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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“While we are ecstatic that children are finding ways to get exercise and enjoy being outside, we want to remind parents to make sure that kids are protected while having fun,” said Kara Starnes, D.O., medical director of Urgent Care at Cook Children's.

Helmets are a Must for Fun on Wheels

ATV and dirt bike crashes are a common occurrence during summer. Over Memorial Day Weekend, the emergency department in Fort Worth saw 10 injuries related to motorcycles, dirt bikes, ATVs and skating.

Always ensure your child wears a properly fitted helmet to avoid head injuries. Adult supervision is essential when a child is riding any motorized vehicle, and children should never ride on ATVs or dirt bikes designed for adults.

“Please supervise your children on motorized vehicles,” Taylor Louden, M.D., medical director of Pediatric Emergency Medicine at Cook Children’s Medical Center – Fort Worth said. “They should always be wearing their seat belt and appropriate safety gear. The start of summer is a great time to check your kids’ safety gear and make sure helmets fit appropriately and are in good condition.”

A helmet that fits correctly will feel snug but not uncomfortable. 

A few other key points:

• Helmets that passed federal safety standards in testing will say “U.S. Consumer Product Safety Commission certified” on the label.
• Helmets should be worn in a level position just above the eyebrows.
• If the helmet rocks backward and forward or side to side, adjust the straps. No more than two fingers should fit under the buckled chin strap.    
• Never ride without a helmet.

Water Safety: A Constant Vigilance

Drowning is the leading cause of accidental death for children ages 1 to 4, and the second leading cause for kids 1-14 in Texas. Drownings can happen silently and quickly. A submerged person might not attract attention or appear to be in danger. These tragedies highlight the importance of constant supervision around water.

Sharon Evans, trauma injury prevention coordinator at Cook Children's, emphasizes, "There's no off-season for drownings. A moment of inattention can be devastating."

Unplanned swim time is a major culprit, with roughly 70% of drownings at Cook Children's occurring when parents weren't expecting their child to be near water.

Layers of Protection: Keeping Curious Toddlers Safe

Multiple safety measures, known as "layers of protection," can significantly reduce drowning risks. Fencing around pools with self-latching gates, preferably 5-feet high, is crucial. Door and window alarms can alert you if a child exits the house unsupervised. Remember, young children are naturally curious, so removing pool toys and floats when not in use minimizes temptation. For above-ground pools, make sure to remove the ladder when the pool is unsupervised. Consider using a pool surface alarm for added security.

Cook Children's has developed the "Lifeguard Your Child" campaign to raise awareness about childhood injury prevention. Through this initiative, you can find resources like free swim lessons, safety videos, and loaner life jacket stations at lakes across North Texas. Visit lifeguardyourchild.org for more information.

Sun Safety: Protecting Young Skin

Sunburns are not just uncomfortable; they can increase a child's risk of skin cancer later in life. Zinc oxide-based sunscreen is best whenever your child is outdoors. Covering skin with SPF is another way to protect your child’s skin. Apply sunscreen generously 30 minutes before sun exposure and reapply every two hours, or more often after swimming or sweating. Protective clothing, hats with wide brims, and sunglasses that block UV rays offer additional defense.

Hydration: Keeping Cool and Healthy

Dehydration can lead to nausea, dizziness, headache, or even heat stroke. Encourage frequent sips of water throughout the day, even if your child doesn't feel thirsty. Avoid sugary drinks that can worsen dehydration.

Your child’s urine colors can range from clear to dark yellow to orange, depending on how hydrated they are. To tell if your child is dehydrated, read this article from Celina D. Cepeda, M.D., a nephrologist at Cook Children’s Medical Center – Prosper.

Fishing Fun Without the Hooks

Fishing is a popular summer activity, but fish hooks can pose a safety risk. Teach children to handle hooks with care and supervise them closely while fishing. Consider using barbless hooks to minimize injury if a hook snags on skin.

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It’s summer! That magical time of the year when school is out, and kids can be more active. It also brings sweltering temperatures, which leads to sweaty, thirsty children that can become dehydrated. Dehydration can lead to nausea, dizziness, headache, or even heat stroke.

So, how can you tell if your child is staying hydrated? Ask them what color their pee is! Urine color has been found to be a good marker of how hydrated a person is. Keep reading to find out if your child is staying adequately hydrated. (This, of course, also applies to adults.)

This is an 8-color urine color chart.

Some things to keep in mind:

• When hydrating, water is best, but other fluids count if they don’t include caffeine.
• The amount of fluid that should be consumed differs from person to person depending on weight; ask your child’s pediatrician for an estimate.
• Urine that has no color/transparent means overhydration; cut back on water intake; there is such a thing as water intoxication.
• Some vitamin supplements, like those containing B vitamins, can turn urine bright yellow.

The highs this week will be above 100, with temperatures expected to reach 105 degrees. As we head into the scorching heat, it’s important to remember that infants and young children rely on adults to keep them cool, hydrated and safe while outside.

Stay Cool

Too much time out in high temperatures can cause heat-related illnesses such as heat exhaustion and heatstroke.

"As the outside temperature rises, your family's risk of heat stroke rises right along with it," said Corwin Warmink, M.D., medical director of Emergency Service at Cook Children’s. “On 100-degree days, it's best to stay inside. If temperatures exceed 90 degrees, stay in the shade and keep a close eye on the kids."

Take these steps during the summer to prevent heatstroke and heat exhaustion:

• Wear appropriate clothing: Choose lightweight, light-colored, loose-fitting clothes. Wear a hat to shield yourself from the sun, until you feel yourself getting warm. Then remove any items covering your head which can trap heat close to the body.
• Schedule outdoor activities carefully: Heatstroke can occur in less than an hour when you are participating in strenuous activity during a hot day. Try to limit outdoor activity to when it’s coolest, like morning and evening hours. Rest often in shady areas so your child’s body has a chance to recover.
• Hydrate: Drink plenty of water during the day, especially if you are engaged in any strenuous activity. Be sure to drink water or a sports drink before, during and after any strenuous activity.
• Ventilate: Stay where there’s plenty of air circulating to keep the body cool. If you are without air conditioning, visit a shopping mall or public library. Remember, electric fans may provide comfort, but when the temperatures reach the 90s, they will probably not prevent heat-related illness. A bath or cool shower is a much better way to stay cool.
• Wear Sunscreen: If you got outside, use sunscreen, wear a wide-brimmed hat, sunglasses and put on sunscreen of SPF 15 or higher 30 minutes before going outside. Continue to reapply according to the package directions.

Don’t Leave Your Child Alone In A Car

Over the weekend, a 6-month-old girl in Ohio and 17-month old boy in Florida died after being left inside vehicles. Twenty-four children have died in hot cars in the United States this year, according to noheastroke.org.

Since 1998, 767 children have died nationally as a result of being left in a car. Texas leads the nation in children dying from pediatric vehicular heatstroke with 16 deaths since 1998.

For the Trauma department at Cook Children’s, statistics are much more than numbers. They represent very real, too often tragic consequences.

“Every time we hear of a child dying in a hot car, it’s heartbreaking for all of us,” said Sharon Evans, Trauma Injury Prevention coordinator at Cook Children’s. “It’s especially devastating because these deaths are preventable."

For More Information On This Topic:

• Tips for Preventing Heat-Related Illness - CDC
• Heat Exhaustion and Heat Stroke
• Child Safety Center
• Vehicle/Car Safety
• Drowning Prevention

We always get plenty of phone calls

Here are some common scenarios for which we have parents call our office:

Vomiting with diarrhea—could be a viral gastroenteritis, commonly called the “stomach flu”. It’s usually not dangerous, but very uncomfortable. Very young children are most at risk for dehydration. But, because most children are very resilient, significant dehydration won’t occur if the child is able to take sips of liquids frequently during the illness and the illness is short, typically a day or 2.

Vomiting with fever—many conditions can cause this from early symptoms of a cold or the flu to some gastroenteritis or strep throat.

Vomiting with bloody diarrhea—could be due to serious intestinal infections and the child should be seen as soon as possible.

Vomiting with change in mental status (confusion, disorientation, excessive sleepiness)—could be due to a head injury, a poisoning, etc. A child with this presentation should be seen immediately.

Vomiting with a headache—may be due to a migraine, an infection such as the flu or strep, but if these symptoms occur after a head injury, this could signal a serious problem due to the injury. In this case, go to the emergency room.

Over -the-counter products are not typically recommended for young children.

If a clinician determines that the condition isn’t serious, then recommendations for home treatment will be given.

We would love to be able to “turn it off” so your child feels better, but most of these conditions are only treated with supportive care and TLC—care that parents can provide at home.

Often we see children in the office to assess for dehydration. Signs to watch for include:

• Dry cracked lips and a dry mouth
• Decreased urine output and very dark urine
• Drowsiness or irritability
• Cold or dry skin
• Low energy levels, appears weak or limp
• No tears when crying
• Eyes sunken or a baby’s soft spot (fontanelle) sunken in

Commercially available solutions such as Pedialyte, Gastrolyte or Enfalyte will contain the properly balanced amounts of water, sugars, and salts to promote absorption of the fluid. Oral rehydration is the best option for mild to moderate dehydration. Give your child 5-10 milliliters (1-2 teaspoons) of one the previously mentioned drinks every 5 minutes, slowly increasing the amount as your child tolerates. If you breastfeed your child, continue to do so.

If your child refuses to take an oral rehydration solution, try giving fluids you know your child likes, such as milk or water mixed with juice. But if your child has severe diarrhea, milk and juice may make it worse. So encourage the oral rehydration as best you can.

If you think your child is severely dehydrated, go to the Emergency Department immediately.

It can be a hard thing for adults to deal with. Unfortunately, many children suffer the same pain. For some, it’s a genetic condition that’s been passed along to them. But for others, migraines are the result of injury. For 15-year-old Olivia Gillespie, her migraine problems began when she received her third concussion.

“It happened in cheerleading practice, I was kicked in the head,” says Gillespie. “I was fine. I didn’t think it was that big of a deal.”

Then months later, Gillespie was on a ski trip with her youth group when a headache came on and never went away.

“I just kept doing what I was doing and tried to not let it have an effect on me,” she said.

Gillespie tried to ignore the pain for two months before she said anything to anyone, but then the pain got worse.

“Olivia had an ongoing headache that would not fade. On a scale of one to 10, it was a consistent five," said Amelia Gillespie, the teen's mother. "It wasn't until her pain reached level seven that it really began to affect her.”

When Cynthia Keator, M.D., pediatric neurologist at Cook Children’s, first saw Olivia, she wanted to make sure her headaches could be treated without medication. Together, they worked on her sleep habits and diet. Dr. Keator also suggested supplements such as B2, and Omega 3, which has shown to help with headaches. In addition, Gillespie was referred to the Biofeedback Clinic at Cook Children’s.

“Biofeedback teaches patients how to control their pain by controlling their breathing, heart rate and body temperature,” says Dr. Keator.

Biofeedback specialist Nanny Christie, Ph.D., has been teaching the painless technique for decades.

“We place the child in a reclining chair and use pads to measure their body activity,” says Christie. “The equipment plugs into a laptop so the kids can see everything on the computer screen. If they tighten a muscle, a line goes up. If they relax, the line goes back down.”

Christie says teaching children to harness their breathing and muscle movement this way allows for real time learning. She says about 80 children are seen in her clinic each month. A typical visit is 45 minutes to one hour and each child is seen roughly four times.

While it wasn’t the end-all, be-all cure for Gillespie, it did help. She says she uses the technique to curb her head pain. If she feels a headache becoming worse, she can focus and calm her anxiousness which in turn can help the headache.

Also, ask your doctor about preventative medication. Your doctor may prescribe something prescription strength or a natural supplement to ease the pain.

Make sure you DON’T ask your child this question:

“How’s your headache?”

You may want to, but remember that asking about a headache is like scratching a mosquito bite. By asking, you’re reminding your child about their pain.

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

In today's video, Doc Smitty explains:

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

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

Primary headaches are the result of problems with pain sensitive structures in your head. These include migraines, tension headaches, chronic daily headaches, cough headaches and exercise headaches.

Secondary headaches usually point to an underlying condition activating the pain sensitive nerves in the head. These include sinus pressure, concussion, dehydration, ear infection, flu, tooth pain, etc. More serious causes of headaches can occur, for which you would need to see a doctor immediately.

Physical therapy is well suited to help patients with headaches. Most primary headaches can be related to or made worse by muscular tightness in the neck, base of skull, and head. This tightness can be due to trauma, joint stiffness, joint instability, poor posture or overuse. Physical therapists can address this muscular tightness in several ways. We work on increasing the flexibility of the muscles involved, improve the strength of the musculature in the area, and mobilize stiff joint segments. We also address the child’s posture and stability of the area by retraining the musculature to work in symphony with each other to achieve good posture and stability of the neck and shoulders during static and dynamic activities.

Here are four ways for kids to improve their headaches:

1. Be aware of your posture. How are you sitting when at school? Where do you do your homework or read? Is it on your bed, or couch, or on a desk? Try to improve your posture by sitting up straight, preferably in a chair that offers low back support and keeps you upright. Make sure that the computer or books are close enough that you can read easily without looking down or sticking your chin forward.
2. Take mini breaks throughout the day. A good rule of thumb is a 2 two- minute break for every 30 minutes. During this time, get up walk around your space, stretch.
3. Stretch. Your muscles tend to tighten down to match the movement they are allowed during the day. If they don’t move much, they will begin to tighten. Neck and shoulder stretches are important to loosen the muscles you use to hold your head up and use your arms during the day. The stretches should be held for at least 30 seconds for better results.
4. Build strength in the muscles of the neck and shoulders. The stronger your muscles are, the better they can handle the stresses of the day. Exercises could include chin tucks, shoulder shrugs, lat pulls, rowing, pushups and tricep dips.

If you have any questions, please feel free to contact your pediatrician.

About the author

Bruce Morgan, PT, is a SPORTS physical therapist at Cook Children's. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind.

How do you know when it is something else or when it could be more dangerous?

A report last week from the CDC described a cluster of infections caused by shigella, a bacteria that can cause severe diarrhea.

Shigella is common, causing an estimated 500,000 cases of diarrhea in the United States annually. But this group of infections is unique because it has been found to be resistant to the most common type of antibiotic used in adults used for shigella. Most cases have been located on the East and West coast and many have been associated with travel outside the United States.

Fortunately, there were no cases of this more severe form of shigella reported in Texas so I feel that we are pretty low risk at this point. I did want to take a second to tell you about warning signs that might alert you that diarrhea might be more than a stomach bug.

Here are some symptoms that might alert you that should trigger a call to your doctor:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that last more than one week.
6. Let your doctor know if your child has traveled recently.

What are Salmonella and Shigella?

Two of the most common bacterial causes of infection are salmonella and shigella. They are both fairly frequent causes of severe diarrhea in children.

They can both be transmitted by contaminated food or water but can also be spread from person to person. Salmonella is more frequently caused by transmission from contaminated food, but also can be contracted from infected reptiles. Shigella is more frequently acquired from other children and is much more contagious than salmonella.

(Just to give you an idea, stool of a child infected with shigella contains 100,000,000 bacteria per gram of stool. Ingesting just 200 bacterial cells is enough to cause infection. Because of this, outbreaks of Shigella are common in child-care settings.)

The most common symptoms with both infections are diarrhea, abdominal pain and fever. With shigella, fever is often higher and children are more likely to have blood or mucous in their stools.

For either infection, your doctor can run stool studies to confirm the diagnosis. This may not be necessary if there are known cases that the child has been exposed to.

Both infections will typically go away on their own in seven days or less. Most healthy children do not require antibiotics. I do not routinely recommend anti-diarrheal medications in children because they can prolong symptoms with some infections.

If you suspect your child has one of these infections, consult with your doctor and keep them out of day care until we are sure they will not put other children are risk.