“Children are searching for their own understanding and making sense of the world they live in,” said family therapist Chris J. Gilbert, M.Ed, LPC, CCLS.

Parents may be wondering how to talk to their child and how to best support them. The most important thing is every child is unique and has different needs, Gilbert says.

“You are your children’s best expert,” Gilbert said. “Trust your gut, give yourself some grace if you do or say the wrong thing. The most important thing to remember is that your presence and willingness to listen is ultimately what your child is needing the most.”

Watching the news

Gilbert said to be mindful of what you’re watching on the news and where you’re watching it because children are very receptive to what they hear and see.

“If they do show interest in staying informed, I would say watching the news with them is OK and to give them perspective to what is occurring," he said. 

Gilbert said parents can also watch the news ahead of time, record it and rewatch it with them later. This allows parents to provide highlights and manage how much news they are taking in.

He suggested limiting the access of things that your child sees on social media.

“Parents, be available for questions and allow time for questions,” he said. “Do your best to provide information and know that some of those questions you won’t have answers to. It’s OK to say ‘I don’t know.’ It’s also OK if they are not interested or don’t show interest.”

Validate feelings

Parents, stay calm because children are very receptive to emotional and nonverbal cues.

“When having conversations, always attempt to validate feelings,” Gilbert said. “Feelings of anxiety and sadness are normal. Provide an environment of safety and allow them to share what they are feeling. Reflect what you heard and give them the space to share."

Kids may be seeing images and videos of the refugees fleeing Ukraine and feel sad or uneasy.

“Validate that, say ‘that’s horrific,” Gilbert said. “Allow them to vent and share their own frustrations and reflect that back.” 

No one emotion/feeling is right or wrong, everyone perceives what is going on differently and processes in their own way.

He said adults can’t always put answers to their questions, but it’s important to validate your child’s feelings.

Turn to action

Anxiety and worries about the unknown can be paralyzing. Turn those fears and angst into actions, he said.

“Families can brainstorm together for ways to help,” Gilbert said.

Some ways are:

• Donating to charity
• Writing letters to potential refugees
• Use your faith and pray with your children for the needs of others

All of this allows a sense of ownership, control, predictability and a healthy outlet which is something all kids need and frankly what we all could benefit from.

Parents, take care of yourself

“As for parents, I would recommend on relying on your own support systems as well as community support systems to work through your own fears and uncertainties about current events,” he said. “Allowing yourself these outlets provides you the best opportunity to be the most present and comforting to your own family and children.”

For starters:

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

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

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

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

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

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

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

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

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

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

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

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

Hope this helps!

Hugs,

Dr. Diane

Despite repeated calls from experts to lifeguard your child, 19 children have been rushed to Cook Children's for drownings and four children have died since May 1.

Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s, said parents and caregivers should take important steps to save their children from drowning, including taking CPR lessons.

"Seconds really do matter," Dr. Warmink said. "Quick, efficient CPR performed before EMS arrives has been shown to improve outcomes. Learning CPR should be an important part of any family's safety plan. You want to be prepared in critical situations."

Studies show CPR doubles the victim’s chance of survival. Learning CPR can save a child’s life by restoring breathing and circulation until advance life support can be given by health care providers. Please watch the following video from Steve Muyskens, M.D., medical director of the Cardiac MRI at Cook Children's.

Dr. Warmink describes drowning as the inability to breathe, normally due to submersion in a liquid, usually water. The outcome, including death, of the person who drowned depends on how long she or she is under water.

"Everything is based on getting oxygen to vital organs,” Dr. Warmink said. “The outcomes of drowning and the adverse effects are based on the lack of oxygen. The most effected parts of a drowning victim are the brain, lungs and the kidneys. The one that is most catastrophic and the one that will kill you is the brain.”

The amount of time children spend under the water while drowning usually determines their outcome. The lack of oxygen destroys brain cells and that causes damage to the brain, ranging from short term (forgetful, clumsy …) to severe (can’t walk to vegetative).

Dr. Warmink says there are several variables that shape how severe the brain damage will be, including how long the child was submerged in the water and how quickly he or she received CPR.

Once a child arrives at Cook Children’s Emergency Department, treatment begins that may include oxygen, X-rays, intubation or medication.

“But a lot of what we do is supportive care for the children that come in here,” Dr. Warmink said. “We may have to support their lungs because they have been damaged and they have difficulty breathing. Their kidneys could be damaged, so we will do lab work to see what’s going on there. But our biggest concern is the brain and honestly, there’s not a whole lot we can do. The vast majority of treatment for drowning is supportive. We see what we can do to keep that child alive. That said, the earlier you can intervene, the better. One of the things that helps outcomes is early, good CPR. By the time they get to us, it may be too late.”

Lifeguard Your Child 

It's time to make Texas #1 in drowning prevention. Drowning is the leading cause of accidental death for children ages 1 to 4, and the second leading cause for kids 1-14 in Texas. But with your help, we can change that. Please join us in our drowning prevention effort. Together, we can Lifeguard Your Child around water.

Want to know how you can get involved or create an awareness campaign in your community? Contact Dana Walraven, Safe Kids Tarrant County coordinator at 682-885-1619 or email safe.kids@cookchildrens.org.

More resources for you:

• Cook Children's Upcoming CPR Classes
• Project Adam
• Red Cross CPR Training
• Fort Worth Red Cross Safety Class, Including CPR
• American Heart Association
• Texas Heart CPR Training 
• DFW CPR Training Center
• Texas OnSite CPR
• CPR Training in Fort Worth, Texas
• CPR Training in Denton, Texas
• Drowning prevention page at Cook Children's
• Is your baby ready for swim lessons?

Unfortunately, it can also be a time of tragedy when kids are rushed to Cook Children’s for help.

The daily routine for most kids with type 1 diabetes includes multiple insulin shots, numerous blood sugar checks and analyzing the carbohydrates in every food eaten. Mental focus and motivation are essential and it’s a challenge to maintain the constant effort.

But new technology has the potential to make life easier for these children. The U.S. Food and Drug Administration has approved the first automated insulin delivery device for type 1 diabetes. The device is intended to automatically monitor glucose (sugar) and provide appropriate basal insulin doses in people 14 years of age and older with type 1 diabetes.

The human pancreas naturally supplies a low, continuous rate of insulin, known as basal or background insulin with spurts of insulin released when food is eaten. In patients with type 1 diabetes, the body’s ability to produce insulin is destroyed or severely impaired.

Joel Steelman, M.D., an endocrinologist at Cook Children’s, says this technology is the latest in insulin pump treatment that began to emerge in the 1980s with the promise of more precise insulin dosing and eliminating daily shots.

The old, basic insulin pump has steadily evolved into a smaller, smarter insulin pump. Current progress has allowed the joining of the relative diabetes technology newcomer, the continuous glucose monitor, with an insulin pump – displaying CGM readings on the insulin pump.”

In spite of all these advances in diabetes care technology, there remain two major challenges facing those affected by type 1 diabetes:

1. Daily mental work of diabetes care is not much different in pumping vs. injections.
2. Variability in blood sugars remains even when using a pump and keeping up consistent efforts.

The new diabetes technology holds the promise to shrink these two challenges and help children have more stable blood sugars. The device called a hybrid closed loop system pairs an insulin pump with a continuous glucose monitor (CGM) which has already been done, but contained within the software program of the insulin pump is an “AI co-pilot” that adjusts basal insulin delivery from the pump based on blood sugars detected by CGM.

“We’re getting there,” Dr. Steelman said. “It will only be a matter of time, people are testing devices now, before we achieve an insulin pump device where kids can ‘set and forget it.’”

Dr. Steelman believes the current technology to be a major step in the right direction, but he does see some concerns:

1. More diabetes technology makes a child more visible and obvious to the general population that could result in bullying or discomfort in sharing his or her condition. He said that will be a topic that the pediatrician and the parents will have to address with the patient.
2. It is technology. Computers, smartphones, etc. do break. “We do get lazy and rely on them more than we should sometimes,” Dr. Steelman said. “Kids using the device will need to stay engaged and responsible for their own health. They can’t just rely on the technology.”
3. While a step forward, the hybrid closed loop system still requires counting carbs in food and activating the pump to give boluses of insulin. Also, blood sugar finger prick tests must still be done.
4. According to Dr. Steelman, the equipment is expensive and physicians will have to work closely with insurance companies to find out what is covered for children and be aware of age restrictions.

Once he addresses these issues with the patient family, Dr. Steelman anticipates the Cook Children’s diabetes team will discuss the new technology with interested teens who have demonstrated good basic understanding and practice in their diabetes self-care. He said the staff and patients will need some additional training on the specifics of the technology, but looks forward to the possibilities.

“We already speak with parents about insulin pumps and technology in diabetes care. We have a formal process that we follow on insulin pumps,” Dr. Steelman said. “This technology has the capacity to further improve diabetes control and chip away at the pesky unpredictability in care. I’m especially excited about the positive impact of reducing nighttime low blood sugars.”

About the source

Dr. Joel Steelman grew up a military brat, on the move every three to four years, to a new home, in a different state. Nevertheless, his family roots remained in Texas, where he finished high school and developed a love for writing, working on the school newspaper and yearbook. He attended Texas A&M University both for his undergraduate and medical degrees.

He trained in endocrinology at the University of Colorado Children’s Hospital in Denver. During his tenure in Colorado, where he met his future wife, Dr. Steelman trained at the internationally renowned Barbara Davis Diabetes Center, one of the world’s largest and most esteemed diabetes medical facilities for adults and children, specializing in type 1 diabetes research. Along the way, he discovered another strong research interest in the area of bone disorders, and Dr. Steelman began to treat children with osteogenesis imperfecta, or brittle bone disease-- a rare, crippling malady. After completing his training, Dr. Steelman left the West to enter academic medicine at Vanderbilt Children’s hospital in Nashville, Tennessee. Over the next seven years he focused on research projects and medical education.

The birth of his daughter, in 2005, and the desire to be closer to family, brought Dr. Steelman back home to Texas, and to Cook Children's. Today, he provides endocrine care for children living in the Dallas/Fort Worth metro area, as well as Denton and West Texas. He expanded his practice, after arriving atCook Children's, to include the care of childhood cancer survivors, collaborating with the neuro-oncology program and Life After Cancer programs.

An early advocate for distraction osteogenesis in the facial skeleton, he helped to develop one of the first multi-planner devices used for lengthening the mandible in children. After a brief surgery, the device is used to slowly lengthen bones that are congenitally too small. Over the course of two weeks, daily adjustments actively stretch the native structures so that new bone and soft tissue can be created as the surgeon works to restore facial balance and harmony.

Dr. Hubli has crisscrossed the globe in the name of craniofacial and cleft care, operating and educating from Brazil to Romania and from Finland to Saudi Arabia. He has been asked to speak on the topics of quality in medicine, craniofacial and cleft care and enhancing patient satisfaction at sites, including Harvard University and the Mayo Clinic. His work has been featured on the Oprah Winfrey Show and in Parade Magazine.

But Dr. Hubli is known for more than his skill as a surgeon. It’s the approach to the way he cares for “his kids” that makes him special.

“When I meet new families I like to joke with the moms and dads and tell them, ‘Now, these are my kids too,’” Dr. Hubli said. “I have two wonderful kids of my own. These are my extra kids, my extended family if you will. When I offer advice to parents or make medical or surgical decisions for my patients, I make the same decisions based on what I would do for my own child and trust me … I love my children dearly.”

Dr. Hubli has two children – Alexander, 17, and Sidney, 12, -- and has been married to Joni for 26 years.

It was Dr. Hubli’s brain that Joni says first attracted her to him. No so much his intelligence that would make him a world-class craniofacial surgeon, but his sense of humor.

“He likes to make everybody laugh,” she said. “He’s always been that way. I liked him the first time I met him. He had a great sense of humor. It helps him as a doctor, especially treating children and talking to parents. He has a way of lightening up a situation and that helps them to feel good.”

Dr. Hubli has a unique reason as to why he relates well to his patients – he was once in their shoes. As a child, Dr. Hubli spent many hours in a hospital while he was a youngster in Connecticut. He suffered from complications due to allergy induced asthma.

Things were different back then. Parents were only allowed to visit for a couple of hours a day and there were no parental overnight stays. A week-long stay in a cold-multi-bed pediatric hospital ward left a lasting impression on a 5-year old mind. The facilities were grim, but Dr. Hubli found that the caregivers, the doctor and staff could be rays of sunshine when times were trying. Joni believes that’s what led him into a career as a physician.

And what made him work with kids? More than anything else, Dr. Hubli simply wants to repair a child’s face so he or she can smile. After all, smiles and laughs are so important to the self-professed clown.

Watch him walk down the halls of the medical center and you’ll see him stop and joke with almost anyone he sees, especially the children. Maybe, it’s because he identifies with their sense of humor.

“Pediatrics is a perfect fit for Eric because he can still see the lighter side of life,” Joni said. “Like a kid, he looks to have fun in everything he does and that makes him fun to be around. He has a saying, ‘I have to grow old, but I don’t have to grow up.’ He’s a great doctor and very skilled, but he is not afraid to let his silly side out. We were talking at lunch the other day and he said, ‘Our 12-year old daughter is more grown up than I am.’”

But make no mistake; Dr. Hubli takes his career and the kids he cares for seriously. For him craniofacial and cleft surgery is not just a job, it’s a vocation. Joni will tell you that “he takes his work home. He still studies, he still reviews, he challenges himself to be better every case and we see the distracted dad at home sometimes because he’s thinking about a patient.”

His dedication is energized by the strength of his patients and their families whom he calls “an essay in courage.” Dr. Hubli thought of becoming a priest as a teenager, but felt a stronger calling to becoming a physician. Either way, healing was the goal.

“Would that all of us have the same grace as these kids do! I don’t know if I would,” Dr. Hubli said. “But wow, these kids are cool. If you don’t believe in God, take a look at the kid next to you. It’s a miracle. It’s beyond my comprehension. You can talk to me about DNA and all the wonders of science, but how did these little strands make all of that? I have the degrees. I’ve taken genetics. I’m an educated person. But I say, ‘That it’s still a miracle.’”

Dr. Hubli’s surgical work on children varies. At times, he may be preventing a speech impediment that will stop a lifetime of being made fun or getting bullied. At other times, it’s a matter of performing a surgery that saves a child’s life by giving him or her opportunity to eat or breathe properly.

“Each case is unique because each child is unique. It’s not because of what they look like or why I’m seeing them, but because of who they are,” Dr. Hubli said. “Regardless of the child, the surgical goal is always the same. If I’m successful, their life truly becomes their own to mold and make. Their potential and their future are in their own hands.”

And many times, he’s performing that surgery with Richard Roberts, M.D., a neurosurgeon at Cook Children’s.

“I love working with Eric. We have a great friendship and work well together,” Dr. Roberts said. “The days that we have surgery together are among my most enjoyable. He is a funny guy and great entertainment, but when we step in the operating room it becomes all business. We share a common goal of trying to do the best for the children and we both carry that attitude through surgery until we’re finished.”

So you have two sides of Eric Hubli. The funny guy with hyperactivity issues (his word) … and the other guy, who happens to be a brilliant surgeon.

“I love having fun. In general, I think we all take ourselves too seriously,” Dr. Hubli said. “Don’t get me wrong. This work is not a game and I’m wholly committed to what I do. I work hard and I take my job very seriously. That said, there is healing in humor. I want what’s best for the children I care for, but that’s the thing, they are children and we are a children’s hospital. We should have fun so that our kids, our patients, can have fun even when what we do is some of the most serious and important work that you will ever find.”

Here are four reasons I don't recommend putting a breastfed newborn on a feeding schedule:

1. They need comfort and bonding. Imagine being thrown into a brand new, anxiety-provoking environment with no skills for calming yourself and no way of escape. Plus, the person who can give you comfort is right there. Sure, you can cuddle them to help, but sometimes they just need to nurse.
2. They are hungry. I can't wait three hours to eat. I'm pretty sure if I could only eat 1-2 ounces of a liquid meal, I'd be starving before three hours came up again as well.
3. Scheduling can hurt your milk supply. Frequent feeds help your milk come in. I've seen too many babies who've been on a rigid schedule come in at 1 week with lower weight gain. Then we are scrambling to get mom's milk supply up so that they can maintain breastfeeding.
4. They will find their own schedule. Implementing a rigid schedule out of the nursery is not necessary. By paying attention, you can discover an ideal schedule for you and your child and help them keep to that without having a rigid schedule.

So I got home the other day from a LOOOOOOONGday at work. You know what I’m talking about …It was a Monday (few things go right on a Monday), the beginning of the work week. And my son was off his schedule from a long three-day weekend because his grandparents spoil him.

All my wife and I want to do is get home and lay on the couch. WAIT! I can’t because we have a 2 year old who just wants a little attention. All he wants to do is … eat a snack, wrestle, play the tickle game, go outside, go on a bike-ride, kick the ball, throw the ball, go see the ducks, eat another snack, watch a movie, run up and down the stairs, go on another bike-ride, play hide-n-go seek and wrestle some more. No big deal, we can do this. To think, it’s only MONDAY!! Oh, and someone has to make dinner.

As hectic as that sounds, and believe me it is, it’s worth the time we spend with him. It would be so easy to put an iPad in front of him or even just sit him in front of the TV for a few hours until bedtime. Remember all those activities that my son wants to do? Think about each one and consider the number of vocabulary words and the amount of rich language I would be able to provide him in each of those activities.

It really is endless.

The only way a child will learn words is by hearing words. Wouldn’t it be awesome if we just had a magic wand and anytime we wanted our children to learn a new word, all we had to do was wave it at them, “Abracadaba!” Wave the wand with me two times. My child needs another word, I’m thinking of an animal, so he will say, ‘BIRD”!” There it is, BOOM!! He just improved his vocabulary. That just isn’t the way life works. Believe me, if it was that easy, I wouldn’t have a job as an SLP. The models that my wife and I provide my son Dominic has influenced his language and now he says things like “Where is it?” because we play hide-n-seek. He says “Let’s go!” because he wants to go on a bike-ride.

I recently went to a course where the presenter said that about 90 percent of what young children learn is through play. When you look back, isn’t that what a child’s life should look like? Sleep, play, eat, play, poop and some more play. Their lives revolve around play. At one point, I thought that in order for a child to play, they had to be in a soccer or basketball league, a club or camp, etc. That isn’t true! Play can be anything you make it and you can even play during activities that you are already more than likely doing at home.

1.Bathtime - Get some toys and make them swim, splash, dry them, make them jump.

2. Ball - You can kick, throw, catch, run with it

3. Hide-n-seek- Hide a favorite toy under, on top, in various objects

4. Super Hero Game - use action words(verbs). You can run, jump, roll, throw, etc. Caregivers can even carry their child and make them fly or vice-versa.

These are only a few activities. The best thing to do is go through your day and reflect back on a time or multiple times where you are already interacting with your child doing daily activities. Now think of how you can make the activity into a play activity. Just have FUN!!

Stephen Baker said it best when he said “Of all the toys available, none is better designed than the owner himself. A large multipurpose plaything, its parts can be made to move in almost any direction.It comes completely assembled, and it makes a sound when you jump on it.” We don’t have to buy things to play with our children. All they need is US.

About the author

Jonathan Suarez is a speech pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. 

“What have you been up to this summer? Did you play outside at all or has it been all video games?”

“Pretty much video games.”

“Oh cool, what kind of games do you like? Sports?”

“No, stuff like Call of Duty and Grand Theft Auto.”

It would be one thing if I was having this conversation with a teenager (still not ideal) but this CHILD was 7 years old.

Twenty years ago, considering TV alone, a study estimated that children see 8,000 murders and 100,000 acts of violence before middle school. With the TV, movies, social media and video games available today, there is no telling what that number would equal.

Studies are clear that exposure to virtual violence increases aggressive behavior and thoughts. Yet, the means by which children can be exposed to virtual violence seem to increase exponentially every year. A recent statement from the American Academy of Pediatrics encouraged pediatricians to talk with families about virtual violence and to provide guidance for how to address virtual violence in well-child visits. I read through it and, frankly, was tempted to throw it out with some of the other policy statements, etc. that I don’t think apply to me. Here are four reasons why I NEARLY ignored the new virtual violence policy statement:

1. I have too much to do in a checkup as it is. It’s true that there are a lot of things to cover in a checkup and it’s possible that I won’t get to the topic of virtual violence every time, but when I can I should.

2. Kids are dealing with real-life violence. I work in a clinic where tragically, for some kids, being exposed to virtual violence might be a good day for them. Again, we need to provide the best possible pediatric care for the patient in front of us. If a child needs to be physically safe that should take priority but if, for another, virtual violence is their biggest risk, we should address that as well.

3. Kids have started with violent media before I even get a chance. See conversation above. This may be a real concern, but it means that I should start the conversation earlier, not ignore it all together.

4. Parents who let their kids be exposed probably don’t care about what I have to say about it. It’s possible that one parent is concerned and the other not. Perhaps my information and support might be enough to cut down on or eliminate virtual violence exposure.

I’ve always had casual conversation about media with my patients. Despite my reluctance to focus on this, I think it’s an important piece of information for parents to consider for their children. Here are some tips that you can use to help decrease you child’s exposure to virtual violence:

1. Start early engagement with your child about screen time and habits. If you let your child watch unlimited screen time as a one year old, imposing strict restrictions on anything related to screens later only gets harder.

2. Co-watch almost everything with your child. I get it. I’m a parent and I’m tired of watching kid shows. I’d rather be on Twitter. But if there’s anything new or potentially risky, I watch it or play it with my kids.

3. Don't let your child play first person shooter games or any game where the goal is violence or killing. They don't have the ability to separate real vs. virtual violence and their growing and developing brains cannot handle that level of exposure.

The 19 year old’s defeat of Efimova was not only a matter of national pride, but serves a teaching moment for children everywhere about doing things the right way. Efimova had served a 16-month suspension for doping from late 2013 to early 2015. Russia has been under heavy scrutiny since its track and field team was banned following a state-sponsored doping program.

“It’s incredible, just winning a gold medal, and knowing I did it clean,” King said after her victory.

Joel Steelman, M.D., an endocrinologist at Cook Children’s, hopes young people watched and listened to King.

A survey in 2014 by the Partnership for Drug-Free Kids found that 11 percent of teens in grades 9-12 reported “ever having used” synthetic human growth hormone without a prescription.

The U.S. Department of Health’s Youth Risk Behavior Survey, published in 2012, stated that about 3.2 percent or 640,000 high school athletes, both boys and girls, had tried steroids at least once.

Dr. Steelman said what has happened to the Russian Olympic team is a perfect example of why kids use performance enhancing drugs (PED). They want a competitive edge in sports, hoping they can be a star athlete and make it to college or pros.

Another reason for taking PEDs is the body image factor. A kid may be looking for a shortcut to achieve that idealized body – more muscular or lean.

Dr. Steelman said symptoms of PED use may be subtle, but there are signs:

• The body change is the most obvious one – a more muscular appearance.
• A growth spurt in height may occur in younger kids as natural androgens produced by the body in puberty lead to a growth spurt.
• Dramatic slowing in height gain occurs later, post puberty, because one of the effects of these drugs is closing the growth plates more rapidly.
• Acne and other skin changes in both boys and girls.
• Facial and other body hair may occur for both boys and girls.
• Mood changes – anger, moody, etc.

Dr. Steelman said parents should be looking for these red flags, especially changes in temper and behavior. He also advises parents to watch for obsessiveness about sports, competition and body image.

When talking to your children, Dr. Steelman suggests reminding them that performance enhancing drugs are illegal and can cause serious damage to their health. Steroids and other PEDs are harmful to the body both in the short term but also longer term risk:

• Growth stunting
• Impacts on fertility
• Risk for liver disease/tumors
• Increased blood clotting/stroke risk

“The achievement of athletes like Lilly King is a great example to young people,” Dr. Steelman said. “I hope parents take this opportunity to talk with their kids. They should know that they can still achieve their goals by doing things the right way.”

Photos from USA Swimming. 

About the author

Joel Steelman, M.D., is an endocrinologist at the Cook Children's Endocrine and Diabetes program, which treats infants, children and teens with conditions that are caused by or affect the hormonal balance of the body. We understand the importance of working together and that's how we approach the care of our children.

Fort Worth ISD tested nearly 1,500 samples of water across 116 campuses. Thus far, results have shown elevated levels of lead from 28 schools, most of which were tied to problematic water fountains (generally 1-2 per school).

The ISD has taken those water fountains out and flushing the water lines have already resulted in decreased lead levels to below the recommended EPA action levels in those affected schools.

Recent news about lead exposure in Flint, Mich. has appropriately heightened awareness about lead. However, it’s important to note that this situation is very different. In Flint, the central water was the source of lead, which caused prolonged exposure and significantly increased the risk of toxicity. Because the number of elevated sites of lead at each Fort Worth ISD campus was low, the likelihood of a buildup of lead over time is highly unlikely.

While the attention right now is on schools, the primary source of lead exposure in the United States is not from water, but more often is from lead dust and soil from deteriorated lead-based paint homes built before 1978.

Children at the highest risk for increased blood levels from water are infants and children under 6 years of age. The risk to an individual school aged child is considered low because they would have to drink water repeatedly from a contaminated drinking fountain over an extended period of time to achieve a clinically significant blood level.

Lead toxicity in children results from exposure to lead over a long period of time. Symptoms of lead intoxication (high blood lead levels) might include:

• Vomiting
• Anorexia
• Abdominal pain
• Irritability
• Lethargy
• Headaches
• Convulsions

While it’s easy for me to tell parents the risk of toxicity in the students of Fort Worth ISD is low, I understand you might be concerned about your young student. If you have concerns about your child, it’s important to talk to your pediatrician.

About the author

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

The physicians, nurse practitioners, and staff at Cook Children's Willow Park Pediatrics have all fully vaccinated their children. Every single child. Every single vaccine.

August is National Immunization Awareness Month.

Vaccines save lives. It is a thankless accomplishment.. We can't know the good they have done, as they are arguably the greatest preventative invention in the history of modern medicine.

The vaccines you've received may have saved your life. You will never know. Think about that - a shot you got on a random day, in a random year of your life, may be the reason you're still alive.

We've watched children die of vaccine-preventable illness. We've watched parents cope with the horrific loss of a child, knowing that what happened was preventable. We never want you or your children to go through that.

Let's learn about them. Tune in this month as we teach about the diseases we vaccinate against. Sometimes knowing the other side helps us remember why they're so important.

‪#‎savinglivessilently‬

Hugs,Dr. Diane

Last year, 24 kids died in the U.S. and from 1998 to present, 676 children have died.

“What’s heartbreaking is that this is a serious public health issue that is totally preventable,” said Dana Walraven, Community Health Outreach manager at Cook Children’s and Safe Kids Tarrant County Coordinator. “Every mom and dad out there must realize it can happen to you. Texas leads the nation in child heat-related car deaths.”

Parents may mistakenly think they can safely leave a child in a vehicle for a “quick” errand, but that’s simply not true. Temperatures inside the car can be 20 or more degrees hotter than the temperature outside, rising to dangerous levels in minutes. Unfortunately, it only takes a few minutes for tragedy to occur.

Safe Kids Worldwide says that heatstroke is the leading cause of non-crash, vehicle-related deaths for children.

“Heat is much more dangerous to children than it is to adults,” Walraven said. “When left in a hot vehicle, a young child’s core body temperature may increase 3 to 5 times faster than that of an adult. This could cause permanent injury or death.”

Heatstroke, or hyperthermia, occurs when the body isn’t able to cool itself quickly enough and the body temperature rises to dangerous levels.

Safe Kids recommend the “ACT” method to prevent tragedy to your child or to a child you see left in a car:

• A: Avoid heatstroke-related injury and death by never leaving your child alone in a car, not even for a minute. And make sure to keep your car locked when you’re not in it so kids don’t get in on their own.
• C: Create reminders by putting something in the back of your car next to your child such as a briefcase, a purse or a cell phone that is needed at your final destination. This is especially important if you’re not following your normal routine.
• T: Take action. If you see a child alone in a car, call 911. Emergency personnel want you to call. They are trained to respond to these situations. One call could save a life.

It’s difficult to think that as parents, we could “forget” our children, but it happens each year with no exception to socioeconomic or education level. Often times, a change in routine, a distraction along the way, or the event a child falls quietly asleep, unseen, in the back seat, allows for a parent/caregiver to “forget” and leave a child in the car.

Here are some important tips to help prevent unintentional injury to your child:

1. Dial 911 if you see an unattended child in a car. Sometimes, people don’t want to get involved or just assume the parents are on the way out. But as you read earlier, it doesn’t take long for a child to die in a hot car. If you see a child or children alone in a car without an adult, call 911 immediately.
2. Never leave your child alone in a vehicle, even for 1 minute. Windows left slightly open will not affect rising temperatures in the car.
3. Set safe habits: leave a cell phone, purse, briefcase, etc. in the back seat before driving, forcing you to always check the back seat and see a child is/is not back there.
4. Program your cell phone and/or computer to remind you to drop off your child each day.
5. Have a plan with your daycare provider to contact you within a few minutes of being late or absent. Let your daycare know that you want them to call you if you are late or you have not called in saying your child will not be in that day.
6. Teach children not to play in any vehicle.
7. Lock all car doors, even at home.
8. If a child goes missing, always check the cars and trunks.

Learn more by clicking here. Also, visit noheatstroke.org for the latest on heatstroke deaths of children in vehicles.

For more information

Every year children are rushed to the emergency room to be treated for car related injuries, many don't even involve traffic or another car. Some injuries occur without the car ever leaving the driveway. Click here for some of the top dangers to be aware of and the key things you can do to help make your car safer for your kids.

A new study suggests you might want to relax about letting your kids suck their thumbs and bite their nails. The study participants compared children with either or both of these “bad” oral habits with those who did not. The subjects underwent skin allergy testing at age 13 and 32. Those who had one of the habits showed decreased skin sensitivity relative to those who did not (38 percent vs 49 percent). Those who both sucked their thumb and bit their nails showed sensitivity rates of 31 percent. An important note is that the study did not find a difference between the two groups for the development of hay fever or asthma.

This falls in line with similar studies that having a dog early or parents who cleaned your pacifier with their mouth also might have the same effect of decreasing sensitivity on allergy testing.

There are many who believe that exposure to more microbial organisms early on might help children develop tolerance and decrease their risk of allergic diseases later on (this is known as the hygiene hypothesis). This study would support that thought and would suggest that our obsession with sterilizing and purifying everything might be creating problems with allergic diseases later in life.

The lack of association with asthma and hay fever suggests that we should use caution as we consider the results of this study. Further research is necessary to determine if the decreased skin sensitivity will actually produce a better clinical outcome with less allergic disease. For now, let’s just let all our parents with thumb suckers and nail biters have a reason to celebrate for a bit.

That’s how I remembered this:

Blood, frogs, lice, flies, disease, boils, hail, locusts, darkness, death.

You might ask, why was I learning the order of the plagues? Obviously, for a bible quiz game we used to play in Sunday school. Because I’m ultra-competitive, even when it comes to Sunday school.

The recent weather in North Texas has many questioning if we are witnessing plagues or if the Apocalypse is upon us.

Fortunately, it looks like the worst of the drenching rain (and hopefully the flooding as well) are behind us. As the waters recede, the rising threat will be mosquitoes and mosquito borne illness.

What’s the big deal with standing water?

Standing water is the breeding ground for mosquitoes. There are four stages of life for mosquitoes. The adult flying stage is the only one that does not rely upon water for survival. The eggs, larva and pupal stages must live in standing water.

Any standing water - water in a bird bath, pond or standing water from improper drainage can be a place for mosquitoes to breed.

Why do mosquitoes bite?

Female mosquitoes bite because they need a source of protein before they can produce eggs. Otherwise, like males, they can feed on nectar or sap.

When females bite, their long mouthpart breaks through the skin and gets into the small blood vessels just underneath. They also inject a small amount of saliva into the wound to make entry easier and to keep the blood from clotting.

What harm do bites cause our children?

Local reaction - While not technically an allergy, some kids will have a large local reaction with swelling and redness at the site of mosquito bites. These can be itchy and cause distraction in school or lack of sleep when severe.

Local infection – It’s not uncommon to see local infection in kids who have scratched mosquito bites, leaving a gap in skin, which can lead to infection. If the swelling worsens after the first few days or if there is significant warmth from the site of the bites, you should see your pediatrician to see if antibiotics are necessary.

General infection - Because mosquitoes can carry diseases, bites from mosquitoes can transmit infection that can affect the entire body. Mosquito borne illnesses cause over one million deaths world wide, most commonly from malaria. Two other diseases that we have seen in Texas associated with mosquitos are West Nile Virus and Chikungunya.

Given the amount of rain and the season, mosquitoes will be inevitable this summer season. Read more here about the many different ways you can reduce your child’s risk of discomfort and serious illness: How to fight (and) win against mosquitoes.

At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

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

Here are some frequently asked questions:

1. Do kids even get STDs?

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

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

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

3. How serious are STDs?

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

4. Are all STDs treatable?

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

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

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

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

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

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

You don’t expect tragedy and you certainly don’t expect that tragedy to occur as a result of negligence by your child care provider.

Unfortunately, for Katie Mulkey of Reynoldsburg, Ohio, this is exactly what happened. On May 13, she dropped her son Haddix off at the babysitter’s house where his unlicensed childcare provider allegedly gave him two tablets (an adult dose) of Benadryl to help him sleep because he was fussy. When the babysitter went to the back room to check on him later, he wasn’t breathing.

Of course, the family is devastated but they have taken the opportunity to educate and advocate against the use of medications to help babies sleep.

Here are the lessons to learn:

1. Medications have indications for use and they should be used for those reasons and those reasons only. Benadryl works fine for allergies and even for itching. Benadryl is not a baby sedative, period. The promotion of its use for sleep in babies is irresponsible and dangerous.
2. Medications have dosing for children. The difference between the effective dose and the fatally toxic dose is not always as big as you think. Kids are harmed and die from overdoses of just about every over the counter medicine you can imagine. Know the dose and use the appropriate one.
3. Medications come with a dosing cup. Use the cup or syringe to measure out your child’s medications. Using a teaspoon from home doesn’t work because they will likely under or overdose your child.

Use of medications is a huge responsibility.

Giving medicine to your child should only be done by you or by your explicit instruction. They should be given for the right reasons at the right doses.

There, I said it.

Those of you who insist that every child can do so, comment away.

Those of you who tried and started a knock-down-drag-out weekend of fighting in your house, only to quit and come back to it later with a different strategy that was much more successful, you may stand up and applaud.

The three-day potty training method has several different flavors but all of them involve some of the following ingredients:

• Draw a hard line in the sand - no more diapers.
• Let the child go naked for the weekend (or longer).
• Give the child lots of fluids and salty snacks (I’ve seen some recommend soda. I mean, just … NO!)
• Put the child on the potty frequently.
• Celebrate successful pees and poops.

I know that these methods work some of the time, with some kids. The posts about the strategy wouldn’t be so popular if they didn’t. Problem is, I don’t hear much about it when it works. But, I do hear about it when it becomes a disaster. I hear about it when everyone is in tears and tensions are through the roof.

Any of you with more than one child can confirm that kids are different. They do things on their own time and in their own way. Potty training is the same way. To assume that every child can potty train by age 3 and in three days is unfair. Each child may need a different strategy.

Here is my potty training guide:

Readiness

I usually give two signs for potty training readiness:

1.Knowledge of wet and dirty. If a child doesn’t understand what pee and poop is, good luck.

2.Ability to sit still on the toilet. Unless you want to be forcing your child to sit down on the seat every time, they have to be patient enough to wait for the action to happen.

But guess who ultimately decides when your child (and you) are ready to potty train? You and your child! Not grandma, nor your judgy friend or the blog post they shared. So, take your time if you want or go ahead, it’s up to you.

Method

I only have one rule when it comes to your method for potty training. Be patient!

Be patient with your child. Some kids have legitimate fear about the part of their body that they are flushing down the drain. It can be the same to them as flushing an arm. Some kids will get it right away, some won’t. Give them the chance to fail without punishment.

Also, be patient with yourself. You will get frustrated at some point during the process. Pick some fun things to do with your child and alone to recharge. It’s OK if it doesn’t go perfectly.

Pick a method that you think fits well with your child and stick with it for a bit. Don’t change after one day. But, it’s also ok to step back and make a change after a bit if things are going well. It’s even ok to decide that you tried to early and wait to start again in a few months.

Potty training is a necessary step in development. It might not be as fun as the first word or first step but it is just as monumental. So maybe it’s not always a “happy” time but at least it can lead to joy. Don’t let unreasonable expectations steal that.

She is a sweet and happy baby who loves to babble ("mamama"... be still my heart!), pick up small toys and explore them slowly, play peek-a-boo, pick up her tiny foods with two fingers, point, laugh, and clap.

Things she cannot do? Crawl with her belly off the floor. Pull up to stand, or really put much weight on her legs at all. Shift from sitting to crawling to sitting again. Cruise along the furniture while holding onto it. She has delays in what we call “gross motor development” – the development of the “big movements.”

I see patients all the time at our Willow Park office that have gross motor delays, so I know not to worry. Lots of things can contribute to this. Sometimes it's just genetics. Sometimes it’s the baby's weight-to-height ratio. I notice that leaner, smaller kids tend to develop these movements faster, and bigger, longer kids sometimes need more time to build the strength to try these things. As you can see from the pictures, Abby has not missed any meals. There are exceptions to every rule of course, but I think this plays a role.

The baby’s temperament can also lead to delays. Some kids want to go go go...and some are completely fine with sitting still and working with what is in a close vicinity. Abby certainly fits into this latter scenario.

Of course there are numerous medical conditions that can cause motor delays. Always make sure, if your child has delays, to ask your pediatrician for a good neurological exam to check things like muscle tone.

Unfortunately, I believe what has played a big role in Abby’s delay is the amount of time she has spent in her favorite jumpers.

Baby jumpers, bouncers, exersaucers, and activity centers (they’re all basically the same thing) are stationary devices that allow a child to “stand” and bounce prior to developing those skills naturally. Kids love them because they’re fun and stimulating – most have toys and games attached – and they get to see more of the room and things going on around them, along with getting a chance to bounce up and down easily. Parents love them, because, let’s face it – they’re a quick and safe option for a break.

Baby walkers are similar – except they are on wheels so babies can bounce/pull themselves around the house. I have never owned one of these because they come with safety risks – children can fall down stairs, tip over, touch a hot stove, get pushed by siblings, pinch fingers, and slam into walls in these devices, and as fun as they seem, they’re not a good idea.

Around 4-5 months we started putting Abby in a jumper and she was thrilled! Finally she could be propped up and see everyone! She could control her body enough to bounce, and loved it. We were happy too, because we were constantly chasing her 2-year-old brother around, and it was nice to have a safe place to plop her down while that happened. Admittedly, it became a habit. When we’d read books, Abby would be propped up to be able to see the pictures. When we’d sing songs and play music with her big brother…Abby would get to howl and jump along in the bouncer. When we had to deal with the 2-year-old tantrums (and boy are those frequent)…in she went. Emptying groceries? Bouncer. Going to bathroom? Bouncer. Cooking dinner? Boom. Folding laundry? Ker-splat. She was probably in them a total of an hour to an hour and a half a day.

Looking back, she was in the bouncer way too much. Learn from my mistake, friends. Yes, pediatricians make mistakes.

Other doctors may think these things are harmless, but I respectfully disagree. Especially since I suspect my own child has likely been affected. Physical therapists have been warning parents for years about the problems with bouncers. And the more I’ve researched it, the more I’ve realized that too much time in these things can be detrimental to a child’s development.

I spoke with Gail Abaray, a pediatric physical therapist in Weatherford, who told me, "Bouncers don't allow infants to explore and move. They are limited in what they can do, and are stationary. And that pull to explore is so important. When they cruise the furniture, they learn about lateral movement, and how to turn their legs and feet. In a stationary bouncer, all of that coordination can't happen."

Look at the picture of Abby in her favorite bouncer. See how she’s on her tiptoes? This is typical and leads to the majority of the strength being recruited from her calves and thighs. What is not getting a workout is her hip, gluteal, pelvic and core muscles – and these are the ones that help children crawl and eventually walk.

Their hips are spread unnaturally wide by a piece of stiff fabric. They often lock their knees, especially the younger babies.

Babies cannot see their feet or the ground in these devices either – and thus cannot coordinate their body well in them.

Their upper bodies are also thrust forward – taking all the pressure/weight off their gluteal and hip muscles. The very muscles they need to strengthen.

The same things happen in walkers – babies are pulling themselves along while most of their weight is supported, and this works out and coordinates all the wrong muscles. They also can’t see the ground or their feet. “Walkers” are a true oxymoron here – they lead to delays in walking naturally.

So what do I recommend to parents now? Well…go buy a bouncer! They’re great! But – use them in moderation. Don’t put one in every room, like I did – it’ll only lead you to use them more. Use it only for very short periods of time – maybe 15 minutes here and there, once or twice a day – 20 or 30 minutes a day, max! Physical therapist Gail agrees: "I always tell parents not to feel guilty for using them. I did! But moderation is key!"

And avoid walkers in general. I am not convinced they’re safe or worth the money.

Don't feel guilty if you've put your baby in a bouncer - we all need breaks. And it's hard to deny they're so happy in them! But remember the big picture - kids need to learn to explore their environment on their own. It's vital to their development!

As for miss Abby-pants? Well, we got rid of all the bouncers and for the past month have set strict tummy time rules – she must work for toys on the floor for nearly the entire day, and must practice standing several times a day. She yells at me about it all day, but boy has this tough love helped. She has already shown vast improvements. She is now able to stand supporting herself on a piece of furniture, can quickly army crawl (using her arms mostly), and is starting to lift that big belly off the floor! We are also enlisting the help of a local pediatric physical therapist to help with some exercises and strategies. Slowly but surely, she’ll get there!

Hugs,

Dr. Diane

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

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

Should you be concerned?

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

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

Should you give your baby rice cereal?

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

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

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

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

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

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

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

About the author

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

If you make a mistake, it could be harmful.

Myths about fever are common. And, no, you don’t have to go to the ER for fever. Treating a fever at home is often the right thing to do. But, we can’t get so comfortable treating fever that we forget that medicines can be dangerous, even over-the-counter fever reducers.

Here are 7 mistakes parents make when treating their child’s fever:

1. They treat normal temperatures. A child that has a 99 degree temperature does not have a fever. There’s no need to give them medicine. If one of our children has a 101 temperature but is playful, I don’t stop them to give medicine.
2. They wake kids up to give them medicine. If a child is sleeping, it’s OK to let them sleep.
3. They give aspirin. Aspirin should never be given to children with fever. It can cause a rare, but serious condition known as Reye syndrome which leads to confusion, brain swelling and liver damage.
4. They don’t give enough medicine. It is so common for children to be under-dosed by parents. Maybe it’s the psychological barrier to seeing your children grow up, especially when they are sick but giving the same dose to your child at 6 months and 6 years won’t work. Know their weight and dose accordingly.
5. They give too much medicine. Again, know your child’s weight and use a chart. Measure twice, dose once. If you think that you gave too much, you can call poison control to see if you should be worried: 1-800-222-1222.
6. They give too many doses. The old standby of alternating Tylenol and Motrin for fever goes way back but the reality is that overdosing and extra doses occur much more frequently with this strategy. I have quit recommending it for families altogether. Again, if this occurs, call poison control.
7. They leave the fever medicine out and kids get into it. This mistake is common and completely understandable. Often when kids need fever medicine, it’s a high-stress-low-sleep situation; a mental state where we are more prone to let down our safeguards. Don’t do it! Find a place up high to store your medicine and droppers so that they are in a convenient place and put them right back after you pour your dose. If you kid does get into the medicine, any ideas what you can do? 1-800-222-1222.

Here are the two major takeaways for treating fever:

Know your child’s weight and have a chart handy. Use it every time.

Stop right now and store the poison control number into your phone. Here it is again, in case you forgot: 1-800-222-1222.

The troubling trend I have noticed is with a parental mindset that more equates to a “bestie” than a mom or dad. Your child is not an adult. I am not a child psychologist, so I will not wade through those waters. But, from a perspective of someone who performs root cause analysis of incidents, I must say there are dangers associated with a lax parental structure.

I could give a thousand examples of situations where your child should not have total privacy in their lives. Do you keep up with your child’s grades in school or simply leave it up to them to pass or fail? Do you ask them where they are going when they leave the house or do they have complete privacy and freedom to go wherever they want? Would you want to know if they were getting into something dangerous or making a bad life choice?

I do not understand the opposition; but, I do recognize there are those in opposition to using spyware to keep tabs on what their kids are doing online. All I can say to such opposition is I simply do not agree. This does not mean that I am going to read every conversation they have with their friends. This does not mean I am going to keep track of every single detail of every single site they visit. I am keeping eyes on their activity and can be in a position to recognize when I may need to step in and give guidance.

In performing research on the subject and talking to experts regarding child online safety, a few things tend to float to the surface of the sea of information.

1. You tend to get very few physical queues. Picture your child sitting on the couch with their face aglow from the light of their iPad. What are they doing? They could be watching a music video or chatting with a stranger. Switching from one activity to another does not tend to change their outward appearance or mannerisms. I call this the virtually induced poker face.
2. They feel secure in their environment.  They say hindsight is twenty-twenty. This one can be difficult to explain, so let me put it this way: If your child were in a dark alley and was being approached by the silhouette of a large man, they may become apprehensive, keep their guard up, or become standoffish and not be willing to participate in a conversation. However, if your child feels physically secure in the comfort of your home, they may be more than willing to participate in that conversation. That could lead to them being groomed by a predator.
3. A child doesn’t typically recognize the dangers until it is too late. Online predators are not stupid. While they are morally bankrupt, malicious, calloused, brazen and cruel, the successful ones can be rather intelligent. They are master manipulators with a ton of patience and have the tenacity to stick with a target. They find weaknesses and play on them. They weasel their way into a relationship with the child. They comfort them, take their side on issues, and lure them in. By the time your child recognizes they are in danger, it could be too late.

There are real and proven dangers to allowing a child to have complete privacy and freedom in the virtual world.

I don’t like to cite applications in articles because these articles tend to live on when apps die, the name gets changed, or something even better comes along. However, I will make an exception in this case. Currently, my top pick for spyware in regards to monitoring children is PhoneSheriff. PhoneSheriff has the ability to monitor and alert on a large variety of activity, it offers extensive alert and restriction functionality, and is compatible with any major device type.

Another really good spyware product is Mobistealth. While MobiStealth may be prettier, it is also more expensive than PhoneSheriff and, for me, it has one major weakness. MobiStealth does not give you “Geofencing”. Geofencing allows you to set alerts based on the geographical location of the device. An example of this would be setting up a geofence for your child’s school and another geofence for your home. If your child is supposed to leave school at around 4 p.m. and be home at around 4:30 p.m, you would be alerted when your child (device in hand) left the school and when they arrived home. If the times are off, you would know.

As I stated, these recommendations may change over time. Depending on when you read this, you may need to search for “Best Spyware Apps” and do a little research on your own.

Just remember, you are the parent. If your child has a phone or other device, it is because you allowed them to have that device. I do not recommend giving such devices as gifts and I make it crystal clear to my kids that they are borrowing my phone that is on my plan that is paid for by me and I can shut it off anytime I wish. I do not allow them to have passwords I do not know, I do not allow them to lock me out of the phone, I do not allow them to take the phone to the bathroom or their bedroom with the door closed, and I also have a rule that the phone must be charged at night in my bedroom.

I suggest a combination of prevention and monitoring.

Happy parenting and good luck!

The first sign of breast development can begin as early as 8 years or as late as 14 years. Once breast growth begins it can be expected to continue through all the stages of puberty up to age 19. It is normal for one breast to be larger than the other, for one breast to begin growing before the other and to have mild breast tenderness as the breasts grow.

Breast growth is caused by hormones acting on the breast tissue with growth of milk ducts and fat tissue. Final breast size is influenced by a girls hormones and her genetics. Bras can be worn for comfort as soon as breast development begins, but a bra is not necessary for breast growth. Bras do not affect the final breast size. A "training" bra is just a name there is no active training that the bra does. There is nothing that can speed up or slow down breast growth.

Remember that every girl develops at a different time and rate and that there is no normal for breast development. Questions about puberty and breast development are perfect topics to talk to your pediatrician about at your well-child exams as early as age 8 or 9.

Leaving it on the list would have drawn the ire of the overwhelming majority of the scientific community who believe that vaccines are safe and one of the most effective medical ideas ever. If he decided to pull it, he faced the backlash of a loud, but passionate few who sympathize with Andrew Wakefield and his ideas regarding vaccines and autism.

De Niro pulled the film from its single screening at Tribeca.

It went on to be shown in limited screenings, starting in New York. The turnout wasn’t great and the discussion about the film faded almost as fast as it started.

I thought it was over. I was wrong.

Autism is an issue that breeds passionate responses. Robert De Niro, who has a child with autism, is clearly personally affected by them. Many others are personally affected and passionate. Reporting a study that shows no link between autism and vaccines is difficult to do with passion. Science and truth are not always emotionally compelling but passion and emotions do not prove anything.

This morning, on the Today show, De Niro was asked about his decision to pull the movie. He had a lot of things to say … below are some quotes I pulled from De Niro and my response:

“I think the move is something that people should see … there’s something to that movie.”

If a movie came out that said cigarettes are safe and don’t cause cancer, in fact they are good for you, would we insist that everyone should see it? No, and those who did would only do so to see the absurdity of the claims. I will see the movie when I can and I’ll have a better feel for the content. But the bottom line is, Wakefield has worn his credibility thin over the years and doesn’t deserve the benefit of the doubt. His study has been discredited due to his falsifying evidence and unethical means of collecting data.

“To shut it down, there’s no reason to. If you’re scientists, let’s see. Let’s hear. Everybody doesn’t seem to want to hear much about it. It’s shut down. You guys are the ones who should be doing the investigating. Do the investigating.”

“There is a link. The obvious one is thimerosal which is mercury-based preservative. I don’t know, I’m not a scientist but I know because I’ve seen so much reaction about it. Let’s just find out the truth.”

Scientists want truth also. Scientists have done the research. Scientists continue to do research.

Multiple studies looking at vaccines have shown that they are safe. Continuing to research these same topics steals time and resources of our most intelligent scientists who might actually get to more answers about autism. We desperately need help in our understanding of the real cause, how to get an early diagnosis and best treatments for autism. We don’t need another study that disproves the link between MMR and autism.

“There’s something there that people aren’t addressing. And for me to get so upset, here today, here on the Today Show with you guys means that there’s something there.”

Finally, “I am not anti-vaccine. I want safe vaccines.”

I can partially agree with this statement. I am not anti-vaccine either. The difference is that I believe we have already found safe ones.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hugs,Dr. Poop (er, Diane)