The licensed psychologists at Cook Children's have seen this issue throughout their careers. It’s a symptom of a feeding disorder she describes as “pocketing.”

Alaina Everitt. a licensed psychologist, said the issue of pocketing usually begins when children are young. The children may experience something painful, such as reflux or a sore in their mouth, and they find it difficult to eat.

The children then may begin a process of holding, spitting out or refusing food altogether.

Children who pocket food should be checked out by an occupational and speech therapist, even if they have had no other type of therapies or been diagnosed with any medical conditions, according to Everitt. She said those specialists can make sure there are no other problems, such as difficulty moving food around in their mouth with their tongue or if the tongue is weak. These children can usually be cured with basic therapy exercises to overcome these obstacles.

If it’s a sensory issue, more extensive therapy may be needed. Children with sensory difficulties, autistic children for instance, may need a lot of food for them to even feel it in their mouth.

“These kids will over stuff and pile food in their mouth and get the ‘chipmunk cheeks,’” Everitt said. “These children tend to like crunchy or spicy foods because they may have trouble tasting or feeling other foods because of sensory issues.”

Lots of toddlers will hold their food and that tends to be developmentally appropriate. If a child gets closer to age 5 then parents may have cause for concern.

As children get older, they become more skilled at pocketing food. The kids may keep their food in their cheeks until they discard it or the parents can’t get their children to swallow.

“It becomes a meal-time battle,” Everitt said.

Cook Children’s helps parents with a team approach to treating children with a feeding disorder. A pediatrician would help guide the child’s care. A dietitian may help the child find foods they can swallow. Speech and occupational therapists lead the actual therapy portion to teach swallowing and resolve sensory issues. Everitt comes in to help with any emotional or behavioral issues, such as anxiety or parent-child power struggles.

“Therapists have little tricks they teach parents; how to do the right type of massage or how to get in their child’s mouth with a vibrating tool as it helps them from a sensory perspective,” Everitt said. “These things can help children swallow easier. You also have to make sure they don’t have a swallowing problem at this phase and the speech therapist will help with that. If the kid has choked before or has trouble swallowing, why would they try to swallow? Even when that issue gets treated the kids are still scared and that’s when they come to me.”

After all, this is a modern classic. So much so that October 3 has become #MeanGirlsDay.

From Heathers to Mean Girls, these ‘rites of passage’ movies have given us insight into the lives of teenage girls. While they may be full of snobs, cliques and at times, cruel behavior, they can’t fully prepare any girl for the reality of social bullying.

Parents, you may know social bullying all too well and not even realize it. This occurs when a group decides to leave someone out on purpose or tells other kids not be friends with a certain child or teen.

But unlike your favorite teen movie, there's not always a happy ending for the kids being bullied.

Social bullying, along with verbal bullying, is often referred to as “mean girl” behavior, said Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Cook Children’s Behavioral Health Clinic in Denton.

She says this form of bullying also includes name-calling, backstabbing, gossiping and spreading rumors.

“When ‘mean girls’ take this negative and aggressive behavior into the world of social media, it now includes cyberbullying, making it even more hurtful and instilling feelings of powerlessness,” Elliott said. “This can be quite painful and has the potential to be psychologically harmful.”

Girls may engage in this type of behavior for several reasons, including:

• Peer pressure.
• Trying to improve their status on the social ladder.
• Excluding those who may be perceived as a threat to their social status.

Regardless of the type of bullying, three elements are generally present:

1. An imbalance of power.
2. Aggressive behavior intended to hurt someone emotionally and/or physically.
3. Pleasure in observing the pain (or assuming there is pain) caused to the person being bullied.

Elliott says your daughter’s response to the mean girl is key.

“All bully behavior is intended to empower the bully, so your daughter’s response is critical – she must be able to acknowledge what the “mean girl(s)” are doing, but also communicate that they don’t have emotional power over her,” Elliott said.

She says if the victim communicates any type of negative emotion (verbally and/or nonverbally) – whether that be pain, hurt, rejection, fear, anger, frustration etc. then she has validated the bully. The bully will only be encouraged to continue the “mean girl” behavior, simply because it empowers them.

Instead, girls should try to respond to the bullies by using select words such as ‘so,’ ‘OK,’ ‘who cares,’ ‘whatever’ and ‘big deal.’

“These words communicate ‘I hear you, but you have no impact on me,’” Elliott said. “However, equally important is the tone in which these words are communicated. It is critical these words are conveyed with NO emotion! If ‘mean girls’ pick up on any emotional weakness, they will continue the negative behavior.”

Another strategy to apply is humor, where you laugh at yourself thus deflecting any hurtfulness.

“It’s important your daughter displays confidence and can defend herself in an assertive manner that is respectful, does not lower her to their level and does not encourage them,” Elliott said.

In addition to having a prepared response, Elliott encourages girls to stay strong, appear confident and smile, primarily because “mean girls” are quite adept at discerning which girls they can manipulate and control. The more confident your daughter portrays herself (not appearing dejected, insecure, hurt, nervous, left-out), the less likely the “mean girls” will repeat their aggressive behavior to her.

Equally important is being a positive bystander. If your daughter sees “mean girl” behavior happening to others, ask her not to stand by and watch. When “mean girls” do not have an audience, they lose power.

To foster your daughter’s self-confidence, help her find areas she can feel success in, such as school, sports, church, community service clubs, or talents like singing or playing an instrument.

You should also monitor her computer and cell phone, and encourage her to spend less time on social media. If bullying expands onto social media, then you need to talk to her teacher, coach or another school official.

While we’ve addressed “mean girls” in this article, no child is bully-proof.

Elliott points to the death of David Molak, a 16-year old San Antonio boy, as an example of the harm that comes from the constant harassment a child receives in the world of cyber bullying. She offers parents the following talking points when speaking to their child about bullying:

• Even people who say they're your friends can bully you.
• You should confront your friends when they're being hurtful to you or others.
• Retaliating may feel good temporarily, but refusing to stoop to the bully's level will win you more popularity in the long run.
• When you hear a false rumor, just ignore it and be yourself.
• You're most likeable when you respect yourself and others.
• Bullies usually have their own insecurities. Returning meanness with kindness is the best way to break down their defense.

In the end, kids should know they may be the best resources to end bullying where they live.

Stories related to this topic:

• Bullying is a ‘serious public health problem’
• Are popular kids bullied?
• Is your teen's smart phone making them depressed?
• The warning signs of teen suicide
• Cutting: Why kids do it

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

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

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

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

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

Here’s how the debate usually goes:

“Please vaccinate your children.”

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

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

So why do I care?

There are two reasons.

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

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

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

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

How does it work?

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

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

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

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

Scenario No.1:

Scenario No. 2:

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

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

So, in scenario No. 2:

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

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

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

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

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

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

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

That’s the simple message that the folks at Cook Children’s who watch out for your kids’ safety wants you to know.

From March 14 to April 10, 2018, five children were rushed to the Emergency Department for drowning, with one resulting in death.

“There is no amount of time that it’s safe to leave your child alone in the tub,” said Magdalena Santillan, Trauma Injury Prevention specialist at Cook Children’s.

Drowning is the leading cause of unintentional injury-related death in children ages 1 to 4 years old and the second leading cause of unintentional injury related death for ages 1 to 14.

“Safety begins in the home,” said Dana Walraven, manager of Community Health Outreach at Cook Children's and coordinator of the Safe Kids Tarrant County Coalition. “Bath time is not only a good time to bond with your baby, but a dangerous time in and around water. Support safe habits with adult, not sibling, supervision.”

SafeKids Tarrant County, led by Cook Children’s, gives these facts:

• Drowning is quick and silent.
• Children can drown in as little as one inch of water.
• Irreversible brain damage occurs in as little as 4 minutes.

To protect your child from drowning in the tub:

1. Never leave your child unattended in the water.
2. Put the cell phone away. Give your child 100 percent of your attention.
3. The job of supervising a child in the pool is for adults only and not siblings. A child or even a teen should not be held responsible for supervising a child in the bathtub.
4. If you have to answer the door or the phone, take your baby out of the water and hold him or her while you do so.
5. Fill the tub only with enough water to cover the infant's legs.
6. Once the bath is over, immediately drain the tub.
7. Don't rely on bath rings or seats to keep a baby safe.
8. Store empty tubs, buckets, containers and wading pools away after use. Store them upside down and out of a child’s reach.
9. Keep doors to bathrooms and laundry rooms closed.
10. Learn CPR for infants.

Learn more at safekids.org.

Parents can help by making sure that children plan accordingly for testing days at school. Find out from your children and the school how they’re doing and the likelihood of not performing well on tests. This will help alleviate fears by pacing preparation for the tests, creating a plan to help kids succeed and encouraging them to problem-solve their worries.

Here are steps you can take to help your child during this stressful time:

1. Ask for help. If your child is especially anxious about test taking, set up a meeting with the teacher and school counselor to come up with a plan to ease fears on test day.
2. Go online and get sample items of practice tests from previous years and, if needed, practice with your children at home.
3. Practice deep breathing exercises at home. Then on test day, they will be able to put these practices into action.
4. Make sure your child gets plenty of rest. Studies have found that people who get eight hours of sleep before taking a math test are nearly three times more likely to figure out the problem than people who stay awake all night.
5. Control your children’s anxiety by making sure they are prepared. Focus on good study habits and the importance of not waiting until the last minute to cram before the test. There’s still time. Also, make sure your child has everything he or she needs going into the test. Even if it’s a new sharpened pencil. Make a check list the night before to avoid stress.
6. Stay away from entertainment as test time approaches. It’s not easy, but your child needs to study and not spend all night watching TV, looking at Facebook^® or being on the computer. You can wait on that until after the test.
7. Help your child keep mistakes in perspective. Everyone makes them and nobody is perfect. As you move closer to tests and studying, use wrong answers as a learning opportunity.
8. Eat right. Make sure your child has had enough sleep, exercise and healthy food. Avoid heavy food or desserts that may upset the stomach. Avoid  high sugar foods that may keep your child up all night and  make sure your child has a healthy breakfast (low-sugar cereal or oatmeal) the morning of the test.
9. Expect distractions. Let your child know someone in the class will have sniffles. Some kid will be banging his pencil on the desk. Someone may be humming. Those kids have their own stress. Just warn your child this is going to happen, but don’t let it be a bother.
10. After testing is completed, create ways to celebrate with your child. What you want to focus on in this celebration is the success of managing their stress, and not whether they passed or failed, which they won’t know for weeks.

As a pediatrician, I've never been in favor of these medications as a treatment for your child's stomach virus and diarrhea. Studies have shown that use of antidiarrheal medications may prolong the course of the illness. 

Stomach viruses are the most common cause of diarrhea. Diarrhea, after a stomach bug, can last a while, even up to 1 week. A close second is diarrhea associated with antibiotics which can last as long as the child is on antibiotics and even a few days later.

For most cases of diarrhea, you probably don’t need to see the doctor. Here are some things you can do at home to help:

1. Get back to a regular diet as soon as possible. Continuing the Gatorade or Pedialyte only makes it last longer.

2. Do not use antidiarrheal medicines (even Pepto-Bismol). They don’t work and can have severe side effects. 

3. Talk with your doctor about using probiotics. Some studies have shown that they might be helpful.

Here are some reasons it might be time to go ahead and give the doctor a call:

1. Stool with blood or mucous

2. High fever

3. Signs of dehydration (dry lips, not urinating for 6-8 hours)

4. Diarrhea that lasts more than 1 week

Diarrhea will never be fun because it can ruin your life for a few days. But, if your child’s diarrhea lasts more than a week, trot (sorry) on over to your friendly pediatrician. They might need to do some tests to help you figure out what is going on.

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

I should call this: "The Eustachian Tube - Dictator of Ear Happiness." More later on that.

Few things I want to put out there first:

1) There are two kinds of ear infections: middle ear infections (otitis media - the type you get tubes for) and otitis externa (outer ear infection, no tubes for this)

2) "Water in the ear" from a bath or pool typically does NOT cause middle ear infections! It CAN cause something called "otitis externa," or, "swimmer's ear," which is an ear canal/skin infection that may require ear drops to improve. I'm not going to talk about that kind of ear infection today. From here on out when I say "ear infection," I mean the middle-ear kind.

3) Ear infections are incredibly common. Do NOT freak out if your child gets one. Five out of six kids will have at least one by their third birthday (and most will have more than one).

4) A "red ear" does not mean a child has an ear infection.

5) A "baby messing with an ear" does not necessarily mean they have an ear infection.

6) A fever with your child's cold does not necessarily mean an ear infection is happening. The only way to know if your child has an ear infection is to have the ear drum examined by a medical provider.

Why do ear infections happen? Well....snot. And inflammation. Snot and inflammation from colds. Snot and inflammation from allergies. Snot and inflammation from just walking into the door of daycare or that play date.

The inflammation blocks a vital little guy called a eustachian tube. Look at the picture to the left. Find the eustachian tubes. See how they're a little exit canal for the inner part of the ear? They drain the ear. An infant's eustachian tube is smaller than an adults', and more horizontal. That causes problems. It just doesn't drain well.

It swells up, gets blocked off, and the snot in the middle ear has nowhere to go. Once the cold or allergies are better, it de-swells, opens up, and voila!, ear infection is gone. All the junk drains out. The baby's eustachian tube is different than an older kid's, or adult's. This fact along with the fact that babies and toddlers are snot machines and always putting things in their mouths - that's why they get more ear infections. We hope they "outgrow" this eustachian tube problem (and hands in mouth problem) by age 2-3.

It can take 3 weeks to 3 months for the fluid to drain out of the ear. And your kiddo may have an ear infection and you'd never know about it, and that's ok - because they usually get better on their own! Most ear infections are VIRAL! That means the fluid just has a virus in it, and it will all go away on its own thanks to our great immune systems.

When I look into a child's ear, I examine the ear drum to know if they have an infection or not. When there is no infection, an ear drum is translucent, kind of like a shower door. When it is infected, it is red, bulging out, and full of what looks like pus. Sometimes this is just viral fluid. But sometimes, while that eustachian tube is all swollen and blocked off, the liquid stuck in the inner ear gets bacteria in it. We can tell the difference by looking in there. And that is why some children need an antibiotic for some ear infections. To kill the bacteria while we wait for the eustachian tubes to un-swell.

So...who needs "tubes?"

There are a few things that cause kids to get lots of ear infections:

1. Being in a child care setting (lots of kids...lots of snot).

2. Secondhand tobacco smoke exposure (as if you needed another reason to quit).

3. Taking a bottle to bed (when the child lays down and drinks, the milk actually puddles in the area where the eustachian tube meets the nose/throat and causes swelling and bacteria to hang out back there - this habit also causes cavities - no bottles in bed, folks!!)

Some kids have really tiny eustachian tubes that stay really swollen all the time. If they're around other kids a lot, like day care, they get tons of colds each year, and that's normal. However their little eustachian tubes mostly stay swollen shut, sometimes for months at a time. And we see them in our office 1-2 times a month for repeated ear infections.

I guess a "rule" I follow is that if a child gets 5-6 bacterial ear infections in a year, or more than 3 months of constant fluid in the ear, I will send them to the Ear-Nose-Throat doctor to get tympanostomy tubes (or just "tubes", as most people know them) put in. This brilliant procedure creates a little "canal" for the fluid to escape from the inside of the ear. They fall out in about a year, when we hope they've "outgrown" the problem.

Sometimes, I send a kid to ENT if I've put them on 3 or more rounds of antibiotics and they're still having fevers and still in pain and I just can't get that dang fluid to go away. Who wants a kid on antibiotics for that long!? Another reason to see the ENT is if the fluid is making it hard for a child to hear. When a small child can't hear, they can't learn to speak. I've seen kiddos get ear tubes and within 1 week they are talking up a storm! It's amazing.

However, surgeries and anesthesia comes with risks. If you're worried your child has had too many ear infections, talk to us. We will let you know if we think it's time to see the ENT.

Wow...this was long. I hope it helped you learn something about one of the most common ailments we see in the office!

The pop superstar gave an interview in the most recent edition of Vanity Fair and talked very frankly about her battle with postpartum depression, following the birth of her son. She said her postpartum depression made her feel "very inadequate" and as if she "made the worst decison of my life."

New moms experience all sorts of feelings, thoughts, and behaviors that their non-pregnant selves would never dream of! In the first few weeks after delivering a baby, about 80 percent of women will experience crying for no reason, impatience, irritability, anxiety, fatigue, sadness and trouble concentrating.

When do these feelings extend beyond “normal” and into the danger zone?

According to Diana Lynn Barnes, PsyD, an expert on maternal mental health, these are common feelings expressed by women with postpartum depression:

• No one has ever felt as bad as I do (helplessness)
• I have made a terrible mistake (anxiety)
• I am all alone and no one understands (isolation, withdrawal)
• I’m a failure as a mother, woman, and wife (guilt, diminished self-esteem)
• I will never be myself again (hopelessness)
• I’m losing it (despair)
• Everything is an effort (exhaustion)
• I have such trouble deciding (disorientation, confusion)
• I feel like I have soda fizzing through my veins (anxiety)
• Sometimes I think everyone would be better off without me (suicidal thinking)

Luckily, risk factors for postpartum depression are known, so at-risk women and their families can be proactive about their postpartum mental health. Make sure your pregnancy care provider knows about:

• Personal or family history of depression, anxiety, obsessive-compulsive disorder, postpartum depression or psychosis.
• Personal or family history of thyroid illness, chemical dependency, or alcoholism.
• Premenstrual dysphoric disorder.
• Past experience of trauma (physical, emotional, sexual abuse).

Postpartum psychosis is a serious, life-threatening illness that increases the risk of a mother committing suicide, killing her baby, or abusing or neglecting her baby. It occurs in about 0.1 percent of births, begins suddenly within two weeks of delivery, and may require emergent psychiatric hospitalization. A personal or family history of bipolar disorder, postpartum psychosis, or a previous psychotic episode are the most ominous risk factors, but women without any risk factors can develop postpartum psychosis. If you notice a new mom experiencing these things, it’s time to get help NOW:

1. Strange ideas or beliefs which are often of a religious nature, i.e. receiving prophecies, supernatural baby, evil baby (delusions).
2. Hearing commands.
3. Receiving secret messages from TV, music, books, online, etc.
4. Unwanted and disturbing urges to commit violent or other terrible acts.
5. Hallucinations involving smell, sight, or touch.
6. Intense fear of what she might do and a desire to escape.
7. Inability to sleep, a drastic increase in energy, euphoria (mania).
8. Not making sense when talking, easily distracted (disorganized speech, flight of ideas).
9. Frequent arguments, irritability, annoyance, and conflict with family members.
10. A false idea that people close to them are dishonest, dangerous, or trying to hurt them or their baby (paranoia or suspiciousness).
11. Confusion about where, when, and who they are time (disorientation).
12. Obvious lack of self-care.
13. Feeling unable to care for her baby, or extreme worry that she can’t keep the baby safe.

The great news is that postpartum depression and psychosis can be effectively treated, especially if help is sought early.

• The widely used screening tool - the Edinburgh Postnatal Depression Scale
• Postpartum Support International
• More about Diana Lynn Barnes, PsyD

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

What about febrile seizures?

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

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

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

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

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

About the author

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

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.

This was a common sound heard on the inpatient floor this past year as I worked as a hospitalist. Young babies coughing until they couldn’t catch their breath followed by our respiratory monitors alarming for low oxygen saturations and low heart rate. Unfortunately, it was so common I could diagnose the problem from the hallway. If you watch the news often you’ve probably guessed the diagnosis.

Pertussis. Also commonly referred to as whooping cough or, ”the 100 day cough”.

Tarrant County has seen many cases of whooping cough in the past several years:

• 2013 - 700 cases
• 2014 - 467 cases
• 2015 - 308 cases

Recently there was a case in the news media about an infant death from pertussis; unfortunately this happens to between 0.5-1 percent of children under a year who contract this illness.

Pertussis is primarily a respiratory infection caused by the bacteria Bordetella pertussis. It is very contagious! It is a tricky diagnosis to make because the initial 1-2 weeks of infection seem like a cold. Patients have a clear runny nose, sore throat, watery eyes with mild cough and may not even run a fever. These symptoms are usually treated symptomatically at home. When they fail to resolve and become more severe with the characteristic coughing spells they come to medical attention.

To diagnose pertussis a nasal/throat swab (similar to a flu test) has to be obtained. Unfortunately, the diagnosis usually isn’t made until this second phase of illness and treating with antibiotics at this point doesn’t do much to alter the course of the infection. The cough is frequently followed by a “whooping sound” as the patient struggles to catch their breath. Infants don’t tend to make this sound as often as older children. It is common to vomit after these long coughing episodes and this phase of illness lasts for at least a month. A month!

In younger babies (less than 4 months) it is common for them to cough until they are blue and to stop breathing (apnea) and to not be able to maintain adequate hydration or weight gain. Young infants with pertussis frequently require hospitalization. While working as a hospitalist, it was not uncommon for a baby to be in the hospital for a few weeks while we gave them intravenous fluids to keep them hydrated, fed them through a nasal feeding tube and supported them during coughing fits.

Unfortunately, this infection can be fatal and frequently babies do require mechanical ventilation (breathing machine) in the intensive care unit. Less commonly, the infection can cause brain swelling (encephalopathy) and cause seizures.

Pertussis is spread through respiratory droplets. Babies, who are at highest risk of severe complications and too young for vaccination, usually catch the infection from an adult who is undiagnosed. Patients are contagious for a long time, up to several weeks. Often, it is an older family member with a cough for several weeks duration. It is devastating to families when they realize they were unknowingly the source of the infection that has caused the baby to be hospitalized.

All pregnant women are now encouraged to receive a pertussis vaccine in the third trimester of their pregnancy along with the other adults that will be living in the home. Having this “cocoon” of protection helps protect vulnerable infants until they are old enough to receive the immunization themselves.

I want to go over some general information about the varicella virus and discuss complications that can arise. Chickenpox is highly contagious. When one individual in a household had it, there is a 90 percent infection rate for those in the same household who have not previously had it or been immunized. It is spread through droplets (think body secretions – runny nose, sneezing, coughing) and direct contact of lesions on skin when in the ruptured vesicular stage. This virus has a really long incubation period, which means there is a long period between the time you are exposed and the time you develop symptoms. The average time is 14 to 16 days! Just when you think you are out of the woods, you can develop symptoms!

Varicella generally starts with 1 to 2 days of fever, fatigue, sore throat, and loss of appetite, followed by a rash. The rash starts as tiny red bumps to the face, spreading to the torso and then extremities. There are three stages of a chickenpox rash: maculopapules, vesicles, and crusts. The maculopapular rash appears as tiny red bumps from pinpoint to pea sized. Vesicles are typically pea sized and are fluid filled (blister like) on an red skin base. One description I like is “dew on a rose pedal” appearance. After several days the vesicles will rupture and leave crusts. The crusts usually resolve in 1 to 2 weeks and can leave areas of lighter colored skin that will eventually disappear. As I mentioned before, it will usually start on the face and move down to the torso and then extremities. There will be several “crops” of new papules, which allows there to be rashes in different stages of healing. Start to finish, chickenpox can last anywhere from 7-14 days. I missed 10 days of school when I had it! You are contagious 48 hours prior to rash appearance (usually when fever starts) until all lesions have crusted over.

But if chickenpox is so mild, why do we bother with vaccinating? Varicella can have severe complications that can cause as little as discomfort or as much as death. The most common complication is secondary bacterial infections. Here is a list of a few:

1. Soft tissue or skin infections: It’s hard not to scratch when you’re itchy, especially if you’re a child! This can lead to secondary skin infections. The common culprit is strep, a common bacteria that lives on your skin. There are even cases of flesh eating bacteria post chickenpox!

2. Encephalitis: Before vaccinations, this neurological issue accounted for 20 percent of hospitalizations and 50 percent of the deaths related to varicella. Encephalitis is swelling of the brain that can happen after or with a virus. It causes delirium, stroke like symptoms, and seizures.

3. Pneumonia: This is a common complications with lots of viral illnesses, and possibly one of the most feared. The mortality rate with varicella pneumonia is estimated between 10-30 percent. Typically you develop high fever, after initial fever has resolved, and cough.4. Hepatitis: This is a liver condition that can occur in our patients who contract chickenpox and already have a low immune system. Kiddos with cancer or who have had organ transplants are at highest risk.

In my prior work in the ED, I have unfortunately witnessed all of these complications with the exception of hepatitis. Complications can affect any age, regardless of current health. I have seen some previously healthy children develop encephalitis and have permanent neurological and seizure disorders after!

With the development of the varicella vaccine in 1995, chickenpox cases decreased 90 percent! The American Academy of Pediatrics and the Centers for Disease Control recommend two doses of the varicella vaccine at 12 months and 4 years.

As always, if you have questions, please call the office. I am happy to discuss things with you. Our goal is to keep your kiddos happy and healthy while avoiding potentially fatal outcomes from preventable diseases!

Tara, NP

About the author

Tara Haraldson is a nurse practitioner at Cook Children's Willow Park office. To make an appointment for back-to-school vaccines, contact your Cook Children's pediatrician. To find a pediatrician near you, click the following link. 

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.

The AAP (American Academy of Pediatrics) and the Centers for Disease Control’s ACIP (Advisory Committee on Immunization Practices) stated, “Health care providers should not use live attenuated influenza vaccine (LAIV) in the upcoming 2016-2017 season due to poor effectiveness.”

The first thought that went through my head was this: my kids have to get the injectable flu vaccine next year AND I have to convince them that it’s a good thing. (I may be a pediatrician, but I’m still a dad.)

The committee looked at data from the last three flu seasons showing that the nasal vaccine had limited to no effectiveness for preventing flu.

Here are 4 facts you need to know:

1. Even in bad years, the flu vaccine continues to provide the best layer of protection against this deadly disease. Last year’s injectable flu vaccine was 50 percent effective in preventing disease which means thousands of people were protected.
2. Assuming there’s no new information or guidance, your pediatrician should not offer your child the nasal flu vaccine. Even if we hear something new, I would choose to do the injectable vaccine and I will do so for my kids.
3. The committee is hopeful that this early decision will help prevent any issue with the vaccine supply. However, there are flu vaccine supply issues nearly every year so I recommend getting in to get your shot early.
4. There’s a committee out there who is looking at this data and making the best recommendations possible based on the latest information. Is it frustrating that we were giving a vaccine that didn’t work? Of course. Am I glad that I won’t do it for another year? Definitely.

Stay tuned for more information about flu and flu vaccines as we get closer to September when flu vaccine supplies start arriving at your Cook Children’s pediatrician’s offices.

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.

Over the past several years, I have been actively speaking to parents, children, tweens, teens, and young adults regarding the dangers of the Internet and social media. I discovered rather quickly that I could not prepare a single set of presentations to use over and over again. Rather, I need to conduct new and fresh research for every single presentation I do, regardless of how much time has passed from one to the next.

Why? Because that is how fast things change in the world of technology and online interactions.

I am not going to go on a long rant about immorality or express my true feelings about the class of a person it takes to create certain apps for monetary gain, all the while knowing full well that children can and will fall victim while using those apps; instead, I am going to stick with the matter at hand.

Parents, you need to be aware that truly dangerous apps exist and are readily available to your children. And, if you are reading this as a young person or young adult who thinks I am being condescending, tough. In order to write an article such as this that is intended to reach the parents of potential victims, I have to be general in my assumptions and sweeping in my aim. I would rather offend you than not get the message out to someone that could prevent a devastating, life altering event for a child.

In my presentations to parents, I list a handful of apps; however, you have to understand that there are literally millions of apps available and, even those apps where the intended purpose by the app’s creator may be innocent, can be used dangerously. The reverse is also applicable; however, with the apps I am about to showcase, it is unlikely that they would be used in a benign way. With that, let’s talk about them:

1. SeekingArrangement.com - Brandon Wade is the founder of this site and supporting apps are available on GooglePlay for Android devices as well as iTunes for all iOS devices. SeekingArrangement identifies itself as a “sugar daddy dating app”. While discussing SeekingArrangement, it is also important to note that Brandon Wade also created an app called CarrotDating. CarrotDating (no longer available at the time this article was written) was an app that was borderline prostitution in the same way backpage.com ads are also “borderline” prostitution. The “borderline” is fairly evident. Although CarrotDating has been nixed, the philosophy behind the trend is still evident… bribes for dates. Of course, “dates” can be defined in ways other than going out to dinner and a movie.

2. Yik Yak – This App is one of the most dangerous. It allows users to post text-only “Yaks,” or messages, of up to 200 characters. The messages have no filter and can be viewed by the 500 Yakkers who are closest to the person who wrote the Yak, as determined by GPS tracking. Users are exposed to – and contributing to – sexually explicit content, abusive language, and personal attacks so severe that schools are starting to block the App on their Wi-Fi. Although the posts are anonymous, kids start revealing personal information as they get more comfortable with other users. This app is a rumor machine and a perfect channel for the kinds of bullies who hide behind a screen, hurting other people behind a shield of anonymity.

3. Ask.fm – This app allows users to ask a specific person anonymous questions. Users can answer these questions and posts them to their personal page, truly leaving nothing to the imagination. This is especially dangerous because it allows any user to target a specific person anonymously. Bullies, predators, and more can send anonymous messages to a specific person, asking them inappropriate things or even simply making hurtful statements.

4. Kik Messenger – This is a private messenger app and is coveted by those under 18 for a number of reasons. The App allows kids to send private messages that their parents can’t see. This app also allows users to identify themselves by a made up username, posing the dangers of anonymity. To make matters even scarier, third party websites allow users to search for people based on things like age and gender. There is very little you can do to verify the identity of someone on Kik, which obviously poses the risk of sexual predators chatting with your child. And again, this is an easy tool for sexting. Just last month, a 13 year old girl was murdered by a man she presumably met on Kik Messenger. 

5. Omegle – This App has been around since 2008, with video chat added in 2009. When you use Omegle you do not identify yourself through the service – chat participants are only identified as “You” and “Stranger;” the app’s slogan is “Talk to Strangers!” You don't have to register for the App. However, you can connect Omegle to your Facebook account to find chat partners with similar interests. When choosing this feature, an Omegle Facebook App will receive your Facebook “likes” and try to match you with a stranger with similar likes. This is not okay for children. This app is the perfect channel for sexual predators. Experts say these predators blackmail young children, by starting inappropriate conversations with them, then threatening to send the messages, photos, or videos to their parents if they tell anybody, therefore trapping the child in a disgusting, dangerous situation. 

6. Whisper – This is a meeting App that encourages users to post secrets. You post anonymously, but it displays the area you are posting from. You can search for users posting within a mile from you. You are also able to communicate with users who post secrets. A quick look at the App and you can see that online relationships are forming constantly on this App, but you never know the person behind the computer or phone. One man in Washington was convicted of raping a 12-year-old girl he met on this App just last year. 

7. After School – This app is a message board that students can join by scanning their school I.D. or Facebook profile. While the scanning feature provides some security from outside users, once in the app, the user is anonymous. However, this app effortlessly creates drama and conflict among users because they all attend the same school. Students are able to freely post about anything. This year, a single school had problems with posts that included topless photos, alarmingly vulgar posts from males talking about fellow female students, and more. There is even a section where students can scan their driver’s license and enter a discussion only for students ages 17 and up, openly creating an environment for the discussion of more explicit material.

As with my presentations, articles such as this are a moving target as things get more troublesome by the minute. The biggest problem is that these apps make money. Because of this, more apps get developed that push the envelope of morality and safety. Look, if the developers could ensure the apps would only be used between consenting adults, I wouldn’t have a problem with all of this; however, the only way to ensure that to any reasonable level is to pretty much kill the app’s revenue streams. Because of this, we must remain diligent and be ever on the lookout for the next worst thing that could fall into the hands of our children. These apps make criminals out of cowards.

Please note: You can turn location services, or GPS, off on cell phones by going in to the device settings. This will keep the Apps and photos from posting the exact location or whereabouts of the phone user.

About the author

Jody S. Hawkins, Information Systems Security Officer, has been in technology for medical facilities since early 2000 and has been practicing for more than 20 years with his start in the United States Air Force. He is a part of Cook Children's Experts on Call Speakers Bureau. Hawkins specializes in privacy and technology safety and is a regular speaker at the National HIT/HIPAA Conference. He has been quoted and published in several national publications, including Health Information Management Magazine.

Hawkins' can speak on a variety of security topics facing our children & parents today, including:

• Social media
• Cyber bullying
• Sexting
• Safety online (Parents & Child)
• General home networking security
• Virtual Child (Parents)
• Internet Safety (Parents & Child)

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)

One way to narrow this down is asking, "What part of your head is hurting?" and "What does it feel like?" (Note! These are some very general guidelines and don't apply to all headaches. Most headache causes however can be found in one of these categories.)

Migraines are typically a one-sided severe, throbbing and intense pain occasionally accompanied by nausea/vomiting and sensitivity to light. Migraines have a genetic component though so we typically want to know about family history of headaches. They can be triggered by things such as: stress, hormones, dehydration, hunger, and lack of sleep.

What about neck/back of the head pain? Think about what is causing those muscles to pull and strain and cause you pain. Heavy backpacks are a BIG offender. Also, body positioning is huge. For example, staring down at the phone/iPad all day? (AKA every teenager). How about arms not on a level surface when studying? What happens is their shoulders are pulled up all day while they study, creating unnecessary tension and/or pain in the neck and shoulders. Oh, and don't forget heavy ponytails too!

Front of the head/forehead pain: Pain here can be caused by eye strain, so let's start by checking their vision. This type of pain can also be caused by allergies/sinus infections, especially if tender to the touch.

General causes of headaches: The number one reason I see headaches is dietary. Not drinking enough water and not having good protein for breakfast or before exercise is a large factor. This can also make them dizzy and feel faint.

Sleep!! I don't care what or how much you change in your life, if you don't sleep enough you are going to get headaches (I have tried to work around this rule- ya just can't). Most children need 9-11 hours of sleep, depending on their exact age.

Some red flags are: severe headache especially with fever or neck pain, headache that is progressively worsening and not responding to usual treatments, waking up in the middle of the night with a headache, early morning headache especially with vomiting, or any with neurological symptoms (not walking right, personality changes, weakness, decreased vision, etc).

Now, not every headache fits exactly into these categories. This is just a general outline to give you some things to take note of before the visit. I have also included a headache journal that, if you filled out before your visit, your provider would do a happy dance for you!!

We are always happy to talk about your headaches and want to do that. I want this to help make your visit and discussions with us more productive! It will be if we have already been taking note of these common types and offenders.

- Sperry, NP

About the author

Sperry Binnicker is a nurse practitioner at Willow Park. Sperry joined Cook Children's in 2009 in the Pediatric Intensive Care Unit (PICU). In that role, she earned the Daisy Award, an award given to a nurse that is nominated and selected by the parents of patients for excellence in patient care. She continued her education while working full time and received her master’s degree from the University of Texas at Arlington in May of 2015.She is a Board Certified Pediatric Nurse Practitioner and a member of the National Association of Pediatric Nurse Practitioners. Learn more about the Willow Park staff here.

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

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

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

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

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

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

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

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

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

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

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

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

Goat's milk is nothing to kid around with.

Unfortunately, stories of mothers harming their children have become far too prevalent in recent years. But there are often times hints a mom may abuse her child.

Joy Crabtree, Psy.D, a licensed psychologist for the Urgent Care and Pediatric Specialties Clinic in Southlake, said there are sometimes warning signs that a mom’s mental health is unstable or depression may be a concern including increased irritability, loss of patience, quick mood changes, excessive energy or extreme fatigue, and a sense of feeling hopeless or overwhelmed.

More serious warning signs, possibly of psychosis, include trouble distinguishing what is and isn’t real, a sense of extreme suspicion or paranoia, and even hearing voices or seeing things other people don’t see.

At times when psychosis or even an extreme depression is present, a woman can have irrational ideas about her baby — such as that the baby is possessed or that she has to hurt herself or her child. This condition can be extremely serious and disabling, and new mothers who are experiencing these symptoms need medical attention right away.

Women who have other psychiatric illnesses, such as bipolar disorder, major depression or schizoaffective disorder, may be at greater risk of developing postpartum mood symptoms. Any significant changes in behavior or bizarre beliefs require immediate medical attention and, often, a brief hospitalization. If you or someone you know is experiencing symptoms, don’t delay getting medical attention.

“The person who is in the midst of some type of mental health issue likely doesn’t know what is or isn’t reasonable,” Crabtree said. “Family members, friends, teachers, or other professionals in contact with parents need to step in if they feel a person needs help. A child should not be left alone with a parent in crisis. The care of the child then depends on other adults.”

We have said this before (many times), but a new study shows just how true this statement is.

A recent study published in the Journal of the American Medical Association (JAMA) looked at the combined data of 18 published measles studies on several measles and pertussis outbreaks.

Reviewing a total of 1,416 measles cases, 56 percent had no history of measles vaccination. This is way higher than you might expect given that most still choose to have their child vaccinated.

Still the study states that “a substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated.”

Intentionally unvaccinated?

As a pediatrician this concerns me. As a dad, it terrifies me.

In one outbreak the risk of contracting measles was 35 times more likely when parents had skipped the shots. A child who isn’t vaccinated is much more likely to spread measles than a vaccinated child.

We know that the pertussis vaccine is not working as well as we would like. The protection from the vaccine is falling off quickly. However, this study showed that despite this, vaccine exemptions continue to be a factor in the spread of pertussis outbreaks. Somewhere around 1 out of 3 kids who got pertussis during these outbreaks was unvaccinated.

Why are children not getting the vaccines? Not all studies had the information necessary to say. But, for those that did, most families skipped the vaccines for personal or religious reasons (70 percent for measles, 60-90 percent for pertussis).

This is further proof to something we’ve suspected for some time. Having even small pockets of unvaccinated children increases the risk to the whole community.

Each of these families who chose not to vaccinate gamble on 3 issues:

1.Their child would not be exposed to the disease (banking on herd immunity whether they know it or not).

2.If their child was exposed, that they would not contract the disease.

3.If their child contracted the disease, they would not suffer serious consequences.

These are consequences I’m not willing to gamble on.

In the case of measles, consequences could mean pneumonia, hospitalization and, later in life, neurologic complications.

In the case of pertussis, consequences could mean painful coughing, broken ribs and, in the very young, death.

This is further proof to something we’ve suspected for some time. Having even small pockets of unvaccinated children increases the risk to the whole community.

Obesity? That's one.

Car accidents? That's a big risk too.

But would you guess the number one issue is asthma?

In Tarrant County, 19.5 percent of children suffer from asthma, according to data gathered in a survey sent to parents by The Center for Children's Health led by Cook Children's. The Community-wide Children's Health Assessment and Planning Survey (CCHAPS) was completed by more than 8,600 parents in Tarrant, Denton, Hood, Wise, Parker and Johnson counties.

"We questioned parents on everything from how often their child is buckled in properly to how many grocery stores in their neighborhood sell fresh fruits and vegetables," said Larry Tubb, senior vice president of the Center for Children’s Health. "The information we are gathering is extremely valuable when it comes to measuring the overall health of children in our region."

Overwhelmingly, parents in Tarrant County (and all of the surveyed counties) reported their children are dealing with asthma. In fact, children in this area ages 6-9 are three times more likely to have asthma than children living in other parts of Texas. While we don't know why the numbers are so high, we do know people with asthma have varying triggers, and what affects one person will not necessarily affect another. Those triggers include, but are not limited to, cigarette smoke, indoor and outdoor mold, pet dander, air pollution, dust mites, cockroaches, pollen, smoke and strong odors.

The second biggest health issue on parents minds is obesity, with 17.8 percent reporting concerns about their child's weight, activity level and access to healthy foods.

Accidental injuries rings in third. In Tarrant County, 11.9 percent of parents reported their children had been injured and required medical care. Those injuries range from car and ATV-related incidents to drowning, bicycle falls and crashes.

The fourth issue on the list is a lack of dental care for children. Parents reported 9.7 percent of children either didn't see a dentist regularly, didn't brush their teeth enough or some even reported their child didn't have their own toothbrush.

Finally, mental illness is the fifth biggest issue concerning parents in Tarrant County. Behavioral and emotional development is on the minds of 8.5 percent of respondents. Many reported their children have suffered sleep problems, self-esteem issues or have tried to harm themselves.

The survey used to gather this data is part of a Cook Children's initiative to improve the health and well-being of every child in our six-county region by 2020. This initiative launched in 2009 with the very first survey of its kind sent to parents. Since then, the surveys have been sent out every three years.

"The information provided by parents in our community is available on-line and being used by a host of organizations, including Cook Children’s, to build programs and services. There isn’t one perfect answer, but, together we are making solid progress in improving the health of the children in our community by putting the child and family at the center of our planning," said Tubb.

About The Center for Children's Health

The Center for Children's Health, led by Cook Children's, is home to the Community-wide Children's Health Assessment & Planning Survey (CCHAPS), Community Health Outreach and Community Health Research. The center's goal is to create aligned collaborations that will allow us to make our North Texas region one of the healthiest places to raise a child.

Games and apps that are locally loaded and need no connectivity to the Internet to work are not categorized as "dangerous" as long as the content is appropriate for the age level of the child. However, most "free" apps require some level of connectivity for ad delivery. These ads are often unregulated or under-regulated and could contain links to material that is inappropriate for young children.

2. Social Interaction

Xbox, Playstation, and Wii (to name the popular consoles) all have the ability to connect a player with other, anonymous users. There are also games and other apps on Andriod, iOS devices, and PC that also allow social interaction with the gaming community. Kids can be subjected to ridicule, bullying, and age inappropriate conversations. Of course, sites and apps designed specifically for social interaction can be a worry if the content is not filtered and users can remain anonymous.

3. Information Sharing

A good deal of social media sites and apps give out a plethora of information about the user. This data can range from age to birth date and general regional area to specific city or even the exact address. A lot of times the information given is based on the users input and privacy settings; however, sometimes it can be unknown to the user. Take GPS location services as an example. If the young user may not be aware the app is pinpointing their current location to within 30 feet. Or, if they do, they may not realize the dangers associated with this type of situation.

4. False Accounts and Anonymity

Most social media sites and apps - even the most well known - allow for fake accounts to be created. Beyond fake accounts, a lot of apps out there promote anonymity among the users. Apps like "Omegle" and "Chat with Strangers" were built around the premise of anonymity. The problem comes when the child is encouraged to give out their personal information during a chat session. Children can be gullible and may more readily fall for scams being perpetrated by an adult. Even seemingly useless information can be used to create a bigger picture.

5. Lack of Filtering

Some sites and apps are policed for inappropriate content while others are not. However, even on sites that are supposed to be policed and filtered for inappropriate content, some things still get through. Take YouTube as an example. It is very difficult to police millions of videos and code that can successfully filter videos by content are not very useful (i.e. skin tone recognition) and produce too many false positive alerts. Because of this, YouTube relies on the community of users to police the content and alert YouTube if inappropriate material is found. Does this work? Not well. When's the last time you spent hours looking at random videos for inappropriate content? Beyond YouTube, sites and apps usually filter content based on age restrictions. My kids use age appropriate sites for educational entertainment that does filter content. If you attempt to type foul language, the words will be replaced with asterisks. You will also be warned and, if the behavior continues, your account will be terminated. The big problem comes when children lie about their age and sign up for apps designed to be used by adults. In those cases, there are not content filters.

6. Intent of the App

Any app can be used in a benign or harmful way; however, many apps out there are specifically intended to be used for meeting up with people to either date or downright have a sexual encounter. Regardless of what my child may tell me regarding their use of an app specifically designed to facilitate a sexual encounter with an adult, I would never allow continued use of the app. The bottom line is apps intended to be used by consenting adults should not be used by anyone under age - period. Even if the child's intention is to use such an app outside of the apps expected use, other users on the app will not know this. Things can go horribly awry.

7. Maturity level

Continuing with the intent of the app and the age and maturity of the user, children may be signing up on these sites out of curiosity or the lure of monetary gain. Sites and apps designed to be "Sugar Daddy" dating apps can be alluring. "Meet a millionaire" who will bestow expensive gifts upon you! These sites are very dangerous. The judgment of a child is not mature ... because they are still a child. Reactionary decisions can lead to catastrophic results. A young girl may be upset because her parents refused to upgrade her iPhone to the latest version and her friend tells her about some "sugar daddy" dating app where she can meet a man that will buy her whatever she wants. Immaturity can be a hindrance to thinking things through and recognizing the potential dangers.

Here are some of the most important questions about boys with an uncircumcised penis.

How do I tell people we didn’t circumcise?

For the most part, you don’t have to. This is a personal decision, so don’t unless you want to.

If you have a particularly invasive friend or family member who insists on asking questions, it might be wise to be prepared with an answer, but as far as I’m concerned, it’s a medical decision that was yours to make and you shouldn’t feel the need to defend it.

How do I take care of the skin (or clean the penis)?

Treat it just like any other piece of skin. Wash the outside with whatever soap you would wash their big toe with. Heck, use the same technique. You wouldn’t try to peel the nail back to clean under it. Would you?

When should I start to pull the foreskin back?

Really, YOU shouldn’t. Ever. Retraction, even if not that forceful, can cause severe pain, bleeding and tears in the skin.

If you decided that at a certain time you were going to, you would almost certainly decide to do it too early. At birth? Only 4 percent of boys have a fully retractable foreskin at birth. When they start school, 8 percent of first grade boys are fully retractable. Even at seventh grade, only 58 percent of boys are fully retractable.

Boys should be taught that eventually things will start to change down there but there’s no reason to force the issue.

How do I keep someone else from retracting?

Because the teaching of the care of the penis might have changed since your parents had newborns, it’s important to express your desires to anyone who might be changing the baby’s diaper.

Grandparents, aunts, uncles and babysitters might just need a quick reminder how you want them just to use a wipe to clean off any poop they can see there but not try to pull back and clean underneath.

How do I keep a doctor or nurse from retracting?

Ok, here’s the real question and actually the question that prompted this post.

This is tricky.

I’ve heard of parents who were so concerned about this issue that they hesitated to take their children to a good pediatrician just because they might try to retract their foreskin. And it’s not a concern without merit. Good nurses and doctors in good hospitals still occasionally teach that a baby boy should have their foreskin retracted for cleaning.

Even if your baby’s foreskin survives the newborn period unscathed, there’s no guarantee that something won’t happen at an early pediatric visit. In the office, it’s unlikely that a nurse would retract the foreskin. They typically are not doing a full physical exam. The major offender here will be the doctor. So, watch us like a hawk.

One of the most common recommendations I’ve heard is to leave the baby’s diaper on. I’m not sure who thinks this will work. If the pediatrician leaves the diaper on and doesn’t take a second to check for both testicles and that there are no hernias just because you left the diaper on, they aren’t really a pediatrician you want to trust your child’s life with.

I have another suggestion. Play dumb. You made this choice and you’ve made it this far into this article so it must be important to you. You’re not dumb. You know how this is supposed to happen. But I suggest that you play dumb.

Go to a prenatal consult with your prospective pediatrician and ask a simple question, “Since we aren’t planning to circumcise, how do we clean our boy’s penis?” Their answer to this question should tell you what you need to know. If they try to convince you to circumcise, it’s probably time to move on. If they teach anything that is contrary to what you want done for your child, find someone else.

Bottom line is that the answer from the doctor should be …leave it be.

Karen Schultz, M.D., a pediatric pulmonologist at Cook Children’s understands the hype, but she sees at least one potentially dangerous side effect for children with asthma.

“To date, there are no published studies that prove or disprove the benefits of salt therapy,” Dr. Schultz said. “As with any therapy, even natural, there are potential side effects. One known side effect of inhaling a salt solution is constriction of the airways which could worsen asthma. So, even though the idea of a non-medicinal cure is attractive, at this point it cannot be recommended without further studies of both safety and results.”

On a website that lists salt rooms, more than 30 states have them. In Texas, at least two locations are in Dallas, one in Fort Worth and they are also found in Austin, Granbury and Southlake.

Saltescape.com describes a salt room, or halochamber, as “a microclimate designed to simulate the environment of a salt mine. The salt room is a dry, sterile environment that controls air temperature, humidity, air pressure and air content. Salt rooms are covered ceiling to floor in a salt application and utilize a halogenerator to crush pharmaceutical grade salt into small particles for inhalation to create the desired microclimate.”

Salt therapy offers a drug-free, non-invasive treatment where salt micro-particles enter into the lungs to help the healing process. Children as young as 3 months old have received treatment. Proponents of salt therapy believe children benefit from salt therapy because they are more prone to respiratory problems and their lungs aren’t fully developed until they are 9 years old. 

"Treating medical conditions without medications does have its appeal, so we are always on the lookout for new ideas and ways of doing things. We must continue to evaluate new ideas with studies that compare any possible risk against the benefit,” said Dr. Schultz. “You can certainly find multiple testimonies from people who swear that they are better after salt therapy. In fact after people with cystic fibrosis (CF) anecdotally noticed that they did better by the ocean, studies proved that use of an inhaled salt solution slows progression of disease, and it has now become a standard therapy.”

About the source

Karen Schultz, M.D., is a pediatric pulmonologist at Cook Children's. To schedule an appointment with her call 682-885-6299. The Cook Children's Pulmonary team diagnoses and treats children with lung diseases. Our team includes board certified pediatric pulmonologists, clinical nurse specialists, registered nurses, respiratory therapists, Child Life specialists, clinical dieticians and social workers. The professional opinion of each team member, including parents, is considered in developing a plan of care for your child. We place a high value on continuity of care with your primary pulmonologist.

Along with his medical degree, Dr. Pilgrim has completed a combined internal medicine and pediatrics residency, followed by pediatric chief residency at Maimonides Medical Center in Brooklyn, N.Y. His fellowship training in pediatric cardiology was completed at Cohen Children’s Medical Center with the North Shore-Long Island Jewish Health System.

Impressive indeed, but long before the tedious hours of study and hard work, Dr. Pilgrim’s career path began to take shape at a very young age. See, Dr. Pilgrim grew up with a congenital heart disease patient. His younger sister, Stephanie, was born with congenital heart disease, and she has the scar on her chest to prove it! Congenital heart defects represent the most common birth defect in children and occur in approximately 1 in every 100 children born.

Today, Stephanie is 35 years old, married and has kids, looking much like the patients you would see in the waiting room at Cook Children’s Adult Congenital Heart Disease clinic. In fact, conservative estimates predict that there are nearly 1.3 million adults with congenital heart disease in the United States with about 1 in 150 adults being affected. There are now far more adults than children with congenital heart disease in the US.

It makes perfect sense for Dr. Pilgrim to make this his career focus, right? Well, maybe, for everyone but Dr. Pilgrim. At least, it took him a little while to realize treating ACHD patients was his calling. ““There was a great deal of angst in choosing my career path” he said, chuckling. “I really wanted to be able to apply my internal medicine training to a pediatric subspecialty career path that would allow me to assist in the transition of adolescent and young adult patients to the adult medical arena. I was really drawn to the world of intensive care early on in my residency training, but I loved building long term rapport with the patients and their families in the outpatient setting as well.”

Toward the latter half of his medicine-pediatrics residency, Dr. Pilgrim finally latched on to the idea of pursuing a career in adult congenital cardiology. “Congenital heart disease was fascinating to me in medical school. I was drawn to the complexity and singular nature of each defect and the associated repair. As time progressed, I learned of the growing need for ACHD specialists for a large, vulnerable population with a noted care gap. This field has proven to be the perfect fit for me.”

Once he decided this was the right direction for him, Dr. Pilgrim has never looked back. After all, these are the patients he can identify with like no other. He grew up with one.

“My sister grew up with a scar on her chest. As kids, we called it her “zipper”. We, like many patients today, said, ‘It’s fixed! There’s nothing more to be done’. However, in many cases that is simply not true. Surgery is rarely a cure and most congenital heart defect survivors need lifelong specialized care.”

But Dr. Pilgrim and his colleagues know that many adolescent and young adult patients don’t realize the severity of their heart problems, or at the very least, that they need continued care. Most patients were diagnosed in infancy and don’t remember their surgical repair. Many have dropped out of care for a variety of reasons. “Much of my job revolves around providing education to the patient about their heart disease so that they can develop autonomy and learn to advocate for themselves as they grow older.”

Dr. Pilgrim explains that adults with congenital heart disease remain at risk for long term complications including heart failure, abnormal heart rhythms, pulmonary hypertension and premature cardiovascular death. On top of that, adult onset disease such as hypertension, obesity, diabetes and acquired cardiac disease begin to interplay with their unique physiology. Many ACHD patients will require additional surgical intervention or added medications, even if they had a successful repair as a child. This underscores the need for specialized care. However, fewer than 10% of all adult congenital heart disease patients receive the recommended care in a specialized center.

Congenital heart disease has dramatically changed the landscape of another field in cardiovascular medicine, that of pregnancy and heart disease. Rheumatic heart disease has been replaced by congenital heart disease as the most common heart disease in pregnant women in the US.

“A lot of women show up to the clinic, just like my sister, wanting to become pregnant and wanting to know the risks to themselves or the potential risks to the fetus,” Dr. Pilgrim said. “At Cook Children’s ACHD program, we provide women of child bearing potential with important education regarding birth control options, pre-pregnancy counselling and risk assessment. Women with congenital heart disease who are already pregnant are followed in conjunction with the obstetrician, maternal fetal medicine, fetal cardiology and anesthesia teams with a coordinated delivery plan. We can counsel and treat the woman with the heart problem, while also taking any necessary precautions for the baby after birth.”

But Dr. Pilgrim stresses that there is plenty of optimism for the ACHD patient to live a full life despite their heart disease.

“Too often we find that these individuals become defined by what their disease is rather than who they are as a person” Dr. Pilgrim said. “In some ways their defect may limit some of the things they can do, but it shouldn’t limit their happiness or ability to live a fulfilled life, with the proper treatment. I think that’s the most optimistic message that I can give patients in the community. Through education and proper surveillance in a specialized ACHD center, you can live an active and healthy lifestyle.”

Dr. Pilgrim speaks from the example of how well his sister is thriving as an adult with ACHD. Especially, with the right program, like you will find at Cook Children’s, caring for you.

More about Scott Pilgrim, M.D.

• Dr. Pilgrim spends his free time with his wife and three beautiful children.
• He is particularly involved in musical pursuits, having performed with the 6-time Grammy Award Winning Brooklyn Tabernacle Choir for 12 years.
• He is also a sports fanatic, enjoying baseball, football, basketball and anything else involving healthy competition.
• Yes he knows about the movies and graphic novel, Scott Pilgrim vs. The World.

The ACHD program at Cook Children's

At Cook Children's, we care for the needs of patients with congenital heart disease from the moment they're born, and we stay with them all the way into adulthood. Our Adult Congenital Heart Disease (ACHD),  is one of only a few formal programs nationwide to offer inpatient and outpatient care for teen and adult patients with congenital heart disease, because adulthood, like childhood, should be as simple as possible.

She loves to use her baby talk with Dominic. As both a speech-language pathologist and a father, I’m conflicted. The sparkle in his eye and wonderful smile just make you melt anytime she says “O doe ma chikyweekys” or any other baby talk. It’s great, I get it, BUT we have to throw in some real words. Who will ever understand him if he says “chikyweekys.” Again, what is that?!?! (I’m just giving my wife a hard time, hopefully she doesn’t read this!)

You may have heard the term motherese and wondered what it was. Baby talk and motherese sound similar, but if you really pay attention there is a difference. Baby talk is the changing of your voice from high to low, but with nonsense words. Hence, “O doe ma chikyweekys” is a great example. But motherese, or parentese, is a bit more sophisticated and much more preferred by me as a speech therapist and as a male/father:

Parentese is:

• Varying your intonation using a sing-songy voice
• Slowing your rate of speech down
• Using short simple phrases with REAL words
• Having FUN

So if you were showing a baby a puppy for instance, you may want to try it like this: “Oh looook at the puuuuppy. Isn’t it a preeeetty puuuuppy!” As the individual using parentese, you would make sure to put some inflection (raise your voice in a fun loving way) on a few of the important words in the sentence. In this case, you could consider the important words to be “look,” “puppy” (both times) and “pretty.”

Let’s say you were playing hide-n-seek and tickle time with your baby, you could do something like this:

“Where’s my baaaaby? Where’s my baaaaby boy? Oh, I seeee him? ... tickle, tickle.” The important words in this case may be “baby” (both times) and “see.”

Some parents find that using parentese is hard or even embarrassing. I don’t blame them. When I started as a speech therapist, I thought it was awkward and very unnatural. As I used it more, I noticed a huge difference in my interactions with the little kids I was treating. They actually listened to me.

What happens if you don’t use parentese? Does the name Ben Stein mean anything to anyone? “Bueller? Bueller?” He’s that guy. He’s the one in the Clear Eye commercials using a monotone voice. The next time you play with your child, I want you to try a little experiment. While playing, talk in a monotone, Ben Stein-like voice, keeping your pitch the same throughout. Although Mr. Stein can get our attention for those commercials, you will see how quickly you lose your child’s attention.

Just like anything else, talking in parentese takes some practice, but from a child’s perspective hearing parentese is exciting and interesting. As a therapist and as a parent, I need my child’s attention if I want to teach them anything. I have seen how using parentese works in a therapeutic setting and now, with my son Dominic, I’ve seen first-hand how it works at home as well. Using my sing-songy voice, it may sound a little like this ...

Our interactions may sound silly to others, but when Dominic and I are in the moment it’s just plain good old-fashioned fun. I believe Rob Olson said it best when he said “My childhood may be over, but that doesn’t mean playtime is."

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. 

Evaluation, treatment and home programming are available for children with:

• Feeding and swallowing disorders
• Articulation, voice, resonance, and fluency disorders
• Receptive and expressive language disorders
• Aural rehabilitation/ auditory verbal therapy for hearing loss or cochlear implant
• Evaluation for augmentative communication devices

Good dental health is critical for everyone, regardless of age. It's important to remember that the health of you and your children’s teeth and gums can have a direct impact on their overall health. While poor dental hygiene can lead to gum disease, cavities and tooth loss, the bad news doesn’t stop there.

Several studies show that the bacteria in your mouth from periodontal disease (gum disease) can contribute to various health concerns.

Here are 5 health concerns you may not have realized that are currently being studied:

1.Heart disease - People who develop gum disease as a result of poor dental health, have a higher risk of also developing heart disease. The bacteria that causes gum disease can cause inflammation as it travels through the blood stream which in turn can cause a stroke or heart attack. And those individuals who already have existing heart conditions are even more prone to developing endocarditis (an infection of the heart) which can be life threatening.

2.Respiratory disease - Scientists have found that bacteria in the mouth can be taken into the lungs and cause respiratory diseases such as pneumonia.

3.Pregnancy - New research suggests a possible link between gum disease and babies born with low birth weight or premature babies. And optimal oral hygiene during pregnancy may decrease the amount of cavity-causing bacteria that can be transmitted to the new baby.

4.Alzheimer’s - There is current ongoing research that states that the bacteria originating from gum disease can travel to areas of the brain which can trigger Alzheimer’s later in life.

5.Malnutrition - Gum disease and pain can often lead to people not getting the adequate amount of calories and protein needed to maintain a healthy diet. Therefore it is not uncommon for children and elderly to suffer from malnutrition if they are experiencing dental pain.

So make sure you take care of those pearly whites for a great smile and healthy body!

Some choose to stop breastfeeding. Some move on from spending all their extra money on formula. Everyone is wondering what milk to move to next.

The standard answer used to be ... whole cow’s milk. Now 2 percent seems reasonable; even soy in those who have had issues with cow’s milk before. Let’s start off by saying that there’s nothing magical about milk. I like to think of it as an easy way to get your child calories, protein and calcium. But, if they are getting those nutrients from other sources, I am not too concerned about how much milk they drink.

What about almond milk?

Almond milk sales have gone through the roof over the past decade. As more adults identify as lactose intolerant and are turning to plant-based alternatives, it’s no surprise that they are starting to consider it an alternative to cow’s milk for their children.

Let’s start by comparing the nutritional information:

Almond milk is made by crushing up some almonds and mixing them with some water. It’s not fancy. In commercially available products, 1 cup has the equivalent of about 4 almonds worth of nutrition in it.

Given that I consider the primary benefits of milk to be a source of calories (35 in almond compared vs 160 in whole cow’s milk), protein (1 vs 9 grams) and calcium (2% RDA vs 30%), almond milk doesn’t exactly measure up. This could be a problem with a picky eater whom the family is relying on almond milk, thinking it will help supplement when they do not eat well.

Could almond milk be harmful?

A case study published online for Pediatrics (February 2016) describes a case where a child fed predominately almond milk and almond flour from 2.5-10 months of age resulted in the child having scurvy. Scurvy is a disease that is the result of having too little vitamin C and can result in bone thinning and fractures. Of course, the improper use of cow’s milk over this time could also cause a number of health problems as well, including anemia.

Prolonged use of almond based milk has been linked to low chloride levels and failure to gain weight in other patients. I believe these are both also related to poor intake of other foods, as a child can grow just fine without nutritional deficiencies with a balanced diet and water.

What’s the bottom line?

Is almond milk the most terrible thing in the world? No.

Is it a good alternative to cow’s milk for your child? No.

It just doesn’t have the same nutritional value. Your child might as well just drink water. Focusing on a balanced diet is key no matter what.

When I advise my 3 year old patients to wear helmets on their tricycles, then I end up with 10 year old patients who wear their helmets. It’s near impossible to convince my 10 year olds to START wearing a helmet.

Why do you think so many ED doctors end up advocating for car seat safety? They see the results of horrible car accidents that could have been prevented.

That’s how I feel about obesity prevention. Far and away, poor diet and a sedentary lifestyle wreak havoc on the mental and physical health of my patients – from young to old – those with poor lifestyle choices have a decreased quality of life. They come to see me with more illnesses, more headaches and most certainly more abdominal pain.

When I start talking to my families about diet, I try to give anticipatory guidance about offering fruits and vegetables and limiting processed foods. Toddlers and young children do two things really well – they don’t eat when they are not hungry and they stop eating when they are full.

We as parents, and grandparents, mess up their satiety cues by trying to get them to eat when they are not hungry and trying to get them to keep eating when they are full. Allowing children to control the amount of food they eat leads to a long term healthy relationship with food. Parents have control over what is offered but should not try to control how much is eaten.

Along those same lines, children are naturally conditioned to be outside and to be active. We as parents mess that up by keeping them inside in front of an iPad or video game. We have control over their media time.

I think focusing on healthy behaviors rather than BMI is a positive way to talk to parents. Most parents are doing 1 or more things right in the 5-2-1-0 recommendations. Kids are motivated to follow these recommendations, but they need their parents to create an environment at home that allows them to do so. This goes along with the thinking of the Blue Zones.

I do think there is value for using BMI as a tool. I usually show growth charts to families as an objective measurement of what is happening and then we turn to talking about healthy behaviors. But I do see a flattening of BMI with improved diet/activity choices. It is also not uncommon for me to see an increase in BMI and ask what has changed, and families are usually able to say – oh yeah, he quit playing soccer, or he doesn’t have PE this year….etc.

When you look at guidelines for treatment of obesity, the first thing you must have is motivation for change. If that is not there, you really can’t go forward. What if we don’t have to motivate people to change because they have been feeding their children correctly from the beginning?

If you have paid attention to football over the last several years you know that there have been many rule changes geared toward preventing concussions.

Most of these rule changes have been spurred on by a huge law suit that was brought against the NFL by a large group of former players, in which the NFL will wind up having to pay out more than 1 billion dollars. The bottom line and what is portrayed in the movie is that there was research that brought into question the harmful effects of repetitive head trauma related to football. The NFL rather than looking into this and aiding this research in an effort to find out more, put its efforts into discrediting the research and trying to cover their own interests.

The research they were trying to discredit dealt with the autopsies done on the brains of former NFL players that displayed a condition called Chronic Traumatic Encephalopathy or CTE. CTE is a progressive degenerative disease found in people who have suffered repetitive brain trauma, including sub-concussive hits to the head that do not cause immediate symptoms.

Individuals with CTE may show early symptoms of dementia, such as memory loss, aggression, confusion, and depression. Just this past week Ken Stabler former Super Bowl winning quarter back for the Oakland Raiders who played 15 years in the NFL and who died in July was found to have stage 3 CTE.

While there is much more research that needs to be done to fully understand the potential long term effect of concussions and repetitive head trauma the current evidence can’t be ignored. One of the scariest things about concussions is how much we don’t know.

While the NFL is portrayed in a pretty bad light in the movie, in their defense I don’t think they reacted much differently to concussions than the majority of the population does. For the longest time I think a lot of people (myself included) had the attitude of “Oh it’s just a concussion.”

Working with concussion patients in clinic I have heard parents say, “I played football and got a few concussions I didn’t realize that it was a big deal.”

There are many athletes who might get a concussion, recover well and never have any other problems, but there are also patients who have an extremely difficult time recovering. We see patients take months to recover and report constant headaches, dizziness, blurred vision, difficulty concentrating in school, and mood swings.

We have seen patients whose parents report a complete change in their personality where they are much more angry and aggressive than they were before the injury. The scary thing is we don’t know how a person is going to react after a concussion, or how many concussions are too many, or if the repetitive sub-concussive trauma that they sustain is enough to cause problems later in life.

I played football when I was younger. I’m not coming out against playing football, but when I played you couldn’t start playing tackle until your eighth grade year which means 13-14 years old. We have to remember that elementary age through high school kids still have brains that are developing and we need to protect them.

The longer they play full contact football the more hits and more traumas they are exposed to, so I think we need to pay close attention to when we let our kids start playing tackle football. We also need to keep a close eye on how our kids recover if they do sustain a concussion. The longer and more difficult a patient’s recovery is the first time they have an injury, the more likely they will have a long, difficult recovery if they sustained another concussion.

Finally, how many concussions are too many? The answer is we don’t know for sure. What we do know is that concussions are mild traumatic brain injuries. We also know that CTE is a condition found in people who have suffered repetitive brain trauma. So how many concussions constitute “repetitive trauma?” That is a question we cannot answer for sure, but one that I think parents should think long and hard about before letting their kids back on the field.

SPORTS resources:

• The Cook Children's SPORTS program
• Football injury prevention
• What every parent should know about concussions
• There's no such thing as 'just' having your bell rung
• Top 10 questions parents have about sports injuries
• Injury Prevention Guide
• Strength training in children/adolescents
• Young athlete's injury prevention guide
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• Preventing children's sports injuries
• Pain that won't go away

While that was an easy question to answer, I do get more difficult questions about young children with hyperactivity.

In order to start this conversation, it is important to remember the core ADHD symptoms: inattention, impulsivity and hyperactivity.

Based on appropriate diagnostic criteria, you cannot diagnose ADHD until age 4. It is also difficult to diagnose children until they are in school because the diagnosis requires that symptoms be present in more than one environment.

As with any type of behavioral problem, the degrees of severity present a wide spectrum of the various symptoms of ADHD.

Inattention-Some children can focus for hours at a time but some jump from one activity to the next very quickly, seeming to never really focus on one thing for a significant amount of time.

Impulsivity-Some children are very cautious and don’t do anything dangerous, while others jump from my exam table across the room to the chairs on the other side.

Hyperactivity-Some children can sit still for long periods of time, while others are constantly fidgeting and restless.

So, how does this look in a 3-4 year old child?

All 3 and 4 year olds show signs of inattention. There are a select few children in this age group who can maintain focus for extended periods of time. Because of this, it’s hard to get too excited about concerns about a 3 year old’s attention span.

I have definitely seen varying levels of impulsivity in this age group. Those that are highly impulsive, in my experience, often go on to meet criteria for ADHD as they get older. Remember, however, that talking back and aggression are not necessarily impulsivity.

The most common symptom that parents interpret as ADHD is hyperactivity. There is definitely a difference between the general restlessness of a typical 3 year old and a child that truly becomes ADHD in the future.

Children at this age are often described by parents who report, “Their motor is just always running” or “They just go non-stop from the moment they wake up.” Because I see so many children of this age group every day, I also have some subjective sense of what is normal or abnormal for the age group and this can help my assessment over time. However, I never make snap judgments because any child can act like they have ADHD on a particular day.

So, what if you are concerned that your young child may be showing some signs of hyperactivity? A great place to start is here: ADHD Behavioral Treatment-8 Tips.

Here are some basic things to remember:

1. Try to stay patient.

Because so many of these young children will outgrow these symptoms, it is important to stay patient with them.

2. Try to stay calm.

Anxiety only makes hyperactivity worse. Yelling at a kid to sit down and shut up will most likely just make your problems worse.

3. Try to stay consistent.

Children with hyperactivity do their best with structure and clearly defined boundaries. If these children don’t know what to expect from minute to minute, they cannot adjust as easily as most kids. If they are not disciplined consistently, they do not know where the boundaries lie. With any behavior problem, I ask my families to pick out what 1 or maybe 2 behaviors that they want to extinguish and be consistent in the their punishment for those. It is not feasible to fix all of your child’s problems at once.

Also remember to praise them when they do the proper behavior. If a child is only getting negative reinforcement, they will often choose that over positive reinforcement.

Dr. Rogers explains that there’s really not a cure for a common cold and then lets them know why she’s not giving the child an antibiotic and why no one else should either.

“I understand this mindset,” Dr. Rogers said. “You come to the doctor and you want to be treated. Parents often want an antibiotic. That’s why they are there to see me. They can’t afford to take time off when their child is running a fever and sick. They think the antibiotic will make the illness go away faster.”

But if the cold is viral, it’s simply going to run its course. The antibiotics will not have any impact on the cold at all. With something like a cold, you just have to wait it out.

The American College of Physicians and the U.S. Centers for Disease Control and Prevention agree with Dr. Rogers. They have issued new guidelines for prescribing antibiotics for acute respiratory tract infections (ARTIs) in adults.

The two organizations advice to adults is similar to Dr. Rogers’ advice to children: Use antibiotics to treat bacteria that causes the likes of strep throat and food poisoning. For common viruses like the common cold and flu, the recommendation is drink extra water and juice, use a cool mist vaporizer or saline nasal spray to relieve congestion.

“It’s not that I’m against antibiotics, but for the right reasons,” Dr. Rogers said. “Pertussis starts with cold-like symptoms, just kind of a mild cough, and after 2 weeks the cough gets much worse. In those cases, not only the patient, but the entire family, will need antibiotics, but once the patient has been infected, expect him or her to have a prolonged cough.

Other times antibiotics may be necessary with illnesses including:

•  Sinusitis or secondary bacterial infections, related to a cold.
• Certain skin conditions caused by bacterial infections, such as impetigo.
• Strep throat
• A severe ear infection

“I really do try very hard to limit my prescriptions of antibiotics for bacterial infections,” Dr. Rogers said. “If your child has an ear infection and it’s red and bulging, as a parent I would want antibiotics to help ease my child’s suffering.”

However, other caregivers aren’t as careful with their prescriptions, Dr. Rogers warns. She said this can cause the medication to not be effective or even useless when a child actually needs antibiotics. The infectious organisms adapt to the antibiotics, leaving the patient immune to the antibiotic.

Antibiotics have played a vital role in treating patients with infectious disease for 70 years, Dr. Rogers said. When prescribed the right way, antibiotics can prevent illness and even death. But when antibiotics are prescribed carelessly, they lose their effect.

“We frequently see patients who have been prescribed antibiotics at the doc-in-the-box type clinics,” Dr. Rogers said. “It sometimes seems to me that they have a mandate that everyone must walk out with a prescription. They often prescribe an antibiotic, steroid or prescription cough medicine regardless if the patient needs it or not. None of that stuff works for a cold. In fact, studies have been done that say it makes your child worse. The antihistamine thickens the secretion, so you can’t get the yucky stuff out. That’s how you get better, by getting the mucus out and resting. When we’re sick, especially children, we need lots of rest.”

Dr. Rogers’ advice is to see your Cook Children’s pediatrician. Other options include a Cook Children’s Urgent Care Center or Neighborhood Clinic. If a doctor prescribes an antibiotic, she says it’s Ok to ask if it’s the right thing to do. If the doctor says it’s bacterial or to stop an infection, then proceed.

“There’s no magic cure for the common cold,” Dr. Rogers said. “And unfortunately, too many prescriptions of antibiotics are zapping the magic out of what was once a miracle drug."

About the source

Audrey Rogers, M.D., is located at 3200 Riverfront Drive, Ste. 103, Fort Worth, TX 76107. To make an appointment with her or one of her partners, call 817-336-3800. Like her on Facebook.Dr. Rogers received her undergraduate degree from Emory University in Atlanta, Ga., her medical degree at Southwestern Medical School in Dallas, and completed her pediatrics training at Children's Hospital of Oklahoma. Her special interests are behavioral pediatrics and adolescent medicine. She became board certified in 1989.