Cook Children's medical staff saw its own cluster of patients in 2016 and has seen sporadic cases since then, as have other hospitals across the nation.

Acute flaccid myelitis (AFM) presents similar to polio in that it causes an abrupt onset of limb weakness an decreased muscle tone, which can have associated problems with urination and, in the worst cases, cause respiratory failure if the muscles involved in the breathing become weak.

“This is a very rare illness and we’re still not sure what causes AFM,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. “It is mostly like caused by a virus or a genetic disorder. At this point, we must treat each child on a case-by-case basis, but the earlier a diagnosis is made, the quicker a plan of action can take place.”

The Centers for Disease Control and Prevention (CDC) says most patients will have a sudden onset of limb weakness and loss of muscle tone and reflexes. Some patients will also experience:

• Facial droop/weakness
• Difficulty moving the eyes
• Drooping eyelids
• Difficulty with swallowing or slurred speech

If you notice any of these symptoms, please notify your doctor immediately. Through thorough testing of the nervous system, doctors will be able to diagnose AFM.

The CDC recommends the following as means of prevention:

• Up to date on all recommended vaccinations, including the poliovirus.
• Protect yourself from mosquito-borne viruses such as West Nile by using mosquito repellent and staying indoors at dusk and dawn.
• Remove standing or stagnant water from properties to minimize the number of mosquitoes in your area.
• Wash hands with soap and water.
• Avoid close contact with sick people.
• Clean surfaces with a disinfectant, especially those that a sick person has touched.

Paralysis

It may surprise you to know that there are more than 100 known varieties of non-polio enteroviruses in the world. All of these different types of enteroviruses can cause confusion and panic.

The non-polio enterovirus strains range from the common cold to meningitis. You may have noticed those strains are non-polio enteroviruses, which means that yes, an example of an enterovirus strain that can cause paralysis is polio.

Approximately 1 in 200 infections with polio will cause paralysis. Other enterovirus strains can cause similar symptoms, but do so much less frequently.

There have been a few reports stating that cases of EVD68 have possibly been associated with paralysis, most notably 10 cases in Colorado, 5 cases in California and now a case identified in Dallas. The most common locations for weakness have been the upper arms and hips.

But much work still needs to be done to decide what role EVD68 played in the paralysis. In a published Morbidity and Mortality Weekly Report last week, only four of the 10 children in Colorado tested positive for EVD68.

Investigation is ongoing to determine if these cases were actually caused by the virus. Those patients affected will be undergoing extensive physical therapy to regain function.

Death

The CDC released a report this week that announced there have been five deaths in which enterovirus D68 has been associated. We currently don't know the details of two of these cases. We do not know where the patients lived, their ages or if they had other medical conditions. These would all be important factors in determining the cause of death. The fourth patient was a 10-year old girl from Rhode Island who tested positive for enterovirus D68, but also for a bacteria in her blood stream called Staphylococcus aureus. Staph aureus infections are known to be dangerous, often progressing rapidly, and are resistant to many antibiotics.

Another case reported today described a boy who after an unexplained death was found to be positive for enterovirus D68. Prior to his death, he showed no signs or symptoms of upper respiratory infection, other than a case of pink eye which was proven not to be connected to EVD68. Because of these complicating factors, it is unclear what role EVD68 played in these deaths.

It is entirely possible that the others had similar stories with multiple infections or that they had other chronic health conditions which put them at risk for complications. At this point, I continue to believe that, in almost all children, enterovirus D68 causes mild runny nose and cough and that our biggest complication is the progression towards wheezing. Again, there are not many details out surrounding the deaths, but we felt it was important to update you on the situation given that we have stated all along that there had been no deaths clinically caused only by enterovirus D68. We will follow along and update you as soon as we know more.

Enterovirus D68 peaks in late summer and early fall so I expect that the number of cases to begin dropping soon (if it is not already on the way down). Other regions that experienced earlier outbreaks have already seen the end…they are doing what we will be doing soon, preparing for flu.

Our previous articles on Enterovirus D68:

• Health alert: What is Enterovirus D68?
• Enterovirus D68: What you need to know?

We’ve spent a lot of time recently talking to you grownups out there about all of these conditions in an effort to inform you, but also hopefully to calm your nerves.

But what about your kids? It’s easy to understand why they would panic, especially if they hear of school-aged children being kept home or other kids simply afraid to go to school in fear of Ebola. And it’s all happening in Dallas, so close to where many of them live.

So, what do you say to them?

A lot of it has to do with their age and how much they can comprehend, according to two of our licensed child psychologists at Cook Children’s.

Joy Crabtree, a licensed psychologist for Cook Children’s Behavioral Health in Southlake, said the most important thing parents can do is be there for their children. If your children come to you with questions about anything scary in the news, reassure them that you love them and are there for them. Tell them the chances of them getting a disease such as the Ebola virus is rare. For example, one of the main symptoms of Ebola is fever yet, reassure your child that unless they or someone in their family has travelled to West Africa, or come in contact with anyone from that region, their fever is no more dangerous than any other time they had a fever. We get fever from a lot of things and recover. Answer the questions they ask you, but don’t go off on tangents that will increase their fear. Make sure you know the facts and check them with a reputable source. Don’t drift into other areas that may cause your children discomfort.

Your older children may not want to talk to you about the issues of the day, try to put up a brave front or be blissfully unaware. You know your children better than anyone. If you feel your children are old enough and/or mature enough, and you feel they have heard about it anyway, you might consider bringing up recent events from the news to get their opinion, and to offer reassurance and support.

“For older children, they may have a few initial questions based on what they’ve heard on the news or from friends at school,” Crabtree said. “Make sure that you are giving them accurate information. Make sure to reassure your child, but also let them know that bad things do happen in life. We have to be careful and cautious, but we also can’t live in fear of the unknown. We have to live life to the fullest. You might also let them know that just like there are people (doctors, nurses, etc.) whose job it is to take care of kids, there are people, such as the public health department, whose job it is to take care of communities. They let us know when there is danger and what to do.

Lisa Elliott, a licensed psychologist and clinic manager at the Cook Children’s Psychology clinic in Denton said to keep younger children, elementary age, away from the news and don’t talk to them about something like Ebola unless they ask you. There’s no need to bring up a fearful topic to children, unless it’s for their own good.

For older children, Elliott said ,“There has to be limits to the news and it has to be age appropriate. The older kids can become fixated on bad news sometimes. Help your older children process what they are hearing and make sense of the news. But at the same time, limit them on the amount of news they are watching or reading about. They don’t need to dwell on the issue.”

As for your kids or yourself, Elliott adds it’s a good idea for the entire family to get away from the news and spend some family time together.

After all, the most important thing is to be there for your children.

Related links:

• Ebola in Dallas
• Are you concerned about Ebola?
• 4 reasons not to fear Ebola
• Enterovirus: What we know now
• The flu season
• Whooping cough makes a comeback
• Breaking news: Chikungunya case confirmed in Tarrant County
• Breaking Tarrant County news: Measles alert

For more information

Cook Children's Behavioral Health services provides a broad range of care that focuses on children from 3 years through 17, and their families. We also have some limited services available for children age 2. As part of family-centered care all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.

Along with vaccinations, hand-washing is one of the most effective ways to prevent flu. Alcohol based hand sanitizers are not effective against enterovirus 68, only good, old fashioned hand-washing.

Hand hygiene is especially important while children are attending school, where nearly every interaction carries the possibility of transmitting viruses.

“Children should wash their hands before and after going to the bathroom, as well as before eating or drinking,” Frank McGehee, M.D., a Cook Children's pediatrician in Fort Worth, said. “They should work the soap into a good lather and scrub for at least 20 seconds—the amount of time it takes to hum ‘Twinkle, Twinkle, Little Star.’ Have them scrub especially well around fingernails and jewelry.”

It’s also a good idea to have children wash their faces frequently during flu season.

Sometimes it's difficult to make your child take the time to wash his or her hands. How do you get your children to wash their hands? We would love to hear from you.

Thus far, we have not seen the outbreak to be as severe as those seen in other regions. In my office, we are continuing to see the usual rise in respiratory illness as would be expected this time of year.

I want to take this opportunity to remind you that the severity of illness with EVD68 varies. Most children will have a common cold with runny nose and cough (most do not even have fever).

All of our Cook Children’s providers from the primary care offices to the hospital are aware of the situation so that we can continue to provide the best care for your children.

Here are some of the questions we have addressed in our previous coverage of this virus.

Does my child with runny nose and cough need to be seen by their doctor?

As with most viral infections, many of the children who get EVD68 will only have a runny nose and cough. There is no specific treatment for the virus and no way to predict who will become more ill once they have it. Because of this, there is no reason to rush in to be seen for mild symptoms. It is likely that the majority of children with these symptoms will get better on their own without treatment.

Watch your child for signs of wheezing or difficulty breathing, which would warrant a visit to your doctor or the emergency room. If you have any other concerns about your child, do not hesitate to contact your pediatrician for advice. Children with asthma need to be monitored especially closely. If your child has asthma, be sure that you have the prescribed nebulizer medication at your house should wheezing develop during the night.

How do we know if a child has EVD68?

Because there is no rapid test for the virus, your doctor or emergency room cannot determine if your child has it. That is why there is no need to be seen if your child’s symptoms are mild. At this point, testing is being recommended only for children hospitalized in an ICU setting.

How do we protect our children from EVD68?

As with all viruses, washing hands and keeping your child away from other sick children are important strategies. An important note: alcohol based hand sanitizers are not effective against EVD68, thus it is important to have your children wash their hands with soap and water before eating and periodically throughout the day.

My quick thoughts:

· Any new and emerging disease can be scary for parents.

· Media coverage increases the level of anxiety.

· Having a name for a virus increases the level of anxiety.

Fortunately, for most people, having information and being prepared help to decrease the anxiety. We see that as our job to you as your children’s hospital.

The good news is that there are many parts of the country that have already seen the peak of the illness and it is on the down swing. We have been able to monitor those outbreaks to be better prepared should we see an increase of cases in our area.

Get to know Justin Smith, M.D.

Justin Smith, M.D., is a pediatrician in Trophy Club  and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. Dr. Smith is an experienced keynote speaker for a variety of topics including pediatric/parenting topics, healthcare social media and physician leadership. If you are interested in having Dr. Smith present to your conference or meeting, please contact him at thedocsmitty@cookchildrens.org.

He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. 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,” open now. Click to learn more. To make an appointment, call 817-347-8100.

Back to school time has brought with it an unexpected and unwelcome virus to much of the United States. Center for Disease Control (CDC) officials are warning health care providers in affected states to be on the lookout for a respiratory illness that starts with symptoms similar to the common cold, but rapidly progresses to wheezing and difficulty breathing. The virus is suspected to be enterovirus D68. Once thought to be rare, we have seen increasing frequency of infection and outbreak in recent years.

The recent outbreak has been noted in several states, 10 of which have requested help from the CDC: Colorado, North Carolina, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma and Kentucky. It is of particular concern because of the number of children whose illness progresses to wheezing and difficulty breathing. Early estimates are that about 15 percent of children who contract the virus may require hospitalization and many have required care in the intensive care unit. As with other respiratory viruses, any child with asthma or other chronic illnesses are more susceptible. The virus has been reported to cause wheezing even in children who do not have asthma.

Enterovirus D68 is spread through contact with others (often via coughing and sneezing), so avoiding people who are sick and washing hands frequently are important steps to prevention. It is important for parents to be aware of the illness and seek medical care should their children develop wheezing.

There are currently no published reports of activity in Texas, but if you have recently traveled to any of the affected states, it is important to be aware and let your pediatrician know if your child develops respiratory symptoms. As always, we will continue to monitor the situation and provide updates when new information is available.