No doubt – the HPV vaccine (Gardasil) is the vaccine I hear the most hesitancy about. And yet I convince parents each and every day to get it – with patience, understanding, and some awesome, strong evidence that it works and is safe.

Little background: HPV (Human Papilloma Virus) is a nasty little virus that you get from other people – through intercourse, oral sex, or just heavy “making out” (yes: kissing can spread HPV).

The CDC states that at least 75% of the reproductive-age population has been exposed to HPV!

HPV lays dormant in most people, but sometimes it causes growth. Sometimes, uncontrolled growth.

Uncontrolled growth = cancer. Cancers of the cervix, vagina, anus, mouth, throat, head and neck in women and men. It also causes anogenital warts. Fun times.

HPV is one of the main reasons women get Pap smears – to see if this virus is causing trouble.

“The HPV vaccine? Isn’t that the new one? It seems like it hasn’t been out very long.”

• The first HPV vaccines were released in 2006.  That’s almost 17 years ago! 17 YEARS!
• The updated version (from the 4-strain to the 9-strain) came out in 2014. 9 years ago!
• It ain’t new! It’s been used for almost two decades and has been given safely to over 270 million people across the world!

“Isn’t this a little early to get a vaccine for something that’s transmitted through sex? My kids aren’t having sex.”

• The vaccine works BETTER when you are YOUNGER. Your immune system is SMARTER when you’re younger, and holds onto the “information” for longer periods of time!
• As evidence of this, you only need two shots if you get the series before age 15. After age 15, you need three shots.
• It is devastating to think about – but why not protect our kids from things that are out of our (and their) control as well? What if something happened to them, like sexual abuse?

“Are there any bad side effects or reactions to this vaccine?”

• In my 12 years of practice as a general pediatrician, I have never seen a severe reaction to an HPV vaccine.
• A sore arm, dizziness, and fainting can be common 15 minutes following the vaccine, so we often will watch them in the office for a while after they get the shot.

“Does it work?”

• Heck yes, it does. Like, really well. Better than most vaccines, actually.
• The longest studies done on these vaccines are at 10+ years, and they seem to be between 90-97% effective at preventing these cancers and warts.
• There is evidence nearly 99.9% of people who get the shot create some form of antibody to the virus.

“Why should boys get this vaccine?”

• Boys give HPV to girls. And vice versa.
• Boys can get anal cancer, anogenital warts, oral cancer, and throat cancer from this virus.

“Why should I believe you about all this? The internet says I shouldn’t get this vaccine.”

You don’t have to believe me. Though I am a pediatrician who has given thousands of HPV vaccines in my practice.  It’s OK. I know some vaccines just seem plain ole scary.

Maybe believe my cousin, though? She’s a cancer doctor. A gynecologic oncologist, to be exact. And what virus does she spend all day battling in order to save the lives of women? HPV.

My cousin is Mae Zakhour, and she practices gynecologic oncology at Spectrum Health Medical Center in Grand Rapids, MI. She treats HPV cancers in women, daily - some as young as 25!

Her exact words to me – to share with you – are:

“Timely HPV vaccination is the safest and most effective way to prevent cervical cancer and other HPV-related diseases. As a gynecologic oncologist, I see and treat young women with cervical cancer on a weekly basis, and even for those in whom cure is a possibility, it comes with a cost.

The treatment for cervical cancer, > 95% of which are caused by HPV, can have devastating effects on a woman’s fertility and quality of life. I want to do everything possible to prevent that for my children. They are getting the HPV vaccine.”

So there you have it. Two moms, who also happen to be doctors, sharing information with you to help you make a very important decision for your child.

And both letting you know we’re getting our kids vaccinated for HPV at age 9 without hesitation!

It’s normal to be nervous about vaccines. What I hope you take from this is more confidence in the HPV vaccine - by knowing it’s super safe, it’s been out a long time, it’s super effective, and it’s super important.

RELATED: New Study Says Boys Less Likely to be offered HPV vaccination (checkupnewsroom.com)

Vaccine and Immunization (cookchildrens.org)

‘We Have a Vaccine That Can Prevent Cancer' (checkupnewsroom.com)

Texas Ranks Near Last in HPV Vaccination Rate (checkupnewsroom.com)

August is National Breastfeeding Month.

And as much as I hate the word “journey,” allow me to tell you about my breastfeeding journey.

I figure there’s a lot of curiosity out there about a pediatrician’s breastfeeding experience. I mean I sit in my clinic rooms all day counseling about it, right? So surely it was an easy task for me? Surely I would sit in daily joyful motherhood bliss while my babe nursed happily with ease and comfort, right?

Heck. No.

In fact, I disliked a lot about breastfeeding. But I loved some of it, too.

(And guess what? GASP! This pediatrician used some formula, too! What? Did she say the F word?)

Before I gave birth to my first kid, I knew breastfeeding could be challenging for some moms. I didn’t worry or fret about it too much, though, because how hard could it be?

I mean, you just put the baby on the boob, right? I’m a pediatrician! I got this!

Ahahahahahahha.

My first kid refused to latch from day one. I worked with lactation consultants. I struggled with pain. I had his mouth anatomy evaluated (all was fine). I tried shields. I had supply issues. My kid screamed. Every. Nursing. Session. And I cried every nursing session. His reflux was constant and affected positioning, length of feeds, and general happiness.

My postpartum anxiety was vicious. And made everything probably 10 times worse than it already was.

So, I decided to pump. Exclusively.

And it was the hardest damned thing I’ve probably ever done.

It satiated my need for control in a situation where I felt I had no control. But it was hard. And mentally and physically exhausting.

I’d pump in my office many times a day, running late for patients and adding stress to an already stressful day. And while my also-pumping work partner would pull out 10 ounces at a time when she pumped during lunch with me, I’d get a measly 3 or 4.

And every day, I went into the bathroom and cried. What was wrong with me? Why was motherhood feeling so robotic and protocoled and cold? Why did I cry for 45 minutes if I spilled a bottle?

But I knew pumped milk was so beneficial to my baby. So I kept on going. For 6 months. Until my supply tanked because I couldn’t pump enough at work. So we used formula. And guess what? My baby survived. And I survived.

It took such a mental toll on me to not be able to breastfeed my child that when I was pregnant with my second, my husband and my mom both nervously asked me…”you have some cans of formula just in case…right?”

They asked me this out of the kindness of their hearts, and I responded with, “yep! In the closet!” because I too remembered the dark days. And I wanted the experience with my next baby to be different.

And it was different.

Guess who breastfed like a champ? My next kid.

And the breastfeeding experience was great. And flawless. And so easy. And tear-free.

I loved bonding with my child in this special way. I loved feeling like nutrition and protection were transferred to her from my body. I even loved the exhausting 3 am feeds.

So why tell you all this?

To let you know that every mother is different, just as every child is different.
To let you know you aren’t alone if you felt breastfeeding was a struggle you totally weren’t prepared for.
To let you know even the professionals are human, and struggle just as much as you do.
To let you know it is okay to both love and hate breastfeeding.
To let you know I (and any pediatrician) will never judge you for the choices you make in how you feed your child.

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

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

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

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

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

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

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

What is a tongue-tie?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are all tongue ties “bad”?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some take-home points from me, a pediatrician:

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

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

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

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

Now, for some extra reading!

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

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

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

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

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

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

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

When I graduated from my pediatric residency 11 years ago, I knew there would be questions from parents daily about their child's growth, development, illness, behavior, etc. 

"What’s this new movement?"

"Is this behavior normal?"

"What should I be doing about this rash?"

But there are seriously some things I get asked about that make me chuckle every day – not because they’re silly, as no question for your doctor is unimportant – but because I never knew I’d be answering them so often!

Here are seven of the most uncommon, common questions asked by parents: 

1. "Is this much earwax normal?” – The answer is probably yes. We make earwax daily, some of us more than others, and in all types of colors and textures. Earwax protects our ear canal and prevents infection.
2. “Is my baby’s teeth grinding normal?” – Yes! When they get those fun new chompers, it’s really common for them to click and grind them as they explore that new feeling in their mouth. I remember it setting off my baby alarm sometimes at night because it was so loud…
3. “Why does my baby have rosy cheeks?” – Sometimes babies get rosy cheeks. It’s often due to dry skin or cold weather. But sometimes, babies just have beautiful, well-circulated cheeks. And 99% of the time it bothers parents more than the baby.
4. “What is this little bump at the bottom of my baby’s skull?” – Okay, I know this is oddly specific, but there are two little lima bean-shaped/sized lymph nodes on the back of the skull, top of the neck area. They are called occipital lymph nodes and nearly everyone feels them on their baby’s scalp at some point, especially after that first bath and shampoo. They’re normal and as long as they’re not growing or more are showing up, you’re okay to just observe them.
5. “Every time I pick up my baby, her shoulder/hip/arm joints pop! Is this normal?” – Yes. Growing joints mean popping joints. As long as your baby isn’t crying in pain, totally fine.
6. Toenails. Toenails. Toenails. Baby toenails are weird. Some have wings. Some are flat. Some are curved. I never knew I’d dedicate so much time to toenails in check-ups!
7. And finally… “Is his penis color normal??” – Baby penises are different from adult penises, including the color. Some are blue. Some brown. Purple, pink, orange. As long as your baby does not appear in pain and that color hasn’t changed recently or suddenly… just go with it.

Newborn Notes From a Pediatrician:

1. The hiccups are normal.
2. The sneezing is normal. It’s not allergies.
3. The booty is going to get red (baby's, not yours). This is from the constant wiping and moisture. If ulcers start to form, be more gentle with the wiping or even run that tushy under some warm water in the sink rather than wiping, and apply a barrier cream with each diaper change (Desitin, A&D, Boudreaux). Air dry booty often.
4. No amount of lotion will help that peeling, flakey skin in the first few weeks. They're like snakes - they shed that first layer after they're born.
5. No need for lotion, unless your pedi tells you so.
6. After they lay down for awhile, they often sound congested. This is usually because of reflux, which all infants experience at some point or another. I wrote a couple of articles on reflux you may find helpful: "Let's Learn About ... Infant Reflux" and "3 Important Questions Answered About Your Baby's Reflux Answered."
7. If you’ve chosen to breastfeed - congratulations on a great way to feed and nourish your child!
8. If you’ve chosen to formula feed - congratulations on a great way to feed and nourish your child!
9. Spitting up is normal now and then. Sometimes it comes out of the nose, yes. That’s okay. It’s just another hole in the head.
10. Putting the baby on a schedule is hard at first. They really need to eat as much as their brains are telling them to - and that often seems sporadic and chaotic, but it needs to happen. You can start some simple sleep training steps from day one, though. Start waking your baby at the same time every morning. And put her in the living room during the day for the first month - make sure there’s lots of light and noise in the area. Even if she’s sleeping through it, this will start to “set” the circadian rhythms - which tell her when to be awake and when to sleep. At the same time each night, turn lights low and put baby in a quiet room.
11. During the day, feed your baby at least every 3 hours. They’ll want to eat more often than that sometimes, and that’s okay. But if it’s been 3 hours, go ahead and wake her up. We want to get as many “daytime calories” in them as possible!
12. There is a very common, very gassy/grumpy phase they start around week 3. It is called the Period of PURPLE Crying. Often, during a certain part of the day (i.e., evening), they will cry, grunt, and generally look uncomfortable.You can read more about my thoughts on it here. 
13. Some babies poop with every feed. Some babies poop once a week. Both are normal.
14. It’s common for the hands and feet to be purple sometimes, especially if their leg is squeezed or they’re cold. This is called acrocyanosis and goes away with time. Always call us or an ambulance if you’re noticing any difficulty breathing, or if the tongue or gums look dusky or purple - this is different.
15. You don't have to clip the finger and toenails. You can peel or file them down.
16. Belly buttons are weird. Umbilical cords are weird. They ooze a little now and then and sometimes there’s a spot of blood on the diaper as they’re drying up and falling off. Let your pedi know if the skin around the cord is red and if that redness is spreading. Or if you feel like yellow goo oozing from it is excessive or soaks into clothes.

I know you feel alone, but know that you're not alone in your isolation these days, and there are still ways to connect. Create a safe "pod" of help and support and if you're my patient, know that I am in it with you.

It's OK to feel weird, and "off" those first few weeks or months - I did.

It's OK if you don't feel connected to your baby at first - I didn't. It was like a loud elephant was suddenly in the room.

If your feelings overwhelm you or worry you, PLEASE ask for help.

The picture you see above is of me and my first baby the night he was born. I was anxious, scared, exhausted, in pain, and I had no idea what I was in for.

Book smarts are nothing compared to experience, my friends. You will know more every minute, hour, and day.

Hugs,

Dr. Diane

Related Articles You May Be Interested In:

• During COVID-19 Pandemic, When Can You Have Visitors Over to Meet Your Newborn?
• Let's Learn About ... Infant Reflux
• 3 Important Questions About Your Baby's Reflux Answered
• Social Isolation and COVID-19 Causing More Anxiety for New Moms
• Should I Breastfeed During COVID-19 Pandemic?

At my house, the 4- and 6-year-old natives are growing restless. The backyard isn’t cutting it anymore, biking up and down the street is growing old, and running around in the sprinkler now holds as much joy as a root canal. The parks are calling our name.

But is it safe?

Let me let you in on a little secret – there’s so much we still don’t know about this virus.

And by “don’t know” I mean, there are no great, large, long-term studies about the virus out there. My guidance for you is, at best….educated guessing. So bear with me.

In my office, I’m constantly asked “well….what are YOU doing with YOUR family, Dr. Diane?”

Well, I’ve read a lot. And it seems like the conditions ripest for catching the virus are in enclosed spaces with a large number of unmasked people, within areas of poor ventilation.

So…playgrounds and parks seem low risk. With some planning.

What is my family doing?

1. We have a heart-to-heart each and every time we go. If a playground has more than 1-2 families presently playing, we will try again later, or try a different park. My kids no longer melt down if a park is too full; it’s part of the game plan to be as safe as possible. They know this is part of the deal.
2. Also – we talk about keeping distance from other families. The CDC recommends keeping 6 feet between households if possible. In most playgrounds this is feasible, if not too many folks are there. My kids have adapted to the idea of “well, the swings are full, so it’s see-saw time until that family is done using the swings!”
3. This may not be easy for little ones, like those under age 3, so it’s important to watch over your kids and gently guide their curiosity to other parts of the park if they seem to drift towards new friends.
4. The CDC says if you can’t keep 6 feet of distance between your family and another, to wear masks if over age 2. In the Texas heat, my kids just wouldn’t be able to deal with this. Also, I’m just not comfortable with crowded parks yet. So we leave the playground if lots of people arrive – and again, that’s part of the heart-to-heart talk we have before we go.
5. We pee before we go. Using public restrooms ups your risk. If you have to use them, wash hands thoroughly afterwards.
6. Some news sources are telling you to “wipe down surfaces before your kid plays on it." I feel like park time is so chaotic, this would be really difficult for me to do. Constant movement and large playground pieces make me feel like this is near impossible. Studies show that the virus can live anywhere from 5 hours to 3 days on metals, which is worrisome, but the virus degrades pretty quickly on hot surfaces (thank you Texas sun). I think if you have wipes and your child is super focused on a favorite piece of playground equipment, absolutely, wipe away. But I think handwashing at the end of your trip is more important.
7. I keep hand sanitizer in my car and we use it the moment we get in. We also wash our hands thoroughly once we get home for at least 20 seconds.

I know it’s sad to think of all this THINKING for something as simple as a trip to the playground. But it won’t be this way forever, you guys. Being careful like this buys us time, resources, education, medications, and possibly a vaccine soon. It’s not forever – but why not keep things as safe as possible in these uncertain times?

Get outside and enjoy this summer safely.

Dr. Diane

Related Stories:

• Cook Children’s Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 Pandemic
• Should My Chld Go To Summer Camp?
• When Can My Child Start Playing Sports Again?
• Should I Take My Child To Daycare?
• Helping Families Manage COVID-19 Stress

As Cook Children’s pediatricians, we are getting the forms daily. And the questions that come along with it.

“Can my kids go to summer camp this year?”

“Are we putting ourselves at risk by letting them go?”

While CLEARING your child for summer camp may be straight-forward for us, deciding whether or not they should attend camp this year can be a much more difficult question for families.

“Over time we will know more about the amount of disease in each community and the risk of being in a group setting at camp. At a minimum, camps have to maintain social distancing, wipe surfaces, enforce hand washing frequently, etcetera - and no high-risk children should attend,“ says Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s.

Some camps nationwide are choosing to hold smaller sessions, with fewer kids. Many are imposing daily temperature checks. Some are even requiring a camper be tested for the virus before starting. The American Camp Association has recently put out a lengthy guide for camps to help them comply with CDC recommendations.

Obviously, there’s no easy answer here. But here are some things to think about in making your decision (developed in part by the thoughtful physicians at Cook Children's Southwest Harris Parkway office):

1. How healthy is your child? Do they have any chronic health conditions that would put them at an increased risk of significant illness from coronavirus, such as diabetes, asthma or immune deficiency?

2. How healthy are your other household members? Is there anyone who your child has frequent contact with who is elderly or at increased risk of severe illness from coronavirus?

3. How important is this camp to your child? If it is something they feel ambivalent about, it is probably not worth the exposure. If they have been looking forward to it since last year, it may deserve a serious family discussion.

4. What safety measures is the camp taking? Is there a screening process? Are there attempts at some degree of distancing? What happens if someone gets sick during camp? It is very possible, if someone gets sick at the camp, everyone will be sent home. It’s for this reason if you do send your child, it’s best that your family plan to be available for an unexpected pick-up.

5. If your child gets sick at camp, it could potentially mean the child or family would need to be on home quarantine for two weeks. What impact would this have on your household?

As for my family? My kids are young, 4 and 6. We had plans to attend four daytime camps in Fort Worth, for 1-2 weeks each. We canceled those plans. My kids aren’t emotionally tied to the idea of camp, and while they’ll be a little disappointed, we will find other ways to get outdoors, plan some fun projects, and interact with other kids virtually (if you haven’t tried a Zoom dinner date with another chicken-nugget-eating family once a awhile…try it!).

Stay Safe,

Dr. Diane

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stay safe,

Dr. Diane

Normally, this is the time of year where I would write a heartfelt letter to moms for Mother’s Day. But given our unique, uh, pandemic situation … nothing is normal. So, instead, let me tell you what my heart feels.

Since mid-March, I have never felt so much like a doctor. And I have never felt so much like a mother. I have never felt – I mean really FELT, like deep in my core – those roles as much as I have these past 7 weeks.

Let’s evaluate my performance as both, shall we?

As a pediatrician, I encourage a thorough and varied education for kids and encourage parents to consistently uphold expectations.

(Yesterday, we literally couldn’t handle any homeschooling because my 6-year-old was having a tiny mental breakdown about his broken Lego set, my daughter threw her letter cards in the trash, and my qualifications as a home teacher are basically a solid nil. I propose giant pay hikes for all teachers ASAP.)

As a pediatrician, I stress the importance of a full night’s sleep. It’s so necessary to keep bedtime consistent to ensure children are getting enough!

(Says the lady who literally can’t understand how her 6-year-old can stay awake until 10 p.m. with enough energy to spare to run a small country - and I swear, child, if you get up out of bed one more time to tell me how your “eyes feel weird, not bad, just weird and I probably should watch some TV or eat something to help it oh and mommy did you know that a scorpion could probably beat a tarantula in an epic battle?” I will lose it.)

As a pediatrician, I ask you to consider socialization of your children, whether that be enrolling them in school, going on playdates, or simply a walk to the local library or park.

(OK well, yeah that’s a no right now.)

As a pediatrician, I ask you to get your children as much fresh air and exercise as possible. Minimum one hour a day!

(When it rains, when it’s too hot, when it’s too cold, or the wind isn’t right, or there is a breeze in the next state, or when just life happens - we are literal lumps. Couch lumps. Sometimes I can’t tell my daughter from a pillow. I literally lost her for 25 minutes the other day because she became a part of the couch.)

As a pediatrician, I tell you to offer your children three well-rounded meals daily. Offer 4-5 fruit or vegetable servings each day. A treat here and there is fine, of course!

(Last night, my kids ate frozen cheese pizza for the third night in a row. No fruit. No vegetable. Just pizza. And if they don’t get to pick out a piece of candy afterwards, God help us, it’s World War 3 in my household and if I hear any more screaming I may literally start bawling in the front yard so yeah, Twix bar? Sure, kid.)

As a pediatrician, I ask parents to set an example for their kids – your strength during these hard times is their strength!

(I have cried alone in my bathroom more times than I can count.)

As a pediatrician, I ask that you limit screen time for your children to less than two hours each day.

(Ask me to recite Olaf’s entire monologue from Frozen 2. Ask me. And prepare to be stunned as I have watched that movie now 54 times and now have it fully memorized. And if I desperately have to get work done? Let me tell you about my friends “Shark Boy and Lava Girl”.)

As a pediatrician, I want you to approach discipline wisely and effectively. Use positive reinforcement for the behaviors you want, and try varying methods to dissuade the behaviors you don’t want.

(Some days in my house, I yell more than I talk in a normal tone. Some days are really hard. Some days are really, really hard. I reach out to others for a break or for help on those really bad days. Click here to find resources to help you during this stressful time.)

I’m not divulging my shortcomings to you as a mother to prove anything to you other than… it’s OK, Mom. You’re human. Guess what? I am too. Just because I’m a pediatrician doesn’t mean I follow my own advice 24/7. And I certainly can’t do that during something as unprecedented as a silly little global pandemic.

Mothers, give yourself a little grace. We’ve never done this before – and no matter what that scientist or leader on television says – none of us know how long this will last. We can’t excel at all things on all days. We can only do our best as parents.

I’m here with you, and I see you trying really hard.

So if your family needs that second (or third) movie…do it. If you need time alone, it’s OK – you’re not a bad parent. If you need to just throw a frozen pizza on the table…I feel you, sister.

Use the extra time you’ve been given to soak in those children. Soak them in! Soak in their funny laugh at this age, and save all those drawings. Get in some giggles during that goofy TV show together. Watch their legs and hair curls grow longer on those walks.

Because things will get back to “normal” eventually, whatever that is for you – and those moments won’t be as visible or obvious. So soak it in! And fail sometimes with me. The beautiful part about motherhood is that if they consistently feel your love and protection, no mistake will be too great. And you can always start over tomorrow.

Here are the general rules:

1. Washing with soap and water for 20 seconds is the best method. The entire hand should be covered and scrubbed.
2. Alcohol based hand sanitizers are an alternative if they have 60% alcohol-but most are not recommended for use under 1 year.
3. Hands should be washed multiple times throughout the day but especially after having been around others, before and after feeding (bottle or solids), after the bathroom and if they are visible dirty.

Click here to learn more.

Fever has been recognized as being around for thousands of years. And yet it’s never gone away. We’ve just not evolved it away. Which must mean it benefits us, right?

The process of a fever, simplified/Dr. Diane-ified:

1. A germ (virus or bacteria) enters your body. One of your immune cells floating around notices it. It freaks out. It makes a whole bunch of chemicals to freak everybody else out. HIGH ALERT, EVERYONE!

2. The chemicals reach your brain (the hypothalamus, in particular). The hypothalamus says OK GUYS, GET THE ARMY OUT THERE, STAT. DO YOUR THANG. I'LL MAKE THIS PLACE REAL HOT TO HELP OUT!

3. The brain thermostat is set at a new number. Instead of 98 F, he’s now gonna re-set at 102 F.

4. Heart rate speeds up. Breathing speeds up. Blood vessels open, flush. The body is physically pushing the blood around faster, to get the white blood cells there quicker.

5. Muscles shiver, generating heat. You start making more immune cells. They travel around faster. They talk to each other more effectively. They “stick” to the bad guys better.

6. You feel cold, because your new “set” thermostat wants you to be 102F. You're not there yet, so your body is trying to get you there. You shiver. Your muscles ache.

7. Soon, the germ can’t replicate as much as it wants to. It can't divide and conquer. Maybe even its protective coating starts to break down a little bit.

After a few days of fever, you beat the germ! Thank you, glorious fever and fabulous immune system!

Studies have shown (in rats and iguanas) that there is even a higher success rate at overcoming a virus or bacteria if a fever is allowed to burn rather than when they're given medications to bring it down.

Oh my gosh. Aren’t our bodies amazing? And are you feeling a teeny bit better about that number on the thermometer?

Most of the time, fever is just a sign that the body is fighting something, and you just need to try to keep your kiddo hydrated and comfortable.

You do not have to run to the ER, or my office, at the very first sign of a fever if your child is over age 3 months.

But sometimes, fever isn't OK.

My son once woke up with a fever of 105.7F. I remember the day clearly. I totally freaked out, just like you do. Then I asked myself – what do I tell my patient families to do?

Once I tried a few different thermometers and they all read the same number, I gave him a dose of ibuprofen and put him in a warm bath (NOT cold – warm) and let him play.

I watched him closely. I made sure he was breathing OK, and able to drink. He seemed fine, just super grumpy.

After about 45 minutes, I re-checked his temp. It was 102F. He was sitting on the couch, drinking water and talking comfortably. I was OK with this. And he did fine. He had a fever for three days, and a runny nose and a little cough, and it went away. He had a virus, and his body took care of it.

6 Types of Thermometers:

1. Thermometer forehead “strips”, pacifier thermometers, and wearable thermometers - don’t buy them. Save your money. 

2. Forehead “temporal” thermometers – they’re OK. We use this kind in the office. Good days and bad days, and I think they’re usually as accurate as the ear ones.

3. Tympanic (ear) ones – easy to use. Pretty accurate. Don't use under 6 months, ear canals too tiny.

4. Rectal - most accurate (good luck)

5. Oral - second most accurate, if they can hold their mouths shut

6. Armpit - least accurate

Yes, you add one degree to the armpit temp measurements. Although again, I dislike the math.

But what I want to drive home is: if the child looks fine otherwise, the number often doesn’t matter too much to me.

Febrile seizures:

Something like 2-4 percent of kids between the ages of 6 months and 5 years have febrile seizures. This means they may have a seizure when they have a high fever spike. They usually stop by age 5.

These are super scary, but actually don’t cause any brain damage. The child should be rolled onto his side, and watched closely. Don’t stick anything into his mouth.

VERY rarely, unrelenting and long febrile seizures may indicate a bigger problem like something neurologic or genetic going on. But again, this is super rare.

Febrile seizures may run in families. If the seizure lasts longer than 5 minutes, call an ambulance. Again, these are rare, and usually very benign.

Whew. OK. I hope this helps you understand fevers better!

Education is empowerment in your child's health! The more you know, the better you feel!

Want even more on beautiful science of fever? It's all laid out here, with lots of big words and acronyms.

Have a great day, friends!

Dr. Diane

When I first met little Pierce a few days after he came home from the Neonatal Intensive Care Unit, I noted two things: Pierce was a tough little guy, a real fighter, and his parents were two of the most caring, loving and excited first-time parents I had ever met.

So you can imagine my horror to learn that my new sweet little buddy had contracted the potentially deadly disease called whooping cough (pertussis) before he was even 7 weeks old.

Pierce was born 5 weeks early, was very small, and had respiratory distress at birth. After spending 18 days in the NICU, our little fighter was healthy enough to go home.

His parents worked really hard at getting enough calories in him daily, and I saw him in my office a lot to assure he was growing well and thriving. And he was.

A few days before Christmas, Pierce’s mom, Whitney, emailed me on our portal system to let me know he had some congestion, but seemed to be OK otherwise. Cool. No biggie! Baby’s first cold. Keep him drinking, watch for fevers, watch his breathing closely. Lots of kids have colds right now. Keep me updated.

A couple days later, he had a tiny temperature elevation to 99-100. Since he was born so early, and so small, I asked them to come in so I could check him. He looked great! So I sent them home.

Pierce’s cough was getting worse. Really junky. I checked on him again a few days later in my office. He seemed fine. We talked about what to watch for:

• A dusky color to gums and tongue.
• Chest muscles working hard to breathe.
• Not wanting to drink.
• Fever coming back.

Let me know if these things happen. I sent them home and asked them to email me updates over the next few days.

I didn’t like what I read in those updates in the next 24 hours.

“He’s starting to turn blue with this cough, Dr. Diane.”

“His cough is coming in huge fits, and it’s making him throw up.”

Pierce’s mom Whitney told me, “The moment we became super worried was when we started realizing how hard he was working to breathe. He was turning blue and dusky. He was choking. He was coughing until he would just gasp for air.”

They went to a Cook Children’s Urgent Care center that weekend, because things were getting worse. A nasal swab was done there for whooping cough, since his fits were getting so bad. The results would take a few days to come back.

But surely it wasn’t whooping cough, his parents (and I) thought! His parents had gotten their pertussis (Tdap) boosters when his mom was pregnant. And they’d asked all grandparents, aunts, uncles, and a cousin to all get their shots too. They wanted to protect their precious new baby from a known danger.

The day the whooping cough test came back positive on a Sunday, Pierce turned really blue with a coughing fit. The family went to the Cook Children’s ER immediately. I called the hospital doctor to let them know he was coming, and that I was worried about him. I sent in antibiotics for his family to take, with the hopes they wouldn’t catch it too. Pierce took antibiotics too, which made his pertussis not “spreadable,” but unfortunately this does not cure or even improve the illness once you’ve started coughing.

Whooping cough is a bacteria that we have a vaccine for. However, babies can’t get their first vaccine until they are about 2 months old. Infants are usually the hit the hardest by pertussis. They often have to be on ICU support, and 1% of infants who contract it will die.

Sweet Pierce was scheduled to get his whooping cough vaccine (Dtap) with me in my office the day after he was admitted to the hospital.

Pertussis is spread by microscopic droplets in the air. Someone coughing or sneezing near you can pass it to you. Or, just being in the same part of a room, breathing the same air, can pass the disease on to someone. It is HIGHLY contagious.

It starts with cold symptoms for 1-2 weeks. Then, the horrible coughing fits start. Adults and older kids can break ribs and pop lungs because they cough so hard. And it’s known as the “100 days cough” because it can last a long time.

Listen to Pierce’s cough in the video. You hear how he struggles to take in some breath between coughing fits? The “whoop” sound? This is how the disease got its name.

Our little hero spent a full week at Cook Children’s. He needed oxygen, fluids and supportive care. They assured he was able to drink and was breathing comfortably. They helped support him through the coughing fits and assured his oxygen levels never went too low.

“Cook Children’s was just as amazing as I knew it would be. I had heard from friends and family that the care they got there was truly the best, and we can agree with them now based on our experience,” Whitney said. “Everyone was so sweet and thoughtful. Some nurses and techs went above and beyond when they knew we were exhausted, rocking our baby so we could get some sleep. They didn’t just look after Pierce’s well-being, they looked after ours, too!”

We’re not sure how Pierce contracted whooping cough. It is such a contagious disease. It could have been at the grocery store as he napped. It could have been a well-meaning family member who hadn’t been vaccinated in a while. It could have been a bystander at the post office. Just waiting in line at a doctor’s office or sitting next to a table full of people at a restaurant can spread the disease.

Dr. Susie Whitworth, the director of the Infectious Disease clinic at Cook Children’s, told me “I wish the public understood how very safe the vaccine is, how very commonly we still see children with pertussis, and how infants still die of this vaccine-preventable disease. “

The most important thing YOU can do to protect babies like Pierce is to vaccinate yourself and those you love. The vaccine is 89% effective in children if they get all the boosters, but the effectiveness slowly wanes over time. This is why we give boosters to kids at age 4 and 11,  and why we recommend getting the vaccine at least every 10 years as an adult. So the MORE of us that get the vaccine, the LESS chance this disease can penetrate a community. And, if you’re vaccinated and do catch pertussis, several studies have shown the length and severity of illness is much less severe.

Pierce is now at home, and is feeling great. He survived a disease that so many infants do not. He came to my office a week after going home from the hospital and got his first set of vaccines. His parents told me, “We want to tell his story. We want people to understand what he’s been through. If it’s read by even one person who is on the fence about vaccines, and we change their mind, it will be so worth it.”

For More On This Topic:

• Immunization Schedule
• Calendario de vacunación
• Let's Learn ABout Whooping Cough
• Vaccines and Immunizations Information
• Pertussi (Whooping Cough)
• Is It Croup or Whoop?

What The Flu Is

The flu is a respiratory illness.

The flu happens every year. It hits hard from December through March (and other months, but those primarily). There are deaths every year. Kids, healthy people, old people, babies and folks with chronic illness die every year. This year we're trending lower at Cook Children's than in previous seasons. I really, really, really hope it stays that way.

Overall, remember that the flu is usually a "mild" illness (I mean, you feel like you've been hit by a truck, but we call that "mild" in medicine, ha).

It hits fast and fevers can go high, which is worrisome. But with a lot of rest, fluids, pain and fever reducers, things usually get better after 3-5 days. The cough and congestion can last for 2 weeks.

Sometimes, rarely, it can get bad. Really bad. The flu can cause: Pneumonia. Sinusitis. Ear infections. Brain inflammation (encephalitis). Heart inflammation (myocarditis). Asthma attacks in asthmatics. Death. That escalated quickly.

You hear us talk a lot about Flu A and Flu B. They are just two different strains of influenza. They are the two types that circulate the globe each year. In the states, Flu A usually arrives first and in general is considered the more severe strain. But overall, there is little difference in how they present clinically and we can’t really tell them apart without a flu test.

What The Flu Isn’t

The flu is not a stomach bug. There is no "stomach flu." That's called gastroenteritis. Your child is throwing up, but doesn't have a runny nose or cough? It's not the flu.

How Do You Prevent The Flu?

Scared to vaccinate? Hear stories? Hate shots? Have an uncle who loves to talk up a good conspiracy theory? Know this: some years, you can still get the flu even if you get the flu vaccine. It depends on how well we predict what strains of the flu will be circulating the globe that year. And some years, it's not a good match.

BUT it's usually milder, if you do get it. It GREATLY reduces your chance for hospitalization and death. I get it every year for my kids and my family. If you ask any pediatrician or ICU doc what viruses put fear into their hearts, I'll bet you influenza tops that list. I always tell my patients, even if it’s a "bad match" year, isn't a 30 percent effective seatbelt better than no seatbelt at all?

We can't know how good of a match the vaccine was until the flu season is over in April. So ignore the dramatic news reports.

Tamiflu can help make it less severe sometimes, for some people.

WASH YOUR HANDS! The flu can live on some surfaces up to 24 hours in cold weather! Think about all those door handles you touch! The cash you get handed back from the cashier! The snot that flies from every person's sneeze can cover a 6 foot radius around them! Wash. Those. Hands!

How Long Are You Contagious?

You are contagious with the flu 1-2 days BEFORE you start showing symptoms. How sneaky is that?

You are contagious 5-7 days after you start to show symptoms. Your KIDS can be contagious up to 10 DAYS after they start to show symptoms.

You should keep your kids out of school for at LEAST 24 hours after their last fever. This means fever without the use of meds to keep it down. If it's financially feasible for you, I'd even try to keep your kids out at least 7 days after the first symptoms start.

When Should You Worry?

Call us (or your pediatrician) anytime if you're worried about the flu. We can walk you through what is normal and what isn't.

These are the reasons to worry:

• Fast breathing or trouble breathing
• Bluish skin color
• Not drinking enough fluids
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms that improve but then return with fever and worse cough

Stay Healthy Friends,

Dr. Diane

To Learn more about this topic:

• Infuenza/Flu Information
• Is It a Cold or the Flu?
• Pediatricians Say Kids with Egg Allergies Should Now Get The Flu Shot

I think it’s really important to know the difference – one is fairly common, and the other is much more rare – and can be deadly.

Croup is a common viral infection I see daily. It is caused by a virus, and can cause a high fever, runny nose, sore throat, and cough.

It can be scary sounding, and can show up out of nowhere. Your kiddo will SEAL BARK when they cough – it really does sound just like a seal. I can often hear it and diagnose it in the waiting room!

This virus makes the area around the voice box and the windpipe swell up. This makes them hoarse, and sometimes they have loud breathing with inhalation.

We treat it with comfort – kids often get scared of their own breathing and cough sounds, and it really makes their throat hurt – so give them ibuprofen or Tylenol, steamy showers, cool humidified air, popsicles, cold drinks. Your doc may prescribe steroids for it if they seem particularly hoarse or loud with breathing.

Most kiddos with croup do just fine at home – and they can get it more than once. However, very rarely the swelling of the windpipe is severe. If they are having a hard time breathing, seem short of breath, lethargic, won’t drink, some kids have to be seen at the hospital for support, breathing treatments, and care.

Whooping cough, or Pertussis, is a whole different beast. The word “whooping” came from the sound that babies make when they’re trying to inhale during the coughing fits of this awful bacterial infection.

Cough-cough-cough-WHOOOOOOOOP (catching breath)

Cough-cough-cough- WHOOOOOOOOP

It starts as a cold, then gets worse in a week or two. It is absolutely heartbreaking to see a baby struggle with whooping cough (watch a Youtube video of “Infant with Whooping Cough” like the one down below, courtesy of the Mayo Clinic and try not to tear up), and it can be deadly to them. They often stop breathing, and almost always must be hospitalized.

Pertussis is easily caught from others via coughed droplets in the air. Older kids and adults can catch it too, and it causes long fits of coughing – to the point of turning blue, or vomiting. Patients cough so much they commonly break ribs.

Antibiotics are given to make the person less contagious, but do not cure the illness or stop the symptoms.

The best protection from whooping cough is VACCINATION. We start this series at age 2 months, so that children are protected as young as possible.

Adults should get their pertussis booster – a.k.a. the Tdap or Tetanus shot at least every 10 years, or with every pregnancy (I and my husband both got it for both our kids).

Hope this helps clarify those confusing words we use for these special cough sounds!

More On This Topic:

• Why Children Like Olivia Need You To Immunize
• Let's Learn About Whooping Cough
• "Croupy" Cough
• 7 Facts About Whooping Cough You Should Know

2. Fifteen-20 percent of kids WITH NO SYMPTOMS AT ALL will be POSITIVE FOR STREP if tested. This means 15-20 perecent of kids are strep “carriers.” A tiny amount of strep lives in their throat all the time, and it doesn’t make them sick. Let that sink in a moment. Think about all the unnecessary antibiotics kids are getting!

3. The most common symptoms of strep throat are a sore throat, fever and swollen glands in the neck. I also see kids get nauseous, have stomach aches and headaches. It’s odd – sometimes their only signs are fever and vomiting or nausea and a headache.

4. Sometimes, strep comes with a rash. We then call it “Scarlet Fever” and it is no more dangerous than just plain strep throat. Someone just gave it a cool name and then we get to feel like we are living in that computer game “Oregon Trail.”

5. Most people look at the back of the throat to see if their kiddo has strep. I don’t look there – that’s typically where drainage from the nose causes bumps and other changes. When I look for strep, I look at the tonsils and the ROOF of the mouth – the arch over that dangly thing (the uvula) to see if there are dark red spots.

6. If your child has congestion, coughing, a runny nose, watery eyes and/or diarrhea, she most likely doesn’t have strep. Chances are it’s just a cold or some allergies – and postnasal snot drip is the most common cause of sore throats in my office.

7. Strep is passed from kids to kid through “large respiratory droplets.” Yum. This means kissing, sharing drinks or food, or a sneeze or a cough either lands directly on another kid’s hand which then they put that hand in their mouth, nose, or eyes. Or, the drops land on a surface and another child touches it and touches their face somehow.

8. If you are a strep carrier, you don’t have much strep in your throat. It’s enough to catch on a strep swab, but not enough to fly out of your kid’s mouth and onto things and people (ew). Also, these bacteria aren’t as “mean” as typical strep bacteria are. So you aren’t really very contagious at all. And with 15-20 percent of kids being carriers, many of us live with them on a daily basis and are just fine.

9. I always talk with incredulous parents in the office about how “the strep came right back” after finishing antibiotics. They finished treatment and then the fever and sore throat hit again, and the test is positive again. I call these kids “strep bounce-backs” and it’s more common than you think. It doesn’t mean anything went wrong, and there are lots of explanations. Sometimes there are a lot of kids in the class passing it back and forth, and getting treated at different times. Sometimes, it is because the bacteria is hiding deep inside the tonsil folds and the antibiotic had a hard time reaching it. Changing up the antibiotic, or just repeating a course, can help it go away.

10. You can get over strep on your own, without antibiotics. Isn’t that amazing? Our immune systems are awesome. BUT, we like to treat strep with antibiotics anyway. Why? Because it makes you feel better sooner. It makes you less contagious to others (you are no longer contagious 12 hours after the first dose of Amoxicillin). And it can prevent the VERY rare complications we see with strep – when strep attacks the heart (acute rheumatic fever).

Hope this helps you to better understand strep!

❤️Dr. Diane

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

Olivia is 7 years old and has fought a battle that most 7 year olds (and 70 year olds) have never and will never face.

Olivia has spent the last two years in and out of Cook Children’s battling neuroblastoma. It was a cancer that started in her adrenal gland and had spread by the time it was found – around her spine, and all over her stomach.

She is a tough cookie. Olivia has undergone countless procedures, tests and chemotherapy. And in 2017, Olivia underwent something called an autologous stem cell transplant.

This means that before chemo, her own stem cells (which you can think of as neutral “beginner” cells) were taken from her bone marrow, harvested, and after the chemo wiped everything out, put back into her bone marrow as a “fresh start” for her immune system! It was a huge part of her cancer treatment.

This also means that all of the “memory cells” she used to have are gone.

And it means that the vaccines she got as an infant and small child are “forgotten”.

So Olivia now has no protection against vaccine-preventable illness. Her immune system is like a baby’s again.

When she came to see me for her checkup last week, I hadn’t seen her in two years! She was bouncing all over the room, and smiling, and happy. Like 7 year olds should be! She’s doing great! Her oncologist is watching her very closely, but her cancer seems to be gone!

I know that’s a lot of exclamation marks, but all deserved for this awesome little girl.

We now have to start re-vaccinating Olivia. This is a slow process that will take a few years. Until she is fully vaccinated, she is susceptible to illnesses like whooping cough, pneumonia, measles and others.

I’m telling you Olivia’s story (at the urging of her father, who wants you to know her story) so that you understand why everyone should be immunized.

Olivia CAN’T be immunized fully yet. Her body needs time to re-learn all of her vaccine protection.

If all of us AROUND Olivia get vaccinated, we are creating an impenetrable wall of protection. The disease cannot get into our community to potentially attack Olivia’s brand new immune system.

When you make a choice to vaccinate yourself and your child, you also prevent something devastating to those who cannot protect themselves – like Olivia.

And she’s fought too hard a battle to look back now!

Learn more by clicking the links below:

• Vaccines and Immunizations
• Immune Suppressed Children and the Measles: What Parents Need To Know
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Measles In the Classroom
• Pediatricians Remember Experiences with Measles
• 'Vaccines Are Safe and Effective'
• Cook Children's Hematology and Oncology
• Bone Marrow and Stem Cell Transplant
• Neuroblastoma

What makes this park so special? Well, it’s not your typical run-of-the-mill playground. It’s a park for “children of all abilities.”

Children in wheelchairs. Children with low muscle tone. Kids with movement disorders and trouble with coordination. Kids with sensory processing problems. They will all be able to enjoy Dream Park!

“Dream Park is a universally-inclusive playground; custom designed for children of all abilities, that goes above and beyond Americans with Disabilities Act guidelines,” mentions the website.

The over $3 million playground was privately funded by numerous folks and companies in the community, including Cook Children’s.

It came together over the past six years by the work of “Dream Park Fort Worth,” a nonprofit led by Rachael Churchill, Sandy Mesch and Corrie Watson.

What does a park “for all abilities” look like?

Well…nothing that makes kids feel it’s any different from any other awesome playground.

What I saw was nothing that indicated it was a park for kids who are “different.” The colors are bright, the layout is fun and huge, the inclines are gradual and easy to manage for even the smallest or poorly coordinated of kids.

There are swings that can be shared by more than one person. There are awesome zip lines that can be enjoyed by children and older kids – I wanted to get on those myself!

The pathways and inclines are wheelchair-friendly and so many of the amenities can be enjoyed by both parent and child together in play.

There are musical instruments, a really cool “rolling slide” that could be sped up or slowed based on the comfort of the child, a gentle and large four-person seesaw, and a sound dome that would be soothing for kiddos with trouble processing a lot of sound sensory input.

The whole park is enclosed with a fence to help with any kids who have tendencies to run or stray from families. I felt secure that my two runners were contained!

It is totally cool to have this gem right here in Cowtown. What a great job done by some pretty amazing people in our community.

So yeah. It’s a park for kids of all abilities. But you’d never know by looking at it – and that’s the magic of it. Kids won’t feel weird or different being at Dream Park. They can play easily with their friends, and families will love seeing their children enjoy more freedoms and fun.

The time has come. You and your kids spent time at the park on a beautiful spring afternoon. A few hours later, at home, the symptoms start (cue M. Night Shyamalan strange horror music). Or heck, for those really allergic, the symptoms began at the park!

• Itchy, watery eyes
• Congestion
• Draining, watery, itchy nose
• Sneezing
• Itchy roof of mouth (is this just me? Seriously? Anyone else get this?)
• Clearing the throat
• Coughing
• Complaining of a sore throat (this is due to drainage)

Congrats. See that bright green dust coating your trash cans and car? That’s pollen, and it’s now stuck to all the tiny hairs inside your nose, throat, and lung airways.

And the symptoms you’re having? That’s your body reacting to the certain pollens it doesn’t like.

Kids don’t really get seasonal (grass, plant and tree) allergies until at least age 2. I always tell parents, “your kiddo has to be EXPOSED to the planet’s seasons a few times before it can become allergic to them!”

Your child can become allergic to things like foods, pets, mold, and dust earlier than age 2 – because these are things they are exposed to daily in their home.

To help control your kid’s symptoms, there are a lot of over-the-counter medications you can try.

Listen – I’m a doc that usually says “less is more” when it comes to medication. But I do usually recommend daily meds for kids who suffer allergies, because I don’t want it to affect their happiness, or ability to get good exercise.

Start with a daily antihistamine – Allegra, Claritin, Xyzal, Zyrtec, Benadryl. If your child suffers from a lot of nasal problems like sneezing and congestion, add on a nasal steroid spray like Flonase or Nasacort.

There are also many types of antihistamine eye drops out there you can use daily to treat or prevent the itchy and watery eyes.

Here’s the thing – they’re often PREVENTATIVE. So, use them DAILY during the times of year you or your child suffer to PREVENT the symptoms from showing up.

You can dive further into treatment with your pediatrician – there are a few prescription options you can try to further help the problem.

If your child has asthma, it’s even more important to come up with a treatment plan with your pediatrician. These kids sometimes can have full-on asthma attacks this time of year if that’s a common trigger for them.

And do what an old, wise allergist once told me – “the minute you and your kids come in from playing outside, hold your heads over the sink, and spray nasal saline up in the nose to irrigate the nose and rinse out all the pollen!” You could also try this in the shower.

Makes sense to me! Try it! And good luck out there!

Lots of RSV. Last week of the 422 kids tested at Cook Children's, 137 had RSV and six had Flu A. 

So there's probably lots of coughing at your house as you prepare for your Thanksgiving travels. But keep this in mind: Coughing is good. GOOD! Here's why:

1. We need it! Coughing helps us to perform the "clean-up" process with each and every cold. If you don't cough, the mucus gets in the chest, and that's how pneumonia happens. So...most of the time, cough is Ok! And you can expect it for at least 7-10 days with colds.

2. Sometimes if kids have a hard cough, they gag and puke. While this is scary, it's OK and sometimes a normal part of the process. Always let us know if this seems to be worsening/happening more often though. Or if your kiddo has a new fever with it, or seems more fatigued.

3. Coughing with viral illnesses (colds) tends to happen more at night and first thing in the morning. This has to do with the physics of the postnasal drip when we lay down, and in the mornings we do a lot of hacking to clean up all the sludge that settled in the airways overnight.

4. Sometimes, people worry about "feeling the cough in the chest". This is often due to how air rolls over mucus in the nose and tree trunks that go to the lungs (bronchi) and doesn't necessarily mean anything is wrong. If your kiddo is happy and playful and otherwise well, let it be.

5. Don't be frustrated if your kiddo coughs up some wet stuff, and then swallows it. People try really hard to get their kids to spit it out - it's OK if they don't. We cough, swallow that mucus, and then poop it out. This is why many people get looser stools with colds (adults and kids). 

We worry about them because kids get hurt in them sometimes. It’s also because they actually don’t encourage walking –they hinder the natural neuromuscular development that needs to happen for walking to occur.

Just to be clear - the walkers I speak of are the ones that you sit your child down into. There is a seat into which you slide their legs, and there are usually wheels on the bottom.

A recent study by the American Academy of Pediatrics found that from 1990-2014, over 230,000 kids visited ERs across the country because of injuries related to infant walkers.

The majority of the kiddos in the study ranged from age 7-10 months. Most of the children suffered head and neck injuries (90%). Almost 75 percent were injured by going down stairs in the walker.

I’ve also seen kids get neck and chest injuries from being whipped around by an older sibling. And some even get finger injuries from gripping the sides of the walker and then slamming into a wall!

The study states that “walker–related injuries can be severe and can include skull fracture, brain injury, burns, poisoning, and drowning” and that “from 2004 to 2008, infant walkers were associated with 8 pediatric fatalities”. This is absolutely eye-opening to me.

Another thing that is troublesome about walkers is that they keep kids from doing that very thing: walking.

If you sling a child’s pelvis in a sack, it lifts the child’s weight for them while they pull along the ground with their toes/feet. It doesn’t force the kiddo to lift his own weight. It keeps certain hip and pelvic muscles from developing the strength and coordination they need to actually learn the process of walking. This is the reason physical therapists have disliked walkers for a long time.

This article does not apply to the “push walkers” that kids stand up and push. We actually like those more, because there are less injuries involved with these devices, and kids are lifting and moving their own weight properly.

My advice is to throw out your sit-in infant walker. It seems they’re even more dangerous than we initially thought, and to me, the fun freedom of movement is just not worth it. Throw that sweet kiddo on a soft rug or blanket, spread out some toys on the ground and on the couch, and watch that child learn how to move on his own.

For starters:

1. No, it's not that cattle disease with a similar name. Heehee. 
2. Yes, it's super contagious. 
3. Nope - no reason to freak out. We see it all the time. You probably had it when you were a kid.
4. Go get some popsicles. I'm gonna prescribe them.

Hand Foot and Mouth Disease (HFM from here on out) is caused by a virus. What does that mean? Come on - I know you're sick of hearing me say it - that means no antibiotics needed! Woo hoo! This is a virus which your strong kiddo can clear on his own!

Most of the time this happens in kids under 5. They catch it from day care or school classmates. Usually they catch it by getting oral secretions or fecal secretions in their mouth or airway from a buddy. I'll let your imagination run wild on the methods kids go through to experience this fun transfer of germs. It's really contagious.

People with HFM are most contagious during the first week of their illness. However, they may be contagious for weeks after symptoms go away. Some people, especially adults, may not develop any symptoms, but they can still spread the viruses to others.

This is a common SUMMER virus! But can happen any time of year.

Soon after catching it (like 3-5 days), kids start with a fever and a new rash. The fever is usually low (under 101) but can be high at times. Sometimes they have a runny nose, or other cold symptoms.

The rash is unique. They're red spots with/without thick bubbles of fluid.

Usually, they're on or in the mouth, and on the palms of the hands and soles of the feet. Hence the name. However, I joke with parents that it should be called "Hand-Foot-Mouth-Butt-Arms-Legs" because you can see the spots in other places, too.

HFM is commonly mistaken for other things. Often, parents worry about chicken pox. Remember - chicken pox is itchy and tender. HFM is not. People also mistake these for bug bites - again, not itchy like bug bites are.

The mouth sores hurt. They're typically the main complication I see with HFM - they hurt so much kids don't want to eat or drink. The eating I don't mind -but it's important that they drink. Load up on popsicles. All my "sugar rules" go out the door when a kiddo has HFM. Sometimes if it's really bad we will prescribe a mouthwash for pain.

Something else you should know - more than one strain of virus causes this bad boy. So kids can get it more than once. And if an older child/adult catches it? It can be more troublesome/painful than in a younger person.

It'll go away on its own. This can typically take 7-10 days. The fevers usually last just a couple of those days. Kids typically are just fine. It's actually adults that can experience the worst of it!

Hope this helps!

Hugs,

Dr. Diane

Parents worry SO much when I hear one in their kiddo's chest and I tell them about it.

But I am here to help you not freak out!

I feel like I need to add "Parental Freak-Out Support and Management" to my resume. Maybe underneath "Office Donut Day Coordination Specialist"?

...

I hear heart murmurs in kids Every. Single. Day. Sometimes numerous times a day. We're deep into school physicals this time of year and that's when many doctors will find a heart murmur on exam.

They're really common.

I have read that anywhere from 30-70 percent of children and adults have a heart murmur at some point in their lives.

A heart murmur is a whooshy sound I hear in between the heart's little beats. So instead of "bum-bum, bum-bum," I hear something like "WHOOSH-bum, WHOOSH-bum".

Lots of things cause heart murmurs. A heart murmur can show up at any time in a child's life. And just because it wasn't heard before doesn't mean something bad has happened or is happening.

Anemia can cause murmurs. Dehydration can. Illness in general can.

Fevers are a common cause of murmurs. I can't tell you how many times one of my little patients goes to urgent care at night and a parent is told, "you should know your child has a heart murmur." And then of course they worry! When really, it was your poor kiddo's 102F temp that caused it.

Sometimes it's just the shape and size of your kiddo's heart at that time in their life. A "Still's Murmur" is something I often hear anywhere from age 2 to 6. It can come and go and causes no problems. It just has to do with the way the blood sounds whooshing through the valves and rooms in the heart.

Pediatricians have heard thousands of heart beats. We are pretty good at knowing which murmur sounds okay, and which murmur doesn't. And we will send you to a pediatric cardiologist if we are concerned or just wanna see why the sound is there.

So when do I worry a little more about a murmur?

• Any murmur heard in a newborn to 6 month old (these are more likely to be a structure problem in the heart that they were born with, and we need to investigate those further).
• Any murmur accompanied by other symptoms of heart problems, like: Skin that appears ashen or blue from poor circulation (cyanosis), pale skin, heavy or rapid breathing, a rapid heart rate, tiredness, difficulty feeding or poor growth.
• If your child has a murmur and you tell me that they can't keep up with their friends when playing sports, or have chest pain or tightness related to activity.
• If you have a family history of sudden and early cardiac death (think young people under 40 who suffer a heart attack during play).

If any of these are happening, more studies (like an EKG or heart echo) are usually needed.

I hope this helps you understand murmurs a little better!

As always, if you're concerned, just ask your pediatrician to explain things a little more if they mention your child has a murmur.

Have a great day!

Dr. Diane❤️

That is why when Cook Children's asked me to write something about what Star Wars means to me today, what with it being Star Wars Day (May the 4th Be With You), I may or may not have squealed and jumped up and down (while sitting in full Han Solo costume, of course)!

Star Wars was a fun movie series that I started watching in my teens. None of my friends were into it...my family didn't seem to care much about it...but I loved it! What a fun story about a galaxy far, far away!

It got my mind out of the stress of college and medical school. The characters were fun, hilarious, and sometimes complicated. The plot was always fast and the lines between good and evil were so clearly drawn (and yet...sometimes not so clear?)

Let's face it. Star Wars, like any well-made movie series, is a great way to escape.

Now that I have kids, Star Wars is even more fun. While they're still young and the movies may be still a little too scary for them, my son and I have racked up HOURS of conversations about why Darth Vader (um only the coolest guy ever to a 4-year-old) is on the Dark Side, who gets to own a lightsaber, and what kind of creature is Jabba the Hutt? Halloweens are full of fun costumes.

I have found that Star Wars has been such a fun connection to have with my patients, too! When a shy 5-year-old will not make eye contact with me all I have to do is pretend that tongue depressor is a lightsaber and....we're besties having a lightsaber fight!

And I publicly apologize to the mother of the 8-year-old last week who had to endure a conversation her son had with me about the shocking events of "The Last Jedi" for the entirety of his check-up 

And I'm not the only one! I've connected with so many other Cook Children's providers who are die-hard fans, too! NP Tara, Dr. Peak, Dr. Gray, Dr. Perry, I'm looking at you ...

And I mean, is there any better way to live your life than by the quotes of the Master Yoda? "The greatest teacher, failure is," is my new mantra.

Sure, in the end, it's just a dorky movie universe. But is there a more fun way to connect with people you might not otherwise connect with? Loving the same characters, the same story ... it's allowed me to grow close to others in so many ways.

May the Force Be With You!

Hugs,

Dr. Diane 

Both allergies and colds share a lot of similar symptoms:

• Sore throat
• Runny nose 
• Sneezing 
• Coughing 
• Feeling tired 
• Feeling achy

Honestly, it can be hard even for us to tell the difference when we examine kids.

HOWEVER, you don't get a fever with allergies. If you have a little fever (or a big fever), that's most likely a cold.

ALSO,  "itchiness" in general of nose and eyes, makes me think more allergies than cold.

AND, the time is important - Did  it come on really quickly? That's most likely a cold. Has it been going on for months with a slow onset? Most likely allergies.

Both allergies and colds can make you more susceptible to other problems like ear infections and sinus infections. That's why we say if your symptoms are lasting longer than 2 weeks, come in and see us so we can help.

"How do I know what to do?" Well, that depends on a lot of things.

Is your child under age 1? If so - this is more likely a cold than allergies (a child has to be alive longer than a year to develop allergies to their environment). Elevate the head of their crib. Stick a blanket under the mattress. Would you want to lay flat on your back with a bad cold? Suck out all that snot with a Nose Frida (dont knock it til you try it). Use saline drops. Tylenol (or ibuprofen if over 6 months) for the headaches and throat pain. Run a hot shower and sit in a steamy bathroom for a bit. And lots of lovins. There ain't much you can do for the tiny ones. They just have to push through it.

If they're over age 1 and they have what seems to be a cold, try some honey along with all of the above. It's been proven to help just as much as medication. There are some over-the-counter medications that have honey in them too. I wouldn't try cold medicines until they're at least 4. Studies don't even show that they help much.

If it's allergies - you have lots of over the counter options like Benadryl, Zyrtec, Claritin, and Allegra. Some nose sprays are also very helpful and we can prescribe those in the office. And there is a prescription medication called montelukast that I find can help some kids.

Also, a wise allergist once told me that if you rinse out your kid's nostrils when they come indoors, it helps a lot (it washes away all the allergens/pollens clinging to the hairs in the nose and really helps symptoms go away faster). You could also try nasal saline spray here and just have them hold their head over the sink.

Hugs!

Dr. Diane

Let me be real for a second – it’s been a pain in the you-know-what. We’re updating, changing, training, stressing. I may or may not have purchased more wine this month than usual.

Why are we doing this?

Because it’s better. It’s faster, more efficient, more organized, and SAFER than our old systems.

We are doing it because it will lead to better overall care for your child.

I’m actually really excited about it. As a pediatrician, my days revolve around a computer. Many of you may notice I always bring a computer into the room with me. I show you how your kiddo has grown. I take notes to remember important things you tell me. I look up what happened in the hospital when you went to the Cook Children’s ER. I read that consult note from when your child saw the ENT.

The way I do those things will be changing.

Things will be new and glitchy at first – just like any big change is -- but overall, the improvements in your child’s care will be awesome.

But… what does all of this mean for you and your children?

It means that, for a little while, you might experience a bit of a longer wait in the pediatrician’s waiting room, or urgent care, or ER as we learn to use the system.

You might experience slightly longer hold times on our phones while my staff is figuring out how best to schedule your kiddo’s appointment.

Our front desk people have to get used to the changes in booking appointments, changing charts, and updating your insurance information. Don’t worry, it’ll speed up with time.

Our nurses might need a little extra time to type in what medications your child is on, their medical history, and your concerns. Again – this’ll improve quickly.

It means that I, as your PCP, will be able to know every single thing that happened to your child in the hospital (as opposed to a tiny summary that doesn’t give me much information). Every single vital sign, oxygen reading, X-ray, lab result, consult note – I’ll have access to all of it! I may fumble around for the first few days when I try to show you things on my computer. Feel free to giggle at me.

It means that your child’s specialists and I will be able to communicate more effectively.

It means that YOU will have a new portal system called MyChart.

This thing is awesome!

• You’ll be able to look up your child’s vaccine records and print them, see summaries of all of our visits together, and ask me (and my staff) direct emailed questions!
• You can look up test results, see lab work, and find out when your next appointment is!
• Go to www.cookchildrens.org/mychart for more information - You can sign up now!
• It means that we will be SAFER – more safety checks on prescriptions, and constant updates to how we calculate and order things.
• It means it will be less of a hassle for us to get your child’s medical records from many hospitals around the country.

Bear with us, friends, as we embark on this new journey. I promise, it makes a difference in your child’s care.

And feel free to bring us some sympathy chocolate at the office on March 1st…. ;-)

OK. Tamiflu. Let's talk about some facts.

At Cook Children's, 921 kids were tested for the flu the week before Christmas and 353 kids were positive (314 Flu A, 39 Flu B). So the flu has arrived in our area.

Every year our office gets inundated with phone calls about Tamiflu. Who can take it? Will it help my kiddo? Will it help me? Will it prevent contraction of the flu?

Let me try to spell a few things out so it makes some simple sense:

1. If you got your kiddo the flu vaccine this year, I want you to give yourself a big old fat kiss in the mirror because congrats on making a great decision for your child! While we aren't sure how good of a match it is until the season is over, way to give your child a fighting chance! The kids in the office that I've seen with the flu who have been vaccinated have typically been less sick than those who haven't.

2. Tamiflu (oseltamivir) is a medication anyone can take within 48 hours of starting the symptoms of the flu to REDUCE THE NUMBER OF DAYS ILL BY 1-1.5 DAYS. Notice how I didn’t say "make the symptoms go away" or "make it less severe." It mostly just reduces the number of days sick....by about a day.

3. Notice how I didn't say it cures the flu. Nothing cures the flu. It is a virus, and thus has no cure.

4. These are the reasons the AAP and CDC think a person should take Tamiflu if diagnosed with influenza (and are at "high risk of complications"):

• If under 2
• If over age 65
• Anyone with a chronic illness (diabetes, asthma, chronic heart disease, epilepsy, amongst others)
• Anyone who is immunosuppressed (cancer treatment, immune system deficiency)
• Women who are pregnant or postpartum
• Anyone hospitalized with influenza
• Healthy kids who have documented influenza and have a baby sibling under age 6 months

5. TAMIFLU DOES NOT WORK FOR VIRUSES THAT ARE NOT THE FLU. Meaning - if you or your kiddo has a "flu-like illness," and there are only about 400 circulating our area right now, Tamiflu will do nothing for you.

6. Tamiflu DOES NOT work much at all if taken more than 48 hours after the first symptom of influenza. Studies have proven this time and again.

7. Tamiflu sometimes causes more problems than it helps. It is infamous for making kids puke, be nauseous, have diarrhea, and have stomach cramps. (I personally took one dose of it a few years ago and swore I'd never do it again)

8. Tamiflu can help prevent a child from catching influenza, but given its cost and side effects, and chance for failure, we usually mostly recommend this for children who are at "high risk of complications" or have a very young or chronically ill sibling (see that list above).

9. Any provider can prescribe Tamiflu for any child they deem to be experiencing severe symptoms. If your child is really sick, and they have a positive flu test, and it's been less than 48 hours, we will write the prescription. But remember that clinicians also always have resistance in the back of our minds. The flu virus will LEARN and REMEMBER Tamiflu. And someday, maybe soon, it will no longer work. So if we seem "stingy" with this medication - that's why.

If you want to get jiggy with the beautiful science of all of this, a good stop for you would be this VERY informative page by the AAP: https://redbook.solutions.aap.org/selfserve/ssPage.aspx….

(Have fun with the 8,000 links on that page. SCIENCE! YAY!). If you don't want to read all of this information, please talk to your pediatrician if you have questions.

People are always asking my opinion of it, and I think I'm very "meh" about Tamiflu. It is costly and it can cause a lot of side effects. I do think it benefits the very young, the very old, and those with chronic illness, and I think it's worth it in those cases. Your best protection against the flu every year is to get the vaccine and wash your hands.

The flu virus can live on some surfaces for up to 24 hours. Isn't that astounding? Think about that. A guy sneezes in his hand, touches a door handle, and someone 12 hours later could touch it, wipe an eye or nose....and boom. Flu.

Again - WASH YOUR HANDS!

Hugs, everyone! Hang in there!

Dr. Diane

Aunt Flo. The Red Tide. Shark Week.

I know. Everyone’s favorite topic.

If you have a daughter, I know it’s crossed your mind. "Is my kiddo’s body normal?" "This seems too young!" "What if she has questions?" "How do I start talking about this?"

Girls are going through puberty at earlier ages these days. I hear lots of theories about this in my office. Processed foods. Dyes. Hormones in milk. I haven’t read anything in medical literature that proves these theories, but we are still studying this stuff.

What most strongly dictates when a girl gets her period is her genetics. Namely, when did Mom get her period? Mother and Daughter “starting” ages usually correlate pretty closely.

And don’t underestimate the power of nutrition and body fat. Over the decades, we as a nation have become healthier, more well-nourished, and, in some cases…larger.

It is well known that fat releases a hormone that helps initiate puberty. It makes sense that the more “nourished” a population, the earlier girls’ bodies feel they are ready for reproduction.

Girls who are very lean, very athletic, or chronically ill may start periods later than others.

Girls often start to show the first signs of puberty around 9-10 years old. This is typically breast development, but sometimes pubic hair shows up first. In about 2-2.5 years, periods typically start.

Don’t worry if your kiddo isn’t following these trends – remember that many girls are healthy with a different timeline, and ask your pediatrician for reassurance at check-ups.

Speaking of checkups – they’re so important at this age. We pediatricians want to know that your daughter is developing normally and need to do a good exam to check this out. I try to talk to each girl about what to expect with her body – the changes that are coming and may be happening.

For example, it may be totally normal for girls to have normal white vaginal discharge 6-12 months prior to starting their period. I have seen many sighs of relief when I bring this up with a worried, shy preteen!

I also get sighs of relief from parents who are nervous to discuss these things. Know that your daughter may not bring these concerns up to you because they are shy or embarrassed. It’s important to initiate the conversation yourself.

I think it’s time to start talking about it even before any body changes happen, around ages 8 or 9.

Let your daughter know that breast development is normal, and happens differently in each girl. Let them know it’s okay for them to feel tender or even painful sometimes. Again, periods usually start 2-2.5 years after breasts develop. Keep this in mind and open the conversation as needed, because she likely won’t!

If your daughter asks about Mom’s tampons or pads, I think it’s OK to give a simple and direct answer like, “Those are for my period every month. They help keep me clean.”

Talk about what happens when periods start. Let them know it’s not giant gushes of blood! Lots of them are scared of it starting in school. Many girls panic, some even have to go to the nurse’s office, or home.

Go for a “test run” before it starts – teach her how to use a pad, put it on her underwear, and let her see how it feels. I can’t tell you how reassuring this can be.

Periods can be pretty irregular for the first year, sometimes even the second. Remind your daughter to keep pads in her backpack or purse “just in case”.

I don’t think many girls are ready for tampons right away. Pads are less scary and easier to deal with. As girls learn more about their anatomy and periods grow more regular, it’s fine to talk about how tampons work, and let her read the package inserts and see the pictures.

If any of this conversation seems too daunting, or too embarrassing…that’s what your pediatrician is for! I welcome the opportunity to teach young women about their bodies. It is empowering for them and can be very reassuring. But I encourage and commend parents who take the opportunity to do this teaching themselves! Open lines of communication are key.

Good luck!

Dr. Diane

Let me make you feel better.

Dark circles under a child's eyes are usually caused by these things:

1. Genetics
2. Anatomy
3. NASAL CONGESTION

I used my friend Caps Lock there to let you know this is often the most likely cause.

The skin under the eye is pretty much some of the thinnest skin on the body. You can easily "see things under it" sometimes.

Some kids have thin skin under there. Some kids have really really thin skin under there. Genetics differentiate this.

Some kids have deeper eye sockets than others. Some kids have more veins under this thin skin than others. Anatomy.

But new appearance of dark circles under the eyes can usually just be blamed on the nose. When the inside of the nose becomes congested (think allergies, think colds), everything swells up, right? More blood is trying to get there, but it can't really go anywhere because everything is all swollen.

Blood gets backed up. Traffic jams happen. Veins draining this area get fuller and fuller.

And guess what? Some of those veins run directly under eyes. Where that thin skin is. And you can see it. Voila! Dark circles!

If it's really bad and you're worried, of course come in and we will have a good look and make sure this is all that is going on.

Notice how I didn't mention the causes of dark circles under the eyes of adults...as I sit here, the aging-by-the-minute parent of two small kids guzzling down coffee at 6 a.m. 

Hugs,

Dr. Diane

P.S.

I tried to find a picture of my son's dark eye circles, which he always gets when he has a cold, but I couldn't, so you get to see the best day of his life when he got to eat a giant ice cream cookie sandwich (hey it's kind of a "dark circle." right?!?) 

I'm gonna get a little personal with this one.

And while I typically write about pediatric health issues on this page, I'm going to broaden things to include adult health too right now.

Did you know you could literally save someone's life by swabbing the inside of your cheek?

Last year, in search of a new way to exercise (and calm my overactive brain), I found a yoga studio in Fort Worth which I now lovingly call home for one hour, three days a week. 

One of the main reasons I love the place so much is that their front staff is so warm, inviting, and cheerful (after a day full of loud toddlers in the office and two loud -angry- toddlers at home, this is what I NEED).

The woman in the picture with me is Suzanne. She has never failed to ask me how my day is going, what challenges I'm facing, and has given me so many resources to better myself. She's amazing and I'm proud to call her my friend.

Suzanne recently started telling me about some strange symptoms she was having. She was really tired all the time. She had new bruises everywhere. She got some weird bloodwork results back. 

She was diagnosed with myelodysplastic syndrome (MDS). This means her bone marrow is failing her. Bone marrow is the goop in the middle of our large bones that makes our blood - our white blood cells, red blood cells, and platelets. Our immune system. Our oxygen delivery system. Our wound-healers!

When your bone marrow decides to tucker out and stop making this stuff, the only thing that will work to "fix" things is a bone marrow transplant. It is a CURE!

She (and thousands of others across the world) are in search of a bone marrow match. The human body is very picky about what bone marrow/blood it will accept as a donor. Usually, a brother or sister can be a good match.

Her siblings, unfortunately, were not a match.

This is where you, me, almost anyone can HELP! I registered to become a bone marrow donor. It was easier than ordering a pizza (which I promptly did soon after).

You type in your name and address and they send you an envelope with swabs in it. You swab your cheeks (for cheek cells) and throw it in a pre-paid envelope and, voila! All done! POTENTIAL LIFE-SAVER STATUS COMPLETE!

I hope so badly that I am a match for sweet Suzanne, but if i'm not - I could help someone else! About 1 percent of people who register become donors. And being a donor usually means something as simple as a blood draw. Read about it! It's so easy!

I encourage each of you to consider doing this! You could save someone's life!

Love,

Dr. Diane

#bethematch #swabbinforsuzy #inthistogether #bonemarrowdonor

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

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

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

If you want proof, read this diverse list of our most popular stories of 2016. We hope you enjoy our look back:

10. 7 Ear Infection Myths Every Parent Should Know. Parents flocked to this blog from Doc Smitty. Can your child go swimming with an ear infection? Do all ear infections need antibiotics? If your child gets ear tubes, will the infections stop?  All this and more was answered in this blog.

9. 7 Online Challenges This ER Doctor Warns Could Be Deadly Oh the Internet. Where kids do all kinds of things to get noticed and maybe go to hospital in the process. We asked our medical director of the Emergency Department to look at seven really silly, really dangerous dares that kids (or grownups for that matter) shouldn't try at home. 

8. Almond Milk: A Nutty Fad or Healthy Alternative. Almond milk sales have gone through the roof over the past decade. But is it the right drink for your child? Doc Smitty gave the answer in this informative piece. 

7. The Death of Ethan: A Life of Chronic Pain Ends in Tragedy. This is the most recent entrant in our list of top 10 stories. Only the fact that it was published in December kept this story out of the top five. We were so honored that Ethan's parents shared their son's story of a life filled with chronic pain. They want you to read it to learn about their son and hopefully help other children who may be suffering as well.

6. New Hope In Fight Against Deadly Brain-Eating Amoeba. The Lewis family holds a special place in the hearts of everyone involed in the Checkup Newsroom. Following the tragic death of their son Kyle to a brain infection caused by a water-born amoeba, Jeremy and Julie Lewis created Kyle Cares. Read their inspiring story as they fought to bring a drug to Cook Children's and other hospitals around the nation that may save children's lives.

5. 11 Tips That Could Save Your Daughter's Life.  In Janaury 2016, Rylie Whitten made national headlines after suffering one of the worst cases of toxic shock syndrome (TSS)  that her doctors had ever seen. Rylie's story moved us to run this informative piece on TSS that we hope every parent of a daughter reads.

4. A Sign From Heaven: Family Travels Across U.S. For Care at Cook Children's. A family's desperate search for answers on Google led them to Cook Children's. Read the fascinating story of what led this family to travel from Detroit, Mich. to Fort Worth, Texas, to be treated for a rare condition called hyperinsulinism.

3. The Most Common Rash You Never Knew About. Ever heard of molluscum contagiosum? We hadn't when Dr. Diane Arnaout wrote this blog for the newsroom. Dr. Diane's informative blog "that will save you and your child pain, money, time and anxiety" went viral quickly and became our third most read story of the year.

2. RSV On The Rise: 6 Things Every Parent Should Know. Here we are at the beginning of 2017 and we have been lucky in that we haven't seen much flu yet at Cook Children's. But we have seen plenty of RSV (respiratory syncytial virus), which explains the popularity of this great blog from Dr. Lizy Varughese.

1. Let's Learn Something: Bouncers, Jumpers and Walkers. Dr. Diane Arnaout's "Let's Learn Something" series was a big hit this year and none were bigger than this tale of caution. Dr. Diane's blog on how baby bumpers, bouncers and activity centers could play a role in your baby's motor delays is our most read new story of 2017. You've probably read this blog. But if you aren't one of the more than 117,000 readers who took a look, now's the time. And if you have read it, feel free to click again.

Well, that's it for 2016. Thank you all for reading. We'll be back with plenty more stories to tell in 2017.

You try to talk some sense into him, but it’s almost as if you aren’t there. He’s babbling gibberish.

His heart rate is up – probably not as high as yours. Why is he acting this way? Is something wrong? Is he even awake? You attempt to talk to him, wake him up, anything - but he’s not paying attention. You lead him back to his bedroom and lay him back in bed. The next morning, he’s happy, playful ... and doesn’t remember a thing.

So what happened? A night terror happened.

I hear about these all the time at my office in Willow Park. It’s pretty common. But just because it’s common doesn’t mean it isn’t super scary to see in person.

Look up “child night terror” videos on YouTube and you’ll see what I’m talking about. The babbling, sitting up in bed, screaming, sweating, crying, wandering the halls. Sleep walking and talking is very common. It’s very easy to feel helpless as a parent in this situation. They can last up to 30 minutes!

We’re not totally sure why they get them – it’s probably the over-arousal of the brain’s “panic center” after the first 2-3 hours of deep sleep – but it’s usually genetic. Eighty percent of kids who have night terrors have a parent who had them, too.

I usually find kids who are going through major growth spurts have them more frequently – maybe there is a link between brain growth and night terrors?

They’re more common in boys, but happen in girls too. They’re most often happening between ages 4 and 12, but I’ve seen them in younger kids too.

They’re different from nightmares. Nightmares tend to happen at different times in the night, in different stages of REM sleep. Kids remember nightmares – they have visual images they can recall – but they have no memory of night terrors.

If your child gets night terrors, please try not to worry (easier said than done, I know). It’s always fine to talk to us about them and we will mostly reassure you that they will get better, and your child will outgrow them.

If your child has a night terror, know that they likely don’t even know you’re there in the room. You have to patiently wait it out.

Move anything on the floor that might get in his way so he doesn’t get injured. Put yourself between the child and anything that could potentially hurt him (a tall dresser, for example).

Ways that you can reduce how often they’re happening is to assess your kiddo’s stress level. Sometimes these happen more often when a child is under stressors like a parents’ divorce, or starting a new school, or new sport. Talk about these stressors during the day.

Establish a good bedtime routine. Bath, teeth brushing, and a book is always a favorite at our house. Try to avoid screens for an hour before bedtime.

Here’s the part where I am supposed to tell you about the 7-14 days of awful symptoms. Tell you that your body will feel like it is sinking into a deep hole. That your muscles will ache with every racking cough that escapes your body. That you will burn with high fevers for five days. That your head will feel like it’s exploding. That the drainage from your upper airways will puddle into your stomach, and that will make you barf. Sounds great, right? Well, you’ll get over it.

And you’ll slowly pick yourself back up. And eventually you will go back to work or school.

And you’ll tell yourself, “Geez…I am getting the flu shot from now on.” ;-)

But that’s not what I’m going to talk about. I’m going to speak for the thousands of people who no longer are able to speak about influenza. Because the flu can kill. And it has. 

Heck – there have been giant worldwide pandemics of the flu. The influenza pandemic of 1918-1919 killed more people than those that died in World War I - somewhere between 20 and 40 million people (though some sources list 50+ million). It has been cited as the most devastating epidemic in recorded world history.

The last flu pandemic we had was in 2009 (H1N1) and it killed over 200,000 people.

The flu is a “really really bad guy”, as my 2 year old likes to say. It’s super contagious (an infected sneeze or a cough a few feet away from you, and you’ll start to show symptoms within 4 days). It’s meanest to young children, older individuals (age 65+), pregnant women, and folks with underlying medical problems (think chronic lung problems like asthma, people with immune system dysfunction, diabetes, kidney disease, liver problems).

But let’s put all that aside. Let’s say you’re a healthy young person.

The flu can kill you, too. Or at least – make you really really really sick. Sicker than the majority of lucky souls who get away with the scenario in the opening paragraph.

I am a general pediatrician. During my training in medical school and residency I personally have taken care of:

• Countless cases of severe sinusitis, pneumonia, and ear infections due to getting the flu (which then makes kids susceptible to bacterial infections like these).
• A teen girl who was so sick with the flu that within 24 hours of catching it, she started urinating a brown substance. This substance was broken down muscle proteins. She was experiencing a well-known complication of the flu: rhabdomyolysis. Her muscles were literally breaking down and her kidneys were trying so hard to clear all the junk out that they eventually shut down. She needed dialysis. She spent 3 weeks in the hospital.
• A young pregnant woman contracted the flu while 29 weeks pregnant. The flu killed her in 24 hours due to respiratory distress (pneumonia) and her organs shut down. The woman birthed the baby while on life support and the child never knew his mother.
• A child with relatively mild asthma caught the flu, which made his asthma flare so bad that he required ventilation by a machine for over a week in the ICU. During that time, the flu made his body susceptible to other organisms, and he had to be treated for pneumonia and a blood infection called sepsis as well.
• In the PICU, I cared for a young boy who was, prior to the hospitalization, happy, vibrant, and healthy. There were pictures all over his ICU bed of him riding bikes and eating birthday cake. He caught influenza in school and within a few days it attacked his heart, causing something called myocarditis. The heart stopped beating as well as it usually does, and he needed full life support. That child eventually needed a heart transplant.

I want to say, “I’m not telling you these stories to scare you.” But I am. I want you to be scared of the flu. Because I’ve seen what it can do. And I don’t want that to happen to you or your family. Yes, the majority of the cases of the flu are mild. But sometimes, they aren’t.

The flu vaccine can help your body fight the flu. If you get the vaccine, our hope is that you or your child will either not suffer from any clinical symptoms, or develop an illness that is much milder than if you did not vaccinate. The vaccine was developed not only to save lives, but to prevent millions of days of missed school and missed work.

The people who are against vaccination will argue a couple of points I’d like to discuss:

• “The flu vaccine makes you sick.” – This is a common misconception. The flu vaccine can’t make you sick because it is either completely inactivated or it is not even the virus itself, but a protein that looks like the virus (tricking your body into making an army against it). Sometimes people get mild symptoms after the vaccine like a headache, general achiness, and a low-grade fever. People mistake this as being “the flu” when really it is their immune system generating antibodies and starting a great immune response. Also remember that the flu vaccine is usually given in the fall and winter, when tons of other respiratory viruses are circulating. Folks may catch those and the vaccine is usually blamed.
• “The flu vaccine doesn’t work”. – Actually, some years, this has been true for some people. The World Health Organization (WHO) recommendations are based on global surveillance of circulating influenza strains and on the effectiveness of the vaccine from the previous year. Sometimes they get it right. Sometimes they don’t. The flu is sneaky – It can mutate quickly. We don’t know until the flu season is in full swing. By that point, the vaccine has already been made and shipped out. So it’s important to get it every year regardless. And we hope for the best. Most years, it is right on target.

PLEASE consider yearly vaccination against influenza for yourself and those you love. The flu vaccine changes every year, so you need a new shot every year to boost your immunity against the strains we think will be the “bad guys” that year.

Related links:

• It's only the flu that killed her
• Chicken pox: Why We Vaccinate
• 4 Facts Parents Need To Know About the Flu

I’m going to teach you about a rash that we see weekly in our office at Forest Park – often many times a day.

It freaks parents out, looks weird, and (always surprising to me)….none of the parents I speak with daily have ever heard of it.

Let’s learn about – molluscum contagiosum!

Ugh, molluscum. People stress so much about these little guys. And honestly – they’re usually no big deal and are totally harmless.

Molluscum contagiosum is the name of a rash that looks like fleshy little bumps. They’re caused by a virus and they can be found anywhere on the body.

They’re round, shiny, vary in size, and look like a cuter, cleaner version of warts. They can be white, pink, or flesh-colored. They often have a little “pit” or dot in the middle of them. They also sometimes have cheesy white stuff in them – this isn’t pus. Try not to pop them – this can lead to infection and scarring.

They spread from person to person very easily. They are passed by skin-to-skin touching, sharing towels or clothes, or using wrestling or gymnastic mats. They are also a common STD. I find that water is a common transmission source – baths, pools, hot tubs.

In my experience, they typically last 6 months to 2 years. The CDC mentions they can last as long as 4 years, but I’ve never seen that.

I always tell folks, if they can, to just leave them alone and let the body get rid of them. There is less scarring that way. Molluscum usually look a little inflamed right before they go away, because the body is finally paying attention to the virus and fighting them off.

Like I mentioned before – molluscum are usually harmless. They can, however, cause kids and parents to worry about their appearance, get irritated by clothing, and can get infected by scratching.

There are different ways to go about getting rid of them. Treatment is designed to irritate the spots. This is to encourage the body's immune system to recognize the virus and destroy the infected cells.

Just like with warts, we can freeze them in the office, or apply a blistering compound (“beetle juice”) to hopefully cause enough irritation to make them go away. Sometimes if they’re really bad, I’ll send kids to the dermatologist where they can inject yeast antigen into the lesions to make the body pay attention and get rid of them! Isn’t that crazy cool? This works sometimes for warts as well.

Other ways to approach getting rid of them involve creams we can prescribe. There are even oral medications that sometimes help (although I haven’t had the best of luck with these). You can also try a compound called Zymaderm. I’ve had some patients have luck with tea tree oil. And I’m a big fan of apple cider vinegar for both warts and these guys.

Bottom line is – they’re pretty benign, they typically are just annoying, and I promise you they will go away eventually. If you’re really worried about it, come on in and we will walk you through some treatment options.

Hugs,

Dr. Diane

Constipation is the cause of alllllll the things. Just joking.

No, but really – it’s one of the most common things I see in my office at Willow Park, and it causes strange problems sometimes. Parents often don't believe me when I tell them it's constipation causing the problem. 

What is constipation? It doesn't necessarily mean your child isn't stooling daily. A kiddo can be constipated and poop many times a day. Constipation means hard, dry stools. They’re often painful to push out. And yes, most kids with constipation will go a few days between stools.

I really feel that constipation has become more prevalent over the years because of how our kids' diets have changed. In general, kids are eating less fresh fruits and veggies and depending more on packaged goods for snacks and meals. 

There are lots of medical causes for constipation as well. Did you know that hard poops can cause:

1. Stomach pain
2. Withholding of stool
3. Vomiting
4. Refusal to eat
5. New urinary accidents
6. Wetting the bed
7. Diarrhea
8. Poop accidents 
9. Blood in stools, blood in diaper
10. Fever (yes it can cause fever! mostly lowgrade)

Here's the deal - and let's get down and dirty about it. The things your kids eat affect the quality of their poop. If they eat and drink things that don't have much fiber (think cheese, yogurt, pastas, cookies, white bread, bananas, milk, goldfish crackers), their stools will be harder. 

Also, did you know our bodies absorb water out of our stools if we need it? So if your kiddo isn't drinking enough water, his body will just take it out of the poop, and it will become hard. 

The poop gathers at the “end of the tube” in a child’s body – the rectum and descending colon – and stretches everything out a lot. See the pic. This chronic distension leads to problems with the “valves” inside the rectum. Sometimes, this leads to leaking – soft stools can leak out without the child being able to control it. 

These big bulky stools can also push on neighboring organs, like the bladder, and even push urine out sometimes. And children with chronic constipation tend to develop poor control of their pelvic muscles and can lose control over their bladder, leading to leaking. One study showed that after being treated for constipation, 89% of 250 kids had complete resolution of their daytime wetting problems.

When the stools become hard, they hurt to push out. So kids don’t want to poop. So they hold it in. And the body slowly takes water out of it. And the stools get harder. And more difficult and painful to push out. Thus starts the painful cycle. 

Kids can get constipated anytime, but I find it’s most common 1) when babies start solid foods, 2) when kids start potty training, and 3) when kids start school.

So how do you fix the problem? Well, that depends on the severity of the problem and the age of the kiddo. But some general rules:

1. WATER. LOTS OF IT. Children and teens should drink at least 6 to 8 cups of water a day. 
2. Fresh fruits and veggies! I encourage kids to eat green veggies, prunes and other fruits (but not bananas), bran, whole grain bread. Sometimes those puree pouches with the kale, spinach, and broccoli are a good start for the picky kids.
3. Certain fruit juices – ok, we pediatricians are NOT big fans of juice. But I’ll make an exception in this case – go with prune, or pear.
4. Fiber supplements – flax seeds are great. Fiber gummies and cookies are good, too.
5. Behavioral and schedule changes – encourage a routine for “potty time”. 20-30 min after meals, have your kiddo sit on the toilet for 5 minutes. Encourage your child to listen to his body and stop playing when he feels the urge to “go” (and not hold it in). 
6. Do not punish your child, or get mad, if he has an accident (urine or stool) – remember, this isn’t under his control!
7. Avoid those foods I mentioned before for a few days – bananas, cheese, crackers, milk (if over age 1), breads, pastas.

If there is anything I can’t express enough to parents – it’s BE PATIENT! It takes many months for the intestines to stretch out and constipation to form in toddlers and children, and it takes many months (sometimes even years) to treat it. Sometimes we use safe laxatives or glycerin suppositories to help during the really rough patches – call or come visit us to talk more about that if you think its necessary. 

Hugs,Dr. Poop (er, Diane)

8 isn't enough ... life with 9 children

Nine children, ages 3 to 19 years old, make Mother’s Day a pretty special time for Kristy Goodnight. After all, that’s a lot of hugs and kisses to go around ... But when you consider each child has his or her own special needs, life can be amazingly hectic and difficult. And what’s the biggest challenge for the mom of nine? Click to read more.

Dr. Mom: How motherhood changed me as a pediatrician

After completing 24 years of schooling and medical training, you’d think that once I graduated from pediatric residency, I’d know a thing or two about the health of children. And I did. I knew a lot ... Then, I was blessed to have a beautiful son...who decided that I needed to be re-taught a few things about children.

And by a few things, I mean everything. Click to read more.

How being a mom shaped her practice

I am a better pediatrician because I have experienced life as a mom. I know the tears and tiredness of a new mom and so when she cries at the new baby check I can tell her it's normal and she believes me. Click to read more. Click to read more.

When my son Jack was born via C-section, everyone had something nice to say about his beautiful round head. “It’s so perfect! Not like the poor little cone-headed babies!” Little did they know that his pretty little spherical skull would soon resemble a pancake on one side.

Does your baby’s head have a flat spot? A flat region?  A flat continent?  Do not fear!  It’s likely normal skull flattening (the fancy medical term is positional plagiocephaly), it’s totally normal, and only rarely do baby craniums need any “fixing.”

Let’s talk about infant skulls – like many baby body parts, they aren’t small versions of the adult skull. They are unique and functional. They are made of bone plates that are loosely held together, and they can move and shift. This special ability helps the baby with an easy exit through the birth canal, and allows the brain to rapidly grow during the first year of life.

However, after that exit, there are lots of external forces that can flatten the infant skull. Often, it’s due to your pediatrician’s golden rule of putting her on her back to sleep. In 1992 we launched this campaign to reduce the rate of SIDS, or Sudden Infant Death Syndrome. What came next was a beautiful drop in the number of babies dying in their sleep, and the unfortunate side effect was the rise of plagiocephaly. 

So your baby is a few months old now, you’ve been putting her on her back to sleep like your pediatrician recommended, and now she’s got a big ole flat spot on the back of her head. What can you do to make it better?

• Give her plenty of supervised tummy time while she’s awake. Find new toys or objects to stimulate her everyday. A mirror is very entertaining! Prop her up on a pillow to give her a little height (And her heavy head a soft landing pad). I find the breastfeeding pillows have the perfect curve for it. 
• Hold your baby while she’s awake to relieve pressure from carriers, swings and infant seats.
• Alternating things in the room to encourage laying on the other side of the head. I found that putting a bright light-up toy, or a mirror, or even myself on a certain side would encourage Jack to look that direction and relieve the pressure on the flat spot. This also works during naps/sleep time – if your baby likes looking out the slats of the crib, flip her head/feet orientation in the crib so that she has to turn her head a different direction.
• There are many commercial items that claim to “round out baby’s head,” with new things coming out everyday. Research these products carefully and bring it up with your pediatrician before making the purchase, to assure they are safe.

When is a funny-shaped head a true medical problem?  If you have concerns about your baby's head shape, always feel free to talk with your pediatrician about it. Pediatricians typically evaluate the shape of an infant's head during the physical exam at the many checkups they gets during her first year. Usually positioning changes (like the ones listed above) can fix a flat head over time, but sometimes a helmet can be used in severe cases to help it along. In rare cases, we advise that a specialist be seen, like a physical therapist or a neurosurgeon.

Rare instances include:

• The flattening has led to facial changes, like a protruding portion of the forehead, and/or one ear that sits asymmetrically to the other.
• A misshapen head that is due to the skull's bone sutures closing too early (called craniosynostosis - your pediatrician is trained to notice signs of this)
• If you notice that your baby has problems with or may even be unable to turn her head to one side, leading to skull flattening, it may be due to a tight neck muscle - a condition called torticollis.

So my point – and I do have one - is that I’ve seen many funny-shaped heads in my office (and witnessed the evolution of a pretty darn cute one at home), and the vast majority fix themselves over time. Always talk with your pediatrician if you’re worried. That’s what we’re here for!

And as for Baby Jack, he did lots of tummy time to help get rid of those flat spots!

When I came home from the hospital with my new bundle of joy last fall, the first two weeks were filled with the tasks of survival – learning to feed my son, making sure he was growing appropriately, entertaining family and friends who wanted to meet him, catching a snooze here and there, and establishing a routine. After those two weeks ended and I had barely left my house, my next plan of action was: Operation Mama Sanity! I needed to get out!

Everyday in my office I have parents who ask me when they can take their newborn babies out and about, and get into the swing of life with their new child. My answer is always the same: now! But … with a few rules.

From day one it is absolutely fine to get out into the fresh air and go for a walk in the park, or in your neighborhood, if the weather permits.Try not to go out on extremely hot or extremely cold days, and as a rule of thumb, dress your little one in as many layers as you are wearing. Make sure the baby is not exposed to direct sunlight. Most strollers these days come with a nice shade for this purpose, or you can use an umbrella.

If you’d like to go out where there are a lot of people, like a busy restaurant, grocery store, or mall, I always tell parents to try to keep their infant’s seat completely covered by a light blanket.This serves a few purposes. First, a baby’s immune system before age 6-8 weeks is still immature. If someone at the next table sneezes or coughs, its best to have this protective canopy over them so viruses and bacteria are less able to come in contact with her. Also, it keeps the baby hidden as a deterrent to well-intentioned patrons from touching your sweet little one. As nice as that is, it’s best if people don’t touch your baby during those careful first weeks. 

If it’s holiday season and you and your new baby are expected at the family get-together, don’t fret. Just politely ask that everyone wash their hands before they hold her. If you’re too shy to ask them yourself – do what I tell my patients to do – blame me! Say, “My pediatrician says everyone has to wash their hands before holding her!”  This way no one can get their feathers ruffled. Carrying a small bottle of hand sanitizer and offering it to everyone is also a great and easy way to get germy hands cleaned. If someone appears to be sick and you don’t want that person to hold your baby at all, don’t. It’s Ok. You can blame that on your pediatrician too.

Don’t be afraid to go out with your new baby – she and YOU need it! Getting fresh air, exercise and social interaction in those first few months is vital to parents, and happy parents make happy babies. 

Hope my two cents help you muster the courage to venture out! And remember, many pediatricians have slightly differing opinions about these things, so it’s best to speak with yours if you have questions.

About the author:

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