Respiratory illness is on the rise, causing a jam of patients at the Cook Children’s Emergency Department (ED) and Urgent Care locations.

In the last 24 hours, our Urgent Care sites across North Texas saw 731 patients, many with respiratory syncytial virus (RSV) and other seasonal illnesses. That compares to 684 visitors the previous day.  

At the same time, our ED was treating 524 patients, up from 448 one day earlier. That’s nearly a patient checking in every three minutes.

Swabs for the virus came back positive on 29% of the 834 patients who were tested at Cook Children’s Medical Center – Fort Worth during the week of Oct. 29-Nov. 4. That’s an increase from the 25% who tested positive for RSV one week earlier. Numbers for COVID-19 and influenza, meanwhile, are running much lower at the current time.

RSV is a common respiratory virus that usually causes mild, cold-like symptoms such as runny nose, cough and fever. But it can be serious when it turns into bronchiolitis and pneumonia. RSV sends anywhere from 58,000 to 80,000 children under 5 years old to the hospital each year, according to the Centers for Disease Control. Infants are particularly vulnerable if they were born premature or have weakened immunity or heart or lung conditions. 

Our ED and Urgent Care centers are crowded, and wait times are longer for non-emergency illnesses and injuries. How do you know if your baby with RSV needs medical attention – and where to go? The doctors at Cook Children’s have answers.

Your Pediatrician

Go to your primary care physician if your child is experiencing mild respiratory symptoms but is not having difficulty breathing. Your pediatrician can test for RSV, COVID or the flu.

Jonathan Nedrelow, M.D., associate chief medical officer for the Medical Center, said infants should be seen by a doctor if they’re struggling to breathe. Watch for faster breathing than normal, flared nostrils, airway congestion, wheezing or a rattle you can hear or feel in their chest. Other concerning signs are excessive sleepiness, lack of appetite and trouble feeding.

“If parents notice their infant’s breathing is hard or labored, they need to be evaluated,” Dr. Nedrelow said. “RSV is not the only virus that can cause these symptoms, so it’s good to be checked out.”

Urgent Care

If you can’t get in to see your child’s primary care physician for mild difficulty breathing or wheezing, then Urgent Care is the next best place to go, said Kara Starnes, D.O. medical director of Cook Children’s Urgent Care Services. Decreased fluid intake (not as many wet diapers) is another sign to watch for. 

“There is no medication to treat RSV,” Dr. Starnes said. “Treatment for mild to moderate RSV involves frequent saline and suction of the nose and supportive care for fever as well as increased fluids. Cough and cold medications are not recommended.”

Virtual Care Visits

Cook Children’s primary and urgent care locations both offer virtual visits that can be accessed from the comfort of your home. Cook Children’s Virtual Care appointments can help you avoid packed waiting rooms and allow you to see a physician at your convenience. This is also a great option if you need a doctor’s note for school. Visit our website to learn more.

Hospital Emergency Department

Call 911 if your child is having severe difficulty breathing, is turning blue or has become lethargic. Don’t seek RSV treatment at the ED unless you see signs of struggling to breathe, such as the muscles sucking in between the ribs, or if your child can’t stay hydrated.

“If your child has mild symptoms such as cough, congestion, or low-grade fevers, we recommend following up with your pediatrician or urgent care, please do not come to the emergency department,” said Taylor Louden, M.D., in pediatric emergency medicine at Cook Children’s.

Severe cases of RSV typically need supplemental oxygen until the virus runs its course. IV fluids may also be necessary.

Preventing RSV

RSV season typically runs from October through early spring. These steps help avoid catching the virus or passing it along:

• Wash your hands frequently
• Cover your sneezes and coughs
• Stay home when you’re sick

And a new antibody-boosting injection, called nirsevimab, helps prevent severe RSV by providing a temporary boost to the immune system. The medication is in short supply nationwide, and available doses are reserved for patients at highest risk. Additional doses are on order at Cook Children’s, so check with your pediatrician for availability.

RELATED STORIES:

• CDC Recommends RSV Shot for Infants. Infectious Diseases Doctor Shares What Parents Need to Know 
• Clinic Watches out for Respiratory Trouble After Prior RSV Care

A new shot that helps prevent respiratory syncytial virus (RSV) is in short supply nationwide and Cook Children’s is following guidelines to prioritize infants at the highest risk of illness.  

Like other health care organizations across the country, Cook Children’s has limited doses of the new medication, called nirsevimab. Eligible patients are receiving the antibody injection as it arrives at Cook Children’s locations.

“While availability remains limited, patients may find their offices intermittently out of the product,” said Alice Phillips, M.D., at Cook Children’s Pediatrics Cityview. Additional doses are on order and Cook Children’s sites remain in contact with supply sources to maximize access for high-risk infants. 

Meanwhile, cases of RSV are on the rise at Cook Children’s, including at the Emergency Department (ED) and Urgent Care locations. At Cook Children’s Medical Center – Fort Worth during the week of Oct. 22-Oct. 28, tests for the virus came back positive on 25% of the 764 patients who were tested. That compares to a 6% positivity rate for COVID-19 tests and 1% positivity for influenza A.

Jonathan Nedrelow, M.D., associate chief medical officer for the Medical Center, said infants should be seen by a doctor if they’re struggling to breathe. Watch for faster breathing than normal, flared nostrils, airway congestion, wheezing or a rattle you can hear or feel in their chest. Other concerning signs are excessive sleepiness, lack of appetite and trouble feeding.

“If parents notice their infant’s breathing is hard or labored, they need to be evaluated,” Dr. Nedrelow said. “RSV is not the only virus that can cause these symptoms, so it’s good to be checked out.”

The Centers for Disease Control and Prevention on Oct. 23 advised health care providers to allot any available doses for patients most susceptible to severe RSV. That group includes:

• Premature infants
• Infants 6 months and younger
• Children younger than 2 years old with chronic lung disease or congenital heart disease
• Children with weakened immune systems
• Children who have neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

In July 2023, the Food and Drug Administration (FDA) approved nirsevimab, a monoclonal antibody to prevent severe respiratory disease due to RSV infections in infants and young children with underlying medical conditions. An injection provides a temporary boost to a child’s immunity to get them through the worst of the RSV season, typically the fall and winter months.

Cook Children’s pediatrician offices, neighborhood clinics, specialty clinics and Medical Center -- Fort Worth are navigating the shortfall by following the CDC advisory until the supply improves. At the Medical Center, supply is reserved for the highest risk patients such as infants admitted to the neonatal, cardiology and pulmonology units.

“All areas of Cook Children’s are working diligently to provide this product and to keep our families up to date with the most current information on supply and recommendations,” Dr. Phillips said. “Cook Children’s Health Care System remains actively engaged to provide this important preventative medication to our most vulnerable infants.”

The medication comes in single-dose syringes of 50mg and 100mg. The smaller dose is meant for infants weighing less than 5 kilograms (11 pounds). High-risk infants weighing more than 5 kilograms would receive the larger dose, which is especially scarce.

“Many infants pass this weight by 1-2 months of age, so careful consideration and early administration are key,” Dr. Phillips pointed out.

The CDC also recommended that doctors not give nirsevimab to children who are eligible for another medication, called palivizumab, instead. 

It’s important for parents to talk with their child’s health care provider to find out which medications are appropriate and available. And follow these key tips to prevent the spread of RSV: Wash your hands frequently, cover your sneezes and coughs, and stay home when you’re sick.

Background on RSV

RSV is a common respiratory virus that usually causes mild, cold-like symptoms such as runny nose, cough and fever. Virtually all children will be infected by RSV by the time they are 2 years old. Most recover in a week or two.

But RSV can be serious when it turns into bronchiolitis and pneumonia. RSV sends anywhere from 58,000 to 80,000 children under 5 years old to the hospital each year, according to the CDC. Dr. Nedrelow said those with severe cases typically need supplemental oxygen until the virus runs its course.

Taylor Louden, M.D., in pediatric emergency medicine at Cook Children’s said the recent increasing number of RSV patients has led to longer wait times in the ED. If your child has only mild symptoms -- including cough, congestion, or low fever -- please do not come to the ED, Dr. Louden said. 

“For milder symptoms we recommend frequent nasal suctioning at home, appropriate hydration, and follow up with your child’s pediatrician,” he said.

If you can’t get in to see your child’s primary care physician, then Urgent Care is the next best place to go, said Kara Starnes, D.O., medical director of Cook Children’s Urgent Care Services. Call 911 if your child is having severe difficulty breathing, is turning blue or has become lethargic, Dr. Starnes said.

Boosting Immunity

Clinical trials show that nirsevimab reduces the risk of hospitalization for RSV by 75%. Research and clinical trials show the medication is safe and causes only mild side effects. The injection is neither a vaccine nor a treatment.

This particular use of monoclonal antibodies for the prevention of severe RSV is new even though a similar type of RSV protection has been on the market for more than a decade. Nirsevimab needs just one injection to provide a period of protection that lasts about five months. The older medication requires an injection each month during the RSV season.

RELATED STORIES:

• CDC Recommends RSV Shot for Infants. Infectious Diseases Doctor Shares What Parents Need to Know 
• Cook Children’s | Medication to Prevent RSV 

The Centers for Disease Control and Prevention has recommended a new antibody shot to help prevent severe respiratory syncytial virus (RSV) disease in all infants.

RSV is a leading cause of hospitalization for infants. The use of nirsevimab (trade name Beyfortus) is a long-acting monoclonal antibody infusion, which has been shown to reduce the risk of both hospitalization and healthcare visits in infants by about 80%, according to the CDC.

The CDC recommends:

• One dose for all infants 8 months old and younger born during or entering the RSV season (fall through spring)
• One dose for children between 8 and 19 months old who are at an increased risk of severe RSV, including severely immunocompromised children

“This new antibody treatment, which has now received the Food and Drug Administration approval and CDC's Advisory Committee on Immunization Practices recommendation, will truly be a game-changer,” said Jason V. Terk, M.D. of Cook Children's Pediatrics Keller Parkway. “This will dramatically reduce the burden of this infection among infants in their 1st year of life and I am excited about that!”

What is RSV?

RSV is a common respiratory virus that usually causes mild, cold-like symptoms. Virtually all children will be infected by RSV by the time they are 2 years old. Most people recover in a week or two, but RSV can be serious, especially for infants and older adults.

Every year, there are between 58,000 and 80,000 hospitalizations for RSV for children under 5 years old, according to the CDC.

RSV can also cause severe illnesses such as bronchiolitis and pneumonia. The risk is especially high for premature infants.

According to the CDC, those at greatest risk for severe illness from RSV include:

• Premature infants
• Infants, especially those 6 months and younger
• Children younger than 2 years old with chronic lung disease or congenital (present from birth) heart disease
• Children with weakened immune systems
• Children who have neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

Previously, there were limited treatments for RSV; most are available only for premature infants, infants with other lung diseases, infants who are considered immunocompromised, or patients with congenital heart disease.

Nicholas Rister, M.D., of the Cook Children's Infectious Disease team, shares what parents and caregivers need to know.

How severe can RSV be, if my baby is infected?

RSV is a very common infection for infants and young children. Most will only have a typical “cold” or “viral URI.” Although, given how many infants become infected, many children are admitted to the hospital and intensive care unit each year.

RSV infections can be very serious for some babies in particular. This includes very premature infants 36 weeks gestation or younger, but especially if younger than 32 weeks gestation. This also includes babies with congenital heart disease and babies who required several weeks of oxygen support after birth, such as ventilators or cannulas.

What is the difference between this antibody and a typical vaccine?

A vaccine is designed to trigger your body to produce its own antibodies to a disease. This provides both immediate protection and longer-term memory. An antibody infusion gives you protection immediately but has not trained your body to continue creating those antibodies. This leads to a quick but only temporary period of protection.

Many vaccines work well in older children but not infants. Providing antibody infusions can cover at-risk infants who would otherwise not create antibodies in response to a vaccine.

Can my baby show symptoms once they receive the antibody? Are there any side effects?

With any infusion of medication that was not created inside your baby’s body, there is always a chance their immune system will notice it and react. Thankfully young infants, due to their immune tolerance of recently living inside of another human body, develop these reactions less frequently. Your doctor will monitor for any signs of a reaction during the infusion and after with your assistance.

How long has this antibody been tested? How do I know it is safe for my child this fall?

The use of RSV antibody infusions has been present and tested for over a decade. While this newer treatment provides more widespread application, the core safety of the treatments is well established.

What is the most important takeaway for parents of infants?

RSV is a highly prevalent disease and every family should talk with their pediatrician about the potential benefit of this antibody infusion for their child. While some children will clearly benefit more than others, it is an important conversation to have for all families.

How soon will it be available at pediatrician offices?

The CDC expects nirsevimab to be available this fall. Expectant parents and parents of infants under the age of 8 months, as well as those with older babies, should talk with their pediatrician

Before leaving your infant with a friend, grandparent, other relative or babysitter, it’s important to make sure the caregiver practices the basics of safe sleep. It might feel like an awkward or unnecessary topic to bring up with your mother or mother-in-law or favorite auntie who provides free babysitting. But not all caregivers are aware of the safe sleep practices backed by medical evidence, as they have been updated over the years.

At nighttime and every nap – whether at home or away, with parents or sitters -- the safest way for infants to sleep is: 

• on their backs
• alone (no co-sleeping)
• in a crib or bassinet with a firm and flat mattress
• without pillows, sheets, blankets, toys or other objects

More than 3,500 sleep-related infant deaths occur annually in the U.S., according to the Centers for Disease Control and Prevention. In 2022, 25 infants at Cook Children’s Medical Center in Fort Worth died from cardiac arrest, respiratory failure or other trauma due to unsafe sleep incidents that happened at their homes. A majority of those deaths involved co-sleeping with at least one parent or caregiver who awoke to find the child unresponsive.

So far in 2023, Cook Children’s has seen nine deaths due to unsafe sleep conditions, including co-sleeping with adults. Suffocation can occur if someone rolls onto the baby or if bedding covers the baby’s face.

Juan Cocjin, M.D., of Cook Children’s Neighborhood Clinic – Renaissance, said grandparents shouldn’t assume that it’s OK for babies to bed-share, even if that’s the norm the grandparents are used to or have done in the past.

It’s a sensitive topic because sleep customs get passed down in families from one generation to the next, Dr. Cocjin says.

Some of his patients are being raised by grandparents or even great-grandparents. He occasionally hears a caregiver say their baby shares a bed with others in the family. While these conversations can be tough, it’s important to break through misconceptions that co-sleeping is safe.

“I share with them the hazards of co-sleeping,” Dr. Cocjin said.

Creating a safe sleep environment for your baby takes consistent practice until it becomes automatic. Dr. Cocjin urges grandparents to seek out reputable sources of information and have an open mind about what the experts say. As he puts it: You can’t stick with unsafe habits hoping “maybe it’ll be OK.’’

Communication

Cook Children’s social worker Lorie Palacios, LMSW spreads the word in English and Spanish as a Safe Baby Sleep Council member, a coalition of partners including the Cook Children’s Center for Community Health. She shares safe sleep education at injury prevention at community events.

Palacios emphasizes the importance of sharing your safe sleep plan with everyone who cares for your baby. If mom and dad don’t live together, for instance, they should communicate about their baby’s sleeping arrangements in both residences. Ask if your baby’s caregivers have a crib or bassinet.  

“We want to make sure that conversation is happening,” she said. Transparency and communication are key.

Palacios pointed out that licensed day care facilities in Texas are required to follow protocols for safe sleep. That’s not the case when a friend or family member volunteers to watch your infant. And if a parent feels indebted to the babysitter, she said, they might worry that they’ll be seen as critical or questioning the sitter’s abilities if they speak up about safe sleep.

“If you’re dependent on a family member, especially a grandparent, that’s a very difficult conversation to have with someone you love and trust,” Palacios said.

When Palacios’ children were little, their grandmother kept them while Palacios worked. One day she found her 3-month-old daughter sleeping on the grandmother’s bed with a pillow and blanket.

“I had a playpen. I had a bassinet,” Palacios said. “All these things were available, but those were not the things that my mom used when she was raising her babies. To her, the bassinet felt awkward.”

Prior to that day, Palacios said she and her mom had only touched on the topic of safe sleep.

“The toughest thing is this idea that you’re questioning your elders,” she said. “I wasn’t really pushy because I wanted to maintain my respect.”

After that day, Palacios clearly and specifically told her mom her expectations for the baby’s sleep environment going forward. The words weren’t easy to say; but her mom respected Palacios’ wishes.

When you rely on a network of relatives or neighbors to help care for your baby, she said, you need to stand your ground on matters of safety. A caregiver might mean well but be misguided.

“It definitely takes a little more courage to find your voice when you’re part of a big village,” Palacios said. 

--------------------------------

More about safe sleep from Cook Children’s Checkup Newsroom:

• Safe Sleep Starts With Babies in Their Own Separate Sleep Area (checkupnewsroom.com)
• Safe Baby Sleep: Keep Decorating 'Extras,' Blankets Out of Infant Cribs (checkupnewsroom.com)
• Pediatrician's Advice: Straight Talk About Sleepless Nights (checkupnewsroom.com)

By buckling their children into car seats and lifejackets, parents are taking steps to protect against tragic accidents. Safe sleep practices fit into that same mindset.

Taking precautions in an infant’s sleep space -- just like the precautions involving car seats and lifejackets – helps reduce the risk of serious or fatal injury. That’s why Cook Children’s urges families to make it a priority to create a separate, safe sleep environment for babies 1 year and under. The safest place for babies to sleep is on their backs, on a flat and firm surface, in their own bassinet or crib without pillows, blankets or soft toys.

The message of Safe Sleep gained urgency at Cook Children’s and across the community after we shared that 30 infants died over a 15-month period from cardiac arrest, respiratory failure or other trauma due to sleep incidents that happened at home.

From January through April 2023, five sleep-related deaths were recorded at Cook Children’s, all to infants under 1 year old. These deaths happened on couches, adult beds, and during co-sleeping. 

It isn’t safe for anyone to sleep in the same bed with babies at night or even for quick naps on the couch or in a recliner, due to the risk of unintentional suffocation. Babies can fall, be strangled or wedged between furniture and walls. Loose sheets, a comforter or another person’s body can cover the baby’s face and block the airway.

Co-sleeping already creates unsafe risks for babies. The U.S. Department of Health and Human Services identifies several factors that increase the risk even further, including:

• Co-sleeping with one or more people
• Co-sleeping on a waterbed, old mattress or an especially soft surface
• Napping on a couch or armchair, either alone or next to someone else  
• Co-sleeping with adults whose fatigue or use of medication, drugs or alcohol makes waking up difficult 

More than 3,500 sleep-related infant deaths occur each year in the U.S., according to the Centers for Disease Control and Prevention.

What are some reasons that bed-sharing occurs?

Some parents share reasons such as convenient breastfeeding, generational or cultural habits, busy lifestyles, the expense of cribs, limited space to put a baby bed in a crowded home, and the belief that “it won’t happen to me.”

Bianka Soria-Olmos, D.O. of Cook Children’s Pediatrics Haslet says that when her patients report that they bedshare, she shapes the conversation from an injury prevention perspective. In her experience, most families that choose to co-sleep have tried but given up on putting their infants in a separate sleep place. 

“The majority of the time moms say the baby just won’t stay in the bassinet,” Dr. Soria-Olmos said.

Some parents opt for bed sharing because they believe it will promote strong emotional bonds. Dr. Soria-Olmos wants them to know that co-sleeping isn’t required for bonding. That’s because everything that parents do to care for their baby – feeding, bathing, diaper changes, singing, play and more – creates the parent-child bonds. 

Paulette See, M.D. at Cook Children’s Pediatrics Haslet understands how tempting it can be for parents to bring their baby to bed with them, especially when they’re exhausted. 

“I get where you’re coming from,” said Dr. See, who is a mother and grandmother. “As much as we want to love and cuddle our babies all the time, for them to sleep on their backs in their own space is the safest.” 

In Dr. See’s experience, postpartum anxiety can lead some mothers to incorrectly believe that their baby is safer sleeping in the parent’s bed. It eases their minds to realize they can still see and touch the baby if the bassinet or crib is within arm’s reach, she said.

Dr. See empathizes with patient families who say their baby sleeps longer and cries less in the parents’ bed. But “just because something fits our lifestyle better doesn’t make it right,” she pointed out.

Here’s a comparison Dr. See makes: Your baby might scream in their car seat, but you buckle them in anyway. The same logic applies to the crib, where your baby might cry at first when learning to sleep separately, but you stick with it from a safety standpoint.

Cook Children’s pediatricians and health care providers want to share the information you need to keep your child safe and healthy. Cook Children’s encourages all families to understand that they can check on, feed and comfort their baby without sleeping in the same bed. Share a room, not a bed. A safe sleep space for your baby can either be a bassinet, portable crib or play yard near their parent’s bed.

RELATED:

Pediatrician's Advice: Straight Talk About Sleepless Nights (checkupnewsroom.com)

So the Rock-N-Play’s Been Recalled. Now What? (checkupnewsroom.com)

Pediatricians Offer Virtual Newborn Classes for Parents (checkupnewsroom.com)

The saying “timing is everything” could not be more true for Crystal Schnabel, Eric Massey and their son Rogan Massey. Rogan was born on April 13, nearly six weeks early, but not a minute too late.

A few days prior to her son’s birth, Schnabel had an appointment scheduled with maternal-fetal specialist Holly Dunn, M.D., an Abilene-based high-risk obstetrician with Cook Children’s Health Care System. Because Schnabel experienced low amniotic fluid levels in her first pregnancy, she needed to be monitored closely. But a scheduling conflict led her to cancel her 34-week appointment. Two days after her missed appointment, just to be on the safe side, Schnabel, a radiology technologist, asked a fellow sonographer to do a quick ultrasound to check her fluid levels. Her colleague told her to stop by the next day during a break in her schedule.

On April 13, at 2:45 p.m., Schnabel met her colleague for the scan, and they both noticed something peculiar. Rogan’s heart rate was irregular and beating faster than normal at 254 beats per minute. The sonographer urged Schnabel to go to the labor and delivery department at Hendrick Health in Abilene for an exam. Schnabel alerted her obstetrician, called her husband and made her way to the hospital.

There, she was hooked to a fetal heartbeat monitor that produced what appeared to be normal readings for the baby’s heartbeat, but Schnabel’s obstetrician asked Dr. Dunn to take a second look.

“Her OB called me, had me look at the monitor strip and something didn’t sit right with me. So I told her to send mom over,” Dr. Dunn said.

Schnabel and Massey immediately made their way to Dr. Dunn’s office located just across the street from the hospital. By this time, it was a little after 3 p.m.

Schnabel was seen and counseled by Dr. Dunn’s nurse practitioner who recommended that she be admitted to the hospital for overnight monitoring. As the couple left to make the short trek back across the street to the hospital, Dr. Dunn reviewed her sonogram images and made the call to act sooner than later.

When the couple arrived at Hendrick Health’s labor and delivery department they received shocking news. Schnabel needed an emergency cesarean section.

In the five minutes it took Schnabel and Massey to walk from Dr. Dunn’s office to the hospital, the labor and delivery team received a call from Dr. Dunn to alert them that Rogan’s heart was in supraventricular tachycardia (SVT), a fast and erratic heartbeat that prevents the blood from pumping throughout the body, potentially leading to congestive heart failure and death.

“The baby’s heart was barely moving,” Dr. Dunn said. “The rate was quick, so the electrical conductivity was passing through, which is what we were detecting on ultrasound and monitors, but the heart itself was barely moving and weary from working so hard. There can be some arrhythmias that are benign, that are sustained for days to weeks. But SVT, in this case, is something that can only be sustained for a few minutes to hours before the baby either comes out of it spontaneously or death occurs.”

Rogan needed to be delivered immediately. His life depended on it.

“We walked in and all of the nurses are standing around and anesthesia is ready,” Schnabel said. “The doctor was ready. The NICU team was there, and I was in a gown with all my jewelry off and an IV going within a matter of probably four minutes. It was very fast.”

The couple knew something was wrong but they had no idea how serious it was.

“Everything happened so fast that it was hard to understand the severity,” Massey said.

Rogan was born at 5:25 p.m., a little more than two hours after Schnabel met her colleague for that impromptu ultrasound.

Schnabel and Massey were able to see their newborn for a few brief moments before he was whisked off for care. Around 8:30 p.m., Cook Children’s Teddy Bear Transport arrived at Hendricks Hospital to transport Rogan to Cook Children’s Medical Center – Fort Worth for treatment of his dangerous heart arrhythmia.

Collaboration Counts

Schnabel’s on-the-fly ultrasound that fateful Thursday set in motion a number of collaborative efforts between pediatric specialists that resulted in an accurate diagnosis and treatment plan, and much of it came together during the couple’s short walk from Dr. Dunn’s office to the hospital.

“It's a reassurance to know that they're in sync with one another to be able to communicate so quickly and get an accurate specialty-type diagnosis within five minutes of the scan,” Massey said.

After connecting the dots between Rogan’s unusual heart rate, the ultrasound, monitor readings and the report from her nurse practitioner, Dr. Dunn made an urgent call to Lisa Roten, M.D., a pediatric cardiologist at Cook Children’s Medical Center. Dr. Roten is the medical director of Cook Children’s fetal electrocardiography program. Scott Pilgrim, M.D., medical director of Cook Children’s adult congenital heart disease program, was also looped into the case.

“There's constant collaboration between us, but in this case, it was just so seamless and easy and I was able to orchestrate the management plan between Dr. Roten and myself, and then Dr. Pilgrim became involved as the handoff happened from here to the medical center in Fort Worth,” Dr. Dunn said. “There was also so much collaboration with the Hendricks Health staff, with anesthesia, the nursing staff and the neonatologist.”

Dr. Roten recommended an immediate c-section for any chance of saving Rogan’s life.

“SVT, or atrial flutter in this case, is not life-threatening if for a short duration,” Dr. Roten said. “However, if it does not break, as was the case here, it results in death. This baby’s heart function was very poor and we did not have time for medicines to be given to mom to try to correct the rate.”

Undetected arrhythmias are the suspected cause of many stillbirths where there is no known genetic syndrome or structural problem, according to Dr. Dunn. If the sequence of events had been any different, Dr. Dunn says it’s likely Rogan would not be alive today.

“I think a lot goes into Rogan’s story,” Schnabel said. “I had the sonogram on that specific day and at that specific time when my coworker had an opening on her schedule and I could have her scan me, and the fact that his heart did what it did at that exact moment is proof that he is here for a reason. We were able to go to labor and delivery and have him within 15 to 20 minutes of showing up and the OR team was ready. Every little thing had to happen for him to still be alive. Through it all I was reminded I’m not in control, God is. This was his plan, not mine. The progress we’ve made over the past few weeks has been from above and I’m thankful for every moment.”

It’s unclear what caused Rogan’s arrhythmia, as is the case with many babies who develop the condition. Rogan spent 19 days in Cook Children’s Neonatal Intensive Care Unit where he was diagnosed with a type of SVT known as atrial flutter, in which the upper chambers of the heart pump rapidly. He underwent two cardioversion procedures to shock his heart back into a normal rhythm and is now on medication to control his heart’s pumping function.

It’s possible he’ll grow out of the condition altogether. If not, he may need a cardiac ablation in the future. An ablation is a procedure where doctors burn or freeze tiny scars into the heart to block irregular electrical pulses so that the heart stays in a normal rhythm.

“The electrical system of a newborn is immature and most babies outgrow the arrhythmia by one year of age,” Dr. Roten said. “But this rhythm was harder to control and sometimes they need to go to the cath lab to have an ablation.”

For now, Schnabel and Massey, are back home in Abilene with their newborn enjoying their full house, which includes Rogan’s brother and sister, both 10 years old.

“I'm just thankful for the support that we've had from the community,” Massey said. “Our friends and family have been overwhelmingly supportive.”

If you are the parent of a baby, you’ve probably been given the advice to sleep when the baby is sleeping. While well-meaning, it’s not always that easy.

As a mother of twins, now 14, I often rolled my eyes when someone would tell me this. It was hard enough getting one baby to sleep, much less two asleep at the same time long enough to catch any meaningful minutes of shut-eye for myself.

I’ll never forget one night in particular. On the way home from an outing the babies fell asleep in the car. My husband and I carried them into the house in their infant car seats and placed them by our bed. We were so tired and didn’t want to risk waking them in a transfer from their carriers to their cribs. Never wake a sleeping baby, right? Another well-meaning but not so practical or sound piece of advice.

So we left them strapped in their seats thinking they would wake on their own soon and we could move them then. In the meantime, we decided to get a little sleep, too. Hours later I woke up to find both babies still in their car seats and, uncharacteristically, still asleep.

I’ve since learned how dangerous it is to leave babies asleep and unattended in their car seats for long periods of time when not in a moving vehicle. Babies can and have died while sleeping in a sitting device like a car seat, bouncer or swing when used improperly as a sleeping location. A 2019 study that reviewed more than 11,700 sleep-related deaths over 10 years found that 3% of infant sleep deaths occurred in baby-sitting devices, most of them a car seat used improperly outside of the car.

So far in 2023, Cook Children’s Medical Center has recorded five baby sleep deaths, with one of them occurring while a baby was sleeping in a baby chair, according to Sharon Evans, Cook Children’s trauma injury prevention coordinator and car seat safety expert.

The danger lies in the positioning of the baby’s head and neck while asleep in a sitting device. The incline of the seat can cause a sleeping baby’s chin to fall and rest on its chest, closing their airway. Most newborns do not have the muscle strength to raise their heads on their own and, when in this position for too long, they can suffocate.

A seat’s degree of incline poses a risk, too. Baby sitting devices with an incline greater than 10 degrees is unsafe for baby sleep, according to the American Academy of Pediatrics. The incline makes it easier for a baby to turn over onto their belly in the seat. For those not strong enough to turn back, this can result in suffocation or injury.

A lot of babies are lulled to sleep while in their car seats in a moving vehicle, and that’s okay, Evans says. Who among us hasn’t driven extra miles during an outing so that your baby could finish their nap? When a car seat is properly installed in a car, it sits at the correct recline angle, which helps ensure the baby’s airway remains open. When placed on a flat surface like the floor or a table, the angle could pose a danger. Also in the car, you’re right there with your baby hearing their giggles and cries and are more likely to know if something is wrong. That’s not always the case when outside of the car where you can easily walk away, get distracted or, like me, go to sleep.

We were fortunate that nothing tragic resulted from that night of car seat sleeping, and were careful not to make the same mistake with our third baby. But, sometimes, exhaustion and desperation speak louder than reason and safety.

So what is a sleep-deprived parent to do?

Sireesha Mutyala, M.D., a pediatrician at Cook Children’s Pediatrics Plano Legacy, is a mom, too. As a working parent, she knows the exhaustion from sleepless nights followed by busy days as well as anyone. She also knows the dangers that certain factors bring to a baby’s sleep. Factors like cribs with blankets or stuffed animals, or unattended bouncy seats, and bed sharing, to name a few.

“With the alarming number of infant deaths from unsafe sleep that our medical center has already seen this year, I am so thankful that Cook Children’s is getting the word out to families about safe sleep,” Dr. Mutyala said. “It’s an issue near and dear to my heart.”

I asked Dr. Mutyala to demystify baby sleep. What’s normal and what isn’t? How can parents create a safe sleeping environment that encourages our little bundle — or bundles — of joy to sleep peacefully for as long as is appropriate for their age and development so that mom and dad can get some much-needed rest, too.

What is normal baby sleep in the first year? How long do babies usually sleep and how many times do they typically wake at night?

Usually, during the first three months, babies sleep about 14 to 17 hours per day, but in short spurts, like 30 minutes to two hours at a time all day and night. Newborns need to feed about eight to 12 times a day, so they have to eat almost every two to three hours even during the night. So there's very little continuous sleep happening in that stage.

Once they get to 4 to 7 months old, they're sleeping about 12 to 16 hours per day. Hopefully, five or six of those hours are at night, and they have three or four naps throughout the day. Those could be one to two-hour naps during the day and then a little bit longer stretch at night. At just a little under a year of age, they're still sleeping the same amount, 12 to 16 hours, but we're hoping about eight to 12 of those hours are at night, and they take about two to three naps during the day. Again, those are usually one to two-hour naps.

Typically nighttime sleep gets better as they get older. When a baby sleeps five to six hours in a row at night, we consider that sleeping through the night. Most babies will be able to do this between 3 and 6 months old.

Is it true that formula-fed babies sleep longer than breastfed babies?

That’s somewhat of a myth. Studies show that babies who are breastfed actually get more sleep throughout the night. They do wake up a little more frequently but their total sum of sleep is actually more, at least for the first few months or so. By the time babies are about 6 to 8 months old, the differences are gone and formula-fed babies and breastfed babies are sleeping much the same.

It’s important to know babies wake up for different reasons throughout the night, not just because they are hungry. They go through their sleep cycles multiple times throughout the night, so when they hit that light sleep cycle, that's when they wake up. For most that will be about four to six times a night. A lot of times they'll just go right back to sleep after a few minutes, which is why it's good not to rush in to them and automatically assume that they need to be fed every time. If you know they are safe, give them some time to fall back to sleep, especially if they're over 3 to 4 months of age. They will never learn to fall asleep on their own if we don't give them a chance to do it!

How should parents set the stage to encourage their baby to sleep?

Most importantly, make sure that it's a safe sleep environment. For every stage of infancy, babies need to sleep flat on a firm surface in a bassinet or crib and on their back. Close by is good, but definitely not in a bed with anyone else.

Most babies will sleep in a bassinet near the parents’ bed in the same room as them until they're about 3 months old. Then, they usually have to move from a bassinet to a crib. I wouldn’t wait too much past three months to move into a crib because it becomes really hard for a baby to change sleep environments after that age. A lot of families will keep the crib in the parents' room for maybe the first six to 12 months. The American Academy of Pediatrics recommends babies sleep in the parents’ room but on a separate surface for at least the first six months and up to one year, ideally.

Whatever you do, consistency is key. End the night where you started it. If your baby is in a crib, start the night in the crib. Keep the lights dim and the noise low from the beginning of the bedtime routine all the way through the night. That helps signal to them that it's nighttime.

Also, one of the things I really try to talk to families about is making sure that the baby's getting enough of their eating and drinking done during the day. Try to meet all those calorie needs during the day so that the baby understands that daytime is for eating and nighttime is for sleeping.

A lot of families do give babies a bath in the evening, give one last feeding, clean their gums or teeth and maybe read a bedtime story. Reading to them is important even at this early age as it helps with language development. Then, place the baby in the crib while they are sleepy, but still a little awake and have them fall asleep there.

Speaking of routine, how important is routine for a baby? Does it impact their sleep?

I find that routines really help babies understand what's happening around them and what to expect. You might not be able to do an actual schedule with exact times, but you can have an order and pattern to things. I liked having a pattern of eat, play, and then sleep for the baby. Even from the newborn period you can start establishing that pattern. Keeping a similar time for waking up in the morning and falling asleep at night actually helps them sleep better in general, too. It may be counterintuitive, but we don't want to make them overly tired by taking away naps in order to try to get them to sleep more during the night. Overtired babies can have a more difficult time falling asleep or staying asleep.

Look for their sleepy cues, too, like rubbing their eyes. Every baby may be different in what they do that signals they are tired, but look for those behavior patterns. When they start displaying those sleepy cues, that’s a good time to start getting them to sleep. If you wait too long, they’ll get past the point of tiredness and sleep will be harder.

There are a number of books written about different sleep training techniques. What do you recommend to parents about finding one that works for them?

Every baby is different, and so is every family. Sleep training can be very personal based on the parents’ comfort levels, their cultural practices and beliefs and a whole bunch of other factors. Families just need to be realistic in using a technique that they're going to actually be able to stick with and continue for a consistent amount of time.

Most of the common themes in these techniques is making sure the baby gets sleepy and then putting the baby down in their crib while they are drowsy but awake so they can learn to fall asleep on their own. This way, if they do wake up in the middle of the night, they look around and know that they are in the same place they fell asleep. They will be more comfortable going back to sleep again instead of being shocked that they're not in their parent’s arms or wherever they fell asleep initially.

I’d say the biggest difference in each of the techniques is what you’re supposed to do when the baby starts to cry during sleep time. Just remember it's not always hunger when they do wake up in the middle of the night, so don't rush in to them just because they're waking up. Give them a few minutes, and you might find they’ll put themselves back to sleep on their own.

The biggest thing that we find is parents say it doesn't work, but they're not sticking with it and being consistent. Give whatever method you are using a good solid two weeks of implementing it and continue with it as long as the baby is healthy.

I do not recommend any sleep training method before three months, as newborns need to eat every two to three hours for their growth and development.

What is sleep regression and how can parents get their baby back on track?

Sleep regression is when a baby who was previously sleeping well all of a sudden has trouble either falling asleep or staying asleep, and it can last a few weeks. A lot of times it can be triggered by things like growth spurts, teething, changes in routines like traveling or the baby starting a new daycare, or an illness. Reaching a new developmental milestone, like learning to roll or sit, can also cause a regression. We see it a lot around four months and then again at six months and nine months.

To get over the hump, you want to stay consistent with that bedtime routine, avoid letting them get overly tired and always give them a few minutes to try to go back to sleep themselves before you jump in there. Sometimes you do have to go back to your original sleep training method for a couple of weeks if you used one. It does tend to be much easier the second, third and fourth time around with that sleep training.

What is the most important thing you want parents to know about baby sleep?

Have your baby sleep in a safe sleep environment, flat on their back and alone in a bassinet or crib with a firm mattress every single time. This is healthy for the baby and really helps the family sleep soundly, too, knowing that the baby is safe.

When we are consistent with our baby's bedtime routines and have them fall asleep on their own, they tend to sleep so much longer and better. That continues on through early childhood and through those transitions with school bedtime routines. It really fosters good, long-term sleep habits. They grow better when they sleep well. They eat better when they sleep, and it translates to all sorts of healthy habits during the day, too.

Building healthy sleep habits is a marathon, not a sprint. We really need to remember that, even when we're exhausted, we've got to do what is going to be best in the long run and not just what is easiest to get us through the night. Healthy sleep habits are built over time and we just need to be very consistent with them. 

Wind chills are expected to be below zero degrees on Thursday, according to the National Weather Service. Be sure to dress warmly, cover up any exposed skin and limit your time outdoors. Hypothermia begins when our body temperature drops two to four degrees. 

By Thursday night, low temperatures will fall into the single digits across most of the Dallas-Fort Worth region. By Friday morning, temps will be in the teens or possibly in the single digits with high wind gusts.

People exposed to extreme cold are susceptible to frostbite in a matter of minutes. Areas most prone to frostbite are uncovered skin and the extremities, such as hands and feet.

Take these tips from MedStar on what a winter weather plan should include:

• Make sure that you have important phone numbers, including for your health care providers, pharmacy, and veterinarian.
• Assure you have enough medication for several days on hand.
• If you rely on medical devices in your home, have a backup plan in case you lose power for an extended period of time, such as a backup generator or battery pack and backup oxygen bottles.
• Have a communication plan for your family.
• Know how to get reliable information during the storm.
• Gather supplies in case you need to stay home for several days without power.

Carbon Monoxide

If the power does go out, be very cautious of carbon monoxide.

During the Texas winter storm in February 2021, Cook Children’s treated 13 patients for carbon monoxide poisoning in one night. Sam Selby, D.O., worked the overnight shift in the emergency department on Feb. 15, 2021 and saw families use propane or diesel-burning engines that are meant for outside use with adequate ventilation.

Dr. Selby described how families used generators inside or too close to their homes or garages to keep warm. Generators emit fumes and can cause carbon monoxide poisoning.

“Carbon monoxide poisoning prevents your blood from being able to bind to or carry oxygen. You suffocate while you are still breathing,” Dr. Selby explained. 

Here are some additional ways to keep your family safe during this time:

• Don’t use anything such as a BBQ grill or propane tank to heat your home.
• Don’t run a vehicle inside of a garage attached to your home.
• Don’t heat your home with a gas oven or stovetop.
• Don’t burn charcoal inside of your home. 
• Do seek medical attention if you suspect carbon monoxide poisoning.
• Do ensure the carbon monoxide detectors in your home are properly functioning and installed in areas that will wake you if it alarms.
• Do check for local resources, such as warming shelters, to keep your family safe. 

Coats & Car Seats

Don’t strap your children into their car seats with their heavy coats on. In a crash, padding from a coat or thick layers will flatten out, leaving room under the car seat harness. This increases the risk of a child slipping through the straps and being thrown from the car seat. Instead, dress your child in thin layers. Once buckled up, slip the coat on backward with the sleeves on the child’s arms. This way, the coat acts as a blanket and doesn’t affect the fit of the harness.

Pack an emergency bag for your car. It’s a good idea to have blankets, warm clothing, hats, and gloves available in case you become stuck in winter weather. You’ll also want to have nonperishable snacks packed away.

Dressing Warmly

When Outside

• Make sure newborns are dressed appropriately. "A good rule of thumb is to dress newborns in as many layers as you're wearing," said Diane Arnaout, M.D., Cook Children’s Medical Advisor for Digital Health. "That includes covering their heads, hands and feet. Those areas can lose a lot of heat and be harder to keep warm."
• For the most warmth, dress your little ones in wool instead of cotton. Essential winter items include hats and gloves, as well as sweatshirts or T-shirts that can be layered under overcoats or jackets.
• Blue skin, shivering and a cool chest and stomach are signs that children may be dangerously cold. If you see these signs, take action immediately to get kids out of the cold. Seek immediate medical attention if you're not able to warm the body.

Recognizing Hypothermia

According to the Centers for Disease Control and Prevention (CDC), hypothermia, or abnormally low body temperature, "is a dangerous condition that can occur when a person is exposed to extremely cold temperatures." To learn more about the warning signs of hypothermia, click on this site from the Centers for Disease Control and Prevention (CDC).

Warning signs for adults include:

• Shivering, exhaustion
• Confusion, fumbling hands
• Memory loss, slurred speech drowsiness

Infants:

• Bright red, cold skin
• Very low energy

Victims of hypothermia can include babies sleeping in cold rooms.

Want to know more about winter weather safety? 

Check out these articles from Checkup Newsroom contributors:

• Cold Weather and Kids. How to Keep Your Family Safe at Home, Outside and in the Car. 
• Bracing for Freezing Weather: Plan Ahead to Protect Your Family on the Road
•  Common Winter Mistakes Parents Make
• Cook Children’s Sees Spike in Carbon Monoxide Poisoning Patients During Freezing Temperatures

Finding infant formula on store shelves can still be tricky if you’re shopping for specialized types made for premature infants or babies with digestive complications.

Nutritional experts at Cook Children’s say some patient families are struggling even though formula availability generally has improved in recent months. The 2022 shortages have been blamed on a manufacturing recall and supply chain disruptions.

Brand options tend to be limited for preemies, who require formulas with higher calcium, phosphorous and protein for their bone and brain development. Likewise, infants who undergo surgery on their stomach or intestines might need certain easy-to-digest formulas.  

We spoke with three registered dietitians – from the Cook Children’s Neonatal Intensive Care Unit (NICU), the N.E.S.T. Clinic, and the Gastrointestinal Clinic – about tips and support for parents when the formula their baby takes is out of stock.

Their advice? Consider switching to another appropriate brand. Use the imported formulas that received approval from the U.S. Food and Drug Administration. Ask your pediatrician for samples. Don’t dilute formula or make your own version. And don’t give up.  

“I still see grocery stores with formula shelves that look about half empty or less,” said Hayley Spinks, a clinical dietitian in the NICU. “If you’re looking for a specific formula, it doesn’t really matter if the shortage is getting better overall. If you can’t find the formula that your baby needs, it’s really a big deal.”

One resource the dietitians share is a substitution list they created to help families know which brands fall in categories for particular needs. The substitutions list includes standard formulas, premature formulas, reduced lactose formulas and more. Go here to view the formula substitution chart.

The shortage continues to cause challenges and frustration, but dietitians are working to help parents find solutions. Here are their viewpoints.

In the NICU

Dietitians in the NICU monitor growth of the smallest babies, who sometimes need fortifiers added to their feeding regimen. When a preemie product runs out of stock, Spinks said, they turn to alternatives with the right nutritional components that the infant can tolerate. Signs of formula intolerance may include diarrhea, vomiting and belly bloating.

Before patients are discharged, Spinks and her colleague in the NICU like to ask the parents whether they’ve been able to find the formula they need. “Some moms are telling me that they’ve looked and they can’t find the formula that their baby is on,” she said. Others tell her they’ve enlisted relatives and friends to help search the stores.

Spinks makes a habit of checking the formula aisle when she’s shopping. She also belongs to formula finder groups on social media. “I’m always trying to keep my eye on the situation of what we can expect,” she said.

She encourages parents to have confidence in the safety of formulas that have been imported since May to relieve the shortage in the United States. But she cautioned that the measurements might differ (milliliters versus fluid ounces). Always follow the recipe on the can.

In the N.E.S.T. Clinic

The Cook Children's N.E.S.T. Developmental Follow-up Center (cookchildrens.org) provides support, interventions and care coordination for NICU babies as they transition home.

 “A majority of our patients require specialized formula either to meet their increased nutrient needs from prematurity or to improve their tolerance and absorption,” said registered dietitian Kayla Harrell.

Harrell said the shortage has forced some patients to change formula multiple times, incurring the risk of tummy distress, allergic reactions and other symptoms of intolerance. She has seen some improvement in availability. But parents tell her stories of driving up to two hours to track down formula or shipping it from out of state.    

For children with medically complex dietary situations, Harrell said, the formula hunt can be difficult and heartbreaking.

“You are not alone,” she said. “We are always here to help find the best solution for your precious child.”

In the GI Clinic

Gastrointestinal conditions can include bleeding, inflammatory bowel disease, chronic liver disease, swallowing dysfunction and nutrition absorption disorders. Some patients require formula fed through gastrostomy tubes called G-buttons.

Chelsea Barrow, a registered dietitian, said many children with GI problems have significant allergies, growth failure or reflux that causes them to rely on highly specialized formulas delivered from medical supply companies. Some of these formulas have gone in and out of stock, causing shipments to be delayed or partially fulfilled, Barrow said.

“Families are telling us they are driving around everywhere to find formulas,” she said. “They’re unable to find formula on the shelves or online. There’s limited access to grocery stores and pharmacies in their small rural towns. Families are asking if anyone has formula to spare or looking to social media for options.”

Barrow said it’s important to communicate with your health provider regarding brand substitutions. Not all formulas are interchangeable for individual patients, and mixing instructions can vary between brands. She urges patience as the dietitians navigate the inconsistent formula availability by adjusting orders, communicating with medical supply companies, fielding phone calls and continuing to see a full clinic load.

“There is indeed a light at the end of the tunnel with the return of many specialized formulas,” she said. “We are all working very hard and long hours to ensure families have something safe to feed their child.”

RELATED: Two Cook Children’s pediatricians shared their guidance on the infant formula shortage. Click here to watch videos in English and Spanish. 

It’s never too early to teach children to be safe around water. After all, if a baby can crawl, they can make their way to a pool or open body of water. Any number of things can lure them there — a floating toy or sheer curiosity as they naturally explore the world around them. Whatever the reason, the result could be deadly. 

The American Academy of Pediatrics says children as young as 1 year old can benefit from water competency training, which is teaching kids to understand the danger water poses, how to avoid it and how to survive should they find themselves in water alone.

“I think the No. 1 thing that water competency gives a young child is confidence,” said Jillian Mitchell, a community health program specialist at Cook Children’s Medical Center. “If a child falls in unexpectedly they are in a situation that might induce panic, but being water-competent is having the confidence to know what to do to survive.”

While most toddlers aren’t coordinated enough to learn traditional swim strokes, they can learn basic survival skills like surfacing, turning onto their backs to float with their head above water and reaching for the wall of the pool.  

Kelsey Strieby calls it aquatic problem-solving. She is a Certified Infant Swimming Resource (ISR) Self-Rescue® instructor and has taught hundreds of children water survival and self-rescue skills. 

“There are two components to this,” Strieby said. “It's the roll-back-to-float program and the swim-float-swim program. But the first priority is being able to float to survive.”

Survival Becomes Second Nature

As an ISR instructor, Strieby teaches infants and children to roll onto their backs and float if they fall into the water. After the child has been walking for a few months, they’ll advance to learn to swim, then roll onto their back and float, and swim again until they can grab the side of the pool. If they are in a larger body of water and cannot get to the side, Strieby teaches kids to survive by floating on their backs until help arrives. 

Her students don’t learn a specific swim stroke or even to tread water, but to use their natural movement, like when they are crawling or walking, to bring themselves to the surface. 

“Self-rescue is taught using muscle memory and each child’s unique muscle movement,” Strieby said. “So the kids actually simulate like they're walking or crawling through the water. We don't teach a specific movement of the hand or leg. We will guide them through how to move effectively in the water and reinforce that moving their arms is great, but how that arm moves or how that leg moves is specific to that child.”

Just like riding a bike, consistency and repetition with these skills promote muscle memory and competence. If the unthinkable happens, those trained responses kick in, giving little ones a chance to survive.

“We want their survival response in water to become second nature,” Mitchell said.

Children with special health, developmental and learning needs benefit from this approach, too, especially if traditional swim lessons are not a good fit for them or learning specific swim strokes is outside of their developmental abilities. Every one of Strieby’s students undergoes a health assessment that is reviewed by a nursing team before beginning lessons, so she can tailor her teaching to their particular needs. 

Choose Wisely

When it comes to finding the right water competency program for your child, Strieby encourages parents to do their research. A quick social media search of infant swim lessons will return all kinds of videos of very young children, even babies, seemingly learning to swim, but Strieby cautions that not all of these approaches are practical or safe. 

“We don't throw babies into the water and let them sink or swim,” she said. “Programs that claim they teach survival and show videos of them chunking children into the water—that should never ever happen in an ISR self-rescue lesson. It should be a guided, safe and gentle approach. I always tell people, if you are going to commit to doing a survival swim program, please do your homework and make sure it's a program with a certified instructor who has had quality training and that the program has safety protocols in place.”

Strieby’s lessons do include simulations of situations in which a child may fall into the water. They even practice survival skills in diapers as well as summer, fall and winter clothing because many drownings occur when kids are fully clothed and not expected to be near water. In 2021, over 60% of patients brought to Cook Children’s following a drowning incident were from accidents that occurred during an unplanned swim time.

Respect the Danger

Water competency and rescue skills also teach kids to have a healthy fear of water as they are introduced to the natural consequences of going into the water alone, like not being able to breathe and the hard work it takes to stay afloat. 

“Kids who learn to self-rescue learn that if they fall into that water and mom is not right there, they are going to be responsible for their own lives and getting their own air,” Strieby said. “As silly as it sounds, this creates a healthy boundary for many kids, because they don't want to have to do that hard work. They don’t want to have to use their skills unnecessarily.”

The majority of Strieby’s students are under the age of 4, but she does teach self-rescue to children up to six years of age. Once they master survival and self-rescue skills, some kids go on to traditional lessons with other programs to learn specific swim strokes. Either way, children who learn water competency and rescue skills from an early age are better equipped to survive a water-related accident. 

Even so, Mitchell cautions that swim and self-rescue lessons are not a replacement for the layers of protection needed to prevent children from drowning. Maintaining barriers to and around the pool, keeping pools clear of toys attractive to little ones when not in use, having a designated water watcher and wearing a life jacket are all important components of water safety, whether a child does or does not know how to swim. 

A recall in February from Abbott Nutrition has placed extra pressure on the supply chain and some stores are limiting the amount a customer can purchase.

Here are some tips from the AAP, the U.S. Food and Drug Administration and our doctors.

Never dilute with water

Never dilute breast milk or formula with water. The extra water causes the sodium level in their blood to drop. Low sodium will lead to brain swelling which can cause poor feeding, lethargy, seizure and eventually death.

Do switch to a store brand

For most babies, it's OK to switch to store brands unless your baby is on a specific extensively hydrolyzed or amino acid based formula such as Elecare (no store brand exists), the AAP says. If you're unsure, talk with your pediatrician. Store brand formulas are equally regulated by the FDA, which has requirements for nutrients in infant formulas.

Don't make your own

The AAP and the Food and Drug Administration strongly advise against homemade formula because of serious health and safety concerns. “Although recipes for homemade formulas circulating on the internet may seem healthy or less expensive, they are not safe and do not meet your baby's nutritional needs," the AAP said. "Infant deaths have been reported from use of some homemade formulas.”

The FDA said it has “recently received adverse event reports of hospitalized infants suffering from hypocalcemia (low calcium)” that had been fed homemade infant formula.

In February, batches of three infant powdered formula brands were recalled because of possible bacterial infections. So far, four instances of infant illness have been reported to the Food and Drug Administration.

Do use breast milk

Breast milk is an option. Consider reaching out to a breast milk bank for support.

Don't substitute with alternative milk products

Be careful to avoid milk alternatives, like almond milk, oat milk and other plant-based milks. They are not recommended for infants under a year of age.

Don't buy from third parties

Consumers should also avoid purchasing imported formula or formula that has been diverted from normal distribution channels and relabeled, as it has the potential to be counterfeit, the FDA says. 

For example, if an infant formula is past the "use by" date, a counterfeit label may bear a false "use by" date to obscure the fact that the product may no longer contain the amounts of nutrients listed on the label and may otherwise not be of acceptable quality, the FDA says.

Do check with your trusted medical provider

Pediatricians often have samples or can connect with a formula brand representative for supplies if needed. Check with your local WIC office. They may also be able to help.

At the Neonatal Intensive Care Unit (NICU), patients dressed up and posed with their moms to celebrate their first Mother's Day!

Other patients and their moms celebrated with Mother's Day arts and crafts at the Atrium inside the Cook Children's Medical Center.

I remember scrolling through a Facebook group for physicians a few years ago, and a popular post rolled onto my screen, written by a confused pediatrician.

“What the heck is up with all these moms wanting their baby’s tongues cut?”  It was followed by hundreds of comments of confusion and agreement from other physicians.

I chuckled a little because the tremendous pressure on parents to have their baby’s tongue evaluated is something I literally talk about every day now -- and I hardly talked about it at all when I started my career.

One study showed that from 1997 to 2012 the incidence of tongue-tie diagnosis went from 3,900 to 32,000 – a nearly 10-fold increase -- in a matter of 15 years! This might be because more moms are choosing to breastfeed compared to a few decades ago.

So what’s up with tongue ties? And when should you think about getting your baby’s tongue tie cut (frenotomy)?

Tongue ties are a hard thing to write about, as it is a topic that can be pretty controversial. Depending on whom you talk to, the advice you get will change. That’s because we’re still lacking large, sweeping studies that prove one way or another that the procedure helps more than harms. Also, a gentle reminder that some folks who perform the procedure make very significant income because of it – thus creating biased advice in some ways, I think.

Clipping a tongue tie comes with risks: infection, tongue ulceration, bleeding, tongue damage, and salivary duct damage are all possible.

What is a tongue-tie?

Tongue-tie, or Ankyloglossia, means the tongue has a tight band of tissue underneath it that restricts the tongue’s movement. The tongue typically can’t be stretched upwards very well, beyond the lower teeth or lips.

The existence of a “tongue-tie” and merely HAVING a tongue frenulum (a small fold of tissue that secures the tongue to the floor of the mouth) are not the same thing!

There are different types of tongue ties – some attach to the front of the tongue, some to the middle area, and some to the back.

All tongues have some portion of tissue tethering itself down to the floor of the mouth. Just because you see a thin band of tissue underneath your child’s tongue doesn’t mean it necessarily needs to be cut. But let’s explore when to worry.

When writing this, I decided to phone some trusted friends, because a well-rounded approach is vital. There’s a lot of information here, but I hope it gives you food for thought in making this important decision for your child.

A dentist: Drew Jamison, D.D.S., with Fort Worth Children’s Dentistry (“D”)

A Speech-Language Pathologist: Sara Adams with Cook Children’s (“SLP”)

A lactation consultant (and fellow pediatrician): Andrea Wadley, M.D., with 127 Pediatrics (“LC”)

An Ear-Nose-and-Throat (ENT) physician: Kristen Honsinger, M.D., with Cook Children’s (“ENT”)

What trends are you seeing when it comes to tongue ties?

D: There is certainly an increase in inquiries about tongue-tie in our office. I would estimate at least double the number of inquiries in the past eight to 10 years. Most of these come from new mothers looking for a solution to difficulties nursing. A majority are feeling stressed and feel like they have reached a dead end. Most have also already worked with a lactation specialist and treating the tongue-tie is a "last-ditch effort". We don’t offer this procedure in our office. I have always worked to practice evidence-based dentistry. I'm waiting for more data. I want to make certain that the procedures we provide are in the best interest of our patients. We are certainly open to including these procedures in the future, just not quite yet.

SLP: In our speech therapy and feeding evaluations, parents have questions about if the tongue-tie needs to be clipped or not. They have often received different recommendations or opinions from their different healthcare providers about “to clip or not to clip.” Parents are concerned not only about a baby’s ability to breastfeed or bottle-feed, but they also have questions about if a tongue-tie will cause speech sound differences. For speech sound concerns, the evidence we have says that tongue-tie is not directly related to articulation (speech sound) disorders in most situations.

LC: The trend that I am seeing is that the diagnosis of “tongue-tie” is the explanation for a lot of breastfeeding problems in the community. Tongue, lip and now cheek ties are "en vogue" diagnoses to the point where some will refuse Vitamin K administration, but be upset that I decline to do an elective tongue-tie clipping on their child due to the bleeding risk.

ENT: In the ENT world, we’re seeing more people referred by lactation specialists, speech therapists and other non-physician providers. Previously, most of the referrals came from pediatricians. Another trend we are seeing is referrals for speech issues/concerns related to ties. To date, there have been no good quality research studies linking tongue-tie with any kind of speech delay, speech issues such as articulation problems, or feeding issues besides breastfeeding problems. There is good quality research suggesting that tongue-tie release in babies may improve maternal pain with nursing and may improve latch and therefore breastfeeding outcomes.

Are all tongue ties “bad”?

D: No. We have a large number of patients that could be diagnosed as "tongue-tied" that we simply monitor. Most of these patients thrive. If they ever have concerns that involve speech or other issues, we try and work with speech pathology to discuss diagnosis and treatment.

SLP: Not necessarily, some children have tongue ties and can drink, eat, and talk with no difficulties. This is why it is important to have the child evaluated by a medical professional that is familiar with tongue ties and can help look at those functions.

LC: Not all tongue ties are bad. As the baby grows, often the "tie" or frenulum will stretch and grow over time. Occasionally, ties will need to be corrected later in life, but often kids get by just fine without having them repaired. If the baby has a visible tongue-tie but is transferring milk well from the breast or sucking well from the bottle, I often leave these alone and follow up over time.

ENT: It’s normal to have a frenulum or “tie” under the tongue -- most babies (and adults!) do and it’s a normal part of the anatomy. An evaluation by a qualified specialist is necessary to determine whether or not the frenulum is restricting tongue movement or causing other difficulties, however.

When do you think it’s a good idea for parents to seek out frenotomy (tongue-tie clipping)? Are there any patterns you watch for or anatomical problems you notice in an exam?

D: I can certainly expand on philosophy here, but to remain concise, we typically tell parents: If you feel like you have exhausted all other options, including consultation with lactation consultants, then we promote the procedure. Scientific literature confirming effectiveness and results are scarce. However, we find that about half of our patients report an improvement in nursing.

SLP: If the tongue-tie is impacting the child’s ability to eat or drink – then it is time to consider frenotomy. I look at the overall function of eating or drinking to help determine if the family should talk to their doctor about that procedure. Sometimes, a tongue can look severely tied, but the child still has a great range of motion and no difficulties with eating or drinking. Sometimes a “mild” looking tongue-tie can present with really significant difficulties eating or drinking. You can’t always go by how it looks. For breastfeeding babies, if the mom is experiencing pain with feedings and has tissue damage to her breasts – then I collaborate with physicians about a frenotomy.

LC: I consider clipping tongue ties for babies whose tongues have a "heart shape" when they are extended. If they are unable to lift the tip of the tongue, it is very difficult to breastfeed. If the mom is having a lot of pain with breastfeeding and has lesions/blisters/bruising along the edge of the nipple that is in a "tube of lipstick" distribution this could be due to a tongue-tied baby or if the mom's nipple is shaped like this after every feeding and does not "round out" quickly. I also consider them for breast (or bottle) feeding babies who are taking in a lot of air with feedings, clicking with feeds, or who cannot sustain a latch long enough to transfer milk from the breast. I will also evaluate "posterior" (back of the tongue) or submucosal tongue ties if the baby is not transferring milk well and all of the other factors are accounted for.

ENT: In general, the sooner the better. One of the main goals we have is to help parents who choose to breastfeed to be able to do so- and making sure that we fix a tongue-tie when necessary can be an integral part of this. If there is something that we need to fix, it’s generally best to try to do it as soon as possible so that both the baby and mom can reap the benefits as soon as possible.

Should tongue-tie clipping be done in the newborn period, or do you think there are instances where it should/could be done later in life?

D: I think I answered this in the second question, however, I emphasize limiting any procedure unless necessary.

SLP: Hopefully, if there are concerns noticed with breast or bottle feeding, the procedure is done quickly so that we can support breastfeeding or can help that baby bottle feed. I have seen a few instances where the patient was older, about 12-18 months because the difficulty became more apparent as they were not able to use their tongue appropriately as they began to chew foods.

LC: As a newborn hospitalist, I would clip tongue ties during the newborn period if they were causing very obvious problems or mothers were having significant pain with breastfeeding. Often, I would clip them if the mom was an experienced breastfeeder and had lots of pain or had a previous baby with a tongue-tie that needed to be clipped. Now as an outpatient physician, I will clip tongue ties that have been referred to me by other professionals who have evaluated the mom and baby. These are often done around 1 to 2 months of age. After the parents have exhausted other options.

ENT: It’s easiest if we’re able to do a tongue-tie release procedure before around 3 to 4 months of age because the procedure can be done in the office. When a child gets much older than that, it’s typically recommended to do the procedure in the operating room. Since the research shows that the procedure improves breastfeeding outcomes, it is best performed as soon as possible.

If parents are on the fence about the procedure, who do you think they should reach out to? Do you think they should get advice from more than one profession?

D: I think a team approach is best when diagnosing and treating a tongue-tie. Different specialists’ understanding and communication of specific concerns lead to a well-informed treatment plan. If it is related to nursing, I would follow the advice of a lactation consultant or pediatrician.

SLP: Lactation consultants can help with questions on the latch at the breast. Speech pathology can help with feeding/bottle concerns and speech sound concerns. Dentists and ENTs are also great resources because they can provide insight as well. If you have a concern or are unsure, reach out to qualified health care professionals that are willing to listen to your concerns and that have knowledge on tongue ties – have an open and honest dialogue with them and come prepared with your questions.

LC: If parents are on the fence, I would recommend getting opinions from several trusted physicians. Pediatricians, family doctors, ENT and of course physicians with extra lactation training would be ideal. I would warn families to beware of "professionals" who are pushing the procedure without having done a full evaluation (which includes a feeding assessment).

ENT: I think the child’s pediatrician should always be the first one to evaluate a child and determine if they may benefit from a tongue-tie release. As far as asking other professions what they think/recommend, I would say that it is not uncommon to receive very different advice and recommendations based on who you ask. Each provider likely gives their recommendations based on their own experiences, training and background. ENT physicians also tend to rely heavily on what research papers have shown to help us to determine who will and likely will not benefit from a tongue-tie release.

Some take-home points from me, a pediatrician:

• Tongue-ties are a complex issue that is still being studied, and many factors should be taken into account when trying to figure out whether or not a procedure is needed.
• Not all tissues under the tongue are “tongue ties.” The vast majority of tongue frenula cause absolutely no issues. And many tight tongue ties can stretch out over time.
•  Be careful about what you read on the internet. I can tell you from experience – there is a lot of garbage out there, and I’ve seen many babies fall victim to a painful and unneeded procedure because a parent was so worried about something they read online.
• I’d say that in my personal experience of 12 years as a pediatrician, tongue tie clipping leads to improvement of a feeding or nursing issue maybe 50% of the time. And 50% of the time, it does not help.
• According to our current evidence, tongue ties do not seem to affect speech. Again, this is based on what we know now.
• Some older kids do report having difficulty licking their lips or teeth or licking an ice cream cone. This is one of the rare reasons older kids may need it cut.
• If you’re wondering about getting your baby’s tongue tie cut, consider talking to more than one specialist – the more, the better, especially if you are considering getting a “posterior tie,” or back of the tongue, cut.
• I’d definitely consider getting your baby’s tongue-tie evaluated if he struggles with drawing milk out of the breast or bottle if you are a mother who continues to experience a lot of pain with nursing after more than 2 weeks, and/or if he cannot extend his tongue past his lower teeth or lips (plus struggles with one of the issues above).
• When you read the comments of this post, you’re going to see a lot of “just do it! It helped my baby!”, or “getting the tongue tie cut was the worst decision ever…” – please remember that every child is anatomically and physiologically different, and one person’s experience may not be what you experience.

I hope this post helped give you the slightest bit of clarity on a topic that is not so clear.

For as many tiny studies I found showing that cutting a tongue tie doesn’t help a baby feed, I found an equal number showing that it does in fact help. The truth is, we need more data -- more big studies involving lots of babies -- before our answers will be clearer and more confident when it comes to tongue ties.

The baby in the picture is a sweet patient of mine. He has a normal tongue frenulum that might appear worrisome when you see it, but as a newborn, he was able to transfer milk easily, and he thrived.

Now, for some extra reading!

Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. https://pubmed.ncbi.nlm.nih.gov/28168891/

Breastfeeding: What to do about Ankyloglossia. https://publications.aap.org/aapnews/article-abstract/36/6/11/25079/Breastfeeding-what-to-do-about-ankyloglossia-lip?redirectedFrom=fulltext

A systematic review: The effects of frenotomy on breastfeeding and speech in children with ankyloglossia. https://pubmed.ncbi.nlm.nih.gov/33501864/

Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. https://pubmed.ncbi.nlm.nih.gov/25941303/

Frenotomy for tongue-tie in newborn infants.  https://pubmed.ncbi.nlm.nih.gov/28284020/

Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review. https://pubmed.ncbi.nlm.nih.gov/25941312/

The effect of ankyloglossia and tongue-tie division on speech articulation: A systematic review.  https://pubmed.ncbi.nlm.nih.gov/33964037/

Parker arrived at Cook Children’s Neonatal Intensive Care Unit (NICU) on June 29 for treatment of chronic lung disease and heart defects after being born two-and-a-half months early and weighing 1 pound 10 ounces. A complication with umbilical cord blood flow contributed to his premature birth and development issues.

Since then, Cook Children’s NICU has been home for Parker and his mom, Misty Kent of Brownwood, who stays with him each day and sleeps at the nearby Ronald McDonald House at night. His dad makes the two-and-a-half-hour drive from their family’s home to see him on weekends. But Parker’s grandparents and siblings—two sisters and two brothers, whose ages range from 14 to 21—have seen him only once when his condition worsened to the point that physicians called the family in.

“They got to come up and see him for two hours, but they didn’t get to touch him. He was so little then,” Kent says, glancing at Parker, who now weighs 10 pounds. “It has been a journey, to say the least.”

But a newly installed camera system in the NICU may help ease some of the stress for Parker’s family and others like them—especially with restricted visitation in the pandemic—by giving them a chance to lay eyes on their babies whenever they want. The system, created by AngelEye Health, went live last week, allowing families 24-hour-a-day access to their babies via individual room cameras, says Sheralyn Hartline, RN, and NICU director at Cook Children’s.

Funded by private donors in the community, AngelEye cameras—a total of 106 in the NICU—are set over patients’ beds and turned off only if patients are out of bed or if care is being performed, she says. One access link is given to the NICU patient’s mom, who then can share with other family and friends, Hartline says.

The AngelEye system will benefit the parents and families alike, she says.

“This will allow our parents to go home, get a nice rest and still have the comfort of looking at their baby from home,” she says, adding many of them live out-of-town and face long travel distances. “It’ll allow grandparents and siblings to see the baby, too, because many people haven’t been able to meet the newest family member due to COVID restrictions.”

COVID restrictions limit families to two visitors during an entire NICU stay, Hartline says. An average NICU stay lasts about 20 days, but some patients like Parker remain for months, she says.

“We’re hoping the cameras will help take the place for some of what’s been missing for quite a while now,” Hartline says. “It will allow for some family moments we haven’t been able to have over the past year and a half.”

As soon as the cameras were turned on, it made a difference for Parker’s family, Kent says.

“Our family is over the moon. This morning, as soon as it went live, I sent a link to Parker’s dad and grandma, and they were both on it within two minutes,” she says. “And, of course, grandma cried because she was so excited to be able to see him.”

His siblings also planned seeing him on camera later in the day, she says.

It is unclear how much longer Parker—who needs a tracheostomy tube to breathe and uses a gastrostomy-button for feeding—will remain in the NICU.

“We’re still watching his heart pretty closely,” says Kaitlin Tarver, RN, who works in the NICU.

His heart and lungs might continue to develop on their own in the next couple of weeks, she says, or he may need surgery to repair two holes in his heart before he goes home. In the meantime, they’re placing him on the floor to play on his belly, sitting him up with a support pillow, putting him in a swing or just getting him out of bed to look at the sunshine, Tarver says.

Kent understands the challenges her son faces in the coming weeks.

“He has been here a long time, but we’ve overcome huge obstacles in these six months. We’ll be here for a while longer, but that’s what we need to do to get where we need to be,” she says. “Cook Children’s is one of the biggest blessings we’ve ever had in our lives. If he wasn’t here, he would not be alive.”

And while her son is in NICU, she sees AngelEye cameras as an asset in case she wants to check on him in the middle of the night or if she needed to go home for a school function for one of her children.

 “I think people who aren’t in the NICU or who have never had to face this situation might not understand the gravity of it and how this will help people going through it,” Kent says of having room cameras available for families. “If you’ve never been in this situation, it’s hard to grasp. But I can speak to it because I have other children and have never had to deal with this until now. It’s a life-changing event—like your entire life changes.

“So, if you cannot be here for whatever reason, it may give you peace of mind that your child is OK—you can see it with your own eyes,” she says. “It’s a very, very big deal.”

Well, that’s not really the question. But is there an amount of Vitamin D that a breastfeeding mom can take in order for the breast milk to contain recommended levels of Vitamin D for her baby?

There have been numerous studies confirming the fact that breast milk does not contain enough Vitamin D to meet the nutritional needs of an infant. Even in mothers who are still taking prenatal vitamins; there’s not enough that makes its way into the milk ducts. 

The American Academy of Pediatrics recommends that all babies should be given a daily Vitamin D supplement which provides 400 International Units (IU) of the vitamin. Yes, even formula-fed babies need it (at least until they’re consuming a daily minimum of 32 oz per day of a Vitamin D fortified formula)!

There’s been some new light shed on this topic, however. Some studies have suggested that lactating mothers who take 4000 IU to 6400 IU of daily Vitamin D, will produce an adequate amount of the vitamin present in the breast milk to meet the nutritional requirements of the infant. This is pretty awesome news! Especially if you’re like me and forget to give your little one their daily dose; or better yet, if your little one gives the Vitamin D right back to you (stained clothes or furniture anyone?). 

It’s important to note that the research noted that adequate Vitamin D levels weren’t reached until about 4-5 months AFTER taking the increased dose. 

With that being said, we still recommend that you give your baby a Vitamin D supplement until there is more research done in this area. I would also highly recommend that mothers who are interested in breastfeeding discuss taking an increased dose of Vitamin D with their OB/Gyn as elevated Vitamin D levels in the body can pose some health risks. 

Dr. Olvera and Dr. Hanson have been piercing ears as part of their clinical practice within the Cook Children’s Network since 2016. They both use a medical ear piercing system only available to pediatricians and medical providers.

When should I get my baby’s ear pierced?

This is truly an individual decision. If you decide to pierce your baby’s ears, we only ask that they have received their first set of immunizations at age 2 months. Dr. Olvera and Dr. Hanson prefer to pierce ears from 2 to 9 months and then after age 4 years. Piercing a child’s ears between the ages of 1 to 4 is the most difficult age in terms of cooperation. It is important to understand that most children will cry when getting their ears pierced.

As far as age, some parents prefer to wait until a child can make the decision for themselves. Again, no judgment here. For some, the decision is a cultural one. In some countries, such as Spain, infants' ears are pierced right after birth. Dr. Olvera had her ears pierced at age 8, so she offered the same for her own daughters. Many families have the tradition of waiting until age 10 or 13 to have ears pierced. We respect all decisions!

Where should I get my baby’s ear pierced?

Again, this is a personal choice. More and more pediatricians do offer this service to their patients. First, ask your pediatrician if they offer the service. Some families will choose to go to a local tattoo parlor or the local mall. We recommend that you do your research on the place you choose and determine the age groups they serve. Make sure that you know families have had a good experience at the place you decide to go to.

Dr. Olvera and Dr. Hanson provide medical ear piercing to everyone in the Cook Children’s Network, even if your pediatrician does not offer the service.

What earrings should I use?

With the system that we use, the earrings are provided. You will have a choice of either medical-grade titanium or medical-grade plastic earrings. The earrings used for piercing are only designed to stay in for 6 weeks. You are asked to remove the earrings after 6 weeks and replace them with earrings of your choice. This step is important as the earrings used for piercing have thicker posts. We caution patients to stay away from costume jewelry for the first year. It can take up to a full year for the holes to be completely healed. If a patient has very sensitive skin, we recommend buying replacement hypoallergenic earrings to use for the first year. The medical-grade plastic earrings are excellent for patients with sensitive skin.

How do I take care of my ears after piercing?

The medical ear piercing system we use requires no special cleaning agents. The company recommends cleaning the piercing site (around the earring) with soap and water twice a day. Older children should be reminded to not touch their ears with dirty hands.

What sites do you pierce?

We do traditional ear piercing, usually single lobe piercing on each side. However, we are also comfortable offering second piercings on the lobes to preteens and up. We do not offer cartilage, nose, or belly button piercings.

Do you pierce boy’s ears?

Absolutely!

I encourage breastfeeding when possible, but FED is BEST. If breastfeeding isn’t working out for mom or baby, we have plenty of other options with formulas. There are so many types of formulas that the process of choosing which one is right for your baby may seem overwhelming.

What’s the difference between organic formula and non-organic formula?

Be comforted by the fact that all infant formulas are regulated by the FDA which requires a standard of basic nutritional needs. Both organic and non-organic formulas support the healthy growth and development of infants. The difference is organic formulas must be manufactured from organic milk that is sourced from cows eating an organic feed and have no added hormones or antibiotics, no GMOs, no artificial or synthetic ingredients and ingredients are grown without pesticides. Be aware that some organic formula brands that are only sold online are manufactured in Europe and do not have U.S. FDA approval, including some popular goat milk formulas.

What is the benefit of eating organic food?

There are dozens of scientific papers published on potential benefits of eating organic. In one U.S. study, eating an organic diet compared to a conventional diet showed a decrease in pesticides found in children’s and adults’ urine output but more research is needed to determine the connection between that and positive health outcomes. In another recent study, researchers found higher rates of antibiotic resistant E. coli bacteria in non-organic chicken. And in India, researchers recently determined that soil with organic fertilizer contains more nutrients, more good strains of bacteria and significantly lower concentrations of toxic heavy metals.

Do organic formulas have extra ingredients that make them better?

Many organic formulas advertise added prebiotics, DHA, ARA, lutein, and a variety of other ingredients to make formula as close to breast milk as possible. However, many non-organic formulas have these same added ingredients. Always read the label and ask your pediatrician if you have any questions.

Is there anything in organic formulas that is bad for baby?

A few organic formulas contain sucrose, which can cause excess weight gain and dental cavities.

Who should choose organic formula over non-organic formula?

Choosing organic formula over non-organic formula is a personal choice—not a requirement. If your household is committed to eating organic foods, you have the option to purchase organic formula for your baby. How nice it would be if ALL our food could be organic or fresh from a local farmer’s market, but that’s not how our food supply chain operates. And it’s okay. If cost isn’t a factor, eating organic foods and feeding your baby organic formula would be a nice bonus, so go ahead and purchase it if you’d like. But don’t feel bad by choosing the non-organic and generic formulas, as they have plenty of good nutrition for your growing baby.

Is this information cause for concern? Yes, but it’s not exactly new and sadly, there’s no easy fix for the problem.

The report is the result of a congressional investigation released on Thursday, Feb. 4. It says four of the nation’s largest manufacturers knowingly sold baby food with “significant levels” of metals that can impact brain development for babies and toddlers. Previous studies (which we have covered in the past) have found similar results but the significance of the increased levels is still not clear.

The latest investigation focuses on seven brands and the four heavy metals listed above: arsenic, lead, cadmium, and mercury. Each brand analyzed showed significantly higher levels of at least one heavy metal than allowed by the Food and Drug Administration (FDA). You may be thinking that organic brands are safer, but even they contained elevated levels.

Where are these metals coming from?

The chemicals in question are naturally occurring elements and are in the soil where crops are grown. This is why they are found in the ingredients of baby food, and are difficult to eliminate, even if you’re feeding your child organic brands or making food yourself.

So, what should we do?

We should:

• Ask government and industry leaders to make every effort to eliminate heavy metals from food where possible. This could mean changes at the production or processing level.
• Ask scientists to research the real effects of these amounts of heavy metals are on our babies as they grow up.

But what can you do as a parent?

• Remember that switching to organic or providing homemade purees probably does not significantly reduce risk. If you weren’t already doing these things, I wouldn’t suggest changing what you’re buying.

• Avoid high-risk foods, especially those without nutritional value. Some of the foods I don’t recommend include: 
  • Rice cereal
  • Teething biscuits
  • Rice-based puffs
  • Apple juice
     
• Provide a variety of foods over time. Sticking with one particular food may contain significant amounts of an individual metal and could cause higher risk for your child.

Being a new parent is hard.

Being a new parent today is even harder.

With the limitation of visitors, changes to doctor’s offices, and lack of ability to get out of the house (among many other challenges), being a parent in COVID-times is causing new parents to feel even more isolated and ill-equipped.

But, when can you have visitors over to meet your newborn?

Like most things COVID-related, it’s not a simple question.

It’s also a decision that, given all the same information, two families might make very different choices.

Even in “normal” times, I believe that babies under 2 months should have a pretty tight circle drawn around them, which can relax more with each round of shots at 4 and 6 months. COVID has just heightened my desire to protect them even more.

It appears that infants less than 1 year are at a higher risk of severe illness than other kids.. Because of the upfront, face-to-face nature of caring for them, they may be at higher risk for exposure from a caregiver. When considering this decision, it’s essential to keep in mind the reverse (and perhaps more significant) risk to the person entering the house. Many grandparents and other family members might fall into higher-risk categories based on age or medical conditions.

But that doesn’t mean you have to go it alone.

Here are three factors to consider:

1. The purpose of the visit.
2. The behavior of the visitor.
3. The activity at the visit.

The purpose of the visit.

The first time this comes up is at the time of delivery. If you have an older child at home, they need to be taken care, of and you should have the opportunity to have someone to support you at delivery. This one is easy. Ask the grandparent or other caregiver to take caution with social distancing, masking and other precautions around 36 weeks so that they can be as safe as possible entering the home.

After the initial delivery phase, some parents may need ongoing support from a close family member. When a parent has to go back to work or doesn't have a lot of experience with babies, they may need ongoing support. The safest way to do this is to ensure that the person entering your home has been following guidelines for at least 2 weeks before the visit. If possible, they should plan to come and stay as much as possible rather than coming and going frequently. Staying put limits their number of contacts and lowers the risk for everyone.

Purely social visits are probably the riskiest. Having any number of visitors drop in to say hi significantly increases the baby's risk because of the number of possible contacts and the lack of control over their behavior and exposures. Some parents might feel comfortable with a very close friend or family member. Still, we all must recognize the risk of doing so.

The behavior of the visitor.

There are many different approaches and mindsets concerning coronavirus. While I wish everyone took a cautious approach, that’s not the case. And while you may have family members who argue they have the right to make their own decisions regarding social distancing, mask-wearing and the like not everyone has the right to make their own decisions AND get to spend time with your baby.

If you have a close friend or family member you trust is taking an extremely cautious approach, you may feel more comfortable inviting them come over to meet your baby. Remember that you get to make your own decisions about what makes you comfortable. If you decide to take a more conservative route than your family appreciates, feel free to blame your pediatrician (especially if it's me). I promise we’re cool with that.

The activity at the visit

Once you’ve decided you’re going to see family, there are still questions about what will happen at the visit. Of course, at a baseline, we’re going to do all the usual things we would ask anyone to do when visiting a newborn.

1. No one comes over who has possible symptoms, such as a cough, runny nose, (obviously) fever, etc.
2. No one holds the baby without washing hands first.
3. No one kisses the baby period.

Extra precautions you might consider in the context of COVID would be (in decreasing order of safety): drive-by only visits, patio/outside visit, no-holding/across the room visit or a masked visitor visit.

Be gracious with yourself and others

Remember again that every parent and family will make different decisions and have different comfort levels. Be kind to yourself and your fears. Consider the impact of not having visitors vs. having visitors and what that means for your level of stress because it might affect each parent differently. If you are the potential visitor, be kind, and understand if the new parents in your life ask you to stay away

We're all in this together for the long haul, and they are dealing with enough stress as it is.

Is breastfeeding worth the possible exposure to Covid-19?

Short answer: yes.

Unfortunately, the risk of COVID-19 is everywhere in our lives right now, but the reality is your baby needs another human to survive. So regardless of the way your baby gets their nutrition, having them completely secluded from the world, or attempting to limit their exposure to you, is not only impossible; it's also not a good option for optimal health and growth as well as bonding for your baby.

As always, the way you feed your baby is a personal decision, but it doesn’t change the fact that breastmilk provides protection against many illnesses and is the best source of nutrition for most infants, even and especially during this world health emergency.

What precautions should a well mother take?

• Practice skin to skin, especially immediately after birth during the establishment of breastfeeding.
• Maintain social distancing. In the UK, this time of lockdown and isolation has shown that without the constant stream of visitors, mothers and babies have had better opportunities for uninterrupted bonding, therefor mothers have a better supply, and babies have quicker weight gain.
• Wash your hands before feeding and frequently throughout the day.
• If pumping, limit the people who feed your baby bottles.
• Routinely clean and disinfect surfaces.

But what if you are diagnosed with Covid-19?

In limited studies on breastfeeding women with COVID-19 and other corona virus infections, the virus has not been detected in breast milk; however the bigger risk is likely transmission through respiratory droplets.

With precautions in place, WHO and the CDC both agree that the benefits of breastfeeding are outweighed by the risk.

If you are sick and choose to direct breastfeed:

• Wear a facemask and wash your hands before each feeding.
• Avoid touching your or the baby’s eyes, nose and mouth.
• Continue skin to skin.

If you are sick and choose to express breast milk:

• Express breast milk to establish and maintain milk supply.
• Use a dedicated breast pump.
• Wash hands before touching any pump or bottle parts and before expressing breast milk.
• Follow CDC guidelines for proper cleaning and disinfecting recommendations of pump parts.
• Consider having someone who is well feed the expressed breast milk to the infant, if possible.

Breastfeeding is a key preventative health step, especially during a pandemic.

Talk with your pediatrician about recourses that are available for help during this time. Cook Children’s Virtual Lactation services are available: Virtual Lactation Consultation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stay safe,

Dr. Diane

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

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

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

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

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

Some reasons babies don’t need water:

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

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

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

Bundle Up

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

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

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

Pay Attention

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

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

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

About the source

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

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

Baby eye tear ducts don’t work well sometimes.

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

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

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

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

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

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

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

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

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

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

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

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

Whatever you call it, parents have lots of questions about pacifier use.

Let’s look at some of the most common:

1. When is it OK to start a pacifier?

A pacifier can be a life-saver for the baby that doesn’t need to feed at the moment, but desperately wants to suck.

The classic teaching for breastfeeding moms is to wait 3 to 4 weeks for breastfeeding to be established prior to introducing a pacifier. But, I think the most important thing is to make sure you feel confident in your baby’s latch and nursing before introducing a pacifier (or bottle for that matter). If your baby can latch, it’s OK to give him or her a pacifier. This will help your baby’s need to suck and your need to sleep and get a break from the constant nursing.

So day 1, probably not, but you don’t necessarily have to wait 3-4 weeks if you have a baby who is latching and nursing well.

2. When should we stop using a pacifier?

Prolonged pacifier use can primarily lead to two problems: Interference with speech development and dental issues. To prevent these problems from occurring, I recommend changing your strategy for pacifier use to nap and sleep times only after one year of age and starting to wean completely by 18 months with a goal of having them gone entirely by age 2.

3. Do pacifiers actually work to calm a baby?

Yes. Babies have a desire and drive to suck and it’s not always limited to feedings. Some babies never really take to it but for others, it can be a life-saver. Be careful not to jump to the pacifier for every fuss, learn your baby’s other needs and check for those before using the pacifier. But using the pacifier for everyone to get some sleep is perfectly fine when all of your baby’s other needs have been taken care of.

4. Do pacifiers prevent SIDS?

Way below some of the other more significant risk factors for infant death like sleeping on the back, no smoking in the house and other significant findings, pacifier use may be protective for SIDS. Is it a direct and absolute reason to use one? Probably not. But it doesn’t hurt and may actually help.

5. What kind of pacifier is best?

Babies will like all different kinds of pacifiers so don’t buy a whole bunch of one type until you know your baby’s preference. Pacifiers that are single piece may be preferable because they are unlikely to break and turn into a choking hazard. At the very least, pay attention to multiple part pacifiers to make sure they are in good shape. Pacifiers that are easily cleaned and simple seem to make the most sense.

6. Should I put something on the pacifier?

No. The practice of putting sugar or honey on pacifiers is unnecessary and potentially harmful. They can both accelerate the damage to teeth and honey has been known to cause a severe infection known as botulism in infants.

7. When should I replace or change pacifiers?

Pacifiers that are damaged or have been chewed should be thrown away. Small pieces can dislodge and become a choking hazard. In addition, throw away a pacifier when a child can put the whole thing in his or her mouth.

8. Should I use a pacifier-attached lovie?

This might be the most controversial (or at least unwelcome) advice in this whole post but using a lovie attached to pacifier particularly at sleep times could be just as dangerous as having a large blanket or pillow in bed with the child and shouldn’t be used.

9. How should I clean my baby’s pacifier?

Use warm water to rinse a baby’s pacifier. Some are dishwasher safe. Soap can be used intermittently and some can be placed in boiling water. Can you clean them with your mouth? Yes and there have been studies that show it might decrease your child’s risk of allergies but can also spread germs.

I hope this helps. What other questions do you have about pacifiers? Respond in the comments and we’ll get back with you.

“My baby never spits up, but seems like they are fussy all the time."

I know this sounds like reflux, but the truth is spitting up can be normal. Even if it’s with every feed, even if it seems really bad.

Maybe you just have a happy spitter.

I call babies who spit up a lot but still gain weight and who aren't fussy with feeds “happy spitters.” They present more of a laundry problem (their clothes, your clothes, sheets, burp cloths, couch cushions…) than a medical problem.

The passage of milk and stomach contents into a baby’s esophagus is a normal process and can even result in VERY frequent, VERY large amount of spitting up and still be normal. It happens because the muscle that sits on top of the stomach is relaxing off and on all day long. If the pressure inside the stomach is higher than the resistance provided by that muscle, the baby can spit up.

But when is it a problem?

I consider reflux a problem if one of two things are happening:

1. The baby seems fussy after feeds or they are fussy when they spit up.
2. The baby is having significant spit up and is not growing well.

Fussiness after feeds is particularly concerning for reflux if the baby is arching their back or starting to refuse their feeds once they start. 

Because pressure is a big player in the spit-up/reflux process, there are some simple things you can do:

1. Make sure you are not overfeeding the baby. Babies who are overfed and spit up can seem hungry after, but that only makes the problem worse.
2. Avoid laying the baby down immediately after feeds when possible. Keeping a baby upright 20 minutes after feeds can help the milk to move further down and be less likely to come back up.

So when do we need to consider medication for reflux?

When the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, despite limiting overfeeding and keeping the baby upright, we consider treatment with an acid reduction medication.

One common medication is a group of acid reducers known as H2-blockers, the most common example is ranitidine. Another group of acid reducers are known as PPIs, such as lansoprazole.

It’s important to keep in mind that the medications don’t do anything to keep the milk down, so it’s likely that the baby will continue to spit up hopefully without being fussy and gaining weight (and another good reason not to treat a “happy spitter”).

Maybe not and that’s OK, at least for your baby. You, on the other hand, may need some rest.

Let's start with your baby. Does their lack of sleep pose any risk to their health or development?

A recent study in Pediatrics looked at the percentage of babies who were sleeping through the night (6 to 8 hours of uninterrupted sleep). The study went on to further explore the relationship between sleeping through the night and future development.

The bad news

At 6 months, about 4 out of 10 babies are still not sleeping 6 consecutive, uninterrupted hours. At 12 months, it’s still close to 3 out of 10 babies that are not sleeping 6 straight hours.

If you change the definition of “sleeping through the night” to 8 hours, the numbers get even worse.

So, if you have a newborn or you’re expecting soon…prepare yourself for the possibility that you won’t be getting a great night’s sleep for a while.

The good news

The study also didn't find an association between maternal mood and baby’s sleep.

This contradicts two potential misconceptions about sleep and a mother’s moods:

1. Mom’s mood can be affected by lack of sleep. While this might be true for an individual mom, the study did not show it across the study population.
2. Mom’s mood could be affecting the baby’s ability to sleep.

The best news

One of the major concerns about babies who don’t sleep well has been whether it has any effect on their development. Results showed that the lack of sleeping through the night had no effect on their later mental development. So, while it may be frustrating and exhausting, at least you don’t have to worry about negative effects in development later in life.

But what about you?

So if your baby isn't sleeping through the night, how are you doing? You're already exhausted from taking care of your newborn, now you just want to get some rest. Here are 5 tips that might help you when your baby isn’t sleeping through the night:

1. Do your best to rest or sleep when your baby is sleeping during the day. Sometimes this isn’t possible because of older siblings or housework, but it saves a lot of frustration during those long nights when you can.
2. Don’t rescue your baby at the first stirring. Give them a second to calm themselves down. They might just surprise you.
3. After your baby is established in their growth, you don’t have to feed them for every nighttime awakening.
4. Get help. If it’s a partner, grandparent or friend-having a one night break from getting up can seem like a life saver for an exhausted parent.
5. Turn off your monitor, if your baby is close enough for you to hear if they get really upset. Having the monitor turned off (or at least down), so that you don’t wake up to their every stirring can also help you get a better night’s sleep ... even if they aren’t sleeping through the night.

In the meantime, here are some things you can do to help.

Suction, suction, suction. Your old friend the bulb suction (aka nasal aspirator or booger-sucker) is the best thing you have against congestion. Many times people tell me they don’t get anything out when they use it but that is usually because they aren’t doing it right. Depress the bulb, push the tip in the nose until you have a seal on the nostril and then release. Repeat for each side. There are other devices that you can use to accomplish the same goal. I’ve seen a mom place her mouth directly over the nose and suck (yeah, wow) and there’s also the battery operated device. The other one that I have a handful of families using is the Nose Frida. This device allows you to suck mucous out of baby’s nose with a tube that has a filter in it. Seems kinda weird to me but my families who use it swear by it.

My two main recommendations about suction are that you should stop whenever you are no longer getting anything and that you shouldn’t suction thousands of times a day. If you continue to suction without production, you are only causing swelling in the nasal passage and making the problem worse. If the child is happy and noisy, there is no reason to suction them. Reserve your suction times to before meals and at bedtime. If they are just noisy, it is bothering you more than it is bothering them.

Nasal saline drops-putting some nasal saline drops in the nose can be very helpful with that hard to reach congestion in the back of the nose and when the congestion seems to be thickening such that it cannot be extracted with suction. Just place a few drops to each side of the nose and then pull with suction to get a little more snot out.

Humidity-keeping the nose nice and moist actually helps to smooth the air flow as it goes from the nose to the trachea and into the lungs. This helps the babies breathing stay comfortable. I get asked all the time about whether it should be warm or cool mist and I frankly don’t care. If you have child have bad congestion/coughing, getting the bathroom with the shower going can be helpful as well.

So, these are my helpful tips for congestion.

Any one else have anything that they have used out there? Any one used the Nose Frida?

That’s the simple message that the folks at Cook Children’s who watch out for your kids’ safety wants you to know.

From March 14 to April 10, 2018, five children were rushed to the Emergency Department for drowning, with one resulting in death.

“There is no amount of time that it’s safe to leave your child alone in the tub,” said Magdalena Santillan, Trauma Injury Prevention specialist at Cook Children’s.

Drowning is the leading cause of unintentional injury-related death in children ages 1 to 4 years old and the second leading cause of unintentional injury related death for ages 1 to 14.

“Safety begins in the home,” said Dana Walraven, manager of Community Health Outreach at Cook Children's and coordinator of the Safe Kids Tarrant County Coalition. “Bath time is not only a good time to bond with your baby, but a dangerous time in and around water. Support safe habits with adult, not sibling, supervision.”

SafeKids Tarrant County, led by Cook Children’s, gives these facts:

• Drowning is quick and silent.
• Children can drown in as little as one inch of water.
• Irreversible brain damage occurs in as little as 4 minutes.

To protect your child from drowning in the tub:

1. Never leave your child unattended in the water.
2. Put the cell phone away. Give your child 100 percent of your attention.
3. The job of supervising a child in the pool is for adults only and not siblings. A child or even a teen should not be held responsible for supervising a child in the bathtub.
4. If you have to answer the door or the phone, take your baby out of the water and hold him or her while you do so.
5. Fill the tub only with enough water to cover the infant's legs.
6. Once the bath is over, immediately drain the tub.
7. Don't rely on bath rings or seats to keep a baby safe.
8. Store empty tubs, buckets, containers and wading pools away after use. Store them upside down and out of a child’s reach.
9. Keep doors to bathrooms and laundry rooms closed.
10. Learn CPR for infants.

Learn more at safekids.org.

Brayden was born premature at 27 weeks, weighed less than 3 pounds and couldn’t breathe on his own. Right after birth, he was immediately taken to Cook Children’s Neonatal Intensive Care Unit (NICU).

It took eight days before Whitney could hold Brayden for the first time and another five days before his dad, David, held him.

Once Whitney was finally able to hold Brayden, the NICU staff recommended kangaroo, or skin-to-skin, care. Kangaroo care means holding your baby, who is wearing only a diaper, against your bare chest. The baby snuggles on your chest covered with a blanket, just like a kangaroo’s pouch.

“We were told the best thing we, as parents, could do was kangaroo care,” Whitney said. “Holding Brayden skin-to-skin proved to be beneficial. Even on his worst days if he was skin-to-skin with one of us he was calmer, his heart rate maintained better and he required less oxygen. Holding Brayden was the only bonding time we felt like we had. It's hard to bond through glass. It was beneficial for us too. It reduced our anxiety and helped us acclimate to taking care of Brayden.”

Brayden was at Cook Children’s for 160 days and only during 18 of those days was he off the ventilator. Brayden returned home with a tracheostomy and on a home ventilator. Even with these complications, Whitney said she was prepared to care for her son on her own, without the NICU staff, because of her experience with kangaroo care.

“We were so comfortable holding him because we had spent eight hours a day ‘kangerooing’ in the NICU,” she said.

The NICU staff at Cook Children’s encourages skin-to-skin care because of the strong benefits for mothers, fathers and babies, whether the baby was born without complication at term, those born prematurely or who are ill at or after birth.

Benefits for the baby:

• Keep baby’s body warm-more stable temperature.
• Keep baby’s heart and breathing regular.
• Better weight gain for baby.
• Baby spends more time in deep sleep which supports brain development.
• Baby spends more time being quiet when awake and less time crying.
• Baby has a better chance of being able to breastfeed.

Benefits for the parents:

• Mom makes more breast milk.
• Reduces parents stress.
• Feel closer to baby and learn their likes and dislikes.
• Builds parents confidence as baby’s mother or father becoming more in-tune to baby’s needs; bonding.

“As a therapist in the NICU, the most rewarding part of my work is re-uniting babies and parents through kangaroo care,” said Betsy O’Hara, an occupational therapist in Cook Children’s NICU. “It is so important that these babies and parents begin to form a strong bond that will support their relationships for a lifetime. A transformation happens as the baby responds to his/her parent and the parent finally ‘feels’ like the baby’s mom or dad. It’s magical!”

In the NICU environment at Cook Children’s, therapists emphasize that kangaroo care or “encircled holding” (wrapping your arms around your sick or premature baby even if he/she cannot be held) helps parents feel like a parent to their baby by offering this special care that only parents can provide.

Studies show kangaroo care helps babies who were born prematurely not only to support development while in the NICU, but also cognitive development especially related to behavior and self-control across the first 10 years of life.

Kangaroo Care has also been found to foster stronger maternal attachment in the post-partum period. Receiving Kangaroo care as a premature infant supports better sleep patterns and stress responses in the growing and developing child

Before kangaroo care, the conventional neonatal care model had the infant removed from the mother and let the nurses assume all care of the baby. Kangaroo care represents a shift in neonatal care to a family-centered care model that incorporates both parents into the care of their infant.

“Unlike breastfeeding, which is also so important to the care of the baby, kangaroo care allows for both mothers and fathers to be involved, “O’Hara said. “This care provided by the parents has lifelong benefits for both the baby and the parents. Mom or dad’s chest is the best place for the baby to grow while in the NICU setting and can continue once the family goes home.”

Normally, tears are produced all the time to keep our eyes moist and those tears are drained by the nasolacrimal duct. If this duct is obstructed, or clogged, the tears flow out of our eyes causing clear drainage. When tears sit for long periods it can form crusting or ‘gunk’ near the eye and eyelashes. This type of obstruction occurs in around 6 percent of all newborns and is a common topic discussed in our pediatric office.

When a pediatrician diagnoses nasolacrimal duct obstruction, we ask parents to massage the area gently several times each day. This technique, called Crigler massage, is thought to help relieve the obstruction and encourage the duct to function normally. The technique is easy to do at home, effective and, best of all, costs nothing. See the video below at the end of this blog demonstrating this technique.

We also ask parents to keep the area clean with a soft, damp wash cloth.

The good news is that most cases of nasolacrimal duct obstruction go away over time. In fact, approximately 90 percent of all cases will resolve by 6 months of age. After 6 months, there is still a two-thirds chance the problem will resolve, but after 12 months the problem will need treatment by an eye doctor (ophthalmologist).

If a child is referred to the ophthalmologist, the treatment usually involves inserting a small probe into the duct to clear the obstruction.

Nasolacrimal duct obstruction is not the only reason for an infant to have eye discharge. It is important to speak to your doctor if the eye becomes red, is causing the baby discomfort, has pus-like discharge or the baby has a fever.

So if your newborn has a watery eye, talk to your pediatrician. With their help, some gentle massage at home and a bit of patience, the problem will likely go away on its own.

Here is a video demonstrating Crigler massage: 

But in the days after her birth, enthusiasm turned into fear as baby Ella began to show signs that something wasn’t right.

“She would get jittery. She would scream and she was constantly hungry,” said Carol.

Doctors at the Tucson hospital where Ella was born quickly realized that the little girl with a full head of hair had dangerously low blood sugar, also known as hypoglycemia. Ella couldn’t go home and that big Christmas celebration, along with everything else in her life, now seemed in doubt.

Ella’s caregivers tried several different treatments and when nothing worked, they began to suspect Ella had a rare disease called hyperinsulinism (HI). Hyperinsulinism occurs in about 1 in 50,000 babies. If uncontrolled, it can cause seizures and permanent brain damage.

“The doctors in Tucson did a great job diagnosing Ella’s hyperinsulinism, which was quite severe. They called us knowing about our work with the 18F DOPA PET scan and transferred her here,” said Paul Thornton, M.D., medical director of Cook Children’s Hyperinsulinism Center, one of the top such centers in the world.

Cook Children’s is one of only two institutions in the country to offer an HI program. It’s also one of the only places using the new investigational drug 18F DOPA. When combined with a PET-CT scan, the drug gives doctors a way to treat and even cure patients with few to no side effects.

The Vallecalle family received the call in late November that it was time for Ella to go to Texas. They would be traveling with Cook Children’s Teddy Bear Transport team.

“I was so nervous about leaving my son and also about what we were going to find out about Ella’s condition,” said Carol. “Then all of the sudden, I see these people in blue jumpsuits. There’s this beautiful Texan woman with her big, thick accent and she’s like ‘How y’all doing?’ and I just knew we were going to be fine.”

Carol rode with Ella on the plane to Texas and when they arrived at Cook Children’s, Dr. Thornton and his team got right to work. Using the 18F DOPA drug and the PET-CT scan, they were able to pinpoint the exact location in the pancreas that was causing Ella’s low blood sugar. They were also fairly certain that she had a form of HI known as focal disease, meaning there’s was a chance she could be cured.

“About half of the babies born with HI who are resistant to medical therapy have focal disease which we can treat and cure. The other half has diffuse disease which means they will have persistent hypoglycemia throughout their lifetime,” said Dr. Thornton.

One week after she arrived at Cook Children's, John Uffman, M.D. performed surgery on Ella. Using results from the PET-CT scan, he removed a small portion of the pancreas where a lesion was triggering her HI. She recovered quickly and days later underwent a 16-hour fast. Without any food for that extended period of time, Ella was able to maintain a healthy blood sugar level and her body was able to make ketones, molecules that should be produced during periods of low food intake.

Ella was officially cured.

“I never saw this day coming,” said Carol. “She’s going to have a normal life. She’s going to be able to travel and fall in love and do all of things that she wants to do. It’s a blessing.”

Dr. Thornton is also thrilled about the good news.

“It’s a really big deal for a baby like Ella to be cured because this disease is very serious. The new 18F DOPA drug and PET scan have really made a difference in how we are able to treat these HI patients. In the past, we might have cured a patient but we would have had to remove much more of the pancreas causing almost certain diabetes after surgery.”

Not only are doctors able to offer a cure without the threat of diabetes, they’re also able to send children home much faster than before. Within two weeks, Ella was able to leave Cook Children’s HI free. Before 18F DOPA and the PET scan, Dr. Thornton says most children would be in the hospital for 40 to 50 days.

“I’m just so excited to be home for Christmas,” says Carol. “When we left Arizona, we were fully expecting to be in Texas for a month or more. My son was worried that Santa wouldn’t find us.”

Santa will know exactly where to find the Vallecalle family. For the first time in her life, Ella went home Dec. 15. They will spend Christmas with their family.

More about Cook Children's Hyperinsulinism Center

One of only two such programs in the nation Cook Children's Hyperinsulinism Center uses a specialized team approach to treat this rare disease. Hyperinsulinism affects many areas of the body, so to truly treat the disease, each child is seen by top physicians, nurses, researchers and specialists in the field. These medical professionals have spent additional years of intense study and have dedicated their practice to focusing on hyperinsulinism so that your child has access to the medical care that treats all the symptoms. It is this level of treatment that has helped earn our program a distinguished international reputation for extraordinary care and achieving positive results.

"I would hear that song 'I'll be home for Christmas' in my head, and I'm like, 'I'm not going to be home,'" said mother, Carol Vallecalle.

It was a tough notion for Vallecalle to accept, but not as tough, she says, as what her 6-week-old daughter Ella has been through.

See the full story here.

Never in a million years did she dream that he would not be able to leave the hospital with her after he was born.

As an adult oncologist in Abilene, Dr. Amechi is accustomed to the ups and downs that go along with medicine. But she wasn’t prepared at her twentieth week of pregnancy when she learned that the amniotic fluid that was supposed to be surrounding her unborn son was missing.

“You never really expect to be in that situation,” said Dr. Amechi. “I just thought I was pregnant, I arranged my maternity leave and I was ready to have my baby.”

When Dr. Amechi’s son, Samuel, was born, he immediately began suffering from respiratory issues and needed to be intubated. On top of that, his kidneys were not able to fully develop due to the lack of amniotic fluid, leaving him in need of dialysis. He was admitted to the Neonatal Intensive Care Unit (NICU) at the hospital where Dr. Amechi gave birth. For two months, Dr. Amechi spent day after day by Samuel’s side. The hospital was three hours away from their home in West Texas, and with a steady round of complications, the Amechi family had little hope of Samuel being discharged anytime soon.

“When I realized we weren’t going to get out of the NICU before September, I started bawling,” said Dr. Amechi. “That’s when my nurse said that’s it, let’s look for other options.”

After talking with the medical staff at the hospital, Dr. Amechi and her family decided to transfer Samuel to the NICU at Cook Children’s Medical Center. While it wasn’t home, it was a little closer to home. The Amechi family now only had to drive two hours to Fort Worth instead of the three hours they’d grown accustom to. And for the first time, they could spend the night next to Samuel. Unlike many other NICUs in the U.S., Cook Children’s NICU has private rooms with couches that pull out into a bed. This means families don’t have to leave their child’s side if they don’t want to.

“Cook Children’s has a way of arranging things to make life a little easier for families, even small things like parking. It was nice to be able park and not worry about finding a spot or having to pay for the garage,” said Dr. Amechi.

She says there was also a common goal among the NICU staff at Cook Children’s to get her son home, something she didn’t necessarily feel was the case before the transfer.

“We have a diverse and caring group of specialized people who are taking care of these very sick infants,” said Jonathan Nedrelow, M.D., medical director of the NICU at Cook Children’s. “From our nursing staff, to pharmacy, respiratory therapists, physicians and advanced practice nurses, we are all focused on doing what is best for the patient and their family.”

After three months at Cook Children’s, Samuel was finally deemed healthy enough to go home for the very first time. He was discharged in early September and is enjoying life with his two big sisters.

“Being able to leave the hospital with my son was a blessing,” said Dr. Amechi. “I remember when I was first told that I couldn’t take him home and I felt like the floor was going to fall from under me. So even though I was scared, I couldn’t wait to take him home.”

Stories like Dr. Amechi’s are not uncommon. In fact, Cook Children’s sees more than 1,000 babies admitted to the NICU each year. But often, when parents learn their newborn is in need of specialized care, they don’t realize they have a choice as to where that care is facilitated.

“Parents should know that they have a say when it comes to the care of their child,” said Dr. Nedrelow. “They should also know that there are different levels of care available.”

The NICU at Cook Children’s has been designated as a Level IV NICU by the state of Texas, meaning it provides the highest standard of neonatal care. Dr. Nedrelow says parents interested in transferring to Cook Children’s should contact their insurance company first. Because every company is different, having written approval from your insurance company before the transfer is the best way to ensure the care will be covered by your policy.

“If you’re considering transferring your baby to another hospital, be sure to talk to your physician,” said Dr. Nedrelow. “Ultimately, it’s your decision on where your newborn is treated, but your physician makes the referral and remains part of the treatment process so it’s important to discuss the process with him or her.”

About Cook Children's Neonatal Intensive Care Unit

If you would like to schedule an appointment for a NICU tour, refer a patient or speak to our staff, please call our offices at 855-687-6428. You can also find more information on our website. 

According to the study published this month in the journal Pediatrics, just half of mothers surveyed said they always put their babies to sleep on their backs.

The findings are alarming for physicians who say back-sleeping is a key way to reduce the risk of sudden infant death syndrome (SIDS).

“We see it all the time, and it is tragic,” said Corwin Warmink, M.D., medical director of the Emergency Department at Cook Children’s Medical Center. “SIDS is responsible for more infant deaths in the United States than anything else during the first year of life.”

While experts don’t know exactly why back-sleeping is best for preventing SIDS, it is believed that babies who sleep on their stomach get less oxygen and retain more carbon dioxide because they are “rebreathing” air. It is also possible that tummy-sleeping can lead to upper airway obstruction and choking.

“Infants should always sleep on their backs in a crib with a firm surface and a tight fitting sheet. No bumpers, pillows or soft bedding should be used,” mentioned Dr. Warmink.

Another big reason infants arrive in Cook Children’s Emergency Department is co-sleeping. While many parents find comfort in sharing a room with their baby, bed-sharing is never recommended.

“New parents are understandably exhausted, but even a quick nap with a newborn can turn deadly,” said Dr. Warmink. “It’s horrible to see a parent lose a child because they were accidently smothered in their sleep. Sharing a bedroom with an infant makes sense, but never on the same sleep surface.”

Dr. Warmink also insists infants should never sleep on a couch, sofa or cushioned chair, even when alone, and especially not with another person.

About Safe Sleep

Tarrant County has one of the highest infant mortality rates among Texas counties–exceeding the national average. The Center for Prevention of Child Maltreatment is guiding a safe infant sleep awareness campaign in collaboration with Baylor All Saints, JPS and Texas Health Harris Methodist. Learn more here.

Those probably won’t be the words that are said, but it might be the message that you hear.

Breastfeeding can be a tricky thing and many different problems can lead to a poor latch or such. One of the most blamed is tongue-ties. We should be careful not to attribute every nursing problem as a tongue tie because it can lead to unnecessary procedures, stress and a lot of time wasted on the wrong things instead of finding the real reason.

A tongue-tie is an attachment of skin and/or muscle below the tongue that restricts the movement of the tongue. Defining what is too tight is often very tricky and often two providers will disagree as to whether a tongue-tie is present.

Tongue-ties can lead to three problems:

1. Difficulty with breastfeeding - Tongue-ties can lead to poor or painful latching.

2. Difficulty with speech - Certain sounds require free movement of the tongue but children often accommodate and are able to speak clearly despite having a tongue-tie.

3. Difficulty with kissing - Another activity that requires free movement of the tongue. Although you might find them being a terrible kisser a benefit as a teen-parent, they might disagree.

When you or your doctors are checking your baby, there are a few signs that might points toward a tongue-tie:

• Obviously short attachment that inserts near the tip of the tongue
• Tongue never passes out past the lower teeth or lips
• Notched appearance of the tongue due to the attachment (like a heart)

If your baby is having breastfeeding problems and there is agreement that it is because of a tongue tie, treatment involves a simple procedure to either clip or laser the attachment. Most ENTs and dentists perform this procedure in the office and the baby goes right back to nursing immediately (often moms report feeling a difference right away).

Making the decision to treat an older child with tongue-tie is usually more difficult. The symptoms and benefit of treatment are not as clear and there are often other means of treatment, such as speech therapy, that can be tried first.

About The Author

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

This question comes up fairly often in my clinic, but with Summer travel many parents are thinking about traveling with their babies.

Here are the top concerns that parents have about flying with a baby:

1. Infection - Will your baby be at risk for getting sick because of the circulated air on an airplane? The short answer is, probably not. The uncertainty of who your neighbor is and what they might be carrying is potentially more scary that someone in the back of the plane with a contagious illness. I usually get more concerned about your baby catching something from the destination. When you travel to visit family or go to a wedding, sometimes people get so wrapped up in their desire to hold the baby that they forget that lingering nasty cough they have had.

2. Injury - Is it safe to travel on a plane with a baby? Because air travel is relatively safe, the risk of injury on an airplane is low; especially if you compare it to travel by motor vehicle. However, there are particular safety concerns you should be aware of. Most airlines do not require a ticket and separate seat for children under 2 years of age; however, many organizations have lobbied for a requirement that every child be required to have their own seat and be properly restrained. Some car seats can be placed and buckled into airplane seat but you should check your manufacturer and model. Another tip is to be sure that, no matter what, you make sure that safe car seat arrangements are available at your destination.

3. Oxygen - Can babies handle the climb to altitude without dropping their oxygen saturation? This question has been studied and the evidence suggests that babies born term can easily fly without oxygen issues even in the first week of life. Preterm infants could safely fly once they reach 39 weeks corrected gestational age (about 1 week from their due date). Infants with lung disease because of prematurity should be evaluated prior to flight.

4. Sanity - Safety of flying with an infant not withstanding, can you fly with a baby and maintain any semblance of sanity? Some might think you are crazy but clearly it depends on the reason for travel. If you have a big enough reason, you can survive anything. For younger babies, I recommend trying to save a feed for time on the flight. Nursing or drinking from a bottle is a great way to comfort a baby when they get fussy in flight. Spend times times as long packing your bag as you think reasonable possible. Especially if it’s your first flight with your baby, you never know what emergencies pop up and having those supplies below your seat is way better than having them in the overhead bend (not to mention packed away). If possible, take a second helper with you. This might not always be possible but it sure is nice to have someone to hand the baby to if you need to make a trip back to the bathroom or just for extra hand to accomplish those “simple” tasks that take on a life of their own at 30,000 feet.

These are the main issues you should consider when you are thinking about flying with a baby. I do believe that you can fly safely with a baby but I also think you should really consider if the trip is worth the stress and hassle.

About the author

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

“Is it GERD?”

Or, as I frequently see it spelled, “Is it gurd?”

Every baby spits up ... there is definitely a spectrum from the babies that spit up once in their whole life all the way to the babies that spit up every single time they eat.

It can be hard to understand what a doctor or patient means when they use the terms spitting up, reflux or GERD because people use them in different ways.

I try to keep it simple and only use the terms reflux and GERD when I think that the spitting up might be causing a problem:

So, if every baby spits up, how do I decide what is normal? When is it spitting up vs. reflux vs. gastro-esophageal reflux disease (GERD)?

The answer to this is tricky but I’m hopeful that I can help you decide.

Studies have been done where they watch how many times a baby regurgitates milk and stomach acid by placing a probe down his or her esophagus (this is reflux). The answer ... on average, 30 times per day. Most, but not all, of these episodes were associated with milk at least making it into the mouth.

Why does this happen?

There's a muscle that sits on top of the stomach that is meant to properly relax and squeeze to allow milk into, but not out of the stomach. Unfortunately, in most young infants, this muscle is both weak and dumb. It's not strong enough to override the pressure of the stomach pressing on it and it frequently relaxes when it is supposed to be contracting, letting stomach acid run back up into the esophagus.

So, reflux is, for the most part, a mechanical problem that's based on the pressure of the stomach and the strength of the muscle that sits on top of it. That is why, I think, that the most common cause of spitting up is overfeeding.

Often a family of a 2 month old will come in for their checkup and have questions about why their baby (who eats 6 ounces per feed) is spitting up. The issue is that the stomach is only a few ounces big at this age and everything else that you try to squeeze into it just raises the pressure and causes the baby to spit up.

So, if it’s so common what makes it abnormal?

There’s really only 2 reasons why I will treat babies for reflux: poor weight gain or associated pain/fussiness. So, the most common thing I will do to treat reflux is check the baby’s weight and if weight gain is good, reassure the family that they have a “happy spitter.”

I also see babies who are consistently fussy with their spitting up or that have fussiness predictably during feeds or in the 30 minutes following each feed with or without spitting up. Some people have termed this “silent reflux,” but I don’t really like that term because the screaming associated with it is anything but “silent.” Babies can also arch their backs which is sometimes confused for seizures but is, in fact, reflux.

What do we do about it?

Many babies can be helped by just cutting back on the amount of milk they are ingesting ... most babies need about 2-3 ounces per feed at 2 months and this goes up about 1 ounce per month of age after (6 ounces at 6 months).

I still commonly discuss with families that they can slightly elevate the head of the crib although it looks like review of the literature questions whether this is actually helpful,  so I may have to rethink this.

Studies have shown varying percentages about babies with reflux who have an allergy or sensitivity to cow’s milk protein (some studies show it as high as 40 percent). Thus it might be reasonable to try a short trial of a hypo-allergenic formula (Neutramigen or Alimentum). Many babies who are sensitive to cow’s milk will also be sensitive to soy. Many publications don't recommend a trial of soy, but because of the expense of the hypo-allergenic formulas I will sometimes have families do a trial of soy formula first.

Finally, in those babies who aren't gaining weight well or who are fussy with their GERD or following feeds, a short trial of an antacid medicine can be attempted to help with symptoms. There are two types of medicines that can be used: H2-blockers (ex Zantac) and PPI (ex Prevacid). I try to remind families that neither of these medicines are meant to help keep milk in the stomach. They only change the acidity of the contents that are coming up. So, it's likely that the baby will continue to spit.

Summary

1. Most babies with reflux have a laundry problem and not a medical problem (think happy spitter).

2. Limiting overfeeding is the major non-medical treatment for spit up.

3. Medicines for reflux can be used in babies with poor weight gain or fussiness but should be used sparingly and with appropriate expectations.

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

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

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

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

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

Here are the questions to consider:

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

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

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

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

What diseases should I be worried about?

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

1. Flu

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

2. Pertussis

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

3. Measles

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

What criteria should I use for being around others?

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

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

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

Here are some thoughts about some things you might say:

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

I hear this almost daily as a pediatric physical therapist. However, tummy time is more important than ever these days.

Our babies today tend to have more time on their backs than on their tummies. The Back to Sleep Campaign instructs parents to place children on their backs in their cribs to prevent SIDS (Sudden Infant Death Syndrome). We also have car seats that transport easily into shopping carts and strollers, bouncy seats, swings and rockers. Even when babies are nursing or taking a bottle, they are held in a parent’s arms, essentially on their back. All of this leads to decreased tummy time. But if we have all of these safety precautions and modern conveniences, then why make a baby cry on her tummy?

• Tummy time promotes neck and trunk strengthening for head control. It can be a baby’s first workout.
• Tummy time prevents babies from getting a flat spot on the back of their heads. These flat spots can lead to changes in head shape, facial appearance, and jaw alignment. In more significant cases, children may require the use of a special helmet to reshape their head. In tummy time, babies are taking pressure off the back of their heads and learning to move.
• Tummy time allows a baby to visually explore their surroundings.
• Babies learn to move, roll and reach side to side while on their tummies. These are all the first steps to bigger things like walking, running and climbing.
• In tummy time, babies push up on their hands and arms. They are building strength in their shoulders and hands. This time in weight bearing plays into handwriting, gripping and sensory development.

Tips for Tummy Time

Tummy time is not always easy, but there are definitely ways to help make it a success.

1. Start early. Even newborn babies can play on their tummies. It’s never too soon to let babies learn to explore on their tummies, getting that sensation of weight bearing on their stomachs, pushing with their hands and toes.

2. Build them up! If your baby is having a hard time lifting their head up, you can lay them on your chest while you are reclined on the couch. You can also place a rolled up blanket or towel under their chest to lift them a little and help make it easier for them. As they build their neck strength and head control, you can try laying them flat on their tummies again.

3. Get on the floor with them! Infants of all ages love faces. Especially the faces of those who care for them. A child will follow and respond to a caring face at a younger age than they will a toy. Getting on the floor with them and talking with them will often help them stay on their bellies longer without fussing.

4. Perform tummy time frequently. To start, a few minutes of tummy time after every diaper change is great. Each day, try to add 5 more minutes to their tummy time practice. With these short but frequent times, they will begin to build their strength and tolerance for tummy time.

5. Don’t give up! As tummy time becomes part of a baby’s routine, they will gain strength and learn to move and explore. Once it’s part of a baby’s routine, his strength will build quickly. He will be getting all of the wonderful benefits of moving, exploring, feeling and seeing the world from his tummy. And watch out! You might soon find that your baby actually loves being on his tummy!

About the author

Carrie Carney is a physical therapist at Cook Children's. Physical therapy focuses on large motor and functional skills to enhance development restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's offers Rehabilitation Services in Fort Worth, Hurst and Mansfield.

The pop superstar gave an interview in the most recent edition of Vanity Fair and talked very frankly about her battle with postpartum depression, following the birth of her son. She said her postpartum depression made her feel "very inadequate" and as if she "made the worst decison of my life."

New moms experience all sorts of feelings, thoughts, and behaviors that their non-pregnant selves would never dream of! In the first few weeks after delivering a baby, about 80 percent of women will experience crying for no reason, impatience, irritability, anxiety, fatigue, sadness and trouble concentrating.

When do these feelings extend beyond “normal” and into the danger zone?

According to Diana Lynn Barnes, PsyD, an expert on maternal mental health, these are common feelings expressed by women with postpartum depression:

• No one has ever felt as bad as I do (helplessness)
• I have made a terrible mistake (anxiety)
• I am all alone and no one understands (isolation, withdrawal)
• I’m a failure as a mother, woman, and wife (guilt, diminished self-esteem)
• I will never be myself again (hopelessness)
• I’m losing it (despair)
• Everything is an effort (exhaustion)
• I have such trouble deciding (disorientation, confusion)
• I feel like I have soda fizzing through my veins (anxiety)
• Sometimes I think everyone would be better off without me (suicidal thinking)

Luckily, risk factors for postpartum depression are known, so at-risk women and their families can be proactive about their postpartum mental health. Make sure your pregnancy care provider knows about:

• Personal or family history of depression, anxiety, obsessive-compulsive disorder, postpartum depression or psychosis.
• Personal or family history of thyroid illness, chemical dependency, or alcoholism.
• Premenstrual dysphoric disorder.
• Past experience of trauma (physical, emotional, sexual abuse).

Postpartum psychosis is a serious, life-threatening illness that increases the risk of a mother committing suicide, killing her baby, or abusing or neglecting her baby. It occurs in about 0.1 percent of births, begins suddenly within two weeks of delivery, and may require emergent psychiatric hospitalization. A personal or family history of bipolar disorder, postpartum psychosis, or a previous psychotic episode are the most ominous risk factors, but women without any risk factors can develop postpartum psychosis. If you notice a new mom experiencing these things, it’s time to get help NOW:

1. Strange ideas or beliefs which are often of a religious nature, i.e. receiving prophecies, supernatural baby, evil baby (delusions).
2. Hearing commands.
3. Receiving secret messages from TV, music, books, online, etc.
4. Unwanted and disturbing urges to commit violent or other terrible acts.
5. Hallucinations involving smell, sight, or touch.
6. Intense fear of what she might do and a desire to escape.
7. Inability to sleep, a drastic increase in energy, euphoria (mania).
8. Not making sense when talking, easily distracted (disorganized speech, flight of ideas).
9. Frequent arguments, irritability, annoyance, and conflict with family members.
10. A false idea that people close to them are dishonest, dangerous, or trying to hurt them or their baby (paranoia or suspiciousness).
11. Confusion about where, when, and who they are time (disorientation).
12. Obvious lack of self-care.
13. Feeling unable to care for her baby, or extreme worry that she can’t keep the baby safe.

The great news is that postpartum depression and psychosis can be effectively treated, especially if help is sought early.

• The widely used screening tool - the Edinburgh Postnatal Depression Scale
• Postpartum Support International
• More about Diana Lynn Barnes, PsyD

Let's begin by looking at the facts:

• About one to three babies out of every 1000 will be born with a permanent hearing loss.
• Infant hearing loss is the most common health condition identified through routine newborn screens.
• Nine out of 10 cases of genetic hearing loss occur in families where both parents have normal hearing.

The earlier children with hearing loss are identified and start getting help, the more likely they will reach their full potential. Hearing loss can cause children to fall behind their peers in speech, learning, reading, and social-emotional development, which can result in lower educational and employment levels into adulthood.

1-3-6 Goal

In fact, the Centers for Disease Control recommend the following 1-3-6 Goal:

1 — All infants get a hearing screen before 1 month of age.

3 — Hearing loss is confirmed before 3 months of age.

6 — Hearing loss intervention begins before 6 months of age.

So now that we know it’s better to identify hearing loss as a baby, just how are babies tested anyway? There are two types of tests used to screen hearing in babies and both are safe and painless.

Types of Hearing Screens

Otoacoustic Emissions (OAE)

For this test, a small earphone and microphone are placed in the ear, sounds are played, and a response is measured in the ear canal. If a baby hears normally, an echo is reflected back and measured by the microphone. When a baby has a hearing loss, no echo can be measured on the OAE test.

Auditory Brainstem Response (ABR)

For this test, sticker electrodes are placed on the baby's head to detect responses while sounds are played in the baby's ears. This test measures how the hearing nerve responds to sounds and can identify babies who have a hearing loss.

The two tests can be used separately or together. Both tests require a quiet, if not sleeping baby. If a problem is found, follow-up testing should happen as soon as possible.

What if My Baby Fails a Hearing Screen?

If your baby fails a hearing screen, you will be referred to an outpatient facility where an Audiologist will complete a more in depth ABR. It will measure the softest level that the ear responds to sounds using different pitches or tones. If testing is done before a baby is 4 months old, the baby can usually sleep naturally for the testing. For older or very active babies, sedation may be needed to help them sleep during testing. It is important that babies are sleeping for ABR testing.

The newborn hearing screen is one of the most important first tests your newborn takes. Babies start learning how to use sound as soon as they are born and listening prepares them to speak. Therefore, if a baby has hearing loss it is important that services begin right away. If you have any questions or concerns about your child’s hearing, contact your Pediatrician and ask about seeing an Audiologist.

See below for additional resources on newborn hearing screening:

• Cook Children's Audiology
• CDC information on hearing loss/screening
• Babyhearing.org
• Joint Committee on Infant Hearing

About the author

Christina Graham is an audiologist at Cook Children's. Cook Children's audiologists focus on diagnosing specific types of hearing loss for kids. They work closely with the child, his/her family, speech pathologists, school personnel, specialists, and physicians to create a plan that will enhance a child's functional hearing and help them learn and develop. To learn more, click here. To make an appointment, click here.

A new study in Nature Medicine started the process of trying to answer this exact question

You might be thinking, “What the?” But there is some logic to this:

1. Babies born via C-section have been shown to have slightly higher risk of some diseases (obesity, allergies and asthma for example).
2. We are beginning to understand how the makeup of bacteria in our intestines affects many different diseases.
3. Babies born via C-section are not exposed to the normal bacteria that line the birth canal

The question then would need to be asked: Can you reverse this process by exposing babies to the vaginal flora after they were born via C-section? This small pilot study of four babies seems to suggest that you can.

The process: Within in the first two minutes after birth, take a piece of gauze, which has been placed in the vagina. Swab the babies mouth, forehead and the rest of their body. Test these babies to see what bacteria are present in their bodies.

The answer: Those C-section babies who were swabbed with vaginal secretion showed that the bacteria they carried more closely resembled babies who were delivered vaginally.

This was a small study, which needs to be repeated on a larger scale and there are still many questions to answered:

• Does changing the bacteria that a baby carries actually help to prevent diseases?
• How do we make sure this procedure is safe? How do we screen moms to make sure there is no added risk to the baby?
• What is the best means of transferring the bacteria? Is there a better way that what was done in this study?

The role that the bacteria we carry play in our health is gaining interest. I’m sure that we will continue to see studies like this and many others in this area. Stay tuned.

Don’t get me wrong, I’m glad he had his baby vaccinated for his baby’s sake, but I don’t want it to affect your decision to vaccinate at all.

I don’t want your vaccine decisions to be based on what a celebrity does, even if that celebrity is one of the most brilliant guys around.

Why?

Because some other really smart person will choose next week to skip vaccines and then where will we be? No better off than getting vaccine information from celebrities like Justin Timberlake or Jenny McCarthy.

If you vaccinate, you are not alone.

Studies show that over 95 percent of you have chosen to vaccinate your children.

Does it feel like that to you?

Does the media portray it that way?

Does your social media stream reflect that vaccination is the overwhelming majority?

The answer, I believe, is no.

But, why?

Maybe it’s not cool or politically correct to vaccinate you child, or at least to say that you do.

Maybe it’s because you are afraid of the comments you will receive if you support vaccines or report that your child just received some.

Maybe you worry what would happen if you question that thousandth share of some 2012 Italian court case. (P.S. That decision, which was made in some really low level court in Italy, was thrown out by a higher court so just stop already with Italian court decision memes.)

I promise you the world wouldn’t end if you do. If you get a comment that is rude, it’s OK to ignore it. If you have an answer, answer. If you don’t know, get advice from someone who might know. Tag me.

So, I don’t care that it was Mark Zuckerberg who chose to vaccinate his child. But, I do appreciate when anyone speaks up to say, “I vaccinate my child because I believe it is what is best for them.”

Let’s start something today:

Share this post that you are reading right now and say, “Thanks for sharing Mark. I #vaccinate too."

• You will be awake during hours of the night you didn’t even know existed.
• You will begin to interpret everything as a smile.
• You will allow words like spit up and poop become normal dinner conversation.

As you talk about poop, you will uncover something you will be concerned about or at least something that gets your attention. So, here are some weird things you might find in a baby’s diapers:

1. No poop - Babies need to poop in the first day or two after birth to prove that they can. After that, skipping a day or two shouldn’t concern you.
2. Lots of poop - Infrequent stools can be normal but so can pooping all day long every day. It’s also not uncommon for babies to poop every meal with a few stuck in the middle. So much poop, you literally can’t even.
3. All the colors - Pretty much any color stool can be normal. Yellow, green and brown are the most common. In the first few days, it will be black. But there is one color that should get your attention…
4. White or clay-colored poop – This is the one poop color that should prompt an immediate visit to the doctor. Do not pass Go, do not collect $200. It can point toward a rare, but serious liver condition and the baby needs to be seen.
5. Seeds in poop – These little flecks are common in breastfed babies and won’t grow breast milk trees if planted although that would be cool.
6. Blood or mucous poop – This could be a sign that your child is allergic to the protein in their milk. Call your doctor.
7. Red specks in pee – These little red crystals are not blood but are actually urate crystals. They are common and normal.
8. Swollen scrotum – If your little boy has one sided scrotum swelling or both sides are increasing in size, it could be a hernia. This is much more of an emergency if the baby seems to be in pain or there is redness of the skin.
9. Diaper rashes – Most of these are just general irritation from stool. For those, large amounts of thick cream, keep stool off the skin and allow it to heal (you probably aren’t using enough).
10. Bloody or clear/white vaginal discharge – This discharge is very common and is the result of hormonal changes that occur after birth and nothing to worry about.

There are plenty of other weird things your baby will show you, even some more in the diaper area. Some of these are more severe abnormalities that should have been picked up by the doctor before you left the hospital. Hopefully by reading this, you can avoid having to talk about if your baby’s poop is normal tonight. Have a great dinner!

“Vaccinations are still the best answer to preventing the flu and protecting your children from the upcoming season,” Dr. Whitworth said.

The flu shot is recommended for children ages 6 months and older. However, the Centers for Disease Control says only 47 percent of the nation’s eligible population received a flu shot. The only age group that met the CDC’s coverage goal of at least 70 percent was children 6 months to 23 months of age with 75 percent getting their shot.

It’s important for babies to get their shots beginning at 6 months of age. Flu shots are not approved for younger infants,” Dr. Whitworth said. “Because these younger babies cannot be protected by getting flu shots, their caregivers and household contacts must get theirs. If those individuals who are around the baby don’t get infected with influenza, the baby is much less likely to be exposed. It’s especially important for pregnant women to get their vaccines in order to protect their newborns.”

Last year, a lot of talk focused on how ineffective the flu vaccine was, with the CDC saying it was less than 23 percent effective against the dominant strain. The CDC says the vaccine will be more effective this year based on data from early detected cases.

Dr. Whitworth says it’s too soon to predict what the flu season will bring as far as severity and it’s difficult to say how effective the vaccine will be because different strains circulate each year. But vaccines are still the most effective way to fight against the flu.

During the 2014-2015 flu season, 145 children died in the United States from influenza-related illness and the American Academy of Pediatrics says many of those children had no underlying medical condition. The AAP states that an estimated 90 percent of pediatric deaths have occurred in unvaccinated children.

Two types of influenza vaccines are available for children this year, according to the AAP:

• The inactivated influenza vaccine (IIV) is given by injection and is approved for children 6 months of age and older. It is available in two types, one which protects against three strains and one which protects against four strains of influenza.
• Also available is the live attenuated influenza vaccine (LAIV), which is given by intranasal spray. It is approved for healthy patients 2 through 49 years of age and protects against four strains of influenza.

 The AAP also recommends:

• Everyone who is 6 months of age and older should receive annual influenza vaccine.
• Children ages 6 months through 8 years need two doses this flu season, if they have had less than 2 doses of flu vaccine before July 2015.
• Special efforts should be made to vaccinate household contacts and out-of-home caregivers of children with high-risk conditions, and all children under the age of 5.
• Parents should not delay immunization in order to receive a specific vaccine formulation. It is more important to be vaccinated at the earliest opportunity.
• Pregnant women, who are at high risk of influenza complications, can safely receive influenza vaccine at any time during pregnancy. This also provides protection for their infants during their first 6 months of life.
• Mandatory influenza immunization programs for all health care personnel should be implemented nationwide.

About the source

Mary Suzanne Whitworth, M.D. is the medical director of Infectious Diseases at Cook Children’s, which offers care for children and teens with diseases caused by bacteria, parasites, fungi or viruses. Our team provides a broad range of services including diagnosis, inpatient and outpatient consultations, immune deficiency evaluations and treatment of recurring infections.

How do we know that parent-talk builds children’s brains? A study by Betty Hart and Todd Risley, “The Early Catastrophe: The 30 Million Word Gap by Age 3” showed that by age 3, children from lower socioeconomic backgrounds heard 30 million fewer words than children from prosperous backgrounds. This disparity of 30,000,000 words heard had effects on children’s IQ and test scores by the time they were in third grade. Why is this important? All children have the right to full access for learning; to grow their brain; to learn to talk, read and write. What parents and caregivers do and say has a profound impact on a child’s development.

Dr. Dana Suskind, a pediatric cochlear implant surgeon at the University of Chicago recently released her book Thirty Million Words: Building a Child’s Brain. At the center of her program are the “Three T’s.”

• Tune In
  • What does your baby/toddler like to do? Let’s say your little one is super interested in those pots and pans in your cabinet but you would rather baby play with the ball. Think about helping baby explore those pots and pans: making noise, pretending to stir, wearing the pan as a hat, etc. Make it all about baby’s interests.
• Talk More
  • What are you saying to your baby? For example, “Come over here and get this” could have many meanings. A richer language example could be “Walk to sister and get the ball!” By using ‘walk, sister, and ball’ baby hears specific words instead of more non-specific words (‘here’ and ‘this’). By using specific, rich language, baby’s vocabulary increases. We learn to talk based on what we hear. I often encourage parents to ‘be a thesaurus’ – constantly increasing the complexity and richness of their language.
  • Another tip is to teach verbs, verbs, and more verbs. Verbs carry far more meaning in communicating than nouns. For example, the word ‘drink’ will result in more action from parent than ‘milk’. Baby says ‘drink’ parent says, “Oh you want a drink? I have milk, juice, water, ____”. If baby says, ‘milk,’ parent says, “Here’s some milk.” ‘Drink’ can be paired with many other words as children start stringing words together: drink more, drink please, drink milk, drink all gone, drink spill, drink hot, etc.
• Taking Turns
  • From the moment parents meet their new baby, communication begins. Babies coo, giggle, scream, cry, and babble to communicate. Parents then respond with sounds, words, and actions. These early interactions are the beginnings of conversation. As very young children start using words, listen to what they have to say. The more you talk back and forth with them, the more words they learn. The more words they learn, the better readers they will be.

Talking to our babies and toddlers is something we can all do to help babies’ brains.

What can we do as parents and professionals to close that Thirty Million Word gap for all children? How can you use Dr. Suskind’s “Three T’s” strategies to grow your child’s vocabulary?

She is obviously looking for some sort of action on my part other than my smiling and nodding affirmatively. Since she’s my number one girl, I’ve learned the idiosyncrasies of her developing speech and know exactly how to handle this request. But to the layperson (or even Daddy or Grammy), I’m fairly certain I would need to come to the rescue with my toddler translator skills.

Mamas, I know you’ve been there. Your 3 year old launches into a monologue you find equal parts incomprehensible and adorable. Adorable, that is, until the tantrums and frantic attempts to understand and obey her demands kick in. In my practice, I have observed some masterful decoding mamas and some skillfully adaptive little ones navigating the waters of communication breakdown. Let’s talk a little bit about speech sound development and when to fret.

Articulation is the movement of the tongue, lips, soft palate and jaw to make speech sounds. It’s also the driving force behind your toddler’s incomprehensible speech. As parents, we are so excited when our little bundles of joy begin talking, but oftentimes, that excitement is quickly replaced with frustration when we realize we can’t understand a lick of what they’re saying.

An articulation disorder occurs when a child has difficulty forming speech sounds, most likely due to a structural or motor-based deficit. Most children tend to have some difficulty with certain speech sounds. Because creating sounds is challenging, he may substitute easy sounds for tough ones (think dumb for thumb), delete sounds (ha for hat), or distort problematic sounds (this is most often noted when children have a “slushy” quality). An articulation disorder occurs if these substitutions continue past the expected age.

Are all sounds created equal? In short, no. Children master sounds gradually. Most children can pronounce all of the speech sounds of English correctly by age 8. While each child’s speech sound acquisition is different, the following are age ranges in which most children master certain sounds:

• Introducing the “early birds”: Most wee ones will use m, n, y, b, w, d, p and h correctly between 18-30 months. That may explain why mama, dada and ball are frequently reported as first words.
• Not to be outdone, the middle of the road sounds includes: t, ng, k, g, f, v, ch and j. You may hear your little one utter these sound appropriately as early as 2 or as late as 6 years of age.
• Finally, the late bloomers include: sh, zh, r, s, z and th. This final pack of sounds contains the frequent offenders when it comes to articulation disorders. They are challenging for children to master and can wreak serious havoc on the clarity of their speech. We expect children to master these sounds between the ages of 3-8. (Based on Shriberg, 1993)

As children get older and learn new speech sounds, they gradually become easier to understand by a wider variety of listeners. Developing clear speech is a journey for our littles, albeit a frustrating one at times. And like all journeys, no two are equal. Some children are clear as a bell by their second birthday while others need a bit more time. As parents, we typically understand our babes before the rest of the world and therefore, are awarded the esteemed role of toddler translator. In many situations, one parent has a better handle on their child’s speech sound system than the other. But, as a general rule of thumb (or rule of “fum” if you happen to be a toddler):

• By 2 years of age children can be understood by familiar adults most of the time.

• By 3 years of age children can be understood by unfamiliar adults most of the time.

• By 4 years of age children can be understood by unfamiliar adults almost all of the time.

• By 5 years of age children can be understood by unfamiliar adults all of the time.

(Based on Flipsen Jr, 2006)

Although a continuum exists when it comes to speech sound development, there are a few red flags to be mindful of when chatting with your child.

It may be time to check in with your pediatrician regarding an evaluation with a speech language pathologist if your child:

• Uses only vowel sounds and a few consonants or shows limited babbling at 18 months.
• Seems to have a “slushy” (think mouth full of marbles) quality to his speech.
• Is difficult to understand and has a history of frequent ear infections.
• Leaves off the beginning or ending sounds of words (hatàha).
• Leaves off entire syllables of words (pa for purple).
• Is not understood by people outside his immediate family by age 3.
• Seems to be frustrated by his difficulty with speech or appears hesitant to interact or respond to peers or adults.

So what can you do to help him along?

Above all, it is important to always show your child you value WHAT he is saying regardless of HOW he is saying it. Always reinforce his attempts at striking up conversation with you! When you hear one of those adorable substitutions, help him to learn by repeating it correctly (If he says “tar” you can say “yes! A car!”) and moving on with the flow of conversation. Play face to face with him so he can watch the way your mouth moves to make sounds. Emphasize beginning and ending sounds in your own speech so he can hear them and begin to realize they are part of the word, too. If all else fails, ask him to SHOW you what he needs. And take comfort in the knowledge that this process is a gradual one.

Oh, and my daughter? She wanted to watch Frozen on the big T.V. and relax a little bit. Obviously.

1. Shriberg, L.D. (1993). Four new speech and prosody-voice measures for genetics research and other studies in developmental phonological disorders. Journal of Speech and Hearing Research, (36), 105-140.

2. Flipsen, P., Jr (2006). Measuring the speech intelligibility of conversational speech in children. Clinical Linguistics and Phonetics, (20) 4, 303-312.

3. http://www.asha.org/public/speech/disorders/SpeechSoundDisorders/

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

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

In today's video, Doc Smitty explains:

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

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