With more adults across the country getting a COVID-19 vaccine, we can finally see the light at the end of the tunnel. It is vital to keep in mind that children 16 and younger cannot yet get vaccinated, and we all must do our part to protect them.

In an interview on Monday with Lauren Zakalik from WFAA, Justin Smith, M.D., a pediatrician at Cook Children’s Pediatrics Trophy Club, warns, “the risk outweighs the benefit of large gatherings for Easter because all children are not yet vaccinated.”

Dr. Smith says he understands parents are eager to let their children spend time with their fully-vaccinated grandparents and family members; however, it’s essential to take extreme caution this weekend and for the near future. 

“Anyone at a gathering who isn’t vaccinated could potentially bring the disease to the gathering,” Dr. Smith warns. “It is necessary to still follow the guidelines in place and not gather with several households until everyone can get vaccinated.”

Another critical point to remember is not only could spending time with other households potentially be a space to spread COVID-19, taking your children to large Easter egg hunts and other Easter festivities could also prove to be problematic.

“Social distancing can be challenging and it's likely there will be a lot of people unmasked,” Dr. Smith said.

As a physician and a father of three, Dr. Smith says large gatherings of any kind this Easter are not something he would be comfortable with his children or his patients doing.

“We are closer to the end of this than we’ve ever been, and I think we can make decisions for a short-term now that could potentially get us to the end,” Dr. Smith said. “I’m nervous about really trying to get back to normal right now when it feels like we’re so close, because I’m afraid it could set us back.”

While Texas has opened up vaccines to everyone 16 and older, it is not clear when younger children will begin to receive vaccinations. “Just like we’ve been doing for a year, we are advising adults to use caution and choose activities that are done in the safest way possible,” Dr. Smith explains.

Get to know Justin Smith, M.D.

Being a new parent is hard.

Being a new parent today is even harder.

With the limitation of visitors, changes to doctor’s offices, and lack of ability to get out of the house (among many other challenges), being a parent in COVID-times is causing new parents to feel even more isolated and ill-equipped.

But, when can you have visitors over to meet your newborn?

Like most things COVID-related, it’s not a simple question.

It’s also a decision that, given all the same information, two families might make very different choices.

Even in “normal” times, I believe that babies under 2 months should have a pretty tight circle drawn around them, which can relax more with each round of shots at 4 and 6 months. COVID has just heightened my desire to protect them even more.

It appears that infants less than 1 year are at a higher risk of severe illness than other kids.. Because of the upfront, face-to-face nature of caring for them, they may be at higher risk for exposure from a caregiver. When considering this decision, it’s essential to keep in mind the reverse (and perhaps more significant) risk to the person entering the house. Many grandparents and other family members might fall into higher-risk categories based on age or medical conditions.

But that doesn’t mean you have to go it alone.

Here are three factors to consider:

1. The purpose of the visit.
2. The behavior of the visitor.
3. The activity at the visit.

The purpose of the visit.

The first time this comes up is at the time of delivery. If you have an older child at home, they need to be taken care, of and you should have the opportunity to have someone to support you at delivery. This one is easy. Ask the grandparent or other caregiver to take caution with social distancing, masking and other precautions around 36 weeks so that they can be as safe as possible entering the home.

After the initial delivery phase, some parents may need ongoing support from a close family member. When a parent has to go back to work or doesn't have a lot of experience with babies, they may need ongoing support. The safest way to do this is to ensure that the person entering your home has been following guidelines for at least 2 weeks before the visit. If possible, they should plan to come and stay as much as possible rather than coming and going frequently. Staying put limits their number of contacts and lowers the risk for everyone.

Purely social visits are probably the riskiest. Having any number of visitors drop in to say hi significantly increases the baby's risk because of the number of possible contacts and the lack of control over their behavior and exposures. Some parents might feel comfortable with a very close friend or family member. Still, we all must recognize the risk of doing so.

The behavior of the visitor.

There are many different approaches and mindsets concerning coronavirus. While I wish everyone took a cautious approach, that’s not the case. And while you may have family members who argue they have the right to make their own decisions regarding social distancing, mask-wearing and the like not everyone has the right to make their own decisions AND get to spend time with your baby.

If you have a close friend or family member you trust is taking an extremely cautious approach, you may feel more comfortable inviting them come over to meet your baby. Remember that you get to make your own decisions about what makes you comfortable. If you decide to take a more conservative route than your family appreciates, feel free to blame your pediatrician (especially if it's me). I promise we’re cool with that.

The activity at the visit

Once you’ve decided you’re going to see family, there are still questions about what will happen at the visit. Of course, at a baseline, we’re going to do all the usual things we would ask anyone to do when visiting a newborn.

1. No one comes over who has possible symptoms, such as a cough, runny nose, (obviously) fever, etc.
2. No one holds the baby without washing hands first.
3. No one kisses the baby period.

Extra precautions you might consider in the context of COVID would be (in decreasing order of safety): drive-by only visits, patio/outside visit, no-holding/across the room visit or a masked visitor visit.

Be gracious with yourself and others

Remember again that every parent and family will make different decisions and have different comfort levels. Be kind to yourself and your fears. Consider the impact of not having visitors vs. having visitors and what that means for your level of stress because it might affect each parent differently. If you are the potential visitor, be kind, and understand if the new parents in your life ask you to stay away

We're all in this together for the long haul, and they are dealing with enough stress as it is.

Recently, I wrote a post titled, “Is Going Back to School or Online Learning Best for Your Child?” A Pediatrician Shares what Parents Should Consider?”

Following that initial article, we received a lot of questions from you all. I wanted to take this opportunity to answer them all at once.

Let’s get started.

For families with multiple school-age children, is it counter-productive to send some children and keep the others home? I think one of my kids can thrive with online schooling, but it would be much harder for the other two (due to dyslexia, age, socialization needs, etc.).

Not necessarily. While the child at school could contract the virus and bring it home, the fewer children and contacts, the less likely the family is to be exposed. I can easily see a family weighing the risks versus benefits and making different decisions for each child.

When looking at a child as a whole and not just at the physical, can you talk about what repercussions we could be looking at from keeping kids home from school. As a nurse, one of our core principles is looking at the entire patient and not just the patient's body. I think we should have a discussion about the mental health, emotional health, educational health, and even social health repercussions of keeping kids home. This won't be the often very successful home schooling that people do.

Yes, I think it is very important for families to consider both the medical risk of COVID on children and household contacts in the context of how being home from school would affect their child educationally, socially and emotionally. It should definitely be a whole child conversation.

Is it worth sending kiddos with special health needs to public school this year? We had hoped to send our youngest who has cystic fibrosis back to public school for his high school years starting this year.

And ...

Hi Dr. Smith, My soon to be 1st grader is on methotrexate for Crohn’s disease. How worried should I be about sending him to in person school? I’m worried the medication will make it harder for him to recover from Covid. Thank you for your insight!

This decision will be different for every child and every family depending upon the needs and risks for an individual child. These decisions would be best made with the pediatrician or specialist who knows the child's history the best.

If our kids go back to school, are we basically giving up seeing grandparents and anyone high risk? We’ve been very careful all summer in order to be able to spend time with my mom.

This is probably one of the worst parts about this decision for families. Based on the best information available currently, once our kids go back to school, I think we will have to use extreme caution with grandparents and other at risk contacts. Hopefully we will learn more over time what it looks like to protect grandparents and maintain connection.

My oldest is entering kinder, and it just seems/feels like such a big year for him. He loves school, and excels, but is also shy and sensitive to new things and transitions. We also have a grandparent that we see often who has cancer, so sending him would mean that we couldn’t see family. We are leaning towards homeschooling for the year, but don’t want him to miss out on such a big and important year. Is kinder a good year to homeschool or would it be more important to send him for the socialization and such?

Transitional years seem like the one that most families are struggling with. Kindergarten, 6th grade, 9th grade...as well as the obvious 12th grade. Unfortunately, I don't think that there is a straightforward answer but I am trying to remind families that everyone is facing the same decision and your child wouldn't be the only one who stays home...all that to say, there will be several kids starting first grade the next year who also home schooled.

For me it’s, if we as a family decide to send him back to school, how do we protect the rest of the family from germs he may bring home? Is it even possible? And at 13 is social interaction crucial for his mental state (he’s kind of a home-body anyways)?

I think I would be extra cautious about hand washing, perhaps even showering and changing clothes once they get home. Is it possible to keep them completely sterile? Probably not but it might make me feel better to make sure I was doing everything I could. Is social interaction crucial? It definitely depends on the kid. But it might not be as simple as thinking introverts don't need to go but extroverts do-perhaps it's our introverts who have the most to learn from being in a social environment. It's hard to say.

One of my two children has already tested positive. My youngest has not. Is it safe to send the one who has tested Positive back to school? Is there such a thing as immunity?

This is something I truly don't know if we have the answer to. Can a child who has had it get it again? Can they still bring it home even if they are immune? I don’t know the final answer to these questions.

What about the nonverbal language skills kids will lose by not being able to see their teachers and peers facial expressions behind a mask.

I think it’s safe to say that even being at school will not be normal and there will be some downsides and missed opportunities for learning. Even things as simple as not having lunch in the larger community and skipping recess (if a school chooses to do those things) will be something we need to consider.

Guilt. Am I a bad parent if I send my kids because I think they need in school learning? The spring at home was minimally successful and I do not think we have the capacity to do the teaching from home. How do I NOT feel like a bad parent?

I think this one will affect everyone. Trying to make the right decision with limited information and two options directly in front of you is a huge challenge. Dealing with the downfall when things go wrong or there are challenges down the road will inevitably lead this towards you wondering if you made the best decisions.

It’s the Bachelor phenomenon-how can an individual get to the end with two competitors and choose one-completely forgetting that the first was an option and not wondering if they made the right call? It’s probably why it seems to fail more than work out. (Except Sean and Catherine and a few others…)

And it’s not just the decision to send them that will have parents feeling guilty…parents choosing to keep kids home will have similar struggles.

How do you help with the guilt:

1. Remember that you’re not in this alone. Everyone else is having to make the same decisions.
2. Remember that kids are resilient. If they have a parent who loves them and is agonizing over this choice. They are likely to be ok in the long run.
3. Remember that no choice is forever. It feels like you’re making a decision that could have effects on your child for the rest of their life, but we will have options over time. None of them may be great options but we can make changes as we go and modify based on how it’s going.

What should performing arts classes do for safety? Is it safe for a bunch of teenagers to be singing, playing instruments, performing plays and musicals together in one room? 

Yes, I believe that most school will have to forego performing arts classes for the near future due to the risk that these activities could increase the risk of spreading droplets and disease.

How do we keep 2600 high school students from passing this like wildfire when we can’t easily keep them in 1 or 2 classrooms all day? Are teenagers being affected symptomatically similar to “kids” or more like “adults”?

I think secondary schools are going to present the biggest challenge to keeping infections at bay due to their mobility throughout the school day. We may see schools make decisions to keep kids cohorted for core classes and limiting electives or presenting electives in an alternative way. It does appear that adolescents appear to be presenting with more symptomatic disease-which may help monitoring infections and spread easier than in kids who are asymptomatic.

If one child in a classroom is positive will the entire class need to quarantine/virtual school for a 14 day time period?

It does not appear that the class will be shut down if a classmate tests positive for COVID. According to the TEA and local health departments, notification will be provided to families should a person on campus test positive but it is not clear how much information will be provided.

What are the thoughts on preschool. If we have the option is keeping them home worth the reduced risk of Covid despite it keeping the children from other children and a classroom? Will our preschoolers be behind come Kinder?

Keep in mind that many children start their first formal schooling experience with kindergarten and do well. Parents may still make a decision to send their child to preschool but I don’t think it should be out of fear for their education.

My heart breaks for my kindergartener who will start his public school experience looking SO different than his older sister. How much should I allow a 5 year old to endure. What are the “new rules” that are too much to expect (an active) 5 year old to adhere to?

I think they should be prepared that things will be a little different than their preschool years. Masks, recess, PE, lunch-everything will look a little bit different. Reassure them that all of the changes are to help them be safe. But also keep in mind that they probably don’t know what Kindergarten is supposed to look like. So, what does that mean? There’s no point in having significant discussions with them about what they are missing out on. Focus on the positives. The way we frame these discussions with our kids is going to mean a lot to them. Are masks going to be required? Don’t say it’s stupid but we’re going to do it anyway, just say, it’s part of life. Recess with just your class? Think of how much more room you’ll have on the playground. You’ll get so many more turns!

What happens when our 4 yo inevitably picks up another cold of virus at school with the same symptoms. Will we need to get her tested for Covid every time to rule it out? I also have a 6 month old so worried about him getting it from her. Just can’t wrap my head around how this will work when she does get sick with something.

This is going to be one of the biggest challenges of the fall. Because the list of COVID symptoms are so broad, we’re going to have to learn quickly what symptoms require testing and what can be monitored. Early on, I expect we’ll be doing a lot of tests out of precaution until we get better guidance. We’ll all be doing the best we can to minimize unnecessary visits but also to keep everyone as safe as possible.

I’m choosing to start my son out at home this year. How do I approach the decision with him? What is appropriate for elementary aged kids to know about why I made the decision and how do I make sure to address the missing of friends?

I think informing them of your thought process to the level of their development is an important part of how you transition them towards thinking about doing school at home. Finding ways for them to connect with peers will be something that you need to focus on-through technology or finding ways for them to participate in extracurricular activities that are following COVID guidelines are two thoughts that come to min.

Is it ok for a 3rd grader to wear a mask for 8 hours a day at school?

Yes! It will be a learning curve for sure but kids in schools all over the world have adjusted to wearing masks both now and in flu seasons throughout the years. Start practicing now. Explain to them the importance at their level. It’s just like covering your cough, washing your hands and not picking your boogers. Just another thing that we have to teach them in order to keep the environment safe for themselves and their classmates.

Should I have my child tested for antibodies to COVID if I think they had it earlier in the year? If they have antibodies will this help protect them when they go back to school? One of my children has special needs and gets sick very easily. I am fearful for him to go back to school but also fearful that lack of socialization for him will be detrimental.

Unfortunately, the accuracy of antibody testing has not been consistently good-some studies have shown that have shown false positive and negatives at a rate of 50%. In addition, we are not sure what antibodies actually confer immunity.

Wow, what a difference a few months make.

Just around four months ago I wrote about an emerging virus which was spreading across a province in China. I urged awareness but not panic as we were seeing a few cases spread outside the local area.

Within the next couple of months, our kids were asked to stay at home. Schools were canceled and professional sports were postponed, activities were stopped, and even doctors’ offices slowed down the types of visits we were doing.

Today we are modifying vacations, staying 6 feet apart and wearing masks out in public.

Everything moved so fast, it’s been hard to keep up. So as a quick summary and with the way everything has changed, I thought it might be helpful to put together the top 10 things we’ve learned about SARS-CoV-2 and COVID-19:

1. SARS-CoV-2 is a new type of coronavirus that began circulating in the Wuhan province of China. The disease associated with the virus was named COVID-19. You might hear those terms used one in the same. There is a subtle difference, but not enough to dive into right now.

2. The symptoms of COVID-19 have been varied and what has been recognized as symptoms has changed over time. Upper respiratory (cough and congestion) and lower respiratory symptoms (rapid or difficult breathing) as well as fever or a flu-like illness are the core symptoms and the following have also been reported: loss of smell and taste, vomiting, diarrhea, sore throat, headache and muscle soreness.

3. Many people who are exposed and contract COVID-19 will not have symptoms. It’s not clear how these people without symptoms contribute to the spread of COVID-19. However, even those who develop symptoms later are likely contagious before their symptoms develop.

4. Kids have been relatively spared from severe illness from COVID-19, but not entirely. Children can develop classic symptoms and severe illness. Caution should be used for children with chronic medical conditions and infants under 1 year of age.

5. In addition to classic COVID-19 symptoms, children have also developed a condition known as multi-system inflammatory syndrome, which is similar in nature to a known syndrome called Kawasaki disease. The symptoms are varied but include prolonged fever, belly pain, vomiting, neck pain, a rash, red eyes without discharge and extreme irritability or fatigue.

6. Specific treatment for COVID-19 has been challenging. Multiple reports of various treatment options showed promise in small studies but have failed to produce results when brought into larger studies. The most promising treatments recently are a specific antiviral called remdesivir and for severe illness, a steroid called dexamethasone.

7. By far the best defense against COVID-19 at this point is avoiding exposure. Studies have demonstrated a clear benefit to maintaining social distancing, washing your hands and mask wearing as a safe means of slowing the spread of COVID-19 through communities.

8. Speaking of masks, they are a courtesy to others. They protect people who are more vulnerable to the disease, such as the elderly or those with chronic illnesses. Masks should cover the mouth and nose to keep others safe. Also, they are perfectly safe to wear.

9. Vaccine trials are ongoing for many versions of a COVID-19 vaccine but we currently don’t have any time frame for when a vaccine will be available. Vaccine trials take significant time to demonstrate safety and effectiveness.

10. Science changes. Yes, at first we were told we didn’t need to wear masks and now we know that masks are vital in protecting others from COVID-19 and that they actually save lives. So what happened? Science. This disease is so new, scientists and doctors are gathering information, or data, as quickly as they possibly can to make sure we are safe. We have gained a lot of information in a relatively short period of time and we will continue to gather more.

COVID-19 has been and will likely be the biggest disruptor to “normal” life of our lifetimes.

Keeping up with the latest information and the behavior of the virus is challenging for scientific experts. Keep in mind that as recommendations appear to change, that they are based on the latest information as we know it about the virus.

We will get through this but, as we have learned, it will only be as we can do it together.

But many parents are still asking the question, 'Should I take my child to daycare?'

Of course, there's no one clear answer for all families. The bottom line is that everyone should consider carefully whether taking their child to daycare is the right decision for them.

The first consideration is whether you think your child’s daycare center is ready to open.

The Center for Disease Control (CDC) has issued some guidance for child care opening. Before I sent my child back, I would ensure that they are at a minimum following their recommendations that daycare centers should only open when:

• They can be compliant with local and state orders, are ready to protect high risk children and employees, and can screen children and employees on arrival.
• The following health and safety actions are in place: promote hygiene practice such as handwashing with employees wearing masks, intensified cleaning, encouraged social distancing when feasible, adjust activities to limit sharing of toys/supplies and training all employees.
• Ongoing monitoring is in place. Children and employees should have a process for checking for signs and symptoms upon arrival, sick employees should be allowed to stay home and a plan should be in place should employees or children get sick.

Once daycare center readiness has been determined, each family will still need to make a determination for when their child should go back. Here are some factors to consider:

1. Child’s medical history - This may seem obvious but children with chronic conditions are who are immunosuppressed would be at higher risk with returning to day care.
2. Child’s age - Children 2 and older will likely be asked to wear a mask but the younger kids are, the harder it will be. It might be easier for children who aren’t mobile to be separated. Toddlers will be the trickiest as they are mobile and can’t wear masks.
3. Family medical history - At risk family or household members will be at risk for contracting disease from asymptomatic children who bring infection home.
4. Family work situation - As offices open up, many parents will not have a choice. Even parents who work from home may face increasing pressure to be more productive as the economy begins to open up. Parents need to be able to provide for their family and maintain insurance coverage in a time where work insecurity is a real issue.

While each parent will have a choice to make in regards to taking their kids back to daycare, hopefully these considerations will help you make the best decision for you and your children.

We miss you and your sweet kids!

What a crazy time the last few months have been. Our entire lives have been changed-work, school, family and free time-they are all different.

During this time, we, your Cook Children’s pediatricians, have learned a lot about COVID-19. We have been following what’s happening all over our country and the world. Fortunately, Cook Children’s supported us through this time so that we could make the safest, best decisions for your family.

While we learned, we made an immediate switch to do as much as we could via telemedicine but continued to do checkups under age 2. We have slowly started to incorporate more visits as we grew more comfortable with our ability to keep you and your family safe and now, we are ready to see your child for their checkups!

What do you need to know about your upcoming check-up?

Safety is our primary concern

Changes to clinic workflows and traffic patterns in the office will ensure that your family is able to maintain social distancing.

Scheduling will be modified to keep well and sick children in the office at separate times of day.

Masks will be worn by staff at all times. In addition, we ask that you and your children over age 2 also wear a mask while in the office.

Rigorous cleaning of all surfaces throughout the clinic will continue between each patient encounter. This includes surfaces in the room and common areas.

Regular checkups are important for your child’s health

Assessing children for growth and development helps us act quickly when things aren’t going well. Diagnoses of growth hormone deficiency, autism, anxiety and depression frequently are recognized during well child care.

Vaccine schedules are designed to allow shots to be given at the most critical time. Waiting for long periods, often leaves them vulnerable during the times when they need protection the most.

Physical exams during well care often pick up dangerous conditions such as scoliosis and even cancer. Neuroblastoma (cancer in the adrenal gland above the kidney) and testicular cancer in teenage boys are often diagnosed during well child care.

Cook Children’s Pediatric offices will be reaching out to patients in need of checkups, but you don’t have to wait, give your office a call to schedule their visit.

1. They don't leave enough time for their commute. Even if the roads get mildly slippery and you were born and raised in North Dakota, keep in mind that us native Texans pretty much absolutely freak out about winter weather. We'll either be taking it too slow or driving like a maniac. Give yourself some extra time to get the kids to school.
2. They leave their kids puffy coats on in the car. Car seats are not meant to be buckled around big puffy jackets. Take them off and use them as a blanket before you take off. Read more about this here. Give your child an extra second to put it back on in the school drop off line. (Yet another reason to see No. 1 above).
3. They forget to take care of their kid's skin. Get outside and play in the cold weather, but remember that sun and snow can still cause significant sunburns. Apply sunscreen like you're at the beach. Cold wind can also lead to dry, red cheeks in children of all ages. Apply some vaseline to the cheeks after being outside and at the first sign of irritation.
4. They ran out of their child's albuterol. Weather change can be a significant risk factor for children with asthma. A sharp drop in temperature often bring the wheezers into the office in droves. Make sure you have inhalers or albuterol for your nebulizer on hand (and not expired).
5. They worry about things that don't really matter. "Cover their head so they won't catch a cold." "Don't let them outside with a wet head." Here is more information about these and many other Winter Wives' Tales.

Now that you know some of my big tips for keeping your child safe when the weather turns cold, stay safe and enjoy the winter while you can!

“Wear shoes outside.”

“Put on your hat.”

Does any of this really matter? Is any of it true?

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

Not all old wives’ tales are fictitious – some are grounded in truth. However, if you have questions or hear health advice that doesn’t make sense to you, always ask your children’s pediatrician before acting on the information or simply believing a statement is true.

Let’s take a look at the facts on these weather health myths.

Myth 1: Sudden changes in the weather make you sick

One day you are wearing shorts and the next day you are dragging out all of your winter gear. Welcome to Texas. So doe the fluctuating weather make you sick? In general terms, the answer is no. I know no matter how much science I use in my answer, many of you won't believe me. The truth is there's no scientific proof that changes in the weather will make you sick or keep you from getting better. 

But as usual there are exceptions. The changes in the weather can be really hard on your child's skin. Moisturizing children's skin during the winter is important and that includes wearing protective lip balm. Also, make sure your child uses sunscreen when playing outside whether it's cold or hot outside. 

The other concern would be kids with asthma. People have different triggers for their asthma. The most common ones tend to be weather changes, viral infections and exposure to certain allergens. Cold, dry air can cause bad flare-ups and viral infections are the most common trigger this time of year. Parents should stress to their children the importance of handwashing, especially this time of year.

Myth 2: If children go outside with wet hair or without shoes, they’ll get sick.

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

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

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

Myth 3: People lose most of their body heat throughout their heads, so children should wear hats while playing outside in cold weather.

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

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

Myth 4: Feed a cold and starve a fever.

We’ve all heard this and probably most of us can’t even keep the saying straight. But there’s no scientific evidence to support the idea that children should fast when running a fever. Children who are sick should eat when they feel up to it and drink plenty of fluids to prevent dehydration.

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

Myth 5: All fevers should be treated with medicine because high fevers are dangerous.

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

Myth 6: You can’t prevent your child from catching a cold.

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

Don’t buy into the weather myths. Here are some tips for preventing health issues:

• Help your child eat healthy and get good sleep.
• Get your child up and active in some way every day.
• Teach your child to wash their hand and cover their coughs.
• Get your child a flu shot (it’s still not too late).

"What happens if my child eats all of my adult vitamins?"

We received this question recently. Let's discuss.

Just like any adult medication, vitamins should be locked away so that kids can't get to them. Vitamins are particularly risky because, while they may seem harmless, ingestion of multiple vitamins can be dangerous. In addition, vitamins are colorful and often made in forms that kids love to eat (chewables and gummies).

Vitamin toxicity can occur if a child is taking a few extra vitamins per day or if a child ingests a large amount of vitamins in one sitting.

The most dangerous vitamins ingested by kids are the fat soluble vitamins (A, D, E and K) and iron. Other vitamins and minerals can cause problems as well, but many are passed in the child’s urine without concern.

If you suspect your child has ingested a large amount of any vitamin, call Poison Control at 1-800-222-1222.

They can help you asses the amount that the child ingested and what the risk is.

Most commonly your child will have some stomach upset with or without vomiting. Severe toxicity can occur with Vitamin A and iron, which can lead to multiple problems and ultimately lead to death.

Hope this helps. Just remember to keep all medications locked away and out of reach of your kids. 

Doc Smitty

When parents report a croupy cough, it means different things. Some parents call bad/deep/dry/wet/rattly coughs croupy.

When I think of “croupy cough,” I mean “barky” like a dog or a seal. We are seeing quite a bit of croup this winter so I thought a quick update might be in order.

Age (When will my kid stop barking?)

The disease typically occurs between 6-36 months (can be as young as 3 mo but usually not older than 6 years).

Season (What time of year does my kid bark?)

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

Most ER admissions for croup occur between 10 p.m. - 4 a.m.. Unfortunately, things really can get worse at night.

Pathology (What makes my kid bark?)

Initially, the virus infects the nose and throat and then spreads downward causing swelling in the area just below the vocal cords. When looking with a camera at this area, there is a lot of swelling and redness (inflammation). The vocal cords themselves can also become swollen, causing them not to close as well. This is what can cause children to have a hoarse quality to their voices when they speak. The speed of the air as it travels through this area coupled with the swelling and inflammation causes the noisy breathing and barky cough.

Recurrence (Why does my kid get croup over and over again?)

Research has shown that some children are more prone to croup than others. I think that this has something to do with shape of the area around their vocal cords, consequently putting them more at risk for difficulty breathing and barky cough with any viral infection.

Treatments (What do I do for my little seal?)

All the treatments listed are intended to reduce the swelling in the vocal cords and below, helping your child to be more comfortable.

1. Warm steam – We used to put kids in croup tents where we pumped a humidifier in to get the humidity way up. To achieve the same affect, you can turn on the shower in the bathroom and just sit with the child. You can also run a humidifier in the child’s room.
2. Cold steam – Open the freezer door and put the child’s face in front of the steam the freezer emits.
3. Steroids – Giving the child steroids by mouth (or a shot in severe cases).
4. Racemic epinephrine – This is a specific breathing treatment that currently can only be given in the office or hospital.

Two take home tips:

1. The next time your child is barky, feel free to come in and tell us that your child is “croupy.” However, if your child isn’t sounding like a little seal, it’s helpful to try to find a different word to describe the sound of his or her cough, as there are many different causes for the different sounds of a cough.

2. If I start to explain this process to you in the office, stop me and say, “I got this. I read your blog about it.” Nothing would make me happier.

I've been interested in essential oils for a while now, beginning with a Facebook post where I sought out questions that might come up regarding essential oils and their use in children. Well, after much consideration, study and investigation, I think it’s time to release some of those results.

Whether you agree with my conclusions or not, I think you’ll find the information helpful and interesting…so here goes!

The slippery assumptions of oil supporters

We all have pre-conceived ideas about things. We can’t help ourselves. We were brought up in a particular culture or educated in a certain way or have friends that believe certain things. One of my primary goals as a person is to constantly challenge what to believe to see if there are holes in my thinking or understanding of things that are not logical.

I’m going to go ahead and put some of my pre-conceived notions and assumptions out there so that we can all be on the same page:

1.I have a strong trust in science, the scientific method and organized medicine. I can’t blindly follow any of those things, but I’m going to rely on them most of the time to make decisions for myself, my children and my patients. If the science proves that something works, I’m willing to use it or at least allow it to be used by my families.

2.I am very skeptical of anecdotal stories and advice. I often have to say, “I can’t contradict what you are saying, but it goes against what I know about this condition.”

3.I am generally very nervous about new treatments or new uses for old treatments. I often say, “I don’t want to be the first to try something nor the last. Somewhere in between is where I feel comfortable.” I want to weight risk vs benefit for everything.

4.I believe that the overwhelming percentage of parents (99.9999 percent) want the best for their child and would never intentionally harm their children in any way.

Because of these assumptions, I may evaluate oils in a different way than most people who use them do. I get that. But my patients who use them will tell you that when we talk about them, I am not judgmental (at least, I try not to be) and I am willing to listen to how they are using them as long as they will listen in return when I provide suggestions or push-back. (Most of them pretend to listen, at least, ha!)

I thought as we move through all the evidence about oils I have discovered, it would be helpful to challenge some statements made by my oily friends that imply false assumptions about me:

1.“I just don’t want to give them medicine for every little thing.”

That’s awesome, me neither. When patients leave my practice, it’s most commonly because I don’t give them a medicine or test that they want. The four most common examples are medicine for colds (cough and congestion), reflux, colic or antibiotics. If medications are not indicated for those conditions, I’m not going to be writing for them. If the decision is on the fence or unclear, I’ll engage the parents to help make a decision. The three little kids running around my house rarely get any medicine, especially for those symptoms for which I see oils being used. They rarely get medicine for fever or runny nose, never for cough and certainly never because their behavior is bad that day. Most of you probably don’t use oils for this-but some of you do…I’ve seen it. I’m not trying to single out a child with special needs or developmental problems, I’m more referencing a kid/parent who just aren’t quite getting along that day. In many of these cases, the use of oils is not in place of a medication, it is often additional to what I would do.

2.“You are a medical doctor so I’m sure you don’t like alternative medicine.”

Not exactly but this one is closer to true. Traditional medicine, to me, means tried, tested and proven. Alternative medicine might be old, might be tried but in my mind the definition means that it is unproven. In fact, through my studies the last few weeks, I have come across a couple of ideas that I am considering incorporating into my practice. But, at that point, if I begin to recommend it based on review of the scientific literature, is it alternative? Or, if the oils work like some claim they do, then eventually won’t we all be using them? Are they still alternative? This assumption is partially true but only because I want to be clear with my patients on what we absolutely know about oils, not what some have claimed.

3.Patients don’t tell me about their oils because they are scared of my reaction or assume I don’t want to know.

Incredibly wrong. I have to know what medication your child is on, period. If there is information about drug interactions or negative outcomes as a result of any medication use, I need to know who’s taking it so I can get in touch with people who are using them. We do the same thing for vaccines and everything else we use in the office so that if there is a recall or another issues, we can get the word out to our patients and tell them what to be on the lookout for.

Now we can move on to some research…

The Research on Essential Oils in Kids

These are the oils for which I found some research. I’m sure I left some off but I thought these were a representative list from a Facebook question I saw come across my timeline and would give us enough information to start the discussion.

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

I started by looking myself and then had our staff librarian follow up with a PubMed search. Because I knew that would not be enough for some, I also reviewed the following websites at the suggestion of the followers of my Facebook page (The Doc Smitty): aromaticscience.com, Dr. Robert Pappas Essential Oil University and airase.com (cost me $75). I also used the NIH Center for Complimentery and Integrative Health, the MedLine Encyclopedia & Natural Medicines Comprehensive Database and the Sloan Kettering Integrative Medicine Database.

First, I’ll summarize what we found from the more traditional medical research on each oil (PubMed, NIH Complimentary and Integrative Health, MedLine and Sloan Kettering):

Lavender

• One study shows use of lavender associated with decreased use of acetaminophen after children had their tonsils out but did not show decrease in pain intensity or nighttime awakenings. (48 patients)
• Several adult studies showing calming effect of lavender.
• Another very small study showed that lavender use in babies had a calming effect.
• These and other published research involve small sample sizes (less then 50 subjects) and often the study design is lacking or flawed in other ways.

Tea tree oil

• Some fair quality studies that included children showed some possible benefit for lice, acne and warts.
• A small study in adults showed possible improvement in toenail fungus.
• Many reports of side effects from accidental overdose are pretty common with tea tree oil (confusion, drowsiness and possibly coma). Just a reminder (just like other medicines, I’m not singling out oils) that we should keep these oils out of the reach of children. I have seen people make comments like, “These are natural so you can’t possible overdose on them.” This is simply not true.

Chamomile

• A review of the use of alternative methods for treating colic (including chamomile) was published in Pediatrics in 2011. The conclusion of the reviewers was that a further look into the issue was warranted.
• Colic studies are difficult because defining what is colic is difficult, if we can agree, deciding what constitutes improvement is even harder as most “cases” resolve on their own without treatment.

Peppermint Oil

• Some studies (some including children) have shown benefit for use in irritable bowel syndrome and recurrent abdominal pain.
• Other possible uses have been studied in adults (including headache), which has shown some promise but no definitive answers have been found at this point.

Eucalyptus

• Studies have shown that use of eucalyptus and lemon can work as an insect repellant although there have been case reports of toxicity from widespread application on the skin.
• There are multiple reports of severe toxicity after excess ingestion in children.
• Some studies have shown benefit for treating head lice.

We tried to research some other oils (thieves and frankincense) but found any evidence for their use in children to be lacking or unavailable.

Of note, you’ll see that there is no evidence for the use of these oils for some of the common uses I see them touted as being beneficial for: fever, cough, congestion, allergies, teething symptoms and (the one that makes me the most frustrated-see above) behavior problems.

Other Sources

At the suggestion of readers I also reviewed the literature from aromaticscience.com and discovered one article for which I had not previously found and only discovered 11 studies when searching for children.

I also reviewed Dr. Robert Pappas’ website but could not find further information about studies in children.

The gist of most of these websites is to list tons of articles of test tube and animal models with adult studies mixed in but they have very little to no information on children.

An example of this is the Facebook page of Scott Johnson who is “one of the world’s leading experts on evidence-based, therapeutic use of essential oils and natural products.” I looked back over 6 months of his postings on Facebook. There are roughly 2-3 posts per day. I found four posts related to children: one about probiotic use for colic, one about mother/baby skin-to-skin contact, one promoting increased physical activity in kids, and one about exercise during pregnancy promoting brain growth in children. None that truly show evidence of the efficacy or safety of the use of essential oils in kids.

Finally, I signed up for a website so that I could review a study that got a lot of buzz last year in the essential oil community. It was looking at the use of oils in autism spectrum disorder (ASD). You can read more about ASD in my post here. There are many issues with the study that limit its ability to be used as proof of effectiveness: the sample size is small (12) and there is no control group (even a group that used a different concoction of oils would be helpful). It’s not that this type of study should not prompt further thinking into the issue, it’s just that the number of children and parents who started using oils for autism based on it is inappropriate. For more traditional investigations into the use of medications for autism, this would be one of the most preliminary studies and would need to be followed up by significant further studies to test for effectiveness and safety of the regimen that was recommended. Why do I care so much? Because my parents of children with developmental concerns are desperate for something that might help. I’m desperate to have something more to offer them, but I am very protective of them when it comes to those who might take advantage of them.

Summary of Research

There’s just not much out there. What is out there is small studies or case reports and other poor study designs. This effectively turns their current use by consumers into the study of essential oils. The problems is that, with no oversight, no one is systematically watching for effectiveness or safety so we may not know until much later.

They can be very ugly. They can cause pain if they’re in a tough spot. They can last forever.

Because of this, I’ve seen families try just about anything and everything to treat them.

But what actually works?

Many warts will go away on their own over time. Studies have shown about 80% of warts are gone after four years … but sometimes we can’t wait that long, especially when it’s your child in pain.

Here’s a look at some of the alternative and conventional treatment options for treating warts, along with my thoughts on if they are worth your time:

1. Apple cider vinegar – There are limited studies that show mixed results for using apple cider vinegar. It can be very irritating to the skin for some children. It’s OK to try but I wouldn’t get my hopes up.
2. Salicylic acid – Yes, this is a cream typically used for acne, but salicylic acid has been shown in some studies to effectively treat warts. The skin irritation associated is common and expected, but it has a better chance of working than apple cider vinegar…so it might be worth it.
3. Tea tree oil – While tea tree oil has been studied (and actually works for a few pediatric skin issues), warts are not one of them.
4. Crushing aspirin or Vitamin C and applying – No on these as well. No evidence that they are effective and it sounds like a lot of work.
5. Aloe vera – While unlikely to cause any problems, aloe vera is not effective treatment.
6. Duct tape – One small study showed that covering a wart with duct tape led to resolution of the wart. Later studies were done which showed it didn’t work, but the researchers used clear tape instead of silver duct tape. So, right now we’re in a sticky situation (sorry) where we don’t know if it works or not. I would use the silver if I wanted to try it. It has been suggested to combine it with the salicylic acid treatment.
7. Freezing – The most standard treatment is freezing. Freezing works well, but might require retreatment after a few weeks if it doesn’t completely go away. Freezing can be difficult for warts on the feet or hands because the underlying nerves can be damaged.
8. Surgical removal – If all else fails, a physician can provide local anesthesia and remove the warts.

So there are lots of alternatives to try, but a conversation with your pediatrician is a great place to start. From there, you may be referred to our Dermatology team or to Pediatric Surgery. 

But for the most part, the best weapon against warts is patience.

Related To This Topic:

• Plantar Warts
• Molluscum Contagiosum: The Most Common Rash You Never Knew About
• 7 Skin Conditions Young Athletes Need To Know About
• 5 Common Medical Conditions That No One Shares On Instagram

They were doing great, breastfeeding or taking a bottle and eating some solids but now what?!??! You're expected to change everything. First off, remember that if you plan to continue to breastfeed (which is awesome if that’s your choice!), some of this won’t apply to you but some of it will.

With everything else going on, I’m here to tell you it doesn’t have to be that complicated.

Here are my 5 simple rules for transitioning to milk at 1 year of age (and only two low-stress choices for you to make):

1. Remember that there’s nothing magical about milk.

Cow’s milk is an easy source of calcium, calories, and protein but if they are eating those things then they actually don’t have to drink milk at all. Especially keep that in mind when you make the change if their milk intake falls off. It’s OK. I generally recommend 18-24 ounces per day. This should be enough to get your baby some extra calories, but not be so much that it can lead to constipation. Also remember that yogurt and cheese have similar nutritional content so they can be included in the total as well.

2. Transition to a cup before 15 months.

The closer to 1 year that you can transition to a cup, the better. Hopefully you’ve been offering some water at meal times with a cup for a while. Don’t buy any large quantities of a cup until you find out what your baby likes. Put the cup in front of them, they’ll eventually drink.

3. Decide on a milk. You have some choices.

Remembering rule  No. 1, it’s OK to give yourself some flexibility in the milk that you choose. I’m not worried about cow’s milk or dairy intake as a general rule. Depending on baby’s weight, I am Ok with either whole milk or 2% milk. Talk to your doctor about which might work for your child. There are a few milk alternatives that closely resemble cow’s milk in nutritional content (pea and soy milk are examples) but there are others that are basically water (almond milk). I don’t routinely recommend toddler formula unless medical indicated or recommended by your doctor.

4. Decide on a plan for your transition.

I’ve seen families make the change cold turkey the first day it was possible. I’ve seen families slowly transition by adding in milk alternating bottles with formula. I’ve also seen families mix some formula and some milk in individual cups. I haven’t seen any one particular strategy work better than another. I think most babies would do fine with a quick transition or cold turkey swap…but every baby is different.

5. Try not to stress too much about this.

There are plenty of things to worry about in parenting. Deciding what to give them to eat and drink shouldn’t add to your stress. Provide them plenty of fruits and vegetables. Decide on your milk choice and your method of transition and don’t stress the rest.

They will have good days and bad days (just like us).

But, I promise everything is going to be OK in the end.

To identify the hot spots, researchers from the University of Texas at Austin and Johns Hopkins University looked at each area’s volume of international travel from foreign countries with large measles outbreaks and the prevalence of nonmedical exemptions from childhood vaccinations.

The same researchers previously predicted outbreaks in Washington, Oregon and New York which are all experiencing an influx of measles cases.

“For measles, most experts believe that there will be one to two deaths per 1,000 cases, most likely infants. We are set to see over 1,000 cases in the U.S. in 2019. So, for the first time since the 1980s, we may expect infant deaths from measles in the U.S.,” said the study’s lead author, Sahotra Sarkar, a philosophy and integrative biology professor at UT Austin and an expert on public health, in UT news. “We have long known that vaccine avoidance is a critical public health issue in the U.S. and Europe. Our results show how travel from regions elsewhere compounds this risk.”

The Texas Department of Public Safety has confirmed 15 measles cases in Texas this year, including one in each: Tarrant, Dallas and Denton counties and two in Collin County. Comparatively, Texas had nine measles cases in 2018 and only one in 2017.

Already this year, more than 760 cases of measles have been confirmed in the United States, the highest number in decades.

Physicians at Cook Children’s call this news frustrating because measles is a disease once thought to be all but gone from the planet. Texas has one of the highest rates of unvaccinated children in the U.S., partly due to a 2003 state law allowing parents to opt out of getting their children immunized for reasons of conscience.

“It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning.”

Measles is a highly contagious respiratory illness spread by contact with an infected person through coughing and sneezing. Measles is so contagious that if someone has it, 90 percent of the people around that person who are not immune will become infected.

The Centers for Disease Control and Prevention (CDC) recommends children who are older than 12 months get two doses of MMR vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Teens and adults should also be up to date on their MMR vaccination.

Two doses of the MMR vaccine are about 97% effective at preventing measles; one dose is about 93% effective.

"Populations who choose to not follow the recommended vaccine schedule are actually setting up the perfect conditions for the diseases they are unvaccinated for to erupt into an outbreak. It is really not a question of whether these outbreaks will occur but when," said Jason Terk, M.D., a Cook Children's pediatrician.

Other Texas counties to make the Top 25 were Harris at No. 9 and Travis at No. 22.

To learn more about where you can receive vaccines in the Tarrant County area, visit the Immunization Collaboration of Tarrant County website.

For More on This Topic:

• 25 U.S. Counties Identified as Most at Risk for Measles Outbreaks
• Vaccines and Immunizations
• Immunization Collaboration of Tarrant County
• Common Questions About Immunizations
• Why Children Like Olivia Need You to Immunize
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know

And, I’m pretty sure my freshly minted 10 year old will soon be asking about his own Twitter, Instagram or YouTube account soon. I realize this is a tricky situation. Especially since I’m the medical advisor for Digital Health at Cook Children’s and I’m active on social media.

Trust me I see the irony … or maybe the hypocrisy.

But Right now I’m planning to hold off AS.LONG.AS.I.CAN.

Why?

Because I’m a parent. I worry about my kids like everyone else and I want them to be safe and protected

I’m also a pediatrician and I talk to too many kids in my office who are dealing with the negative fall-out of social media. I also see way too many studies addressing how social media has caused harm.

Social media can lead to:

• A fear of missing out. I wasn’t cool in high school (this may shock you and if it doesn’t just stay quiet) but I really didn’t know what I was missing out on. Everyone partied on the weekend but didn’t say much to me about it on Monday. If there had been pictures and posts from the weekends, I would’ve understood how left out I probably was.
• Inappropriate expectations of appearance. We don’t look like the celebrities we follow on social media and we probably never will. Sometimes though it’s important to remember the celebrities don’t look like the celebrities when they are on social media either. They are photoshopped and edited many times. But still, our kids are left to compare themselves to people who taking professional photos or using editing software to make everything look perfect. It’s their job after all. Unfortunately, that doesn’t keep many of us from feeling jealous or feeling like we’ve fallen short when we don’t.
• Bullying. Anonymous or even semi-anonymous (or “behind the screen”) empowered bullying can cause isolation and fear. And it doesn’t stop when you go home from school like it did when I was a kid/teen.
• A lack of ability to process our feelings. The constant ding of dopamine we get from the amount of likes on our posts enables us to continue posting to get our fix rather than process and dive into our sadness.
• Oversharing and shame. Teenagers and preteens don’t understand the significance of oversharing and what can happen later when those details (or pictures) get shared to a wider audience.

So what should we do as parents?

Here’s what I recommend:

• Keep your child off social media as long as possible. I know. I hear it too with my three kids. But the longer you can keep them away from it, the more time you have to talk to your kids about this issue and let them mature to handle what will inevitably come their way.
• When they get on, you get copies of their passwords and connect with their accounts. You can have privacy when you are out from under my roof. Oh man, I’m starting to sound more and more like my dad. But until then, sorry kids, I’m doing everything in my power to protect you.
• You reserve the right to delete the account and take their phone at any time. I paid for it and I can take it away.

I hope this helps. Just know I’m dealing with it too and would love to hear your thoughts. Again for irony … on social media.

Here are a few of my thoughts that will hopefully make you feel better. And who knows? This actually could turn out to be good thing for all of us (myself included) on what it means to be a good parent.

1. I don’t think it’s real. Despite all the drama and buzz. I can’t find anything that proves this is really happening. It appears to be a hoax  and this isn’t the first time this same story has circulated.

2. It’s motivating parents to reconsider their child’s media consumption. MoMo challenge or not, unsupervised browsing of user-generated video content is a terrible idea (even if that platform is labeled “kids"). Watch what your kids are watching with them. Censor. Protect. That’s what we we’re supposed to do. But we’ve gotten lazy because it’s easier to let the algorithm decide than to actually sit and watch and guide.

3. You get to have a hard conversation with your kids. If you decide to take an app off their device for their protection, you can explain that their safety trumps any momentary joy they might get from watching videos on a screen. You care too much about them to put them at risk.

4. You get to ask your child deep questions so that you might learn about their deepest fears. Because even if this thing isn’t real, some kids are really scared by what they’ve seen and heard. Simple questions like, “Have you seen anything in your device this week that scared you?” “Have your friends been talking about anything that gets you worried?” “How can I help?”

5. Because even if this turns out to be a hoax (which it seems to be), the fact that kids are scared and talking about it is heartbreaking. The fact that someone thought spreading this would be funny at the expense of our kids feeling safe is infuriating. You don’t have to validate the fears to ask about them but you should ask.

Don’t let your kid live in fear without knowing you’re looking out for them.

Here are a few articles about the Momo Challenge you might find helpful:

• Parents, please stop freaking out over the Momo Challenge
• Momo Is Not Trying to Kill Children
• The 'Momo challenge' isnt' a viral danger to children online. But it sure is viral.
• What Is The Momo Challenge?

According to the National Conference of State Legislatures, Texas is among 18 states that allow families to opt out of vaccines for personal or moral beliefs. The Morning News reports that Plano, Fort Worth, Austin and Houston all ranked among the 15 U.S. metro areas with the most such conscientious exemptions for kindergartners. Each had more than 400 kindergartners exempted from vaccines.

Fifteen years ago, about 2,300 students opted out of at least one vaccine. Today, that number has grown to 56,737 kindergarten through 12th grade students.

This has many doctors, including myself, worried about more measles outbreaks in Texas.

"Populations who choose to not follow the recommended vaccine schedule for themselves and for their children are actually setting up the perfect conditions for the diseases they are unvaccinated for to erupt into an outbreak. It is really not a question of whether these outbreaks will occur but when," Jason Terk, M.D., a Cook Children's pediatrician in Keller.

News about vaccine preventable diseases is important for us to share, but it brings up many strong opinions.

Here’s how the debate usually goes:

“Please vaccinate your children.”

“If your child is vaccinated and vaccines are such a good thing, why do you care if my child gets vaccinated?”

Most people don’t have a good answer for it so it tends to be a good trump card.

So why do I care?

There are two reasons.

1. I care about your child. I firmly believe that vaccination is the right thing to do. I vaccinate my children on time and on purpose. I would not want any child to receive less care than I would provide my own children.

2. Vaccines sometimes do not provide complete protection. Most provide protection in the 90-percent plus area (some nearly 100, some lower). Because of this, even a vaccinated child can contract the disease. I will go into this in more detail below, but the more children who are vaccinated for a disease the less likely it is that any child will contract that disease. This occurs through a process known as community, or herd, immunity.

Many people will stop reading right here because they have already decided or have read somewhere that herd immunity is not a real thing. Here are some of the arguments against herd immunity I come across from time to time:

• It’s not based on a science, but on epidemiology. Epidemiology is the study of the way diseases spread. It is a very complicated field, involves tons of statistics and research and IS science. To say that it is not science is a false comparison.
• We still have outbreaks even in areas where there are high vaccination rates. This is most definitely true, but does not prove that herd immunity is not real.

How does it work?

Since it's most timely, let’s use measles as an example. First, you need to know some things about measles…

Measles has an attack rate of a susceptible individual at 75 percent. This means that 75 percent of people exposed to measles who are not protected will contract the disease. I’ll use 70 percent to keep my numbers round and err on the side of people who would disagree with me.

Measles vaccination has a 95-100 percent protection rate. Again, I will use 95 percent so that I am not cherry picking the best results to prove my point.

There are two scenarios below. The first scenario has a case of measles in a classroom where everyone else is vaccinated. The second scenario is a case of measles in a class with one child who is not vaccinated.

Scenario No.1:

Scenario No. 2:

In scenario No. 1, all the children are vaccinated which means they have a 5 percent chance of catching measles. If that child goes to another class or event where all children are vaccinated, each of those children have much less than a 5 percent chance because the child doesn’t likely have the disease and they only have a 5 percent chance of catching the disease even if he did.

In scenario No. 2, one child in the classroom is unvaccinated. He thus has a 75 percent chance of catching the disease. He’s going to go to other locations with other children, even if those children are all vaccinated, we have potentially opened up a whole second circle of exposed children. Not to mention that the children in the first class have now potentially been exposed twice.

So, in scenario No. 2:

• If I gave you a choice, would you want your child in group A or B?

• Does it matter if your child is vaccinated or not?

• What if you also have a baby in your house who cannot be vaccinated?

• What if you child is in class B, but has a disease for which they cannot receive the MMR vaccine?

The answer is no, none of these things matter. Logically, we should all want our child in room A because it decreases the odds of our child being exposed. Is it 100 percent? No, but it doesn’t matter. Are you more likely to be angry about a measles outbreak if your child cannot be vaccinated? Yes, and I understand that.

For one last thought, consider this … a  study in Pediatrics described geographic clusters of people who choose not to vaccinate at all or to under-vaccinate their children. I suspect that is true across our area as well, but I also suspect that there is clustering according to other factors as well: socioeconomic status, church/religious affiliation, etc. Populations where there are multiple families who choose not to vaccinate would be particularly susceptible in an outbreak situation. Let’s pray we don’t get there.

This is herd immunity and why the question, “If your child is vaccinated and they are such a good thing, why do you care if my child gets vaccinated?” doesn’t end the conversation.

So, are gluten free foods better for your child?

The answer is…

Complicated. It depends on your child.

Gluten is a protein found in wheat, rye and barley. The protein works as a “glue” to hold the foods together. It is often found in foods that might be unexpected or surprising.

Are gluten-free kid’s foods healthier for my child with celiac disease?

Yes. Definitely, absolutely yes.

Celiac disease is a genetic condition in which people have a severe auto-immune reaction to gluten that leads to damage of the small intestine. It can be difficult to diagnose because the symptoms are wide and varied but often include abdominal pain, bloating, diarrhea, stool changes and behavioral changes. Diagnosis can be tricky but involves lab testing and usually a visit with a gastroenterologist.

Avoidance of gluten is the primary treatment for children with celiac disease.

Are gluten-free kid’s foods healthier for my child with gluten intolerance (non-celiac)?

First of all, you have be very careful to determine if there is something to this. Because many of the proposed symptoms of gluten intolerance are vague and not specific (there are many doctors who question if it is a true condition). Whatever you believe, it can be easy to attribute normal child stuff to a sensitivity to foods.

Because of this, I highly recommend a long conversation with a pediatric, GI doctor or allergist before making the changes to your diet. Studies have shown that it is more difficult to obtain adequate calories and nutrition for kids on gluten free diets. Thus, it’s not without risk to decide to eliminate gluten from your child’s diet.

Are gluten-free kid’s foods healthier for my healthy child?

The answer to this is categorically no. In fact, they could be less healthy.

A recent study compared food for kids based on whether those foods were advertised as gluten free or not. The results might surprise you.

Gluten free supermarket foods were found to be nutritionally similar to regular child-targeted foods. One change was that 80 percent of gluten free kid foods had higher sugar content than non gluten free kid foods. Previous studies have shown that gluten free products have similar total calories but less protein and fiber.

Bottom line, if your child has a medical need, gluten free foods are important. Otherwise I’d save my money and skip them.

The Dallas Morning News reports that person from another state who had mumps traveled to Dallas for the National Cheerleaders Association All-Star National Championship, which took place Feb. 23-25 at the Kay Bailey Hutchison Convention Center. 

At this point no Texas residents have developed mumps in connection with the case, but people are urged to watch for symptoms. 

This is another reminder about the value of vaccination in preventing what can be serious illness. Mumps cases decreased 99 percent after the introduction of a successful strategy for vaccination.

Here's a quick look at mumps cases over the years according to the CDC:

*Case count is preliminary and subject to change

** Cases as of Jan. 27, 2018 Case count is preliminary and subject to change

Mercury (Thimerosal)

Thimerosal is a preservative that was used in vaccines starting from the 1940s. The preservative contains a small amount of mercury and chronic mercury toxicity has been shown to be related to psychiatric problems and other medical issues. Because of this, it was brought up as a concern around 1999 because the overall number of vaccinations was increasing that perhaps over time the exposure to mercury could be a cause of autism.

Studies started quickly to determine if this could be the case, but in the meantime, the vaccine companies, at the request of the American Academy of Pediatrics (AAP) and the Food and Drug Administration (FDA), began to take Thimerosal out of their vaccines. Thus, by 2001, Thimerosal (and mercury) were removed from vaccines except for one exception (see below). Fortunately, in 2004, further studies released by Institute of Medicine determined that mercury was not a cause of autism.

Currently, the only vaccines that contain mercury that I offer in my clinic are seasonal flu vaccines when they are given in a mutli-dose vial. I try to order as much “preservative free” flu vaccine as I can so that this is not even a concern for my patients. However, because studies have shown that mercury is not a cause of concern, I do not worry that receiving their flu vaccine from a multi-dose vial would harm my patients.

MMR Vaccine

Autism is generally diagnosed around 15-18 months, right after the time when children receive their measles, mumps and rubella (MMR) vaccinations. I believe that is because of this relationship in time that MMR was ever thought to be associated with autism.

The original paper that reportedly found a relationship between MMR and autism by Andrew Wakefield was published in The Lancet. The research has now been completely discredited after multiple other scientists were unable reproduce the results and significant problems with the methods he used for conducting his research. In addition, further information has come out regarding Dr. Wakefield’s conflicts of interest and his motivation for publishing the paper. Over time, ten of the twelve authors involved in the writing of the paper retracted their support of its conclusion.

Finally, after many years, The Lancet published the following statement, “We wish to make it clear that in this paper no causal link was established between (the) vaccine and autism, as the data were insufficient. However the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper.”

Despite this overwhelming criticism of his paper, the damage done by Dr. Wakefield and The Lancet still persists today. Parents continue to ask about and remain fearful of MMR and a possible (although incorrect) link to autism. His belief caused parents to fear the use of MMR vaccine and unfortunately, this often extends to all vaccinations.

“Too Much, Too Soon”

Are children getting too many shots too soon?

Will receiving all the scheduled shots, so many more than we got as kids, overload their immune systems?

This is a conversation I often have with parents of newborns. And despite the fact that I’m pro-vaccine, I am not afraid to have discussions with parents who have fears and simply want what is best for their child.

Because of that, I follow the evidence closely and love to see new studies that look at different angles of the vaccine discussion.

That’s why I was I excited to see a recent study in the Journal of the American Medical Association (JAMA) that analyzed children with infections not covered by vaccines to determine how many vaccines they had received and if that was a potential reason why they got the infection.

The research looked at around 200 children with diseases and compared them to 750 other children. Those who contracted the diseases had a total vaccine exposure of 240.6 antigens while those in the control (without the disease) group had 242.9.

So, it doesn’t appear that vaccine load on the immune system is a contributing factors towards children contracting other diseases.

This study is another perspective and further evidence that lends support to the idea that vaccines are one of the most successful, safest advancements in the history of medicine.

You probably did, but hopefully that didn't prevent you from getting your child's flu vaccine.

New data from the CDC suggest that the vaccine was 50 percent effective for pediatric illness, which is actually a fair year. We’ve had better. We’ve had worse. But it's definitely way better than the 10-30 percent estimates that were being thrown around earlier this year.

In previous years, data have shown that nearly two-thirds of pediatric deaths have occurred in children who were not vaccinated. This data is even more significant as three-fourths of pediatric deaths have occurred in children who were not completely immunized (either no vaccines or only one vaccine in a baby who needs 2 for full protection).

Only 54 percent of children who died of flu had a condition that characterized them as high risk. This means that they were older, healthy kids who got the flu and died.

Is the flu shot perfect? No. Do I wish it were better? Yes.

But do any of these reasons for not getting one hold up?

"It doesn't sound like it's going to work very well this year anyway.""My kid's healthy, so I don't think they really need one.""We stay really careful to avoid others who are sick so we'll be good."

Nope. Nope. And, unless you live in a bunker from October to March: Nope!

It's actually still not too late. You can get protection from this year that will help and there is mounting evidence in adults that getting flu vaccines year over year may provide more protection than just for that season. We're still waiting on that evidence in kids, but logic says it could still apply.

Most pediatricians recommend breastfeeding as the primary source of fluid intake for up to one year of age (even longer is fine).

For those who choose not to or could not breastfeed, I recommend an iron-fortified formula until one year.

After one year, a healthy, normal developing children should be transitioned to a well-balanced diet.

Cow’s milk can be used as an easy source of calories, protein and calcium but there’s nothing magical about it. If your child doesn’t like it, or you choose not to, just make sure that they are getting a nice rounded diet.

So, what about toddler formulas and toddler drinks?

The formula companies would like you to believe that they are an essential part of a toddler’s diet. They have added components to make them more attractive including probiotics and DHA. They make the cans look similar to your infant formula, to make it feel like the transition is expected and necessary.

But, I think you can and should skip them, unless instructed by or prescribed by your pediatrician. Here are 3 reasons why:

Many of them have ingredients that I wouldn’t recommend for toddlers anyway: corn syrup and other caloric sweeteners for example.

We really don’t know much about what giving DHA to a toddler adds to his or development or intelligence. If you are worried about it, add some fish to your toddler’s diet.

Most kids get plenty of calories and nutrients from other food sources. They don’t need the added calories and the extra nutrients are unnecessary except for the pickiest, most restrictive eaters.

So, what is toddler formula?

Mostly hype and marketing.

What should you do about it?

Unless instructed by your pediatrician, save your money for college…and I mean it.

Here’s the calculation:

Assuming three 8 ounces cups of toddler formula per day, you will need about 70 cans of toddler formula from 12 to 24 months. Each can costs about $20. That’s a total of $1400 during that year. If you invested that $1400 over the next 16 years (until they reach college age) and averaged 10 percent growth, you’d have about $6,500 by the time they reach college age.

Are you panicked about the flu? How do you know if your kid is getting worse? What about all these kids getting really sick, even dying?

Here's what I've been saying all day, every day in my office this week.

1. Healthy kids who get sick from the flu get really bad because they get dehydrated. Push fluids. If they don't want to eat, that's OK. But they have to drink. Monitor urine output. Kids should pee about every 6 hours. If they aren't, they need to be checked out.

2. Healthy kids also get sick from the flu because of respiratory complications. Monitor for signs of difficulty breathing, especially fast breathing or signs that they are working hard to breathe. Look under their ribs, is it sucking in and out heavily? If so, they need to be checked out.

3. Look out for kids whose fever gets better and then comes back. Many times parents write off those symptoms as just a little left over from the flu but they could be a sign of a secondary infection. Ear infections, sinus infections and pneumonia often frequently follow the flu. Once the flu is over and the kid is getting back to normal, they shouldn't come back.

4. Kids with chronic medical conditions should be watched closely for worsening of their condition. Asthmatics should be watched closely for breathing. Diabetics should have their sugars watched, etc.

But I’ve been asked about some other treatment options. Do they work? Are they safe?

When it comes to “alternative” medications, I try to keep an open mind; but, I basically divide them into three categories:

1. Yep, go for it - Treatment options that have been studied and shown to be safe and effective in kids (or in adults but with reasonable belief it would also be safe and effective in kids).

2.  Meh, if you want, go ahead – Treatment options with mixed studies or no studies proving effectiveness but no studies or reason to believe that they would harm kids.

3. Nope, not a chance – Treatment options that have no studies and no logical pathway by which they could be effective and/or any reason to believe they could be harmful for kids.

Let’s look at a few alternatives:

Elderberry syrup/gummies/soup…

There are some VERY small studies (less than 50 patients) in adults that showed some improvement in flu systems for people already diagnosed with the flu but treated with elderberry within 48 hours of symptom onset.

I cannot find any studies addressing its use in kids or an appropriate dose. Also, despite its frequent use as a preventive option, I can’t find studies that support elderbery will decrease you or your child’s likelihood of getting the flu. I also haven't found a study that says it is safe to give over long periods of time.

So for me, it’s “Meh, if you want, go ahead.” I wouldn’t spend my money on it and I definitely wouldn’t give it over long periods of time for prevention, but I won’t give you a lecture if you are using it over short periods to treat flu-like symptoms.

Oscillococcinum

What is it? It’s a homeopathic medicine (meaning it’s a super diluted substance which supposedly maintains an imprint of the original chemical makeup) made initially from anas barbarae hepatis et cordis extractum 200C, which sounds impressive but is actually Muscovy duck liver. Keep in mind that the mixture is so dilute, it’s actually very unlikely that there is any duck liver present in the little tablets you put in your mouth. But, even if there was, just research how the guy came up with the reason for using duck liver and you’ll understand that there wasn’t much science or even logic that went into the idea in the first place. Large systematic reviews of the studies for use of oscillococcinum for both prevention and treatment of flu have shown no evidence that it works for either.

Fortunately because this is a homeopathic medication (and mostly sugar), there are no major side effects with its use. Because of that, I was tempted to put it into the “Meh” category. But because its use defies all science and logic, I just can’t, so it’s, “Nope, not a chance.”

Essential oils for treatment of symptoms/flu

We’ve covered this one…extensively. Our first post on it is called “Essential Oils and Their Use in Children.” Then you can read, “How safe are essential oils for children?” And finally, “Essential oils and children –more questions answered.” If you don’t have time or interest in reading those, here’s the TL;DR summary: If you use them within reason, and diffuse but don’t ingest, they are a “Meh, if you want, go ahead.”

But, you have to promise me you won’t go crazy and if things aren’t going as expected, or your child is getting worse rather than better, that you will seek help. Do you promise?

Neosporin in the nose to prevent flu

Neosporin is an antibiotic ointment. Flu is viral. There are no studies to support this. I don’t see how this could be helpful. So, “Nope.”

Sinus rinses

Besides the feeling like you got hit by a truck, one of the other most frustrating and annoying problems with the flu is the feeling of congestion so severe that it feels like you can’t breathe. Saline sinus rinses, either as a flush like a Neti-pot or spray and suction for babies, can be helpful to relieve this feeling. So, “Yep, go for it.”

Honey

The cough associated with flu can be deep and severe…but, as you probably know already, I don’t believe that any cough medicines (prescription or over-the-counter) work very well in kids and they can be harmful. So, my go to for cough for kids over one year of age? Honey. Yep, just honey. Yep, just give it with a spoon. Yep, as many times a day as you think your kids needs it. Seriously, just honey. (This might be a conversation I have daily to a parent with a look of complete and utter untrusting disbelief).

There are probably a million other alternative flu treatments out there but these are some of the common one that I get ask about.

What other alternatives have you seen?

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

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

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

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

Guess what?

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

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

Maybe you thought it was no big deal. Maybe you heard something about it that made you worry.

Here are 4 facts about sugar bugs that you should know:

1.Prominent veins are common in the newborn, infancy and childhood period. They can occur on the face, hands/feet, trunk and extremities (basically all over). If you look closely enough in all babies, you’ll find some veins that are more noticeable than others.

2.One suggested link with sugar bugs has been an association with mutations in a gene known as MTHFR. MTHFR mutations are common, approximately 50 percent of the population carries some type of mutation. The significance of MTHFR mutations is still unclear but no studies link the presence of sugar bugs to these mutations. You can read more about MTHFR mutations and there significance here: A Pediatrician Goes In-depth into MTHFR.

3.While it has been speculated by practitioners of traditional Chinese medicine that sugar bugs might suggest a syndrome (known as Kanmushi) where children show a voracious appetite and severe sensitivity to sugar, I find no evidence that support this is a true connection.

4.Proponents of Kanmushi suggest that you limit your child’s sugar intake, provide a structured environment and opportunities for physical activity. Obviously, these are great ideas for all children.

So, should you be worried about your child’s sugar bug?

It’s always possible that further information could surface, but given current theories and information, I would say that any connection to a more serious issue is unfounded and not a concern.

Learn more about Kanmushi by clicking here.

“Should I even bother getting the vaccine,” I get asked.

“Yes. You should definitely still get your child’s flu vaccine.”

Here’s why.

Is it going to be a bad flu season?

Widespread influenza activity is present in 46 states, including Texas. Hospitalizations for influenza associated illness are on the rise, with nearly 4,000 reported. Children under 5 (as well as adults over 65) appear to be at the highest risk for hospitalization.

As of December 29, there were 13 pediatric deaths associated with influenza in the U.S. And it wasn’t just little babies either, six of those deaths occurred in children over 5 years of age. Only two of those children were known to have high risk conditions, which means that many of the deaths occurred in healthy children. 

One of the major concerns, regarding the severity of the season, is that much of the circulating Influenza A virus is of the type H3N2. In previous years where H3N2 has been common, we have seen increased numbers of cases and more severe disease. Last week, more than 237 children tested positive for Flu A at Cook Children’s. Two weeks ago, 380 kids tested positive for Flu by our lab.

Is the flu vaccine coverage going to be terrible?

Scientists often use the previous flu season from Australia to predict what type of flu season and vaccine effectiveness we are going to have. You might have heard early reports that suggested that this year’s vaccine might only have 10 percent effectiveness. But, the important point to remember is that meager 10 percent only reflected activity against H3N2 and truly predicting which strain will be most common is tricky.

Another important factor to consider is that flu activity is regional. Influenza A activity nationwide is showing H3N2 activity at 7,012 out of 7,754 overall cases, or 90 percent. But, in region 6 (of which Texas is a part), H3N2 was present in 466 of 589 or 80 percent of Influenza A cases. Still not great, but there’s plenty of vaccine preventable flu out there.

So, will the vaccine coverage be terrible? Maybe, but we won’t know for sure until the end of the year and I believe there is evidence to suggest that it will be better than the 10 percent estimates we were reporting earlier in the year.

Should I still get my child’s flu vaccine?

Flu vaccine is an important part of protecting our children from this terrible disease.

Your child will almost certainly be exposed to the flu this year, and probably multiple times. Flu causes serious illness, even death. Even if the coverage was only 10 percent (and I think it will be better), I would still recommend it. Flu vaccine has been proven, even in bad years, to prevent flu-associated death in pediatric patients.

Flu vaccine cannot cause flu. It is an injectable, killed virus which cannot cause infection. Side effects might include soreness at the injection site, low grade fever and mild body aches.

You still have time. We expect flu activity to be increasing over the next few weeks, possibly even into mid to late February. Once you get the vaccine, it takes about two weeks before your protection is up and going.

So, call and get the vaccine today…for you and your children.

Last week, 1,118 patients were tested for the flu at Cook Children’s and 429 tested positive (380 for Flu A and another 49 for Flu B).

Get your flu shot (go ahead, it’s not too late), wash your hands, say a prayer…all the things you should do to prevent you and your family from getting the flu. The flu season is in full force and you’ll want to protect your family as much as possible.

Unfortunately, despite all your efforts… you still might get the flu.

So, now what?

Here are 6 tips for helping your child get through the flu:

1. Push fluids, fluids, fluids. Healthy kids with flu often get sick and worsen because they get dehydrated. Kids with the flu should have something to drink beside them constantly. Water, Gatorade and Pedialyte are all good options. Watch to see how much they are peeing. They should pee at least every six hours.

2. Treat your child with a fever reducer. Using acetaminophen or ibuprofen can help with not only fever, but also the headache and body aches that come with the flu. Remember the goal is not dropping the number of the temperature, but making your child feel better.

3. Allow your child to rest as much as possible. This is not a time for strict adherence to screen time guidelines. Resting and taking it easy is a big part of getting through the flu.

4. Use a humidifier or steamy bathroom. Steam can help to loosen up the congestion and help your child breathe, it can also help with their cough.

5. If your kids are over 1, given them honey to help coat their throat and prevent coughing.

6. Follow your child’s chronic condition. Children with asthma should be watched closely for signs of wheezing and difficulty breathing. Children with diabetes should have their sugars monitored closely. Children with chronic conditions are more likely to need Tamiflu so call your doctor at the first sign of symptoms if you suspect flu.

I hope you all have a healthy and happy 2018 but when you do have problems, call your Cook Children’s pediatrician. We’re always here to help!

I know Serena, babies are hard to read. As I read Serena Williams' tweets and the struggles she's going through with her baby my heart went out to her.

There were times in my own parenting journey where I wasn’t quite sure that everything I had been teaching my patients for years was actually the right thing. So, pediatricians aren’t immune to a little doubt when the going gets tough.

As Serena Williams discovered over the weekend, celebrities aren’t immune to this either. Apparently her 3 month old was having a REALLY fussy day. And, no doubt, those days are hard. You feel helpless. You’re sure that something is terribly wrong. You want to attribute it to something and you want to have something that will fix it. But…it doesn’t always work out that way.

https://twitter.com/serenawilliams/status/942435383027097600

I guess it didn’t get any better from there…

https://twitter.com/serenawilliams/status/942435460948922368

Of course, she got some suggestions.

Many of which have been shown to be useless (and might even be dangerous) such as: teething gels, homeopathic teething tabs and amber necklaces.

But, the best advice she received came from a friend of mine, a pediatrician from down in Austin, Dr. Ari Brown (@baby411):

https://twitter.com/baby411/status/942613460273238016

Because Dr. Brown is right, teething does get blamed for fever, diarrhea, fussiness, vomiting, diaper rash, sleep disturbance, poor eating, extra eating….I could keep going but instead here’s a post about 4 teething myths.

The reality is that babies most cut their first teeth after 6 months of age and they don’t show signs or symptoms of teething for 3-4 months. If they show any signs, it’s the day before and the day that the tooth erupts and even that is up for debate.

So, what could be the cause of your child’s “teething” symptoms? Here are 3 things to consider:

1. Viral illnesses-Because viruses can cause fever, rash, runny nose, diarrhea and a number of other symptoms for which teething is often blamed, they are a common cause of visits to my office for a concern of “teething.” Because viruses are self-limited (they go away on their own), they will resolve in 3-5 days which just further reinforces the idea in parent’s minds that the symptoms were due to teething.

2. Ear infections-It’s possible for children to have ear infections, even at early ages. Because fussiness and disrupted sleep are common symptoms of ear infection, they are often mistaken for teething. Especially if your child has fever and upper respiratory symptoms along with their fussiness, consider ear infection a possible cause.

3. Normal development-This is the least popular of my opinions on teething but I believe it is probably the most accurate. I think it is normal for babies to have periods of fussiness and sleep disruption. Just like we have bad days and just like we have nights where we don’t sleep as well, babies can too.

Because of that, here was my advice:

https://twitter.com/TheDocSmitty/status/942618451788615681

Alani Murrieta, a 20-year-old mother, died only two days after she began feeling ill from the flu, according to the Washington Post. Her young children and other family members had become sick during a long Thanksgiving holiday. While the other family members got better, Murrieta became progressively worse.

She went to a nearby urgent care center where she was prescribed Tamiflu. By the next day, she was coughing uncontrollably and, at one point, she coughed up blood. She was admitted to Banner Estrella Medical Center, where she was diagnosed with pneumonia. Two days after she became ill, Murrieta died.

Her family told CBS News that Murrieta did not get a flu shot, but doctors couldn’t say for sure whether it would have made a difference.

Murrieta was the eighth flu death in the United States this season, according to a Fox News report. Five deaths were reported in North Carolina, two in Oklahoma and then the latest in Arizona. CBS News, citing data from the Centers for Disease Control and Prevention, reports that 7,000 cases of influenza have been confirmed in the U.S., more than double the number this time last year.

“What we do know is the flu vaccine is still the best form of protection we have to fight off getting sick,” said Justin Smith, M.D., a pediatrician at Cook Children’s in Trophy Club. “Even if you do get the flu, people who are vaccinated generally get a milder and less dangerous form of the illness.”

The flu has arrived in Fort Worth. Last week, 33 kids tested positive for the flu at Cook Children’s and 28 of those cases were Flu A, the more severe and dominant strain.

Some experts are predicting a potentially severe influenza season based on what has been seen in other parts of the world. This year, Australia saw record-high amounts of flu cases. The flu vaccine, which is the same one used in the U.S., was only 10 percent effective in preventing Flu A.

“The concern is when people hear that news, they wonder if they should even bother getting the flu vaccine for themselves and for their children,” Dr. Smith said. “We saw some of those comments posted on Cook Children’s Facebook page. The answer is without question, ‘Yes!’ Parents, should take every precaution to protect their children during this time of year and that begins with the flu vaccine.”

Another concern often voiced by parents is the risk of contracting the flu from the vaccine itself.

Mary Suzanne Whitworth, M.D., medical director of Infectious Disease, stresses a person cannot get the flu from the flu shot. They may feel achy for a day or two but that is very different from being in bed with a high fever for a week from a true influenza infection.

“We do know that thousands of deaths nationally are prevented every year by vaccination against the flu,” Mary Suzanne Whitworth, M.D., medical director of Infectious Disease said earlier this week. “It is important to note that although the vaccine has known side effects that are similar to all vaccines given, side effects are mild and uncommon. Serious side effects are very rare.”

Along with getting the flu shot, parents should take the following steps to protect their kids from the illness:

1. Teach your kids to cover their coughs. Remember to cough into the crook of your elbow and not into your hands. And throw away the tissues.
2. Wash your hands. Other than a vaccine, this is the most important thing you can do to protect yourself and your kids from the flu. Teach kids to use soap and wash their hands for at least 20 second or long enough to sing “Happy Birthday.
3.  Kids with the flu are usually sick 3-5 days and then start to improve. If you or your child’s symptoms are worse than you expect or last longer, please call your doctor to discuss.

Just in time to travel for the Thanksgiving holidays, 23 kids tested positive for the flu (20 Influenza A, 3 Influenza B) last week (November 12-18). That’s the most patients we’ve seen since a really bad 2014. In comparison, we did not see a single case of the flu during the month of November in 2015 and 2016.

“We’re seeing flu consistently now, and I expect it to continue increasing,” said Morgan Pence, Ph.D., a clinical microbiologist at Cook Children’s.

So what can parents do to protect their kids from the flu? Here’s some advice:

1. Get the flu shot. The flu shot takes two weeks before it can protect you from the virus. So you won’t have time for it to work the time you get to the grandparents’ house, but promise me you will get your vaccine as soon as you can. Click here to read more about the flu shot.
2. Teach your kids to cover coughs. Remember to cough into the crook of your elbow and not into your hands. And throw away the tissues.
3. Wash your hands. Other than a vaccine, this is the most important thing you can do to protect yourself and your kids from the flu. Teach kids to use soap and wash their hands for at least 20 second or long enough to sing “Happy Birthday” or Adam Sandler’s “Thanksgiving Song” (just making sure you are paying attention).
4. Call ahead. You’ve waited (or in some cases dreaded) all year to see the relatives, but it might be worth a call to see how everyone’s feeling. If someone is sick, steer your child away from the person as much as possible. Maybe, make a joke (but be firm) about a quarantine room for the sick folks.
5. If your kids do get sick while you are out of town, keep them comfortable. Give them an antiviral medicine (Tamiflu) and make sure they have fever reducers – ibuprofen or acetaminophen.

Hope this helps. Everyone have a safe and healthy Thanksgiving.

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

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

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

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

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

*Photo from SelenaGomez.com.

– Will Shudde, M.D.

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

Crying is normal.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Benign (or not concerning) causes:

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

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

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

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

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

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

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

.

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

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

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

2.What are the diet modifications for treating constipation?

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

3.What are the treatment alternatives for MiraLax?

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

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

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

5.Are probiotics an option for treating constipation?

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

6.Is MiraLax absorbed into the bloodstream?

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

7.Would you give your child MiraLax?

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

This question comes up fairly often in my clinic, but with Summer travel many parents are thinking about traveling with their babies.

Here are the top concerns that parents have about flying with a baby:

1. Infection - Will your baby be at risk for getting sick because of the circulated air on an airplane? The short answer is, probably not. The uncertainty of who your neighbor is and what they might be carrying is potentially more scary that someone in the back of the plane with a contagious illness. I usually get more concerned about your baby catching something from the destination. When you travel to visit family or go to a wedding, sometimes people get so wrapped up in their desire to hold the baby that they forget that lingering nasty cough they have had.

2. Injury - Is it safe to travel on a plane with a baby? Because air travel is relatively safe, the risk of injury on an airplane is low; especially if you compare it to travel by motor vehicle. However, there are particular safety concerns you should be aware of. Most airlines do not require a ticket and separate seat for children under 2 years of age; however, many organizations have lobbied for a requirement that every child be required to have their own seat and be properly restrained. Some car seats can be placed and buckled into airplane seat but you should check your manufacturer and model. Another tip is to be sure that, no matter what, you make sure that safe car seat arrangements are available at your destination.

3. Oxygen - Can babies handle the climb to altitude without dropping their oxygen saturation? This question has been studied and the evidence suggests that babies born term can easily fly without oxygen issues even in the first week of life. Preterm infants could safely fly once they reach 39 weeks corrected gestational age (about 1 week from their due date). Infants with lung disease because of prematurity should be evaluated prior to flight.

4. Sanity - Safety of flying with an infant not withstanding, can you fly with a baby and maintain any semblance of sanity? Some might think you are crazy but clearly it depends on the reason for travel. If you have a big enough reason, you can survive anything. For younger babies, I recommend trying to save a feed for time on the flight. Nursing or drinking from a bottle is a great way to comfort a baby when they get fussy in flight. Spend times times as long packing your bag as you think reasonable possible. Especially if it’s your first flight with your baby, you never know what emergencies pop up and having those supplies below your seat is way better than having them in the overhead bend (not to mention packed away). If possible, take a second helper with you. This might not always be possible but it sure is nice to have someone to hand the baby to if you need to make a trip back to the bathroom or just for extra hand to accomplish those “simple” tasks that take on a life of their own at 30,000 feet.

These are the main issues you should consider when you are thinking about flying with a baby. I do believe that you can fly safely with a baby but I also think you should really consider if the trip is worth the stress and hassle.

About the author

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

Several treatment options are available but does one of the most common options for treating constipation pose a serious risk for your child?

You may have read one of the recent media articles highlighting a concern among some families that MiraLax may lead to neurologic or psychiatric side effects such as tremors, tics or obsessive-compulsive behaviors. Previous reports have shown that some samples of MiraLax had trace amounts of ethylene glycol and diethylene glycol (which are ingredients in anti-freeze and have been linked to neuro-psychiatric problems). The FDA has fielded these concerns over time and commissioned a large study which is currently ongoing looking at the safety of MiraLax in pediatric patients.

With those concerns, I thought now would be a good time to give you some of my thoughts on MiraLax.

Treatment for Constipation

Children who are constipated often only pass stool once or twice a week, have hard stools or have stools that are large and cause pain. If constipation is very severe, it can lead to stool leakage into the child’s underwear as loose stool passes by the hard, formed stool in the intestine.

Treatment for constipation is generally based on the idea of softening stool up so that it can easily pass through the intestines. I always recommend that parents start with a change in diet and fluid intake. Children who are constipated should drink extra fluids (32-64 ounces). This is the one instance where I will recommend introducing some juice (usually prune or pear). In addition, children should eat foods that are high in fiber (think fruits and vegetables).

However, these changes are sometimes not enough. So, what do you do next? After talking with your doctor, it’s likely they will recommend a medication. Which medication? Most commonly, Miralax. But, is MiraLax safe? Should you be giving it to your child?

How Miralax works

MiraLax works by attracting water into the intestines which helps to soften the harder stool which is leading to constipation. It is a synthetic material which is manufactured in a lab (the ethylene glycol and diethylene glycol are byproducts of manufacturing). I like to think of it as synthetic fiber. One of the things that is nice about MiraLax is that it’s tasteless so it can be added to a child’s drink. You can also increase or decrease the dosage based on the child’s needs.

The FDA has not approved the use of MiraLax in children, nor has it approved its use for long periods of time. However, many children can and do take MiraLax on a daily basis.

The Studies

There have been at least five open label studies focused on kids (where the participants knew what they were giving their children) which showed MiraLax to be safe and effective. These studies had about 300 patients combined. Other studies blindly comparing MiraLax with other laxatives such as lactulose and Milk of Magnesia have shown it to be either more effective or as effective and with less side effects. Children in those studies included patients taking MiraLax between 2 weeks and 12 months (most in the 2-6 month range).

The most common reported side effects in studies were: diarrhea, bloating and abdominal pain. All laboratory testing including electrolytes, liver and renal function remained normal. Of note, I could not find a single patient that was reported to have dropped out of a study based on neuro-psychiatric symptoms.

One of the most renowned pieces of evidence in medicine is a Cochrane review. The team at Cochrane reviews all the available studies and makes a recommendation about the safety and effectiveness about treatment recommendations. The Cochrane review of 18 trials (including 1643 patients) showed good effectiveness, safety. There was one child who had an allergy to polyethylene glycol but there were no other serious side effects documented.

About the author

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

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

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

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

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

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

What are the possible causes?

1. Trauma

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

2. Infection

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

3. Just Because

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

4. Conditions that Cause Easy Bleeding

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

5. Bloody Noses

Children with bloody noses can also shed bloody tears.

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

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

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

Will it give you peace of mind? Will it prevent a bad outcome in your child?The answer is probably…no and no.Newborn technology innovation is driven largely by cashing in on the fears of parents. SIDS is the No. 1 fear of newborn parents. Of course, there will be those that try to capitalize on that fear.

The American Academy of Pediatrics (AAP) recommends against the use of these baby monitors in healthy infants, mainly because there’s no proof they work. A new article in the Journal of the American Medical Association (JAMA) has come out strongly against buying “smart” clothing with vital signs monitors. These monitors attach to your baby’s socks, onesies, buttons … and continually check vital signs like breathing, pulse rate and oxygen levels. If there are any abnormalities, you are notified on your smart phone. The problem is the amount of false alarms that freak out parents.

I know I would be freaked out if we were still in the baby stage. My wife and I no longer have babies at our house (Hallelulah!), and fortunately we got out of that stage before this stuff became popular. We went with the video baby monitor with sound and the ability to talk back. But, even if they were available, I wouldn’t have owned a respiratory monitor. Here’s why:

1. They won’t prevent SIDS. There has never been a study showing that a monitor, even a fancy hospital issued monitor prevents SIDS or any other negative health outcome. Particularly not in healthy babies.
2. It “medicalizes” sleep and safety. Ok, so I made that word up. But sleep is a normal process. Safety is something you do your best at but you can’t control for everything.
3. It would tempt me to do unsafe things with my baby thinking I had another layer of protection. Well, maybe not me because I’m the back-to-sleep-nothing-soft-even-crib-bumpers-and-stuffed-animals guy. But, someone might be tempted to.
4. I know what prevents SIDS. And it’s not a monitor. (See No. 3 above.)
5. I would be a nervous wreck. And not just me, but for my wife too. Every false alarm would literally lead to a whole night of missed sleep. I was crazy enough with the video monitor. Did you see that? Did she just move her leg a little?

So for me, it’s not time to be buying respiratory or other fancy monitors for your newborn. If you want to, whatevs. Go for it, but just know that it’s not completely benign.

About the author

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

“Despite being a staple in pediatric care for decades, cough medicines don’t work,” said Justin Smith, M.D., a Cook Children’s pediatrician. “Since being first approved for use in children in 1976, they have failed to prove their effectiveness for acute cough.”

This message is echoed in a new video released by the American Chemical Society. In it, the narrator explains how antitussive drugs are supposed to block the body’s cough reflex. But most studies have found no evidence that over-the-counter medications actually work. Often, they proved no different than a placebo.

Not only do they not work, they can have serious side effects. Thousands of children are sent to the emergency room every year due to accidental overdoses on cough medicine. More than half of those are children under the age of six.

“I don’t give my children cough medicine and I don’t prescribe it for my patients,” said Dr. Smith. “Instead, parents need to know that keeping a child hydrated can help with a cough. By drinking plenty of fluids, kids are able to thin out any extra mucus triggering their cough.”

Dr. Smith says humidifiers are also helpful for children. You can place one in their bedroom while they’re sleeping to ease their breathing.

“In medicine, you have to weigh the risk with the reward. For cough medicines, there are numerous risks and possibly zero benefit.”

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

It’s not the most common I see but it might be #number2.

And, no, I’m not advocating for an Instagram stream of abnormal poop pictures; but, we should all know that all of our kids will have some kind of weird poop this year. Here are the most common types:

1.Hard balls - In babies, little hard boo-boos are how I define constipation. It’s not about the frequency of poop or how hard a baby strains because all babies turn into purple Troll dolls when they are pooping. I like to say they are just learning which muscles to poop with …

2.White - White stools in babies mean that the gall bladder is not working the way it should and can point toward a serious liver condition. This should be evaluated and the child’s bilirubin should be checked.

3.Hard stools/stools that are hard to push out - This is how I define constipation in older kids. If a kid feels like they need to go but can’t, it’s probably constipation. Other common symptoms are vague belly pain but when you ask them … Guess what? The kid hasn’t pooped for days.

4.Large - Some kids just make humongous BMs. I don’t know why. If there are no other symptoms and they can go regularly without pain, it’s probably just fine.

5.Bloody - Bright red blood, particularly if on the outside of the feces or that comes off on the toilet paper is likely the result of a small tear in the rectum (the area right before the poop comes up). This is really common in children who have constipation and can lead to very painful attempts to poop. If there is a lot of blood, or it doesn’t go away, the child may need to be checked for rectal polyps.

6.Red - The most common cause I’ve seen for this lately: Hot Cheetos. Just because it’s red, doesn’t mean it’s blood. Think about what the child has been eating. Particularly if you parent the one child in the world who likes beets.

7.Black - Dark, black stool are one of the most concerning stools but not always. It can be an indication that there’s bleeding somewhere higher in the stomach or intestines. If the child has other symptoms, they should be seen fairly quickly. Other possible causes include: ingesting blueberries, taking iron supplements or Pepto-Bismol (which we don’t recommend but can also cause dark green stool).

8.Looseish - Not really diarrhea but not normal either. This can be the norm for some kids. Think about places where your child might be ingesting some extra sugar (especially juice).

9.Runny - The most common cause of diarrhea is a stomach bug. Usually these children have vomiting as well (but not always). It generally last a few days to a week and the child should not appear particularly sick. Children who have diarrhea that lasts longer than a week or that has blood or mucous should be seen by a doctor as it could point towards a different kind of infection.

10.Snotty - Small amounts of stringy mucous in poop can be normal, especially for a very short period but if the child has blood or belly pain along with it, it could point toward an inflammatory bowel problem like Crohn’s or ulcerative colitis.

11.Nutty/Corny - Yep. It happens. You all know it does. In fact, it’s one way to know how fast everything is passing through …

Next time you’re wondering if your child’s poop is normal, I hope this takes a load off your mind. Sorry. Couldn’t resist.

About the Author

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

The 8 year old woke up in the middle of the night with a nosebleed that lasted 20 minutes. After drenching the bed and several towels, Casey, Carter’s mom, became concerned. Carter tried his best to calm his mom by saying, “I’m going to be Ok mom. It’s going to be OK.” During the nosebleed, Carter became progressively weak , seemed very pale and was complaining of vision changes like he was about to pass out.

Casey called 911, worried that something bad might happen before she could get help. Fortunately, while the first responders were on their way, the nosebleed slowed and Carter started to get back to normal but Casey still needed some reassurance that things would truly be OK.

I saw Carter soon after that night. As we talked, it became clear that, while had a history of nosebleeds, things were worsening in both how often they were occurring and how severely his nose was bleeding. We decided to keep a close eye on him and monitor when the nosebleeds were happening. Later in the week, she contacted me to let me know that his nose had bled for over an hour the previous night. During this nose bleed, he didn’t have any of the other more scary symptoms, but we both felt it was time to get him some more help.

Fortunately Natalie Roberge, M.D., one of Cook Children’s Ear Nose and Throat doctors was able to see Carter the next day. Dr. Roberge described what she discovered, “His nose bleeds were unusual because they lasted so long (up to 1-2 hours), and blood would also come out his mouth when he pinched his nose.”

The day following his appointment, Carter was scheduled for a surgery in which she “cauterized a little artery on each side of his nose to seal up the blood vessel and prevent bleeding.” He did very well with his procedure and has had no further nosebleeds since.

Nosebleeds are very common this time of year and it’s very unusual for children to require a procedure to help control nosebleeds. The blood usually comes from dry, cracked skin and fragile vessels in the nose especially in dry seasons. Even minor trauma like nose picking can cause significant bleeding.

Most nosebleeds can be controlled by applying pressure to the bridge of the nose for 5 minutes (and don’t check every 10 seconds). You can prevent nosebleeds by applying some nasal saline or Vaseline to the nose at night time, especially during dry seasons.

Dr. Roberge states that parents should “seek care for nosebleeds lasting more than 10 minutes, when the amount of blood is concerning (more than a quarter cup), more than twice a week or associated with other concerning symptoms.”

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

What about febrile seizures?

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

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

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

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

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

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Ft. Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in the fall of 2016.

With the upcoming season, now is the time to get your child’s flu vaccines.

Only flu shots will be given this year to protect kids from becoming sick. This is due to recommendations from the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) after last year’s FluMist was found to have failed against certain strains of the flu.

But parent’s shouldn’t worry, Cook Children’s has increased its doses of the Quadrivalent Influenza Vaccine (flu shot) for its primary care offices.

“Even in bad years, the flu vaccine continues to provide the best layer of protection against this deadly disease,” said Justin Smith, M.D., a Cook Children’s pediatrician. “Last year’s injectable flu vaccine was 50 percent effective in preventing disease which means thousands of people were protected.”

The AAP recommends children ages 6 months and older be immunized against influenza every year. Previously, the CDC and AAP had recommended either form of flu vaccine – the inactivated influenza vaccine (IIV) that is given by injection and is approved for all patients older than 6 months, or LAIV which is given by intranasal spray and was approved for healthy patients ages 2 through 49 years. But that is no longer the case. Only the injection is recommended.

To find a Cook Children's pediatrican in your area, click here.

Trust me, you don’t want to get advice about sex or STDs from teenagers.

Here are some frequently asked questions:

1. Do kids even get STDs?

Yes. About 10 million new cases of STDs are diagnosed each year between the ages of 15 and 24.

2. How will I know if my boyfriend/girlfriend has an STD?

Many STDs don't have obvious symptoms and many teenagers are ashamed to or do not want to talk about it. Because of this, you will never know for sure if your partner has an STD.

3. How serious are STDs?

Identifying and treating STDs is very important. Some like gonorrhea and chlamydia can start with small symptoms but get worse and cause severe, life-threatening infections. Others, like HIV, may not show symptoms at all but can lead to serious health complications later.

4. Are all STDs treatable?

Some STDs go away after treatment but not all. HIV can lead to AIDS which is a life-long condition with severe consequences. Herpes can cause recurrent outbreaks of sores on the genitals which can come back again and again. Human papilloma virus (HPV) causes genital warts which can lead to cervical cancer (in girls) and penile cancer (in boys).

5. Do you just get STDs from sex, or from other stuff too?

You can get an STD from vaginal sex but that’s not the only way.

Oral sex can also transmit most of the infections. A person can get gonorrhea or chlamydia of the throat. HPV and herpes can also be transmitted via oral sex.

HPV and herpes are also contagious via skin to skin contact so even touching another’s genitals can transmit these infections.

If you are a teen reading things, there's a lot more you can learn about STDs. If you have other questions, ask your doctor or talk to a parent. Mom and dad, if you are reading this, please be available to talk to your child.

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

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

Should you be concerned?

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

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

Should you give your baby rice cereal?

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

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

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

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

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

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

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

About the author

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

A new study in Nature Medicine started the process of trying to answer this exact question

You might be thinking, “What the?” But there is some logic to this:

1. Babies born via C-section have been shown to have slightly higher risk of some diseases (obesity, allergies and asthma for example).
2. We are beginning to understand how the makeup of bacteria in our intestines affects many different diseases.
3. Babies born via C-section are not exposed to the normal bacteria that line the birth canal

The question then would need to be asked: Can you reverse this process by exposing babies to the vaginal flora after they were born via C-section? This small pilot study of four babies seems to suggest that you can.

The process: Within in the first two minutes after birth, take a piece of gauze, which has been placed in the vagina. Swab the babies mouth, forehead and the rest of their body. Test these babies to see what bacteria are present in their bodies.

The answer: Those C-section babies who were swabbed with vaginal secretion showed that the bacteria they carried more closely resembled babies who were delivered vaginally.

This was a small study, which needs to be repeated on a larger scale and there are still many questions to answered:

• Does changing the bacteria that a baby carries actually help to prevent diseases?
• How do we make sure this procedure is safe? How do we screen moms to make sure there is no added risk to the baby?
• What is the best means of transferring the bacteria? Is there a better way that what was done in this study?

The role that the bacteria we carry play in our health is gaining interest. I’m sure that we will continue to see studies like this and many others in this area. Stay tuned.

Here are 4 reasons goat's milk is dangerous and could even be deadly:

1. It is usually not pasteurized which can lead to all kinds of bad infections (listeria most commonly).
2. It has more protein so baby's kidneys can't handle it well. This along with high sodium level can lead to strokes.
3. It doesn't have enough folate which can lead to anemia.
4. It doesn't have the same electrolytes which can lead to extra acids building up in the baby's body. This causes multiple downstream problems.

Breast is best. Modern formula is really, really good too.

Goat's milk is nothing to kid around with.