I remember uttering these words to my nurse manager after she encouraged me to pursue an open position as a clinical nurse educator. This came after I requested a meeting with her during a time that I was trying to navigate a period of restlessness, eagerness to contribute to my unit, while simultaneously experiencing a feeling of career confusion.

The joys of being a bedside nurse are endless. There is nothing more satisfying than delivering care that you would hope your family and friends would receive during tender times. There is an immediate satisfaction in knowing that you are advocating for your patients and families in the moments they need you most. Every patient was my brother or sister, every mother or father was my own.

I would arrive at my shifts ready to work and give everything my patients and their caregivers deserved and more. I was involved in my unit, eager to find solutions to problems, and was enthusiastic about making my work environment better. I felt ready to do more.

However, I often felt limited because of feelings of self-doubt and because I just felt so… new. While I had taken my fair share of difficult assignments, trained newer nurses, and taken on informal leadership roles within my unit, I was still what you would consider newer in my nursing career. I had these self-imposed ideals of what it meant to be a leader in a healthcare environment because I worked with so many of them: someone who had decades of experience, had “seen it all,” was tough as nails, and inexplicably knew the answers to every problem. I was simply a newer nurse with a few ideas and an optimistic attitude. On the outside, I’m sure the perception was that I was a stereotypical, bright-eyed “millennial.”

Millennials in the workplace have received quite the reputation, gaining much more attention in the media. Millennials have perplexed leaders in the workplace so much that it has inspired over 12 million search results when anyone searches for the terms “Millennials in the Workplace.”

I’ve been told that we are a generation of contradictions: wanting positions of higher responsibility, but entitled to our days off and fearlessly asking for things that we shouldn’t. I’ve been told that technology has corrupted us and social media even more so.

Regardless of these preconceived notions and my anxieties of not being taken seriously, I took that manager’s advice because I figured, what have I got to lose? The worst thing that someone could tell me was “no” and I could go get those decades of experience I always thought you needed to do the things I wanted to do eventually: teach, inspire, and support nurses transitioning into and developing themselves within the endless potential of the nursing profession. One where you could improve the lives of your patients, but also inspire real changes in healthcare.

I have since been in the role of a clinical nurse educator for over three years now, and I’ve struggled in the last few years to reconcile the reality of what society thinks of my generation as a whole with the person that I truly am and the kind of nurse leader that I want to become. Throughout my journey, I have learned a few things…

Defining Professional and Personal Boundaries 

While this is no novel idea for any new leader, it has been an especially new experience during a time when social media is omnipresent. As someone who essentially grew up in the world of social media before “social media” was even a term, I found myself navigating the terrain of professional boundaries in the workplace and the internet, too. While there have been many challenges to doing both, the resources are endless now on how to do this skillfully.

Professional Development is Invaluable

I love taking advantage of opportunities that help me not only be a better leader, but also help me to connect with our frontline nursing staff as well. Continuing education and really committing to personal and professional growth is what helps me come back every day. Finding ways to make things better for my peers and the people that I serve is exciting and that would be impossible without equipping myself with the tools necessary to initiate and support change.

Work/Life Balance is a Real Thing

No, I don’t mean I need a ping pong table in our lounge, but I do need to make it a personal commitment to step away from work that can seem never-ending. In healthcare where services are literally provided 24/7, it can be easy to get caught up in feeling like you need to be accessible all of the time. However, after my first year of nursing education and working a traditional 40 work week with employees calling me at 2 a.m., I simply realized that it wasn’t a sustainable model. Everyone needs intentional rest and time away to be able to come back and be at 100%. It has been especially important to work with executive leadership members and supervisors who are supportive of this notion.

Experience is important, but so are many other things.

Of all the lessons I have learned, this has been the most important. I do not want to discount experience – a strong foundation is necessary in order to speak to and have insight on the needs of the people you serve. However, leadership doesn’t rely on experience alone. A willingness to serve a purpose greater than yourself and the willingness and optimism to work towards solutions are even more important. A commitment to the people you serve is important. The willingness to listen more than you speak is even more invaluable.

Intentional Authenticity

I recently went through an old journal and found a quote that I had written down that stated, “am I failing or am I being refined?” There were many times through my first two years where I felt like a complete failure. Were educators supposed to feel that way? We are, after all, seen as “clinical experts.” However, I’m not anything if not honest. There were times throughout those years that I simply acknowledged my shortcomings, apologized, and addressed it in the best way that I knew how. I wasn’t always the expert, but I was committed to being resourceful. This is what I’d like to call intentional authenticity. I commit to being myself and honest always and being myself within the scope of my role.

I want to commit to always be a learner. It’s why I wanted to be an educator in the first place. And although I’m a “bright-eyed millennial,” I’m thankful for the opportunity to make a difference in whatever capacity I can, ready or not. I don’t believe we are defined by the broad generalizations of our generation. Instead, I’m more interested in what our generation has and will continue to contribute to everyone’s future.

I have a few tricks up my sleeve: fun toys, silly pictures, asking them about something they brought in or something they are wearing. When I’m asked to evaluate a child who isn’t talking, I begin with some easy tasks like pointing to things or naming familiar items. Most kids begin to warm up in a short amount of time and I frequently have to steer them back toward our speech activities because there is so much more they want to talk about.

But sometimes a child won’t talk to me. Week after week, they won’t talk to me.

Parents tell me that he talks a lot at home, A LOT, but rarely to other people or away from home. This is more than being shy. When the parent describes what the child says at home, I learn that they use a variety of words and usually talks in full sentences. Sometimes, I’m able to determine that the child doesn’t even have a speech problem. They may have an anxiety disorder called Selective Mutism.

Selective Mutism is a childhood social communication anxiety disorder. It occurs when children do not speak for at least 1 month in certain social settings, but are able to speak in other settings. (Important note: this does not include kids that refuse to speak during the first month of school or children learning a new language.) The inability to speak is not related to a speech delay or disorder and is not the result of other medical or psychological problems that interfere with speech.

When it comes to talking or engaging with people, some kids experience an extreme level of fear and anxiety causing them to be silent, or mute. Maybe they are afraid to engage with other people or afraid they will embarrass themselves when they speak. In the moment, no amount of reassurance or pressure will help them bring words out. They are frozen.

Some studies estimate that this happens to 1 in 1,000 children*. However, several researchers have stated they believe this is largely underestimated. Selective Mutism is slightly more common in girls than boys. Most kids are diagnosed around the age of 5, but parents report difficulty starting years earlier. Selective Mutism may last for months or years. It may even extend into adulthood if left untreated.

What should parents do?

Never try to force or bribe a child to speak.

Talk to your doctor or a psychologist. They will likely gather a team to help diagnose your child’s difficulty and develop a plan of care:

• Are there hearing problems?
• Does she have difficulty speaking or being understood?
• Has there been a recent traumatic event?
• Does she express fear about talking or other things?

Frequently there are other underlying issues that have led to the anxiety disorder.

A psychologist or counselor can help your child understand their fears and work through them using play therapy, family counseling and behavioral or cognitive strategies.

Many times a speech language pathologist is called in to help. I know this seems unusual as we have just said there is not a speech problem, but an anxiety disorder. However, speech language pathologists  are able to set up activities in a nonstressful manner with low expectations for talking.

Let’s start with playing with a train set. The therapist helps the child build the train track and continues to make comments about the activity, train sounds and try to engage in taking turns with the child creating a fun shared activity.

The next level may include asking the child to point to a picture of the train car they want to put on the track first. Recently, a child I was seeing began saying the color as they were touching the picture. I smiled and continued playing, not making a big deal about them speaking.

Slowly, week after week, the therapist helps the child build success and confidence.

We set up activities that include more people and work with parents to design practice activities they can do between therapy visits. As we provide more challenging activities, we always have a backup plan ready if the child begins to feel unsure.

With older children, once we build trust, we can help them identify challenges in speaking or socializing. We can build on skills they already have and gain confidence in communicating with others. We will also help them problem solve specific situations that cause stress.

If you suspect your child has difficulty speaking, whether it be due to anxiety or other speech skills, please talk to your pediatrician to seek help.

* Estimate from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

– Will Shudde, M.D.

Most of you won’t know Dr. Shudde, but he’s the first doctor I ever shadowed during the summer between my second and third year of medical school and I heard this speech about 10 times a day in the hospital and office. There might not be a more profound but simple statement in pediatrics because ...

Crying is normal.

It’s a normal part of being a baby and learning to deal with a crying baby is one of the first challenges you will face as a new parent.

Studies have shown that average crying in the newborn period can reach as high as two hours per day. Which seems like a lot when I write it out and would seem a lot longer if I had a screaming baby in my arms. The same studies suggest that the baby is not outside the realm of normal until we reach a gut-wrenching four hours of crying per day.

The definition of colic varies depending on where you look but the most commonly agreed upon criteria are crying that is:

• More than three hours per day
• More than three days per week
• In a healthy baby less than 3 months of age

Does the definition really matter? Just because a baby doesn’t meet these criteria, doesn’t mean that their cries can’t be extremely stressful to any given family. In fact, I tend to believe that colic is just an extreme form of fussiness or a parent’s perspective of fussiness and not a unique diagnosis.

Studies have attempted to link medical conditions to colic with very little success. Stomach problems, underfeeding, overfeeding, not burping enough, formula problems, intestinal immaturity, intestines that move too much, early migraines ... each possible cause has some studies that suggest a possible link while others do not.

One thing that is clear. Fussy babies affect the entire household. Links have been found between colic and:

• Marital dissatisfaction
• Parental perception of stress
• Lack of parent self-confidence
• Levels of family stress 

It’s hard to know if these are caused by the baby’s crying or if the presence of these in the family dynamic affects how parents view their baby’s crying.

If your baby is crying a lot, it’s important for your pediatrician to do a thorough history and physical to determine if there is any possible medical cause for the fussiness. Sometimes, with very stressed parents, I almost wish I could find something to fix. We all want our babies to feel better. If, however, there is no medical cause, here are some tips you can try with an extra fussy baby:

1. Quit smoking. Studies have shown that smoking during pregnancy or after delivery increase the amount of crying in newborns.
2. Don’t go on the formula carousel. There might be a subset of babies who are sensitive to cow’s milk protein or lactose but most are not. Talk with your pediatrician if you are concerned, but trying 100 formula probably won’t help.
3. Know that colic resolves by 3-4 months of age (and usually much sooner). This may be a horrible stage, but at least it’s a stage.
4. Take comfort that the child is not sick. If your pediatrician has checked them and everything is ok, they probably aren’t sick.
5. Admit that your baby is hard to comfort. There’s no reason to pretend that they are the easiest baby in the world. Admitting that they aren’t can help you to give yourself a break.
6. Try some of these comforting techniques: pacifier, holding, rocking, warm bath or playing white noise have all been suggested and helpful in my patients with fussy babies.
7. Take a break. The best breaks are longer and involve grandparents or other caregivers and some true time away. A break in the moment might mean putting them in a crib, closing the door and walking away for a few minutes.

Once people have heard my reasoning, they can get on board that fever isn’t as big of a deal as they once thought except for one MAJOR question:

What about febrile seizures?

The bottom line is that febrile seizures for the most part have to do with genetics and other uncontrollable issues. It has very little to do with the parent’s treating or not treating fever. Basically some kids are simply more likely to have them than others. You might just consider it a bit of bad luck.

On that note, here are 13 facts about febrile seizures:

1. Seizures can only be classified as febrile seizure if they happen when the child has fever.
2. Most febrile seizures occur on the first day of illness (often before the family knows the child has a fever).
3. The child cannot have a history of seizures or an infection that causes inflammation of the brain (like meningitis).
4. Febrile seizures occur between the ages of 6 months to 6 years (most commonly 12-18 months).
5. Boys are slightly more likely to have febrile seizures.
6. About 1/3 of all kids who have a febrile seizure will have another febrile seizure in their lifetime.
7. Kids with febrile seizures are only slightly more likely to have non-febrile seizures (only 1-2 percent).
8. Febrile seizures involve whole body shaking. If it’s just one sided or one body part, other causes should be considered.
9. Most febrile seizures are less than five minutes.
10. Head imaging (CT or MRI) and EEG (which look at brain activity) are not necessary with febrile seizures.
11. Treatment at the time of a febrile seizure is not necessary if less than 5 minutes.
12. Children with febrile seizures do not need to be admitted to the hospital unless the underlying cause of the fever makes it necessary.
13. Trying to prevent febrile seizures by treating fever aggressively has not been shown to be effective.

These are the 13 facts that I walk through with all of my families who have experienced a febrile seizure.

Hopefully knowing the facts will decrease some of the fear and relieve some of the guilt that has been placed on them for not preventing febrile seizures by catching fever in time.

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Ft. 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 the fall of 2016.

Rice is one of the foods most commonly associated with arsenic. Earlier this year, the Food and Drug Administration (FDA) released a statement expressing their goal to take “steps to reduce inorganic arsenic in infant rice cereal, a leading source of arsenic exposure in infants.” One of those steps is to reduce the allowable amount of arsenic in rice cereal. (Before you ask, brown and organic versions also have arsenic.)

A new study in JAMA Pediatrics released online yesterday shows that intake of rice cereal and rice-based snacks increased the levels of arsenic in the children’s urine. In high levels, it has been shown to cause problems with almost every body system, including poor growth, immune system function and development. It is unclear what health problems smaller increases may cause.

Should you be concerned?

I would not run out to have your child’s arsenic levels checked. Children have been eating rice cereal for ages with no obvious health effects.

We should definitely be aware of the ongoing research about arsenic and the FDA should continue to work with companies to limit the amount of arsenic in rice cereal.

Should you give your baby rice cereal?

There will be different opinions on this debate, but you’ve read this far for my opinion so here goes: I say ... no.

I actually moved on from recommending rice cereal (or cereal at all for that matter) for my patients for over a year now.

There are several reasons why we used to recommend rice cereal as an early first food but each one has fallen by the wayside as a real concern:

1. Iron - Rice cereal is a good source of iron and exclusively breast fed babies were thought to need more iron. But, the reality is, the iron that is in breast milk is absorbed well and there are plenty of other options to get iron.
2. Allergies - We used to think that feeding other foods early could be a cause of food allergies. Turns out, the exact opposite is true. Delaying other foods doesn’t prevent (and might actually be a cause of) food allergies.
3. Safety - Rice cereal can be mixed up into a bunch of different textures for your baby, but so can fruits and vegetables. If you are worried about your child’s safety and what he or she is eating or don’t want to deal with purees or other baby foods, it’s also perfectly OK to wait for solids until 6 months when a baby can handle more “whole” foods.

I recognize that many doctors might give other advice but I tell my patients to skip cereal (for lots of reasons, arsenic being a small one).

Either start with fruits and vegetable puree/baby food at 4 months or wait until 6 months to let babies feed themselves soft items (this is called baby-led weaning). Some great first foods for either puree or baby led weaning are avocados and bananas.

The main thing about early feeding is to have fun! Don’t let worry about arsenic poison your ability to enjoy this exciting developmental milestone.

About the author

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

Quick Refresher

• What is the thyroid gland and what does it do
• Hypothyroidism (underactive, low thyroid)
• Hyperthyroidism (over-active, high thyroid)
• Autoimmune thyroid disease
• Congenital hypothyroidism
• Acquired hypothyroidism

Question 1: I’d never heard of thyroid problems in children until my child was diagnosed with hypothyroidism. Are thyroid problems increasing in children?

Answer: It depends on the specific thyroid problem to which you are referring.

Acquired hypothyroidism is a maybe. Autoimmune thyroid disease also known as Hashimoto disease is the leading cause of acquired hypothyroidism in adults. Research studies have definitely shown a worldwide increase of Hashimoto disease in adults, and there is likely also an increase in children.

The most scientifically validated reason for the worldwide increase in Hashimoto disease is improved iodine intake. Iodine is a very important mineral that is necessary for thyroid hormone production. Lack of the mineral remains a common cause in certain third-world areas of the world for a specific form of hypothyroidism termed endemic goiter. For some reason, however, the improved supplementing of iodine may be a culprit in triggering autoimmune thyroid disease in adults.

Congenital hypothyroidism is a yes. Researchers are trying to understand the observed increase in incidence of congenital hypothyroidism. The historic quoted incidence is roughly 1 in every 4000 new births. Current trends are showing higher incidence at roughly 1 in every 2500 births. There are a number of different theories about why this is seen. One factor is the increased number of surviving premature babies. Many of these babies have a thyroid problem termed transient hypothyroidism during their early life requiring treatment with thyroid hormone and are counted in the same category as congenital hypothyroidism .

An increase in the Hispanic population is another factor theorized to account for the change. There is a higher incidence overall in Hispanics of congenital hypothyroidism which may be influencing the incidence numbers.

Radioactive iodine exposure during pregnancy has definite negative impact on fetal thyroid activity, and exposure must be avoided. Concern was sparked in 2012 with a controversial study published suggesting a link between the Fukushima nuclear disaster and a spike in the number of cases of congenital hypothyroidism seen in U.S. Pacific Coast states.

Question 2: Why did my child develop Hashimoto disease?

Answer: Medical science doesn’t know the precise reason(s) for autoimmune thyroid disease which includes Hashimoto thyroiditis. We believe that there are factors both genetic and environmental involved.

Research suggests that genetics underlies about 70 percent of the susceptibility in Hashimoto disease which is why a family history of thyroid problems is often seen in children with Hashimoto disease. Of the various genes identified with risk for Hashimoto disease, the HLA-DR gene association is best known. The gene location is known most widely for its importance in organ transplant

Environmental triggers are the great unknown not only in Hashimoto disease but also in many other autoimmune conditions. Infection triggers seem to be the most likely candidates in this process. Hepatitis C infection and Rubella (German measles) are two infections with known links to autoimmune thyroid disease. In addition to known harmful infections, possible impact of disturbance in beneficial intestinal bacteria as a trigger in autoimmune thyroid disease as well as other autoimmune conditions is being investigated.

Smoking in adults has been linked to increased risk for autoimmune thyroid disease and is another of the many reasons to avoid smoking. More controversial theories include environmental pollutants role in autoimmune thyroid disease. PCBs and PBDEs have been linked to increased risk in some research studies mainly in animals.

Radiation exposure is a known risk in many thyroid problems in both adults and children. Childhood thyroid cancer rates increased drastically after the Chernobyl disaster. Both autoimmune thyroid disease and thyroid cancer risk are increased in cancer survivors who received radiation treatment. Fortunately, routine medical radiation exposure doesn’t appear to be linked to higher risk of thyroid damage.

Question 3: Can diet help prevent or improve thyroid problems?

Answer: Yes, to some extent

The mineral iodine is essential for proper thyroid hormone production. Fortunately, in the U.S., lack of iodine is extremely uncommon. Seafood and dairy are both good sources of iodine, and iodine is added to salt as well. Risk of iodine deficiency is very low in in children who eat a healthy, balanced diet and have no digestive problems.

Goitrogens are naturally occurring chemicals in certain vegetables such as cauliflower that can interfere with function of the thyroid. Overall, the health benefits of goitrogen-containing vegetables probably outweigh the risks to the thyroid when eaten in a balanced manner.

Question 4: What can I do to help others in my family or family friends be more aware of thyroid problems?

Answer: Awareness is the key.

Awareness of symptoms of thyroid disease is important when there is a family history of thyroid problems. An exam of the thyroid and a blood testing can uncover thyroid problems. Sharing the story of your child’s medical history with concerned friends can also help.

I hope these answers help those of you who have a child diagnosed with a thyroid issue. If you still have questions or need more help, please contact your primary care doctor or the Cook Children’s Endocrinology division.

I see a sizeable number of children and teens in my practice with diagnosed thyroid problems. I also care for a number of patients whose parents or doctors have referred to me for concerns about the possibility of thyroid disease. A large block of the time I spend with these children and their families during clinic visits involves education about the thyroid gland and its importance on childhood health.

I’d like to help those who might be in search of credible information on this topic by sharing basic, sound medical facts and data that I believe can be of good use to parents or caregivers in better understanding thyroid function and problems in children.

What is the thyroid gland and what does it do?

The thyroid is a small, butterfly-shaped gland, weighing less than an ounce in an adult. It is located in the lower, middle, front part of the neck and is regulated by the small, pituitary gland located deep within the brain. The thyroid’s main function is to produce thyroid hormone which consists of a combination of protein and the mineral iodine. This super hormone acts very deeply within the body binding onto the DNA in cells throughout to regulate metabolism, growth and body temperature. The thyroid has a stronghold on how the body uses energy and can speed up or slow down your metabolism.

The metabolic effects of thyroid hormone are multiplied in children. It is an essential partner of growth hormone in aiding height growth in children and serves a vital role in regulating the start and progress of puberty. Too little or too much of this essential hormone released into the body can wreak havoc causing serious negative effects on the health of a child. The two main types of thyroid disease are called hypothyroidism and hyperthyroidism.

What is hypothyroidism and what causes it?

Hypothyroidism is a lack of enough thyroid hormone production. A number of problems occur with lack of thyroid hormone and the symptoms and their severity correlate to the level at which production has been depleted.

A big divide, based on age, exists in what is the underlying cause of hypothyroidism. Congenital hypothyroidism refers to a specific type that is diagnosed in newborn infants in the first one to two months of life. This serious condition occurs in roughly 1 in every 4,000 newborn babies and can have devastating effects if not detected and treated within the first 2-3 weeks after birth. A hypothyroid infant is unusually quiet and inactive, with poor appetite and sleeps for excessively long periods. In the past, the consequences of untreated congenital hypothyroidism developed into lifelong mental retardation. Thankfully, state mandated newborn screening programs that began in the 1970s now routinely test the blood of all newborns for evidence of congenital hypothyroidism as well as other metabolic diseases. As long as this test is administered, there is little risk of missing its presence.

Acquired hypothyroidism refers to hypothyroidism that begins anytime after the newborn period which encompasses the first six months of life. Whereas the expected number of infants born each year with congenital hypothyroidism is well-known worldwide, the expected numbers of children and teens with hypothyroidism is not well known as symptoms are often misdiagnosed. It certainly seems the case when the most recent study that attempted to determine the number of children and teens with hypothyroidism showed the number at less than 1%.

Iodine is an important mineral in the production of thyroid hormone. Lack of dietary iodine remains a cause of this malady around the globe. In the U.S. and many parts of the world, fortification of salt and foods with iodine has made this deficiency a very unlikely cause of hypothyroidism. The most common reason for its occurrence in the U.S. is autoimmune thyroid disease (also known as Hashimoto disease). This condition is still a mystery in terms of what causes the body’s immune system to attack its thyroid gland. We do know that it runs in families with links to certain inherited genes increasing the risk of passing it on to future generations. In addition, triggers such as infections, stress, or pregnancy might activate this condition in susceptible people. In children, it tends to occur in girls more often than boys, and the peak in occurrence is in the mid-teenage years.

While it is rare, problems can occur when the pituitary gland leads the thyroid astray. This improper regulation of thyroid function can cause a subtle form of hypothyroidism known as central hypothyroidism.

What are symptoms of hypothyroidism and how is it diagnosed?

It is important to understand that a correct diagnosis of hypothyroidism should be made by exploring both physical symptoms as well as through targeted blood testing. As a pediatric endocrinologist at Cook Children’s, I focus heavily on the impacting that thyroid hormone has on a child’s growth as a key finding. Weight gain does occur in hypothyroidism, but very rarely leads to severe levels of obesity. Some of the more common symptoms of hypothyroidism are summarized in the table below.

• Short stature and/or abnormally slow height growthOverweight, weight gain
• Dry skin
• Cold intolerance – feeling cold all the time
• Enlargement of the thyroid gland (goiter)
• Fatigue, excessive sleepiness
• Constipation
• Problems with puberty
  • Delayed puberty
  • No menstrual periods or irregular menstrual periods in girls
  • Early puberty (rare)
• Headaches

Blood test measures of thyroid hormone (known as T4 or free T4) and the pituitary hormone thyroid stimulating hormone (known as TSH) assist in the diagnosis of hypothyroidism. The cardinal finding on blood testing is a high TSH and low thyroid hormone. An ultrasound of the thyroid gland as well as special nuclear medicine scans is sometimes quite helpful in both making the diagnosis and determining an underlying cause of hypothyroidism.

What is hyperthyroidism and what causes it?

Hyperthyroidism, by contrast, is a condition where too much thyroid hormone is released into the body upsetting the balance of the metabolism and causing devastating effects on well being. Thankfully, this condition is rare in children, occurring in less than 1 percent. In its early stages, symptoms may be subtle so unfortunately many children are in advanced stages upon diagnosis. Hyperthryoidism in its most severe form can be life-threatening.

The most common cause of hyperthyroidism is Graves’ disease which is an autoimmune condition similar to autoimmune thyroid disease with the exception that the immune system is stimulating the thyroid to over-produce thyroid hormone. This condition remains a mystery as well to the medical world in terms of what causes it to happen. We do know that like autoimmune thyroid disease, it does run in families.

What are symptoms of hyperthyroidism and how is it diagnosed?

Because of the seriousness of hyperthyroidism, rapid recognition is important. Exophthalmos (bulging of the eyes), a condition affecting the late actor Marty Feldman, is the most recognized physical sign of Graves’ disease. Some of the more common symptoms of hyperthyroidism are summarized in the table below.

• Weight loss
• Increased appetite
• Heat intolerance – feeling hot all the time
• Fatigue, muscle tiredness
• Enlargement of the thyroid (goiter)
• Rapid heart rate, high blood pressure
• Excessive sweating
• Tremor (shakiness) in hands
• Irritability, problems concentrating
  • Poor school performance
• Bulging eyes
• Irregular menstrual periods in girls

Blood test measures of thyroid hormone (known as T4 or free T4) and the pituitary hormone thyroid stimulating hormone (known as TSH) assist in the diagnosis of hyperthyroidism. Converse to hypothyroidism, we expect to find blood testing measures with a very low TSH and high thyroid hormone level. A nuclear medicine scan is often times very useful in evaluation of cases of hyperthyroidism. Additionally, an ultrasound test might be prescribed.

How are hypothyroidism and hyperthyroidism treated?

Treatment of hypothyroidism requires daily tablets of thyroid hormone (levothyroxine, synthroid, levoxyl, and levothroid) combined with scheduled return visits to see the pediatric endocrinologist who will monitor progress via physical exam and blood testing. Congenital hypothyroidism is permanent and requires lifelong treatment whereas acquired hypothyroidism, however, is not always permanent.

Treatment of hyperthyroidism is far more complex than the treatment of hypothyroidism and involves the use of a thyroid suppressing medication in the early phase of therapy. Due to the long-term mixed outlook for a cure of Graves’ disease, many sufferers must have their thyroid destroyed either by radioactive iodine treatment or surgical removal. Once the thyroid is destroyed, these individuals must remain on lifelong thyroid replacement like those with hypothyroidism.

Conclusion

It is my hope that by sharing some important medical facts and data you have been enlightened about this powerful gland. Furthermore, I hope it will enable parents and caregivers to recognize symptoms of a possible thyroid condition in a child and better understand the proper treatment plan.

Because societal factors such as TV, school, friends and the Internet can strongly influence a young child’s behaviors, it’s important that parents help young ones map out and focus on a few simple, healthy resolutions that can later translate into positive behaviors as children grow and develop.

“Making New Year’s resolutions can be very beneficial for children because it teaches them the importance of setting goals and following through,” said Lizy Varughese, M.D., a pediatrician with Cook Children’s in Lewisville. “Not only can goals be applied to a child’s eating habits and physical activities, but they also teach important life lessons about the benefits of planning ahead and the success that comes from it.”

While it may be tempting as a parent to jump ahead and make a list of New Year’s resolutions for your child rather than waiting for them to develop a list on their own, empowering your kids to creatively embrace this time-honored tradition can be filled with good times and great memories.

Encourage children to start with a list of broader, bigger goals such as eating less junk food, picking up their toys or making better grades. No matter how far-fetched the goals may seem at first glance, parents should stay open-minded and flexible, resisting the urge to criticize their child’s resolutions. Remember, keeping the mood light and enthusiastic makes goal setting seem less like work and more like fun.

From there, Dr. Varughese suggests children break down their resolutions into small bites by using journaling as a method to solidify goals.

“Begin the new year by writing down specific goals for eating and participating in sports and exercise activities,” Dr. Varughese said. “Children are more likely to complete a task if it’s written down and there is accountability for their progress. It’s also important to be flexible so the parent can help kids for a more attainable goal if a particular goal is not met or seems difficult for the child.”

About the source

Dr. Varughese attended Texas A&M University and received a B.S. in Biomedical Sciences. She attended medical school at the University of Texas Health Science Center in Houston, Texas and completed her residency at Stony Brook University Hospital, Long Island, New York. She was then appointed Clinical Professor of Pediatrics from 2005-2006. After that, she joined a private practice in New Jersey for five years. She moved back to her hometown of Dallas, Texas, and joined Cook Children's Physician Network in Lewisville in 2013.

She is married to Dr. Shane Varughese and has two children, Noah and Sarah. Dr. Varughese enjoys photography, cooking, and church activities. Her passion in life is taking care of children and educating families on preventative care and battling childhood obesity.

I am shocked at the number of patients we see where bad posture plays a role in their pain and physical limitations. Whether it be sports injuries, overuse injuries or postural dysfunction, the trend is younger patients are starting to report more injuries. I see technology driving our kids to be more active in an online space than it does in a physical space.

So I would like to take a minute to address how to get our kids active again, but not just any activity. I want to talk about core activity.

What is the core?

The core is a muscular system that works synergistically to provide support and power generation to the body in all positions and with every activity. Think of a soda can to explain the core. The can has a front (deep abdominals), back (multifidi muscles), top (diaphragm muscle) and bottom (pelvic floor muscles). And just like the can, as long as no one pokes a hole in it, it is very strong. As soon as someone creates a weak spot in the can/core, it can easily be crushed.

When do you use your core?

The core should be used during all of life’s daily tasks, but we lose this ability as children when no one teaches us how to use the core during modern-day tasks such as playing on your Ipad or texting your friends.

How do I train the core of a child?

Return to the basics. Too often we see young athletes who have been given formal instruction in how to pitch a ball or perform a round-off back handspring, but little or no training on what it means to use their core functionally. Schools have our kids doing pushups before teaching how to plank. Physical therapy can definitely help patients of all ages with core training, but there are also some things you can do at home. For really young children (3-6yrs) this can mean returning to games that require you to hold positions, such as Twister or Untying the Knot. For slightly older children (7-12yrs), yoga or even just plank holds (3 positions) help build core strength and endurance. For our teens and young adults more formalized training for power generation and power transfer using the core can be very beneficial.

What does a strong core mean?

For your child a strong core means improved performance in their activities whether that is football, dance or band. It can mean no pain when sitting in class or when trying to be active with peers.

For parents, a strong core means fewer complaints from your child, better posture, and less risk of injury while your child is performing their activities.

If you or your child would like help with core training, please contact your physician and seek a referral to Cook Children’s Physical Therapy Department.

More SPORTS resources related to this topic:

• Top 10 questions parents have about sport injuries
• Young athlete's injury prevention guide

Unfortunately, for many children, allergies are simply a way of life in Texas. Usually, allergies occur in kids beginning at the age 2 years and older.

Physicians don’t know why some children suffer reactions when exposed to allergens such as pollen, ragweed and mold that can cause allergic symptoms, while others experience no problems at all.

Sometimes parents aren’t sure if their child has a cold or allergies. Some say you can tell by looking at the mucus. That’s not really the case. The only way to tell for sure is by seeing your pediatrician. But if your child develops cold-like symptoms at the same time every year (now for instance), he or she probably suffer from seasonal allergies.

Symptoms of allergies are often times similar to a cold – sneezing, itchy nose and/or throat, nasal congestion, clear, runny nose and coughing. With a cold, the symptoms run its course over a matter of days. With an allergy, the symptoms last as long as the child is exposed to allergens.

Parents should be especially careful that their child doesn’t develop wheezing and/or shortness of breath. That may mean your child’s allergies have progressed into asthma.

It’s possible to relieve allergy symptoms by eliminating or reducing a child’s exposure to allergens. A key, as you hear so often with colds and flu, is for your child to wash his or her hands often. Also, children should change clothing and shower after playing outside. Please don’t let your child mow the lawn during this time of year if they suffer from allergies.

Educating your child early about what causes allergic reactions and allergy symptoms is a crucial step in helping your child reduce or prevent allergic reactions.

Sometimes no matter how much you try to prevent allergy symptoms in your child, they still occur. Fortunately, various treatments are available to help your child when an allergic reaction happens, including:

• Over-the-counter medications. Some decongestants, antihistamines and nasal sprays can be purchased without a prescription. But even if you are thinking about picking up something from the drug store, please do not do so without contacting your pediatrician.
• Prescription medications. Those with more severe allergies might need stronger versions of over-the-counter medications prescribed by their pediatrician.
• Immunotherapy. Also known as allergy shots, these injections of allergens into the body help patients build tolerance to help relieve symptoms.

Eventually, your child might grow out of his or her allergy. However, until he or she does, talk to a pediatrician or allergy specialist to determine the best treatment option for your child.

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

In-toeing

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

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

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

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

Bowlegged

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

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

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

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

About the author

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

I know you are at your wits end. You are tired of getting the phone calls from teachers. You are scared that every time the day care calls, it could be the call saying that your child needs to be picked up and never come back. Believe me, I want to help … but medication does not fix everything.

The primary and best, first treatments for Attention Deficit Hyperactivity Disorder (ADHD) are not medications.

If your child is hyperactive, he or she needs structure and a consistent behavior plan that is applied across all caregivers. This means that mom and dad, grandma and grandpa and the school need to all be on the same page about what is acceptable behavior and what is not. Reward good behavior, be consistent in responding to bad behavior.

For children who have problems with attention, medication might help them remember to get their homework home or turn it in on time or help them get their chores done at home. It might help, but many times their bad habits are so entrenched that medication won’t touch it until you put a system in place that will help them organize their day. A system of folders for homework, listing chores with checkboxes and other simple fixes can go a long way and will likely be necessary whether your child is on medication or not.

Anytime I make the diagnosis of ADHD and we move toward using medication, there is one message I want my parents to hear loud and clear: “The goal of using ADHD medication is not perfection.”

We are not looking to get your child to be the citizen of the year … at least not with medication. The goal of medication is to help your parenting strategies to be more effective.

Here are some symptoms that are not necessarily a result of your child having ADHD: being disrespectful (especially talking back), physically violent or being mean to other children. Medication is not likely to improve any of these behaviors. Yet, many of these are the behaviors you specifically want me to help with.

However, when these symptoms are present or when things are not improving the way we would like, it is important to include counseling in the treatment regimen for ADHD. Counselors can help children understand what is going on and give them strategies to cope. Perhaps more importantly, they can help you, as the parent, better understand and manage your child’s ADHD and other behavioral problems.

I can’t “fix” your child with medication but together we can help them.

Sincerely,

Justin Smith, M.D.

Dear person who think that ADHD does not exist,

I get it. Most likely you’re reacting to one of the following:

1.It seems like everyone you know is putting their kids on medications.

2.A teacher recommended that your child be put on medication even when you think they are normal (and they are).

3.You think that ADHD is a result of bad parenting.

You have a good reason to be concerned. But do not overreact and make the statement that ADHD is not real or smugly share the article, “Inventor of ADHD on his deathbed says that ADHD is a fictitious disease.” What he actually said was ADHD is over-diagnosed and doctors should investigate all the psychological and social reasons why the child is struggling before prescribing medication.

What I see in practice is this:

1.Parents who want a quick fix for everything (see above).

2.Parents who are desperate to help but just don’t know how.

3.Parents who are desperate to help, have tried everything and are coming to me as a last resort.

Some of my most difficult patients are #1. They get very angry when I will not prescribe medication and recommend counseling instead.

Some of my favorite patients are #2 and #3.

Most of these kids are not “bad kids.” They are struggling. They can be challenging to manage in the classroom and in the home. I am often exhausted after just a 30-minute consultation with them and their families; I can’t imagine what the parents are feeling.

My first discussion is generally walking through the non-medical tools we can use for ADHD. I can plug the families in with a good counselor. I can talk about what medication can do for their child, as well as the possible side effects, but I never prescribe medication as a first treatment.

The satisfaction that comes from seeing a child, who is struggling in school and at home, respond to either non-medical or medical treatment is amazing. I do not care what brings about the results, the goal is results.

So, please stop saying ADHD doesn’t exist. Stop sharing articles without knowing the true story. It’s insulting to me but, most importantly, it’s insulting to parents who are simply working hard to do the best for their children.

Sincerely,

Justin Smith, M.D.

When first learning to walk, it’s normal for children to walk on their toes or the balls of their feet. By 18 to 24 months, children should be able to walk flat on their feet. If toe walking persists, it can cause excessive muscle tightness, pain and weakness. As a result, children may have difficulty running, increased falls and decreased coordination. It may also be a cause for concern for a parent or teacher.

Toe walking can have several causes:

1.Hypersensitivity – children with hypersensitivity dislike the feeling of certain sensations such as walking barefoot. To avoid textures they dislike, they may walk on their toes.

2.Hyposensitivity – children with hyposensitivity have a difficult time receiving sensory input. They may walk on their toes to compress the bones at the ankle joint and help the brain figure out where their body is in space (proprioception).

3.Positional – if your baby spent a lot of time on their toes in a walker or bouncer, they may have developed muscle tightness. This may cause your child to continue to walk on their toes as he or she gets older.

4.Underlying neurological problem – this may cause increased muscle tone or weakness that leads to toe walking compensation. Children diagnosed with cerebral palsy, muscular dystrophy or autism are more likely to walk on their toes.

5.Idiopathic – this means there is an unknown cause. Your child may have developed a habit that led to muscle tightness or shortening or it may be hereditary.

When should you be worried about your children’s toe walking?

1. If they are unable to put their foot in a flat position when standing or walking. This indicates muscle tightness or a shortened muscle in your child’s calves.

2.If they only walk on their toes on certain surfaces or when their shoes are off. Your child may have trouble tolerating certain sensations and rise up on his or her toes to minimize contact with that surface.

3.If they suddenly start to walk on their toes or if they have changes in their bowel and bladder function, they may have an underlying condition causing the toe walking.

4.If they frequently fall or have trouble running and always walk on their toes.

5.If they are older than 3 and/or you notice any of the above problems.

Talk to your child’s physician if you notice any of the above issues or are concerned about his or her toe walking. The doctor may monitor your children’s walking; refer you to a specialist or physical therapist for further examination.

Profession

Physical therapists are highly educated professionals trained to identify problems with movement and function of the human body. The physical therapists at Cook Children’s have either doctorate or master level education. Our physical therapists and physical therapist assistants are constantly advancing their training through continuing education and advanced certifications. We collaborate regularly with your doctors to ensure the highest level and quality of care.

Together, physical therapists and physical therapist assistants work to restore and improve normal body motion. We educate and empower our patients and families to be active participants in their recovery process. We also instruct on future injury prevention. The American Physical Therapy Association’s vision is “transforming society by optimizing movement to improve the human experience.” At Cook Children’s, our physical therapists and physical therapist assistants really do transform lives.

Patients

Our physical therapists see children for many different reasons. Some examples might include:

• Complaints of knee pain while running or back pain from sitting too long.
• Shoulder pain from playing a musical instrument.
• A difficult time recovering from surgery.
• Recovering from a broken bone.
• Growing pains after a quick growth spurt.
• Lack of endurance after a long hospital stay.

Physical therapy can help with all of these things and more. Physical therapists look to find what is causing the pain or difficulty. We then guide the recovery process and help restore normal function through the use of manual (hands-on) therapy, stretching, strengthening and neuromuscular re-education.

Cook Children’s

At Cook Children’s, our SPORTS (Sport Performance Orthopedic Rehab Team Specialists) physical therapists and physical therapist assistants have experience with pediatric specific problems. We recognize that children are unique and not just “small adults.” Kids require specialized care. We take time to perform focused evaluations and customize each child’s treatment. We seek patient and family input in the entire recovery process. We understand the importance of one-on-one time with your child to give them the attention they deserve.

Pain is never normal, and pain from activity should not be ignored. If you think your child may benefit from physical therapy, talk to your doctor or contact our department.

About the author

Melissa Bro, PT, DPT, is a physical therapist for the Cook Children's SPORTS Rehab program. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind. As a part of Cook Children's integrated pediatric health care system, our patients have access to a multitude of pediatric specialty areas with board certified doctors, as well as laboratory services, nutritional consultations and sports medicine counseling.

Patients benefit from this integrated system because it allows our staff to use all of the system's resources during treatment. It also improves communication between the various departments whose physicians are focused on caring for children and adolescents.

Paralysis

It may surprise you to know that there are more than 100 known varieties of non-polio enteroviruses in the world. All of these different types of enteroviruses can cause confusion and panic.

The non-polio enterovirus strains range from the common cold to meningitis. You may have noticed those strains are non-polio enteroviruses, which means that yes, an example of an enterovirus strain that can cause paralysis is polio.

Approximately 1 in 200 infections with polio will cause paralysis. Other enterovirus strains can cause similar symptoms, but do so much less frequently.

There have been a few reports stating that cases of EVD68 have possibly been associated with paralysis, most notably 10 cases in Colorado, 5 cases in California and now a case identified in Dallas. The most common locations for weakness have been the upper arms and hips.

But much work still needs to be done to decide what role EVD68 played in the paralysis. In a published Morbidity and Mortality Weekly Report last week, only four of the 10 children in Colorado tested positive for EVD68.

Investigation is ongoing to determine if these cases were actually caused by the virus. Those patients affected will be undergoing extensive physical therapy to regain function.

Death

The CDC released a report this week that announced there have been five deaths in which enterovirus D68 has been associated. We currently don't know the details of two of these cases. We do not know where the patients lived, their ages or if they had other medical conditions. These would all be important factors in determining the cause of death. The fourth patient was a 10-year old girl from Rhode Island who tested positive for enterovirus D68, but also for a bacteria in her blood stream called Staphylococcus aureus. Staph aureus infections are known to be dangerous, often progressing rapidly, and are resistant to many antibiotics.

Another case reported today described a boy who after an unexplained death was found to be positive for enterovirus D68. Prior to his death, he showed no signs or symptoms of upper respiratory infection, other than a case of pink eye which was proven not to be connected to EVD68. Because of these complicating factors, it is unclear what role EVD68 played in these deaths.

It is entirely possible that the others had similar stories with multiple infections or that they had other chronic health conditions which put them at risk for complications. At this point, I continue to believe that, in almost all children, enterovirus D68 causes mild runny nose and cough and that our biggest complication is the progression towards wheezing. Again, there are not many details out surrounding the deaths, but we felt it was important to update you on the situation given that we have stated all along that there had been no deaths clinically caused only by enterovirus D68. We will follow along and update you as soon as we know more.

Enterovirus D68 peaks in late summer and early fall so I expect that the number of cases to begin dropping soon (if it is not already on the way down). Other regions that experienced earlier outbreaks have already seen the end…they are doing what we will be doing soon, preparing for flu.

Our previous articles on Enterovirus D68:

• Health alert: What is Enterovirus D68?
• Enterovirus D68: What you need to know?

More and more young athletes are experiencing pain while participating in sports. Some have traumatic injuries like sprained ankles and torn ligaments, while others experience overuse injuries like low back pain and tennis elbow. All of these athletes can suffer from significant pain on and off the field. No athlete is exempt.

All sports require a baseline of flexibility, strength, stability and endurance, as well as a time of rest between activities to safely perform the required activities. With the rise in athlete specialization in a single sport, played year-round, we have seen an increase in injuries and pain in these young athletes. These young athletes are also starting at a much younger age. Many more stress injuries have resulted, such as ligament tears, shoulder strains, stress fractures and back strains. In addition, there has been a rise in chronic pain (pain lasting longer than 3 months) among younger athletes. I never heard of a teenager with chronic pain when I was growing up! How do we deal with this growing population? “No pain, no gain?” “Just grin and bear it, the pain will go away?” “Slap some ice on it and get back out there?” There needs to be a better way. Fortunately, there is!

The best plan is obviously prevention. However, for the purpose of this article, we will assume the athlete is already experiencing pain. In this case, there are several things to be done. Pain should not be ignored! Our body is trying to tell us there is something wrong. Acute pain should be addressed with the gold standard: Rest, Ice, Compression and Elevation (RICE). We are typically willing to ice, compress and elevate, but many times rest is not followed properly. “He’s our best pitcher!” “If she’s not playing, we will lose our chance to make it past district!” “I really want to play, so I won’t tell coach about the pain.” If we do not allow the tissue to heal properly, the tissue can become weaker and will be at a higher risk for being injured again, maybe even worse than the first time. Now that pain is being addressed properly, what do we do? Now is the time to work on the basics again:

Flexibility: Muscular flexibility is vital. Tight muscles are much more prone to injury than flexible muscles. Tight muscles can be damaged during high velocity movements. Also, tight muscles can alter how our joints move, making other structures more prone to injury, such as ligaments, joints and bones.

Strength: Muscular strength is also very important. Strong muscles allow our bodies to perform the tasks that we put them through. Strong muscles also allow greater protection from injury.

Balance/control: And don’t forget about core strength! This is maybe the most missed strengthening component in most sports and possibly the most important muscle group for any sport! A weak core places an increased stress on other body parts and increases our risk for injury. How can we expect a soccer player to avoid ankle or knee injuries if he/she can’t even balance on one foot?

Return-to-sport: If the athlete’s strength is improving and the pain is under control, we can work on sport specific activities. This is where a physical therapist or athletic trainer with a strong knowledge of sports performance is vital. Coaches properly trained in technique can do this as well as long as they are able to spend dedicated one-on-one time with the athlete.

If pain from a recent injury is not properly dealt with, or the injury leaves the athlete with pain that lasts more than 3 months, chronic pain may develop. Now our focus as a physical therapist is more on return of function versus the pain itself. Seeing a physician that specializes in pain, such as Dr. Artee Gandhi and Dr. Aimee McAnally at Cook Children’s, can be beneficial as well. The physician could prescribe or recommend one or more of the following treatments in conjunction with the physical therapy:

1. Medications to reduce pain or inflammation while working on regaining function.

2. Biofeedback therapy with a psychotherapist, such as Wayne Martin, LCSW, psychophysiologist at Cook Children’s, to help the athlete learn how to relax muscles, reduce stress and visualize performance for relief of pain and return to normal activities.

3. Pediatric massage therapy to address tension and/or increased sensation.

4. Acupuncture therapy to help control pain.

Related links:

• Football injury prevention
• Baseball injury prevention
• Softball injury prevention
• Basketball injury prevention
• Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• Tee-ball injury prevention
• Swimming injury prevention
• Tennis injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Dance injury prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries
• Pain that won't go away

http://www.slate.com/articles/podcasts/education/2013/11/schooled_podcast_is_giftedness_real.html

Your child is gifted because every child is gifted.

But wait you say, my kid struggles in school and barely gets by. I even tried to get them in the gifted program at school but they didn't get in.

Gifted education generally focuses on a select few students to give them a unique educational experience in an effort to foster their unique intellect or creativity. Students can be identified based on several criteria, but usually center upon some combination of the following: IQ testing, achievement or end of year testing, parent and teacher evaluations. The parent and teacher evaluations are based upon a child's ability to show behaviors that are consistent with giftedness - creative thinking and intelligence, early language development and deep exploration of particular topics are just a few of the criteria that might be used.

Gifted curriculum tends to be more focused to the individual child's interests and abilities and tends to allow for more creativity and differentiation based on ability. There is often a component of an affective (teaching about emotions) and cognitive component (teaching children how to think rather than what to think).

Some educators have questioned the paradigm that we should identify students as either gifted or not and have begun instead to focus on particular gifted behaviors that any child might possess. A group in North Carolina set out to see what happened if they treated all kids as if they were gifted.

The Study

The program was called Project Bright IDEA and was run in low-performing and low socioeconomic school districts and included about 10,000 Kindergarten and first graders. The two researchers, William "Sandy" Darity and Margaret Gayle, set out to see what would happen if all the teachers in these schools were taught strategies for gifted education and began to implement them throughout the school.

The Results

After three years in the project, 15-20 percent of third graders in the schools were identified as gifted compared with 10 percent of control schools. Of note, in the year prior to the change in educational styles (2004), in the Title 1 schools involved, there were no third graders identified as gifted. The researchers state that by changing your outlook on students (thinking about and treating them like they are gifted), you are actually causing more of them to be identified as gifted.

One of the biggest things noted by the educators in the schools is how it changes the way they think about their students. They begin to change their own expectations and beliefs about what the students are capable of. Subsequently, many of the students seem to rise to those expectations.

The Point

It would be great if we could adopt the changes that were made in these schools across the board, but that will be difficult and expensive. I'm skeptical of how they are going to keep up the extra training necessarily to sustain these programs even on the scale that they have done them. However, we can make these changes in our homes in a way that nurtures gifted behaviors in our own homes.

Here are some suggestions on how to do this based upon some of the tenets of gifted educations:

1. Affective curriculum (emotions and interpersonal skills) - Read books over and over again. But don't read them the same way. Stop and ask questions. Ask how a particular character in the book might be feeling and why. Have your child make a face that matches how that character is feeling. It makes for some pretty funny selfies BTW and you can use the selfies to reteach later.

2. Acceleration - There's no reason that your child has to learn everything at the same pace or at some expected pace for their age. Your child might not understand numbers at all but might be reading well above his or her age level. You can't completely ignore math, but you also can't completely ignore reading just because it is one of their strengths. Find them a computer program that focuses on their strength or find a teacher that teaches students older than them that is willing to work and challenge them to advance in their strengths. You'll be surprised where it will take them and this area of success will give them confidence to tackle anything that is put in front of them.

3. Differentiation (provide your child with different opportunities and ways for learning new things) - Find out what is available in your area that gives your child different ways to learn new things. Many children learn best by doing so classes and instruction that involves hands-on activities can be very helpful. This doesn't have to be expensive; libraries, the zoo and many other low cost options offer simple, brief learning opportunities that will stick with your child for a long time.

4. Foster their interests  -If you child likes dinosaurs, let them learn through dinosaurs. Think about all the things you can do with dinosaurs along the way ... Learn the alphabet by writing letters on plastic dinosaurs: Can you hand me the dinosaur with the A on it? Later, can you hand me the dinosaur with the letter that says, "Ahh?" You can count dinosaurs. You can add up two piles of dinosaurs. You can read books about dinosaurs. You can go to museums with dinosaur exhibits. You can watch movies about dinosaurs (within reason). You can learn about fossils and herbivores vs carnivores ... I could keep going, but I won't because I think you get the point. This is the biggest thing I can give you to take away that gifted educators do well. They capitalize on the child's interest to push them further than anyone thinks they can go.

Let me give you an example: My 4 year old would look at flash cards (all by himself) for hours when he was 2. He would see the flash cards on the $1 section at a store and beg for a set of number cards (not to mention we already had six at home). My 2 year old won't touch flash cards. If he even sees the 4 year old with a set we start hearing, "I don't have to." Or my favorite old ones, "Don't want it, do cards!!" What my 2year old will do is count if he's throwing a ball. With a little help, he'll count to 100 every single time he throws the ball back and forth with dad. So, guess what? We do a lot of throwing and catching in our house. 100s and 100s of times (literally).

With generous oversimplification, the study says that by doing these things with your children, they are more likely to be identified as gifted when the time comes ... but that's not the point. The point is that you are using some of the best evidence and teaching strategies that help your child learn and develop well.

“He snores just like his daddy.”

Are these things that you have said about your child? If so, you may want to ask your doctor if your child might have sleep apnea. Because pediatricians often forget to ask about snoring during checkups, it is not uncommon for the diagnosis of sleep apnea to be significantly delayed or even missed altogether.

It is probably more common than you think. I spoke with Natalie Roberge, M.D., an ENT (ear, nose and throat) doctor with Cook Children’s, who estimates that obstructive sleep apnea occurs in 1-5 percent of children.

Snoring alone does not make the diagnosis of sleep apnea. Here are some of the other symptoms that could be present:

1. Pauses in breathing. (If your child snores, it might be worth listening to them occasionally to see if you hear these).

2. Bed-wetting.

3. Mouth breathing (at night or during the day).

4. Daytime sleepiness.

After discussing symptoms and examining your child, the doctor may recommend a sleep study. During a sleep study, a child will be observed for many different characteristics of their sleep including: apnea, excessive movement and level of oxygen in the blood during sleep.

There are many causes of sleep apnea but according to Dr. Roberge, “The most common cause in children is large tonsils and adenoids. The next most common, potentially treatable cause is obesity. Other causes include craniofacial, genetic and neurologic disorders.” If your child has any of these risk factors, it is important to pay closer attention to his or her snoring and quality of sleep.

Sleep apnea is treated differently depending on the cause of the apnea. If large tonsils are the problem, the pediatrician and ENT might recommend having them removed. If the child is obese, addressing healthy lifestyle and decreasing excess weight may help to improve the apnea.

It is important to address apnea for many reasons. You can find many different conditions associated with sleep apnea such as bed-wetting, ADHD and other behavioral problems, as well as hypertension and other cardiovascular problems. The consequences of untreated sleep apnea can be missed because they are common in many children.

Despite the fact that it might be fun to tease your child about his or her snoring, it is important that we consider the serious consequences of snoring and sleep apnea. If you have questions, please discuss them with your pediatrician and they can recommend a referral to an ENT if it is necessary.

About our sleep lab

The staff in our Ear, Nose and Throat Center collaborates with other specialties within Cook Children's system to treat and rehabilitate children with speech and hearing disorders. At Cook Children's, we can diagnose and treat many ear, nose and throat conditions. Our expert pediatric specialists have access to many services within Cook Children's system to provide your child with the best care.

About the author

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

My family and I LOVE, LOVE, LOVE the state fair. We go every year and get our corn dog and our roasted corn. We see the dog show, and we watch the acrobats. The sights and sounds are the same as they were 20 plus years ago, and I hope to make the same happy memories for my own kids.

How do we enjoy the fair without compromising the healthy lifestyle that we enjoy? Here are some tips from our staff members and from the nutrition department at Cook Children’s.

1. Start your day off with a healthy well balanced meal at home. Do not show up hungry!
2. Bring waters and healthy snacks with you (nuts and dried fruit travel well). This will also help your ticketbook!
3. Allow your child to pick one treat.
4. If he or she (or you) can’t decide – pick a few treats to share – 1 or 2 bites of a fried Oreo^® is probably enough to satisfy even the worst sweet tooth.
5. Pick healthy alternatives to the fried foods: the roasted corn (a must), smoked turkey leg, fruit kabobs, and chicken kabobs.
6. The fairgrounds are huge! Walk a lot. Walk off those calories that you consume!

Special occasions like The State Fair of Texas include traditional foods to be enjoyed together. Remember that there are always healthy alternatives, and that the quality family time is the most important part of these magical moments.

Step 1: Groundwork

This phase is really a pre-step. Ideally, it should happen prior to the merger. Both parents need to take the time to learn and understand their own parenting styles and preferences. Whether you take a quiz online or read a 300 page book, it doesn’t matter as long as you understand your style well enough to be able to talk to your partner about your style of parenting. It may also be helpful to plan an "observation" date where you can watch your partner interacting and parenting his (or her) child. Afterward (not in front of the child) you can ask questions of your partner and discuss your differences and similarities. Be careful not to openly challenge your partner’s style. This is an opportunity to learn about each other, not to criticize.

Another very important part of the self-discovery phase is to check for emotional baggage. Most blended families are the product of divorce or the death of a parent which often involves intense personal emotions. Be sure your parenting style is not going to be affected by guilt, anger or defensiveness. Many parents feel so guilty subjecting their children to the turmoil of divorce that they parent out of guilt and become more permissive. It’s a myth that children need a break from discipline and structure following an event like this. They often need more structure and will find comfort in the predictability of your consistent parenting.

Step 2: Rebuilding

Bringing two families together creates an opportunity to craft something new. You and your partner get to construct a new household. Depending on the age of your children, this may be the perfect time to make new rules and establish new consequences. Having regular family meetings is particularly helpful and gives parents an opportunity to lay out details of the new plan while fielding the "But why…." and "How come…." questions. Even with proper explanation and clarification, details of the new plan are likely to be challenged and tested in the days, weeks, or months following the merge. This leads us to the final and most challenging step.

Step 3: Settling

You planned ahead, you laid it out, and now it’s time to let it settle. Some parts will work like a charm and other parts will seem like a complete failure. This is part of the parenting process and isn’t unique to blended families. However, blended families often come with circumstances that may make the settling process a little rough. There may be joint custody arrangements with your ex-spouse which make it necessary to think through rules and consequences you set in your home. You can’t ground your child from video games if he is going to be able to go over to his mother’s house and have unlimited play time. It’s better to set consequences you know you can enforce.

Another significant issue that might arise during your well-planned settling phase involves your child’s emotional and behavioral reaction to the divorce. If your child displays uncharacteristic behaviors such as sleep difficulty, appetite changes, poor school performance or social withdrawal it may indicate the development of an adjustment disorder, depression or anxiety. If this is the case, you and your child may need a mental health professional to steer you through the settling process. These issues can’t be addressed through consistent parenting alone.

Following these three steps does not ensure a perfectly blended family. It does, however, ensure that you will have established a foundation of open communication, compromise and flexibility that will enable your new family to weather any storm.

But how do you do it in a way that keeps you from becoming mind-numbingly bored and keeps your child learning to their full potential?

To answer this question, you are going to need a quick lesson in neurology, biochemistry and addiction. Don’t worry, I promise it will be quick.

Dopamine is a very powerful chemical that works in the brain to assist motor control, motivation, cognition and reward. It was once thought to be decreased in children with attention-deficit hyperactivity disorder (ADHD), although this has come into question recently. Regardless, the treatments that seem to help best in children with ADHD are those that increase the activity of dopamine in the brain. Dopamine is also involved heavily in addiction whether that’s exercising, gambling or doing drugs.

In his book “Talk Like TED,” Carmine Gallo describes the work of Martha Burns, Ph.D., on dopamine and learning. He writes, "Drugs and gambling are artificial triggers and lead to serious consequences. Isn’t there a less-harmful means of achieving that mental high? There sure is. According to Burns, dopamine is also released when people learn something new and exciting – a much healthier way to feel good!"

Dr. Burns blogs on the same topic on The Science of Learning Blog and says, "I like to refer to dopamine as the 'save button' in the brain. When dopamine is present during an event or experience, we remember it; when it is absent, nothing seems to stick."

So, if you want your child to learn something new, you have to think like you're trying to get them addicted to learning, addicted to new information.

How?

According to Dr. Burns, "The answer is pretty straight forward – 'make learning NEW, EXCITING, and REWARDING.'"

Now, how do you do this when you are reading the same book over and over?

1) Pick a theme for the day (numbers, colors, shapes). At the end of each page, stop and talk about the pictures on the page in the context of your theme. How many trucks are there? Can you find the red truck?

2) Try different voices for different characters. My boys think this is hilarious and it keeps them thinking.

3) After your child seems to have a book memorized, insert the wrong word into the story and see if they catch it. When possible use the opposite word to start helping them learn opposites.

Let's get our kids addicted to learning by making it new, exciting and rewarding.

Gallo, Carmine (2014-03-04). Talk Like TED: The 9 Public-Speaking Secrets of the World's Top Minds (p. 117). St. Martin's Press. Kindle Edition.

I don’t have to look at a watch to know when it’s time for lunch. At around 11:30 a.m. my stomach starts to grumble. I’m ready to eat.

My gut kicked in once again on a Tuesday when my phone rang at 11 in the morning. It was my son’s school. Trouble.

The school nurse, who I have become all too familiar with, was on the line. She told me “Mr. Jack” had bumped heads with another little boy during a game of tag. Jack bled a bit from his mouth, his gums were swollen and his left front tooth was loose. He wants everyone to know that he didn’t cry.

Overall, he was OK, but now my kindergartner needed to go to the dentist to get checked out. Only one problem – I didn’t know the name of his dentist, what her practice was called or the phone number to reach her. I guess technically, that’s three problems, but you get the idea.

My wife flew to Washington D.C. over the weekend for work. She makes this annual trip and during that time I realize how helpless and hopeless I am. As a product of a single mother, I also tend to make more calls to my mom than normal just to say thanks.

As I write this, my wife’s on her way home, but here’s a quick overview of how the two men in her life fared while she was away:

Saturday – I totally caved and bought Jack unnecessary toys that I would have said no to if I had my wife there to back me up. Honestly, I didn’t want to hear him complain. Wimp. Not him. Me.

Sunday – We had cereal for breakfast, a few chicken nuggets from the golden arches for lunch and a flag football game that afternoon. Then that evening, Jack totally ratted me out to his grandparents at a dinner they made for the two bachelors. “I’m starving,” he said. When asked why, he told my wife’s parents how little he had eaten that day.

Monday – We had cereal for breakfast and dinner. That evening, we went out for Jack to work on his bike riding skills. There’s a challenging hill near our house that he’s had trouble conquering. With his helmet safely on, he asked if I would catch him if he fell. I told him I would do my best. He aced the hill. I strategically cut down sidewalk to be there for him as he rounded the corner. The only problem was that he didn’t round the corner. His momentum took him off the path and face first into the grass. As he lay motionless, I hate to admit this, but my first thought was, “His mom is going to kill me!” Jack was OK. Thank you God. He hurt his nose and his knee was scraped up a bit. He cried (don’t tell him I told you), but he was Ok overall. At least physically. That night he had a nightmare that I’m pretty sure was because of the fall and probably new found trust issues with his father.

Tuesday – We’ve covered it. But one thing I really do want to point out in all seriousness, dads know your emergency contact numbers and know the numbers of everyone you may need to call just in case.

Wednesday – Mommy’s coming home! My son can’t wait. He told me this morning that he was going to give her a big hug as soon as he saw her. Me too.