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

Well, you might be surprised to hear that over-the-counter medications like Advil and Tylenol might actually be what’s triggering the headache in the first place. According to Ellie Corbin, M.D., pediatric neurologist at Cook Children’s, taking these medications on a regular basis can lead to something called ‘medication overuse headaches.’

Even if your child isn’t exceeding the prescribed daily dosage, Dr. Corbin says consistently taking several doses of these medicines over a long period of time can be harmful.

Overuse headaches are far more common than people realize, Dr. Corbin says. Close to 50% of her patients who come in with headache complaints inadvertently put themselves in this situation, by overusing headache medicine. Instead of the medicine relieving the headaches, it made them worse.

The International Classification of Headache Disorders defines medication overuse headaches as:

• A headache that occurs on more than 15 days a month, in patients with pre-existing headache conditions (migraines, or tension headaches).
• The regular overuse of headache medication like: Tylenol, Advil or Ibuprofen for more than three months.

Dr. Corbin diagnoses medication overuse headaches by asking two simple questions: how long and how often have you been taking the medication? These two questions are enough for her to know if her patient is suffering from too much medication. The only form of treatment is to immediately stop taking these medicines all together and use alternative measures the next time a headache develops.

One alternative Dr. Corbin encourages her patients to do is hydrate with fluids that have electrolytes, like Gatorade and Powerade, when their headaches start, instead of taking medicine. Preventative medicine is prescribed to the majority of children with overuse headaches during the “washout” period of over-the-counter medications, Dr. Corbin says. During this “washout” period, your child doesn’t have to suffer. A form of therapy known as “bridge therapy” is used. This is when other means are used to make your child comfortable while their body adjusts to the withdrawal of headache medicine, it usually comes in the form of steroids.

Once a patient has stopped taking over-the-counter pain medicines, relapse is rare. Dr. Corbin emphasizes that reducing the use over-the-counter medication might result in headaches at first, but in the long run, it will likely mean less pain for your child.

“A lot of patients are scared to go back after the washout period,” Dr. Corbin said. “They’re afraid that if they take these medicines again the medication overuse headaches will come back. There is the chance that a chronic headache condition is so severe that a relapse happens.”

- By Libby Collins

Cook Children’s has been utilizing intranasal ketamine as a rescue treatment to break unrelenting migraine attacks in the emergency room and inpatient setting since December 2016. Originally, the drug was utilized out of necessity due to a shortage of dihydroergotamine – the medication previously used most frequently for persistent migraine attacks which failed to respond to outpatient therapy. The team presented their findings at the International Headache Conference in 2017.

“Until that time, little to no experience with nasal ketamine had been reported in pediatric patients,” said Adrian Turner, a clinical pharmacist at Cook Children’s. “However, our institution’s experience is broadening the horizon of potential treatment options.”

Now the U.S. Food and Drug Administration has approved esketamine, a chemical compound similar to the anesthetic ketamine, to relieve depression in hours instead of weeks. The drug, the first to be approved to fight depression since 1988, is believed to help patients who have been treatment resistant to other depression therapies.

Esketamine, developed by Johnson & Johnson, will be marketed under the name Spravato® and is a nasal spray that allows the drug to be absorbed through the lining of the nose, directly to the blood stream.

Patients using Spravato® will also be required to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program to monitor for serious side effects related to sedation, dissociation, abuse/misuse and to support its safe use. Patients will be required to self-administer the drug under direct observation of a healthcare provider.

“This is potentially a game changer for millions of people,” Dr. Dennis Charney, dean of the Icahn School of Medicine at Mount Sinai in New York, told NPR. “It offers a lot of hope.”

At this time, no plans have been made at Cook Children’s to use ketamine for depression, but intranasal ketamine has been vital for helping patients with severe migraines.

Intranasal ketamine for migraines not only worked for a majority of Cook Children’s patients (almost 70 percent of patients between December 2016 and October 2017), but was safe and well tolerated. Any side effects seen, some dizziness and very mild dissociative effects (i.e. feeling funny, out of body experience) were mild and didn’t last longer than one hour after administration.

No patient had to stop due to side effects.

Turner said using ketamine for migraine offers many benefits:

1. Patients don’t need an IV or injection to receive treatment.
2. The number of medications needed to treat the pain may be reduced.
3. The time needed to treat the pain may be reduced.
4. It provides patient with a wider variety of options to treat their migraine.

Ketamine was first created in the 1960s and was largely used as a battlefield anesthetic and veterinary medicine. By the 1980s, hospitals were using the drug for sedation and severe pain.

Until recently, the FDA approved the drug in patients 16 and older for general anesthesia (dental procedures, outpatient surgery, intubation). Compared to other medications used for sedation/anesthesia, ketamine is relatively safe due to less effects on breathing and blood pressure.

In the past few decades, ketamine became the focus of studies for the treatment of depression. The Department of Health and Human Services reported an estimated 16.2 million adults and 3.1 million adolescents aged 12 to 17 in the United States had at least one major depressive episode. This is especially important when considering the rates of suicide. In 2016, the Centers for Disease Control and Prevention (CDC) reported suicide as the number 10 overall cause of death with more than 44,000 deaths attributed to suicide reported. Even more troubling, suicide was reported to be the number 2 overall cause of death for people aged 10-34, number 4 for people aged 35-54, and number 8 for people aged 55-64.

“Expanding treatment options is not only beneficial to improve the quality of lives of patients with depression, but it may also help save many lives in the future. Depression can be very difficult to treat,” Turner said. “Compared to other diseases and diagnoses, depression is not a one-size fits all treatment. Expanding the treatment options is a huge benefit to patients who have exhausted several treatment options with little to no relief.”

Aside from the new indication for depression, ketamine and esketamine both have potential use in post-traumatic stress disorder (PTSD), migraines, refractory/chronic pain conditions, and seizures. There are active studies underway in the U.S. and internationally examining the use of ketamine to treat PTSD, status epilepticus, and oral ketamine to treat chronic pain in adults and children. Cook Children's Pain team is currently treating patients with chronic/refractory pain with a ketamine IV and oral ketamine.

Some may know ketamine as a party drug. Ketamine (also known as Special K, Super K, and Vitamin K among other street names) is known as a potential drug of abuse and a drug used to facilitate sexual assault crimes. When taken illegally, users often inject, snort, or smoke the drug to feelings of calmness and out of body experiences.

Unfortunately, because these are often taken in very large doses, users also experience complications such as hallucinations, immobility, amnesia, and unconsciousness. It’s especially dangerous when given in very high doses or mixed with other drugs and/or alcohol because this greatly increases the chances of serious health problems and/or death. The World Health Organization notes that ketamine is a potential drug for abuse, but the actual incidence of dependence or overdose is rare. Chronic abuse has been linked to urinary tract problems.

But under the guidance of health care providers, ketamine has been highly beneficial.

“Our experience with ketamine has been positive,” Turner said. “The success we have seen at Cook Children’s combined with the approval of esketamine for refractory depression is very exciting. As a health care professional, it is invigorating to see years of research produce positive outcomes for our patients. I look forward to seeing Cook Children’s on the forefront of contributing to this new frontier. ”

It can be a hard thing for adults to deal with. Unfortunately, many children suffer the same pain. For some, it’s a genetic condition that’s been passed along to them. But for others, migraines are the result of injury. For 15-year-old Olivia Gillespie, her migraine problems began when she received her third concussion.

“It happened in cheerleading practice, I was kicked in the head,” says Gillespie. “I was fine. I didn’t think it was that big of a deal.”

Then months later, Gillespie was on a ski trip with her youth group when a headache came on and never went away.

“I just kept doing what I was doing and tried to not let it have an effect on me,” she said.

Gillespie tried to ignore the pain for two months before she said anything to anyone, but then the pain got worse.

“Olivia had an ongoing headache that would not fade. On a scale of one to 10, it was a consistent five," said Amelia Gillespie, the teen's mother. "It wasn't until her pain reached level seven that it really began to affect her.”

When Cynthia Keator, M.D., pediatric neurologist at Cook Children’s, first saw Olivia, she wanted to make sure her headaches could be treated without medication. Together, they worked on her sleep habits and diet. Dr. Keator also suggested supplements such as B2, and Omega 3, which has shown to help with headaches. In addition, Gillespie was referred to the Biofeedback Clinic at Cook Children’s.

“Biofeedback teaches patients how to control their pain by controlling their breathing, heart rate and body temperature,” says Dr. Keator.

Biofeedback specialist Nanny Christie, Ph.D., has been teaching the painless technique for decades.

“We place the child in a reclining chair and use pads to measure their body activity,” says Christie. “The equipment plugs into a laptop so the kids can see everything on the computer screen. If they tighten a muscle, a line goes up. If they relax, the line goes back down.”

Christie says teaching children to harness their breathing and muscle movement this way allows for real time learning. She says about 80 children are seen in her clinic each month. A typical visit is 45 minutes to one hour and each child is seen roughly four times.

While it wasn’t the end-all, be-all cure for Gillespie, it did help. She says she uses the technique to curb her head pain. If she feels a headache becoming worse, she can focus and calm her anxiousness which in turn can help the headache.

Also, ask your doctor about preventative medication. Your doctor may prescribe something prescription strength or a natural supplement to ease the pain.

Make sure you DON’T ask your child this question:

“How’s your headache?”

You may want to, but remember that asking about a headache is like scratching a mosquito bite. By asking, you’re reminding your child about their pain.

This is often said when someone is hit in the head during a sporting event. But this type of injury should never be taken lightly. A concussion can occur when a person has a trauma such as a blow to the head or the head being shaken. In fact, concussions can happen whether the person is actually “knocked out” (loses consciousness) or not.

Concussions are a common issue among school aged children and teenagers, especially if they are active in sports. In the United States alone, more than 300,000 concussions occur per year as a result of sports. An athlete who plays a contact sport, such as football, wrestling, basketball or soccer, is estimated to have a 19 percent chance of suffering a concussion in a single season. Other activities such as gymnastics, cheer, skateboarding, bicycling, or even jumping on the trampoline also come with an increased risk of concussion.

Can my child still get a concussion if he or she is wearing a helmet?

Yes. Although helmets do protect your child from a fracture of the skull or an injury that causes bleeding to the brain, they do not necessarily prevent concussions. It is possible to sustain a concussion while wearing a helmet because the helmet protects the bones of the head, but cannot stop the brain from making contact with the inside of the skull.

But what exactly is a concussion?

A concussion is a type of brain injury that interferes with the way the brain functions. It can cause symptoms such as:

• Headaches
• Nausea and vomiting
• Vision changes
• Irritability
• Difficulty concentrating
• Memory problems
• Balance issues
• Sleep disturbances

The majority of concussions (80-90 percent) resolve within 7-10 days, but may take longer for children and adolescents. Sometimes, the symptoms of a concussion will linger or worsen. If symptoms become persistent, your child may require further treatment to help symptoms resolve so they are able to return to attending school and participating in normal activities. Even a child with a “mild” concussion should be evaluated by a physician. A doctor will be able to decide if any tests are needed to check for more serious injuries. He or she will also check your child’s symptoms to find out the severity of the concussion, and determine whether referrals to other healthcare providers, such as a physical therapist, are required.

As a parent, what do I need to know to help my child get back on the playing field after a concussion?

Patience is key when it comes to safely returning to sport following a concussion. Every young athlete is eager to get back to sports or activities as soon as possible. It is up to the parents to make sure that this process is not rushed and happens in a safe way. More and more research studies are proving that the effects of concussions can compound and have long-term effects if another concussion occurs before adequate time for recovery is allowed. If an athlete or child returns too soon, he or she may be susceptible to negative effects of post-concussion syndrome such as depression, memory loss, fatigue, chronic headaches or pain. Parents should be diligent with following up with healthcare providers to get appropriate treatment prior to returning to sports.

How can a physical therapist help an athlete return to sport after a concussion?

Physical therapists will assess the need for treatment of any musculoskeletal injuries that occurred at the time of concussion. If your child has pain in the muscles or joints of the neck or spine as a result of injury, a physical therapist can help decrease this pain with hands on techniques or exercises. An injury to the brain can affect the brain’s ability to tolerate physical activity, movement, and balance. Sometimes these symptoms interfere not only with an athlete returning to his or her sport, but also with every day activities such as attending school, reading a book, or playing video games. A physical therapist will also assess the athlete’s tolerance for activity, function of the vestibular system (a part of the inner ear), and balance.

A physical therapist has the ability to monitor a patient’s symptoms while safely progressing from light aerobic activity, to sport-specific drills and eventually to non-contact drills. This allows the athlete to return to full practice and eventually to his or her sport. The vestibular system is a part of the inner ear that sends signals to the brain regarding a person’s movements and position in space. Additionally, the vestibular system is closely associated with an athlete’s ability to maintain balance. Balance can be affected when a child suffers a concussion, and can require rehabilitation from a physical therapist. Physical therapists can use specific exercises designed to strengthen the vestibular system and improve balance to prepare your child to safely return to sport or activity.

So what’s the bottom line when it comes to concussions?

1.Head injuries, or “getting your bell rung”, should not be taken lightly.

2.Helmets protect the skull, but do not always prevent concussions.

3.It is important that a physician evaluate your child after an injury to the head.

4.Parents and athletes must be patient in order to safely return to activities in order to allow concussions to fully heal.

5. Physical therapists can treat patients who have had a concussion to help with musculoskeletal or vestibular system issues, tolerance for physical activity, and balance training to help safely return to sport.

For more information:

• What every parent needs to know about concussions
• Concussion management and update
• Football injury prevention
• ​Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• ​SPORTS resources
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries

About the author

Jessie L. Diebold, PT, DPT, OCS, is a SPORTS physical therapist at Cook Children’s. Cook Children’s SPORTS Rehab is a leader in the community in sports injury. Additional information and helpful tips can be found on the Cook Children’s SPORTS Rehab website. Cook Children’s SPORTS Rehab is a leader in the community in sports injury prevention.

Primary headaches are the result of problems with pain sensitive structures in your head. These include migraines, tension headaches, chronic daily headaches, cough headaches and exercise headaches.

Secondary headaches usually point to an underlying condition activating the pain sensitive nerves in the head. These include sinus pressure, concussion, dehydration, ear infection, flu, tooth pain, etc. More serious causes of headaches can occur, for which you would need to see a doctor immediately.

Physical therapy is well suited to help patients with headaches. Most primary headaches can be related to or made worse by muscular tightness in the neck, base of skull, and head. This tightness can be due to trauma, joint stiffness, joint instability, poor posture or overuse. Physical therapists can address this muscular tightness in several ways. We work on increasing the flexibility of the muscles involved, improve the strength of the musculature in the area, and mobilize stiff joint segments. We also address the child’s posture and stability of the area by retraining the musculature to work in symphony with each other to achieve good posture and stability of the neck and shoulders during static and dynamic activities.

Here are four ways for kids to improve their headaches:

1. Be aware of your posture. How are you sitting when at school? Where do you do your homework or read? Is it on your bed, or couch, or on a desk? Try to improve your posture by sitting up straight, preferably in a chair that offers low back support and keeps you upright. Make sure that the computer or books are close enough that you can read easily without looking down or sticking your chin forward.
2. Take mini breaks throughout the day. A good rule of thumb is a 2 two- minute break for every 30 minutes. During this time, get up walk around your space, stretch.
3. Stretch. Your muscles tend to tighten down to match the movement they are allowed during the day. If they don’t move much, they will begin to tighten. Neck and shoulder stretches are important to loosen the muscles you use to hold your head up and use your arms during the day. The stretches should be held for at least 30 seconds for better results.
4. Build strength in the muscles of the neck and shoulders. The stronger your muscles are, the better they can handle the stresses of the day. Exercises could include chin tucks, shoulder shrugs, lat pulls, rowing, pushups and tricep dips.

If you have any questions, please feel free to contact your pediatrician.

About the author

Bruce Morgan, PT, is a SPORTS physical therapist at Cook Children's. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind.

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

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

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

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

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

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

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

Still, Dr Keator takes precautions.

She states, “I suffer from migraines, as due several of my colleagues. Most migraine sufferers have busy lifestyles, and a main trigger is fatigue. Therefore, what I tell my patients and also practice myself: exercise regularly, stay well hydrated, eat well and get adequate sleep. Another very important recommendation is to limit time on electronic devices. I do my best to minimize migraines and headaches by taking frequent computer breaks.”

Most professional and educational activities are spent on some sort of electronic device, and in today’s world, introduction to electronic devices starts at a very young age. Media is everywhere and it is competing for children’s attention.

Statistically speaking, over 75 percent of children have some degree of hand-held or electronic devices. A great portion of the child’s day is spent on these devices, which by default, take away from other activities. Headaches and/or migraines in children can be exacerbated or increased due to spending excess time using electronic devices: watching TV, video games, texting, playing on tablets, etc.

The concern is that the time spent (and the content) on the devices may interfere with other regular childhood activities and natural sleep/wake cycle, especially when used in excess. Dr Keator states, that when children use electronic devices in excess, this leads to interruption in sleep which will lead to fatigue, and for many children it can lead to headaches/migraines. It can also lead to attention problems, school difficulties, eating disorders and obesity. Prolonged time spent on electronic devices interrupts other activities: homework, dinner time, family time, exercise, and sleep.

The American Academy of Pediatrics recommends limiting or completely eliminating screen time for children under the age of 2 years. Then as children get older, media is slowly introduced. For children age 3-5 years, limit to 30-60 minutes; children age 6-9 years 60-120 minutes a day; and for older children over 120 minutes is allowed.

But let’s be realistic; these time limits no longer fit in our current world of technology.

“Technology is here and electronic devices are a multi-billion dollar industry and it is not going anywhere,” Dr Keator states. “In neurology, our recommendation is time limits. The younger you are, the less time that is allowed. However, everyone needs breaks regardless of the age. Try to limit time on electronic devices to 15-30 minute increments followed by breaks. During the breaks, I recommend doing something outside, spending time with friends or family, or just resting; then resume activity on the particular device.”

Dr Keator does acknowledge that many schools are incorporating computers or touch screens into the academic curriculum. For children who are migraine or headache suffers, she recommends getting up and relaxing the eyes and giving the brain time to rest.

“It’s a balance,” she emphasizes. Parents and teachers have to work on positive media/electronic use with time limits and breaks. Media/electronic devices should not be in the bedroom and this includes smart phones. Make dedicated family time without electronics. When electronics are used, make sure it is monitored and make it educational as much as possible.

More about Dr. Keator

Dr. Cynthia Keator joined Cook Children's Neurosciences in July 2012. She is board-certified by the American Board of Psychiatry and Neurology with special qualifications in Child Neurology and sub-specializes in pediatric epilepsy. A good portion of her clinical practice in spent in the Epilepsy Monitoring Unit at Cook Children's Medical Center where she diagnoses and treats patients with epilepsy. 

Dr. Keator is a native of Fort Worth where she was raised and attended Trinity Valley School for 13 years. Uniquely, she volunteered at Cook Children's when she was in high school. "I can truly say that it was my volunteer experience that attracted me to pediatrics andCook Children's. Now having finished my training, it was an easy decision to choose Cook Children's". Dr. Keator completed her undergraduate training at Texas A&M University and then obtained her medical degree at the University of Texas Health Science Center at Houston.

Dr. Keator's husband is also a native of Texas. They live in Fort Worth with their German Shepherd. Dr. Keator enjoys spending time with her family who still reside in the DFW area.