occur?

An asthma flare up occurs when someone is exposed to a trigger of their asthma. The muscles around their airwaves actually squeeze down and make it even more difficult for people to breathe. They can also get more mucus and more swelling in their lungs, which also makes it harder.

3.What are the triggers?

People have different triggers for their asthma. The most common ones tend to be weather changes, viral infections and exposure to certain allergens. Cold, dry air can cause bad flare-ups and viral infections are the most common trigger this time of year. Parents should stress to their children the importance of handwashing, especially this time of year.

Allergens could include cats, pollen, grass and mold. Another big trigger is exposure to smoke. Exposure to second-hand smoke is a big issue with kids with asthma. Not only can it be a trigger for an asthma flare, but it can keep your child’s asthma from ever getting under control in the first place. Any parent who has a child with asthma, should not smoke. Even smoking outside exposes your child to some smoke particles and can still keep their asthma out of control.

4.Who gets asthma?

Asthma happens to people with a genetic predisposition who then have the right trigger to start their asthma flaring at the right time.

Depending on the age, asthma can be diagnosed in different ways. In very young children and toddlers, it’s diagnosed based on their symptoms and what their physician on examination. So kids that have recurrent wheezing are diagnosed with asthma.

In older kids, 5 years and up, lung function testing can be done to help determine asthma severity.

5.What are the symptoms?

Common starting symptoms of an asthma flare often are just cough. Sometimes families can start seeing the kiddos breathe harder and faster and sometimes they can actually hear them wheeze. But often the wheezing can only be heard by a physician.

If they start noticing their child is breathing very rapidly, if they are sucking their air in above their sternum or in between their ribs, then those are signs that they are really struggling to breathe and a doctor needs to take a look at them.

6.How is asthma treated?

Asthma is treated with inhaled medications generally. The most common medication we use is albuterol which helps relax the muscles that tighten down around the airwaves. However, this will not prevent asthma attacks. To prevent asthma attacks, patients are often placed on inhaled steroids to help control the swelling and mucus in their lungs so they can breathe easier.

Asthma is monitored mainly by symptoms. Your physician may ask how often you are using your rescue inhaler or your albuterol to help determine whether your asthma is under good control or not.

The best way to control your child’s asthma is for him or her to take the medication that your physician prescribes on a regular basis. Many people will think that their children’s asthma is under good control and they will stop their medications and that’s when they start having more flares of their asthma.

Everyone with asthma should have an action plan. It will list out your child’s medications and what to do when they start having symptoms. It will tell you what to do when they have mild symptoms or more severe symptoms and should direct you to the appropriate health care resource should they start having more difficulty.

When children use inhalers for their asthma, they are more effective if they use a spacer, which is generally a clear plastic tube with a mouthpiece that helps the medicine deposit into your lungs rather than stuck on your tongue if you just puff the inhaler in your mouth.

7.When should I see a pediatrician?

If your child is having an asthma attack that’s difficult to get under control, you can try doing extra albuterol treatments or extra puffs of your albuterol. If your child needs more than three extra treatments in a day, then you need to contact your physician.

Related articles

• Asthma Information from Cook Children's
• Asthma Center
• Asthma and your child
• Can my child die from asthma? Yes.
• Why asthma shouldn't be an excuse for keeping your child off the field
• Innovative program keeps kids with asthma in class - and out of hte ER

Wheezing, coughing and the struggle to catch a single breath.

Sounds like asthma, right?

But there may be another cause for respiratory distress in your child: vocal cord dysfunction.

Asthma and vocal cord dysfunction (VCD) seemingly show the same symptoms, especially in adolescents. But what’s the difference between them?

Cook Children’s Emergency Department sees an average of 13,000 children each year exhibiting wheezing and difficulty breathing. The similarity of symptoms between asthma and vocal cord dysfunction may be difficult to differentiate to the eye so it’s important to note the small distinctions.

“Asthma and VCD are quite different even though some of the symptoms can overlap,” Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s said. “VCD causes difficulty breathing in compared to asthma, which makes it more difficult to breathe out. They also sound different when using a stethoscope to examine a patient.”

Unlike vocal cord dysfunction, asthma is an immune response when the body is exposed to various “triggers,” such as air pollutants, physical activity and airborne particles like pollen and pet dander. When triggered, the bronchial muscles in the airways constrict and the sudden obstruction causes the reaction of an asthma attack.

You may be experiencing an asthma attack if your symptoms include:

• Tightness in the chest

• Difficulty breathing

• Shortness of breath

• Coughing and wheezing

• Excess mucus

Vocal cord dysfunction is the abnormal closing-together of the vocal cords, resulting in the loss of airflow. Unlike asthma, VCD does not involve an immune response or a reaction from the airways. Vocal cord dysfunction makes it more difficult to breathe in than breathe out when symptoms occur.

Children who are active, vocal and use their vocal cords more than usual may have higher tendencies to experience VCD.

“We see VCD most common in female teenage athletes although it does occur in males,” Karen Schultz, M.D., pulmonologist at Cook Children’s said. “Type “A” personalities are at higher risk.”

You may be experiencing vocal cord dysfunction if your symptoms include:

• Tightness in the throat

• Difficulty breathing

• Coughing and wheezing

• Hoarse voice

Asthma and VCD are regularly confused as the symptoms and triggers are similar. Many patients with VCD are originally treated for asthma.

“Patients are diagnosed by history, exam and lung function testing,” Dr. Schultz said. “Lung function testing can be completely normal in both conditions when no symptoms are present. Frequently history alone can differentiate the two. Occasionally lung function testing after exercise can be diagnostic or laryngoscopy after exercise”

Signs you may be experiencing VCD instead of asthma:

• It is more difficult to breathe in than it is to breathe out

• Asthma medications and inhalers do not ease symptoms

The diagnoses for VCD and asthma are different. Asthma requires pulmonary function tests, such as a peak flow and a spirometry test. While a diagnosis for vocal cord dysfunction typically entails results from other pulmonary function tests, such as a laryngoscopy or a spirometry test.

Many children who are diagnosed with vocal cord dysfunction are referred to see a speech pathologist who can assess the degree of dysfunction, and begin a plan of action with different types of breathing and stretching exercises for the vocal cords.

“There are a number of ways we treat different diagnoses, but we will usually start with breathing exercises to make sure air flow is unhindered and the vocal cords can be well supported,” Melanie Van Noy, speech pathologist at Cook Children’s said. “Then we may do simple exercises to lengthen and stretch the vocal cords or exercises to reduce pressure. It depends on the diagnosis and the dysfunction.”

While VCD does not have specific medications to ease symptoms, speech therapy is tailored to allow children and their families learn triggers and how to cope when an attack does occur.

“For kiddos, a large part of our job is helping our young patients to become more aware of their vocal habits and educating not only them but their parents and siblings on how they can help change those habits, Van Noy said. “We also have some sophisticated software programs that help give our kiddos the feedback they need so they can not only hear the difference, but see the difference and the changes they are making as well.”

Speech therapy typically teaches and treats children for three to five sessions. If the child is still showing symptoms, a team of Cook Children’s doctors will begin to assess all the different aspects to their case.

“Our ENTs and pulmonologists work closely together to ensure that if our treatment plateaus or the patient is still showing symptoms despite treatment, we can collaborate on what to do next,” Van Noy said. “That may look like a discussion with the physician regarding compliance and progress of treatment, what other medical intervention strategies are available or maybe just another episode of care, which is what we refer to as our plans of care.”

UNT Health Science Center

Kiasha Jones has managed her son’s asthma for the last 14 years, ever since he was diagnosed at age 6 months following a bout with a respiratory virus called RSV.

Armed at home with an inhaler, a humidifier and a nebulizer that delivers medication to the lungs in aerosol form, Jones’ son Derek James is mostly unhindered by his respiratory condition – and even plays football for Fort Worth’s Polytechnic High.

But last year, Derek’s asthma flared up at school. Such attacks would once typically trigger a call to paramedics and a trip to the emergency room.

In Derek’s case, however, a nurse at Forest Oak Middle School quickly treated him in her office with a nebulizer and a low dose of the asthma-fighting medication known as albuterol. Then she sent him back to class.

The nurse was able to respond quickly and effectively thanks to an innovative pilot program led by UNT Health Science Center called “Asthma 411.” It gives school nurses the equipment, training and medical clearance to treat students’ asthma attacks in the schools, keeping children from missing class, parents from missing work and reducing costly trips to emergency rooms.

“During the school day, the nurse is going to see Derek a lot more than I do,” Jones said. “I wouldn’t have known what to do without the albuterol and the nebulizer machine being right there.”

Such a program is essential in Fort Worth, and other major metropolitan areas, where the percentage of children who have asthma is roughly triple the national average. The program takes a community approach to address the problem and includes collaborative partners such as the Fort Worth Independent School District, Cook Children’s Medical Center, MedStar Mobile Healthcare and JPS Health Network.

“This project reinforces what many of us already know about our community,” said Andrew Crim, Executive Director of the Office of Professional and Continuing Education (PACE) at UNTHSC. “Fort Worth has a number of individuals willing to work together to make it a better place.”

‘A growing problem’

Asthma is the most prevalent of all the childhood issues parents shared during Cook Children's Community-wide Children's Health Assessment and Planning Survey (CCHAPS).

Asthma accounts for more than 3,000 days of school absence in Tarrant County each year which leads to

• Students health and well-being is in jeopardy.
• Students lose classroom time leading to poorer academic performance.
• Parents often miss work to care for their child which also affects businesses.
• Schools lose their per student funding for each day missed (approximately $90,000 per year in Tarrant County).

 "Asthma 4-1-1 is one practical, proven way to virtually eliminate 911 calls to schools related to asthma. It lets nurses be nurses and provide better care for our children and give parents and students more control over their asthma," said Larry Tubb, Senior Vice President of System Planning/Health care Analytics and the Center for Children's Health at Cook Children's. 

"It is exciting to see health care providers, our county government, universities and our schools joining together to make Asthma 4-1-1 available throughout Tarrant County. That’s what Our Promise is all about, working together to improve the health of every child in our region. And it is what makes Tarrant County a great place to raise children."

About 8.6 percent of children in the United States have asthma, according to the Centers for Disease Control and Prevention. But closer to 25 percent of Fort Worth children have it, a figure similar to what is seen in other urban areas, said David Sterling, PhD, Professor of Biostatistics and Epidemiology, School of Public Health.

“Of the many risk factors for asthma, we have all of them,” Dr. Sterling said.

There are three key factors that contribute to Fort Worth’s high asthma rates, he said:

• Geography: Texas is awash in allergens such as ragweed and mountain cedar – much of it bothersome year round.
• Environment: In 2016, the American Lung Association rated the Dallas-Fort Worth metropolitan area No. 11 nationally for pollution with respect to ozone.
• Demographics: People with lower incomes have higher rates of asthma than other groups, often due to substandard housing and associated issues such as dust mites, cockroach droppings, mold and mildew. Lack of access to health care also is a predictor of asthma and asthma severity.

These all contribute to the region’s high asthma rates – and experiences that are truly frightening for children experiencing an attack, said Leslie Allsopp, MPH, a third-year doctoral student in the School of Public Health. During an attack, the smooth muscles of the airway contract at the same time the immune system is busy secreting mucous, further narrowing the airways.

“Having an asthma attack is like drinking a thick milkshake through a straw,” Allsopp said. “You are trying to inhale and exhale through these very narrow openings.”

‘It’s very scary’

If anyone understands the fear a child experiences during an asthma attack, it’s Andrea Smith, RN. She has spent 24 years as a nurse, the last four at Forest Oak Middle School in Fort Worth.

“You can tell from the minute they walk in the door,” she said. “The child is short of breath and can’t talk. You don’t know if their airway is going to shut down, where they can’t get any oxygen in.

“You don’t know what’s going to happen, and it’s very scary thinking about what could happen with this kid.”

Before Asthma 411, Smith could check to see if the child had an inhaler stored in her office along with a signed parental consent form and a physician’s order. If the proper paperwork wasn’t on file, her choices were limited: Lead the child in breathing exercises. Call a parent. Or call a paramedic.

After Asthma 411, the protocol improved. For parents who provide consent, their children can now receive treatment of albuterol delivered through a nebulizer, resources that were donated to the school by Cook Children’s. Critically, a blanket standing order for treatment from Jay Haynes, MD, Senior Medical Director for Employee Health and Wellness at JPS, eliminated the need for parents to go to their child’s pediatrician for an order.

Tobi Jackson, a Fort Worth ISD Board of Education trustee, is a former principal who has witnessed a student suffering an asthma attack while waiting for paramedics to arrive.

“It's terrible to feel so helpless – and even worse for the kid,” she said. “That's why I jumped at the chance to pilot this program in two schools in my district. I knew firsthand the difference it could make – and it has.”

In a small sample size, the program has yielded dramatic results. In the 2012-13 school year, MedStar reported 19 emergency calls for asthma from the two Fort Worth ISD schools participating in the pilot program. In the following two school years, there was one such call. Asthma-related student absences dropped 51 percent over the same time period.

Nationally, asthma contributes to more than 14 million lost school days each year. Excessive school absences are a strong predictor of premature dropout rates, Dr. Sterling said.

“The bottom line is we are keeping these kids in school,” said Pam McFadden, Associate Vice President of PACE. “Because we’re focused on reducing 911 calls, the children can focus on their math and reading.”

Now, and Next

The underlying concept for Asthma 411 isn’t new. Indeed, Dr. Sterling ran a similar project under a CDC grant when he worked at St. Louis University School of Public Health.

What is new – and innovative – is how the project came together and the collaborations that made it possible. When attempts here to start a similar program didn’t receive initial funding, Crim and McFadden in the PACE office took an interest and saw an opportunity.

They won grants from the pharmaceutical companies GlaxoSmithKline and Boehringer Ingelheim, brought in Dr. Sterling and Allsopp for their expertise and secured the cooperation of Fort Worth ISD, Cook Children’s, JPS and MedStar.

They’re not finished. The next phase of the project, dubbed Asthma 211, will provide more resources and supplies for families to improve the indoor conditions of their homes, offer more education and provide direct links for medication. McFadden and Crim want to see it in every Fort Worth school, as well as the programs that provide afterschool care for thousands of children.

In the meantime, the original Asthma 411 program continues to have a positive impact on school nurses – and the students they care for.

“We are with these children for eight hours a day,” Smith said. “They are our responsibility, and Asthma 411 makes a big difference for us.”

* Photo by Jill Johnson, UNT Health Science Center Staff Photographer

It can be really hard to determine the cause of a cough just because of the sound. But here are some different types of coughs and the clues that might help you or the doctor know what is going on.

1. Short time period: Most coughs that last a few days are due to infection, most commonly viruses.
2. Long time period: Coughs that last longer bring up other possibilities, including sinus infections, allergies, asthma, or reflux.
3. Wet cough: Wet coughs with congestion can caused by a variety of reasons but are more commonly infections (most of which are viruses) or allergies. The presence of fever points towards infection while itchy or watery eyes suggest allergies.
4. Tight cough: A tight sounding cough can often be a sign of asthma. If your child has a history of wheezing or the cough is associated with exercise or weather change, think asthma.
5. Cough after eating: Yes, reflux can be a cause of chronic cough and it’s actually more common than you might think. Pay attention the timing and if certain foods might be triggers.
6. Barky cough: Think like a dog or seal. Croup is the most common cause of this type of cough. Usually the child will have runny nose and they can have fever as well. Steam is a good way to treat this cough so use a humidifier or the bathroom with the shower going. If severe or difficulty breathing, the doctor can provide steroids and other treatments.
7. Whooping cough: This cough is severe and comes in terrible spells that end in a whooping sound as the child breathes in. It requires a doctor’s visit and treatment so get it checked out soon.
8. Annoying, chronic throat clearing cough: This can be caused by many reasons but an important one to think about is tics. Children can have vocal tics that sound like throat clearing or even a mild cough.

There are lots of reasons why a child might be coughing but hopefully some of these tips will help you determine what you need to do next.

1. Make sure your house is safe while you are away. Alert the neighbors that you will be out of town. Stop the mail and newspaper from delivering or make sure a neighbor can pick it up for you. Now there’s even technology available to set a timer on the lights in your house. The timer lets you keep your lights on and turn them off the same as you would if you were actually at home, making any potential bad guy think you are there.
2. Don’t let everyone know your plans. Remember it’s not only old high school friends and co-workers following your every move. Crooks are definitely Facebook and Twitter savvy. Don’t announce to everyone that you are taking off soon or that you are trying to get packed tomorrow. Do things the old fashioned way and call the people who need to know you will be out.
3. Get your rest. A report released by the AAA Foundation for Traffic Safety states that drivers who sleep only five or six hours in a 24-hour period are twice as likely to crash as drivers who get seven hours of sleep or more. Crash rates increase with every hour of lost sleep.
4. Make sure your child is secure in their car seat or booster before you travel. You can’t be too careful on the road, both in the U.S. and out of the country. Motor vehicle crashes are the No. 1 killer of kids 14 years and under in the United States.
5. And secure on the plane too. Buy the extra ticket for your baby and make sure your child is properly protected in an approved safety seat. The No. 1 way children are injured in planes is due to turbulence. For safety, children need to be either restrained in their safety seat or in the lap belt in the plane seat.
6. Bring a current picture of your child with you on your trip. Have a very specific description of what your child is wearing in case your son or daughter gets lost. In this day and age of cameras on your phone, it’s easy to take a picture of your child that morning.
7. This is an uncomfortable one, but so important. Let your child know it’s OK to scream and fight if someone tries to grab them. However, just throwing a fit may not work. We’ve all seen kids screaming and crying as parents carry them out of the store. If the child is old enough they need to know to scream “this isn’t my Mommy or Daddy, help me” instead of just screaming like they are upset because they were told “no.”
8. Traveling with asthma. Be sure to pack your child’s quick-relief medicine and long-term control medicine. Keep them where you can reach them and not packed away. Pack your peak flow meter, health insurance cards and your asthma action plan. Consider purchasing a portable nebulizer. Call ahead to where you are traveling and discuss your child’s triggers. Bring your child’s pillow and blanket from home.
9. Childproof your grandparents’ home. Make sure they know about any nut allergies or any other allergy they should know about during your stay. Check all the rooms for any electrical cords, cleaning supplies and loose pills on the floor. Grandparents usually leave them out so they can remember to take them. Don’t let this happen. Put the pills away. Often times they aren’t child proofed and kids can easily mistake them for candy. Also remember to unpack and put away any medications that you bring with you.
10. Avoiding food allergies takes extra prep work. Research local hospitals and medical care wherever you are traveling. Also call ahead or go online to find out about area grocery stores, restaurants and any other place you may stop along the way. Make your family aware. Yes grandma makes the best pecan pie, but make sure everyone knows your child has allergies and one bite can mean horrible consequences. Pack your own food if necessary. Stay alert and be prepared with your child’s medications
11. Be aware of the new surroundings for your kiddo. If they have a family pool without a fence, talk to your children about them. Make them aware of the dangers of stairs and banisters, and go outside with them to point out dangers, such as rakes, power tools, spots where there may be snakes and other critters.
12. Be safe. Cook Children's Trauma team sees lots of ATV/4-wheeler injuries during the holiday break. If your child is on an ATV, please make sure it's built for a child. No child under 5 should be on one at all, let alone driving it. If your child is on a bike, hover board or skateboard, please be sure your kids have on the proper safety equipment (helmets please) and establish the rule of safety first. With family over, it can be easy to think someone else is watching your kids. Mom and dad, make sure you are the ones responsible for supervision.

Hope this list helps during this busy time of year. Happy holidays from Cook Children’s.

Obesity? That's one.

Car accidents? That's a big risk too.

But would you guess the number one issue is asthma?

In Tarrant County, 19.5 percent of children suffer from asthma, according to data gathered in a survey sent to parents by The Center for Children's Health led by Cook Children's. The Community-wide Children's Health Assessment and Planning Survey (CCHAPS) was completed by more than 8,600 parents in Tarrant, Denton, Hood, Wise, Parker and Johnson counties.

"We questioned parents on everything from how often their child is buckled in properly to how many grocery stores in their neighborhood sell fresh fruits and vegetables," said Larry Tubb, senior vice president of the Center for Children’s Health. "The information we are gathering is extremely valuable when it comes to measuring the overall health of children in our region."

Overwhelmingly, parents in Tarrant County (and all of the surveyed counties) reported their children are dealing with asthma. In fact, children in this area ages 6-9 are three times more likely to have asthma than children living in other parts of Texas. While we don't know why the numbers are so high, we do know people with asthma have varying triggers, and what affects one person will not necessarily affect another. Those triggers include, but are not limited to, cigarette smoke, indoor and outdoor mold, pet dander, air pollution, dust mites, cockroaches, pollen, smoke and strong odors.

The second biggest health issue on parents minds is obesity, with 17.8 percent reporting concerns about their child's weight, activity level and access to healthy foods.

Accidental injuries rings in third. In Tarrant County, 11.9 percent of parents reported their children had been injured and required medical care. Those injuries range from car and ATV-related incidents to drowning, bicycle falls and crashes.

The fourth issue on the list is a lack of dental care for children. Parents reported 9.7 percent of children either didn't see a dentist regularly, didn't brush their teeth enough or some even reported their child didn't have their own toothbrush.

Finally, mental illness is the fifth biggest issue concerning parents in Tarrant County. Behavioral and emotional development is on the minds of 8.5 percent of respondents. Many reported their children have suffered sleep problems, self-esteem issues or have tried to harm themselves.

The survey used to gather this data is part of a Cook Children's initiative to improve the health and well-being of every child in our six-county region by 2020. This initiative launched in 2009 with the very first survey of its kind sent to parents. Since then, the surveys have been sent out every three years.

"The information provided by parents in our community is available on-line and being used by a host of organizations, including Cook Children’s, to build programs and services. There isn’t one perfect answer, but, together we are making solid progress in improving the health of the children in our community by putting the child and family at the center of our planning," said Tubb.

About The Center for Children's Health

The Center for Children's Health, led by Cook Children's, is home to the Community-wide Children's Health Assessment & Planning Survey (CCHAPS), Community Health Outreach and Community Health Research. The center's goal is to create aligned collaborations that will allow us to make our North Texas region one of the healthiest places to raise a child.

Karen Schultz, M.D., a pediatric pulmonologist at Cook Children’s understands the hype, but she sees at least one potentially dangerous side effect for children with asthma.

“To date, there are no published studies that prove or disprove the benefits of salt therapy,” Dr. Schultz said. “As with any therapy, even natural, there are potential side effects. One known side effect of inhaling a salt solution is constriction of the airways which could worsen asthma. So, even though the idea of a non-medicinal cure is attractive, at this point it cannot be recommended without further studies of both safety and results.”

On a website that lists salt rooms, more than 30 states have them. In Texas, at least two locations are in Dallas, one in Fort Worth and they are also found in Austin, Granbury and Southlake.

Saltescape.com describes a salt room, or halochamber, as “a microclimate designed to simulate the environment of a salt mine. The salt room is a dry, sterile environment that controls air temperature, humidity, air pressure and air content. Salt rooms are covered ceiling to floor in a salt application and utilize a halogenerator to crush pharmaceutical grade salt into small particles for inhalation to create the desired microclimate.”

Salt therapy offers a drug-free, non-invasive treatment where salt micro-particles enter into the lungs to help the healing process. Children as young as 3 months old have received treatment. Proponents of salt therapy believe children benefit from salt therapy because they are more prone to respiratory problems and their lungs aren’t fully developed until they are 9 years old. 

"Treating medical conditions without medications does have its appeal, so we are always on the lookout for new ideas and ways of doing things. We must continue to evaluate new ideas with studies that compare any possible risk against the benefit,” said Dr. Schultz. “You can certainly find multiple testimonies from people who swear that they are better after salt therapy. In fact after people with cystic fibrosis (CF) anecdotally noticed that they did better by the ocean, studies proved that use of an inhaled salt solution slows progression of disease, and it has now become a standard therapy.”

About the source

Karen Schultz, M.D., is a pediatric pulmonologist at Cook Children's. To schedule an appointment with her call 682-885-6299. The Cook Children's Pulmonary team diagnoses and treats children with lung diseases. Our team includes board certified pediatric pulmonologists, clinical nurse specialists, registered nurses, respiratory therapists, Child Life specialists, clinical dieticians and social workers. The professional opinion of each team member, including parents, is considered in developing a plan of care for your child. We place a high value on continuity of care with your primary pulmonologist.

But summer doesn’t guarantee complete relief for kids with asthma.

“For most children, asthma tends to be better during the summer. This is mainly because there are less circulating viral infections in the community, which tends to be a big trigger for asthma flares or attacks,” Karen Schultz, M.D., a pulmonologist at Cook Children’s said. “During this time of the year, the biggest triggers are allergies and ozone days with poor air quality. In general, it is recommended that everyone avoids too much activity during orange or red ozone days, but this is particularly important for individuals with asthma or other respiratory conditions.”

Dr. Schultz said it appears that grass and elm pollen are in the medium range in Fort Worth, Texas, this time of year and that may be affecting the allergies of children with asthma. She thinks it’s a good idea for parents to download a weather app on their phone to keep up with the outside conditions.

As the school year gets closer, many kids will be starting activities such as band and/or athletics. Dr. Schultz advices parents and children with asthma to listen closely to their asthma symptoms such as coughing.

“It’s important for people to know asthma can happen during the summer,” Dr. Schultz said. “It’s best for children with asthma to practice or work out earlier in the day if possible. As school starts, more children will be outside with PE and recess. Many kids stay inside during the summer if they do not have structured activities. So they may not be used to the outside conditions. Also, we will start seeing more viral infections not long after school starts, so good hand washing is very important.”

About the source

Karen Schultz, M.D., is a pediatric pulmonologist at Cook Children's. To schedule an appointment with her call 682-885-6299. The Cook Children's Pulmonary team diagnoses and treats children with lung diseases. Our team includes board certified pediatric pulmonologists, clinical nurse specialists, registered nurses, respiratory therapists, Child Life specialists, clinical dieticians and social workers. The professional opinion of each team member, including parents, is considered in developing a plan of care for your child. We place a high value on continuity of care with your primary pulmonologist.

Asthma is a big problem across the country with about 25 percent of children age 9 diagnosed. Children ages 6-9 are three times more likely to have asthma than others in the state of Texas.

Fortunately, most of those cases are mild and require only rare treatments with albuterol inhalers. However, some of those cases can be severe and can result in significant issues for families.

The social complications of asthma are costly:

1. Missed school for doctor visits, emergency room and hospital stays.
2. Missed work for families.
3. Decreased activity level resulting in other poor health outcomes.

There are times where these complications might be unavoidable. But these should be very, very rare cases.

I don’t believe that any general pediatrician should use physical activity restriction as a means to manage a child’s asthma.

Why? Most cases of asthma can be managed by the pediatrician and involve the following treatments:

Avoid Triggers

Allergies - If the child has allergies, make sure that he or she is on adequate treatment using a step approach to include antihistamines up to nasal steroid sprays.

Viral infections -Train your children to wash their hands frequently especially during winter months. Get your child a flu shot every year.

Stop smoking - If you are smoking, you do not get to tell your child that they cannot participate in sports. It’s hard to quit smoking, but it’s harder to be a child who wants to do an activity but can’t because their parent’s smoking makes their asthma too severe.

Develop a Treatment Plan

Treatment plans for asthma are called “asthma action plans.” Children with have asthma need one.

Treatment for asthma generally starts with albuterol on an as needed basis. This might be the case in a child who has rare symptoms or who only wheezes once or twice a year when they get a bad cold.

Treatment for asthma should include some type of daily medication for control if either of the following is present:

• Symptoms more than twice a week or a limitation in activities due to asthma
• Symptoms at night more than twice a month (waking up coughing or with difficulty breathing).

Refer to a pulmonologist

If you and your general pediatrician cannot seem to get a handle on your child’s asthma, request a referral to a pulmonologist or allergist before telling your child that he or she cannot participate in physical activity.

Here are a few guidelines based on current asthma severity that might help when you are managing asthma and physical activity:

• Children with well-controlled asthma who are symptom free should not be restricted in any way. They don’t get to run less or skip out if they are feeling well.

• Children who are having mild symptoms (cough from an upper respiratory infection) may need to be modified but sometimes do not need to be completely sedentary. (They can walk around the gym if everyone else is running.)

• Children with moderate to severe symptoms should be receiving medical care by the school nurse or their pediatrician. Asthma can be serious, even deadly so don’t wait to call if you are concerned.

Children with asthma can and should participate in physical activity. I do not believe that they should be restricted based on the recommendation of a general pediatrician alone.

Everything should be done to allow them to play first: avoiding triggers, treating aggressively, even to seeing a pulmonologist.

For more information about what is being done in our area to help prevent and treat asthma, check out the report from The Center for Children’s Health’s Asthma Think Tank-Childhood Asthma: A Guide to Action.

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.

Dr. Schultz is a pulmonologist at Cook Children’s. She teaches children and parents how to control their asthma, but there’s only so much she can do once they leave her.

When children don’t follow their asthma plan, it can be extremely dangerous --even fatal. Every day, nine people die from asthma in the United States and 36,000 children miss school due to asthma-related complications.

What bothers Dr. Schultz is that so often these deaths are a result of patients not following through on their treatment.

“It doesn’t happen very often, but it does happen. Even with all the medications and treatments we have to help children with asthma,” Dr. Schultz said. “One of the big things that lead to children being ill or even death is non-compliance with the medications they should be taking.”

She said she often sees teenagers with a false sense of security because they haven’t had an asthma attack for a while. The reason is because their medication and treatment is working. But the teen forgets why they are doing well and stops taking the medication.

“They think their asthma is better or it’s gone,” Dr. Schultz said. “But it’s just being treated and it’s working. They stop their medications and the kid gets sick really fast.”

Dr. Schultz said it’s important for parents to keep up with their children to make sure they are taking care of themselves. She’s disturbed at the lack of responsibilities some parents have in their children’s treatment.

“Some parents aren’t as good at monitoring their children as others,” Dr. Schultz said. “If mom doesn’t refill the medicine, then the child isn’t going to get it. Some parents think that an 8 year old should be responsible enough to manage his or her own medicine. Teenagers should be taking more responsibility by taking their medicine, but that’s an age when developmentally they think they are invincible. They just don’t take it. As parents, you have to make them take it.

“It’s very frustrating. As parents, you put the pill in front of them and make them take it. It’s just that simple.”

As someone who lives with asthma, I’m proof that the condition does not have to slow you down. It’s important for most children to know they can still partake in all of the fun activities of other kids, just as long as they properly take their medicine.

I join about 10 percent of the general population who are asthmatics. Children have an even greater incidence of suffering from asthma, and the prevalence of asthma is increasing in both adults and children.

First let’s define asthma. Asthma is a condition caused by narrowing of the small air tubes in the lungs with inflammation and constriction of the smooth muscle surrounding the small air tubes.

There are many symptoms of asthma, including wheezing, shortness of breath and exercise intolerance. Some people complain of “tightness in their chest.” The symptoms do vary with the severity of the asthma and whether the person is having an asthma attack.

Anyone who has the condition knows about the triggers that can cause an asthma flare. The most important factor is the common cold; viral upper respiratory infections are the most common reason for an asthma attack in both adults and children. Allergies are the second most important trigger but other factors like, exercise and weather changes can cause trouble as well.

To measure whether your child’s asthma is under control, I use the “Rule of Twos.” Your asthma is not under control if:

• You have to use albuterol more than twice a week on average during the daytime, or twice a month on average at night.
• You have to use oral steroids more than twice a year.
• You go through two albuterol puffers a year.
• When your asthma is not under good control, I would either add an inhaled steroid or increase the dose of the inhaled steroid.

Discuss this with your pediatrician and make sure you have an asthma plan. Teach the plan to your children as they grow up to help prevent asthma attacks.

The most effective preventive medication is an inhaled steroid, which comes in both a puffer form and in the nebulizer. This medication needs to be taken on a daily basis to prevent inflammation, which narrows the small air tubes.

All of the research over the past 20-30 years has shown that if asthmatics take their preventive medication regularly their asthma improves. Another helpful measure is avoidance of allergy triggers such as, dust mites and cat dander, which are the two most common allergens in our society.

The mainstay of treatment for an asthma flare is a drug called albuterol. It comes in several forms, but it is mainly used in a “puffer” or metered dose inhaler, or in a solution that is used in a nebulizer.

This medication is a bronchodilator which opens up tight airways. The other commonly used medication is an oral steroid such as, prednisone which decreases inflammation in the small air tubes.

I wouldn’t describe living life with asthma as easy and it does come with challenges. But if you take care of yourself, follow your medication treatment prescribed by your Cook Children’s pediatrician and avoid triggers as best you can, children should be able to live normal and productive lives.

They may even become a pediatrician themselves someday and take care of other kids with asthma.

Thus far, we have not seen the outbreak to be as severe as those seen in other regions. In my office, we are continuing to see the usual rise in respiratory illness as would be expected this time of year.

I want to take this opportunity to remind you that the severity of illness with EVD68 varies. Most children will have a common cold with runny nose and cough (most do not even have fever).

All of our Cook Children’s providers from the primary care offices to the hospital are aware of the situation so that we can continue to provide the best care for your children.

Here are some of the questions we have addressed in our previous coverage of this virus.

Does my child with runny nose and cough need to be seen by their doctor?

As with most viral infections, many of the children who get EVD68 will only have a runny nose and cough. There is no specific treatment for the virus and no way to predict who will become more ill once they have it. Because of this, there is no reason to rush in to be seen for mild symptoms. It is likely that the majority of children with these symptoms will get better on their own without treatment.

Watch your child for signs of wheezing or difficulty breathing, which would warrant a visit to your doctor or the emergency room. If you have any other concerns about your child, do not hesitate to contact your pediatrician for advice. Children with asthma need to be monitored especially closely. If your child has asthma, be sure that you have the prescribed nebulizer medication at your house should wheezing develop during the night.

How do we know if a child has EVD68?

Because there is no rapid test for the virus, your doctor or emergency room cannot determine if your child has it. That is why there is no need to be seen if your child’s symptoms are mild. At this point, testing is being recommended only for children hospitalized in an ICU setting.

How do we protect our children from EVD68?

As with all viruses, washing hands and keeping your child away from other sick children are important strategies. An important note: alcohol based hand sanitizers are not effective against EVD68, thus it is important to have your children wash their hands with soap and water before eating and periodically throughout the day.

My quick thoughts:

· Any new and emerging disease can be scary for parents.

· Media coverage increases the level of anxiety.

· Having a name for a virus increases the level of anxiety.

Fortunately, for most people, having information and being prepared help to decrease the anxiety. We see that as our job to you as your children’s hospital.

The good news is that there are many parts of the country that have already seen the peak of the illness and it is on the down swing. We have been able to monitor those outbreaks to be better prepared should we see an increase of cases in our area.

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.

Back to school time has brought with it an unexpected and unwelcome virus to much of the United States. Center for Disease Control (CDC) officials are warning health care providers in affected states to be on the lookout for a respiratory illness that starts with symptoms similar to the common cold, but rapidly progresses to wheezing and difficulty breathing. The virus is suspected to be enterovirus D68. Once thought to be rare, we have seen increasing frequency of infection and outbreak in recent years.

The recent outbreak has been noted in several states, 10 of which have requested help from the CDC: Colorado, North Carolina, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma and Kentucky. It is of particular concern because of the number of children whose illness progresses to wheezing and difficulty breathing. Early estimates are that about 15 percent of children who contract the virus may require hospitalization and many have required care in the intensive care unit. As with other respiratory viruses, any child with asthma or other chronic illnesses are more susceptible. The virus has been reported to cause wheezing even in children who do not have asthma.

Enterovirus D68 is spread through contact with others (often via coughing and sneezing), so avoiding people who are sick and washing hands frequently are important steps to prevention. It is important for parents to be aware of the illness and seek medical care should their children develop wheezing.

There are currently no published reports of activity in Texas, but if you have recently traveled to any of the affected states, it is important to be aware and let your pediatrician know if your child develops respiratory symptoms. As always, we will continue to monitor the situation and provide updates when new information is available.