With kids going back to school, new questions are coming up on when kids should be tested for COVID-19 and when they can return to school.

Keep in mind there are some conflicting and confusing pieces of advice out there and this is only promised to be up to date as of on Sept. 25, 2020 when we are publishing this. But here are some reasonable-evidenced based approaches on testing and returning to school.

Who needs to be tested for COVID?

All patients with high risk symptoms and without another explanation should be tested for COVID before returning to school. These symptoms include:

• Fever
• Cough
• Shortness of breath
• Body aches
• Loss of taste/smell
• Headache
• Sore throat
• Sustained vomiting or diarrhea (and usually a combination of these symptoms)

If high suspicion for COVID still exists after a negative test is obtained, a second test the next day may be recommended by your doctor. If the COVID test or tests are negative, the child may be treated as they normally would for that illness (for example, returning to school after they were fever free for 24 hours).

All patients with low risk symptoms and NO known exposure to COVID can be tested before returning to school based on physician discretion. Low risk symptoms include congestion or runny nose, rash or a single episodes of vomiting or diarrhea.

If COVID is negative, the child can be treated as they normally would for that illness. Patients with low risk symptoms and no known COVID exposure may be tested, but do not necessarily need to be if their medical provider feels comfortable that their symptoms do not require it. The patient should be counseled on the high-risk symptoms to look for and they should be counseled if they do discover a possible exposure or develop high risk symptoms.

All patients with any exposure to COVID, regardless of symptoms, will need to be home on quarantine for 14 days after their last exposure to someone with COVID. They can be tested during that time if they are ill, but even if it is negative, they will need to stay home for the full 14 days. If they test positive during that time, they will need to stay home for 10 days after the onset of their own symptoms instead.

When can my child go back to school?

Children with a known close exposure to COVID must stay isolated for 14 days from exposure. Negative testing does not decrease the time of quarantine and should not be used to allow a child to return to school sooner. If continued contact with the exposed case could not be avoided ( for example you, the primary caregiver), longer duration of quarantine may be required. I recommend talking with your doctor or the health department about a safe return to school dates.

Children with a known case of COVID-19 are able to return to school:

• No sooner than 10 days after their symptoms started
• Have improvement in symptoms
• Are 24 hours without any fever while not using fever reducing medicines.

If symptoms are minimal or they are asymptomatic when they get their initial test, this 10 day period will be started at the time the test was conducted.

Does my child need a negative test to return to school or activities?

The quick answer is, No.

As long as the above guidelines are followed, negative testing should not be required to return to school. Some kids may remain positive (in testing alone but they aren’t contagious) for weeks and a sustained positive test should not prevent them from returning to school or other activities. Therefore, it does not make sense to require follow up testing in most instances.

Summary

It’s never been more important to have a sustained, quality relationship with your pediatrician. As we continue to navigate these complex decisions, having a provider who knows your child and can help you make decisions can go a long way to keeping them in school as much as possible and to ensure that their classmates are safe.

Moderate to severe asthma is a possible risk factor for severe COVID-19 disease according to the Centers for Disease Control and Prevention. But a COVID-19 infection can cause a flare up of even mild asthma. COVID-19 is a respiratory virus and contracting an infection with any respiratory virus can trigger an asthma flare-up. In fact, the most common cause of an asthma flare-up in children is a viral respiratory infection.

What does my child with asthma need to do to stay healthy during COVID-19?

The single most important thing a child with asthma can do to stay healthy during COVID-19 is to control their asthma. Here is a list of some important ways to keep your child with asthma healthy:

1. Control their asthma.
2. Wash hands frequently with soap and warm water for 20 seconds, especially before eating or drinking or touching any part of their face.
3. Avoid being around people who are sick.
4. Maintain a social distance of 6 feet outside the home.
5. Wear a face mask in public (if the child is older than 2 years of age and is able to remove the mask by themselves).
6. Absolutely no smoking or vaping inside or around a child with asthma. Now is a great time to try quitting by calling 1-800-QUITNOW!

In addition, make sure to track when the asthma medications need to be refilled so the child does not run out, as this can trigger an asthma flare-up. And keep an extra supply of the child’s quick relief medication (usually albuterol or levalbuterol) at home in addition to the one they are using.

What is “asthma control”?

Children with controlled asthma are less likely to develop an asthma flare-up when they are exposed to one of their triggers, like a viral respiratory infection. Asthma control also means almost no day-to-day asthma symptoms. The symptoms of asthma are wheezing, coughing, chest tightness and shortness of breath. Asthma is UNCONTROLLED if any of those asthma symptoms are:

1. present during the day more than just two days per week
2. OR cause any night waking
3. OR cause any physical activity limitation
4. OR require more than to quick-relief treatments per week
5. OR require systemic steroids (like oral prednisolone or prednisone) more than once in the last 12 months

The best way to control asthma is to avoid or minimize exposure to asthma triggers and take daily maintenance asthma medication (typically an inhaled steroid) as prescribed. Asthma maintenance medication should almost always be taken every day, even when the child with asthma “feels fine.” Not all children with asthma need daily maintenance medications. But, if a child’s asthma symptoms are uncontrolled, they might benefit from daily asthma maintenance medication. Now is a great time to assess your child's asthma symptoms to determine if the current plan is controlling their asthma. If the asthma isn’t controlled, call your asthma doctor to review the plan and adjust if needed.

What if my child with asthma says they “can’t breathe” or is scared while wearing the face mask?

Wearing a face mask is important for everyone going out in public at this time and is especially important for children with asthma. Many young children can be resistant to wearing them at first but with persistence and patience, this can usually be overcome. Here are a few ideas to help make masks seem less scary from the American Academy of Pediatrics:

1. Look in the mirror with the face coverings on and talk about it.
2. Put a cloth face covering on a favorite stuffed animal.
3. Decorate them so they're more personalized and fun.
4. Show your child pictures of other children wearing them.
5. Draw one on their favorite book character.
6. Practice wearing the face covering at home to help your child get used to it.

Regarding a child with asthma saying that they “can’t breathe” while wearing a face mask, it is important to make a distinction between the feeling of being short of breath and a true difficulty breathing causing a drop in the oxygen level in the blood. Only patients with very severe lung disease or who have very weak breathing muscles would have their blood oxygen levels decreased simply by wearing a face mask. If needed, this could be tested with a pulse oximeter at most physician offices. If the feeling of being short of breath is present but their blood oxygen level is normal, then it is safe for them to wear a face mask.

For more information on children and face masks from the American Academy of Pediatrics

Are steroids safe to give to treat asthma during the pandemic?

Inhaled steroids have been the daily asthma maintenance medication of choice for decades now and continue to be very safe, very effective, and very necessary for patients with persistent asthma during in the COVID-19 pandemic. A child with asthma should NEVER stop their daily inhaled steroids unless instructed to by their asthma doctor.

Systemic steroids are related to inhaled steroids but instead are much stronger and given by mouth (or injection) for short periods of time (less than 10 days) to treat asthma flare-ups. Systemic steroids can be safely given for asthma flare-up, if needed, even if that flare-up is triggered by a COVID-19 infection.

Are nebulizers safe during the pandemic?

COVID-19 (like all respiratory viruses) spreads by aerosols created when an infected person coughs or sneezes. An aerosol is a super-fine mist that floats in the air. Another person can then catch COVID-19 by breathing in these infectious aerosols. COVID-19 can also be spread if these aerosols settle on surfaces that are then touched by someone else who then touches their face. In addition to coughing or sneezing, anything that generates aerosols can spread a virus. This includes laughing, singing, loud talking and nebulization.

Nebulizers are devices for administering certain kinds of asthma medication. Nebulizers work by turning a liquid medication into an aerosol that is then breathed in by the patient. If a person infected with COVID-19 (even if they have no symptoms) uses a nebulizer, the virus can become aerosolized and pose a risk of infection to anyone nearby. Fortunately, most nebulized asthma medications can be changed to medication given by inhalers. Inhalers can be used with a mask attached to a tube (such as a spacer or valved holding chamber) in even the youngest asthmatics and cannot create infectious aerosols the way a nebulizer does. Discuss with your asthma doctor if changing from nebulizers to inhalers is right for your child.

How do I tell the difference between COVID-19 and asthma?

COVID-19 symptoms can appear two to 14 days after someone comes into contact with an infected person. COVID-19 symptoms can include fever, chills, cough, shortness of breath, trouble breathing, feeling tired and weak, muscle or body aches, headache, new loss of taste or smell, sore throat, stuffy or runny nose, diarrhea, nausea or vomiting, pinkeye, painful blue or purple lesions on toes and even hives or rashes. Many of these symptoms overlap with those of asthma, allergies, the flu or other viral respiratory infections (“colds”). Because of this overlap, being tested is the only way to know for certain if a child’s symptoms are due to COVID-19.

For more information, The Asthma and Allergy Network has a helpful chart comparing the symptoms of COVID-19, the cold, flu, allergies and asthma

What do I do if my child gets sick with asthma during the COVID-19 pandemic?

The possibility that a child with asthma’s active symptoms could be due COVID-19 infection does not change the initial treatment. I tell my patients that an asthma flare-up due to COVID-19 is still an asthma flare-up. If a child has asthma and develops any coughing, any wheezing, any shortness of breathing, any trouble breathing or any chest tightness, they should start their asthma action plan immediately.

The most common first step in an asthma plan is to treat these symptoms with their quick relief medication (usually albuterol or levalbuterol). If these symptoms do not respond or get worse, the child’s asthma doctor should be consulted immediately for additional guidance.

 When should I take my child with asthma to the doctor?

Most asthma flare-ups can be safely and effectively managed at home by following your asthma action plan and consulting your child’s asthma doctor by phone if needed. But, if the plan is not working or symptoms worsen, a change in the treatment plan or closer monitoring might be needed. Call your child’s asthma doctor if any of the following symptoms occur:

• worsening cough or wheeze
• new chest pain or back pain
• decreased ability to do usual physical activities​
• symptoms not responding to albuterol plan (but otherwise not in distress)
• needing albuterol more frequently than every 4 hours (but otherwise not in distress)
• not improving significantly after 2-3 days of increasing albuterol

Asthma flare-ups can become a life threatening emergency. If your child shows any of the following warning signs, their asthma flare-up has become a life threatening emergency. Start the emergency plan part their asthma action plan (often called “the red zone”) and call 911 or go to the nearest emergency room immediately if your child:

• can't catch their breath,
• can’t speak in full sentences
• can’t walk because of breathing difficulties
• sucking in (retractions) under the ribs or at base of neck
• abnormal movement of the belly while breathing (belly breathing)
• turning a bluish or grayish color around their mouth or fingernails
• making grunting noises
• head bobbing with each breath
• not responding to albuterol treatments
• feeling drowsy or confused

When should I take my child with asthma get tested for COVID-19?

The CDC website has a Coronavirus Self-Checker – an excellent and easy to use assessment tool to you decide if a child (older than 2 years) or adult needs to seek testing or medical care due to COVID-19. The online and mobile-friendly tool asks a series of questions, and based on your responses, provides recommended actions and resources.

If my child with asthma gets sick, when can we be around other people again?

If a child has an asthma flare-up during the COVID-19 pandemic, it is important to stay home and away from other people. Staying away from others helps stop the spread of COVID-19. You can be around others after 10 days since symptoms first appeared and at least 24 hours with no fever without the use of fever-reducing medications

For more information about COVID-19 and children with asthma from the American Academy of Pediatrics, click here.

https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Caring-for-Children-with-Asthma-During-COVID-19.aspx

For more information about COVID-19: cdc.gov

References

** Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2020. Ginaasthma.org

*** https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

For more than six years, Cook Children’s online newsroom has provided the latest in pediatric health news to more than 16 million people in 230 different countries.

But during all that time, the team behind the scenes felt they had more to accomplish. At the top of their list was creating an online Spanish language presence. This month, they reached their goal with the publication of Checkup Newsroom En Español.

This new newsroom is in Spanish, with content written and approved by Cook Children’s pediatricians and health care providers.

“We know the importance of sharing up-to-date and evidence-based information with our patients and their families,” said Bianka Soria-Olmos, D.O., a Cook Children’s pediatrician and primary contributor to the webpage. “Checkup Newsroom is hugely important for getting out timely and relevant health information. With our community being so diverse, we realize making this information available in Spanish is necessary.”

The addition of the Spanish-language newsroom builds on Cook Children’s ‘Promise’ to improve the health of every child through the prevention and treatment of illness, disease and injury.

The COVID-19 pandemic has highlighted the need for credible health information in the Hispanic community. According to Tarrant County Public Health, 27% of COVID-19 cases are among Hispanics, making it the most affected group by race and ethnicity. Further, Texas’ Hispanic population has grown by more than 2 million since 2010 and the state's demographer predicts that Hispanics will be the state's largest population group by mid-2021.

“We are so happy that Cook Children’s is making so many efforts to be inclusive,” said Vicki Kelley, Family-Centered Care Program Manager, who oversees the Hispanic Family Advisory Council at Cook Children’s. “All parents want to do what’s best for their children. Having an online presence such as Checkup Newsroom gives parents a great resource to find helpful and accurate information for their kids.”

“The publication of our Spanish newsroom is a great next step in our diversity and inclusion efforts at Cook Children’s,” Wini King said. “We’ve talked about making this happen for many years, but were limited in time and resources. The timing just felt right, and with the COVID-19 pandemic, we know this information is needed now more than ever.”

Most people develop some redness and itching after a mosquito bite. Unfortunately, some children will have what’s known as a large local reaction, or “Skeeter syndrome.” This happens due to an allergy to mosquito saliva. These patients develop redness and swelling within hours of a mosquito bite. The swelling can be very large (like an entire arm or leg) and typically worsens over 1-2 days. In the worse reactions there can be bruising and even blistering!

It’s not always easy even for your doctor to tell the difference between “Skeeter syndrome” and a skin infection. One of the big differences is the timeline. Skin infections usually happen several days after a bite or an injury, but “Skeeter syndrome” usually starts within a few hours of a bite. Most often children with a large local reaction will complain about intense itching. Only in the more severe cases are pain and fever seen with allergy. It’s not common, but some even develop severe allergic reactions to mosquito bites that lead to difficulty breathing.

Large local reactions are best treated with oral antihistamines (Benadryl or Zyrtec) and topical over-the-counter steroid cream (hydrocortisone 1 percent). Fingernails need to be trimmed very short, because scratching causes local skin damage that can become infected. Cold compresses several times a day help alleviate some of the discomfort. In patients who have a history of this type of reaction, I recommend daily antihistamines such as Zyrtec during the time of the year when bites are difficult to avoid. This doesn’t totally prevent the reaction, but can help keep the swelling from being as extreme. I don’t recommend topical antihistamines (Benadryl cream) because some people develop a contact allergy that actually worsens the problem

So, when should you come to the doctor? 

Any child with significant eyelid swelling or swelling that is limiting activity or skin blistering deserves an office visit because they require further evaluation and sometimes even need oral steroids or more potent prescription topical steroids. Red/swollen/hot areas of skin that are associated with pain or fever should also be examined to rule out a bacterial infection.

Tick bites don’t usually cause itching like mosquitos, but are more of a concern due to infections they can transmit. Ticks are predicted to be more prevalent this summer due to the winter being relatively warm. Ticks can transmit several infections with Lyme being one that is often discussed.

If you find a tick on your child it should be removed with tweezers by grasping the tick as close to the skin as possible and pulling straight up. Different types of ticks spread different infections. For example, infected deer ticks can spread Lyme after being attached for 36 hours or longer. Certain areas of the country have a much higher rate of local tick infection than others. Texas is not a part of that area, but cases of Lyme do occur every year.

It is best if children bathe after coming in from playing outside to wash off ticks prior to attachment. It’s a good idea to look in hidden areas such as behind the ears and on the scalp. Remove ticks if you find them and watch for a rash. Certainly, a rash that looks like a bull’s eye or a target (erythema migrans) is concerning for Lyme infection and needs to be seen for further testing.

Insect bite avoidance is important (and hard)! The large local reactions are definitely very uncomfortable, but infections transmitted by mosquitos such as West Nile or Lyme from ticks are potentially very dangerous. Using DEET containing insect repellant and wearing long sleeves during peak mosquito times are helpful.

As always, see your pediatrician if you are worried about a bite or rash and we are happy to help.

Related:

• The deets on DEET from a pediatrician
• Protecting Your Child From Ticks

It’s natural for parents to want to protect their children when they are distressed. But when it comes to anxiety, taking kids out of anxiety-provoking situations may not always be the right answer.

In fact, we should make a distinction between positive stress and clinical anxiety. Understand that an episode of anxiety/fearfulness/avoidance isn’t limited to a full blown clinical anxiety disorder.

Positive stress (like fears of taking a test, or going down a slide, etc.) is actually vital to normal child development and for teaching a child coping skills and the resiliency in learning to fail and then try again.

If a child’s anxious responses are expanding or not improving, however, they need to seek the help of a psychologist or therapist who can help assess the scope of the problem and craft a unique treatment plan that may include Cognitive Behavioral Therapy (CBT).

The psychologists we spoke to for this article found the parent often have an underlying anxiety disorder that may be untreated. While CBT is one very helpful treatment option (and one that is very applicable for straightforward anxiety in older teens and adults), kids are very different and there may be other factors mitigating the anxious response.

By attempting to protect your children from these situations, you may actually be enabling them to avoid and escape the situation. Then kids never learn to work through the root cause of their anxiety.

Here are 5 quick facts to remember:

Fact 1: Your child may not be happy or comfortable all of the time, and this is OK.

Fact 2: It’s difficult to see your child frustrated or disappointed, and this is also Ok.

Fact 3: Your child WILL get angry with you, and this is OK

Fact 4: Your child WILL say mean things to you, and this is also OK

Fact 5: You do not need to rush to fix it/ make it better.

Fact 6: Your child’s anxious behavior is NOT a reflection on you as a parent.

Anxiety affects 25% of children ages 13 to 18. Let untreated, anxiety can lead to depression, academic underachievement, poor social skills and substance abuse.

Sometimes, it’s difficult for parents to recognized anxiety. Kids can become easily frustrated with changes, have meltdowns, over-react, be difficult to soothe, be very reactive, struggle with transitions, be easily embarrassed, not be able to tolerate feedback/criticism, etc.

Parents (or others), may see these emotions as an anger, mood or ADHD issue, when there can be more to it, and testing can be helpful to decipher it.

One of the best treatments for anxiety is Cognitive Behavioral Therapy (CBT) from a licensed behavioral health specialist, and has proven to provide better symptom reduction than medication for most children. While licensed psychologists play an important role in behavioral health, in terms of providing psychological testing, as well as therapy, our licensed professional counselors at Cook Children’s are vital as well in providing and teaching very creative and useful coping skills every day.

When choosing a CBT therapist, make sure they use “exposure” technique. The goal of CBT is to teach people how to help themselves through anxiety-provoking situations, not to escape or avoid them.

Cognitive Behavioral Therapy will help the parent too, as a child with anxiety affects the entire family unit. There is no “cure” for anxiety, but there are resources to learn to manage it differently. Don’t take away the opportunity to experience bad things, or your child will become emotionally fragile and never be able to handle anything.

Tips:

• Teach by example and be aware of your own feelings/ actions
• Praise the effort
• Don’t reward the wrong behavior
• Plan 15-30 minutes a day of one-on-one time
• Allow 30 minutes of decompression time after school with activity the child needs: either physical activity or calm activity
• After a tantrum, talk about it, learn to problem solve
• Find something to be grateful for in a bad situation/ outcome

Much like a peanut allergy is the body’s over-sensitivity to peanuts, anxiety is an over-sensitivity to worry. Anxiety can include:

• Overestimating danger
• Expecting the worst

Physical symptoms such as palpitations, difficulty breathing, stomach upset, trouble sleeping and attempting to avoid any perceived anxiety-inducing situation.

To learn more about Cook Children's Behavioral Health services, click here.

In the United States the Census takes place every 10 years. By now we hope you have heard that the Census is taking place this year. The goal of each census is to count each person in the US. Why does the census matter? This information helps determine how billions of dollars get spent on things like schools, roads, hospitals and community resources.

The Census has been well underway now since the beginning of this year. Around March of 2020 the US Census Bureau began sending US households instructions on ways to participate. It has never been easier to participate, the following methods to respond include:

• Online - via any mobile or computer device with internet access
• By mail (just drop off the completed census form in the nearest mailbox)
• By phone (quick and easy by answering several questions).

By August 10, 2020, the US Census Bureau estimates that 64.5% of Tarrant County households had already responded to the survey. This is great news! That response rate is better than the overall estimated rate for Texas of 58.3%. However we know we can do better than that. Although the Census Bureau is planning on visiting households that have not yet responded this has become a bit problematic due to the COVID-19 pandemic, which has led to an extension period. Self responses are still being accepted in the forms listed above will be accepted through September 30th, 2020.

North Texas is one of the fastest growing areas in the country. The growth of the our communities leads to more needs for programs and services for growing families and especially children. When completing your survey please remember to include ALL people that live in your home (including newborns to adults). It is estimated that in the last census (2010) almost 2 million children under the age of 5 were NOT counted. If we don’t count everyone, especially children between ages of 0-5 then the programs that provide services to these children may be reduced or eliminated as a result.

If you have not yet responded to the 2020 Census, please visit www.2020census.gov and compete the survey today. Remember it only takes a few moments and all the information is kept confidential. Let’s work together to makes sure all kids get counted, tell friends and family about how important it is to complete the census.

Making sure #EveryChildCounts in the 2020 Census!

And I thought we should end with a word from our friends at Sesame Street about the Census.

For parents who have a child starting school in person, it’s normal to have some anxiety about the entire process, staying informed and connected may reduce these feelings and can give you a way to express concerns that you have regarding practices at your child’s school.

Consider the following if your child is set to start in-person learning and or will eventually be transitioning from virtual at-home learning to in-person learning:

Get organized and stay informed: Make sure you are aware of the safety guidelines that your school will be taking when students are back in the classroom.

Will face coverings be required for ALL children? If so ensure you have taken the last few weeks of summer to have child practice wearing their face covering or mask and encourage minimizing touching the face while putting the mask on or taking it off. Other things to consider regarding masks/face coverings:

• Ensure the mask/face covering you choose fits snugly yet comfortably against the face, covers the nose and mouth completely, and if its design is “re-usable” ensure the material allows washing and drying without damage to shape or build of the mask.
• Once you have found the type/style of mask your child is comfortable in ensure you have several available as backups.
• Tips on practice for wearing a mask (gathered from several different expert pediatricians)
• Have the child wear the mask/face covering during times likes watching a movie or playing a game. Allow them to take breaks but also praise them when they have successfully worn the mask or covering for a significant amount of time.
• For younger children needing help with wearing a mask use a favorite stuffed animal to demonstrate proper mask wearing, or find pictures of children or their favorite cartoons wearing masks.
• Modeling is very important. As a family model wearing masks/face coverings, children learn by example and this is one of the best ways to teach a child the importance of wearing a mask.
• Get in the habit of checking in with your child each morning for signs of illness. If there is ANY concern at all take the child’s temperature (if the child has a temperature of 100.4F or higher even without any other symptoms the child should NOT go to school).
• Thereafter monitor for any other symptoms: ensure your child does NOT have sore throat, cough, diarrhea/vomiting, headache or body aches.

Even if symptoms seem mild they should be recognized and taken into account in order to avoid potential spread of any infectious illness. This will remain important as the cooler weather and fall season are typical for other respiratory illnesses to arise such as influenza.

• If your child is sick and develops symptoms of COVID make sure you are aware of where you child can be tested. Also make sure you know who the school’s point of contact is for reporting illness. Find out what options for instruction/learning will be available for the child if quarantine is required. Make sure you are familiar with the school’s plan of communicating with families when a positive case or exposure to COVID-19 have occurred.
• Ensure your child is up to date on ALL recommended vaccines including the flu vaccine when it becomes available this year. We do not know how these two respiratory illness will affect severity of illness if a child or adult is co-infected.
• Review and practice proper hand washing techniques with your child at home and ensure they are aware of the options available at school for hand hygiene.
• Adjust daily before and after school routines to include the following if you had not been doing them already: remember to pack hand sanitizer and extra face coverings/masks. Have children change out of school clothes into clean set of clothes and wash hands as soon as they return home.
• Make sure the school has up to date contact information including emergency contacts as well as individuals authorized to pick up your child. If the list includes anyone who is considered high risk for developing severe illness for COVID-19 consider choosing an alternate person.
• Plan for potential school closures or quarantine periods. Consider if you will be able to take time off work should the child require quarantine at home. If the parent is unable to work from home or take time off work it is important to identify an adult who would be able to supervise the child during this time.

Stay alert: We know these times of significant change and decreased social interactions can contribute to stress and anxiety in children as well as adults.

Talk to your child about what to expect regarding how school will look different from before. For example desks may be set far apart for distancing purposes, teachers and staff will likely be using masks/face coverings and in some instances eye protection or googles, lunch time may occur at staggered times in smaller groups. Sports and other outside activities may involve different precautions than before. Be alert to changes in your child’s behavior that may indicate they are struggling with stress, anxiety or depression.

These include excessive crying or irritation, excessive worry or sadness, change in eating habits or sleep habits or difficulties concentrating among other changes in their typical behavior.

Remember there has already been a lot of stress with handling the many unknowns and issues the COVID pandemic has brought, it is important for children and adults to take breaks when necessary, get plenty of sleep, exercise and eat well and stay socially connected during this time.

Related Content:

• Returning to School During the COVID-19 Pandemic: Virtual Learning
• Regreso a la escuela durante la pandemia de COVID: Planificación para el aprendizaje en persona
• Regreso a la escuela durante la pandemia de COVID-19: Planificación para el aprendizaje virtual

Did you know that schools consider French fries and ketchup as vegetable servings in their cafeteria served lunches?! In just a few minutes in the evenings, you can prepare a more nutritious lunch for your kiddos.

You can prepare these meals even if you’re not sending your child off to school yet. Go ahead and get in the routine of lunch prep at night, and they can eat their “school lunch” during the noon break from virtual school. In fact, prepping lunch and snacks will limit the constant grazing we might have gotten into the bad habit of over the lockdown and summer.

 Here are my healthy takes on kid-friendly favorites.

Kids Meal Prep Ideas for school lunches:

1.“Pizza Lunchables”: 1 or 2 Wheat English muffin halves, with side of low salt pizza sauce (make your own real quick with low or no salt tomato sauce seasoned with pepper and oregano), shredded mozzarella, and turkey pepperonis. Side Veggie: sliced bell peppers. Side Fruit: fresh mandarin orange

2.“Lunchables”: Handful (approx. 12) of wheat or veggie crackers, 3 slices of low salt, no preservative deli turkey or ham cut in quarters, 3 slices of low fat cheese cut in quarters. Side Veggie: celery sticks with hummus or ranch dip. Side Fruit: No sugar added fruit cup

3.Roll Ups: Corn or wheat tortilla with sliced cheese or spreadable cheese (such as laughing cow) and low salt no preservative deli meat. Can add spinach and/or smashed avocado as well. Slice in 6 equal pieces to have cute pinwheels. Side Veggie: carrots and dip. Side Fruit: grapes

4.Egg muffins:

Recipe: 1 cup Bisquick

• 1 lb cooked turkey sausage or ground turkey
• 4 eggs, beaten
• 1 cup shredded cheddar cheese
• *Optional: 1 cup chopped veggies such as peppers and mushrooms
• Mix all ingredients and split between 12 servings in a muffin tin. Bake at 350 degrees for 20mins
•  Side Veggie: cucumber slices and cherry tomatoes. Side Fruit: berries

5. Pasta salad: Cooked whole wheat or veggie pasta with chopped grilled chicken and vegetables such as tomatoes, zucchini, and spinach. Add a little dressing to the pasta salad such as pesto or Italian dressing. Side Fruit: apple slices.

6. Quesadillas: Corn or wheat tortillas with bean & cheese or chicken & cheese. Side Veggie: broccoli and dip. Side Fruit: mango or peach slices

7.”Chicken Nuggets”:

• Recipe: Cut 1 lb chicken breasts into strips or large chunks.
• Coat in flour mixture: 1 cup or more whole wheat or oat flour mixed with ¼ cup ground flax seeds, ½ tsp salt & pepper, 1 tsp garlic powder, and 1 tsp paprika. Now dredge coated chicken in beaten eggs, and then again coat with flour mixture.
• Bake or air fry until cooked through. (Double recipe to make for dinner, then to have leftovers for next day’s lunches.)
• Side Veggie: veggie chips or sticks. Side Fruit: fruit & veggie squeeze pouch

8. Meatballs:

• Recipe: 1 lb ground beef or turkey
• ½ can pureed pumpkin
• 2 slices wheat bread, torn apart in small pieces
• ¼ cup flax seeds
• 1 egg
• ½ tsp each salt & pepper
• 1 tsp garlic powder
• 2 tbsp low sugar ketchup
• Mix all ingredient until well combined. Make 1-2 inch balls and place on greased sheet pan. Bake 15-20mins at 350 degrees until cooked through. Can serve with ketchup or bbq sauce. (Double recipe to make for dinner, then have leftovers for lunch next day.)
• Side Veggie: Cauliflower and hummus or ranch. Side Fruit: pineapple
• Extra additions to above lunch ideas, 1 per day: small individual cookie packs, all natural fruit twists (actual fruit instead of packs of fruit snacks), granola bar, fruit & nut bar such as LaraBar, ¼ cup trail mix, ½ cup honey wheat pretzels.
• No juice, soda or sports drinks; instead have water or 2% milk.

I hope you enjoy! 

Your child has ADHD, and you’ve gone through testing, 504 plans, in school accommodations, trialing of different medications and dosages. Now what?

ADHD is a difficult condition to treat because treatment has to be tailored to each child. Standard stimulant medications such as Adderall and non-stimulant medications such as guanfacine (Intuniv) do a good job, but what else can you as the parent do to optimize your child’s ADHD treatment?

Behavior therapy by a licensed psychiatrist or psychologist can be very helpful, and they often will have an option for parent training too. Parent training focuses on age and developmentally appropriate behavior expectations, and giving clear commands/ rules rather than a general “behave” or “be good.” Behavior therapy can also be offered to your child one-on-one or in small groups, but is more effective when the parents are involved in sessions.

Children, especially those with ADHD, live in the moment. I recommend a reward chart calendar with stickers given for good behavior and accomplished chores, a daily visible reminder and source of accountability. At the end of the week, review the chart together and only give the small reward (i.e. a Sno-Cone) for a complete week of good behavior. If your child had several days at school of poor behavior notes, no prize should be given that week. Praise good behaviors when they occur, “You’re playing so nice with your brother right now” or “I am proud of you for sharing your toys”, that way your child hears and acknowledges what behaviors you want them to continue.

You also need to appropriately discipline your child. Again, age and developmental ability is key. No 6 year old boy, ADHD or not, can be expected to sit still for eight hours in a row. Children need plenty of physical activity and brain breaks. Find what discipline works for your child. For some, time outs and calm down techniques do the trick, others need electronics or favorite toys taken away for the day.

Regarding discipline: you will NOT irrevocably damage your child by disciplining them. They can be told NO and turn out just fine. They can be punished by time outs or however you deem is necessary and still be fine. The American Academy of Pediatrics offers good advice on the best ways to discipline a child.

Raising children is HARD. Raising a child with ADHD can be harder. When a child misbehaves, respond calmly and clearly. Hold your hands tightly behind your back, bend down to the child, speak in a low and authoritative tone, and let them know that behavior is unacceptable. Then turn away, no attention is given to a poor behavior. I have so much respect for the parent of the screaming child on the floor of Walmart who will not give in to their child’s demand, compared to the parent or grandparent who silences the child by giving the desired treat. What does a child learn from that? Answer: throw a big enough fit and I’ll get whatever I want. This is NOT what we want, the child cannot be the one in control!

After they are settled down from the tantrum, now is the time for a conversation on what wrong they did, their feelings in that moment, and let them brainstorm on how to not duplicate the bad behavior. Now time for the punishment- i.e. put away the toy out of reach but NOT out of sight if the poor behavior was throwing that toy at their brother, or saying I’m sorry and being grounded from an upcoming activity for sass-mouthing mom. Again, point out times the child is acting well so they don’t feel like the only time they’re getting feedback is for naughty behaviors.

Other tips for parents: Create a routine and try to stick to it daily. Limit choices so they still can assert some independence, but not be overstimulated (i.e. choose this outfit or that one, or between two vegetables at dinner). Limit distractions during homework time, but know that some children concentrate better with white noise (i.e. classical music) or when they are moving (i.e. under desk cycle). Be clear, specific and brief when giving directions. Help your child get organized and put their backpack, shoes, etc in the same place every day. Create opportunities for positive feedback, whether from sports, art, or music, find something where they feel good about themselves and watch their self-confidence grow!

In the classroom, busy bodies with hyperactivity need special non-distracting accommodations to better their attention and to not be disruptive. I recommend a balance ball chair, or under desk cycle to allow for muscle movement without constantly jumping out of one’s chair. Give your child’s hands something to touch (not those fidget spinners!). I suggest taping both sides of Velcro strips under the desk to allow for the tactile stimulation that these kiddos crave.

There is evidence that the brains of children with ADHD are deficient in certain kinds of omega-3 fats. I like the Smarty Pants brand of kid’s vitamins that contain omega 3 along with a complete multi-vitamin.

Also, caffeine can HELP your child to FOCUS and be more CALM. I know. This seems counterintuitive! But think of how a stimulant medication works: the same way caffeine does, it balances what brain chemical is low and instead of the brain over-reacting and creating too high of levels causing hyperactivity, the brain can “relax”. I don’t like the thought of children drinking sodas on a daily basis, but allowing a mini can of caffeinated beverage at breakfast for a struggling ADHD child can be of big benefit, just make sure they brush their teeth very well afterward.

Continuing the topic of food/ drinks and ADHD, some children are highly sensitive to processed foods and/or food dyes. Red dye 40, among other artificial dyes, is known to worsen behavior issues. As we should anyway, eat more whole fruits and vegetables, lean proteins and whole grains. Limit or eliminate highly processed, sugary, and dyed junk foods and snacks. This includes breakfast cereals: Lucky Charms, Fruit Loops, Cap’n Crunch and Apple Jacks are full of food coloring. Cheerios (plain and many of their varieties), Trix, Cocoa Puffs, Reese’s Puffs, and Golden Grahams are free of artificial coloring and have no high fructose corn syrup. Start looking at the ingredient list of any packaged item you buy, from cake mix to jello, to ketchup and popsicles- try to find a “natural”, “no artificial dyes or ingredients” version.

There is so much that goes into optimal management of your child’s ADHD. Talk with your Pediatrician about where to start. Talk to them again when you’re stuck in a rut and need to know what else can be done.

Sleep, it’s important, right?!

Has your kid's new COVID-19 schedule got them going to bed after midnight and sleeping until noon?

Well it’s time NOW to start getting back into a normal sleep schedule for school, even if they are learning online.

So how much sleep does your child need? This is a good estimate, but teenagers can require up to 12 hours of sleep while they’re going through a growth spurt.

How much sleep does my child need?

• 3-6 year olds need 10-12 hours of sleep
• 7-12 year olds need 10-11 hours of sleep
• 13-18 year olds need 8-9 hours of sleep

If your child has a midnight or (gasp!) even later bedtime right now, start working on adjusting their bedtime slowly over the next few weeks. I propose the following schedule:

• Aug 1: 11:30 p.m.
• Aug 2: 11:15 p.m.
• Aug 3: 11 p.m.
• Aug 4: 10:45 p.m.
• Aug 5: 10:30 p.m.
• Aug 6: 10:15 p.m.
• Aug 7: 10 p.m.
• Aug 8: 9:45 p.m.
• Aug 9: 9:30 p.m.
• Aug 10: 9:15 p.m.
• Aug 11: 9:15 p.m.
• Aug 12: 9 p.m.*

*Early elementary children will likely need a 7 p.m. or 8 p.m. bedtime, adjust the 15-minute pattern above as needed.

Keep in mind that bedtime means lights out, no screen time. Charge your child’s phone in your room, you’d be shocked to find out the long text message conversations happening at 2 a.m.! No TV in the bedroom either. If your child is having trouble with the adjustment in bedtime, it is perfectly fine to give melatonin about 20-30 minutes before bedtime. One or 3 milligrams is appropriate for elementary age, up to 5 milligrams for teenagers. Don’t allow caffeine after noon either.

Best of luck transitioning to school this year! We’re all going to have to work nicely together to get through this, but we can and we will!

Is it necessary to get a sports physical this year?

After all, are we even going to have sports this year? Plus, in the age of COVID, you may feel hesitant to bring your child to a pediatrician’s office right now.

I understand your concern about going to a doctor’s office, but I promise it’s never been a better time to be seen! We have increased our cleaning protocol, which was already great, in the office and we want you to rest assure we have a clean and safe environment for you and your child.

So to answer your question in short, YES. Let’s take a look at why a sports physical is so important.

Not only is a yearly sports physical required by the school district to be cleared for sports, going to your pediatrician for a yearly well check-up is vital to the health of your child. At a wellness visit, we review growth and development, catch up on vaccines, address any concerns from the child or parent, as well as perform a complete physical exam. We also assess vision, hearing and order any labs or imaging deemed necessary.

It is far better to obtain your child’s sports physical from board-certified pediatricians, such as a Cook Children’s physician, who perform a complete well child checklist. Specific to the sports physical component, we take a heart history of the patient and family and check from head to toe for any joint or muscle issues. So even if your child’s sport gets postponed or canceled because of our current pandemic, this is a great way to evaluate the health of your young athlete.

In 2019, over 495,000 boys and 330,000 girls participated in high school athletics in Texas. Participating in sports is a great way for your child to remain physically active. Healthy bodies fight off infections such as COVID-19 better. We recommend at least one hour of strenuous physical activity daily (this means the heart is pumping hard, and you’re breaking a sweat!).

During the sports physical/ well check, we are making sure the heart is capable to handle this elevated level of activity. One specific condition we evaluate for during a sports physical is a potentially fatal heart condition called HOCM (hypertrophic obstructive cardiomyopathy) that has been found to occur in 1 out of every 500 adults, and can cause sudden cardiac death in young athletes. Your pediatrician will evaluate if your child has an increased risk of HOCM, and we can refer him or her to a Cook Children’s cardiologist for timely assessment. If you’ve ever heard Cook Children’s referred to as a system, this is where it comes in handy. Your pediatrician actually works with the cardiologist to provide history and get your child seen quickly.

Heart ailments and many other diseases can be evaluated at your sports physical. Please call your pediatrician today and schedule your child’s sports physical. School starts in less than three weeks!

Citations:

Raj MA, Bansal P, Goyal A. Hypertrophic Obstructive Cardiomyopathy. [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430820/

Number of participants in high school athletic programs in Texas 2009-2019

Published by Christina Gough, Aug 30, 2019

Being a pediatrician is a special job. You get involved in not only a child’s life, but become a part of the entire family. I was diagnosed with asthma at the age of 4, and this is the reason I became a pediatrician. My pediatrician growing up was so wonderful and caring of both myself and my parents, I wanted to be just like her, providing compassionate care to children.

Our delightful environment in North Texas tends to allow for year ‘round allergies, which can exacerbate asthma and wheezing.

So when should you take your child to the doctor to check their cough or wheezing?

The answer is, any time you are concerned and your normal medications aren’t enough. Some asthma is seasonal when allergens are worse in the air, some asthma is activity-induced, and your child will require an as-needed emergency inhaler called Albuterol. When Albuterol is needed more than once or twice a week for cough, wheezing, or difficulty breathing, it’s time to talk to your pediatrician about starting an inhaled steroid maintenance inhaler.

This is taken every day, and the inhaled steroid lessens the likelihood you’ll need to use the emergency inhaler. There is also a commonly prescribed chewable or swallowed pill called Singulair that is helpful in keeping allergies and asthma symptoms better controlled. When your child has worsening night time cough, trouble keeping up with peers during physical activity, or wheezing, it’s time to schedule an appointment with the pediatrician to discuss increasing or changing medications.

During an acute asthma exacerbation from whatever cause (viral illness, change in seasons, allergy flare, etc), the doctor will often prescribe a short course of oral steroids, around the clock albuterol nebulizer treatments or inhaler use, and perhaps a round of antibiotics if they are deemed necessary. It is critical to take all medications as prescribed. Just because your child feels “better”, doesn’t mean that it is time to stop daily asthma medications. They are better because the medications are working, and stopping any maintenance medicines can cause irreparable damage to their lungs. Let’s keep our children at their best by coming to the doctor at the first sign of respiratory distress, and quickly managing asthma and wheezing.

When is it asthma, and when is it something else?

It's hard to think about right now, but it only a couple of months we will see cooler weather and winter will be here before you know it. Winter season brings on LOTS of cold viruses, all 847 of them, and several can cause wheezing or trouble breathing, also known as reactive airway disease.

Especially known is the dreaded RSV, but other viruses can affect the lungs too, and require extra support from nebulizer treatments to even oxygen given in the hospital. Some children are highly susceptible to every common cold virus spiraling into a reactive airway disease/ asthma/ wheezing episode, and require a doctor visit every 1-2 weeks it can seem. So when it is just “asthma”, and when should the pediatrician and parent confirm it’s not something worse?

When something doesn’t feel right, come in and talk to your doctor. It may be nothing. It may be just another cold and cough virus. But maybe, and it’s a very small chance, but maybe it is something more. And you as the parent deserve to be listened to, to have your concerns validated and heard. And we as the Pediatrician, promise to do right by your child and not only treat in the moment, but plan for further investigation if necessary. Don’t ever feel awkward or hesitant coming in to the office to check the cough or snotty nose virus; I’d rather reassure you that it’s a simple virus and not something more.

Listen to your gut, and I’ll listen with my ears and my heart.

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

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

Let’s get started.

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

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

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

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

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

And ...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How do you help with the guilt:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“What’s school going to look like in the fall?” “Should I send my child or keep them at home?”

These are the questions that every parent is probably already asking as school districts roll out their plans for re-opening school in the context of continued COVID-19 cases in our communities. Many schools may present the option for all in person, all online or some blended method. And parents will have to consider what works best for their children.

There have been many stressful decisions in regards to COVID, but this might be the most anxiety inducing one for parents so far. School districts realize how stressful this is for parents and are taking steps to protect their students and your kids.

 “We understand that some of our families are anxious about the new school year so we are implementing strict new cleaning protocols for every campus. That means that schools will be cleaned multiple times during the daytime hours rather than in the evening as has been the practice for many years,” said FWISD Superintendent Kent P. Scribner. “We are also making a significant investment in both Personal Protective Equipment--for both adults and children—as well as cleaning supplies for campuses and other FWISD facilities. The good health and safety of our students and employees remains our top priority.”

The Texas Education Agency released these guidelines for school reopening on July 7, 2020:

• Daily on campus learning will be available to all parents who choose that option for their children
• Parents may be asked to commit to remote instruction for a full grading period but will not have to commit until 2 weeks ahead
• Health and safety procedures should be in place for student and teacher safety

In normal times, making a decision about what your child will do for school in the middle of July would seem way too late, but this year it feels way too early.

Each parent will have to make their own decision but here are some things that it would help to consider:

Childcare and Other Resources

First and foremost, it’s important to consider that children attending school is an important part of allowing parents to work and function in society. Parent’s jobs help secure food, shelter and in many cases provide health care insurance that allow children to receive care when needed. Not all parents can work from home, stay productive and keep a job. In addition, many of our children receive their most nutritious and guaranteed meal during the school year through their school lunch. Schools provide many resources to our communities and children beyond education.

Medical

Healthy children, for the most part, are considered to be safe in the school environment. Children have been more or less spared from severe illness but, as with most illnesses, children with chronic medical conditions are at higher risk for severe illness. Parents of children with medical conditions may learn toward keeping their child in the online environment in order to protect them from exposure. In addition to the child, considerations must be made for other household members and extended family members with whom the child might have contact. If the child will have contact with family members who have weakened immune systems, they could bring the virus home despite not having significant symptoms.

School

Examining the policies and procedures of the school will be another important decision point for families. Is the school district taking the recommendations for safety seriously and attempting to implement them consistently? With kids involved, there will be a learning curve but districts should be considering policies in regards to social distancing, mask use and movement throughout schools at a minimum. The evidence suggests that most schools are taking the threat of COVID very seriously but each parent should make that assessment for themselves.

Educational

April and May taught us a lot about how capable our students were of learning in an online environment. While the school districts will be significantly more prepared for teaching online, there are certain kids for whom it was obvious that the online environment was not going to be the right choice for them. Children who receive services and support at school might have a more difficult time adjusting to life at home without that extra help. For others, they struggle to learn online and in-person teaching might be a better fit. In addition to the child’s learning needs, families must consider their ability to support their learner with their existing responsibilities. Teachers and school staff can help, but students at home will often require some, if not significant, guidance from someone in the home. This is especially true for younger students and those with special learning needs.

Social and Emotional Needs

Some kids have thrived in regards to their mental health with the online learning environment. Many children with anxiety in regards to school or formalized testing had significant improvement in their symptoms as they transitioned to at-home learning. Other students and families needed the structure and activity of school in order to maintain a sense of normalcy. The lack of contact with friends, teachers and other school staff affected them in very negative ways. Another consideration should be the child’s level of concern about COVID-19. Children with significant anxiety regarding the virus could anxiety, depression and other severe health and mental health issues.

Decisions regarding going back to school in the fall are complex. Each parent should consider how the effects of being at school or at home would affect their children and consider that as part of their decision.

For more information on this topic, read the recommendations of more than 50 Cook Children’s pediatricians, led by Medical Director of Infection Prevention, who worked to create guidelines for returning back to school. The AAP released similar guidelines that support opening of schools for in person instruction.

It’s likely the plans for each school will continue to change throughout the rest of the summer. Parents should consider the best option for their children and be prepared for disruptions to occur based on local case numbers.

For more on this topic:

• Cook Children's Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 pandemic
• COVID-19 Planning Considerations: Guidance for School Re-entry (AAP)
• Young Athletes and COVID-19: 'When Can My Child Start Playing Sports Again?'
• TEA Issues Comprehensive Guidelines for a Safe Return to On-Campus Instruction for the 2020-21 School Year

As Texas enters Phase 3 of Governor Gregg Abbott’s plans reopen the state amid the COVID-19 pandemic, bars, restaurants, amusement parks and sports venues are working to welcome back patrons.

But for many parents, their biggest concern remains what to do during the upcoming school year.

Medical Director of Infection Prevention at Cook Children’s Marc Mazade, M.D, hears questions about how to reopen school again on a daily basis from his patient families as well as his own colleagues.

“Everyone kept asking me, ‘Are kids even going back to school?’ I don’t really know what the plan is. I certainly hope schools reopen in the fall, but we have some work to do,” Dr. Mazade said.

Seeing a need for more guidance, Dr. Mazade worked with more than 50 Cook Children’s physicians to create “Recommendations for the Practical, Fair and Safe Reopening of Public Schools K-12 in the State of Texas.”

The doctors involved work in a variety of primary care offices as well as specialty clinics including Infectious Diseases, Emergency Services, Cardiology, ENT, Neurosciences and more. Dr. Mazade expects this to be a long-term plan, with elements in it that allow for looser restrictions based on current Centers for Disease Control and Prevention (CDC) guidelines for community transmission. He sent these recommendations to the governor and hopes to provide it to schools for the upcoming year.

Dr. Mazade admits to being cautious as kids return to the classroom, but he also believes a common-sense, careful approach will allow children the best opportunity to remain safe.

Students from kindergartners to high school seniors tend to tolerate infection better than adults, especially elderly people. Cook Children’s prescreening of asymptomatic children preparing for a medical procedure identified around 1% of children of all ages shedding the virus locally at the time of this writing.

“In order to put children safely to sleep, we have been testing children who are preparing for surgery for COVID-19 infection," Dr. Mazade said. "As feared, some children who have no symptoms are testing positive for COVID-19. That shows us that children with no symptoms have COVID-19 in our community and infection can spread unknowingly from person to person. We are urging everyone to continue to take precautions to keep everyone safe.”

The physicians worked on the document with the health and safety of students, teachers and their families at the top of mind, but they also thought about a common-sense approach to help bring a return of normalcy to kids’ lives.

“We want children to wear masks, but we also understand that’s going to be difficult for little kids,” Dr. Mazade said. “They may not understand why they are wearing masks, and it may cause problems for them emotionally. In those cases, we are asking for teachers and other adults around these children to take the proper precaution to protect younger children.”

It’s important to everyone involved in creating this document that kids are able to be kids. For instance, under the guidelines, athletes will return to the playing field, but that may mean playing in front of only family where everyone can be properly spaced out for safety.

“As we begin to look at these issues that students may face, we begin to focus on more than the spread of the virus,” Dr. Mazade said. “One of the concerns that came up was making sure we were screening kids for new problems such as starvation and hunger. We don’t know who all are dealing with these issues right now. The kid next door may not get enough to eat any longer. We want to think about screening for depression, too. We added those things to the document because it’s important to be proactive because the stresses are new, different, and so widespread.”

At my house, the 4- and 6-year-old natives are growing restless. The backyard isn’t cutting it anymore, biking up and down the street is growing old, and running around in the sprinkler now holds as much joy as a root canal. The parks are calling our name.

But is it safe?

Let me let you in on a little secret – there’s so much we still don’t know about this virus.

And by “don’t know” I mean, there are no great, large, long-term studies about the virus out there. My guidance for you is, at best….educated guessing. So bear with me.

In my office, I’m constantly asked “well….what are YOU doing with YOUR family, Dr. Diane?”

Well, I’ve read a lot. And it seems like the conditions ripest for catching the virus are in enclosed spaces with a large number of unmasked people, within areas of poor ventilation.

So…playgrounds and parks seem low risk. With some planning.

What is my family doing?

1. We have a heart-to-heart each and every time we go. If a playground has more than 1-2 families presently playing, we will try again later, or try a different park. My kids no longer melt down if a park is too full; it’s part of the game plan to be as safe as possible. They know this is part of the deal.
2. Also – we talk about keeping distance from other families. The CDC recommends keeping 6 feet between households if possible. In most playgrounds this is feasible, if not too many folks are there. My kids have adapted to the idea of “well, the swings are full, so it’s see-saw time until that family is done using the swings!”
3. This may not be easy for little ones, like those under age 3, so it’s important to watch over your kids and gently guide their curiosity to other parts of the park if they seem to drift towards new friends.
4. The CDC says if you can’t keep 6 feet of distance between your family and another, to wear masks if over age 2. In the Texas heat, my kids just wouldn’t be able to deal with this. Also, I’m just not comfortable with crowded parks yet. So we leave the playground if lots of people arrive – and again, that’s part of the heart-to-heart talk we have before we go.
5. We pee before we go. Using public restrooms ups your risk. If you have to use them, wash hands thoroughly afterwards.
6. Some news sources are telling you to “wipe down surfaces before your kid plays on it." I feel like park time is so chaotic, this would be really difficult for me to do. Constant movement and large playground pieces make me feel like this is near impossible. Studies show that the virus can live anywhere from 5 hours to 3 days on metals, which is worrisome, but the virus degrades pretty quickly on hot surfaces (thank you Texas sun). I think if you have wipes and your child is super focused on a favorite piece of playground equipment, absolutely, wipe away. But I think handwashing at the end of your trip is more important.
7. I keep hand sanitizer in my car and we use it the moment we get in. We also wash our hands thoroughly once we get home for at least 20 seconds.

I know it’s sad to think of all this THINKING for something as simple as a trip to the playground. But it won’t be this way forever, you guys. Being careful like this buys us time, resources, education, medications, and possibly a vaccine soon. It’s not forever – but why not keep things as safe as possible in these uncertain times?

Get outside and enjoy this summer safely.

Dr. Diane

Related Stories:

• Cook Children’s Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 Pandemic
• Should My Chld Go To Summer Camp?
• When Can My Child Start Playing Sports Again?
• Should I Take My Child To Daycare?
• Helping Families Manage COVID-19 Stress

"Mommy, I swallowed some magnets."

When 4-year-old Coralie admitted what she'd done, her mom, Alysha Varley, didn't hesitate to go straight to the internet. After all, it wasn't long ago that Coralie told her mom she'd stuck popcorn up her nose, and sure enough, there was a kernel wedged in one of her nostrils.

Varley said she's still not sure where her little girl found the magnets. Perhaps it was from the neighbor's house where Coralie stays while Varley works. Regardless, Coralie swallowed the magnets playing downstairs, while Varley was upstairs with her son. Coralie walked upstairs to calmly deliver the news that she’d swallowed the magnets to her mom.

Still, Varley is a nurse. She’s not one to panic or rush her child to the emergency room, unless she believes it’s absolutely necessary.

After reading about the dangers of magnets and calling an on-call nurse, Varley scooped up her daughter and drove to Cook Children's Emergency Department. They arrived at Cook Children's around 10:30 p.m.

Anthony Anani, M.D., a gastroenterologist at Cook Children's, was the doctor on-call to perform the procedure to retrieve the magnets.

The gastroenterology team has treated 27 children for ingestions of foreign bodies so far this year, averaging about five a month. Coralie was the second child treated for swallowing magnets. Dr. Anani estimates his team will remove 60 to 80 foreign bodies a year, with about six to eight of those episodes being magnets.

In a study performed by the U.S. Consumer Product Safety Commission, high powered magnet sets accounted for 1,700 emergency room-treated injuries between 2009 and 2011. The majority of injuries (70 %) were to children 4 to 12 years of age.

Many of these magnet sets are marketed as sculptures, puzzles, and stress relievers and are labeled not for use by children. However, CPSC staff believes these magnet sets have a strong appeal to children and pose a potential for high-severity injuries.

"Magnets can be hazardous," Dr. Anani said. "They can get stuck in the esophagus and cause problems with swallowing (larger fridge magnets). If swallowed, these magnets, especially the smaller, ball-sized ones, can link together inside a child's intestines. They clamp onto body tissues, causing intestinal obstructions, perforations, sepsis, and even death. Internal damage from magnets can pose serious lifelong health effects."

Gastroenterologists and emergency personnel recognize these ingestions for the cause of increased morbidity and mortality among children. The frequent use of neodymium, or rare-earth, magnets in toys and other small objects are especially dangerous. These magnets have more than five times the attractive force of conventional magnets. They have demonstrated the tendency to cause GI injury much more readily than their traditional counterparts. Although the same potential for damage and principles for management applies to non-neodymium magnets, the relative risk is significantly less because of their decreased magnetic pull.

The magnetic balls, Coralie swallowed are used as toys and known as “buckyballs.” The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has called for the ban of high-powered magnets as toys.

Dr. Anani was able to retrieve the magnets using an endoscope and a forceps with a metal tip, the magnets attached to the tip and were safely removed from Coralie’s stomach.

Typically the procedure lasts from 30 minutes to a little more than an hour. The length depends on the magnets' location, the number swallowed, and if they are all attached or scattered throughout the GI tract.

Coralie was able to have the procedure, recover from the anesthesia, and be released from the hospital in time to be back at her home in Keller by 4:30 that morning.

Like Coralie, most children seen for ingestion injuries are between the ages of 4-12 years of age. In infants below 2, the magnets tend to remain in the stomach and are easier to retrieve. Older teens usually report the ingestions sooner which allows for quicker intervention and reduces the risk of complications

After the magnets are retrieved safely, the child returns to regular activities once the anesthesia wears off. In some cases, if it has passed into the part of the duodenum (the part of the small intestine immediately beyond the stomach), the child can be admitted and watched closely. Most patients expel the magnets without incident but are usually observed in the hospital until it happens. In some cases, the child may need surgery to avoid gastrointestinal complications.

Dr. Anani asks that parents do their best to avoid buying these high powered magnets as toys if possible. He also warns of the dangers of lithium button batteries (20 mm size) that, if stuck in the esophagus, are a real life-threatening medical emergency.

As for Coralie, she's at home two weeks after swallowing the magnets and doing great.

My first child was not like this one," Varley says with a laugh. "Coralie has a big personality. That's for sure. We talked after she put popcorn up her nose about not putting anything in any other place. So I guess we will have another talk about magnets."

Hopefully, we will all listen to the warning.

Normally, it's time for kids to pack their bags, kiss their parents goodbye, get on a bus, and head to Camp John Marc. Last year, 1,081 kids, 175 employees and 231 volunteers went through some form of this ritual.

But as we all know, nothing is normal right now.

The circumstances related to the COVID-19 pandemic meant the cancelation of all summer camps. Well kind of, because while kids won't be going away this summer, they can experience camp from the comforts of their homes.

For several years now, a volunteer program called Happy Camper brought the camp experience year round to the medical center. This summer, Cook Children's will bring a new program called "Happy Camper at Home" to kids who would have attended a diagnosis-specific camp.

Katie Campbell, Child Life manager at Cook Children's, said a lot of kids count on camp for their socialization during the summer. Cook Children's Camp for Kids allows patients to learn about their diagnosis and be encouraged by others who share their same challenges.

"A lot of the kids who have chronic illnesses, at school they may be the only person in their class with diabetes, or they may not know anyone else at school with asthma," Campbell said. "They get a chance in the summer to go camping for a week with kids who are just like them. It doesn't feel as isolating or different. That's something campers will miss this summer is having that opportunity to be with people that share the same challenges and seeing their medical team in a different location. It's different to see their doctor in their regular clothes when you come to the clinic vs. shorts and T-shirt or in their trunks swimming at the pool with you."

So while kids wouldn't be able to attend, the experience to be a part of camp life was too important to cancel entirely. With a lower census than usual because of COVID-19, Child Life specialists focused on creating a different camp environment from home.

"Once we decided to shift gears and do something different, we started meeting weekly, and then everyone got creative and hit the ground running," Campbell said. "Our hope is for kids to opt-in virtually. They will get to come by the medical center in mid-June and pick up their 'swag boxes' with a bunch of branded camp stuff as they would usually get. They will get things like a T-shirt, a flashlight, water bottles, a deck of cards, those kinds of things. But then we also started to think about what activities we could offer the campers."

A YouTube page with content created by Cook Children's Child Life Zone staff will be available for the campers to watch. Just like any other summer, the campers will receive a mix of fun and education through watching YouTube. The YouTube channel will be available to all kids, even for those who aren't a part of the camps.

The channel will offer cooking, crafts, games and scavenger hunts. The medical teams related to a child's specific condition will provide short diagnosis education videos. Plus, kids can watch the Laughter League, Cook Children's clown program, perform comedy and circus skills, origami lessons and more.

More confined to the campers themselves, a private Instagram account will be available during the summer, which will be the home of a live talent show, dog visits, crafts and more.

"The hope is to build a little bit of a community within Instagram," Campbell said.

Campbell has been at Cook Children's for 21 years, and this is the first time that her summer won't center around attending or planning a camp. She said she would miss going, but this summer will offer some unique positive aspects that generally wouldn't take place.

"One cool thing about doing camps virtually is for the first time we'll be able to include kids with cystic fibrosis in our camping program," Campbell said. "Those kids can't go away to camp because of isolation restrictions around having CF. They can't be together in a community setting. So it will be neat because those kids will be able to engage in camp programming when they haven't formally had camps they could attend in the past."

Another interesting aspect of virtual is that other family members will get a taste of what camp is all about during the summer. Other than Camp Sanguinity, siblings of patients aren't allowed to go to camps.

"I think it will be fun to see what conversations kids will have with their parents and siblings about what happens at camp," Campell said. "My hope is it fills in some of the blanks for families of why camp is so important. Maybe, parents get a chance to watch over their kids' shoulders or the brothers and sisters share in some of the activities. I hope it brings the spirit of camps into everybody's house, and other people in the families benefit from it."

So, when can we get back to sports?

Like most else things related to COVID-19, it depends.

There are definitely different levels of risk, depending on the child’s sport.

• Low risk - Home training
• Moderate risk - Small group training
• Higher risk - Team training in low contact sports
• Highest risk - Team training with high contact

Even with these categories, deciding where your child’s sport fits might not always be clear. Cheer can easily be done as a small group but stunts require higher levels of contact. Baseball players can be spread out but baseballs are shared between players.

So, when should you start to get your child more active?

Now. If and when it can be done safely.

Here’s how to keep your child safe:

1. Encourage your child to practice general and sport specific activities daily at home. Conditioning will be an issue as we get back going so the more activity they have now the better.
2. Use small group training exercises where possible. Does the whole team need to practice three times per week or can shorter episodes with small groups be arranged?
3. Ensure that your coach and facility are maximizing social distancing and disinfecting procedures. Practices should be modified to minimize interaction. Waiting should be done in a social distanced manner.
4. General infection control measures should be stressed: wear masks when appropriate, cover cough and sneezes, find other celebrations than high fives and players/coaches should stay home if ill.
5. Travel should be limited as much as possible. Keeping practices and games local helps to minimize spread between communities.

Is it OK to get your kids back to their sports? Yes, but do so with caution and care.

For more detailed information on this topic, visit the CDC.

COVID-19 has now been associated with a syndrome in children known as pediatric multi-system inflammatory syndrome. This condition is similar in nature to two pediatric conditions known as Kawasaki disease and Toxic Shock Syndrome.

While we still don’t know a lot about the COVID-19 related syndrome, let’s take a look at Kawasaki disease.

Kawasaki disease is a syndrome in children which is characterized by fever over 5 days with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye without drainage or mattering
• Swollen lymph nodes of the neck

In addition, children are commonly very irritable with Kawasaki disease. It is significant because the level of inflammation can affect multiple organs (most notably the heart) and lead to very severe illness.

While it’s still not a common condition, even with the newfound association with COVID-19, parents should be aware if their children display persistent fever with any of the associated symptoms.

The cause of Kawasaki disease is unknown. Some evidence suggests there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of Kawasaki disease involve the heart and can be inflammation of the lining or muscles of the heart, or dilation of the arteries that supply the heart.Toxic Shock Syndrome can present in the same way as Kawasaki Disease but the patient has low blood pressure and is significantly more ill.

If you suspect your child has Kawaski disease or Toxic Shock Syndrome it is important to seek your doctor’s advice quickly, as it is much easier for your physician to connect the dots when symptoms are present. Blood tests can help support the diagnosis and treatment can resolve the symptoms and help to prevent complications.

The good news is that children with Kawasaki's disease and Toxic Shock Syndrome, usually return to normal and don't suffer complications.

For more on this topic:

• Kawasaki disease (cookchildrens.org)
• Pediatric multi-system inflammatory syndrome
• COVID-19 and Pediatric Multi-System Inflammatory Syndrome (AAP)
• Kawasaki disease
• Toxic Shock Syndrome
• My Child's Fever Isn't Going Away. Should I Be Worried?
• Chest Pain. Is It Your Child's Heart or Something Else?

There is currently no vaccine available for COVID-19. Studies are currently underway, but they are in the very early stages and there is no clear timeline for when it will be available.

Treatment for COVID-19 in children is mostly supportive. Making sure that they are drinking well and not having trouble breathing are the two major things you can do to help your child. Novel treatments such as antivirals and other medications are being studied, but it is not clear when those will be available for treatment-especially in children.

One of the first things I like to know when ascertaining the seriousness of a child’s condition is whether the child is playing, smiling eating or drinking. If a complaint is brought up regularly, interferes with play or a child really cries, parents should consult a physician.

High Fever

New parents might find the recommendations for when to seek treatment for a fever daunting, but it gets easier with time.

For infants 3 months and younger, any fever is serious and parents should see a physician’s help immediately.

For children older than 3 months, a high fever combined with symptoms such as lethargy, changes in fluid and/or difficulty breathing require prompt medical attention.

Children who are 3 months or older with fevers of 102 degrees Fahrenheit or higher that don’t respond to fever-reducing medicine should see a doctor.

Fevers up to 101 can often by managed with fever-reducing medicine, fluids and rest. However, if your child also has a harsh cough – which may indicate croup – you need to consult a doctor.

Stomach Hurts

If your child has a stomachache, there are three red flags that may warn parents of a serious illness such as appendicitis:

1. Your child has a tummy ache and a fever.
2. Your child can point with one finger to where it hurts.
3. Your child has been vomiting.

Children don’t need to have all three symptoms for parents to seek help because any one of these symptoms can indicate that appendicitis might be a possible diagnosis. Parents should also not wait too long. If symptoms worsen in six to eight hours, consult a doctor.

My Head Hurts

Headaches and even migraines can occur in children as young as 3 years of age. Parents can give their child a nonsteroidal anti-inflammatory medicine, such as ibuprofen, or eliminate headache pain caused by hunger, fatigue or dehydration with food, rest or fluids.

Talk to your pediatrician about his or her treatment recommendations, particularly if you’ve never treated your child’s headache before.

If headaches occur at the same time each day, parents should consult their pediatrician. Headaches can occur with the flu or fever, but we become concerned if a headache is serious enough to make a child cry, interferes with play or is so bad the child is vomiting.

Related Topics:

• Let's Learn About Fevers
• Is It Strep Throat or the Flu?
• Let's Learn About the Flu
• Probiotics for Tummy Bugs: Do They Help Your Chlid?
• My Child Poops Every Day. How Can They Be Constipated?
• Is Over-The-Counter Medication Causing Your Child's Headaches?
• When It Comes To Your Kids, It's Never Just a Virus

Antibiotics have been one of the most amazing advances in medicine, preventing countless deaths and relieving suffering for conditions that historically had no treatment.

While antibiotics are critically necessary in particular infections, doctors must evaluate their necessity on a case by case basis. Bacterial infections often require antibiotics, but some infections (such as ear infections) that were once thought to require them, may be able to resolve on their own. Viral infections do not respond to antibiotics and thus should not be treated with them.

Two studies released in the past few months suggest that the use of antibiotics in infancy likely increases the risk of allergic disease in childhood. The research found the use of a particular type of antibiotic during the first trimester of pregnancy  (macrolides such as azithromycin), increases the risk of congenital anomalies.

Each year, thousands of kids flood the Cook Children's Emergency Department with bronchiolitis. Bronchiolitis is one of the most common illnesses pediatricians see. Lots of viruses can cause bronchiolitis, but the most well known is RSV.  In the past, doctors have tried breathing treatments like albuterol, steroid medicine, cough and cold medicine, and even sometimes antibiotics. We now know that these things don’t help and can make things worse.

"Antibiotics treat bacterial infections, not viruses like bronchiolitis. Giving your child antibiotics when they aren’t needed may cause diarrhea, and over time can cause bacteria to become resistant to antibiotics," Stacey VanVliet, M.D., wrote in her about post about this topic.

Even with more and more information warning against overuse of antibiotics, I hear from parents all the time wondering why I didn't prescribe them to their child.

So when should you give your child an antibiotic? Let's take a look.

What common bacterial conditions require antibiotics? The list is surprisingly short:

• Strep throat
• Whooping cough
• Urinary tract infection

The conditions require antibiotics, either for treating the infection or treating potential complications that can arise when they are not treated (or both). If you suspect your child has one of these conditions, it is important to have them evaluated.

Some common conditions for which antibiotics are often prescribed but could resolve on their own:

• Ear infections
• Sinus infections
• Bronchitis

For certain ear infections, antibiotics can be avoided. It is essential to talk with your doctor about your desire for this if you are interested. Many children with ear infections will get better without antibiotic treatment. Similarly, sinus infections can be both viral and bacterial. Talk with your doctor about whether treatment with antibiotics is necessary.

Bronchitis in kids is almost always a viral infection. It can be treated by treating the symptoms and allowing the passage of time.

There are some standard conditions for which treatment with antibiotics is not indicated. These infections are caused by viruses such as:

• Common cold
• Viral sore throat

Being cautious with antibiotic use is important for preventing unnecessary complications and side effects for you and your children. If you’re not sure, ask your doctor. The CDC provides a helpul guide on when antibiotics are necessary. Here's a quick version for you:

If you want to learn more about these or any other conditions, Cook Children's offers a great service "Ask a Librarian." Click here to learn more, but a Cook Children's librarian can send you information that is up to date and most importantly from reliable sources.

We've also written a ton on this topic for the newsroom:

• Does My Child Really Need An Antibiotic?
• What Is Cook Children's Doing About the 'Antibiotic Crisis'?
• Too many antibiotics not helpful, could cause harm
• 3 Myths About Antibiotic Use Every Parent Should Know
• Probiotics for Tummy Bugs: Do they Help Your Child?
• Is It Strep Throat or the Flu?
• Is It Croup or Whoop?
• Let's Learn About Whooping Cough?
• When It Comes to Your Kid's It's Never Just a Virus

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.”

You walk hesitantly out of the bedroom to find it’s not an intruder, but something that may find even more worrisome: Your child is sleepwalking.

Children walking in their sleep is not uncommon. Twenty to 25% of children may sleepwalk at least once in their lifetime. Hilary Pearson, M.D., a pediatric sleep specialist and medical director of Cook Children’s Sleep Center, sees about 10 kids per month that sleepwalk.

With her expertise on the subject, we met with Dr. Pearson to learn more about sleepwalking, including the causes, what to do when it happens, when to worry, and myths that are far from true.

Common sleepwalking myths include:

• Waking up a sleep walker will harm them.
  • You can’t hurt anyone from trying to wake them up, although waking a sleepwalker may be hard to do Dr. Pearson explains. Waking them up isn’t going to cause any physical harm, but it might prolong the event and make it more dramatic.
• You can kill a sleep walker if you wake them up.
  • “I have never been asked this, but I can assure you it is far from true,” Dr. Pearson said.
• Sleep walking only impacts the sleep walker at night.
  • This is also not true. The time spent sleepwalking is not true restful sleep, so it can cause issues during the day. Kids can also be nervous about going to sleep if they know they may sleepwalk.

So what is sleepwalking? Sleepwalking is a disorder that occurs during the deepest stage of sleep resulting in walking around or performing “complex” behaviors. These behaviors can range from simply walking around the bedroom, to getting dressed, walking out the front door and even driving. There are several causes, but the most common are insufficient sleep, stress, and inheriting the tendency.

If you see your child sleepwalking it’s important to quietly and calmly direct them back to bed.

“Interacting with the sleepwalker too much can cause more confusion and even make the event last longer,” Dr. Pearson said. “You don’t have to awaken them or “snap them out of it”, but can just guide them back to their bed. “

If it happens occasionally there is no reason to be concerned, Dr. Pearson explains. It’s normal and many of us have sleepwalked at some point. However, if it happens more than twice a week and lasts for a few weeks, or if dangerous behaviors are occurring, further evaluation may be necessary.

Some children have succeeded in getting outside of the home, or injuring themselves during sleepwalking events, both of which can be dangerous. Sometimes sleepwalking is a phase that lasts for a few months to a few years. Other times it is caused by an underlying sleep disorder, so treatment could be helpful.

If the sleepwalking occurs more often, it is recommended that you speak with your pediatrician or family physician. He or she may refer you to see a sleep doctor for further evaluation.

Sleep studies are sometimes recommended to diagnose the causes of sleep walking. These studies allow for doctors to identify things like breathing or movement abnormalities. If a sleep disorder is identified, treatments to resolve it may decrease your sleepwalking. In other cases, analysis of the child’s sleep patterns or stress levels can help with identifying ways to decrease sleepwalking.

Sleep apnea has been reported to occur in up to 40% of children with sleepwalking. Other medical conditions that can contribute to sleepwalking are: restless leg syndrome/periodic limb movement disorder, fevers and even ADHD.

A child’s sleepwalking can simply be due to lack of sleep, poor quality of sleep or can be a sign that the child is coming down with a virus.

“Some families have members that sleepwalk into adulthood,” Dr. Pearson added, “But most will outgrow that behavior during their teenage years.” Keeping sleepwalkers safe is the most important part of the process.

"Your child is here with a sore throat. I know they haven’t had a fever, but strep has been going around."

Whelp, there goes your day. Cancel all your meetings. Call your pediatrician's office. Get an appointment in a few hours. Get your child tested and see what happens next.

But for some families in North Texas, there might be a better way to get treated for illnesses.

Through a partnership with Cook Children's, students in Keller ISD join a growing list of other local school districts who can now see a pediatric provider via telemedicine as part of our School-Based Virtual Health program. All while staying at school.

Children with qualifying conditions such as earache, sore throat, pink eye and many others who present symptoms to their school nurse, connect with either a Cook Children's board certified pediatrician or a certified nurse practitioner via a secure video connection. The school nurse can use devices to show the provider the child's ears, throat, rashes, and other physical findings as well as allow the provider to listen via a digital stethoscope. Students also can be tested for both strep and flu while right there in the office.

The virtual visits are completely covered for children who are on Medicaid. For all other patients, the price of a visit is $65 for new patients and $50 for established patients.

Keller ISD and Cook Children's started a pilot program approximately three years ago in five schools. The success of the program led to the adoption of the program to the full district last fall. Funds from the Grainger Foundation allowed for the purchase of more equipment and marketing information to be distributed.

Enrollment at Keller ISD has increased significantly over time. Although registration can be completed on the day of the visit, there are now over 1,000 students pre-registered for visits. More than 150 appointments have been completed this school year. About half of those visits have allowed the student to stay at school. Staying in school means decreasing lost educational time, faster time to diagnosis and treatment as well as prevention of many parental headaches and frustrations.

Interested in more information about Cook Children's School-Based Virtual Health program?

Click here to find out more about the program and how your school might become involved. If you would like to donate to this program, click here and type in "telemedicine" when prompted.

But choosing the best place to go for your child's care  can be a difficult one for some parents. After all, Cook Children's offers several options within its system, ranging from primary care, urgent care, the neighborhood clinics and the emergency department.

So how do you know where to go? To begin with, visit the handy infographic to the right or click here.

"Every patient who comes into our Emergency Department is important to us. However, some patients may be able to receive the care they need from their primary care physician, a neighborhood clinic or an urgent care center," said Corwin Warmink, M.D., medical director of Cook Children's Emergency Department. "The best thing a parent can do is know what constitutes an emergency, so they know where to go when that time comes."

When it comes to choosing where to go, Kara Starnes, D.O. medical director of Urgent Care at Cook Children's, advises parents to think about the severity of the issue.

For instance, your child's Cook Children's pediatrician can see a number of ailments, including allergies, the flu, migraines, pink eye, sprains and vomiting.

During times when your pediatrician's office is not available, the Urgent Care Centers at Cook Children's can handle the same ailments, along with most fractures (broken bones) and cuts. Fractures with severe deformities or open fractures should not come to the Urgent Care but instead should go to the Emergency Department (ED). The ED has more equipment to handle the most severe cases, and the child can be admitted quickly to the medical center for continuing care.

If your child has multiple injuries, neck injuries or head injuries with loss of consciousness and/or vomiting, they should go to the ER. These kids typically need the ER because the UCC is not as equipped in imaging and other sophisticated tests available at the medical center.

"Possible surgery, such as appendicitis, is tough for parents to determine because most of the time, abdominal pain is caused by something simple like constipation," Dr. Starnes said. "But severe abdominal pain, testicular pain or swelling, bleeding when vomiting or severe bleeding with bowel movements are reasons to go to the ER."

You should visit the ED with your child in case of a medical problem that could cause death or permanent injury if not treated right away.

Daniel Guzman, M.D., a Cook Children's Emergency Department physician, adds “when in doubt of the severity, always visit the higher level of care such as the Emergency Department” and if immediate attention is required call 911.

And of course, we are right in the middle of flu season. Last week (Jan. 5 to Jan. 11, 2020), 837 kids were tested for the flu. Of those kids, 141 tested positive for Influenza A, 187 for Influenza B and another 102 for RSV. 

For those kids, Cook Children’s has a variety of options for care including the primary care offices, neighborhood clinics and urgent care locations.

“If your child is over 3 months old and has a fever, even a high one, it’s OK to see your pediatrician as long as they are breathing comfortably and drinking well,” said Diane Arnaout, M.D., a pediatrician at Cook Children’s Forest Park. “If your child has mild wheezing, we can give breathing treatments in the primary care offices. If you’re not sure whether your child’s issue is an emergency, our nurses can talk to you over the phone about symptoms and help you decide between the ER, urgent care and a primary care visit.”

For most of her 20 years, Shanley Stuteville has been a patient at Cook Children’s.

She came to the medical center at the age of 3 after she began having seizures. Even as an adult, she continues to be seen by the Neurosciences team. After receiving care for so long, Shanley knows better than most how overwhelming a hospital stay can be, especially for younger kids.

“I was in the hospital last summer for my second phase [of testing], and my nurses were mentioning they were really glad I was older because a lot of the younger kids get scared,” Shanley said. “After that, my mom suggested I should write a book to help them.”

After years of testing and needles, Shanley has a wealth of empathy for younger patients. She recalls her initial feelings of fear of the unknown, but they were quickly lost when she realized her hospital was unlike any other.

Shanley began to write in July 2018, while scheduled to undergo testing at Cook Children's Neurology Epilepsy Monitoring Unit (EMU), where she would be watched 24/7 for four days to see what the source of her seizures was. The book became a family interest when her aunt began to illustrate Shanley’s medical team and created an animated world where leads, IVs and MRI machines weren’t so scary after all.

“Soon an IV was applied to my hand. Their magical spray made it something I could stand,” Shanley wrote. “It took away the pain and for that I was glad. It did not hurt, not even a tad.”

Shanley donated 50 copies of her children’s book to the Epilepsy Unit, but despite her appointments and hospital stays she’s found other ways to give back to her medical team. As a student leader at her university, Shanley completes a lot of service hours, but her service project last year was a hospital-sized treat.

As a “thank you” to her medical team, Shanley baked over 900 cookies for the Dodson Specialty Clinic staff. It took her a period of several school semesters to complete, but she delivered homemade cookies to each floor.

Although she spends an ample amount of time at Cook Children’s trying to figure out why she has seizures, it’s not uncommon for patients with epilepsy to have periods of time without seizures. Shanley would occasionally go 100 days without seizures, and even celebrated with a cake with her nearly lifelong doctor, Howard Kelfer, M.D., a Cook Children’s neurologist. However a life without seizures was never permanent.

“She’d go long periods of time without having a seizure and then one would come back around so it was really discouraging for them because they thought she was going to be over it,” Dr. Kelfer said. “It eventually became very clear that her seizures weren’t responding just to medications. It was always, ‘well she went this long without a seizure, maybe she’ll go longer this next time.”

Shanley was eventually determined as a surgical candidate after her time in the EMU last summer. Her surgery in May 2019 removed a portion of the front lobe in her brain. While she has not had a seizure since, it will take a year of no seizure activity before it can be deemed a success.

Shanley is now able to sleep through the night, a small comfort she didn’t have before her surgery. Her surgeons were also careful in the placement of her scar, which will be hidden by her hair when it begins to grow back.

“I have to say that I wouldn’t mind if it did [show],” Shanley said. “It will always be a reminder of the wonderful men and women at Cook, as well as hopefully provide an example to other children that they can walk through this and recover too.”

Shanley remains an advocate for younger patients, and is recovering quickly after her brain surgery. Her passion for patients inside the medical center has shaped her life for the last 17 years, and she is hopeful to make it a lifelong expression of gratitude.

“Shanley and her family come to all the family support groups and they’re willing to volunteer to talk to other families,” Dr. Kelfer said. “Shanley is extremely motivated to not allow her seizures define who she is.”

Following her surgery last month, Shanley will return to school this fall where she is studying to become a pediatric occupational therapist.

Kids are gross.

Germs and kids are doubly gross.

As parents, we know this is true, especially during this time of year. The illness visits are piling up in my office and throughout the Cook Children's system. The days off school are starting. Missed workdays are causing stress.

We all hate this part of winter.

In my office, we're seeing lots of barky coughs from croup. We've also seen a ton of kids with sore throats from strep and viruses. Lots of fever from ear infections and flu season is just around the corner.

So what do you do? How do you survive the winter and keep your child healthy?

There's no magic vitamin. There's no magical food. There's no magical anything.

But here's something you can do: teach them not to be (as) gross.

1. Kids, stop licking and chewing stuff: Not the table, not your clothes, not your friends. There is nothing you can lick except your food, and really, you should chew it.
2. Kids, wash your hands. Several times a day. Wash them after you eat. Wash them after you go to the bathroom. Wash them just because you need to wash your hands. Get those germs off.
3. Kids, cough into the crook of your elbow. Don't cough on your classmates or your teacher (this isn't going to get you out of a test). Don't cough into your hands because then you will be spreading germs around the next time you touch someone or hand something to a classmate or sibling. 
4. Kids quit sucking your snot back up into your nose. You're driving us all crazy and making us all nauseous. It's disgusting. Really. And it's also bad for you. Get that crud out of your nose and out of your body.
5. Kids, stay home from school if you're sick. If you have a fever, it's not allergies, and no, you can't take Motrin on your way into school to make it through the day. (Ok, kids. This one was more for your parents.)

I'm sure there's more. What other lessons should we teach our kids so they won't be as gross this winter?

Stay well,

Doc Smitty

Texas flu activity continues to rise and is at an above-average level, per the week’s DSHS flu report.

At Cook Children’s Medical Center, the lab tested 529 children for the flu during the week of Nov. 10-16, 2019. A total of 74 kids tested positive for the flu (63 with Influenza B and 11 with Influenza A) and 152 more were confirmed to have RSV.

“For more than 50 years, hundreds of millions of Americans have safely received season flu shots,” the agency wrote in its tweet.

“The flu vaccine is still the best form of protection we have to fight off getting sick,” said Justin Smith, M.D., a pediatrician at Cook Children’s in Trophy Club. “The vaccine is especially important for children aged 6 months to 5 years. They are at the highest risk for serious flu-related complications, including death. Even if you do get the flu, people who are vaccinated generally get a milder and less dangerous form of the illness.”

Two types of flu vaccine are available for the 2019-2020 flu season. Both protect against four types of influenza viruses: Influenza A (H1N1), Influenza A (H3N2) and two influenza B viruses.

You may remember the spray shot wasn’t previously available for children because it didn’t work as well. The newer versions appear to work as well as the shot. So either vaccine can be given this year, depending on the child’s age and general health.

The nasal spray is approved for use in people 2 years through 49 years of age. People who are pregnant or have certain medical conditions (such as asthma) should not receive the nasal spray influenza vaccine.

You grab your phone and type in a few keywords and are immediately overwhelmed with the wealth of information on the internet.

So, how do you know where to look and, more importantly in this age of "fake news," what's accurate?

"It's so important for today's physicians to make sure they use digital platforms to reach parents and provide helpful and accurate information," said Justin Smith, M.D., medical director of digital health and a pediatrician at Cook Children's. "Parents are so busy these days, and sometimes it's difficult to make sure what you are reading online is accurate. Trusting internet sources for you or your child's health without verifying their accuracy can be dangerous.

The problem for most of us is distinguishing trusted sources of information from misleading or altogether "fake" health news.

"Type 'RSV' into a search engine, and you'll come up with millions of hits," said Barbara Steffensen, MSLIS, family librarian at Cook Children's. "You have to figure out which results are authoritative, which are commercial and which would apply to children rather than adults. Filtering all of those options can be a complex task for parents who want reliable information quickly."

A few tips can help you simplify your search and find information that you can trust.

Consider the source

A website's domain name can tell you a lot about its credibility. Nonprofit, nongovernmental research, advocacy, education and health professional organizations are generally excellent resources that tend to have ".org" endings.

The sites with ".gov" means you are visiting a United States government site. Colleges and universities also can be excellent sources; identify their websites by looking for ".edu." at the end.

So what about checkupnewsroom.com, the site you are reading this on right now? We are an online newsroom run by Cook Children's Medical Center in Fort Worth, Texas. We publish a story almost daily, but not until it goes through an approval process. The articles on this site are either written by or approved by the sources of the story before published. The same is true when you visit the Cook Children's website, cookchildrens.org.

Otherwise, domain names ending in ".com" or ".net" can be tricky. Online encyclopedias and for-profit websites are acceptable to use for the most basic information and a place to start your search, such as finding the definition of a disease but shouldn't be consulted for much else.

Dig deep

A well-designed website can mask flawed information. Before you dive into the material, read the site's "About Us" tab or an equivalent to learn about the organization behind the digital portal. Be careful. These sites may have a hidden agenda.

"Recently, I was searching for information online about a health topic," Steffensen said. "I found a page that looked promising, but when I checked into it, I found a law firm produced it."

Look for red flags

If you open a website and find it difficult to see past the explosion of advertisements, it's time to hit the "back" button.

"Lots of ads are a sure sign that a website isn't a good resource," Steffensen said. "If the site has ads all over the place, endorsements from pharmaceutical companies or solicitations for donations, searchers should be concerned, even if the material looks credible."

Read the fine print

Comb articles you can find online for easy-to-miss details that are essential clues to reliability. Is the author a medical professional? When did he or she write the essay? Was the piece reviewed by such an individual, and how recently?

Many families want to know as much as they can about their child's health and wellness, and becoming more health literate is great. What would be better still is for parents and caregivers to have peace of mind in knowing the information they gather is trustworthy.

Read what the National Library of Medicine suggests about web surfing and search wisely.

For more information

Need accurate health information that you can trust? Visit Cook Children's Education Resources page. Do you have questions about an illness or condition? About how to keep your child healthy and safe? Let us help. Click here to learn about the Matustik Family Health Library, located inside Cook Children's Medical Center.

Cook Children's approved health resources for you:

• Health Education and Resources
• Ask a Librarian Health Information
• Procedure Information
• Condition Information
• Medication Information
• Parent Center
• Teen Center
• Kid Center
• Community Education Events

The CDC found:

• That suicides increased by 56% during the 10-year span among people ages 10 to 24 years old.
• Suicide attempts among African-American teens increased by 73%.
• Suicide is the second-leading cause of death for teens from all demographics and the third-leading cause of death among black youths between the ages of 15 to 19 in 2017.
• In 2017, 2,200 teens between 15 to 19 years died by suicide.
• 1 in 5 high school students admitted to experiencing suicidal thoughts and 1 in 10 said they devised a plan to carry it out.
• The increase in the rate of suicides among 10- to 14-year old children have almost tripled between 2007 and 2017.

The CDC collected data from nearly 199,000 high school students by the CDC and Prevention’s Youth Risk Behavior Study.

Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s, realizes suicide in children and adolescents is a difficult topic for most parents. But she stresses it’s one that can’t be ignored.

“As a mental health professional, my worst fear is a child prematurely ending his or her own life,” Dr. Pyrc said. “As a mother, it is hard to comprehend the profound grief families must feel in the wake of a suicide.”

The American Academy of Pediatrics has updated its guidelines to recommend pediatricians routinely check for signs of depression in their young patients. The focus is to carefully screen patients ages 12 and over during annual checkups.

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” said Vanessa Charette, M.D., a pediatrician at Cook Children’s Magnolia office in Fort Worth. “Even if nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression.”

While researchers say they aren’t sure of the exact causes for the rising suicide rates, experts point to a rise in depression among adolescents, drug use, stress and access to firearms might all be contributing factors.

Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Cook Children’s Behavioral Health Clinic in Denton, is simply fed up. She’s seen too many kids come into her office depressed, frightened or even suicidal because they can’t get away from their bully or bullies.

“I think that bullying is worse than ever before because of cyberbullying,” Elliott said. “Kids can’t get a break.”

No child is bully-proof. Elliott 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 likable 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.

Elliott advises parents to monitor their child’s computer and cell phone, and encourage them to spend less time on social media. If bullying expands onto social media, then parents should talk to their child’s teacher, coach or another school official.

“Parents should watch for any change in a mood like sadness, depression, hopelessness, irritability, anger, and hostility,” Elliott said. “You may see more tearfulness and changes in activity level. Watch for more withdrawal from friends and family, change in friends and loss of interest in activities once enjoyed.”

Elliott says warning signs of teen suicide include:

1. Alcohol/Drug Use
2. Preoccupied with death (writing, drawings)
3. Talking about feelings of hopelessness
4. Talking about being a burden to others
5. Telling loved one's goodbye
6. Decline in performance
7. Giving prized possessions away
8. Isolating and withdrawing
9. Acting highly anxious or agitated
10. Acting reckless and taking risks
11. Rages
12. Changes in sleeping and/or eating
13. Dramatic changes in personality and/or appearance

If you would like to schedule an appointment, refer a patient or speak to our staff, please call 682-885-3917. 

Sources for this Topic:

• Cook Children's Behavioral Health Center
• Youth Risk Behavior Surveillance System (CDC)
• Report: Suicide Attempts Among Black Teens Increased by 73 Percent (The Root)
• Suicide attmepts increasing among black children and teens, study finds
• Youth Suicide Rate Increased 56% In Decade, CDC Says
• Suicides and homicides on the rise in young people (NBC News)

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

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

Age (When will my kid stop barking?)

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

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

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

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

Pathology (What makes my kid bark?)

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

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

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

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

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

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

Two take home tips:

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

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

Ever found yourself  Coming and Going?? Mommy Memory Failing?? Brain on Overload??

Well, I find myself there VERY often, not only because I am a mom of twin 15-year-old boys but as a mom of a severely handicapped child. Most would say “Oh, you are a special needs mom” but I think of it as a “Special Journey Mom”……..Walking through the ups and downs of life with my son who has severe spasitic quadriplegic cerebral palsy.

Our twin sons (Colby and Clayton) were born at 31 weeks. Being born 9 weeks early, Colby was in the NICU for 30 days and Clayton was in for 45 days. Clayton’s body did not handle being born that early and after many complications he received the diagnosis of cerebral palsy. All four of his extremities are affected and he cannot sit, walk, talk, or eat on his own. He has seizures and requires 24-hour-care. He sees 11 wonderful specialists and his fantastic pediatrician at Cook Children’s who have kept him and his medical journey the best it can be.

I am writing this after a request from Kim Mangham, M.D., our son’s pediatrician, heard me talking about Clayton’s Care Board. Dr. Mangham and I were talking about a certain medicine and when it was given. She mentioned changing the time given so it would be easier for me. That is when I mentioned the Care Board and how it helps me remember when all meds are given. She was intrigued and asked me to write about it.

Life can get away from you and can often disappear when caring for a chronically ill child. “ALL THE SCHEDULES” - school schedule, feeding schedule, medicine schedule, therapy schedule, doctor schedule, family time schedule, extracurricular activites schedule, sibling’s schedule, husband’s work schedule, and so on and so forth. I felt like I was drowning in all the schedules so my husband and I thought there had to be a better way.

Clayton requires G-tube feeds every three hours, with water in between, medicine in the morning, late afternoon, and evening times. At times he has to do breathing treatments, so keeping track of that is important. He also needs to be stretched daily (which is called Range of Motion or ROM). Due to some complications with a medicine pump he had in his body, he had to have it removed and start some new oral meds which required a strict schedule on timing to keep the medicine in his bloodstream. Clayton also has many people taking care of him- us, my parents, his therapists, etc. So we all were always asking “When did he have his last feed?” or “When did we give that medicine?” Don't want to bore you with his details - just trying to give you a picture of why Clayton’s Care Board came into play.

As the years have gone by his care has increased and become more complicated. Also as his parents, we are getting older and knew we had to put in place a better system to make sure he got all he needed when he needed it. He needed the consistency of care from caregiver to caregiver - an extra layer to help eliminate human error or memory problems on our part.

So, as simple as it sounds we bought a LARGE dry erase board. I knew we needed almost every hour of the day on the board along with all the items, meds, and things we have to do with Clayton on it. I also bought some magnetic grids to place on the dry erase board so it would be organized and easily changeable. Now, when someone gives Clayton meds or stretches him we write down the time so the next person that comes in knows exactly what is needed and when.

Although, a dry erase board seems like a super simple solution and many of you may not have a medically complex care child, I can assure you that sometimes the easiest solutions can be the most life-changing. Hopefully, this information will help you through the special journey of raising kids and all that comes with it - Crazy schedules, mommy memory fails, brain overloads and all!!

1. The pain is "crushing" or pressing down.
2. There are other symptoms like passing out, nausea or skipping/racing heartbeats.
3. The pain is brought on by exercise.
4. There is a medical history that would worry you (examples are a history of heart disease, Kawasaki disease or Marfan syndrome).
5. There is a history of a murmur. 

And here are 5 other common causes of chest pain:

1. Muscular or chest wall pain. The pain comes back when you touch their ribs or chest.
2. Reflux. The pain is after meals or described as burning.
3. Anxiety. The pain is associated with stressful situations.
4. Lungs. The pain is associated with a deep breath or there is a history of asthma.
5. Who knows? It's fairly common that we can't figure out where it came from but this should only be said after everything else has been considered or checked for.

And only time will tell for sure, but some indicators lean toward a potentially severe influenza season.

Clinical experts in the U.S. watch the Southern Hemisphere of the world for signs of what might be in store for us in the north.

In Australia, where winter recently ended, the Department of Health reported the flu season arrived earlier than normal. Of special concern to the experts is the type of flu season seen in Australia – Influenza A (H3N2). H3N2 is a more dominant strain of the flu and causes more illnesses.

How effective the flu vaccine is depends on how well experts predict what strains of the flu will be circulating the globe that year.

“The vaccine strains are chosen about nine months before flu season, based on circulating strains from around the world by epidemiologists who are geniuses and do this for a living,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases.

Locally, the first case of flu (Flu B) was reported at Cook Children’s Medical Center two weeks ago. Last week, no one tested positive for either strain.

NBC News reports that one pediatric flu death has already been recorded in the U.S. – a 4 year old in California who had underlying health problems.

Jason Terk, M.D., a Cook Children’s pediatrician and a national expert on immunizations, adds his voice to other pediatricians and global health experts who say the flu vaccine remains the best way to prevent influenza.

“The great news about the vaccine is that even when it’s not always a perfect match for prevention, the flu vaccine can reduce the severity of the illness, even if you do catch the flu that season,” Dr. Terk said.

To make an appointment for your child’s flu shot, contact your Cook Children’s pediatrician. The vaccine is currently available in many offices and a second shipment will be delivered next week.

“It takes two weeks for the shot to become most effective. Because flu can hit as early as late October or early November, we recommend getting the flu shot as soon as possible and definitely before the end of October,” said Justin Smith, M.D., a Cook Children’s pediatrician.

More On This Topic:

• Flu Shot Appointments
• Influenza/Flu Information
• Let's Learn About ... The Flu
• How To Tell If It's Strep, Flu, Rotavirus Or Norovirus
• Comfort Menu to Ease Pain, Anxiety for Children Getting a Shot
• Is It a Cold or The Flu?
• Pediatricians Say Kids with Egg Allergies Should Now Get The Flu Shot

As the parents of six, Dave and Jeanie Caselman have mastered the art of handling whatever life throws at them. Whether it’s school events, sports, graduating from high school or starting college, they thought they had experienced it all with their kids.

That is until five months ago when one of their children was diagnosed with cancer.

On April 1, 2019, their 8-year-old son Treagin was playing with a friend when they collided. This kind of thing happens, and once immediate injuries were ruled out, his parents didn’t give it a second thought. After all, kids will be kids. However, shortly after the collision, Treagin began complaining of chest pain that came and went...and eventually never went away.

On April 19, Jeanie and Dave decided to take Treagin to his primary care physician, Smita Suresh Ranade M.D., a Cook Children’s pediatrician in Richland Hills, who found a mass on his left side and sent the Caselmans immediately to Cook Children’s Emergency Department. Once there, X-rays were taken and the Caselmans were told that an oncologist was coming to speak with them.

As parents there is nothing scarier, Jeanie explains. There are some things parents hope will never happen to their child, and this was at the top of the list.

When the X-rays came back they revealed a large mass on Treagin’s left chest wall, as well as a chest full of fluid. A biopsy was performed that confirmed Treagin had Ewing Sarcoma, a rare form of bone cancer. It was at that moment that their world was turned upside down.

No parent wants to watch their child go through what Treagin currently is. Dave and Jeanie admit that it’s easy to get down and ask why or dwell on how he doesn’t deserve this, but watching Treagin’s positive attitude has helped them focus on the good in a tough situation instead of the bad. Treagin’s “it is what it is attitude,” and his ability to roll with the punches, while remaining positive has been a saving grace to his entire family.

“It is our job to comfort Treagin when things get tough,” Dave said. “We want to be strong for him, but what he doesn’t realize is that his positive attitude and constant smile makes it easier for us to dig deep and be strong for him when he needs it most.”

Parents don’t always realize how comforting a simple smile or laugh from their child can be in these situations. Treagin’s first few rounds of chemo were tough on him, Dave explains, the chemo shots he gets usually make his bones ache, but he hasn’t let that stop him.

The thing that has amazed Treagin’s parents the most throughout this journey is how much he wants to know what is going on and how willing his doctors and nurse have been to explain things in ways he understands. He asks questions, wants to see pictures, X-rays and anything else they will show him. He is always aware of what is happening and what is coming next.

“I think the fact that he is so inquisitive and willing to learn about what is going on throughout his treatment has helped us,” Jeanie said. “He doesn’t act afraid when doctors explain the next treatment, he just keeps smiling and as a parent that inspires you to stay strong.”

“Treagin is one of the most curious patients I have ever interacted with, he has the ability to vocalize what he wants to know and exactly how he is feeling,” Anish K. Ray, M.D., a hematologist and oncologist at Cook Children’s, said. “Since he is so aware of what is going on, it only seemed reasonable to me to allow him to be included in any decisions made.”

Even though he has limitations, Treagin continues to live life to its fullest. Whether he’s asking if his friends can come over to play video games or begging his parents to take him to watch his sister, Tavvy, at her different sporting events, Treagin is still tackling life head-on and isn’t wasting a single moment.

“Throughout all of this he has never stopped smiling,” Dave said. “He inspires me to keep going and to find joy in every situation no matter how hard."

By Libby Collins

By Daron Aldridge

For Heather Giattini, RN, Cook Children’s holds a special place in her heart. Less than two years ago her two-and-a-half year son, Brooks, had his first open-heart surgery to address his aortic stenosis (a narrowing of the heart’s aortic valve). It was then that she witnessed firsthand the power of the love and caring Cook Children’s staff and physicians give to their patients and families.

Even though she was a nurse in the adult hospital world at the time, she no more got home from discharge, looked at her husband Matt and said, “I HAVE to work there!” The opportunity finally presented itself and Heather joined Cook Children’s as a cardiovascular surgery nurse earlier this year.

Her desire to work here is simple. She explains, “I wanted to be a part of making people feel the way they made me feel. From our doctors – Dr. (Vincent) Tam and Dr. (Lisa) Roten – to the entire staff that took care of us, it was all amazing. This is where I knew I belonged.”

It wasn’t just Heather who belonged here. As fate would have it, following a recent routine checkup with Dr. Roten, his parents were faced with the reality that a now 4-year-old Brooks would need another surgery. Even though they had hoped it would be years before he would need another surgery, Heather and Matt found solace in the fact that they knew Cook Children’s was the place Brooks belonged also.

But this time, the surgery would be a little different. Thanks to organ and tissue donations and the hand-in-hand work of Cook Children’s and CryoLife, Brooks would be getting a new valve in his heart that will hopefully mean this is the last surgery this young boy will need for decades.

The tissues, like the ones that are helping save Brooks’ life, are donated by families, who have lost loved ones and want to bring joy and hope out of their loss. Through CyroLife, these donations are cryopreserved for 10 years. This means they are able to positively influence and possibly change the lives of children, who aren’t even born yet. When these families make such a decision to be organ and tissue donors, they truly do “Donate Life.” Please visit donatelife.net to learn more about the life-saving importance of the selfless act of organ and tissue donation.

To celebrate the monumental impact such donations can have on patients, Brooks is the first proud recipient of the Donate Life: Recipient pin from CryoLife. The pin, along with similar pins that surgeons and nurses wear, are a quick way to show the world that organ and tissue donations can save lives.

As Brooks’ dad Matt said, “Most people think about the large organs when they think about donation but tissue donations may be small in size but can have a huge impact on lives.”

The day ahead was already filled with taking care of her daughter Winslow, who hadn't even taken her four medications during the day because of her medical condition. Plus, Shelly still had to breast pump and then feed her daughter through Winslow’s G-button. 

Shelly didn’t have time to be on hold, but she did know the one person she should call.

“Rebecca Melville. She’s amazing. Rebecca has always been there for me. She’ll call me or I’ll call her and with a snap of the fingers, she gets things done,” Shelly said. “I needed to speak to someone at Medicaid to update them on something. And it was just impossible. I called early in the morning and then I waited and waited. I called Rebecca and ‘Boom!’ everything was done.”

Rebecca Melville, RN, is a case manager and service coordinator for Cook Children’s Health Care Plan. The program is a local, non-profit company that provides health care for STAR (Medicaid) and CHIP members in a six-county service area in North Texas.

“It can be frustrating for parents, especially for someone like Shelly who does not have time to be on the phone all day. She needs to take care of her child,” Melville said. “I have one contact person who works with the state and I can talk to very quickly. If there’s a medication application or an eligibility issue, our contact is very quick to respond to us. Our role at the Health Plan is to intervene on the parent’s behalf and to be a liaison between them and the state.”

Melville has 42 patient families on her current caseload. She speaks to the families regularly. For instance, she speaks to Shelly once a month and then sees her every three months in person.

“And of course if Winslow gets sick, I go visit her in the hospital and when she gets out,” Melville said.

Each month, Melville calls to make sure that Shelly is receiving the services she’s authorized for and everything is working smoothly for her. Through the Health Plan, Winslow receives her formula and feeding supplies, as well as any private duty nursing she needs.

Shelly admits to being surprised that she and her husband, David, even qualified to be a part of the Health Plan and Medicaid. They both worked and had insurance.

“I thought when you were in a certain income or tax bracket, it disqualifies you for Medicaid,” Shelly said. “But after all we’ve been through and as much time as Winslow has spent in the hospital, I don’t care how much money you make, you are going to be broke after this. So I was pleasantly relieved that we not only qualified but continue to receive help today.”

As Shelly’s telling her story, you can hear Winslow, who is 5 years old, playing with her dog and urging her mom to get off the phone so they can go to the movie.

It all sounds so blissfully normal.

But that’s not how things started from the moment Winslow came into this world.

Winslow was born on Jan. 1, 2014, the first baby born in Wise County that year. Soon after her birth, the celebration ended.

Shelly and David Ogle’s little girl was born with a condition called heterotaxy syndrome. Though heterotaxy syndrome is extremely rare – in the U.S. about one in every 250,000 children are born with it --- it is the cause of some of the most complex and complicated heart defects.

Heterotaxy is a disorder that results in certain organs forming on the wrong side of the body, most typically the heart, lungs, kidneys, liver, stomach, intestines and spleen. Sometimes organs may be facing in the wrong direction, may be divided into multiple sections and even missing.

The result is that a child’s organs cannot function correctly, placing the child’s life at risk.

Vincent Tam, M.D., a thoracic surgeon at Cook Children’s, performed complex heart surgery to repair Winslow’s right ventricle that pumped backward.

The next big surgery was to repair her liver flow into the bowel of the child. Many times children who have Winslow’s condition need a liver transplant by the time they turn 2. Winslow is almost 5 and a half and is doing remarkably well and so far doesn’t need a transplant.

Because of her congenital condition, Winslow was born without a spleen and doctors removed her appendix, which was on the opposite side (the left side) of where it is supposed to be on the body.

By the time Winslow arrived home in August 2014, she was quarantined. After a couple of months, blood work came back to say Winslow was strong enough to go out in public for the first time.

With surgeries behind her, now it was time to begin life at home. That meant four doses of medicine a day, feeding tubes, breast pumping, cleaning supplies, and a G-button.

“Winslow is doing great,” Shelly said. “We think she can live a normal life, go to school, have children ... The only thing we think we will have to say no to is no high impact sports. I want her to be a band camp kind of kid.”

For Shelly to make jokes about her daughter’s condition shows how far she and her family have come. She credits the multiple doctors and nurses who looked after Winslow for saving her daughter’s life. And now she has people like Rebecca Melville taking care of Winslow’s needs.

“Rebecca has always been there for me. She’ll call me or I’ll call her and with a snap of the fingers, she gets things done,” Shelly said. “If I were going to refer anyone, it would be Cook across the board. They saved my daughter’s life. All the team members. The doctors, nurses, coordinators, the STAR Kids Program. You know that little say about it takes a village? Well, they are our village.”

Even as the summer was winding down, every member of the Emergency Department knew a fatal drowning could still happen at any moment. Tragically, that moment came over the weekend when two sisters were found unresponsive in a Haltom City apartment swimming pool. News agencies report the girls were taken to Cook Children’s where they both died.

“Drownings occur year-round and there is no ‘drowning season,’ especially in Texas,” said Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s. “You can’t get comfortable and complacent with children and water, no matter the time of year.”

Before this weekend’s pool drownings, three children had died from drowning at Cook Children’s in 2019 – two separate incidents in bathtubs in March and one child in open water in May.

Even in the month of September, the warm Texas weather means kids are getting in the pool. From 2014 to 2018, there have been a total of  16 drownings (13 in a pool and 3 in open water) during the month of September, with two being fatal.

“I worry that with the end of the summer and kids being back in school that people will relax a bit,” said Dana Walraven, community health outreach manager for Cook Children’s. “But we can’t let our guard down even for a little bit. The temperatures are still warm and there’s plenty of time left for kids to be in the water. All the same rules apply to keep our kids safe.”

As a pediatrician, I have been lucky to practice medicine in the post-vaccine era. Although I have watched kids struggle with whooping cough, meningitis, mumps and pneumonia, I am happy to say I have never seen many of the vaccine-preventable diseases. I rely upon my education and training to know about the diseases and recognize them should the need arise.

I do frequently wonder, ‘What was life like for families and children before vaccines were introduced?’ How did people manage the illnesses and anxiety that came with the disease?

For a firsthand answer, I only had to talk to the person sitting at my dining room table during a typical weekend family dinner – my mom.

It was the summer of 1949. While other children were skipping rocks and riding their bikes, my mom was lying in a hospital bed as one of many children struck down by polio.

The illness began as a fever with trouble swallowing and weakness in her left leg. The doctors quickly admitted her to the hospital for quarantine and treatment. Her most vivid memory of the time has to be of the spinal tap used to aid in her diagnosis. At the time, there were no child life specialists to comfort her. She was told to hold still and if she moved the test might kill her.

After 3 months in the hospital with only her mother allowed to stay, her symptoms seemed to be worsening. Her kind physician came into the room one day to visit and cheer up the family. His kindness unfortunately, resulted in him contracting the disease and being confined to a wheelchair for the remainder of his days. After all, back then doctors did not even realize the value of handwashing.

I asked my mom what people thought about polio in the pre-vaccine era. “Everybody was scared to death of catching it! They did not know how they got it but knew it was prevalent in the summer months. They tried to avoid the sun and swimming holes since those seemed to be related.”

We now understand the transmission of polio much better. Polio comes from a virus that is highly contagious. It is spread person to person through sneezing, coughing or contact with human feces. Before the successful introduction of the polio vaccine in the 1950s, the disease resulted in the paralysis of 15,000 people per year. Since 1979, no cases of polio have originated within the United States but cases can be brought in by travelers with the disease.

My mom was one of the lucky ones. Just as a conversation with her medical team was turning to placing her in an iron lung to support her breathing she began to recover. The impact of the illness, however, continues to this day with residual weakness in her legs that makes walking for her a constant challenge.

I asked her what she thought about vaccines as a mom and a grandmother. She responded, “I experienced polio and its effect on my life. I want all my kids and grandkids protected so they don’t have to go through what I did.”

Vaccine-preventable diseases such as polio and the re-emerging measles and mumps are not historically that far away from us. We cannot forget the tremendous impact these diseases have had on the lives of so many before the introduction of vaccines.

If you want to learn more, you can check out the CDC website on polio. 

Better yet, just look across the table on a sunny Saturday afternoon and if you are fortunate to do so, ask the folks who lived it. Their stories and experiences are powerful.

More Information On This Topic

• 'I'm Worried Too.' Pediatricians Concered As Texas' Nonmedical Vaccine Exemption Rates Hit All Time-High
• 5 Questions We Get Asked About Vaccines Answered
• Vaccines for Your Children: 9 Facts Parents Need To Know
• Vaccines and Immunizations
• Information for Parents

So what is difficulty breathing? How do you tell if your baby or child is having it?

In babies there are 3 main considerations to look for difficulty breathing:

1. The nose - When babies are having difficulty breathing, their nostrils will flare open and closed with each breath.
2. The area below the rib cage - Babies will begin to use their bellies to help them breathe when they are having trouble, this will look like sucking in and out of the area below the ribs.
3. Rapid breathing - Babies already breathe fast and they can breathe at a really unpredictable rates. But if you feel like the rate is faster over a sustained period, it could mean that they are having difficulty breathing.

In older children, there are some similar and some different ways you can assess difficulty breathing:

1. Watching - Just like babies, you can watch an older child under their ribs to see if they are breathing harder than normal.
2. Assessing activity - Are they able to go about their normal activities or are they getting short of breath?
3. Say the alphabet - Can they say the alphabet without breathing? How far can they get?

Obviously these aren't perfect assessments and children should be seen if you are worried. Any change in alertness or change in color (blue or duskiness) is an emergency.

Making a school “seizure ready” can entail a number of steps and it is important to get started on these as soon as possible. M. Scott Perry, M.D., medical director of Neurology and an epileptologist at  Cook Children's, offers the following advice.

Step 1: Does your child have a seizure action plan?

One of the most important components of being prepared for the school year is having a plan in place should a seizure occur. A seizure action plan is a form provided by your medical team which describes the types of seizures a child has and what to do if one occurs. The plan covers the key components of seizure first aid, as well as for instructions on how and when to use rescue medications for the child’s seizures. A standard form is provided by the Epilepsy Foundation and is commonly used.

Click here for a Seizure Action Plan from the Epilepsy Foundation.

For future reference, I encourage parents to begin requesting updated Seizure Action Plans at least a month before the school year starts, as many clinics get thousands of requests before the start of school and completing them may take time.

Step 2: Is your child’s rescue medication appropriate for their current age and weight?

Rescue medications are commonly prescribed to patients with epilepsy and are most often used for seizures that are prolonged or occur in clusters. Each patient will have unique circumstances for which a rescue medication may be appropriate. Some patients may not have a rescue medication as part of their Seizure Action Plan – for example, if their seizures are rare, well-controlled, and typically very brief.

A variety of rescue medications are available. For prolonged seizures, particularly convulsive type, patients may use rectal diazepam or intranasal midazolam. These medications are favored because they can be absorbed quickly for rapid treatment of the seizure and they don’t require putting anything into the mouth of the person that is seizing. Rectal diazepam comes ready to use for the age/weight of the child. Currently, nasal midazolam will have to be measured out by school staff before administration, but a new ready-to-use formulation has been approved by the FDA and should be available soon.

For patients with clusters of brief seizures, rescue medications such as clonazepam can be given by mouth between seizures. Several other medications, such as diazepam, midazolam, and lorazepam, also come in oral formulations that might be swallowed or put between the gum and cheek of a patient for effect.

It is very important that parents and their providers make sure the rescue medication prescribed for the child is appropriate for their age and weight. As a child grows, the dosing of medications will change. For those patients that have rare seizures and rarely require rescue medications, it is possible that the dose prescribed years ago may no longer be appropriate and therefore, may be less likely to work if the dose is too low.

Step 3: Can your child’s school administer the rescue medications provided?

It is important to know what medications your school is able and willing to give. While rectal diazepam is commonly used in schools, there are some school districts in the U.S. that only allow the medication to be given by a school nurse or similar medical personnel, even though the drug was designed to be administered by laypeople. If your school does not have a full-time nurse, there may be times when the medication cannot be given and an alternative rescue plan may be needed. Likewise, some school districts will not administer nasal midazolam because this formulation of the drug is not FDA approved to be utilized in this manner, though in the medical profession, we’ve used it this way for many years. Talk to your school about the seizure action plan recommended by your medical team. If they are unable to give rescue medications suggested, talk to your team to see if there are alternatives or if training can be provided to the school to ensure the rescue plan is followed.

Step 4: Is your child’s school “seizure ready”?

Probably the most important step in making sure your child is safe at school is making sure the people caring for them during the day are prepared to recognize and treat seizures. Despite how common epilepsy is, many people are only familiar with one type of seizure – tonic clonic (previously referred to as “grand mal”).

It is important that teachers and staff understand what seizures look like for each child with epilepsy, so they can recognize when rescue treatments may be needed, but also to keep parents informed if seizures are occurring frequently and may require a visit to the doctor to discuss treatment changes.

Some seizures, such as absence and partial seizures, may only manifest as staring or decreased response. For these cases, it is important that staff are aware so they can recognize seizures and don’t confuse these behaviors with simply ignoring instructions or bad behavior. Finally, for some children, their first seizure may occur at school and it is important that staff be able to recognize seizures in those who may have no prior history.

There are a number of ways for school personnel to become educated about epilepsy. The Epilepsy Foundation provides many resources including online and in-person training of school nurses and staff on seizure recognition and first aid.

Click below for a couple of great tools:

Managing Students with Epilepsy – school personnel and school nurse training

Seizure Training for School Personnel

The Epilepsy Foundation will also provide an ECHO course for school nurses starting October 2019. This is an online, interactive course for school nurses that includes instruction from epilepsy experts and allows for collaborative case presentations to discuss seizure recognition, first aid, and rescue treatments. Information for this course will be available on www.epilepsy.com in the near future. A helpful Seizure First Aid poster can be found by clicking here.

Finally, the Epilepsy Foundation will host a webinar from 7-8 p.m. CST on Wednesday, Sept. 25, 2019, on rescue therapies are open for anyone to attend.

Resources For Parents:

• Cook Chidren's Comprehensive Epilepsy Program
• Epilepsy
• Sam's Law
• Seizure Action Plan
• Seizure First Aid
• Seizure Training for School Personnel
• Managing Students with Epilepsy - School Personnell and School Nurse Training

It was also during this time that measles showed up in Texas and when I received my second MMR.

My sister had been in San Antonio with my mother for two months receiving care at a Bone Marrow Transplant center. While she had no memory of her twenty-third birthday, I saw pictures of the nurses and doctors surrounding her with a cake.

Later when she returned home, she commented on this nice shirt she had found in her suitcase as she had not seen it previously. I did not have the heart to tell her that it had been a gift from me for her birthday, she just had been so ill she did not remember.

As the number of measles cases in Texas were climbing, her doctors became fairly insistent that I receive a second MMR. They really didn’t want me to be around her without being protected.

Some may feel that wasn’t their decision to make. However, those doctors were not only scientifically correct but they cared deeply for my family. They knew me well enough to know that if I gave anything to my sister that would have hurt her, I likely would have never recovered from that guilt.

While measles can harm anyone, it likely would have been a death sentence for my sister. Initially, my mother was concerned about any possibility of me developing measles after the vaccine and giving it to my sister. The doctors reassured her and said the only way to protect her was to protect me. My mom had to make so many difficult decisions that year. Sometimes she did what the physicians recommended and sometimes not. Her goal everyday was to advocate and protect her daughter. So I was vaccinated based on the new two dose MMR policy.

Then I was able to be with my sister. I was with her when they told her that cancer returned. I was there to watch my platelets infuse into her weak body. I was there on the morning she died. Holding her hand. It would have been too risky during the measles outbreak for me to be around her that summer if I had not received that vaccine. While I grieve the loss of her beautiful mind and spirit still after almost 30 years, I realize that experience inspired me to enter medicine and advocate for children.

It is so unfortunate that the discussion around vaccination has become so volatile. Like my mom, parents are just trying to make the best and safest decisions for their children. They have to navigate a much more complex world of information available to them. At my clinic, we spend a good amount of time discussing questions and concerns regarding vaccines. While I try to work with families and guide them, in the final discussion, vaccinating children is the healthiest choice for them. Not just for their own disease prevention but for all of those who cannot receive certain vaccines through age or medical condition.

Honestly, I was a bit nervous writing this realizing potential backlash from those not agreeing with vaccinations. Yet as I was looking through my closet the other day, I saw that shirt I gave my sister. It made me smile remembering her wearing it and it reminded me of how all of us had to be brave in different ways that year. In her memory, I will continue to try and be brave.

Vaccinate. It saves lives.

Recently, Dr. Justin Smith talked about things to remember before your child heads back to school. He specifically mentioned you and your child’s anxiety as back to school approaches. It is true that pediatricians experience first-hand the anxiety that the transition back to school can create. Working in the emergency room as a child life specialist, offers a front row seat to the same pressures and stress. We often see a wave of kids struggling with anxiety and having a difficult time coping as they go back to school. As parents, we are often struggling too. Getting back in the swing of things and managing our kids’ emotions can feel overwhelming and often disheartening.

I want to challenge you, though, as parents and caregivers to enter into this time of transition with some tools in your back pocket ready to combat the stress and anxiety that back to school can bring. As a child life specialist, we are on the hospital side offering kids normalcy in the midst of a stressful situation. We are creating space for kids to learn to cope and develop tools that they can use throughout their lifetime – not just during hospitalization. As parents we need to create this same space in our homes. Here’s a few tips for creating space to cope during this transition. Remember that not every family and schedule can look the same. As you read, think of ideas that fit into these tips but also fit into your family’s culture.

1. Celebrate!!! Instead of back to school being a bummer, make it a celebration. Have traditions around the first day of school. We always have cinnamon rolls on special days so the first day of school is no different in our family. I usually write my girls a special note to commemorate the day and have a Dollar Store goody sitting at their spot for breakfast. I have all girls, so we have a tradition of getting nails done before school starts. School supply shopping day usually includes a lunch or dinner out to eat at a favorite place. You could go to their favorite restaurant or make a special date for a fun activity. These are just a few ways we celebrate, but there are LOTS of ways to celebrate a new school year, the end of the school year and all the things inbetween!
2. Create a routine. Often during the summer, our routine is gone or at best inconsistent. Going to school can provide the opportunity to revamp your routines and boundaries. In our home, there is no screen time before school, no matter how early you get up. There is an order to our mornings that include breakfast, getting dressed, brushing teeth, packing backpacks - all while music is playing in the background. My kids know what to expect each day when they wake up. We also have afternoon routines- a few minutes for a show when they get home, quiet/homework time before dinner and always set aside time for reading. While routines need to include the mundane things, it’s also good to include FUN in your routines. We have fun weekly routines and traditions. We get ice cream after school every Wednesday. We often have movie/pizza nights on Fridays or Saturdays. This year we will be adding a weekly job for our girls to accomplish also. Setting expectations and boundaries for kids sets them up for success. My kids know when to expect screen time, ice cream and family activities, and they can look forward to it without always asking for the next thing.
3. Be nosy! What does that mean? Well, you are the parent. You get to know ALL the things simply because you are the parent. Just because your kiddo is away from you for 7 hours a day or more, you still get to know what is happening in those hours. Ask your kids about their day with open-ended questions - stay away from yes or no questions. Get to know the people at school…your kids’ teachers, principal, even cafeteria workers. Take time to honor them so that they can know and respect you. Get to know your child’s friends and ask who they are eating with, playing with, etc.? Know the other parents in your kids’ class so when the stories don’t quite line up, you can get some more details. Know your kids’ teacher. While you want to be respectful of their time, it is important to address things that come up for your kids during the year. Don’t be afraid to ask questions to know more. Send the email to clear up confusion. Make the phone call when you see a red flag. The more you know, the more you can engage your child. Plan to eat lunch with your child regularly. That might be once a month, but your presence in that space matters…mostly to your child. Volunteer in your child’s classroom or at the school or offer to do things from home. This allows you to know what to ask and to advocate when and where there is a need. You don’t have to be an infamous “helicopter parent,” but being present (and a little nosy) creates space for your kids to trust you and know that you are with them and for them no matter what.
4. Focus on character. So often much of school feels centered around grades, testing, and measured successes. Often those are measured against other kids and expectations are high. While it is incredibly important for kids to master subjects and advance academically, their character will take them through all of life ~ all the challenges that they will face. And while math facts are super important, they won’t teach them how to be a good friend or show respect. I try to assess what character quality my kids need encouragement in and spend time fostering it. Whether it be self-control, patience, humility or the many others, we take time as a family to talk about these things. One thing I do for my kids is start a notebook at the beginning of the year that goes in their lunch box. I focus on character and encouragement in that notebook. I write a note or draw a picture each day that hopefully reminds and encourages them in that character trait. I also always let them know they are loved. I remind them at the beginning of each day, usually on the way to school, to choose others before themselves and treat others as they would like to be treated. We encourage trying over perfection, kindness over being right, and gratefulness when things aren’t going your way. The work will always be there, the vocabulary and math facts, but I don’t want my kids to get so lost in those facts that they forget about being human.

We want our kids to feel prepared and ready for this next year. Preparation alleviates some anxiety while creating space to teach them how to cope with the inevitable stress that comes with this transition. Celebrating, establishing routine, being present (aka a little nosy) and focusing on their character are all ways that you can help your children cope and combat the stress and anxiety of going back to school.

For most of us, a snake bite of any type would send us directly into a panic. However, when Ray was bitten while working in his lawn, he was hesitant to go to the doctor. He didn’t want to overreact. He wasn’t even sure he’d been bitten because of the heavy gloves he wore outside.

“Initially I knew it wasn’t good, the numbness and tingling. I told my wife that I thought I got bit by a snake but I never saw it because I was trimming the shrubs,” Ray said. “I actually called the Emergency Department at Cook Children’s and talked to one of the physicians I work with, and he advised that I go into my local ER to get some labs.”

While Ray was on the phone with the doctor, his wife went to the front yard where he was bit, found the snake and killed it. Later, poison control confirmed the snake hiding in their shrubs was, in fact, a venomous copperhead.

Ray went to Texas Health Resources for testing and bloodwork, and eventually started Crofab (an anti-venom) in the following hours. He spent the next four days in the hospital, receiving additional doses of antivenom while waiting to regain use of his left hand.

Providers aren’t immune to the fear of the unknown that patients often experience. It was in that same unease that he began to sympathize with his own patients.

“Going from a caregiver and being placed into the role of a patient is something I’m going to take away from this,” Ray said. ”I was really anxious in the waiting room because of the swelling, I even knew the science behind it all, but it was still a source of anxiety for me so for children to be a patient, it’s even harder on them.”

Now fully recovered, Ray’s experience has given him a deeper level of empathy for his patients and has made him a better provider for children with anxiety.

“Seeing the compassion of the other physicians and the nurses is something that is going to make me a better provider going forward,” Ray said. “This experience is going to make me more compassionate. I think whenever a provider is forced into the role of a patient it can create more empathy for their future patients.”

Related Topic:

• After the Bite: When and Why Antivenom is Used at Cook Children's
• 1 Year Old Bitten By Rattlesnake Recovering At Cook Children's
• Patients Bitten By Snakes
• What Are The 4 Venomous Snakes Found in Texas?

Sadly, these heartbreaking occurrences no longer shock us. But that doesn’t make these events any easier to talk about with our children, especially as they occur more and more often.

So, where do we go from here and how do we make sense of any of this?

Lena Zettler, director of Psychology at Cook Children’s, says parents should spend time listening and watching their kids after tragedies such as what took place over the weekend. When talking to your children, Zettler encourages parents to focus on what makes their kids safe.

“I know it seems more difficult to do, especially when something like a shooting is close to home or in our same state, but our job as parents is to reassure our kids about the ways they are safe,” Zettler said. “Sadly in this day and age, that means talking about the drills our children perform in school to protect themselves. Maybe, as a family, you have your own safety plan. Remind your children of the safe people in the world who are looking out for them, such as their parents, grandparents, teachers, police or other relatives or close family friends. A good idea, may be to sit with your child and make a list of all the safe people they know in the world.”

When talking to your children, Zettler encourages parents to focus on what makes them safe, based on their child’s specific fears. She suggest parents ask opened ended questions before providing information. For instance, with the El Paso shooting, we are hearing that racism and targeting immigrants played a role. However, don’t assume that kids have made the connection between race and this incident. Find out what they know and what scares them and address those specific issues.

“Focus on what things make your children safe, based on their fears,” Zettler said. “Respond with your eyes, body language and words when kids express their fears. Anytime we are scared, our brains read body language and facial expressions more than words. Kids may express these fears verbally or behaviorally. Pay attention and provide reassurance when you see they need it.”

Lisa Elliott, a licensed psychologist and clinic manager of Cook Children’s Psychology Clinic, said the events of the weekend came up during most of her sessions on Monday. She reminded the children to focus what Mr. Rogers’ mother taught him, “To this day, especially in times of 'disaster,' I remember my mother's words and I am always comforted by realizing that there are still so many helpers ― so many caring people in this world.”

“There are always helpers in crisis and there are more helpers than there are people who do hurtful things,” Elliott said. “Today, this was once again helpful for each one of the kiddos who brought this up. We actually did an exercise where the kids looked up all the stories of those who helped people.”

Joy Crabtree, Psy.D, a licensed psychologist for Cook Children’s Behavioral Health in Southlake, said parents must set the example for their children to follow. Crabtree encourages a discussion of the events, but only if your youngest children have learned about the incident elsewhere. If they haven’t heard about it, don’t share information with them. If they already know about it, answer their questions and most importantly, reassure them as best you can.

For example, talk about the good people like the first responders who took care of the people who were hurt and everyone who worked together to make sure people were safe.

“Parents have to stay calm and cannot be glued to the TV,” Crabtree said. “If you have an elementary-aged child, and they haven’t learned the news, there’s certainly no reason to sit down with them and show them the story. There’s no need to cause fear in your children. By the time children are 7 or 8 years old, they can distinguish fact from fiction and will understand the consequences of what they are watching. If they have heard about it, take as much time as needed to sit down with them and have a discussion/answer session, providing reassurance and support. Answer their questions, but only their questions. There’s no need to add more information that may scare them even more.”

For older children, such as those in middle school and high school, Crabtree encourages parents to again determine if their child is mature enough to handle the information. If parents feel they can handle it, use the DVR as your friend during the news. Watch it with your child and pause the TV to answer questions. Gauge your child’s emotions and turn the TV off if your child becomes too emotional or the news is too intense.

The psychologists we talked to agree the recent tragedies may also be a good time to promote speaking up when your kids see a peer who is in distress. “They are not tattling. If they see a peer who is acting out things or talking about violence, speak up to a trusted adult,” Zettler said.

“It is definitely important for children and teens to speak up and say something if they have a concern, or feel someone may be making a threat, either toward themselves or someone else,” Crabtree added. “And sadly in the times we live in now, it’s also important to have general situational awareness, no matter where you are.”

For a great resource on how to speak up, visit sandyhookpromise.org.

Kids, even teens, look to parents for reassurance. Parents can express their feelings about these events, but do not make this about your feelings. Model resiliency and good coping (calming, grounded practices that could include praying, meditating, deep breathing, laughing, yoga, and exercise for instance).

After listening, ask the child what they need: it may just be a hug for now. Reach out to professionals for help if fears persist more than a few weeks.

Crabtree advises parents to watch and see if their children restrict activity. For instance, they may not want to go to school or to the playground because it is too far away from home, or simply because they are afraid. Also, notice if your child becomes withdrawn or more clingy than usual, and constantly wants to sleep in your bed. For older kids, if you see them avoiding social events or larger gatherings, that might be something to discuss.

“It is common for children to have a mild fear, but if you see an overwhelming fear, it’s important to start by talking to their pediatrician,” Crabtree said. “If it continues to be a concern, then it may be time to get professional help.”

For more on this topic:

• Sandy Hook Promise
• Cook Children's Behavioral Health
• Cook Children's Psychology
• Individual and family therapy
• Parent Education and Support
• Diagnostic Testing

"There are a lot of patients who need specialized care or even higher levels of care and it’s really important that in this rapidly growing community that we have that available to these families," said Dr. Hogan, pediatricitian at Cook Children's Pediatrics Prosper Trail.

Dr. Hogan is one of 24 Cook Children's pediatricians currently treating patients in this region of North Texas. She says patients like hers need a place to access specialized and emergency pediatric care without having to drive 30 minutes to an hour away from home.

"A lot families have hardships and are not able to drive that far, or take off work all the time to go to these visits, and having this inpatient hospital and specialized care right her will make it easier for all the families," Dr. Hogan explained.

Construction of Cook Children's Medical Center North is in the initial phases with plans to have a full service hospital completed in 2022. The new hospital will be located on a 23-acre site in Prosper at Windsong Parkway and Highway 380. Having started in October of last year, phase one is already underway with plans to open a primary and urgent care clinic in the fall. An outpatient surgery center and specialty clinic with imaging and lab services will open in 2020.

"I'm really excited about the hospital opening up and being able to refer my patients to specialists, right here in Prosper, and being able to send my patients to get the specialized care that they need, having higher levels of care right across town," said Dr. Hogan. "I think that is going to be really wonderful for the families here."

Currently, Cook Children’s operates eight primary care offices in and around the Town of Prosper. The expansion near Windsong Ranch marks the first time in Cook Children's 101 year history that a full-service hospital has been built outside of Fort Worth.

"Just like the Town of Prosper is family, a close knit community, so is Cook Children’s," said Dr. Hogan. "We are all here wanting your children to be healthy and do better in life and be able to get the care they need to grow up to be happy and healthy adults."

It was reported by the American Academy of Pediatric Dentistry that sports accidents account for 10-39 percent of all dental injuries in children! These injuries can happen to a child’s face and teeth from falls, collisions, contact with hard surfaces and sports equipment. Activities such as riding a bike, skateboarding, hover boarding and jumping on a trampoline can result in injuries that affect the teeth and the face. The upper lip, gums and front teeth are more prone to injury. These teeth are subject to fracture, nerve damage, becoming loose and even falling out.

Not all sports-related injuries can be avoided, but most of them can be prevented! Wearing helmets, facemasks and mouthguards have been shown to greatly reduce the severity of dental and facial trauma. The National Federation of State and High School Associations only mandate mouthguard use for certain sports such as football, ice/field hockey, lacrosse and wrestlers wearing braces. But it is very important that proper protective equipment and mouthguards be worn for all sports that have the risk of injury (baseball, softball, basketball, soccer, volleyball, gymnastics to name just a few).

A mouthguard is made to protect the lips, gums and teeth from damage. They work by absorbing the energy from an impact and dissipating the remaining energy. There are many different types of mouthguards and if you are thinking of getting a mouthguard for your child, it is important that you visit your dentist. The best mouthguards are the ones that are custom made at the dental office. A mold is taken of the teeth and a mouthguard is made that is the right fit and comfortable for your child. If a custom mouthguard is not feasible for you, then there are many other mouthguards that are available over the counter. Even though they may not be a perfect fit, they will still provide offer some protection.

Bottom line, please protect your child’s face and teeth with the proper protective equipment while they are playing sports and having fun!

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

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

The slippery assumptions of oil supporters

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now we can move on to some research…

The Research on Essential Oils in Kids

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

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

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

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

Lavender

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

Tea tree oil

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

Chamomile

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

Peppermint Oil

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

Eucalyptus

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

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

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

Other Sources

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

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

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

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

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

Summary of Research

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