As pediatric experts, Cook Children’s Health Care System know that protecting a child's health is about preventing emergency room visits just as much as treating illness. Ahead of the major soccer tournament, the system launched "World Cup Wednesday," a weekly healthcare series providing local and international visitors with essential resources on injury prevention, heat safety, water safety and guidance on when to utilize urgent care versus the emergency department.

The hottest time of the year in Texas is here, with temperatures regularly ranging from 80-100 degrees between June and August. Medical experts from Cook Children’s Health Care System advise caregivers and parents on what to know before attending outdoor activities or fan watch parties.

“Children can't cool off the body as well as adults,” said Monica Herrera, M.D., a pediatrician at Cook Children’s Pediatrics Windhaven, “it's important that we keep them hydrated.”

Dr. Herrera emphasizes that hydration is key during these months, as well as protecting children's skin from the sun and mosquitoes.

Learn the signs of heat-related illnesses

Spending too much time in the heat without proper hydration can lead to heat exhaustion and heatstroke. Dr. Herrera said learning the signs for heat-related illness is important, so caregivers know when to seek medical attention.

Symptoms include:

• Feeling faint or confused: A child may begin acting disoriented.
• Walking unsteadily and losing coordination.
• Headache
• Abnormally warm skin: Feels hot to the touch.
• Lack of urination: No wet diapers or bathroom use in eight hours.
• Nauseous and vomiting
• Shallow breathes: The body uses shallow breathing to try to shed excess heat.
• Muscle cramps: A child may complain that their legs hurt.
• Numbness

If a child exhibits these symptoms, seek immediate medical attention.

Preparedness is the number one way to avoid heat-related illness and Dr. Herrera says it starts with hydration.

Hydration Tips

Babies under 6 months old should generally be kept indoors. However, if an infant is outside, Dr. Herrera recommends they stay hydrated with formula or breastmilk. Babies under 6 months should not be given water.

“The breast milk has everything that the baby needs as does formula,” said Dr. Herrera. “If you're outside for a prolonged period they really need to be drinking every 20 minutes.”

As children get older water becomes the priority for hydration, but there are other tricks if your little one isn’t fond of H20. While water is best, other caffeine-free fluids and water-rich foods can help count toward hydration.

“Fluids don’t always come in the form of liquid,” said Dr. Herrera.

Alternative hydration sources:

• Ice cream
• Popsicles
• Snow cones
• Crushed Ice
• Fruits (Watermelon, grapes and cantaloupe) are an excellent source of hydration
• Soft liquids (such as yogurt, applesauce)

How do you know if your child is hydrated?

Check their urine. Urine is the best indicator of hydration status for both children and adults. A well-hydrated child's or adult’s urine should be clear to a light yellow, similar to a light lemonade color. If the urine is dark yellow or tea-colored, dark orange, more fluids are needed.

Sun protection

While hydration is critical, protecting a child’s skin is a close second. Dr. Herrera explained that children’s skin is sensitive and can burn when exposed to the sun for a prolonged period. While sunblock Sun Protection Factor (SPF) ratings range in coverage from SPF 10 to 80, Dr. Herrera recommends choosing products with two active ingredients: zinc oxide or titanium dioxide and use a sunblock of SPF 30.

Babies under 6 months of age should not have sunblock applied. Instead, keep them in the shade and dress them in a wide-brimmed hat.

Sunblock recommendations for 6 months and older:

• Choose a mineral-based sunscreen.
• Use SPF 30
• Apply 15 to 30 minutes prior to going outside.
• Reapply every two hours.
• Avoid sunscreens containing oxybenzone.
• Choose lotions over aerosol sprays to ensure total skin coverage.

Staying Cool in the Sun

• Dress children in light-colored, loose-fitting clothing.
• Choose breathable, absorbent materials.
• Avoid sitting directly in the sun. Seek shade when possible.
• Use cool mist sprays for quick relief.

Mosquitos

Summer heat in Texas also brings mosquitoes, which thrive around stagnant water and in hot, humid climates.

“Mosquitoes, as we know, can carry viruses which can cause severe infections and serious complications,” said Dr. Herrera. “We want to avoid mosquito bites if at all possible.”

The most effective line of defense is insect repellent.

Finding the best repellent:

• DEET is the most effective option.
• For infants up to 2 years of age, use a maximum of 10% DEET.
• For children older than 2, a maximum of 30% DEET.
• Apply repellent only to exposed skin or on top of clothing. Do not apply it underneath clothing.
• If concerned about applying directly on the skin, apply repellent on clothing instead.

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But, driving to work the last few weeks and seeing all the standing water already starts to make my skin itch. Mosquitos are on the way. And I suspect it’s going to be a terrible year.

Mosquitos can cause a variety of problems:

1. Simple itching and discomfort-small bites which can lead to infection when scratched
2. Large local reactions-which can be very itchy, even quite painful (See more at Skeeter Syndrome).
3. Serious systemic illness such as West Nile Virus, Zika virus or Chikungunya.

But our kids don’t have to suffer. There are great options for preventing mosquito bites and warding off some of these miserable consequences.

DEET

N,N-Diethyl-meta-toluamide sounds like a little bit of a scary name for a chemical we can put on babies as young as two months. But DEET has been extensively studied and consistently shown to the safe and effective as a mosquito repellant in children. Recommended concentrations of 10-30% provide great protection with 30% lasting around five hours.

Picardin or Lemon Eucalyptus Oils

Multiple alternatives to DEET have been tried. Studies have shown that these two alteratives can be as effective as 10% DEET and thus last around two hours. Reapplication will be important if there are plans to be outside longer than two hours.

Here are some important facts about applying insect repellant:

1. Spray a thin layer over clothes and exposed skin. Thick layers do not make it more effective.
2. Use your hands to apply repellant to the face rather than directly spraying.
3. Spray in open areas to avoid ongoing inhalation.
4. Assist young children with application to ensure coverage and safety.
5. Avoid combination sunscreen products because reapplication of sunscreen needs to be done more frequently.

Having a healthy and fun summer should include TONS of outdoor play. Keeping your child safe from mosquitos is one part of making sure nothing spoils the fun.

Read more: 

'Skeeter Syndrome': Is My Kid's Bug Bite Infected?

An Infectious Disease Pediatrician Explains Differences and Similarities between West Nile and COVID-19

Everything You Need To Know About DEET and Protecting Your Kids From Mosquitos

Why Do Mosquitoes Bite Me and Not You?

 Chiggers Myths Parents Need To Know

Most people develop some redness and itching after a mosquito bite. Unfortunately, some children will have what’s known as a large local reaction, or “Skeeter syndrome.” This happens due to an allergy to mosquito saliva. These patients develop redness and swelling within hours of a mosquito bite. The swelling can be very large (like an entire arm or leg) and typically worsens over 1-2 days. In the worse reactions there can be bruising and even blistering!

It’s not always easy even for your doctor to tell the difference between “Skeeter syndrome” and a skin infection. One of the big differences is the timeline. Skin infections usually happen several days after a bite or an injury, but “Skeeter syndrome” usually starts within a few hours of a bite. Most often children with a large local reaction will complain about intense itching. Only in the more severe cases are pain and fever seen with allergy. It’s not common, but some even develop severe allergic reactions to mosquito bites that lead to difficulty breathing.

Large local reactions are best treated with oral antihistamines (Benadryl or Zyrtec) and topical over-the-counter steroid cream (hydrocortisone 1 percent). Fingernails need to be trimmed very short, because scratching causes local skin damage that can become infected. Cold compresses several times a day help alleviate some of the discomfort. In patients who have a history of this type of reaction, I recommend daily antihistamines such as Zyrtec during the time of the year when bites are difficult to avoid. This doesn’t totally prevent the reaction, but can help keep the swelling from being as extreme. I don’t recommend topical antihistamines (Benadryl cream) because some people develop a contact allergy that actually worsens the problem

So, when should you come to the doctor? 

Any child with significant eyelid swelling or swelling that is limiting activity or skin blistering deserves an office visit because they require further evaluation and sometimes even need oral steroids or more potent prescription topical steroids. Red/swollen/hot areas of skin that are associated with pain or fever should also be examined to rule out a bacterial infection.

Tick bites don’t usually cause itching like mosquitos, but are more of a concern due to infections they can transmit. Ticks are predicted to be more prevalent this summer due to the winter being relatively warm. Ticks can transmit several infections with Lyme being one that is often discussed.

If you find a tick on your child it should be removed with tweezers by grasping the tick as close to the skin as possible and pulling straight up. Different types of ticks spread different infections. For example, infected deer ticks can spread Lyme after being attached for 36 hours or longer. Certain areas of the country have a much higher rate of local tick infection than others. Texas is not a part of that area, but cases of Lyme do occur every year.

It is best if children bathe after coming in from playing outside to wash off ticks prior to attachment. It’s a good idea to look in hidden areas such as behind the ears and on the scalp. Remove ticks if you find them and watch for a rash. Certainly, a rash that looks like a bull’s eye or a target (erythema migrans) is concerning for Lyme infection and needs to be seen for further testing.

Insect bite avoidance is important (and hard)! The large local reactions are definitely very uncomfortable, but infections transmitted by mosquitos such as West Nile or Lyme from ticks are potentially very dangerous. Using DEET containing insect repellant and wearing long sleeves during peak mosquito times are helpful.

As always, see your pediatrician if you are worried about a bite or rash and we are happy to help.

Related:

• The deets on DEET from a pediatrician
• Protecting Your Child From Ticks

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

So…what is the best mosquito repellent out there?

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

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

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

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

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

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

Hope this helps you navigate your fight against these beasts.

Dr. Diane

Below is the evidence I promised: 

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

Summer is nearly here! Let's quickly hit some of the most common questions I get around this time of year - about sunscreen, DEET, and life jackets.

1. Sunscreen:

Use it! Even on a cloudy, not-very-hot day! 80% of the sun's rays penetrate clouds! And bounce off sand and snow!

Start using it at age 6 months. Prior to 6 months, do not have your baby in direct sunlight - put them under heavy shade and put a hat on them. If you can't find shade, use sunscreen on small amounts of their skin and try to cover skin with clothing.

Go with SPF 30-50 for your kids. I don't care about brand.

Zinc oxide (the stuff that won't disappear when you rub it in) is the best. It physically blocks the harmful rays. Great for nose, ears, cheeks, tops of shoulders.

Put it on 15-30 min BEFORE YOU GO OUT.

Reapply every 2 HOURS.

PUT ON MORE THAN YOU THINK YOU NEED. 1 teaspoon per limb is about right. 1 tsp for back, 1 tsp for chest. 1/2 tsp for face.

I don't like the sprays. They miss spots and can be inhaled. If you have to use them, spray a ton on your hands and rub it it in good.

More good info about sunscreen here: https://www.checkupnewsroom.com/5-tips-to-protect-your-chi…/

2. DEET:

DON'T BE SCARED OF IT. It is not "DDT"! It is safe down to age 2 months. It is the BEST way to prevent insect bites and this has been proven time and again in medical studies.

Read a ton about this in another article I wrote here:

https://www.checkupnewsroom.com/the-deets-on-deet/

If you absolutely don't want to use DEET, go with Picaridin.

Those wrist bands ain't gonna do anything.

3. Life jackets!

Use only life jackets that are approved by the US Coast Guard.

Here are the types (compliments of the AAP Healthy Children website):

TYPE 1: This jacket floats the best. It is designed to turn most people who are unconscious in the water from the face-down position to an upright and slightly backward position. This jacket helps the person to stay in that position for a long time. It is to be used in open water and oceans. It is available in only 2 sizes: 1 size for adults more than 90 pounds and 1 size for children less than 90 pounds. (Type 1 is the most bulky but has the greatest ability to turn a child "face-up".)

TYPE 2: This jacket can turn a person upright and slightly backward but not as much as the Type 1 jacket. It may not always help an unconscious person to float face up. It is comfortable and comes in many sizes for children. (More comfy but will only turn SOME children "face-up".)

TYPE 3: This jacket is designed for conscious users in calm, inland water. It is very comfortable and comes in many styles. This life jacket is often used for water sports and should be used only when it is expected that the rescue can be done quickly. (Least bulky, most comfortable. Good support for children who have some swimming skills.)

This summer, I will be using Type 1 lifejackets for my kids when we go to the ocean or are at the lake. I will be using Type 2 when we are in the wading pool. My kids are 2 and 4 and I will be within a few feet of them at all times when they are in/around water.

WATCH YOUR CHILDREN AT ALL TIMES WHEN THEY ARE IN OR AROUND WATER. DROWNING IS SILENT.

Let me say that again: DROWNING IS SILENT.

Cook Children's has a great drowning prevention resource page. Click here to learn more.

Hope this helps answer your burning hot summer questions!

Hugs,

Dr. Diane Arnaout

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