When should you be worried? The biggest issue is context. You can read the other posts to see all about that.

Another reason you should be more concerned with fever is if it is lasting more than 5 days. Of course, if you end up with a diagnosis where fever is known to last more then 5 days, no big deal, but otherwise, most fevers should be gone by then.

This situation is called fever without a source.

There are many different definitions of fever without a source but I use: fever greater than 101 for eight days in a child in whom there is no obvious source of the fever through the patient’s story or physical exam.

Because children can often have back-to-back viral infections, it is important that this fever be present daily or near daily. For instance, it doesn’t count if they had fever for 3 days then were better for 2 days and then had fever again for 3 days.

The different things to think about are all over the place and can range from very serious to the “no-big-deal.”

Infections - The most common diagnosis in this instance is “unknown” but the fever goes away on its own. While often not intellectually satisfying (to either me or the parent who wants to know what is going on), this is probably the best outcome for the patient. Most of those are probably viruses for which we don’t have or don’t think to run specific tests. Bacterial infections can also cause long-standing fever.

Rheumatologic - Less commonly, children with prolonged fever can have rheumatologic causes, an example is juvenile rheumatoid arthritis. Often these children will have exam findings like swollen, painful joints or swollen lymph nodes that will help point towards their diagnosis.

Malignancy - Fortunately, this is a very rare cause of prolonged fever but it does happen so we all need to keep it in the back of our mind. The most common type of cancer in children is leukemia.

The workup for fever without a source involves a few things:

1. Repeat histories and physical exams - Often things are discovered over time.
2. Preliminary screening labs - Check these in just about all kids with it.
3. Specific tailored labs and exams - Check some of these based on a child’s story or exam.

Kawasaki disease

One specific cause of fever over five days deserves specific attention. Because many parents are not aware of it and because the diagnosis can be tricky, I thought it deserved its own specific mentions.

Kawasaki disease (KD) is characterized by the characteristic fever over 5 days along with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye
• Swollen lymph nodes of the neck

One of the other things to note with KD is that these children are very, very irritable. Not kinda irritable, but noticeably irritable even to a pediatrician who hears crying babies and children all day long irritable.

The cause of KD is unknown. There is some evidence to suggest that there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of KD involve the heart and can be inflammation or the lining or muscles of the heart or dilation of the arteries that supply the heart.

If you suspect your child has KD it is important to seek your doctor’s advice quickly, as it is much easier for your physician to connect the dots when symptoms are present. Blood tests can help confirm the diagnosis and treatment can resolve the symptoms and help to prevent complications.

The good news is that children with Kawasaki's disease, like the child in the photos with this blog, usually return to normal and don't suffer complications.

Effectiveness/General Use

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

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

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

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

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

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

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

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

Marketing

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

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

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

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

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

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

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

Philosophy/Opinion

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

Yes, in fact, I think I must be.

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

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

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

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

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

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

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

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

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

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

Summary

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

Previous articles on this topic:

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

Children initially begin to walk between the ages of 12 and 15 months. In the early stages of walking, you may notice your child “waddling” with their feet wide and their arms out like an airplane. Once a child has become more comfortable with walking, you may notice them becoming “brave” and attempting to walk fast or even run. As a child goes through these stages of development, you may find your him or her falling several times during the day.

It’s normal for children to fall frequently as they are learning to walk. In the early stages of walking/running, a child is learning to plan movements, find their balance and explore new-found independence.

As children gain more control of their body, you will find they begin to walk with a narrower base and their arms are at their side. A child will walk/run with decreased hesitance and you should notice less falls. This will occur within the first 2-3 years of learning to walk.

When should you be concerned about your child’s falling? There are many different reasons why children lose their balance throughout the day.

• Pay attention to when your child is falling and ask yourself a few simple questions:

• Did the type of shoe he or she is wearing change? Often times children have difficulty finding their foot placement with new shoes, especially ones that are heavy (such as a boot) or non-supportive (such as a sandal or slip-on shoe.

• Are they only falling when reaching a curb or changing surfaces? Sometimes vision can play a big role in a child’s ability to maintain balance with walking and running. If you suspect a visual deficit, you should contact an eye care specialist.

• Does your child only fall when playing with peers their age? Children have to think constantly about their next move when walking/running during play. You may find that they will trip or fall when attempting to keep up with peers their age. This could be the cause of decreased coordination, meaning they are having a difficult time organizing movements during play, causing them to fall.

• Try to pay attention to how your child is falling, sometimes a child may have a difficult time clearing their toes when walking/running and will fall. This would be good to mention to your pediatrician for possible referral to a physical therapist.

If your child is falling more than 10 times per day and doesn’t fit into the above categories, it may be beneficial to talk to your pediatrician about a physical therapy evaluation to assess your child’s needs.

About the author

Morgan Hubbard, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield. If you would like to schedule an appointment or speak to our staff, please call 682-885-4063.

My question to you is...what in the world am I talking about? Our children’s vocabulary is very important, and if we use words such as “this” and “that,” we lose out on opportunities to teach our kids new words. I took a course recently that said that children between the ages of 4 and 5 demonstrate the most significant growth in vocabularies.

A child the age of 4 has a vocabulary of about 1,200 words, but a child the age of 5 has a vocabulary of 5,000 words. That is a HUGE growth in words.

Your child's vocabulary is so important. Think of each skill your child develops as building blocks. Starting from infancy, your child begins by cooing, which turns into babbling that then turns into words and eventually sentences. Research shows that children with higher vocabulary results in better decoding abilities. All that to say that their reading skills will benefit from having better vocabulary.

So what can I do to help my child?

1.Be specific when talking to your children. If I changed the story above to something more like this, it would all make sense…..

The other day I went on vacation. We went to South Padre Island. I enjoyed it because we went parasailing and fishing. My son caught a fish but his line got tangled with someone else’s. We couldn’t stop laughing, but eventually we helped him untangle the line and get it on the boat.

Now isn’t that so much better.

2. Try teaching your child new words or even different variations of the same word. For example: “The elephant is big” can turn into “The elephant is gigantic.” or even “The elephant is enormous.”

3. Use the same word in many different ways. Think about the word “run." The dog ran fast. I ran next to him, but I could not run as fast. My brother tried to run, but he fell down. After I ran, I was really tired. Running is fun.

4 .Make learning new words fun. Instead of doing flash cards (snooze), find something that is interesting to your child and think of words based on the activity. If your child likes playing with farm animals, think of several words you could teach your child involving farm animals. As you play, introduce those words you wrote down.

5. Read books to your child. Books offer so many new and wonderful opportunities for learning words. You don’t have to necessarily read all the words, just talk about the pictures. Try thinking of words you can use multiple times throughout the book.

Vocabulary development is critical for children. It helps with building sentences and it’s important for reading as well. Markus Zusak put it well when he said, “The words. Why did they have to exist? Without them, there wouldn’t be any of this."

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?

My first question would be, “how do you define ‘all the time’?”

Some people have unrealistic expectations for a breastfeeding baby. By rule, we know that they need to eat 8-12 times per 24 hours to sustain milk supply and growth. These feeds are rarely consistent by the clock’s standards, so throw the “two to three hour” rule out the window.

During those first couple of months, it tends to take 45 minutes to an hour per feed by the time you are able to get the baby stimulated enough to stay awake, fed on side one, burped, fed from the other side, and back down. The bigger the baby gets, the better they are at removing milk and the duration of the feeds will shorten.

Simple math tells us that if a baby is eating every 2 hours for an hour at a time, that is half of your day—and yes, “all the time!” But it's also completely normal.

Cluster feedings, do occur, from time to time as well, as a way for your baby to adjust your milk supply to fit their growing needs. The baby may cluster the night before your milk comes in, and again between one and two weeks when they reach their birth weight and attempt to double your milk supply from the one ounce they were getting to two, per feed.

Expect more clustering during growth spurts, as the baby continues to adjust the supply/ demand, although the older the baby gets, these are often less noticeable.

Try and not let the demands of the baby during these times get you down. It is not an indication that you do not have enough milk, nor does it last very long.

• No sensation of a let down
• No longer leaking milk
• Mom’s breast do not feel full (or engorged) anymore
• Unable to produce milk with a pump
• Baby does not stay at the breast as long as mom would like

Though some of these things may cause reason to look further, none are indicative of a poor milk supply.

The best way to gauge adequate supply is growth.

In the first few months of life, we expect babies to gain close to an ounce per day, and double their birth weight by 5 months.

Since you may not always have a scale handy, ask yourself questions like:

• Do you hear swallows during the feed?
• Does your baby seem content after the feed?
• Is your baby pooping 4 or more times per day? (this number falls around 3 months)
• Is your baby having 6 or more pale wet diapers per day?

If you answered these questions “yes”, then it is likely the baby’s weight is climbing as well. If some or many of the answers were “no”, then you should follow up with your child’s pediatrician for a weight check and/or evaluation.

Though most people think that a crying baby is ready to eat, crying is actually the last cue and a crying baby is more difficult to latch.

Earlier indicators may include:

• Wiggling around
• Smacking or licking their lips
• Bringing their hands towards their mouth
• Rapid eye movement
• “Rooting”

Before your baby can speak words, this is the first way our children communicate that they are hungry.

If your baby becomes completely overwhelmed, upset, and inconsolable before the subtle cues listed above, it is best to take a moment and calm your little one before beginning to feed.

Recognizing and responding to the early hunger cues jumpstarts good communication between you and your child as well as decreases the anxiety that can be caused between you both when emotions are at high.

Cradle and cross-cradle, football, side-lying, and laid-back nursing tend to be the favorites—while an older baby, especially those who nurse into toddlerhood, tend to take an unorthodox approach that looks more like gymnastics rather than feeding.

No matter the position, the goal is to get a deep latch for effective emptying of your breasts. Make sure to align the baby so that they’re entire body is rolled into yours, belly to belly, and not twisted. A good trick is to check that the baby’s ear, shoulder and hip are all in line.

It is best to work through different positions until you find something that is comfortable to you. Different babies, moms, stages, and even some diagnoses may indicate a different position, so don’t hesitate to try something new!

These symptoms alone do not necessarily indicate too much milk, however, and shouldn’t be used as the only indicator to adjust milk production.

Too much milk isn’t harmful however it can be uncomfortable to mom, always feeling full and may cause clogged ducts, which can lead to mastitis. Breastfeeding may seem more like a battle between you and your baby, and described as more of a “love-hate” relationship as well.

Mothers with overabundant supply also tend to have babies who gain weight more rapidly than the 2 pounds per month gain that we usually see in the first few months.

If you perceive that this is the situation that you are facing, you should contact your child’s pediatrician or schedule an appointment with a lactation consultant.

Sometimes I’m asked, “Why is breastfeeding so important to you?”

Honestly, 10 years ago, I was so close to not knowing the answer. I was struggling and ready to quit, before I finally reached out for help.

Eventually I fell in love with breastfeeding and made it my passion to help any mom who asked for help, find her love for it as well.

When I consult with a new mom, I usually start by talking about the milk itself.

Human milk is made specifically for humans. I wouldn’t give a rabbit baby milk from a horse, if I had plentiful rabbit milk.

Though, there are some women who don’t make milk (or enough to suffice), that is not the case for the vast majority.

The carbohydrates, fats and proteins are exactly what our human babies need to thrive. It’s pure, organic, and no risk involved with additives or preservatives or contaminated water.

Breast milk is full of antibodies, and hormones, and probiotics that are invaluable to our children's health.

Our supply is ever-changing and tailored to our children’s needs, through growth or illness, our milk actually reacts before we do as the saliva exchanges between baby and breast.

Here are just a few of the benefits of breastfeeding:

• Breast milk is free.

• It doesn’t know social status or the thickness of your wallet.

• There’s no mixing, measuring, washing or preparing.

• At midnight and 3 a.m., it is warm and ready to serve.

Then there are the facts:

• Our breastfed children are at a lower risk for obesity, diabetes, asthma, diarrhea, ear infections and some childhood cancers.

• The risk of SIDs is also lower in breastfed children.

• For us as the mother, breastfeeding also lowers our chances of osteoporosis, breast and ovarian cancer as well as helps with postpartum depression.

Finally, the physical and emotional connection between you and your baby is powerful.

Eight to 12 times a day, you have the pleasure (although to be honest I know sometimes it feels like you are forced) to sit and bond with your baby for 45 minutes or more at a time in the early days. Talking, singing and eye contact are a positive byproduct of the inability of anyone else being able to help you feed your child.

Skin to skin is the best way to regulate core temperatures, heart rate and blood sugars; and breastfeeding creates a natural and unforced space to do so.

Breastfeeding is natural. I learned that lesson a decade ago and continue to see its benefits with the thousands of moms I’ve helped over the years as a lactation consultant.

Schedule an appointment with our virtual lactation consultant.

For More Information On This Topic

• Virtual Lactation Program at Cook Children's
• 'Am I Making Enough Breast Milk?'
• New Study Shows Breastfeeding Decreases Risks Of SIDS
• What you need to know about breastfeeding and your baby

"I swear he looked worse when I called."

"She hasn't been this active in days."

"She felt so hot when we left the house."

I get it. I've always tried to understand when I hear parents say these kind of things and this week I was personally reminded how this happens.

After getting a worried text from my wife, I left a Cook Children's Physician Network board meeting and hurried home to rush my daughter off to urgent care. After a few minutes there and a trip to the bathroom...we were as good as new. Back to asking a million questions. Back to telling me to look at the screen to see the same scenes in the same movies we've been watching for years. Back to getting on the table, climbing off the table.

Has this happened to you? Most likely, yes.

But, we got our results back, everything checked out great and we were on our way.

Why does this happen? Maybe no one knows.

Here are my 5 suggested possibilities:

1. Time has passed. Kids can get rapidly better and rapidly worse. That's one of the amazing (and absolutely terrifying) things about working in pediatrics. Kids often get better within hours. So, it's possible they were just due for some improvement after you called for the appointment.

2. Your child's medicine has had time to kick in. Kids can look terrible when they have fever and can pretty much bounce right back to normal when it goes down. If their fever is down, they are going to look much, much better.

3. You're in the presence of trusted professionals. (all modesty aside) When you're really scared, it's nice to have anyone around. Having that someone be a pediatrician who's trained for years to handle just this situation might make them look "better."

4. Kids often look better in the daytime. If you were worried about your child at night but bring the child in the next morning, they often look much better. Viral illnesses often look worse at night. Also, when you are tired, you might be more prone to worry and less able to put your fears in context.

5. I have always joked with my parents that we have a magic spray in the waiting room that decreases fever, fussiness and otherwise just makes kids look better before they get back to the room. What I learned from posting about my experience with my daughter is that I'm not the only pediatrician who does so...some of them call it magic pixie dust, some magic spray but apparently we all have something that does the same thing.

Ironically, there were many other pediatricians who responded by saying that their kids often did the same thing. I wasn't alone.

So, the next time your child looks tragically ill at home and perfectly fine in the office, you can rest comfortable knowing that your doctor has probably experienced the same thing.

How do I know parents shame themselves?

First, I know that parents shame themselves because I AM a parent, and I do it. For example, in the spirit of full confession I will tell you that—once when my son was a toddler— we went to a playdate at a pebble-layered park during which I completely failed to notice his slipping a little handful or two of said pebbles into his mouth. I thought I might’ve seen him sneak something stealthily into his mouth, but I convinced myself otherwise (clean tongue, no dirt on his face). Two hours later at home, he awoke crying from a nap and vomited a pile of pebbles. “I burped, Mommy,” he said, pointing to that which he ejected. Guilt for allowing him to ingest choke hazards followed. “Bad Mommy,” I told myself. Another time, I got confused about the date and time of a much anticipated birthday party. We rang a family’s doorbell with gift in hand only to be told the party had been the prior week. Quiet tear-fall on my daughter’s cheeks ensued. “Bad Mom,” I told myself. These are just two examples, but you get the drift, right?

Second, I know that parents shame themselves because, well, I’ve got this gig as a pediatrician. In this line of work—in which I am fortunate enough to be privy to many joys and happy events among my patient families— not a day goes by that I don’t also see and hear parents judge themselves as “unworthy.” I often see tearful new parents in the midst of extreme sleep deprivation with their wailing and yellowing jaundiced neonates put to breasts that aren’t yet fully cooperating with the nursing plan. “Bad Mommy,” the moms tell themselves, for not satisfying their babies at the breast. “Bad Daddy,” the dads tell themselves, for not being able to better comfort and support their wives and new baby. I have seen many parents fret when I have diagnosed their baby with an ear infection after a rough night of letting their little one “cry it out” in sleep-training. “What bad parents, not going to our crying baby in a time of need,” they tell themselves. Parents have come to me after hearing from a teacher that something was less than great about their child’s performance. They have often internalized this problem or flaw as something they might have prevented “if only we were better parents.”

Honestly, I’ve seen parents— I’m talking about wonderful and oh-so-very well-meaning people— stack everything their child does less-well or more slowly or less confidently or less joyfully than others onto their own backs as their burden to bear in self-flagellation. And self-flagellation doesn’t feel good! The time has come, my friends, for us to stop this abuse of self. Together let’s take steps toward self-preservation, realism, self-acceptance, and love.

Step One: Silence the Self-Critic

Amy Poehler, the awesome one of SNL and Parks and Rec, has a chapter in her book Yes, Please called “plain girl vs the demon” in which she refers to the voice in each of us that “talks badly to us.” She writes that the demon might say to one’s self, “I am too fat or too skinny or too tall or too wide or my legs are too stupid and my face is too smiley or my teeth are dumb and my nose is serious and my stomach is being so lame.” And, on the flip side, another critical voice may then retort (to itself, yourself), “I am so ungrateful— I have arms and legs and I can walk and I have strong nail beds and I am alive and I am so selfish and I have to read Man’s Search for Meaning again and call my parents and volunteer more and reduce my carbon footprint and why am I such a self-obsessed ugly [bleep].”

This is the same self-critic I am suggesting we silence. It is the very one that tells us we are not the model parent we had hoped to be. It says, “You stink, you enabler of pebble-eating, failure-at-exclusive breastfeeding, and non-responder to ear pain— you are a Bad Parent!” In the name of self-preservation and positivity, we must kick this nasty voice out of our consciousness—STAT! Plug your ears and say, “Lalalala,” because the inner demon is a bully.

In addition, our inner demons often talk crazy — that is, their comments aren’t grounded in reality. By way of illustration, imagine I am looking at myself in the mirror after donning my best fancy attire with grooming and make-up quite beyond my usual jeans and T-shirt, around-the-house look. I just might look at myself and think— “Hey, I like this dress— it’s nice to get dolled up sometimes, and I like the way I look today.”

But what would happen if instead an inner crazy-talking voice then pointing out to me that “Nope, Supermodel ___(blank)____(insert the name of your supermodel of choice) would look a lot better in this dress— you actually look bad.” If I listened to that voice, I might feel pretty deflated, as —let’s face it—it is true that any supermodel would look better than I in any dress. My point, however, is that I should not listen to that voice, as why would I compare myself to a supermodel anyway? And even supermodels say that their Perfect 10 appearance in pictures is not their “real” look and is much helped by Photoshop and make-up artists and the like.

The point is that the self-critic is a bully who encourages unhealthy comparison to unreachable ideals. And this brings me to the next step.

Step Two: Recognize and Reject UnREALISTIC Expectations

These days, we parents often burden ourselves with unrealistic expectations for how we will rear our children. Parent and parenting author/blogger Bunmi Laditan summarizes things well and humorously:

“How to be a parent in 2020: Make sure your children’s academic, emotional, psychological, mental, spiritual, physical, nutritional, and social needs are met while being careful not to over stimulate, under stimulate, improperly medicate, helicopter, or neglect them in a screen-free, processed foods-free, GMO-free, negative energy-free, plastic-free, body positive, socially conscious, egalitarian but also authoritative, nurturing but fostering of independence, gentle but not overly permissive, pesticide-free two-story, multilingual home, preferably in a cul-de-sac with a backyard and 1.5 siblings spaced at least two years apart for proper development, and don’t forget the coconut oil.

How to be a parent in literally every generation before ours: “Feed them sometimes.”

Many of us lucky enough to have had supportive and loving parents strive to be like them. However, in many cases societal expectations (safety seats, seatbelts, no smoking, etc) and also our own expectations complicate the mix. Perhaps we have added two parent full-time jobs with ambitious goals for promotion to our list. Perhaps we have added travel, dietary limitations, or exercise ambitions to the day. Perhaps we don’t live close to other family members and have to go at it alone or with the help of nannies and baby-sitters. We have a lot on our plate—too much, if we don’t also throw in some forgiveness and self-acceptance.

Alas, we are only human, and there are only 24 hours in a day. We will not be able to do it all. We all make mistakes.We hope to recognize them. With a positive growth-perspective, we can plan to manage things differently next time, but we will be sometimes misguided and imperfect people even then. And that’s okay. We are great even in the striving. We wear the clothes well, even if not like a supermodel might.

STEP THREE: RECOGNIZE THAT WE ARE ALL SPECIAL, FLAWS AND ALL

In the words of the inimitable Mr. Rogers, “Whether we’re a preschooler or a young teen, a graduating senior or a retired person, we human beings all want to know that we’re acceptable, that our being alive somehow makes a difference in the lives of others.” Working through the steps of this blog, we hopefully have moved away from shaming ourselves and from listening to a cruel inner critic to instead accepting our own humanity. Now we should move beyond self acceptance to a point of appreciation. Let us even embrace some of our limitations and imperfections.

When I was younger, Christmases in our family were great, complete with baking cookies, singing carols, playing games together, and enjoying Christmas movies. One area in which my child-self felt we might improve, however, had to do with decorations and the spectacle of it all. I had some friends whose families really went “all out” in that area—they had amazing decorations and lights inside and outside their homes, beautifully wrapped gifts topped with bells and elaborate bows, and Christmas morning resplendence as in the opening scene of The Nutcracker Ballet.

One day I asked my mom why we didn’t do more of that. “Daphne, I have our family to tend to, a full-time job, and even night classes—the choice is between my using my scarce free time to decorate our home and fancily wrap gifts or my spending that time enjoying the season with you and our family.” She went on, “I thought it would be best to cherish the time together— don’t you agree?” I really did agree. My mom showed me that— within the limits of our situation—she chose us. This was a wonderful lesson of love that sprung directly from human limitation, and I love and thank her for it.

As for my dad, according to what some parenting books say, my dad was a little too loud, yelled a little too much, and wasn’t measured enough in his reactions to the world around him to fit the bill for their “no-scream” and always- calm parenting principles. He was emotional and ever expressive—(mostly in love and joy, but on occasion in frustration or anger )—a true “spicy Italian,” as my own husband referred to him. We always knew where he stood on any given issue.

Though yell he would, if for example the cat pooped on the white carpet or my sister and I misbehaved or talked back, the other side of his honest expression of emotion was that he was the loudest and biggest declarer of love I have ever known. His voice carried so far that— in any piano recital or dance recital or school awards program or anything— I could always hear my dad’s voice above the others, shouting proudly, “Brava, Daphne!” It wasn’t the volume of his voice, though, that made him so special— it was his passion, eloquence, and most importantly his sincerity. Not just at weddings or parties but also very often in our day to day life, he opened his heart to us. I grew up hearing him express how much he loved me, my sister and my mom, how great he thought we were even in our differences, and how lucky he felt to have us. So actually, the expresssiveness some parenting gurus might call his “imperfection” was just the other side of what made him so incredibly special as a father, the best of fathers, truly.

So no more self-shaming! We are important to our children, even with our constraints and our shortcomings. We strive to show them how special they are, but it is important to turn that support and appreciation inward as well. We are unique, and we make a positive difference.

Let us finish with a boost from Mr. Rogers, a voice truly opposite to that of our harsh self-critics. “You’ve made this day a special day, by just your being you,” he always said at the end of his shows, “There’s no person in the world like you, and I like you just the way you are.”

The primary identifying marker of Kanmushi is suggested to be a prominent blue vein on the child’s nose, commonly known as a sugar bug.

Truth? Unlikely. Any syndrome that crosses over this number of systems and describes what often normal symptoms (at least temporarily) should be considered with extreme caution (or ignored).

No scientific studies have shown a link between sugar bugs and any clinical condition.

The good news about Kanmushi are the recommendations for treatment: limit processed sugar, encourage healthy play and set clear boundaries.

Guess what?

I don’t need to diagnose a child with a syndrome to encourage these habits but if it helps encourage these healthy habits…maybe we should all have it.

Learn more about Sugar Bugs from Dr. Smith by clicking here.

Why has kindness endured over evolutionary changes which are tied to survival of the fittest?

Our ancestors evolved as groups and the ones with the strongest bonds survived. The best way to sustain and build strong bonds is being kind to others. Tendencies toward sympathy are instinctual and not some cultural concept. At times, they are even stronger than the instinct for self-preservation:

The quality of kindness is cardioprotective and related to the hormone Oxytocin says Dr. David Hamilton author of The Five Side Effects of Kindness. Oxytocin the hormone responsible for inducing labor is elevated in females who are breastfeeding. Among other things, oxytocin causes blood vessels to expand lowering blood pressure. Oxytocin increases with warm contact and has been postulated to be associated with compassion as well as kindness. Along with oxytocin, dopamine and serotonin ares postulated to kick in and reinforce acts of kindness.

Empathy is described as an effective response that arises from the comprehension of another’s emotional state. It results in having an emotional response that is similar to what the other person is feeling. On the other hand, compassion is usually defined as the deep wish that another be free from suffering, coupled with the motivation to alleviate such suffering. While distinct, it is commonly understood that to be kind and feel compassion, one needs empathy.

This leads us to the area social cognitive skills. We, in the world of Child Behavioral health, commonly see deficits in empathy when children have been through trauma or developmental delays. Working around this has shed some light on looking at practical ways to build on empathy and eventually compassion in children

We can develop in children the habit of having kind thoughts by verbalizing our own kind thoughts about others. It might be easier to share kind words toward family and close friends initially. Smiling more often can be a way of showing kindness in our facial expressions. We can also emphasize kindness by greeting one another in person and complimenting one another when “caught” doing a kind act. Another idea is playing games to help build on social cognition skills for children. This involves mimicking or drawing facial expressions and encouraging children to identify the emotional state associated with expression.

We can read stories around kind acts as well as emphasize news that highlights kindness. This can be valuable to help children focus on the kindness that is ever present in our world. In particular, volunteer activities where the family participates as a unit can not only help teach kindness but also help build the bonds. It’s worth remembering that evolution has taught us that it’s the groups with the strongest bonds that has survived and flourished over centuries. Talking about areas of gratitude in classrooms, at the dinner table or maintaining a gratitude diary boosts happiness, social well-being and health.

Perhaps the most beneficial and unsurprising effect of kindness to others is it teaches us to be kind to ourselves.

In an interview with Billboard published October 8, she reveals that her time her away was a consequence of scary health scare, following the diagnosis and subsequent treatment for lupus.

Fortunately, Gomez is doing well. Her lupus is in remission and she is set to appear in an upcoming movie and her newest album, Revival, will be released October 9.

Here are 8 facts about lupus that will help you understand the disease and explain it to your children if they ask:

1. Lupus is a disease where your body’s immune system (which usually helps you fight off infections) starts to attack your own cells (it falls into a group of diseases call auto-immune diseases).
2. Symptoms of lupus vary from person to person but can include: fever, swollen/painful joints, facial rash, tiredness, body swelling, sun sensitivity and mouth ulcers.
3. Lupus is diagnosed through a combination of symptoms and lab testing. It is often difficult to make because it can look like many other disease s and there is not one specific test to confirm or deny the diagnosis.
4. Lupus is not a contagious illness. The exact cause is not known but is thought to be a combination of hormones, genetics and environment.
5. Lupus most commonly affects women 15-44 years of age but can affect younger children and boys as well.
6. When severe, lupus can cause anemia. It can also cause excessive blood clotting which can lead to strokes and other complications.
7. Pediatric specialists known as rheumatologists treat lupus in children.
8. Treatment of lupus includes use of medicines to treat inflammation, steroids, anti-malarial medications and occasionally stronger medicines, which are used to decrease the activity of the immune system.

For more information about lupus, you can read more from the Lupus Foundation of America at lupus.org.
 

*Photo from SelenaGomez.com.

1.Technology

2.Newborns

So, you might not be surprised to hear that a new tool for evaluating jaundice using a smartphone definitely activated my nerd alert.

Jaundice is a high level of bilirubin in the blood. Yellow skin is a reliable sign, but diagnosis is made with a blood test to measure the bilirubin level.

BiliCam is a smartphone enabled app which helps to measure a baby’s level of jaundice (bilirubin) by taking a picture alongside a calibration card which is then uploaded and analyzed.

The good news is that those measurements were found to be close to those drawn from the blood and, most importantly, were accurate in measuring infants with bilirubin levels over 17 (which is near the level at which treatment would be necessary). Currently, children who are on the border requiring phototherapy might require frequent visits to the doctor for blood draws to assess their jaundice levels. A non-painful option that could be done by the parent at home would be amazing.

BiliCam is just one of a number of rapidly expanding uses of technology in parenting a newborn. Starting with BiliCam, here are 4 technological advances in newborn care and my review:

1.BiliCam

I love the idea and I really think it could be useful. But I found a couple of problems right now. I can’t figure out how to implement it in practice. As far as I can tell, it's not commercially available at this time. Another problem is that it requires parents to have a card. I suppose I could keep them at my office for those babies who I’m sending home that I know will need a screen but, otherwise, if they need to be screened, they’ll have to come and pick up a card (which kind of defeats the purpose).

Overall Rating: B-

2.Respiratory and other vital sign enabled-monitors

We’ve written about these before, but I feel like a new one comes out every month. Every time I publish this story, there are people who comment about how much they loved theirs. But there are also people who echo my concern that they caused tremendous anxiety. Because of this and because there is no proof that they prevent bad things from happening to your child…

Overall Rating: C-

3.Baby tracking apps

Do we really need to know every time your baby poops, pees or feeds? Probably not. But I have found them to be helpful when babies are having trouble gaining weight. I’ve also seen parents use them to help their baby find a more predictable feeding schedule. With very little risk and the benefit of giving my accountant parents something to do…

Overall Rating: B+

4.Your smartphone camera

While you may not find this particularly groundbreaking, I have found it to be one of the best technologies for newborns. Whether it’s taking a picture to track head shape changes or birthmarks or if it’s for connecting with me for a live telemedicine visit that allows parents to stay home with their newborn, a lot of information can be gathered based on the quality of photos that can be taken.

Overall Rating: A

What are some other technologies you used during the newborn period? What other technology would you like to hear more about in the near future?

Extremes in height- short stature or tall stature - further call attention to a person’s uniqueness and may represent challenges for some in everyday life. The judgment of what is normal height can be distorted in a variety of ways including media images, peer groups, and family/cultural backgrounds.

Being short seems to be negatively viewed in the range of height difference. Men and boys, in particular, seem more impacted by short stature with research reports from several decades ago reporting negative psychological and social effects in males with short stature. And while, more recent research calls into question whether or not there is a negative impact, it’s still difficult for many to forget old impressions and stereotypes.

Short stature referrals are one of the main types of referrals seen by most pediatric endocrinologists. While the medical evaluation of short stature is a fairly straightforward process (at least for a pediatric endocrinologist), navigating the family and emotional dynamics can sometimes be tricky. I think offering education to child and family about normal expectations is an essential part early in the first referral visit.

The first and perhaps most important part in short stature evaluation is understanding that a child’s growth and height are strongly connected to genetics of his or her family. In other words, short children typically have short parents.

It is also important before moving further for a reminder of average height for women and men in the U.S.

Average women’s height is 5’4”

Average man’s height is 5’10”

A handy formula used to help estimate a child’s genetic height target (the range of their adult height) is as follows:

Let’s look at two examples to illustrate,

Short Parent Family: Mom 5’0” Dad 5’7”

Height range for son: Middle of target: 5’6”Range: 5’2’ to 5’10”

Height range for daughter: Middle of target: 5’1”

Range: 4’9” to 5’5”

Tall Parent Family: Mom 5’6” Dad 6’1”

Height range for son: Middle of target: 6’0”Range: 5’8” to 6’4”

Height range for daughter: Middle of target: 5’7”

Range: 5’3” to 5’11”

The formula gives a target estimated height with a range of 4 inches above or below the target that will cover almost all children. Still, it’s a wide range when you consider the difference between being a 5’3” woman compared to a 5’11” woman.Knowing a child’s genetic height target range is important in determining the location on the growth chart like the one shown below where most of a child’s growth points should be located.

A child growing below their expected height range needs a closer check. A child progressively falling lower on the growth chart likely needs an in-depth investigation to determine if a problem exists.

Causes of short stature in children are numerous, ranging from normal variations in growth to serious underlying health problems. My first priority when a child is referred to me is to further investigate short stature is answering the following question:

Is the child's short stature OK or not OK?

What I mean by OK is that there is no apparent underlying negative reason for a child’s short stature. There are really only two reasons that fall in the OK category.

• Familial (genetic) short stature
• Constitutional delay of growth

Children with constitutional delay of growth will start off slower in growth compared to other children. They will fall to the lower part of the growth chart in early life which can concern parents and pediatricians. A child with constitutional delay grows at a slower, but normal pace during childhood and early adolescent years and gets the growth spurt of puberty later than average. These “late-blooming children with constitutional delay will eventually reach a height within their family height range.

Answering that initial question of OK or NOT OK can sometimes be difficult. Return visits to monitor growth are almost always a necessity to reassure that “growth and health are OK.”

Key steps in the process of monitoring a child’s growth include a medical history and an examination. The first two steps help me and other pediatric endocrinologists decide both if further special testing is necessary and what kinds of special tests may be needed. Different kinds of special testing include

• Bloodwork
• Radiology tests such as a bone age X-ray or MRI scan of the brain
• Growth hormone stimulation testing

The bone age X-ray is an important tool used by me in the early stage of short stature evaluation. The test looks at the appearance of growth plates in the hand. The growth plates start out in early life with lots of room to grow. The size of growth plates becomes progressively smaller as a child ages. By the time an average child reaches the end of puberty…...

• Girl around age 14 years
• Boy around age 16 years

…….the growth plates are nearly closed, and there will be very little increase in height.

A bone age is a very useful tool in helping me figure out quickly my level of concern and the types of testing which might be done in a child’s investigation.

For instance, look at the two bone age images of a boy’s hand below. The white arrow shows a growth plate located on tip of the finger. A 10-year old boy's hand is on the left and a 15-year-old boy's hand is on the right:

10-year-old boy's hand:  15-year-old boy's hand:

Get to know Joel Steelman, M.D.

Dr. Steelman is an endocrinologist at Cook Children's. He trained in endocrinology at the University of Colorado Children’s Hospital in Denver, where the magnificent setting turned Dr. Steelman into a lifelong outdoor sport enthusiast, with a strong desire to lead a healthy life. On his rare days off, he could be found skiing, mountain biking and trail running. He loves to go back to the Rockies as often as possible, and just a few years ago, he ran the Pike’s Peak ascent half marathon. He continues to run for exercise regularly. 

During his tenure in Colorado, where he met his future wife, Dr. Steelman trained at the internationally renowned Barbara Davis Diabetes Center, one of the world’s largest and most esteemed diabetes medical facilities for adults and children, specializing in type 1 diabetes research. Along the way, he discovered another strong research interest in the area of bone disorders, and Dr. Steelman began to treat children with osteogenesis imperfecta, or brittle bone disease-- a rare, crippling malady. After completing his training, Dr. Steelman left the West to enter academic medicine at Vanderbilt Children’s hospital in Nashville, Tennessee. Over the next seven years he focused on research projects and medical education.

As a self-described ‘techie,’ Dr. Steelman has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to Checkup Newsroom.

1. Health. Often, new teachers don’t know about your child’s health history. Many kiddos have severe nut allergies and teachers need to be aware of those food allergies, as well as if your child needs special medication or an EpiPen® injection. You should let your teacher know if your child has asthma, is diabetic or has any other serious health condition.

2. Educational Diagnoses. Teachers may not know your child has been diagnosed with a learning difference, dyslexia or an attention deficit problem. This is an opportunity to let teachers know about a 504 plan or IEP for your child. This is also a great time to let your teacher know what your child’s learning style is such as whether they are an auditory, visual or kinetic learner. Sharing your child’s areas of strengths and weaknesses is also helpful.

3. Emotional and family. Inform your teacher of any emotional factors that may impact your child such as divorce, death, illness or a parent being stationed overseas. It’s helpful for teachers to know the emotional factors that are impacting your child’s life which may help your teacher to understand and communicate better with your child.

4. Don’t settle for orientation. Teachers are bombarded with information at meet and greets during orientation. It’s hard to keep everyone and everything straight. My advice is to set up a conference with your child’s teacher as early as possible. One teacher told me she found it really helpful when parents provided a list of bullet points that included helpful information about their child, including the health and educational diagnoses, the strengths and weaknesses of the child, how the student learns the best, what the student responds to best when giving direction or correction and some points about the student’s social and personality style. Go in and set up an appointment one on one, especially if your child has special needs or considerations.

5. Be a team player. Every teacher I have spoken with has told me what they appreciate more than anything is for the parent to ask the teacher, ‘how can we help you? What information do you want to know?’ Most teachers prefer that team approach.

6. Be honest with yourself about your child. This is sometimes the most difficult tip for parents, but it’s so important. Know your child’s strengths and weakness. One of our biggest problems in today’s society is not teaching accountability. Set that example. Make sure your child knows his or her responsibility. Teachers have a difficult enough job without always blaming them, the school or another child. Please make sure you know how your child contributed to a situation and then take appropriate action from there.

Of course every child is different, and special, which makes communication between you and your teacher so important in having a great school year.

About the author

Lisa Elliott is a licensed psychologist and clinic manager of Cook Children’s Behavioral Health, located at 3201 Teasley Lane, Ste. 202, Denton, TX 76210. To make an appointment, call 940-484-4311. Cook Children’s Psychology provides care focused on children’s behavior, from ages 3 years through 17.

– 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.

I have moms in my office tell me all kinds of variations of the "I'm a bad mom statement" and it is always for minor things - still using a pacifier, let them have too much candy or still lay with them to help them sleep. I know a lot of this is looking for reassurance but I also think we do this to ward off mom-shaming. If I say it first then you can't shame me about it.

We live in a world where many small joys and achievements are shared online, but also in which we can see and judge each other's actions easily. This causes some of us to doubt our own ability and choices as mothers.

Maybe this doubt causes some of us to make other moms feel bad about choices that were not the same as ours. Maybe we want to shout loudly about the one thing we feel we are doing right and push away all the things we are doing wrong.

In either case shaming a mother is really a selfish act of making one person feel better at the expense of another - even when it is coated in words like "I'm just trying to help."

Moms often come to the end of a well child checkup and have one or two questions they feel they must ask to make someone else happy. Things like - "I'm not really worried, but my mom thinks hitting is not normal at this age" or "my friend says my child is not getting enough milk but I think it's OK, what do you think?"

One of things I love most about being a pediatrician is supporting parents to be the best parents they can be and affirming their skills and abilities.

Parents are showered with choices on how to feed, discipline and teach their children, and it feels like the "rules" or advice is always shifting. Thankfully for many things, there is no single perfect way to raise your child and anyone that tells you there is, is not thinking broadly enough.

Part of our job as pediatricians is to help you raise a healthy child. We will advise you on safety, health and what we have seen work, but we must also take into account different family styles that impact choices around feeding and sleep.

The "I breast fed for a year," "my 2 year old loves broccoli" and “my child slept through the night at 6 weeks of age" are all statements that are wonderful accomplishments of child rearing. But they can be also be used to shame other moms to feel bad about their own parenting.

I want to remind new moms, especially by the time your child is 10 no one will care about how you did any of these things. Your child will be wonderful because YOU are his or her parents.

And if you care enough to read this and ask your pediatrician questions then you are doing a great job already.

I’ve been working on a long piece about MTHFR gene mutation for a while now. It’s something I get asked about a lot from parents. So, I think it’s time we take a look at MTHFR.

“"About four years ago, I found out I have something called a MTHFR gene mutation, which dictates how my body methylates," Courtney revealed. "I suffered miscarriages."

The Friends actress goes on to detail how she has to watch what she eats, avoiding anything with high levels of folic acid, such as carrots, red onions and broccoli that can complicate meythlation. A side effect of MTHFR is an increased risk of blood clots and this can be the cause of her miscarriages.

Scary and worrisome issues for any mom-to-be.

But I think what’s important here is that there’s still so much about MTHFR that we still don’t understand and there’s plenty of research that still needs to be done.

At this point, the American College of Medical Genetics and Genomics does not recommend routine testing of MTHFR for patients with blood clots, for women with recurrent pregnancy loss or for any other condition.

In instances when mutations in MTHFR cause the enzyme activity to be severely impaired, it can lead to an elevated level of an amino acid (the building blocks of protein) called homocysteine. Buildup of this amino acid may increase the risk of blood clotting and heart disease.

Recent studies have cast doubt on this association and have shown that treating the elevated levels of homocysteine may not decrease the incidence of heart attacks, but we know that homocysteine does activate blood vessels and make them more likely to form clots.

Mutations that do not affect homocysteine level have not been proven to cause disease. Many variations exist at the gene level which do not appear to affect the activity of the enzyme. Without further confirmation that these cause problems, they should probably be thought of as normal variations (like eye color).

Studies have attempted to link mutations in MTHFR to more than 600 different medical conditions. There have been thousands of publications on this topic and yet, only one condition has been definitely shown to be an increased risk in children with MTHFR mutations: women with a variant known as C677T have a slightly increased risk of delivering a child with a neural tube defect (like spina bifida).

As I mentioned before, the American College of Medical Genetics and Genomics practice guideline does not recommend MTHFR testing for evaluation of increased blood clotting, recurrent pregnancy loss or at-risk family members despite the fact that these are the most plausible diseases which would be caused by MTHFR mutations. No other medical societies have endorsed MTHFR mutation testing.

Because of this and many other reasons, maybe we should really think twice before going down this pathway except in very specific cases.

And as for those many other reasons … I have so much more to say on this topic and I know many of you want to read more. Click here to read my extensive post on this where I dive deeper and answer many of the questions I get asked the most.

DEET gets a pretty bad rap. In a day and age where people are pushing for the more "natural" approaches to prevention and medical care, DEET seems to be the least natural thing out there, right?

You know what is natural? West Nile virus. Zika virus. Chikungunya virus. Powassan virus. Ugh. All nasty viruses which are passed from human to human thanks to mosquitoes.

Citronella hasn't been proven to last very long and has to be at high concentrations to have any effect. So it has to be used really frequently to make up for its lack in efficacy.

Wristbands have been proven time and again in studies not to work, regardless of ingredients.

Lemon eucalyptus oil actually can help - but studies have shown that it's about half as effective as DEET and hasn't been tested for safety in kids under 3.

"Various botanical oils other than those discussed previously, including sandalwood, geranium, soybean, and others, have been used alone or in combination for repelling mosquitoes and ticks. The majority of studies of these alternative plant-based repellents show that the protection they offer is far inferior to DEET" - straight from a peer-reviewed medical article (UpToDate). I had high hopes for my marigold and lavender plants but I don't think they will work (Insert your own frown emoticon here).

So what do I put on my kids? DEET. Because no other compound (natural or synthetic or otherwise) has been proven to be as effective at keeping away mosquitoes, ticks, fleas, and chiggers.

DEET comes in different percentages - 10 percent to 70 percent. Stick with the 10-30 percent range. Ten percent will get you about two hours. Twenty-four percent gets you about five hours of protection. If your children are older, you can use higher concentrations if you'll be outside longer than five hours. The higher the concentration, the longer the effect will last.

DEET can be used on kids as young as 2 months. I know, I know - the thought of putting a synthetic compound on a sweet baby makes me cringe too. But honestly - it's OK for a few hours at a time. Scary things like neurotoxicity have actually only occurred in giant, massive doses after prolonged exposure, and even then it's super rare. Fewer than 20 cases of this happening have been recorded WORLDWIDE since the beginning of time.

If you have aerosolized spray, do what I do - spray it on your hands, then rub it on their arms, legs, neck, ankles, torso. Don't spray it on them directly , and try to avoid inhalation. Don't put it on their hands (because if they're anything like my kids, their hands are in their mouths nonstop). Avoid the eyes. Give them a bath when you're done with outside time.

DEET really is the best way to keep the bites away. And with such a wet "winter" that we had this year - it sounds like we will all need some.

Hugs,

Dr. Diane

You may not have really ever sat down to think about it, but good handwriting requires many things working together at the same time. Each of these things play an important role in the quality of handwriting your child puts on paper: strength of hands, arms, and core, bilateral coordination (both hands working together), visual perception (how your brain interprets what you see), visual motor (eye-hand) coordination, and fine motor precision (how fine-tuned fingers move together).

Here are some summer activities that DON’T involve pencil and paper that you can do as a family to improve or maintain your child’s handwriting skills:

• Go to the park and use the monkey bars and climbing walls -increases hand, arm, and core strength.

• Paint the side of the house with a bucket of water and a paint brush – increases strength of hands, arms, core and bilateral coordination and visual motor coordination.

• Water play with squirt bottles or water guns using index and middle fingers to squeeze handle – strengthens hands and fine motor precision.

• Soak a sponge full of water and then wring it out in another bucket or an older child could help wash the car – strengthens hands and bilateral coordination.

• Use side walk chalk on the driveway to make pictures, shapes, and/or letters – fine motor precision and feedback to where your hand is in space.

• Pop bubbles with one finger or two hands together– increases fine motor precision and bilateral coordination.

• Play the game “Hot Potato” with a balloon filled with air. See how long you can pass the balloon back and forth without the it falling on the ground. Add more balloons when one balloon is too easy. – Improves visual motor coordination.

• Create with playdough – Increases strength of fingers and fine motor precision.

• Swim freestyle, back stroke, breast stroke or butterfly (with adult supervision, of course!)– increases core, arm, and hand strength, and bilateral coordination.

• Water play in the shallow end with splash balls or a beach ball (again, with adult supervision) - increases visual motor coordination, strength, and fine motor precision.

• Go fishing at a lake, pond, create a pond using a tub, or Bass Pro Shop has a free fishing event Saturday mornings (check your local store): increases bilateral coordination, core strength and visual motor coordination

• Take Karate lessons– increases core and arm strength and bilateral coordination.

• Learn to play a musical instrument – increases visual motor coordination, bilateral coordination, and fine motor precision.

• Woodworking or gardening with an adult either at home or workshops for kids. Some Home Depots offer free workshops for kids on the first Saturday of the month (check your local store)– increases strength, visual motor coordination, bilateral coordination and fine motor precision.

Take advantage of the good summer weather and let your child learn while enjoying the outside!

About the Author

Marybeth Oliva is an occupational therapist at Cook Children's. Occupational therapy focuses on fine motor and functional skills to enhance development, restore function and to prevent disablility from pediatric conditions, illness and injury. At Cook Children's, we understand that no two children are alike. That's why we offer four types of therapy plans, tailored specifically for your child and his or her needs. We want to make every appointment unique for each family. 

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

I would be very silly and extremely uninhibited in a way that, in other settings, I was not. After all, in the words of one of the songs I liked back then, “We can dance if we want to.”

But do they feel welcome at your table?

If you think about our kiddos, that’s all they know these days. Just walk around at the mall. You see a kid and attached to them is a tablet.

Are tablets the worst thing in the world? I don’t think so, but they may be affecting the types of interactions we have with our children according to a study completed in Toronto, Ontario. They found that for “every 30-minute increase in daily screen time was linked to a 49 percent increased risk of what the researchers call expressive speech delay.”

Now, I know what you’re thinking, “What about those educational Apps that go over colors, ABCs or numbers?” I see your point, but that’s only part of a child’s language. Let’s think about conversational turn-taking or even play skills. I don’t think I’ve come across applications that can teach children those important skills.

I’ll be honest, my son is 2 years of age and there are times where we put him in front of a screen. It keeps him occupied while we complete chores or help his infant sister. It happens and I don’t want you thinking that you are the worst parent in the world.

Just like most things though, everything needs to be in moderation.

My son was at a birthday party recently. All the children were doing an activity and the instructor told the kids to yell for help. All the kiddos obviously said, “HELP!” Except my son, who is really into Mickey Mouse Clubhouse. He yelled out, “Ohhh Tooodles.” If that wasn’t a sign that he is watching too much TV I don’t know what is!! It’s kinda embarrassing considering I am a speech therapist.

Just like most parents, you learn as you go. There isn’t a manual for these sorts of things. If parenting wasn’t hard enough, society around us is also continuously changing. My wife and I have quickly learned that although my son asks for Mickey Mouse dance (that’s what he calls it because of the hotdog dance) it doesn’t mean we have to turn it on for him. There are so many games that we can play. Surprisingly, I was doing chores around the house and he wanted to help as well.

Here are some tips to get your kids away from the screen and be interactive with you:

1.Reenact an episode of your child's favorite show (in our case it's the Mickey Mouse Clubhouse). You can do similar games or even make up your own.

2.Pause the TV show he or she is watching and talk about what you just saw or what you think will happen next.

3.TURN THE TV OFF. Our most fun experiences have been when the power has gone out. That forces us to interact and just play.

Interaction involves an action. Just NOT sitting on the couch in front of a screen.

In our area, MayFest is this weekend! But before you go out, be sure to pull out the sunscreen as you head out for the fun!

Here are a few things to remember:

1. We recommend sunscreen for all children 6 months of age and older, regardless of skin type. There are several explanations for not using sunscreen on young infants:

• Their skin may be more permeable, resulting in more absorption of the chemicals in the sunscreen.
• They have a larger surface area of skin, so are more likely to absorb the sunscreen.
• They are also more likely to get dehydrated and suffer negative effects of sun exposure, so we really want you to keep them in the shade.
• I usually tell patients if sun exposure is unavoidable, sun block in better than a sunburn, but the best bet is to use lightweight clothes that cover them and stay in the shade.

2. Use sunscreen rated at least SPF 30.

3. We find lotion more effective than spray products.

4. Apply sunscreen 15 to 30 minutes prior to sun exposure.

5. Plan to use about 45 mL or 9 teaspoons of sunscreen for older children and adults. Estimate 1 teaspoon for the face and neck, 1 teaspoon for each arm, 2 teaspoons for the torso and back and 2 teaspoons for each leg. Reapply every two hours.

6. Stay hydrated and have a great time.

Now with three kids of my own, I often hear, “Am I going to have to get a shot?” My 6-year-old tells me weekly that she doesn’t have to get any more shots until she is 11. She heard nothing else at her well-check appointment except what was said about the shot schedule.

I am a mom to three beautiful girls ages 18 months to 6 years. I am no stranger to doctor’s appointments, shots, and all the fretting that comes with all of it. Heck, some weeks I feel like the office staff at the pediatrician’s office knows what’s going on in my life better than some of my closest friends.

I spend every car ride on the way to an appointment walking my kids through exactly what to expect from their appointments. I walk them through standing on the scale, to the room, to the doctor coming in and finally, when they ask me if they are going to get a shot, I tell them the WHOLE truth. I tell them how many, and where, and even how we are going to sit when it’s time. Are you thinking I’m the crazy mom now? Are you wondering why in the world I would give my kids so much detail at such young ages?

Not only am I a mom, but I’m also a Certified Child Life Specialist (CCLS) at Cook Children’s Medical Center in the Emergency Department. My job is to prepare and support kids throughout their health care experience. Preparation is without a doubt the most important part of my job. On a regular basis, parents tell me that before we start an IV, give a shot of antibiotic, or suture a wound that they would rather we just did it and surprised their kiddo rather than tell them what is going to happen before it happens. Yet, every time I walk in a room, I say some version of this:

“Hi, my name is Ashley. I am a child life specialist, and my job is to make sure you know what’s going to happen before it happens. We don’t like surprises here at the hospital. So let me tell you what we are going to do next…”

And the whole room changes. Children immediately begin to engage with me in conversation.

Research over decades demonstrates preparation reduces stress and increases the child’s ability to cope with healthcare experiences. It is important to note that timing, the child’s age and developmental level, previous healthcare experience, type of procedure, the child’s learning style, and personality should all be considered when offering preparation. (Rollins, Bolig, & Mahan, 2005, p. 44).

My oldest needed to know months before her 4-year-old well-check that she was going to have shots, and she needed me to walk her through the experience over and over. She is an external processor, the first-born, and order is her love language. She even had to talk through her fears and shed a few tears before the visit…more than once.

Many of you may be thinking that this sounds like a lot of work. The intensity that can come with a child’s constant worries and fears can make you say, “Let’s just show up and get it over with!” Trust me when I say that I know that feeling well. You think they will get over it and recover, but the reality is, in those moments of “getting it done,” you may create a traumatic healthcare experience that will follow a child throughout their lifetime.

My youngest is a preemie, and we spent eight days in the NICU at Cook Children's. Every single time, since she was just under 1-years-old, that we walked into the doctor’s office whether it was for her or her sisters, she began to cry and suck her thumb. She is my only child that has had, what I would consider, traumatic healthcare experiences; however common belief is that she was too young for those experiences to affect her. I completely disagree. We walked into the dentist the other day for her sisters’ appointments, and she cried all the way down the hallway because it resembled the doctor’s office. It took her several minutes to feel safe enough to stop crying.

So, all of that to say, it matters. Your children need to have an opportunity to prepare their minds, process their emotions, and be a part of making a plan to help them cope. A few things to consider as you prepare your child for the doctor’s appointment:

My girls love going to the dentist…for real. They LOVE it. I truly believe this is because of the environment our dentist office has created. They prepare them for everything, let them ask questions, and they always let them leave with a prize. Don’t be above a prize. My mother-in-law says that as adults we get paid for our hard work, why shouldn’t they get paid for theirs too. If your child is successful and gives their best, reward their efforts.

A quick note on pain: Children interpret a lot of touch as pain. They are most concerned with what is going to hurt, and they immediately feel out of control. Also what they see is what they believe. So if something appears painful, it is. Your preparation helps to identify what will actually hurt, identify how other things are going to feel, and help them realize that they can be in control by making a plan on how they will handle what they feel. (Kuttner, 1996, p. 77-79)

Going to the doctor doesn’t have to be a horrible, dreaded experience. It really can be just another part of life that we do on a regular basis. So the next time your child asks if they are going to get a shot at the doctor, answer them truthfully, let them ask questions, validate their feelings and then go get some ice cream!

Kuttner, L. (1996). A Child In Pain: How To Help, What To Do. Vancouver: Hartley & Marks Publishers, Inc.

About the Author

Ashley Pagenkopf is a Child Life Specialist in the Emergency Department at Cook Children's Medical Center. The Child Life program at Cook Children's offers a variety of services, all designed to make your experience at Cook Children's the best it can be. Our services include educating, preparing and supporting your child through tests and procedures, as well as coping with any life challenges you and your child may face. 

Studies have shown that activity and movement can be very beneficial to children with ADHD and can aid in their ability to pay attention and learn.

Short bursts of exercise during frequent breaks can be a solution but the number of schools cancelling PE and recess has seemingly increased. In addition, children with ADHD are frequently punished by restriction of PE/recess or asked to complete work during these important breaks in their day.

Outside of vigorous physical activity, studies have shown that children with ADHD perform better on tests of attention and learning when they move. The problem is, if it is not controlled, that movement can be disruptive and distracting to the child with ADHD, their classmates and their teachers.

A new class of products, called fidget devices, seeks to solve that problem by giving children an opportunity to have a slight distraction in a controlled way.

Fidgets devices come in a wide range of options - fidget cubes, fidget spinners and fidget eggs are just a few of the options. Most have a variety of actions that you can do such as spinning, flipping a switch, rolling a ball or turning a dial.

Studies have been done on related items, such as stress balls, which have shown increased attention and learning while children are using them, but we are still awaiting evidence on the effectiveness of the newer and more versatile devices.

So fidgets aren’t for every kid and children should know that sometimes they won’t be welcomed in their classrooms.

But I believe they can serve a purpose for some children. You may even see me using one now and again.

About the Author

Justin Smith, M.D., 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.

That's one of the most common questions I get while doing my AMAs on our Willow Park Pediatrics Facebook page. 

The answer I give, most of the time, is - nothing.

Here's a few points about vitamins. Short and simple.

1. If your kiddo eats a well-rounded, healthy diet, they don't need a daily vitamin. This means meats, milk, veggies, fruits, and whole grains daily.
2. If your kiddo has a "bad day" - a.k.a. a chicken-nugget, mac-and-cheese kinda day, offer a simple chewable children's multivitamin that day.
3. Limit your child's milk intake to 20-24 ounces or less per day. While we love the calcium and Vitamin D in milk, it hinders the absorption of other vitamins, like iron, and fills kids up so they don't eat the other foods they are supposed to eat.
4. Large doses of certain vitamins can actually be harmful. Be careful of natural websites/naturopaths who claim "megadoses" of vitamins can cure ailments. Be especially careful with kids, as there is lacking research about this and some bad side effects can happen.
5. If your child is a vegan or a vegetarian, or allergic to milk, they need a daily vitamin. Talk to your pediatrician about this.
6. Certain medical conditions require vitamin supplementation. Think food allergies, GI tract disorders like celiac and Crohn's, and endocrinologic (hormone) problems. Talk to your doc.
7. Vitamins can have SIDE EFFECTS! Yes! Vitamins! For example, B vitamins are associated with night terrors and nightmares. Other vitamins can cause nausea, dizziness, vomiting, headaches. They're similar to medications, folks - yet not as strictly regulated by the FDA - and you have to be careful with them.

Cook Children's published a good article about vitamins a few years ago. Check it out!

Hugs,

Dr. Diane

About the Author

Have you ever gotten to a point in doing something so much that you feel like you just need to take a break?

No … I’m not talking about marriage. I’m talking more like working out. You know what I mean. You get to the point where you’re doing like 2 or 3 hundred pushups in a row. Who am I kidding? I’ve never done that many pushups. But I have tried having a trainer before. I remember getting to a point in the training where I felt like I could basically take over. As I did the exercises, I knew when my form was off and I knew what exercises I needed to improve on.

Speech therapy can be the same way. So many times, we want therapy to continue year after year after year. I get it. It’s hard to let go of something you know is helping your child. But breaks are sometimes not only needed, but beneficial.

Often, when working out you come to some sort of plateau. You feel like no matter what you do, you aren’t improving. Well, that’s when you can go back to the trainer, who will help you make adjustments and keep the improvement going. Speech language pathologists (SLP) are really knowledgeable and can help adjust your child’s plan of care so your child continues toward attaining his or her true potential.

Let’s first address the purpose of therapy. Your speech language pathologist’s goals should be:

1.Work with you to figure out the needs of your child and how their speech and language difficulties are affecting their day to day life and learning.

2.Come up with a treatment plan that allows for your child to improve in the areas you and the SLP feel are important.

3.Teach you strategies you can use to work on the things your child has trouble with as well as discuss activities that can be done outside of therapy.

4.Teach you to be your child’s speech therapist at home!!

As a clinician, I feel No. 4 is most important. Most kids get therapy maybe 1-2 times a week for about 30-60 minutes. Most parents feel that isn’t enough.

I AGREE!!!

Just imagine if you could learn everything the therapist was teaching and the strategies to teach the concepts. Your child would be getting therapy basically at all waking hours. All of a sudden your interactions change. For example, you know that when your child has difficulty understanding a direction, you can assist them by using the “breakdown” strategy.

This is where you maybe break the direction up into pieces. For instance “Dominic, go to your room and get the ball.”

Well little Dominic may just look at you with a confused face. Kind of like the face my wife says I have when she asks me to do something. But that’s neither here nor there. By “breaking down” the direction, you may first say “Dominic, go to your room.” Then, when that is complete you say “Get the ball.” This allows him to fully understand the direction. Similarly, you may use a strategy that would make it easier to produce a sound, such as providing a tactile or visual cue.

Let’s say little Mia has difficulty producing the “B” sound. We may point to our lips to get her to realize that we need our lips to make lip sounds. Now that is awesome. When children apply what they have learned in therapy, it is wonderful because we want children to improve; BUT when parents apply what they have learned, it is magical. Questions to ask your therapist could include:

1.What are the goals for my child?

2.What strategies are you using to assist my child and teach them the concept? Can you teach them to me and help me do them correctly?

3.What can I do at home to help with generalization of the skill?

Every child is different so each plan of care may differ in how long therapy lasts. At some point though, through ongoing discussions with the clinician there should be an ending point. You get to now apply what you and your child have learned in therapy.

Keep in mind that this isn’t the end-all-be-all. In most cases, I recommend a re-evaluation in 6 months to ensure that there is continued improvement or even to adjust the plan of care. As a therapist, I understand there still may be concerns. I want, however, my parents to feel empowered by the knowledge they now possess. My goal is that the parent leaves my therapy session understanding our objectives and strategies.

Bob Keeshan made a good point when he said “Parents are the ultimate role models for children. Every word, movement and action has an effect. No other person or outside force has a greater influence on a child than the parent.”

Aye, aye captain.

Whether it’s bottle feeding or breastfeeding, you may have some questions or concerns – things that many other parents have also questioned! If not, or maybe you’re just not sure, speak to your pediatrician about a possible feeding evaluation by a speech-language pathologist (SLP). Build or re-build that bond. There’s lots that can be done to help and it will have lasting effects! Let’s take a look at three of the most common problems moms have and suggestions on what can be done about them.

1. Problem: Baby won’t stay latched during breastfeeding or falls asleep.

The best intervention for saving breastfeeding is the earliest intervention. Getting help from a lactation counselor or consultant before you feel like throwing in the towel will help to alleviate some of the frustration you and baby may be experiencing. Don’t wait - below are some resources you can contact. The WHO’s (World Health Organization) stance is breastfeeding serves a nutritional purpose for children until they’re at least 2 years of age! So keep it up, Mama!

2. Problem: My baby coughs, chokes, and is simply a messy eater.

If a baby is coughing, choking or losing milk from around the bottle when feeding, stop what you’re doing and find a nipple that may flow a little slower. Despite their very new presence in the world, babies are usually very good communicators if we’re really “listening”! They may be telling you that the milk is coming faster than they can swallow it. This might be a really easy fix. However, make sure your feedings are not taking too long and baby is getting enough. If you’re unsure, ask for help.

3. Problem: My baby spits up more than what I feel is normal.

Dr. Smith just wrote a very informative and thorough blog about gastroesophageal reflux and how it impacts feeding. Take a look at what he has to say about it and compare it to what you are seeing in your child. While the majority of cases of reflux resolve on their own around 6 months, as SLPs, we do see infants and children whose eating habits have been severely affected by it. Make sure to make notes about your baby’s behavior and discuss them with your pediatrician!

Learn more from the Tarrant County Breastfeeding Coalition

Following our posts on the safety of Miralax and answering some frequently asked questions about Miralax use for constipation, we heard one resounding question:

"When should I be worried and when should more workup be done?"

Benign (or not concerning) causes:

• Constipation starts with a dietary change or at the time of toilet training
• Children show a stool withholding behavior
• Things resolve easily with stool softeners

But what are the warning signs? When should you be worried? Here are nine symptoms or signs that more workup should be considered for your child’s constipation:

1. Constipation has been present since birth or early infancy
2. Any other symptoms with constipation-fever, vomiting or diarrhea
3. Bleeding in the stool or from the rectum
4. Swelling or distension of the belly
5. Long, narrow stools (sometimes called “ribbon stools”)
6. Urinary accidents or recurrent urinary tract infections
7. Poor growth or weight loss
8. Other, non-belly symptoms, especially neurologic symptoms like weakness or abnormal sensation in the legs
9. Abnormal findings in the lower back (birthmarks or hair along the spine)

The workup for constipation can vary depending on the child’s symptoms and exam findings. Some things that might be considered:

Imaging -Most commonly the child will undergo a barium enema which is an X-ray that is enhanced by an enema that shows up on the X-ray. If there are concerns about the child’s neurologic symptoms, an MRI of the spine can be conducted to rule out something called a tethered cord.

Blood work - Depending on the child’s symptoms, blood testing for the following could be indicated: celiac or thyroid disease, calclium and blood lead levels.

In severe constipation or constipation that does not resolve, a referral to a gastrointestinal doctor can be helpful for further workup and treatment recommendations.

.

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.

If you missed the first story, please check it out here. Now for some constipation and Miralax AMA responses:

1.Is short term use of MiraLax for a colonoscopy OK?

Quite a few studies have looked at short-term use of MiraLax for bowel regimens for colonoscopy, which showed MiraLax to be safe and effective (and much more tolerable than more “aggressive” regimens).

2.What are the diet modifications for treating constipation?

Foods that are high in fiber should be offered to children who are experiencing constipation. Some examples would be high-fiber cereal (more than 5 grams per serving), fruits (pears, strawberries, apple with skin, dried fruits) and vegetables (beans, sweet potato, lentils). Children should also be encouraged to drink 32-64 ounces of water per day. One common cause of constipation is ingestions of more than 32 ounces of cow’s milk.

3.What are the treatment alternatives for MiraLax?

Of course, diet and fluid intake are the primary means of treatment and should be for all children. There are other medication alternatives to MiraLax. Some work like MiraLax and are osmotic (draw fluids into the bowels) but others are stimulating (they cause the intestines to contract). Each has its own side effect profile so I would recommend discussing with your pediatrician.

4.Is there tolerance or dependence on MiraLax over time?

According to the available information about MiraLax, there should be no reason to believe that a tolerance to MiraLax could develop. Kids should be transitioned to a high-fiber diet and weaned off MiraLax as soon as possible.

5.Are probiotics an option for treating constipation?

A few small studies looked at the use of certain probiotics for constipation, but nothing I can find on a large scale study or a firm suggestion of which bacterial strains and dosage should be included.

6.Is MiraLax absorbed into the bloodstream?

Based on the available information, there is no reason to believe that MiraLax is absorbed into the bloodstream. A current study in Philadelphia is intended to better address this question by assessing if small amounts of the substance or bi-products are present in the child’s blood.

7.Would you give your child MiraLax?

Given the available information, if my children had problems with constipation that couldn’t be relieved with diet modifications, I would feel comfortable giving MiraLax to them. Should further information from the Philadelphia study surface, I would definitely want to take that into consideration.

In today’s technologically driven world, it’s difficult to know how to accept the advancement of technology while also determining where to set boundaries as a parent. As a mom, I too struggle with this concept.

However, a study through Texas Tech University shows that there are actually positive effects on learning when a parent watches TV alongside their child. According to the study, when a parent is present while watching TV with their child physiological changes take place in the child’s body. The child exhibits more effort to learn from the program they are watching. This is important because parents often underestimate the power and influence they have over their child’s life. This study shows that by just being present with your child, you are having a positive impact on their ability to learn from the program being watched. It is important to note that this can happen when both positive and negative content is being displayed on the TV, which is why monitoring the type of shows your child is watching is even more important.

According to the authors, “Just being there is making a difference.” But, why is being present important?

Well, it provides your child the ability to ask questions and engage in a dialogue about the content being viewed. All too often the TV has become just another babysitting tool. However, I would encourage parents to see it as an opportunity. An opportunity to spend quality time with your child, to learn something educational, to be present, to understand your child’s interests and why they like the things they do.

It’s important to note, that “being present” may look differently depending on the age of your child. For a younger child, it may mean pointing out learning opportunities while watching shows (e.g. while watching Mickey Mouse Clubhouse, discussing what is happening/counting together, etc.). However, with an older child/adolescent, this may mean having conversations regarding the show being watched and addressing how it may/may not pertain to the child’s life. For example, if watching any type of news channel talking with your child about the events being depicted and how it may/may not impact their daily life. Topics may include things such as bullying, violence, political processes, funny videos that have gone viral, etc. Being present allows for the opportunity to open the lines of communication between you and your child. It allows for you, as the parent, to show interest and be able to influence their ability to learn from what they are seeing.

The authors bring up a great point when they state, “I think our focus needs to be on raising a generation of media-literate parents in order for them to make the difference for children that we really want to make.” In my opinion, it’s less about seeing technology in an all good or all bad manner, and more about seeing it as an opportunity to learn, engage in conversations, and explore our child’s interests with them. It’s about figuring out how to incorporate these technological advancements into our daily lives, while also deepening our relationships with our children and realizing the influence we continue to have over their lives.

Tips on being involved:

• Be present and active
• Sit next to your child
• Ask questions
• Discuss the content
• Be mindful of what type of show is being watched
• If developmentally appropriate, talk about events happening across our world and discuss your child’s views, opinions, and thoughts.

About the author

Amanda Jordan is a licensed psychologist at the Cook Children's Urgent Care and Pediatric Specialties -Alliance.Cook Children's Behavioral Health services provides a broad range of care that focuses on children from 3 years through 17, and thier families. We also have some limited services for children age 2. As part of family-centered care, all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.

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.

I have more than once used the "you don't want to be the kid that smells" tactic on my kids and once they are school age it usually works to get them to brush their teeth. In elementary school most kids don't care about life long health but they do care about friends and teachers. I prefer not to use star or sticker charts as I find they are more work for parents--but if this works in your family go for it.

Toddlers are another creature entirely. I suggest that parents start cleaning babies teeth early not only for health but to get them used to it. Under 1 year it can be as simple as wiping the teeth with a wet washcloth, but at 1 year I have families starry using a toothbrush. There are lots of little tricks out there to keep toddlers brushing. My favorites are singing or counting while brushing--same song every night--they love routine. Once toddlers get into the "I can do it myself now" stage, get 2 toothbrushes. Let the toddler "brush" with one and the parent can use the other at the same time to really brush. Does all of this fail sometimes--yes. I have I held my toddlers down to brush their teeth--yes. Have I skipped teeth brushing--yes.

For all kids one of the most important things a parent can do to protect the teeth is to keep kids off of sweet drinks--that means no juice--and not letting them fall asleep with a bottle or cup of milk after age 1 year.

I have seen many toddlers and young children over the years require anesthesia and surgery to repair decayed teeth. This is entirely preventable with good dental care. Please ask your pediatrician if you need help in carting for your childs teeth or contact one of the Cook Children's dentists.

Related Articles

• 5 Reasons Why Baby Teeth Are Just As Important As Permanent Teeth
• Parents, Stop Giving Your Teething Babies Homeopathic Remedies
• Protecting Your Young Athlete From Dental and Facial Trauma
• 4 teething myths every parent should know
• 5 life-saving reasons to take care of your teeth

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

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

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

“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.

But, every now and then, something really interesting grabs my attention as something that you might find interesting, even if it’s highly unlikely you’ll ever see it. This is one of those posts.

Children can cry bloody tears. It’s very rare. It’s usually not caused by anything concerning. But, imagine if your child walked up to you with blood streaming down his or her face.

What are the possible causes?

1. Trauma

I would hope that if your child got poked in the corner of the eye and was crying bloody tears, you would be able to quickly deduce the cause but here it is.

2. Infection

Sometimes infections (like pink eye) can cause enough inflammation such that bleeding can occur. The tissue around the eye is pretty fragile and when it is inflamed, small cracks can cause it to bleed.

3. Just Because

Bloody tears seem to sometimes happen just because. Even after investigation into possible causes, no diagnosis is made. These cases tend to resolve over a few months.

4. Conditions that Cause Easy Bleeding

There are a few conditions that can cause children to bleed more easily. Some children are born with them and some develop them over time. If a child has easy bleeding or excessive bruising, this could be the cause.

5. Bloody Noses

Children with bloody noses can also shed bloody tears.

How? There is a small tube that connects the corner of the eye to the area behind the nose. It’s called the tear duct and this tube is the reason why your nose starts running when you ugly cry.

If your child’s nose is bleeding a lot or if they are trying to stop a bloody nose by applying pressure and sneeze or blow out hard, the blood can come out the duct as a tear.

What do you do for your child if they have bloody tears? Of course, it’s different for each cause. If there’s a stick coming out of it, go to the emergency room. If the child has had red eyes, other signs of easy bleeding or you can find no other cause, call your doctor. If your child has had a bloody nose, continue to apply pressure to the nose to stop the bleeding. Once the bloody nose has stopped, the bleeding tears should stop. If it doesn’t, call your doctor.

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

And that sucker was pushed in real deep. 

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

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

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

Hope this helps you in your time of crisis 

Hugs,Dr. Diane

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

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

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

1)The Manipulator/Negotiator

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

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

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

2)The Screamer/Crier

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

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

3)The Creeper/Sneaker

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

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

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

About the author

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

Have you seen or talked to them since?

Whether it’s a phone, a tablet or the TV, there’s no denying that the use of screens and media have changed childhood and parenting. Do you have a child that seems addicted to their screen?

With any change, there is potential good and potential harm. The American Academy of Pediatrics (AAP) has changed their stance recently based on the current state of research on the use of screen time on children and adolescents.

If you have time (and are a little nerdy), I strongly recommend that you read them:

Media and Young Minds

Media Use in School-Aged Children and Adolescents

Children and Adolescents and Digital Media

It’s a total of about 30 pages of work. But, given the current state of how these affect our children and parenting styles, and the practice of pediatrics, there are fewer more important papers you could read.

AAP reccomendations include limiting screen time to 1 hour per day of for children 2 to 5 years of age. For kids 6 and older, be consistent with the amount of time looking at the screen and don't let it interfere with sleep, physical activity and other activities essential to good health.

In case you don’t have time, here are 11 key facts you should know about the new guidelines:

1. The average age children interact with media in 1970: 4 years; Today - 4 months.

2. You have to teach your toddler to talk, a device can't. Limit solo screen time until 2 years of age.

3.Under 18 months = Video Chat Only. 18-24 months = Choose high quality apps and play with child. Reteach what they are learning if you want any benefit.

4.Children must learn to sooth themselves without a screen. Don’t hand the phone over at the first sign of trouble.

5.Screen free zones are critical = 1) Dinner 2) Meal times 3) Bedroom 4) During play time (yes, parent, that means your phone too).

6.Media use is not ALL bad in teenagers: 1) Knowledge 2) Collaboration 3) Social support

7.Media use and overuse in teens can lead to many problems: 1) Obesity 2) Poor sleep 3) Problematic internet/gaming (addiction).

8.Is monitoring your teen's phone/device enough? No. You can't see/watch everything. You must teach them core values as well.

9.It’s not just kids struggling with these issues. Distracted parenting is a real problem as well across child ages.

10.If you want to succeed in this struggle, you must have a plan. Try out this great free tool from @AmerAcadPeds : http://www.healthychildren.org/MediaUsePlan

11.Just because an app or show is listed as educational, doesn't mean that it is ... do your own research and watch/play with child first.

It happens.

It’s terrifying.

But it’s usually nothing to be worried about.

These events when children hold their breath for a spell are cleverly named “breath-holding spells.”

Despite the fact that they are scary, here are 8 facts about these events that might dispel some of that fear.

1. Fear, anger, pain, and frustration are all possible triggers.
2. Episodes usually start between 1 and 2 years and stop between 4 and 6 years.
3. Seizures should be ruled out, so talk to your doctor after the first episode.
4. Recovery takes less than 1 minute.
5. Imaging of the child’s head is not routinely necessary.
6. Brain damage does not occur as a result of the episode.
7. Treatment at the time of the episode is not helpful.
8. Punishment for breath-holding spells is not helpful because they are an involuntary reflex.

While breath-holding spells can be scary, hopefully these facts will help you remember that things are going to be OK. Children will usually outgrow them at some point (over 50 percent are gone by 4 years of age) as they develop better coping skills.

Until then, make sure you don’t allow tantrums. Teach your kids this is not OK. If you are having trouble disciplining your child or there are other concerns talk to your pediatrician or a counselor.

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

Few things I want to put out there first:

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

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

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

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

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

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

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

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

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

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

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

So...who needs "tubes?"

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

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

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

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

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

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

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

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

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

• Make sure your hair is dry.
• Wear shoes outside.
• Put on your hat.

But does any of this really matter?

Between well-meaning friends and family members and the wealth of websites devoted to health, parents are bombarded with tips and tricks to their kids healthy year round, but especially during the winter. This can make separating fact from fiction difficult.

“Not all old wives’ tales are fictitious – some are grounded in truth. However, if you have questions or hear health advice that doesn’t make sense to you, always ask your children’s pediatrician before acting on the information or simply believing a statement is true,” said Justin Smith, M.D, a pediatrician and medical advisor for Digital Health at Cook Children’s.

And now, let’s let Dr. Smith give us the facts on these five winter health myths.

Myth 1: If children go outside with wet hair or without shoes during winter months, they’ll get sick.

Many people believe that cold temperatures are responsible for the spike in illness that typically occurs during late fall and the winter months. According to Dr. Smith, people get sick in the winter because they spend more time in close proximity to one another – not because they’ve been exposed to cold weather.

The truth is it’s not really going to matter that much if your kids go outside without socks and shoes – except maybe if you don’t want dirty feet or if it’s extremely cold, your child runs the risk of frostbite.

“It’s true that we do see more colds, flu and flu-like viruses during the winter,” Dr. Smith said. “Both the life cycle of common viruses and the fact that people are more likely to be clustered inside their homes and schools when it’s cold outside, which causes viruses to circulate, contribute to this increase.”

Myth 2: People lose most of their body heat throughout their heads, so children should wear hats while playing outside in cold weather.

This tale originated in response to several studies conducted by the United States Army in the 1950s. Further research has since debunked this claim, but it’s true that your face, chest and head get colder faster when you’re exposed to winter weather.

“Your face is particularly sensitive to the cold,” Dr. Smith said. “If your children’s faces are cold while playing outside, they should wear warmer clothes. But colds come from germs – not cold temperatures – so children aren’t going to get sick if they don’t wear a hat.”

Myth 3: Feed a cold and starve a fever.

According to Dr. Smith, there’s no scientific evidence to support the idea that children should fast when running a fever. Children who are sick should eat when they feel up to it and drink plenty of fluids to prevent dehydration.

“Even if children don’t feel hungry, we ask parents to encourage their kids to drink as many liquids as they can,” Dr. Smith said. “I’ve also heard an old wives’ tale that says you shouldn’t drink milk if you’re running a fever, but milk works as well as other fluids when it comes to keeping kids hydrated. Other good choices include water, Pedialyte and Gatorade.”

Myth 4: All fevers should be treated with medicine because high fevers are dangerous.

As parents, it’s only natural to rush to the medicine cabinet at the first sign of a high temperature, but fevers aren’t always a cause for concern. In fact, they help your child’s body fight infection. According to the American Academy of Pediatrics, children’s demeanors are often better indicators of illness severity than the numbers on the thermometer. If children aren’t fussy or complaining of feeling badly, there’s no need to treat a fever unless their doctor says otherwise.

Myth 5: You can’t prevent your child from catching a cold.

While there’s no cure for the common cold, you can take steps that will reduce your child’s risk. In this case, grandma is right. These are the same steps she told you. Wash your hands after you sneeze. Wash your hands after you blow your nose. Wash your hands after you eat. See a theme? Children should sneeze into the crook of their elbow and not their hands. They should blow their nose to get rid of the mucus. For children too young to blow their noses, parents should use a blue bulb syringe and drain the child’s nose with salines. If a cold lasts longer than a week, bring your child in to see his or her pediatrician. It could possibly be a sign of acute sinusitis and may need to be treated differently than the common cold.