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.

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.

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

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.

Are we there yet? “No. 5 more minutes.”

Are we there yet? “No. I will tell you when we get there!”

Did anyone hear this or something like it last week?

We’ve been asking a similar question to our favorite Cook Children’s microbiologist, Morgan Pence, Ph.D.

Is it here yet? No.

Flu season should be just around the corner, but it’s not here yet. Currently, there are only two regions showing Influenza activity across the state of Texas. Tarrant County is not one of those regions.

Flu season usually starts sometime in late October or November but occasionally we have later seasons. It appears that we are going to (knock on wood) make it till December before we see our first case at Cook Children’s this year.

There are few theories about why flu follows a seasonal pattern:

1.As weather gets colder and people are trapped indoors, the virus can more easily spread from person to person.

2.Colder temperatures lead to drier air. Dry air causes our noses to be drier which may make their defense against flu weaker.

3.Cold temperatures may allow the flu virus to live longer on surfaces.

Based on these theories, it’s possible that our warmer fall has caused a delay in the onset of flu season. With the colder temperatures last week, we may be reporting our first case soon.

Dr. Pence reports that our lab tested 74 specimens last week but none were positive for flu. She states, “Currently we are mostly seeing children with rhinovirus and RSV.” Rhinovirus causes the common cold. RSV can cause cold-like symptoms as well, but can be more severe in babies, especially those who were born premature.

What does this mean for you and your child?

1.If you haven’t yet, there’s still time to get your flu shot. (Even if the year starts late, it could still be a bad one).

2.Continue to teach your children to cover coughs and to wash hands.

3.Be aware if your child tests positive with a rapid flu screen, it may not be correct until flu activity is higher.

For now, Dr. Pence will still have to play the role of lab-mom.

Is it here yet? “No.”

Is it here yet? “No, probably 2-3 more weeks.”

Is it here yet? “No, but you’ll be the first to know!”

Poisoned candy?

We’ve heard these scary tales since we were little kids. Parents make sure you check your kids’ candy before they begin munching on their treats, but know that many of the stories you’ve heard are meant to scare your little brother.

Are there some particular dangers you should be aware of for the last day in October? Yes! Here are a couple of other Halloween treat issues you should know:

Food allergies

Children with food allergies can have a particularly challenging time during all holidays, including Halloween. Their desire to feel included in the rite of passage that is trick-or-treating doesn’t always mesh well with the risk of getting food that could harm them.

Many of the most common food allergies are frequent ingredients in Halloween treats (nuts, milk, egg, soy and wheat).

Over the past few years, there has been a movement towards providing non-food options for trick-or-treaters. You can designate your house a food-allergy friendly house by painting a pumpkin teal or for those of you are aren’t as crafty (or are just too lazy or don’t have enough time), you can print out this flyer and tape it to your door.

Listeria in caramel apples

Besides being a risk for ripping my front teeth out, caramel apples can harbor Listeria. Remember Listeria, you guys? It’s why I haven’t had Blue Bell in months. According to a recent study from the American Society for Microbiology, it seems that when the apple is punctured by the popsicle stick, the small amount of juice that comes out can become infected with Listeria.

Listeria is a particular concern for pregnant moms, the elderly and newborns so please don’t let your newborn munch on a caramel apple.

Some stores are pulling caramel apples off the shelves in response to this study.

Halloween can be a great time of fun for all kids.

For more information, check out our Halloween safety page.

You can read my earlier posts on the symptoms of teething and my outright forbidding the use of teething gels.

After these, I think I have many of my readers wondering what in the world they are supposed to do when their child seems to be teething.

There are a select few of you out there who think you have found a loophole … their children are walking around sporting brownish yellow bling around their necks, are as happy as can be at all times and are sleeping through the night like little angels. Right?

Do amber teething necklaces work? If so, how?

Websites selling amber necklaces are all over the place when discussing how they might work to control symptoms that are commonly associated with teething.

They tend to center around three main concepts:

• Magnetism, energy or natural flow of energy

• Thyroid gland stimulation to control drooling

• Succinic acid released causing anti-inflammatory and pain relieving

Magnetism, energy or natural flow of energy

I found this quote in one of the top-ranking articles regarding how amber teething necklaces might treat teething pain:

“The unfavorable environmental conditions prevailing today block the natural flow of energy-related processes in cells. Blocks affect cellular metabolism and significantly weaken the immune system, but the natural energy of amber is able to stimulate its renewal.”

Thyroid gland stimulation to control drooling (or other symptoms)

The thyroid gland makes thyroid hormone which increases metabolism. This results in a whole list of changes inside our bodies, including:

• Increasing body temperature
• Faster, stronger heart beat
• Brain development and growth in children

Slowing drooling is not a function of the thyroid; thus stimulating it would not result in less drooling.

Stimulating the thyroid could result in increased body temperature (which is, ironically, often one of the symptoms of teething that people are trying to treat).

Succinic acid release causing anti-inflammatory and pain relieving

Perhaps the MOST logical explanation (and most often referenced) for why amber teething necklaces might work for teething pain is that amber contains 3-8 percent succinic acid.

Succinic acid is a chemical that is found naturally in the body and is involved in an energy producing chemical cycle known as the Krebs cycle. The basis of the reasoning behind why succinic acid treats teething symptoms is that it is reported to have anti-inflammatory properties.

Let’s look at a few problems with the assumption:

1. I can only find one study that even shows succinic acid to have anti-inflammatory effects. It is almost 30 years old and was published in a journal I have never heard of, in Russian.

2. Assuming succinic acid does treat pain associated with teething, how does the succinic acid get into the child’s body? Amber is fossilized tree resin which is formed under extreme heat and pressure. The Wikipedia article on amber states, “Exposure to sunlight, rain and temperate extremes tends to desintegrate resin, and the process is assisted by micoorganisms such as bacteria and fungi. For resin to survive long enough to become amber, it must be resistent to such forces or be produced under conditions that exlude these." How is it, all of the sudden, that amber decides to release succinic acid in response to 98.6* temperatures and gentle pressure from your child's neck? Seems unlikely.

3. Let’s assume that 1 and 2 are wrong and that succinic does treat pain associated with teething and will absorb into the child’s body from the necklace. How much is absorbed? Medication applied to skin is notoriously unreliable with children.

Let’s flip this around. Say an established drug company comes up with a treatment for a common condition that is not dangerous but may cause some discomfort. The drug rep comes to my office to promote the drug…

Me: Ok, this all sounds great? So, what is the dose? How does the dose change as the child gets older?

Drug rep: Ummmm, we don’t know really. We haven’t really looked into “dosing.”

Me: So, how do you know this works?

Drug rep: Well, it’s actually been around a long time, we just put it in a different package so we’re pretty sure it works and is safe.

Despite the fact that on the surface it seems plausible, I don’t think the succinic acid claim holds up as a mechanism where amber necklaces could work for teething.

Is it a choking hazard?

We have to address these necklaces as a choking hazard. It’s interesting. People say they aren’t a strangulation hazard because they break. Ok. But then they say they aren’t a choking hazard because the beads are tied individually.

I say, you can’t have it both ways. If they break, they have to break somewhere and a bead has to get loose. And if you’ve seen the size of these beads … looks like a choking hazard to me.

So, why do amber teething necklaces “work?”

It’s really based on three points…

1. Teething symptoms are vague and most are only mythically related to teething.

2. Teething symptoms go away on their own 100 percent of the time.

3. Parents are desperate to help when they assume their kids are in pain.

Studies are pretty clear that teething symptoms really only last a day or two around the day that the teeth erupt. Many of the symptoms commonly associated with teething may actually be normal developmental issues-drooling, waking up at night, etc.

Knowing whether a specific treatment for “teething symptoms” works or not is almost impossible. But, for parents who had concerns and tried amber teething necklaces, the results seems magical. Doing something is often thought to be better than doing nothing. It’s certainly easier to brag about.

I have yet to see a Facebook post that says, “My kid was MISERABLE with teething last week but look at him today!! I found the miracle cure - I did absolutely NOTHING! You should try it too.”

I’m coming into a place where I’m not sure treating teething with anything makes sense, even your typical pain relievers. For this reason and because I cannot find a plausible explanation for why they work, I think parents should save their money when it comes to amber teething necklaces.

Last night, NBC 5 Investigates released an enlightening report looking at the rates of concussions in North Texas districts. This report showed a much higher rate with more than 2,500 concussions reported in just 41 districts.

There are still a lot of misconceptions about concussions, what they are and what they might mean to your student athlete.

Here are 5 concussion MYTHS:

1. It was just a “mild” concussion.

Concussions are brain injuries, period.

One might classify a concussion as mild if symptoms were brief and not severe. However, you cannot predict whose symptoms will be severe based on the way the child was injured or even the symptoms right after the injury.

Even seemingly minor trauma can cause headaches and other symptoms for weeks.

2. If the child/athlete didn’t lose consciousness, it wasn’t a concussion.

Symptoms of concussion vary from child to child but passing out or blacking out are not required to make the diagnosis. Basically if a child has a fall or other injury that results in any neurologic symptoms, they can be diagnosed with a concussion.

Some examples of concussion symptoms are headache, nausea/vomiting, vision changes or problems with concentration and memory. Some of these symptoms may take time to develop, so it’s possible to diagnose a concussion a few days after the injury.

3. Concussions are only a problem for football players.

Almost all sports can cause concussions, including the cheerleaders on the sideline of the football games. Some other sports that are known to have higher incidents are soccer, baseball and softball. Other common causes are kids riding bikes and falling off playground equipment.

4. All concussions need either an MRI or CT of their head.

Most concussions can be diagnosed based on telling your doctor the story of the injury and the related symptoms along with a physical exam. Imaging is not necessary because a CT or MRI will most likely be normal even in the midst of a severe concussion.

Also remember that a CT of the head does not come without risk. While we should perform them when necessary, we should make sure we are not using them in situations where they will not provide useful information.

5. Don’t let your child sleep after a concussion.

Treatment of concussions is evolving. If you suspect your child has sustained a concussion, you should immediately seek medical attention and advice from a doctor about how you should treat your child’s symptoms.

There have been some changes in the treatment of concussions. First, we no longer require that you keep someone with a concussion awake for a set period of time. In fact, after their evaluation, the doctor may recommend that you allow them to sleep in order to help their brain heal. Your doctor might also prescribe some time away from TVs and other screens, school or homework or other activities that might cause their brain to work harder.

Concussions are much more common than we previously thought. I believe that the UIL will make changes to better track the risk of concussions for our high school athletes, which will hopefully lead to better ways of evaluating and treating concussions. In the mean time, don’t buy these common concussion myths.

So why did the Tarrant County Health Department just announce that there is a case of rubella in a Texas Christian University student?

Unfortunately, the student returned from a part of the world where rubella continues to be an ongoing concern. The World Health Organization states that rubella continues to cause infection in Africa, the Eastern Mediterranean and Southeast Asia. Despite the fact that rubella is no longer transmitted in the United States, an average of 10 cases of rubella are diagnosed here each year from travelers who bring it back from affected areas.

Don’t get me wrong, rubella is a big deal. Prior to the vaccination, it used to cause millions of cases per year around the world. The most severe complication from rubella is congenital rubella syndrome (CRS) which can affect the babies of women who contract rubella during the first three months of their pregnancy. Children born with CRS are at risk for growth problems, developmental delays and other birth defects.

We should definitely be aware that there is a case of rubella in our area, but I’m advising parents not to panic about their children getting rubella.

Here are the 2 main reasons why I’m choosing not to panic:

1. Rubella is a mild illness in children. It can start with a mild fever (but often doesn’t) and then causes a rash that starts on the face and spreads downward. Other complications from rubella are very rare and are more likely to happen in teenagers and adults.

2. Rubella vaccine works very well. After the first dose of the rubella vaccine (given at 1 year), 90-95 percent of children are protected. After the 4-year booster dose, protection gets much closer to 100 percent. If your child is vaccinated, they are most likely protected. As with anything, the vaccination is not perfect so we are relying on each individual person getting vaccinated to help protect their neighbors from an outbreak. Despite the fact that cases of rubella have been imported into the United States, no outbreaks have occurred, thanks to our relatively high immunization levels.

Children (or adults) who are infected by rubella can spread the disease via droplets spread by sneezing or coughing. We recommend all children be vaccinated against rubella. The vaccination helps prevent children from getting the disease and it also helps protect anyone they may come in contact with, including pregnant women.

Pregnant women with rubella run the risk of potentially having a baby with congenital rubella syndrome.

As always, if you are pregnant (especially in the first three months), use caution around sick individuals especially those with a rash. If you already have a baby, you were likely checked for rubella immunity at the delivery and your doctor should have the results of that test. If you are thinking about becoming pregnant, a doctor can check your immunity level now so that you can be vaccinated prior to getting pregnant.

Let’s not panic about rubella at TCU. If your child is starting classes there, feel free to send them on (I’ll be on campus for a meeting today if that gives you any peace of mind). Let’s be aware. We’ll follow the story and notify you if there are any updates or new reasons to be concerned.

More resources:

• Rubella
• Frequently asked questions about immunization
• Measles: Just a plane ride away
• Should you immunize?

What are the most common causes of a runny nose? How do you treat one? When should you call a pediatrician?

Doc Smitty is back with the latest My Kid Minute. Watch the video to find out all the answers.

Here's why:

There has been an outbreak of severe flu among dogs in the Midwest. Cases of the H3N2 strain have now been seen in dogs in Texas.

Most dogs have cough, runny nose and fever, but it has been severe and resulted in death in some.

So you may be wondering, “Is my child at risk if our dog has this flu?”

The answer, according to the CDC:

“To date, there is no evidence of transmission of canine influenza viruses from dogs to people and there has not been a single reported case of human infection with a canine influenza virus.”

That’s fortunate, but what are some health dangers associated with pets?

Bites

I’ve seen too many severe dog bites in my training to not mention bites first. The most common statement I hear about the dogs who bite is, “We just never thought he/she would do that.”

Dogs can be a great addition to a family but use caution:

• Be careful of rough play. Even a playful snip can be dangerous if it happens near the eye or a fingertip.

• Stay away from dogs when they are likely to be defensive: when they are eating, sleeping or taking care of puppies.

• Stay away from unfamiliar dogs or dogs that seems scared or anxious.

Here are some more tips from the ASPCA on how to avoid dog bites.

Allergies/Asthma

This is actually one of the most common questions I get regarding animals. It’s very intuitive. People can be allergic to dogs and cats, so wouldn’t owning one increase my child’s risk for allergies?

I have seen several studies that suggest the exact opposite. Often by having animals in the house early, kids may have slightly decreased risk of developing allergies. That said, if your child has frequent allergy and asthma symptoms, it may be reasonable to attempt to isolate the animal from the child for a bit to see if symptoms improve.

Infections

Infectious diseases are transmitted through animals frequently; think about the number of diseases that tics and mosquitoes can carry. Although it can happen, they are less frequently transmitted from pets.

Here is a list of pets and some of the diseases they can transmit:

Cats

Cat-scratch fever:

This disease is caused by bacterial infection (Bartonella) of an open wound or a bite that results in the breaking of skin. It is more commonly transmitted by kittens than older cats. Symptoms of the infection in humans are fever, headache and fatigue. There is often a large and tender lymph node near the site of the bite.

Toxoplasma:

Toxoplasma is usually a foodborne illness, but can be transmitted from cat feces. In people with normal immune systems, there are often no symptoms of toxoplasmosis. Pregnant women (and fetuses) are especially susceptible and, for that reason, should not handle cat litter boxes.

Dogs

Hookworms:

Dogs infected with hookworms can have bloody stools; which in severe cases can lead to anemia. Humans are infected by walking barefoot on contaminated soil and develop an interesting rash which consists of red, squiggly lines where the larvae have migrated under the skin.

Reptiles

Salmonella:

Salmonella is one of the most common pet-associated infections. It is estimated that 70,000 people will contract salmonella from pet reptiles. Salmonella generally causes bloody stools but in children and in people with weakened immune systems can be serious. The CDC recommends that houses with children less than 5 and with any household members with weakened immune systems not own reptiles as pets.

Many Animals

Campylobacter:

Ingesting food contaminated with the bacteria transmits most infections of campylobacter, but cases can occur from the handling of dog or cat feces. The main symptom of campylobacter infections is diarrhea (which can be bloody) and usually lasts about one week.

Ringworm:

The fungus that causes can be transmitted from many different animals but most commonly occurs from puppies and kittens. The appearance of the rash on human skin is a circular rash with a raised edge. It can be difficult to distinguish from eczema which sometimes causes circular patches as well.

Pets can be great additions to your family and, in most cases, will not cause any harm to your children. Be aware of the specific risks associated with certain types of pets and take caution to protect your children when appropriate.

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer

Human papilloma virus is a cause of warts that affect the genital areas of males and females. They can also cause infection of the mouth and throat.

HPV is the most common sexually transmitted disease in the United States.

HPV does not show symptoms for many people who are infected but it can lead to cancer of the cervix or penis. Every year approximately 17,500 women and 9,300 men will be affected by cancers that are caused by HPV.

HPV Vaccination

Fortunately, we now have a vaccine that prevents HPV. It was licensed for use in 2006 and targets four strains of the virus: 6, 11, 16 and 18. Types 6 and 11 account for 90 percent of genital warts and types 16 and 18 lead to cervical cancer.

Any time something is “new,” rumors abound. I was privy to an online discussion about HPV on Facebook this week ... because it’s not the best venue for having these discussions I had to hold my fingers (tongue).

But, here are some of the myths I saw that I felt needed to be addressed, beginning with the HPV vaccine has been proven ineffective.This myth takes on a few different forms. I’ll address each one.

HPV Vaccine Myths

1. Myth: The HPV vaccine does not decrease the amount of HPV disease.

Truth: In the United States, the percentage of cases of HPV caused by those strains in the vaccine dropped by 56 percent after the introduction of the vaccine. Other studies in the UK and Australia showed decreases in the number of HPV cases after introduction of the vaccine. The vaccine prevents HPV disease.

2. Myth: The effectiveness of the vaccine wears off over time.

Truth: This study in Pediatrics showed that, at the end of eight years of surveillance, those who received the vaccine continued to have antibodies to the virus. There is no indication that will decrease over time but studies continue. Even if we found a fall-off, a booster could be used to prolong coverage and if we could get protection for any period of time it would decrease the rates of HPV and cervical cancer.

3. Myth: Even if it prevents HPV, the vaccination has never been shown to prevent cancer so why get it?

Truth: Despite the logical conclusion that decreasing HPV infection rates should decrease the rate of cervical cancer, some challenge the HPV vaccine by saying that it has never been shown to decrease the rate of cervical cancer. This study in Denmark showed a 40 percent decrease in atypical cells found on Pap smears (a precursor to cervical cancer). I believe that more studies like this will show even more proof that it is preventing cancer.

4. Myth: The HPV vaccine is not safe.

Truth: This is perhaps the most pervasive of all the different myths about HPV vaccine. News reports and anecdotal stories of teenagers who have received the vaccine and then experience weird, otherwise unexplainable symptoms can be quite compelling. The problem with relying on those stories is that, even before the HPV vaccine, teenagers had events or health outcomes that were unexplainable. Even those who choose not to be vaccinated today have some of the same symptoms. Wouldn’t it be nice if we had some way to determine if these events were caused by the vaccine or were merely coincidental?

Fortunately, we do. If we look at a large population of teenagers who received the vaccine and compare them to another population who did not, we can see if the vaccine increased the risk for bad outcomes or if there were events that would have occurred anyway.

Multiple studies have done this. One of my favorites is one that included almost 200,000 girls who received one or more doses of HPV vaccine. It showed a slight increase in passing out after the shot (we ask girls to sit for a while after receiving it) and skin infection, but no other increase health risks. Another included almost 1 million and showed no increase in autoimmune, neurologic or blood clotting disorders.

I am not concerned about the safety of these vaccines. I understand that, with anything new, parents are going to have concerns but as more and more data come in, the safety of HPV vaccine is confirmed. My kids will get it when they are the right age.

5. Myth: The HPV vaccine allows or causes teenagers to be promiscuous. (Related: We shouldn’t vaccinate because it protects promiscuous kids.)

Truth: This is the most infuriating myth for me regarding the HPV vaccination debate. It angers me because it preys upon the fear of some parents that their child might take sexual risk as a result of something the parents have done. If that is a concern, it might be justifiable if it were true ... BUT it’s not.

Studies have shown that girls who receive the vaccine are no more likely to engage in risky sexual behavior or to have more sexually transmitted diseases. Using that myth to scare other parents is inappropriate, just stop.

6. Myth: Because I’ve raised my child “right,” they won’t be at risk for HPV.

Truth: What? This line of thinking has so many holes.

First of all, you won’t always know about your child’s activities. Trust me, you won’t always know. You may think you know, but I’ve diagnosed a pregnancy in more than one girl who “never had sex.” Stuff happens.

Protect your child even if you’re sure they’d never have sex or won’t until they meet “the one.” Why? You can’t predict you child’s future partner’s sexual behavior. Maybe your children will grow up, meet the partner of their dreams and only have sex with that person for their whole life. But, maybe their partner’s history isn’t the same. Their partner could carry HPV, could give it to your child and leave them at risk for cervical or penile cancer. Why risk it? By withholding the shot, you are only putting your child at risk.

These are some of the common myths I’ve heard about HPV. I’m sure there are many more out there. But I urge you to go in with an open mind and talk with your doctor about your questions or concerns. We’d be happy to help!

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

Sorry that there’s no “all of the above.”

Around 25 percent of kids grind their teeth at some point. It most often occurs at night but can occur during the day (usually they are not conscious that they are doing it.) The most common ages are from 7-10 years and most grow out of it without any problems arising.

We don’t really know the cause of teeth grinding although it has been linked to stress and one study showed it to be more common in kids who talk in their sleep or wet the bed.

Most children do not have complications related to grinding their teeth. Some complications that have been reported are: jaw pain, headaches (more common in adults) and damage to teeth.

Treatment for teeth grinding can be very frustrating as there are no quick fixes. Since stress can be a related factor, try to have open dialogue with your children about factors that could be causing them stress. Mouth guards are not frequently used in children because they are not likely to help and making one to fit is difficult because children grow so quickly.

If the teeth grinding continues, talk with your pediatrician or dentist to see if there are new treatments available.

My wife nudges me. It’s 2 a.m.

“Hey babe, did you hear that? Who is coughing? Can you go check on them? Take your stethoscope.”

That’s what an Emergency Room visit looks like in our house in the middle of the night. This time of year, many of you might wish you were married to a pediatrician … but, alas, Mrs. Doc Smitty is one of the few with that privilege.

We at Cook Children’s, and hospitals around the nation, have seen a significant rise in the use of our Emergency Departments and Urgent Care Centers over the past few weeks. Not only are we seeing more kids, many of those kids are more complex and more sick than we have seen in previous years. We are seeing RSV, flu, vomiting/diarrhea and just about every other pediatric illness you can imagine. It’s all going around.

Not only do we find ourselves servicing our local area, we are accepting transfers from most of North Texas in an effort to provide service to very ill patients who need the level of care that Cook Children’s can provide. This responsibility is based on Cook Children’s promise that every child’s life is sacred.

But that important commitment to helping so many children means helping a lot of kids. Here’s what we know that means to you.

We know that wait times are longer than usual right now.

We follow the trends in wait time closely – both at our medical center and in our region. All across Dallas-Fort Worth, hospitals are experiencing this surge in visits and we are hearing about increased wait times at emergency rooms throughout the area.

We are working to address this issue. We are increasing the number of providers ready to work in the ED. These are not our regular ED physicians but physicians who will be available to help out with patient surges after their “day jobs.” We are working to educate our families about other locations where they can receive care. Unfortunately, once a patient is checked in at the ED, we cannot ask that they leave to receive care elsewhere. Asking them to leave would be a violation of a law known as EMTALA.

Another issue we are facing is limited space. Hospital beds are filled with sick children that are not ready for discharge. This requires that children who need admission remain in our ED as they wait for a room in the hospital.

Space in the ED is already limited based on the fact that it was built to accommodate 45,000 visits per year but is currently seeing more than 120,000. Much of this problem will be addressed when our new Emergency Department opens, but, for now, we have to work to maximize the use of the space that we have.

Therefore, increasing providers will not cut your wait time down to zero but we will do our best to shorten it as much as possible.

You can help by utilizing our various other ways to care for your child’s medical issues addressed. Do not hear this as a lecture to not go to the ER; that is not the point of this post. We are working hard to provide other means that might help you by addressing the problem more quickly. Consider calling your Cook Children’s pediatrician. Even if they are not open, you can get advice from our outstanding pediatric nurses who can take your phone calls overnight. If your issue requires a visit but the ER seems like too much, check out one of the four Cook Children’s Urgent Care Centers throughout the Fort Worth area.

We know that waiting is terrible.

Doctors are some of the most impatient people I know. I don’t like to wait for anything. I get antsy and frustrated and become very difficult to deal with. If the radiology report or the lab result takes longer than expected, our anxiety level goes up. When we know our patients are suffering and we need those results to relieve suffering, we become even more frustrated. We hope you don’t sense our frustrations as frustrations with you. We just hate to see kids sick and to see more of them sick than usual makes us all sad.

You can hear the frustration in this brief interview with Corwin Wormink, M.D., Cook Children's Assistant Medical Director of Emergency Services.

We are working to address this issue. We are working to speed up all the processes associated with caring for your children so that our providers can be as efficient as possible. We are working to support providers (doctors, nurses and all other staff) so that they can be energized (physically and emotionally) to continue to provide excellent care for your child.

We know that waiting with a sick child is even worse.

We hate it that you are waiting hours to be seen in our ER. When our providers walk into the room and see that you’ve been waiting, our heart hurts about the time you’ve spent sitting in an uncomfortable chair trying to corral your sick child (often with their siblings). We know that you are worried about your child because he or she is sick. You’ve been scared to go to the bathroom, afraid you might miss your name being called out and that you are hungry and tired.

We are working to address this issue. We are looking to staff volunteers in the waiting rooms to help you get to where you need to be, to provide distractions for your children and to do anything they can to help you while you wait. We also are looking to increase our use of text and other notifications to update you on the status of your wait times, need for vital sign checks and other issues. Even when you are waiting, unable to be seen by a doctor, our triage nurses are checking and re-checking your child’s vital signs to make sure that your child’s medical condition is not changing, requiring them to be moved up in line to be seen sooner.

Your child is important to us.

Despite the fact that the numbers of children in the ED are high, we want to continue to provide the best care for your child. No matter how long your wait, we want you to feel like your concerns and questions have been addressed and that you have received the personal care your child deserves. If at any point, you do not feel like you have received that level of care, feel free to reach out to us at 682-885-6698.

You may not have a pediatrician lying next to you in bed for a quick ER check in the middle of the night but we do want you to know that we are here for your child in many other ways. Start by picking up the phone and calling your pediatrician or nurse triage line. If you decide your child needs to be seen, think about trying one of our Urgent Care Centers or in an emergency, our Emergency Department.

Our providers in each area are ready to provide the best care for your child.

Previous articles, related to this topic:

• Sicker kids means longer wait time in ED
• More flu, longer waits in the ED
• Emergency? 6 signs from an ER doc
• Cook Children's to build new South Tower on main campus
• Is it RSV?
• 8 flu myths I wish would go away

The growing trend of water birth needs to be addressed on many levels. First off, we need to come up with a definition of what a water birth actually is. Does it mean sitting in a tub during the first stage of labor or going all the way to delivering the baby into the water?

Secondly, we need to be clear about the benefits of water birth. There have been a few reviews that show that water birth can decrease the amount of medicine used during labor.

Finally, can we all agree that if we are going to be using water birth, there should be guidelines and a trained professional (with specific training in water birth) available?

The baby who died in Texas was delivered in a circulating tub, with difficult to clean tubes. The water was drawn from a well, purified with commercially available drops and left to circulate for 2 days prior to delivery. We can pretty safely say that none of these strategies would be in the guidelines.

If you are considering water birth, ask questions. Make sure that you understand the benefits and any potential risks.

If you need or want details, check out this article by a great friend of mine, Dr. Clay Jones: An Update on Water Immersion During Labor and Delivery.

Thalasso Bath Method

A “cute” and “relaxing” video is circulating around social media of twin babies in a bath who, “don’t even seem to know they are born yet.”

The video highlights a bathing method known as the Thalasso method which was developed by a French nurse, named Sonia Rochel. She gives babies a bath in relatively deep water, with water running over their face and eyes and then submersing the babies to where just their face and mouth are above water. The proposed benefit is that the bath is an environment that mimics the womb and thus is calming and peaceful for the baby.

I say that the videos are “cute” and “relaxing” because that’s what all the commenters say, but, frankly, I find it more “anxiety-provoking” than anything else. I have seen the nurse say in several interviews that this should only be done with a health care provider who is familiar with the technique, but I doubt that this prevents many people from trying it out at home.

Consider that the babies in the videos are relaxed and happy, but remember that they are putting their best foot forward. I wouldn’t be surprised to learn that they cut a few videos of screaming, wiggly babies. Seeing that would make this technique look a lot less safe. Just a few things to think about.

Water Neck Floatie Things for Babies

This is, by far, the easiest one to pick on. It’s basically an inflatable flotation device that you stick around your little baby’s neck and leave perilously floating in the water. Apparently, there are even spas cropping up where you can pay to have your baby do this and then be taught how to give them a full body massage.

I am all for physical touch with your baby, but I think we can skip the floating around. Lest you say, surely parents aren’t completely trusting these things to actually help keep their child floating on their own … check out the pictures. I’m hoping there are parents right outside the frames of these things, but often there are 4 or 5 infants floating in a single pool with no parent hands in sight. If you want your baby to like water and physical touch, let’s go ahead and combine the two and hold them in the water.

We should evaluate anything we see as a new trend with skeptical eyes and with a grounding in common sense. If you have questions, ask your pediatrician.

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.

I resolved to quit doing them years ago. Which means I quit systematically breaking them years ago as well.

This doesn’t mean that I don’t work to improve myself; I just try to do it every day and not just on New Year’s Day. Bad habits are easy to form and hard to break. This is no different for parenting.

Here are some things I am working on:

Be purposeful

I have chosen two character traits I want my children to have: grit and integrity. I want my kids to try hard to overcome obstacles and I want to be honest, whole people, even when no one else is watching.

The best way to accomplish this is not to sit down when they are 12 and have a sit-down conversation that magically imparts them. The best way is to take every opportunity now to teach them in a developmentally appropriate way. I don’t swoop in to rescue them when they are having trouble with a puzzle and I make a point to call out (in a loving way-at least most of the time) the little white lies that toddlers and young children often tell.

Be patient

My mind runs 1000 miles a minute. I get from point A to point B really quickly. Why can’t my toddlers do that as well? I also don’t like to waste time doing anything…walking up or down the stairs with a 2 year old is the epitome of “wasted” time. “Daddy come? Daddy scoot?”

I have to remind myself that my goal for ultimate efficiency can harm my kids. If I quickly take the task from them, I am taking away an opportunity for them to learn or try something new. If I end up getting angry with them for this, I’ve doubly harmed them. Why would they ever want to try something new?

Be present

This is my biggest one. I have never been the dad who is gone all the time. I am fortunate that I don’t love golf and my job does not require frequent travel, so I’m home a lot. But just because I am home doesn’t mean I’m present.

The draw of Twitter, sporting events on TV and JackThreads is just as strong (and perhaps more dangerous) than golf ever could be. It doesn’t take long for the kids to notice that you’re not paying attention and their efforts to garner that attention will escalate until they get it.

Find a place for your phone that is not disruptive, turn off notifications for non-essential apps, whatever it takes, just be present.

We can all be better parents in one way or another.

I plan to work on being purposeful, patient and present.

What can you do to be a better parent today?

Oh, and if you do want to find something useful to do with your phone, while you are hanging out with your kids ...

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.

This week presented an excellent opportunity for me to return the favor.

Our family chose to cancel our usual family Christmas. Not because the kids were bad and we’re not rewarding them. Not because we were frustrated with how commercialized it has become and are taking a stand. 

Actually, the rest of our extended family all got together and opened presents on the Sunday before Christmas as usual. We just didn’t go this year.

So, why didn’t we participate?

Flu.

Since I have been a practicing pediatrician, I have somehow avoided bringing the flu home. Whether it was luck or blessing or whatever you want to call it, we have been spared, until this year. My two boys have the flu.

So why didn’t we go?

Believe me, skipping the excitement and fun of watching our kids with their cousins is heartbreaking. This is the first year that all of our kids seem to know something is different about this time of year and Christmas at my grandmothers is always one of the highlights.

But, taking a risk with the rest of our family is not worth it and it should not be for you either. If your child is sick, find some other way to celebrate that doesn’t put others at risk. 

Think about those people who are most at risk from complications of the flu: children under 5 years (especially under 2, all the new babies out there), adults over 65 years (grandma and grandpa), pregnant women (your cousin’s first baby) and people with chronic medical conditions. These are just the types of people who it’s hard to stay away from at Christmastime.

We will make the best of today and pray that we are all better come Christmas Day. You should do the same.

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.

I just got back from a vacation at an indoor water park; otherwise known as The Land of Five More Minutes. I could not walk around without hearing some child be told how much more time they had before they had to leave.

It’s no secret that children, especially young children, have a hard time with transitions.

One great way to ease these difficult times is to set them up with a defined period before their current activity is going to stop. Another is to set clear expectations for what is going to come next and your expectations for their behavior and attitude at the time of the transition.

The conversation might go like this: “We have five more minutes, then we are going to change clothes and go eat lunch, all with a happy attitude.”

I’m pretty sure grandparents think we’re crazy for walking around at the mercy of the timers on our phones all the time but it really can work well.

Here are some ways to fail at using your timer:

1. Bargain - Five more minutes turns into one more and one more until everyone is hangry (hungry and angry) and the whole point of the timer is defeated. Besides, think about the culture you are setting up for your child. Your word and your boundaries mean nothing because they know with enough fussing they will get their way.

2. Choose the wrong time - Thirty seconds isn’t enough. Ten minutes is too long. Somewhere in-between is just right.

3. Be inconsistent - If you only do a timer once a week, it is not going to work. Your children need to know what it looks like, how it works and know that you are going to stick with it no matter what.

You may feel like a timer is the most ridiculous thing you could ever imagine (especially if you don’t have kids, because I was a perfect parent before I had kids too). If you think it is silly, that’s fine, it’s just a suggestion.

If you are doing it all wrong, make those changes.

If your kid screams every time they are asked to stop an activity, give it a try, what can it hurt?

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . 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.

Oh, there she is, over there checking out Facebook.

Are you nervous every time her kid climbs up the ladder he might fall down and injure himself?

She’s still playing Candy Crush. Ok, let me rescue her kid from the top of the slide.

There’s new evidence to suggest that there may be some truth to your concern.

A recent study from Yale Economics professor Craig Paulson showed that, from 2005-2012, unintentional injuries in children aged 0-5 increased. He was able to correlate the increase in injuries with the expansion of 3G cellular networks across the country. Many of these injuries occurred during times of parental supervision (not day care or with other caregivers). There was no similar increase in injuries of children aged 6-10.

This trend is the opposite of the overwhelming decrease in unintentional childhood injuries since the 1970s.

While there could be other explanations of this trend, clearly distracted parenting is becoming more of a problem in today’s world.

Here are some things to think about:

1. You will underestimate how long you will be looking at your screen. Even if you look away for one task, that task will take longer than you think and you are likely to get sidetracked by something else.
2. Injuries in children often take mere seconds to develop. There may be no build up from independent play to dangerous predicament in the time it takes to read and respond to a text.

In any situation, you should be aware of how much time you are spending with your smartphone.

I respect that parents have the right to choose what is best for their children regarding their medical care. There are certain situations in medicine where these decisions truly only affect you and your family.

If you choose to turn your child’s car seat around at 6 months, I will argue adamantly that this is not safe and is unreasonable, but if you leave and decide to anyway, it probably will only affect you and your child should something happen.

If you choose that vaccines are not right for you family, I will discuss with you the benefits and risks of vaccines but ultimately, it only affects you and your child, right?

Wrong.

Let me just give you two hypothetical situations:

1. Your unvaccinated 6 year old has fever and a rash, but you have a planned visit with your old high-school friend who lives hours away. No big deal, you say, your child probably just has a virus so you plan to treat with home care, manage his fever and symptoms which would all be very appropriate, generally. Your friend comes for her visit but brings along big news … they’re pregnant. In fact, she’s 12 weeks along and has been waiting for this visit to reveal it to you.

Your friend leaves and the weekend passes … now your child is getting worse so you decide to go on in and you get a preliminary diagnosis of measles.

Fortunately, unlike some of the vaccine-preventable diseases, measles does not appear to cause birth defects. However, there are some risks of increased miscarriage and premature labor. If one of these things occurs, the percentage of moms who have a miscarriage and enter labor prematurely is so high, it would never be clear if the measles was the cause or if it would’ve simply happened anyway. Even if your child doesn’t have the measles after all, you should tell your pregnant friend and everyone will be pretty stressed for the next few days waiting for test results.

2. You travel with your unvaccinated 18-year-old college freshman on a mission trip to Africa during his first Christmas break from college. You have an amazing time there working in an orphanage, a school and volunteering to sit with people in a local hospital.

Everyone comes back to the United States feeling great so you load up your son and take him back to his college dorm to start the next semester. Two days after getting back to school (eight days after getting home from Africa), he develops fever which progresses over the next day to having a stiff neck. He is subsequently hospitalized and diagnosed with meningococcal meningitis. The average incubation period for meningococcal meningitis is four days, but ranges from 2-10 days.

Hopefully, because most of the dorm will be vaccinated against meningitis, your child’s case will be isolated but there’s no guarantee. Consider other children who used a religious exemption or exemption of conscious. Consider those that didn’t have a good response to the vaccine and remain vulnerable. Consider the next two weeks and how stressful it will be for the other students, their families and the school as they wait to see if anyone else develops symptoms of meningitis.

Medical autonomy does give you the right to choose to vaccinate or not; however, we all live in a social context as well. If you choose not to vaccinate, it's important that those around you are aware of your decision.

It's important that you consider that the illnesses your kids could contract could harm others around them. You need to make responsible decisions in accordance with this fact. We should use caution about having our sick children out at any point, but this is specifically important with children who are not vaccinated.

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . 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.

But, is he allergic?

Listing medications as an allergy may not seem like a big deal, but it can have significant consequences:

1. Your doctor may have to choose “stronger” antibiotics that have more risk of side effects.
2. Your doctor may have to choose more expensive antibiotics.
3. Your doctor may have to choose antibiotics that are known to be less effective against your child’s infection.

If a medicine is listed as an allergy for your children, it will carry on with them into adulthood. When they are 30 and having to make big decision about their medical care, many will have no idea why a drug is listed as an allergy for them.

A recent study conducted in adults at the Mayo Clinic in Florida showed that, out of 384 adult patients who listed a penicillin allergy, 94 percent did not actually have an allergy after being tested. I knew it would be pretty high but, WOW!

Even if a child has a true reaction, the authors report that some people “outgrew” their allergic reaction over time. This is true no matter how severe the first reaction was.

Here are some questions to ask yourself and your doctor about possible drug allergies:

1. Was this an allergy or a side effect? There is a big difference.
2. If we are going to list this medicine as an allergy, does this mean to never try it again? Some doctors might recommend retrying an antibiotic later if the reaction was mild or possibly not truly related to the antibiotics. Some reactions are clearly allergic and the medicine should not be used again.
3. Should we have testing done (at some point) if we are unsure?

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.

“Hey bud, how did you get that BAND-AID^®?”

“I just climbed up on this and got it (from the medicine cabinet).”

Those are 2 conversations that happen frequently and just yesterday, respectively, in my house.

A study released this month in Pediatrics (the journal of the American Academy of Pediatrics) looked at out-of-hospital medication errors in patients less than 6 years of age.

There were many questions that the study looked to answer:

How common are medication errors?

Almost 700,000 errors in these children over the 10 year period, that is equal to 1 error every 8 minutes.

Many of these were minor and required no medical care, but there were almost 2,000 children who required intensive care and 25 death due to medication errors.

What type of medications were associated with more errors?

Liquid medications were the most common, accounting for 81.9% of the errors. These kids are more likely to be taking liquid medications so this might be expected but it’s still a good reminder we need to be cautious.

Where do the ingestions occur?

The child’s own home was the location of the ingestions 96.9% of the time.

What errors were the most common?

The 5 most common errors were:

1. Medication accidentally given twice.
2. Confused the units of measure (1  milliliters (mL) vs 1 teaspoon (tsp).
3. Wrong medication taken/given.
4. Medication given too soon.
5. Accidentally was given or took someone else’s medicine.

So what can you do to protect your child?

1. Be aware. These errors are common and we need to be aware.
2. Be cautious with liquid medications. Kids can find and ingest them more easily and dosing errors are more common.
3. Protect your own home. Make sure that medications are locked away in a safe place.
4. Double, triple and quadruple check your dosing. You know the saying measure twice and cut once? For meds it should be measure 5x and give once.
5. Assign a primary medication giver for the house. If anyone else is giving meds, run it through them first.

Were there monsters under the bed? Did he fall of his bike? No, I just asked him to write his name on a paper for his schoolwork.

I actually kind of feel the same way as him most of the time. Why would I want to sit down and write something that will take me 5x as long and be 1/5 as legible? Some educators agree with us. Many schools are adopting policies where handwriting is emphasized only very early on with a quick shift over to proficiency in keyboarding.

However, just because my 4 year old and I want to throw a temper tantrum any time we're asked to write something doesn't mean that forgoing writing is a good strategy.

Dr. Karin James is a scientist with the University of Indiana. She did an experiment where she presents letters to children; some were asked to trace the letters, some asked to write them on a blank page and some were asked to type them. She then shows the children the same letters while they are inside a machine to measure brain activity. Activity levels in brain areas that adults use to read and write were significantly higher in those children who were asked to write a letter vs. tracing or typing.

There have been many other studies that validate this finding and that show other benefits to learning handwriting:

Studies have shown that good writers have higher levels of activation in brain areas associated with cognition and language than poor writers.

Another study showed that note takers tended to do better on testing of the concepts presented if they were taking notes by hand rather than by computer. Computer note takers also tended to copy down the teacher's message word for word rather than shorten or rephrasing in their own terms which could to contribute to their poorer understanding.

So, what does all this mean? I am constantly tempted to go ahead and have my son learn typing. He is very bright and I know he could type much faster than he could write ... maybe this would lead to less frustration (for him and me). But, this might not be the best thing for him in the long run.

Here's some great examples of ways you can get your early elementary school child to keep writing:

1) Thank you notes for gifts, experiences - Nothing makes grandma and grandpa happier than getting a note from their grandchild about their visit.

2) Story prompts - Give them 1 sentence and let them go. Then help them act out the story they have written.

3) Encourage drawing as well - Fine motor skill development through other avenues can also be helpful.

Let's keep our kids writing as long as we can. It is good for their learning and helps protect them from iPhone thumb.

What strategies do you use to keep your kids writing? 

I recognize that there are many different opinions and stories out there. I want to simply be transparent with you about my thoughts as a physician who spends a lot of time communicating with patients via social media and other platforms.

I know with the spread of the infection in the United States there are a lot of concerned people. I think it raises the level of concern for all of us, so I completely understand that. After thinking, I continue to feel strongly that the risk of Ebola spreading to the general population is still extremely low based on the following thoughts:

1. Thomas Eric Duncan was home for 2-3 days with Ebola. There were many contacts during that time; some considered "high" and some considered "low" risk. Even during that time when he was ill, none of these contacts contracted the virus despite some of them undoubtedly providing pretty intimate care for him. At this point he was sick, but apparently not as sick as he became during his time in the hospital.
2. The 2 secondary cases both occurred in nurses who were actively, involved in very close care of Mr. Duncan when he was at his sickest. We know that Ebola is not contagious until people are showing symptoms and we know that they become more contagious as they get sicker.
3. We will have to wait and see as more details come out, but there are many reports that the staff at the hospital were not following the guidelines for infection containment that we know are effective at containing spread, perhaps through no fault of their own. Again, I want to hear the full story on this before I place judgment. These issues tend to be revealed over time.
4. So far, the only diagnosed Ebola cases in the United States have either been people who were in affected areas and now 2 people with known, direct exposure to those people. I believe that if the transmission pattern for Ebola had changed, we would have seen many, many more cases at this point.

Keep these things in mind as you read the information that comes across during the next few days. You should make your own decisions about how to protect your family, but these thoughts are based on the information we have on hand.

Our previous articles on Ebola:

• Ebola in Dallas
• Are you concerned about Ebola?
• 4 reasons not to fear Ebola
• How to talk to your kids about Ebola

Part 2 - Elementary and Middle School

I'd guess the titledidn't fool as many of you as it did in Part 1. I probably would've clicked angrily on the link and went to disprove the fact that homeschooling is for everyone too, but I assume that the rest of you who clicked on today are actually interested in how you can help your child learn. Remember these posts are all about the fact that despite the fact that we delegate a lot of our role of educating our children to the school we choose to send them to, the responsibility of their education still falls on us, the parents.

I thought of two different things to post about. First I considered writing about feeding your child breakfast. Several studies show that doing so will increase their grades and especially their ability to pay attention throughout the morning. So, feed your child breakfast. Moving on.

One of the major predictors of success in school and in the future for our children is our involvement in their school and their education.

The school will do what they can, but they are limited by many factors:

1)   Your child is not the only child in class. Vying for the teacher's attention can be difficult.

2)   Your child may learn faster or slower than the average person in class and adjustments are often difficult.

3)   Schools have limited financial and personnel resources that don't allow for curriculum to be differentiated for each student.

So, how do we compensate for each of the above deficiencies? We get involved. More specifically, we get involved in the right way. A study done at the University of New Hampshire showed that it would take $1,000 per student per year of extra spending for the school  to achieve the same results as parent involvement.

A comprehensive review of parent involvement was released by the National Center for Family and Community Connections with Schools in 2002 called "A New Wave of Evidence." I know it's 10 years old, but it's so comprehensive, I couldn't imagine using anything else.

So, how does parental involvement improve performance?

Here are just a few of the ways (New Wave of Evidence-pg 13):

•      Earn higher grades and test scores, and enroll in higher-level programs.
•      Be promoted, pass their classes, and earn credits.
•      Attend school regularly.
•      Have better social skills, show improved behavior, and adapt well to school.
•      Graduate and go on to postsecondary education.

But, how do you do it right?  As with anything, you can even mess up being involved in your child's school and education if you don't think about what you're doing.

Here's what studies say actually works (New Wave of Evidence-pg 87):

     1) Provide a stimulating literacy and material environment.

     2) High expectations and moderate levels of parent support and supervision.

     3) Monitoring of TV viewing and homework completion.

     4) Joint learning activities at home.

     5) Emphasis on effort rather than ability.

     6) Promoting of independence and self-reliance.

Let's go through each for a little discussion:

1) Provide a stimulating literacy and material environment - Have stuff around that stimulates your child to want to learn. This is simple in all stages of life but you just have to be careful to provide it. Keep books easily accessible in the current reading level and one reading level above your child so that they can explore what’s next. Read in front of them (no child is going to read in the room where you are watching TV). Keep art supplies, building toys and other items easily accessible and limit screen time so that your kids have time to play with them.

2) High expectations and moderate levels of parent support and supervision - Don't hover over their shoulder the whole time they are doing homework but check in frequently to make sure they are on task and don't have questions for you. I usually get my son started on something and then walk away and come back a few minutes later. He gets a lot more done when I'm not standing there and he doesn't rely on me to help him along the way.  My favorite thing to see him do is when I come back and he says, "I had a little trouble with this one so I moved on to the next one till you could help me." “Awesome, bud, let’s do it.”

3) Monitoring of TV viewing and homework completion - Set a rule for the TV and homework completion.  I guess it doesn't have to be, but I would think that having the same rule for all the children in the house would be helpful.  You could choose to have no TV until homework is complete or maybe one show (15-30 minutes) before you start.  Sometimes that break can be a refresher for a kid who is worn out from a long day at school but for other kids is impossible to get them back on task.  You need to decide what works best for your family and stick to the plan.

4) Joint learning activities at home - This is where you get to be creative. You can read my post called: Your Child is Gifted to get more advice on how to do this well.

5) Emphasis on effort rather than ability - You can see my entire post about this: You're So Smart.

6) Promoting of independence and self-reliance  -Remember that your goal is to get your child to be independent and ready to move off and do something else when they finish high school. It's hard to remember to think about it when they are young but giving them opportunities to be independent now when you are still close by is a great way to teach them to make better decisions later.

While we're at it, here are some things you should not do whenever it comes to being involved with your child's education:

1) Don't do their homework or projects for them. It's OK to help them if they are choosing wisely but it's also OK to let them make a bad grade if they are relying on you to do it all for them.

2) Don't ever tell you child's teacher that they are "bored" because the class is to easy. It may be completely true, but after saying it, you have eliminated almost any chance you had of working to get a solution to the problem.  Some other things you could say: How can we challenge him/her? Is there some way we could change x/y?

3) Don't go above your child's teacher to the principal unless you've tried to work with the teacher first. It actually causes a problem for everyone involved. The principal doesn't like it, the teacher doesn't like it and you're unlikely to get the results you desire.

4) Don't reward solely for grades. Everyone handles grades a little differently. Some families dole out huge money for good grades, some none and others everywhere in between. Rewarding for grades alone sets them up to choose easier classes and cut corners (cheat?) to get better grades.

Let’s be involved with our kids’ schools, but do it in the right way. The results could be amazing!

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . 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.