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

Just a quick reminder of my big fever rules. Click the links to learn more:

1. You don’t always have to rush off to the ER for a fever. No matter how high.

2. In a well-appearing child, it’s OK to watch fever at home, even up to 5 days.

3. You only have to treat fever to keep the child comfortable. Don’t treat the thermometer.

But what if your little one has a fever and it doesn’t seem to be going away? What should you be worried about?

Let me just start by saying this…this article is intended for children 6 months to 3 years who are fully vaccinated and are otherwise acting pretty normal. Why?

• Older kids are usually much better about telling us if something hurts.
• In children who haven’t received all of their vaccinations, we have to consider some other infections that have otherwise pretty much gone away.
• If a child isn’t acting normal (is lethargic, not drinking and peeing or has other concerning symptoms), they should be taken in for care (probably to the ER).

Sometimes it’s really obvious where the fever is coming from but other times it’s not. Here are some infections we think about when it’s not really clear:

1. Ear infection – Often kids with ear infections will have fever, fussiness, runny nose/cough and will be pulling at their ears but other times it might not be so clear.

2. Pneumonia – Most children with pneumonia will have symptoms such as rapid breathing or difficulty breathing but not always.

3. Urinary tract infection – This is actually one of the most common reasons for kids to have fever without symptoms in this age group. They just can’t tell you that it hurts when they pee.

4. Meningitis – The younger you are, the more likely a child is to have meningitis only presenting with fever.

5. “Viruses” – This might be the answer you don’t like to hear but, besides ear infections, it’s probably the one you want to have. Sometimes a child will present with just fever or fever and very little else until a few days into the illness when viral symptoms like runny nose, cough or rash become more prominent.

So, if your baby’s fever doesn’t go away after 3-4 days, what should you expect?

Your doctor should take a thorough history and do a full physical. If the diagnosis isn’t clear, here are the tests that are likely to be run:

1. Blood work – A blood count and some markers of inflammation will help determine if the infection is more like viral or bacterial.

2. Urine sample – Even though it’s not fun because urine catheterization in this age is no fun for anyone, getting a urine sample is critical because UTI is such a common cause.

3. Chest X-ray – Due to the fact that pneumonia can be a cause, getting a chest x-ray will usually be necessary.

4. Other – Depending on the baby’s story, physical exam and the results of the initial lab work, further testing may be necessary.

When your little one has a fever, it can be really scary. Keep in mind that most fevers have obvious causes or go away quickly on their own. But when they don’t, now you’ll know what to expect.

With so many people out on the road, it means more opportunity for danger.

From Dec. 20 to Dec. 31, 2018, the Trauma Department at Cook Children's reports 17 children were admitted at the Medical Center for injuries related to motor vehicle crashes and an additional 29 children were treated and released after a visit to the Cook Children's Emergency Department. One wreck during that time frame included a fatality and a total of three children died during the entire month of December.

“Unfortunately, we've seen children die around the holidays," said Debbie Wheeler, a Child Life specialist for the Emergency Department at Cook Children's. "With other traumas, we’ve seen young kids live by the grace of being properly restrained in the correct car seat. I really want to encourage parents to travel safely this holiday season, especially for everyone in the vehicle to be buckled up appropriately. It is really sad to see a patient hurt and have injuries that could possibly have been prevented if they were in a car seat, a proper car seat, or a seat belt.”

Motor vehicle injuries are the leading cause of death among children in the United States. Many of those deaths could have been avoided if parents took the extra time to make sure their children were properly restrained.

Sharon Evans, Trauma/Injury Prevention outreach coordinator at Cook Children’s, says it’s extremely frustrating because she has seen wrecks where one child who was properly restrained lived and the other child not buckled died.

“Honestly, it’s just so infuriating,” Evans said. “These crashes are preventable. It’s because the adults in the car aren’t doing something that could save their child’s life. I don’t think people think it can happen to them. But it can happen to anyone. It breaks my heart because these are deaths that shouldn’t occur if people would just place their kid in the proper car seat and buckle them up with a seat belt."

Holiday Injuries Treated at Cook Children's (Dec. 20-31, 2018)

The Centers for Disease Control and Prevention (CDC) found that in one year more than 618,000 children ages 0-12 rode in vehicles without the use of a child safety seat or booster seat or a seat belt at least some of the time. Statistics show this is especially a problem for Hispanics in the community. Ninety percent of the ejections that have occurred since April 2015 were Hispanic.

“I think a lot of it has to do with our culture,” said Magdalena Santillan, Trauma Injury Prevention Specialist at Cook Children’s. “These are people who love their kids, and they want to hold their baby. A lot don’t want to hear their baby cry, and so it’s easier to hold their baby in the car. They are showing love, but the consequences are too high and can be a deadly mistake.”

Texas law states that “all children younger than 8 years old, unless taller than 4’9”, are required to be in the appropriate child safety seat system wherever they ride in a passenger vehicle. The safety seat MUST be installed according to the manufacturer’s instructions.”

That means that when a child reaches his or her eighth birthday – no matter their height, it is legal for the child to use only the adult safety belt in the passenger vehicle.

However, the Texas Department of Public Safety states on its website that best safety practice is: “if the child is not yet 4’9”, they are better protected if they continue to use the appropriate child safety seat system until they can fit properly in the adult safety belt.”

“From a safety standpoint, I encourage parents to follow the best safety practice guidelines,” Evans said. “Graduating to a seat belt too early does keep children in the car if they crash, but when the seat belt doesn’t fit properly, it can cause serious injuries. That is something else we are seeing right now at Cook Children’s – children in a halo brace for severe neck injuries because they were in seat belts too young and too early.”

Call 682-885-2634 to set up a FREE car seat checkup to ensure your seat is properly installed.

I have seen so much of this over the last month at Willow Park! So much so that I did some research to better inform our patients about this "fun" rash. I want to go over a few basics with you.

Fifth disease, also known as erythema infectiosum, is a common childhood virus. I typically stick with calling it “Fifth’s” because the medical term sounds a little bit like a Harry Potter spell. It is caused specifically by parvovirus. About half of us have been infected with the virus at some point in our life. It's usually spread from person to person through contact with fluids such as saliva, sputum coughed up from the lungs and nasal mucus. Yes, it's all the gross stuff. And no, this isn't the parvovirus found in dogs and cats. Contact with those animals with a parvovirus won't make you sick.

After a child is exposed to this illness it can be 1 to 2 weeks before symptoms occur.

Usually kids will start with nonspecific viral symptoms, such as fever, headache, redness or drainage to eyes, and sometimes nausea or diarrhea. Think flu-like symptoms. The most obvious part of this illness is the rash that comes with it. Fifty percent of children will have viral symptoms 1 to 2 weeks before the rash appears, 25 percent will have symptoms 2 to 5 days before and 25 percent of children will have no symptoms prior to the rash presenting. Kiddos are contagious during the viral symptoms stage of this illness.

The rash can be pretty shocking if you are not familiar with it! It is described as a “slapped cheek” appearance and a “lacy” body rash. After the rash appears the child is no longer contagious! You will still probably get some looks when you go to the grocery store, but you’re totally safe to be around others.

The rash is not harmful, but it is frustrating. It can last for several weeks and will look worse with heat, sun, stress or warm baths. Over time it gradually fades.

It should be mentioned that Fifth disease can cause complications during pregnancy. Most women have immunity to parvovirus, but about 5 percent of women are not. If a mom is not immune, the unborn baby can develop anemia, so it is important to let your doctor know if you have another child with fifth or have been exposed otherwise. The best way to prevent fifth disease is handwashing!

I'm posting a picture for reference, but if you have questions please call your pediatrician.

Tara, NP

If you are concerned about your child, here are seven facts you need to know:

1. Monitor your child for cough, particularly if it is occurring in severe spells or they cough so hard that they vomit. The characteristic whoop of whooping cough occurs when the child is inhaling after their cough.

2. Older children and teenagers may have severe cough but usually do not have the whoop. Infants are very susceptible to pertussis and have an increased risk of hospitalization and death.

3. Be aware that the vaccination for whooping cough is not perfect. Even if your child is vaccinated, you should be on the lookout for symptoms, particularly if you live in the Grapevine-Colleyville area or know that your child has been exposed.

4. If you are concerned your child might have whooping cough, your doctor can run a test and start treatment with an appropriate antibiotic. (Even with treatment, the cough can last several weeks.)

5. Students who are diagnosed with pertussis should remain home until they have completed five days of antibiotics or until 21 days have passed since their cough started.

6. Those who live in the house of persons diagnosed with pertussis should receive treatment to prevent the infection as soon as the infection is confirmed.

7. Other close contacts (not in the house) that should receive treatment for exposure include: those at high risk for pertussis (infants and pregnant women in the third trimester), those with health conditions that put them at more risk (severe asthma or immunodeficiency), contacts of a case that have contact with a child less than 1 year of age and contacts who work in high risk settings (NICUs, childcare and maternity wards.)

If you have further questions, please contact your pediatrician.

Related articles:

• Let's Learn About Whooping Cough
• Measles, Pertussis Increase due to 'intentionally unvaccinated'
• 3 Reasons to Still Give Your Kids Whooping Cough Vaccine
• Newborns Depend On Rest of the Family To Protect Them From Whooping Cough

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.”

A study published by the American Academy of Pediatrics found that kids ages 5 to 17 were admitted to children’s hospitals for thinking about or trying to kill themselves twice as often in 2015 as 2008. 

Statistics show suicides among young people can happen at almost any age. Suicide is the second leading cause of death for children, adolescents and young adults, ages 5 to 24 years old.

Because of these numbers, 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.

Brad Mercer, M.D., a pediatrician at Forest Park, calls the recent focus on mental health “a wake-up call” to American pediatricians and family practitioners who treat kids, especially adolescents. He said more health care providers must make time to ask children about depression and suicidal thoughts.

“We must address the mental health problems in our youth as a preventive measure,” Dr. Mercer said. ““As pediatricians, we have to take the time to interact with teens and take the time to screen for these conditions during regular office visits,”

Cook Children’s has taken several steps to screen patients throughout its system:

• Cook Children’s offers the American Psychiatric Nurse’s Association Competency Based training (6.5 hours) on suicide assessment, intervention and prevention. 
• Patients are screened at the initial intake assessment and throughout the stay on inpatient psychiatry and Partial Hospitalization Program (PHP).
• The Emergency Department (ED) and the Department of Psychiatry have combined their efforts to begin screening all patients who present to the ED ages 10 years and older, regardless of the child’s presenting problem. The staff also uses an evidence-based screening tool called the “Ask Suicide Screening Questionnaire-ASQ.
• Cook Children’s also screens for mental health issues and/or suicide in outpatient clinics (primary care and specialty), as well as screening for suicidal thoughts at each Psychology outpatient visit.

“This process has already identified several children with mental health issues and at risk of suicide that may not have previously been identified. We know that screening for suicide risk, referring to the appropriate level of care, providing a safe environment with skilled staff observation for high risk patients, and offering suicide education is imperative to address suicide prevention,” said Lisa Farmer, director of Psychiatry at Cook Children's.

Vanessa Charette, M.D., said she and her fellow pediatricians at Magnolia, screen every patient at well-child checkups, ages 12 and up for depression.

“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,” Dr. Charette said. “Even if on the well check nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression. I believe the screen helps open that door and the conversation. I also find for teens that are not having any signs of depression/anxiety and wonder why they are doing the screen it still opens a conversation. I then talk about how it is great that they are doing well but that many kids are not. Parents appreciate this – it helps open why some other kids might be depressed, what can be done to prevent it and helps with empathy for others.”

More On This Topic:

• New Behavioral Health Center Offers Hope for Children in Crisis
• Pediatrician Calls Focus on Children's Mental Health a 'Wake-Up' Call
• Dramatic Spike In Children Attempting Suicide
• Pediatricians Urge Screening for Depression at Well-Child Visits
• Kidness Matters. How To Teach Your Child Empathy
• The Death of Ethan
• 13 Warning Signs of Teen Suicide
• Don't Ignore CDC's Suicide Report

Life as a parent with a child who has Sickle Cell Disease (SCD) is already frightening enough, but could you imagine this diagnosis with two of your kids?

Mykhia and Malik, now 11 and 12 years old, were diagnosed with SCD within the first two years of their lives. When the family first learned of the diagnoses, they were referred to the Hematology and Oncology department at Cook Children’s.

Their mother, Monique Hammon, was familiar with the disease as it already ran in her family. She knew Malik and Mykhia would eventually need the cure of a bone marrow transplant.

“On my dad’s side, I grew up watching my family deal with sickle cell and a majority of them died from it,” Monique said. “My sister’s son went through the same thing that Malik and Mykhia went through, except he didn’t have a sibling that could donate bone marrow.”

Malik began to have more and more SCD crises, an acute pain episode that occurs when the sickle-shaped blood cells start to clump in the blood stream, and was frequently hospitalized at Cook Children’s.

Monique watched her children struggle to act like kids. They couldn’t play sports or swim due to the frequent crises and health problems, such as signs of stroke and organ failure.

“Mykhiah never had an episode. Her eyes would stay yellow, but one day her spleen swelled up and she had to have it removed,” Monique said.

Siblings typically have the highest chances of becoming potential bone marrow donors, but only 30 percent of families can find a match. Malik and Mykhia’s oldest brother was eventually tested to determine if he could be their cure, and he was.

“They [Malik and Mykhia] had a donor match,” Monique said. “I just thank God that my oldest son was a match for both of them instead of them waiting for a donor to come.”

Mykhia received her transplant first in 2015, due to signs of stroke on her MRI test results while Malik received his in 2016. The siblings can now swim and play soccer without fear of potential crisis.

“While Stem cell transplant can provide a cure for Sickle Cell Disease, it is not an easy cure. There can be many complications. Some patients may not engraft, meaning the donor cells may not grow, and the patient’s own cell grow back instead or a second transplant is needed," said Clarissa Johnson, M.D., medical director of the Sickle Cell Programt at Cook Children's. "There can also be challenges with finding a donor. So unfortunately we cannot consider stem cell transplant to be a universal cure that is available to all with the disease. More research for a universal cure is needed. There are small trials with gene therapy being done currently which I hope will prove successful to offer the chance of cure to even more people with Sickle Cell Disease.”

SCD is the abnormal shaping of red blood cells. The red blood cells are shaped like crescents instead of circles. They don’t last long and they can get stuck in the blood vessels, which blocks the blood flow, often resulting in pain and organ damage.

Approximately 100,000 Americans have Sickle Cell and an estimated 3 million Americans carry the trait, which can be passed onto their children.

Among the many misconceptions of SCD, African Americans are not the only race affected by the disease. While the African American race makes up a reported 60 to 80 percent of Americans diagnosed, people of Indian, Middle Eastern, Hispanic and Mediterranean descent may also be affected.

The cure for SCD lies in bone marrow transplants, and while siblings typically are the best matches for this disease, anyone willing to donate can be tested.

An estimated 3,000 people die each year in the United States from waiting for a donor for a bone marrow transplant because of the lack of donors on the registry.

Donating bone marrow requires less than five percent of bone marrow cells and is typically taken from the hip of the donor or through a non-surgical procedure in which it is collected through an IV.

I remember uttering these words to my nurse manager after she encouraged me to pursue an open position as a clinical nurse educator. This came after I requested a meeting with her during a time that I was trying to navigate a period of restlessness, eagerness to contribute to my unit, while simultaneously experiencing a feeling of career confusion.

The joys of being a bedside nurse are endless. There is nothing more satisfying than delivering care that you would hope your family and friends would receive during tender times. There is an immediate satisfaction in knowing that you are advocating for your patients and families in the moments they need you most. Every patient was my brother or sister, every mother or father was my own.

I would arrive at my shifts ready to work and give everything my patients and their caregivers deserved and more. I was involved in my unit, eager to find solutions to problems, and was enthusiastic about making my work environment better. I felt ready to do more.

However, I often felt limited because of feelings of self-doubt and because I just felt so… new. While I had taken my fair share of difficult assignments, trained newer nurses, and taken on informal leadership roles within my unit, I was still what you would consider newer in my nursing career. I had these self-imposed ideals of what it meant to be a leader in a healthcare environment because I worked with so many of them: someone who had decades of experience, had “seen it all,” was tough as nails, and inexplicably knew the answers to every problem. I was simply a newer nurse with a few ideas and an optimistic attitude. On the outside, I’m sure the perception was that I was a stereotypical, bright-eyed “millennial.”

Millennials in the workplace have received quite the reputation, gaining much more attention in the media. Millennials have perplexed leaders in the workplace so much that it has inspired over 12 million search results when anyone searches for the terms “Millennials in the Workplace.”

I’ve been told that we are a generation of contradictions: wanting positions of higher responsibility, but entitled to our days off and fearlessly asking for things that we shouldn’t. I’ve been told that technology has corrupted us and social media even more so.

Regardless of these preconceived notions and my anxieties of not being taken seriously, I took that manager’s advice because I figured, what have I got to lose? The worst thing that someone could tell me was “no” and I could go get those decades of experience I always thought you needed to do the things I wanted to do eventually: teach, inspire, and support nurses transitioning into and developing themselves within the endless potential of the nursing profession. One where you could improve the lives of your patients, but also inspire real changes in healthcare.

I have since been in the role of a clinical nurse educator for over three years now, and I’ve struggled in the last few years to reconcile the reality of what society thinks of my generation as a whole with the person that I truly am and the kind of nurse leader that I want to become. Throughout my journey, I have learned a few things…

Defining Professional and Personal Boundaries 

While this is no novel idea for any new leader, it has been an especially new experience during a time when social media is omnipresent. As someone who essentially grew up in the world of social media before “social media” was even a term, I found myself navigating the terrain of professional boundaries in the workplace and the internet, too. While there have been many challenges to doing both, the resources are endless now on how to do this skillfully.

Professional Development is Invaluable

I love taking advantage of opportunities that help me not only be a better leader, but also help me to connect with our frontline nursing staff as well. Continuing education and really committing to personal and professional growth is what helps me come back every day. Finding ways to make things better for my peers and the people that I serve is exciting and that would be impossible without equipping myself with the tools necessary to initiate and support change.

Work/Life Balance is a Real Thing

No, I don’t mean I need a ping pong table in our lounge, but I do need to make it a personal commitment to step away from work that can seem never-ending. In healthcare where services are literally provided 24/7, it can be easy to get caught up in feeling like you need to be accessible all of the time. However, after my first year of nursing education and working a traditional 40 work week with employees calling me at 2 a.m., I simply realized that it wasn’t a sustainable model. Everyone needs intentional rest and time away to be able to come back and be at 100%. It has been especially important to work with executive leadership members and supervisors who are supportive of this notion.

Experience is important, but so are many other things.

Of all the lessons I have learned, this has been the most important. I do not want to discount experience – a strong foundation is necessary in order to speak to and have insight on the needs of the people you serve. However, leadership doesn’t rely on experience alone. A willingness to serve a purpose greater than yourself and the willingness and optimism to work towards solutions are even more important. A commitment to the people you serve is important. The willingness to listen more than you speak is even more invaluable.

Intentional Authenticity

I recently went through an old journal and found a quote that I had written down that stated, “am I failing or am I being refined?” There were many times through my first two years where I felt like a complete failure. Were educators supposed to feel that way? We are, after all, seen as “clinical experts.” However, I’m not anything if not honest. There were times throughout those years that I simply acknowledged my shortcomings, apologized, and addressed it in the best way that I knew how. I wasn’t always the expert, but I was committed to being resourceful. This is what I’d like to call intentional authenticity. I commit to being myself and honest always and being myself within the scope of my role.

I want to commit to always be a learner. It’s why I wanted to be an educator in the first place. And although I’m a “bright-eyed millennial,” I’m thankful for the opportunity to make a difference in whatever capacity I can, ready or not. I don’t believe we are defined by the broad generalizations of our generation. Instead, I’m more interested in what our generation has and will continue to contribute to everyone’s future.

Pediatric Palliative Care (PPC) has been a board certified subspecialty in pediatrics sponsored by the American Board of Pediatrics since 2008. PPC has been a specialty service at Cook Children’s Medical Center (CCMC) since 2007. Palliative care is widely misunderstood by many medical professionals, as well as the general public. While many believe that palliative care is synonymous with end of life care or hospice care, this is not entirely true. Palliative Care is a specialty service that helps care for any child and their family living with serious and potentially life limiting complex chronic conditions. Hospice care is along the continuum of palliative care. All hospice is palliative care, but not all palliative care is hospice. The PC team is grateful to become involved as early as diagnosis and at any time along the disease trajectory including in the midst of therapy with curative intent. The role of the palliative care team is to help with symptom management (caused by disease or treatment), medical decision making and to support families through the uncertainty of serious illness.

The PPC team at CCMC is comprised of physicians, nurse practitioners, nurses, social workers and chaplains. The team collaborates with child life specialists and other supportive services available at the medical center. The PPC team works alongside the child’s medical team to alleviate the suffering of the child and family. We address not only physical suffering (pain, shortness of breath), also psychological (anxiety, depression), social (isolation, financial stress) and spiritual suffering of the child and their family.

We have worked with hundreds of children with serious, complex chronic diseases and assist with anticipatory guidance and medical decision making along the disease trajectory. For example, the family of a child with swallow dysfunction associated with neurologic impairment may be faced with a decision of whether or not to pursue gastrostomy tube placement when aspiration continues despite other means of prevention. The PC team helps to facilitate informed decision making along the disease trajectory in hopes of preventing the need to make critical decisions in times of crisis.

If you have a patient that you feel might benefit from Palliative Care services, you may speak directly to our nurse coordinator, nurse practitioners or physicians to ask questions or make a referral. We can see patients in both the inpatient setting and in our outpatient clinic. PPC does not admit children to the hospital and we do not primarily manage the patients. We work with the primary care providers and the child’s other specialists to ensure that the child is receiving care that is consistent with the family’s goals of care and that we are looking at the whole picture and not just individual systems.

So Your Child/Teen Wants To Be a Vegetarian: Ventures into Vegetarianism/Veganism

One of my favorite movie moments is when Aunt Voula in My Big, Fat Greek Wedding learns that Ian Miller, the non-Greek protagonist soon to join the family, is a vegetarian. She asks, “What do you mean he don’t eat no meat?” and the hoopla of the engagement party falls to a stunned silence. The festivity only resumes with her reassurance, “That’s okay, that’s okay—I make lamb!”

I laugh at this scene because for me it hits home. You see, when my younger sister was eight years old, she announced to my family that she intended never, ever to eat meat again. My usually well-spoken Texan grandparents, who expressed their love for us (at least in part) by buying us kids barbeque, could only stand there and say, “Huh?” And my Italian grandmother and extended family on the other side— well, they acted like Aunt Voula. My grandma would say she understood the vegetarian thing and then would proudly present my sister with an aromatic vegetable dish that was exquisitely seasoned and essentially perfect except that it was decorated with bits of …were those bits of ground beef? Let’s just say my sister’s vegetarianism, which often has edged into veganism, has been an education for my entire family over decades. And my sister, as per her promise, truly has never eaten meat again.

What did my parents do, after a short period of puzzlement? And —more to the point—what should YOU do, should your child or teen make a similar declaration? Here are a few tips I hope you will find helpful.

1. Consider the reasons behind the choice. My funny and, yes, perhaps dated movie reference for this section is a scene from Notting Hill, when Hugh Grant’s character, William Thacker, has a dinner date with a fruitarian woman who says she believes “fruits and vegetables have feelings, so we think cooking is cruel.” Hugh listens attentively and non-judgmentally as she clarifies her position. He starts, “So these carrots,’ and she cuts in, “have been murdered, yes.” “Murdered,” he says sensitively, “Poor carrots—that’s beastly.” In all seriousness, however—and with all due respect to fruitarian Steve Jobs, listening is important. My parents listened carefully to my sister’s reasons in accordance with their goal of rearing a self-assured, independent thinker. Like many school-aged children, she expressed her horror on learning that beef, pork, poultry, and seafood were cows, pigs, chickens, and fish. She became a fervent spokeswoman for animal protection and for humane farms. Inspired by a recent school unit on the environment, she — like Dr. Seuss’s Lorax— also spoke for the trees. She listed ecological concerns about large food industry’s destruction of the rainforest and the need to share earth’s resources responsibly. My sister’s heartfelt explanation helped my parents arrive at acquiescence and ultimately support of her decision.

Indeed, there are many very good reasons people have in choosing vegetarianism (eating no meat) and/or veganism (eating no meat, dairy products or eggs). Aside from the environmental and ecological arguments, it is a decision that for many is tied to cultural or religious beliefs. Teens who are trying to define themselves and formulate their own beliefs may want to back their newly-stated opinions with actions.

Words of warning:  While I strongly advocate really listening to your child’s reasons, as a physician I am also on the alert for a teen who does NOT seem to have well-thought-out positions. Beware of kids and teens who choose veganism for the WRONG reason, such as using it as a cover for excessive or unhealthy caloric restriction and eating disorders.

2. Make a general team strategy. Something as big as dietary change is best done as a family unit. It is too big a project, with too much potential for family dissension, for poor, dear Mom or Dad to tackle alone or for the child to manage without help. In the movie Everything is Illuminated, Elijah Woods’s character visits Ukraine and explains to utterly baffled companions at a restaurant that he eats no meat. When he is told that there is nothing available without meat, he asks if he can have just one of the potatoes that would otherwise be served with meat. The scene’s ending is poignantly and amusingly pathetic, as he is presented with a single, peeled baked potato on a plate, without even a sprinkle of chives … only to then roll onto the floor. Poor guy— oh, the plight of the unaided vegetarian! Honestly, that simply should NOT be how it is, for a good vegetarian effort takes teamwork. Meal-planning, grocery shopping, and cooking are all affected. In fact, if you have been a family of omnivores all along, it may be wise to take baby steps into vegetarianism or veganism. After all, it is truly daunting for a parent who knows how to cook a certain repertoire of meat-based meals to face the task of relearning a vegetarian selection (and as a pediatrician, I do recommend home-cooked meals as often as possible). To borrow Sheryl Sandberg’s phrase, you might consider “leaning-in” to a change—in this case, changed dietary habits— by instituting Meatless Mondays, or Meatless Mondays, Wednesdays, and Fridays! After all, cutting out half the meat still makes a positive impact on animals and on the environment.

My sister would consider nothing other than being a full-on vegetarian, while the rest of us still enjoyed our brisket and Chicken Marsala. However, we omnivores did slowly learn to cook more vegetarian dishes, to modify the ones that had dashes of bacon bits to include the veggie mock-bacon bits or perhaps sesame sprinkles instead, and to cook the vegetable dishes that we already knew more frequently than before. We cooked things that had vegetarian versions, like pasta that she could eat with straight red sauce, though we added meatballs. Many Sundays, my mom cooked a big pot of some variation of vegetable/bean soup, made with vegetable broth, NOT chicken broth! We often enjoyed it that first night as our family dinner entree, after which it made for great vegetarian left-overs for my sister throughout the week.

3. Be Smart about Nutrition. There is a classic scene from I Love Lucy in which Lucille Ball does a commercial for a syrup called “Vitameatavegamin” that is supposed to provide everything needed for good health. The scene is a riot, as Lucy endures its foul-taste for many repeated filming takes until she becomes drunk on the concoction. For a wonderful laugh—check it out! But, seriously, back to your vegetarian child, there is not one simple formula to ensure good nutrition. ANY restricted diet means more potential for nutritional deficiency, and that means more of a need for planning. To begin with, be sure calories are sufficient. I recommend the website choosemyplate.gov, which also includes a tracking feature called supertracker.usda.gov that can help in following calories and nutrients in a child’s diet. If your family is new to vegetarianism/veganism, it might be a good idea to have your child take a multivitamin. Truth be told, however, if your child is a non-picky vegetarian who eats milk and eggs and a pretty wide variety of vegetarian foods, he/she is probably getting all the nutrients needed without said vitamin. Similarly, if your child or teen has chosen to be a vegan but consumes a varied diet including fats and protein as well as a fortified milk substitute (like fortified soy/almond/cashew/coconut milk), then he/she is also probably set on nutritional requirements (due to supplementation in these dairy replacements). Without milk substitutes, though, I do worry about your child’s not meeting nutritional needs and would definitely recommend a multivitamin, particularly for Vitamin B12, calcium, Vitamin D and zinc. If in doubt, I recommend meeting with a nutritionist (Cook Children’s has a wonderful nutrition department).

4. WILL MY VEGETARIAN CHILD GET ENOUGH PROTEIN?

For lacto-ovo vegetarians, those who are not vegan and therefore consume both milk and eggs (both good sources of protein)—the answer is most likely YES, without even much forethought. Vegans, however, might not be getting enough protein and will need to strategize. The take-home message for them is that they need to eat a VARIETY of protein-sources each day and enough of them to meet requirements. I suggest counting protein grams for a few days, and—once you get the idea of what you need—then go for gestalt.

As an overview, animal-based foods (like meats, fish, dairy and eggs) are considered “complete proteins,” containing all 9 essential amino acids in a quite digestible form. On the other hand, plant-based foods are generally deficient in at least one amino acid, so— in order to get all 9—you need to eat a variety of different plant-based foods with “complementary proteins.” For example, legumes (beans) are low in methionine but high in lysine, while grains are the reverse. If you eat both legumes and grains in one day, you get them all. Also, plant-based protein is less easily-digestible than animal —based, so you need to consume more protein daily as compared to a carnivore, to get the same benefit. Do note that there ARE a few plant based proteins which are becoming more popular and which are complete, including quinoa, hempseed and chia seeds—hooray!

If vegans drink soy milk as their milk-substitute, they will get nearly as much protein from it as someone drinking milk (6-7g per cup as compared to the 8g in milk). However, there are some concerns about the relationship between soy and estrogens and the potential impact on children’s endocrine/hormonal systems (endocrine-disruptors). If you would like to limit soy milk, another option for a milk-alternative is Ripple Pea Milk, made from peas and containing just as much protein (8g/cup) as regular milk. Simple almond, cashew, and coconut milks do not typically contain any protein, but there are starting to be some nut milks on the market that are fortified with pea protein (check out Silk Protein Nutmilk container 10g of protein—woo-hoo!).

To touch on details, people generally need around 1 gram of protein per kilogram per day ( just over 1 g for toddlers, and 0.85-0.95 for kids/teens, but requirements can be 20% higher if protein is from harder-to-digest vegetable sources). Let’s consider a young teen who is 100 pounds, or 45 kilograms. That teen needs 43 grams of protein per day, which is pretty easily achieved if the child eats milk and eggs. In breakfast alone, she can get 17 grams, with her cup of milk and cup of bran flakes (8 g plus 3 g respectively) plus one boiled egg (6 g). Not bad for one meal alone! If that teen is a vegan, though, she may need as many as 51 grams of protein daily, since her proteins will be harder to digest. Tofu faux-eggs scrambled in the morning could help reach that goal (5g/oz), along with a cup of Ripple Pea milk (8g). Beans are a great go-to (8 g per half-cup), as are broccoli (4 g per stalk), spinach (5g per half-cup), and artichokes (4g per one medium-sized). Expand into ancient grains such as quinoa and amaranth, the latter which can be made into breakfast porridge and sprinkled with hemp or chia seeds for even more protein. And don’t forget peanut-butter sandwiches—they have 13 grams each!

Pearls of Protein Wisdom:

1. It helps to eat dairy and eggs, which are protein-rich.
2. Soy milk and pea milk (Ripple) are protein-rich milk-alternatives.
3. Nut milks like almond, cashed and coconut milks do NOT USUALLY contain protein, but there are some high-protein varieties fortified with pea protein.
4. Eat beans, hummus, soybeans/tofu, spinach and peas.
5. Sprinkle hemp or chia seeds over salads or smoothies, and try the ancient grains like quinoa or amaranth (which you can make into a breakfast porridge).

5. WILL MY VEGETARIAN/VEGAN GET ENOUGH FAT? Omega-3s?

It is absolutely possible and important to do so, but it is not a given! Keep in mind that people of all diets can make healthy or unhealthy choices even within their dietary restrictions. If your child vegetarian leans toward a diet heavy on the grilled cheese sandwiches and macaroni and cheese, not to mention donuts and cookies, while perhaps tending away from as wide a variety of vegetables as you would like, he/she may actually have a high-fat diet. Many teens, however, go the opposite direction and eat overflowing and deceptively- filling plates of vegetables that do not have enough fat. Fat is important and should make up approximately 30% of the energy a child/teen consumes in a day. Since fat provides 9 kcal per gram, teens consuming 2000 - 2600 kcal per day need around 75g of fat per day.

Good sources of fat include avocados (32 g each!), peanut butter, nuts, seeds, and oils (including olive, canola, and coconut oil). A cup of milk contains 2.5 g of fat, and fortified substitute milks have about that much or more. You will have to read labels on them, as there is some variability—Silk Coconut milk and Ripple Pea Milk top the charts with 5 g and 4.5 g per cup, respectively.

And, while we are on the subject of fats, what about those Omega-3 fatty acids (DHA, EPA, and the precursor called ALA) that everyone is always talking about, the ones that help for eye and brain development and also for heart health? The main sources of omega-3s are fish, eggs, and algae, but how much algae is your vegetarian/vegan eating? Indeed, vegetarians and vegans have been shown to have generally lower levels of omega-3s than omnivores and would likely benefit from more, though as of yet there are no officially recommended daily allowances for omega-3s for children (or adults). For adults, there is a suggestion that 250-500mg of combined DHA and EPA is a minimum goal. Kids/teens can get one of the omega-3s, alpha- linoleic acid (ALA), through flaxseeds and hempseed (which can be added to pancake mix or oatmeal), chia seeds (which can be added to smoothies), soy, and canola oil. Kids can also get omega-3s (DHA) from Ripple Pea milk, the milk substitute made from peas.

A WORD ABOUT PERCENTAGES ON FOOD LABELS

When you look at food labels to see how much of many of our next nutrients are in foods, sometimes instead of a number of units, it will list a percentage. That percentage is telling you what percentage of Daily Value is provided, but Daily Value is NOT the best guide when thinking about your child’s nutritional needs. Daily Value (DV) is a single number issued by the FDA for labeling purposes and is different from the more precise and age-specific Recommended Daily Allowances (RDA), which is what we pediatricians recommend parents follow. RDAs are determined by the Institute of Medicine and can differ from DVs— so get wise to it! In the case of Vitamin B12, for example, younger children have an RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentage of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child (it’s not just half of what he/she needs!). In some cases, like for Vitamin D, on the other hand, the DV is less than the RDA, so you can get misled into thinking you are getting enough Vitamin D, when you are not.

6. WILL MY VEGETARIAN/VEGAN GET ENOUGH IRON?

They can if they plan! It is certainly easier for meat and fish eaters to get enough iron, and—unlike the protein situation—milk and eggs are not too helpful as iron sources. Consequently, vegetarians and vegans are both in the same boat. There is a lot of iron in meat, and that “heme-iron” is more easily absorbed than “non-heme iron” in vegetables. So vegetarians and vegans alike will need to eat more of their iron-containing vegetable-based foods to get the necessary protein. It is also important to note that some foods can help or hurt you in your efforts to get iron. Legumes (which have phytates) or coffees and teas (which have tannins) decrease iron absorption from other foods, while your friend Vitamin C —think oranges, strawberries, tomatoes—increases iron absorption.

Toddlers and school kids need between 7-10 mg of iron daily, whereas teens need more, 11mg for boys and a whopping 15mg for girls (who lose iron with their periods). One cup of kale or collard greens has just 1mg, so you can see that you will need quite a bit to approach the daily requirement. Remember oatmeal as a great source of iron—13 mg in one cup! Dried fruits can be helpful to have around (1.75mg in 1/2 cup of dried apricots), as can peas and pistachios (2mg in 1/2 cup peas, 1.2 mg in 1/4 cup of pistachios). Ripple pea milk, a milk substitute made of peas, has quite a bit of iron—2.7 mg per cup (on the label it says 15% of the 18 mg/day Daily Value)! Soy and nut milks do not have nearly that, but some have 0.75-1mg (Chocolate Silk Cashew Milk has just over 1mg, or 8% of the DV), and every little bit helps!

As I have warned before, don’t be misled by percentages of Daily Value on the food labels. The DV for iron is 18mg, but that is actually more than your child needs according to RDAs (even if your child is a female teen who needs 15 mg per day). So, if your oatmeal has 20% of the DV of iron, it has 3.6 mg. That is not just 20% but more like 33% of what your child needs.

Pearls of Iron Wisdom:

1. Eat iron-rich foods (oatmeal, leafy greens, legumes, dried fruit, soy products, etc)

2. Eat Vitamin C, to help iron absorption, along iron-containing foods (think

citrus, strawberries, broccoli or tomatoes)

3. Reduce your intake of tea/coffee with tannins (that reduce iron absorption)

4. Ripple Pea Milk is a very good source of iron!

7. WILL MY VEGETARIAN/VEGAN GET ENOUGH CALCIUM and VITAMIN D?

As Marisa Tomei’s character said in the movie My Cousin Vinny, “It is a trick question.” She also used other words not fit for this blog. Still, this question is tough because truthfully, many teens of even unrestricted diets seem to struggle these days to get enough calcium and Vitamin D, as many replace their milk-drinking habits with a sugary-beverage habit. However, if a teen (vegetarian or not) has about three servings of dairy a day plus vegetables that contain calcium, he or she can usually get the recommended 1300 mg of calcium (RDA is 1000 mg for kids 4-8 years old and 1300 mg for kids 9-18) and the 600-800 IU of Vitamin D recommended (600 for 1-9 year-olds and 800 for 9up). Vegan kids and teens also can get enough calcium these days, too, IF they drink a fortified milk substitute. This is a wonderful gift of the food industry to vegans, as they have added calcium and Vitamin D to their milk substitute drinks. Whereas regular unfortified soy milk has 6 times less calcium than regular milk, most soy, almond, coconut, cashew and even pea (Ripple) milk at grocery stores today are fortified and have ample calcium, even 1.5 to 2 times the amount in regular milk!

Many other foods have been fortified with calcium and sometimes Vitamin D as well, such as cereals, waffles, and orange juice (look for “Calcium added” in big letters on the packaging— but, remember that juice is sugary and not that healthy, so limit it!). Other good sources of calcium are spinach (240 mg per cup) and broccoli (180 mg per cup). Dark sugarcane-derived molasses has quite a bit, too (135 mg in 1 tbsp) — maybe put that over your fortified waffles? Also, mushrooms are your friend— they contain a lot of Vitamin D (634IU in 1 cup of portobello mushrooms)!

Note that for label-reading purposes, Daily Value for Calcium is 1000mg, which is LESS than the RDA for age 9+ of 1300 mg, and the Daily Value of Vitamin D is 400IU, also LESS than the RDA for kids 1year and older. So, when a label on your almond milk says it contains 45% of the DV of calcium, it means 45% of 1000, or 450mg. This is actually more like a third (33%) of what your child’s recommended Calcium intake should be.

Pearls of Calcium/Vit D Wisdom:

1. Drink milk or fortified milk substitutes or have other dairy 3 times a day
2. Enjoy calcium-rich greens like kale, bok choy, mustard greens
3. Look for other calcium-fortified foods like cereals, waffles, and orange juice
4. Molasses (dark, sugar-cane based) for calcium!
5. Mushrooms for Vitamin D!

8. IS MY VEGETARIAN/VEGAN GETTING ENOUGH VITAMIN B12?

Similar to the calcium and Vitamin D discussion, this is an area in which we pediatricians USED to tell vegetarians who consumed milk and eggs that they would be fine, whereas we told vegans they were not getting enough Vitamin B12 and would need a supplement. However, the food industry has come to the rescue! Fortified milk substitutes like coconut, soy, and almond milk now are fortified with Vitamin B12. One cup of Silk Soy or Organics Plain Soy milk has the Vitamin B12 that you need in a day. Fantastic! So—you decide— you can take a multivitamin with Vitamin B12, or you can make a habit of drinking fortified milk substitutes. Without either of these things, though, a vegan may not get enough Vitamin B12.

Again, don’t be confused in reading labels. In the case of B12, Daily Value —which is what percentages are based on for food labels—is a lot higher than RDA, which is the vitamin recommendation for kids by age. Younger children have a Vitamin B12 RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentile of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child.

9. IS MY VEGETARIAN/VEGAN GETTING ENOUGH ZINC?

Lacto-ovo vegetarians who are good about drinking milk probably are, but vegans may not be. To make things even harder, zinc quantities are often not even listed on packaging. The RDA of zinc for kids 9-13 yrs is 8 mg/day, whereas girls and boys fourteen and up need 9 mg/day and 11 mg/day, respectively. The DV of zinc is 15 mg —quite a bit higher than these RDA recommendations—so remember that when reading packages!

The kings of zinc provision are oysters (74 mg/cup), which provide 70x the amount of zinc in servings of a lot of other foods, but that doesn’t help our vegetarians/vegans (or many of our omnivores who are texturally-challenged when it comes to oysters). Legumes, nuts and seeds, however, can help you get enough zinc. A half cup of baked beans has 2.9 mg of zinc, and an ounce of cashews or pumpkin seeds have 1.5-2 mg.

10. IS MY VEGETARIAN/VEGAN GETTING ENOUGH FIBER?

Vegetarians and vegans SHOULD be getting enough fiber if eating a varied diet with many types of vegetables. However, this is not a given! Some vegetarians subsist on breads and cheese and are not getting the fiber they need. Fiber is a challenge for many children and teens these days, as evidenced by our seeing a lot of constipation problems in the pediatric office. Look to whole grains, vegetables and fruits (with the exception of bananas) to be excellent fiber sources. Kids need about 25-30 grams of fiber daily, and they can get 5 grams in a serving of bran flakes alone. One rule of thumb is that for every 1000 kcal that a person eats, they should strive for 14g of fiber.

11. Make things delicious.

One of my sister’s biggest pieces of advice to other vegetarians/vegans and their families is to continue to expand your culinary and dietary horizons and not view the vegetarianism as an impediment to enjoyment. As a physician who wants people to strive for variety in even a restricted diet, I whole-heartedly agree. Take a world view. Asian food is great for vegans—the only big things to avoid are fish and oyster sauces, but many recipes and restaurants can make do with soy sauce alone. Curries often are made with coconut milk—perfect. Mexican food allows for many vegan options such as veggie tacos, guacamole and salsa, and black bean soup. Italian food with its pasta and tomato and pesto sauces, pizzas that can be made vegetarian, and risotto (great with mushrooms) offers great options, as does do Greek, Mediterranean, and Middle Eastern cuisines with their salads, hummus, and baba ganoush. Indian cuisine with its rice, naan, garbanzo beans, and spinach paneer (to name just a few things) is perfect. The list goes on. Often, the heart of a dish is really its seasoning and spices, and those can be enjoyed with just vegetables or a meat substitute!

There are so many options available at grocery stores now, too. Score! You can buy faux chicken fingers, veggie burgers, “meat”balls,” meatless-sausages and of all kinds, and even vegan hotdogs. And—from experience—they can taste pretty good!. Veggie bacon may not taste quite as amazing as real bacon, but it helps fulfill a craving, doesn’t allow for feeling deprived, and holds to your vegetarian choice. You can also learn to cook with meat-substitutes like tofu, tempeh, and seitan (contains gluten) that are now featured entrees of some world-class vegan restaurants. And, on the subject of dining out, we at the Cook Children’s Henderson office are extremely close to a great Fort Worth vegan establishment — Spiral Diner!

There is also the potential for amazing desserts. There are many vegan ice creams available now, including several options by Ben and Jerry that are incredibly tasty. You can also whip up cashew cream to use in place of real cream in cake and other recipes. My sister likes to slice bananas, freeze them, and then put them through the food processor with peanut-butter and/or chocolate syrup for a delicious and pretty healthy vegan dessert.

Best wishes for your ventures into vegetarianism and veganism. Who knows, dietary change that seems intimidating now may become second nature and a part of your child and your family’s identity. Think of Reese Witherspoon’s character in Legally Blonde, introducing herself to her Harvard Law School classmates. “Hi, I’m Elle Woods, and (holding up her chihuahua) this is Bruiser Woods,” she says, “and we are both Gemini vegetarians.”

Bon appetit to all, and many thanks to my awesome sister, Ariana Nizza-Chapman, for the inspiration and the many tips!

Last year, 35 children were treated for snake bites at Cook Children's, up from 21 bites in 2017 and 20 in 2016. Earlier in the week, a 19-month-old girl became the first child to be treated for a venomous snake bite at the medical center. She was admitted to the ICU and given three vials of anti-venom over the course of two days, according to Fox4News. The child is now recovering at home.

When children are taken to Cook Children’s Emergency Department, a careful snake bite protocol begins that can result in antivenom given to the patient.

"We have advance practice providers with years of experience and expertise in caring for snakebite victims as part of the Trauma Team," said Melinda Weaver, Trauma Program Manager at Cook Children's. 

The Trauma Team uses an evidenced based clinical guideline along with a scoring system, lab results and other indicators to decide if the antivenom is needed or not. If it's determined the antivenom is needed, the Cook Children's Pharmacy team is notified.

Cook Children’s Pharmacy carries one of the largest stocks of Crofab®, a snakebite antivenom treatment, in the area for rattlesnake, copperhead and water moccasin (cottonmouth) bites at all times.

Once the patient is brought to Cook Children’s, he or she is watched carefully for signs and symptoms to a venomous bite.

The initial evaluation of the patient includes the “A-B-Cs” (airway, breathing, circulation) and vital signs. The wound is then examined for swelling, discoloration and bleeding. Signs that the antivenom is needed include:

• Respiratory distress
• Nausea
• Vomiting
• Abdominal pain
• Bleeding from nose, skin or gums
• Tingling or prickling sensations
• Abnormally low blood pressure
• Faster than normal heart rate.

Ean Miller, a manager in the Pharmacy Clinic and a pediatric clinical specialist in the Emergency Department at Cook Children’s, said the signs that Crofab will be needed usually occurs within the first couple of hours.

“Once we know it’s a snake bite, we are immediately drawing the labs,” Miller said. “We will then assess the bite wound. One of the things that we watch for is if the redness and swelling around the bite starts to expand rapidly. If it’s not a venomous snake, usually there will be a little bit of redness and swelling but it doesn’t spread."

The initial care is administered by the Emergency Department and then the Trauma team at Cook Children’s takes over for treatment. An order is given if it’s determined the child needs the antivenom. The mixing takes 15 to 20 minutes by the pharmacist to get the antivenom ready.

The most important factors to giving CroFab are evidence of coagulopathy (blood clotting factors out of normal range) and evidence of respiratory distress, low blood pressure and fast heart rate.

If the patient responds to the initial dose and no allergic reaction occurs then an additional two vials will be given every six hours for three more doses.

Miller said 90 percent of patients start to improve after that first four to six vials of Crofab. Most of remaining 10 percent show improvement after an additional four to six for an almost 100-percent rate.

On rare occasions, a patient will develop an allergic reaction to the antivenom. If that happens, the patient cannot receive any more antivenom and treatment consists of symptomatic and supportive care.

Antivenom is not effective for the other venomous snakes in this country. Coral snakes, which also are in Texas, and other exotic species make up the remaining 1 percent of venomous snake bites in this country. Crofab® antivenom is not used to treat these bites. Patients are admitted to the hospital for 24-hour observation and supportive care.

The life-changing news can mean the loss of a “normal” life. Even the most straightforward cancer with a 95-percent cure rate can impact jobs, marriage and the children’s sense of security.

And in the most tragic cases, the diagnoses can result in the death of a child.

“Despite amazing advances in childhood cancer treatment, too many children will lose their battle,” said Kelly Vallance, M.D., a hematologist and oncologist at Cook Children’s. “Parents, siblings and friends are left behind to deal with their loss and grief, often without support.”

As a pediatric resident, Dr. Vallance noticed the special bond that developed between families of a child with cancer and their health care providers. So many families were in and out of a hospital over the course of years.

“That can be a sharp sever for families,” Dr. Vallance said. “In my training I felt there was a lack of end of life support for families. A lot of families feel once the goal of treatment changes from cure to comfort and they leave the hospital, a lot of families feel abandoned. Now they are home, meeting new caretakers or leaving the hospital without their child. They feel they’ve lost the security they have felt for so long being in the hospital.”

Dr. Vallance joined Cook Children’s in 2009, specializing in treating childhood cancer. In the back of her mind, she knew wanted to do something to help grieving families.

Cook Children’s Pastoral Care plays a pivotal role in helping families throughout the hospital who are coping with the death of a child, including children with cancer. But because of the special bond created with families and staff in hematology/oncology care, Dr. Vallance wanted something specific for those families.

After applying and receiving a scholar grant through Hyundai Hope on Wheels, Dr. Vallance started the Cook Children’s Oncology Bereavement Program. The purpose of the program is to provide and maintain a therapeutic relationship for patients and families during the entire spectrum of their disease, up to and including their death and 18 months past that date for their family and friends.

As Family Care Coordinator at Cook Children’s, Mandy Sale serves as a familiar face and primary contact for families in the Hematology/Oncology department. She visits the families and is an advocate for them during their stay in Hematology/Oncology. Because of her familiarity with these children, it only made sense that she would also help facilitate the Oncology Bereavement Program.

Sale and Dr. Vallance are two of a group of health care professionals involved in the program, including physicians, nursing, child life, pastoral care, social work and ancillary staff.

The group supports the patient and family throughout the continuum of end of life, death and the grieving period.

The experts in this field also offer help to those treating the families. An aspect of the program involves supporting the emotional needs and preventing compassion fatigue for the pediatric oncology staff.

But the primary focus is on the families. Few Pediatric Oncology Centers have organized or standardized support protocols in place for families during and after the loss of their child.

“We want to give comfort to parents, siblings and friends who are left behind to deal with their loss and grief," Sale said. "They are often left behind without support. Children with incurable or progressive illnesses, such as cancer, often express concern for their parents and siblings. They worry they will not be able to cope when they are gone. Through the bereavement program, we help to meet these hopes of our patients by caring and helping their loved ones during one of the most stressful life experiences and the lifelong grieving process."

The Oncology Bereavement Program includes:

Oncology Caregiver Bereavement support provides personal communications with the family, including:

• Maintaining a therapeutic relationship with all patients.
• Facilitate legacy building activities with families including trips/wishes when possible.
• Support for patients/families that remain inpatient for end of life care.
• Support for patients/families through transfer to home care or hospice care.
• Continued support by phone, for those who have left the hospital, by a familiar and involved team member during the hospice phase until time of death.
• Bereavement package at time of death with resources for support.
• Attendance by Oncology representatives at local funerals.
• Coordination of letter from caregivers.
• A personal card to family on patient’s birthday and anniversary of death.
• A bereavement phone call data base for follow up phone calls, from an involved familiar care giver, to families at 3,6,9,12 and further as needed.
• The option of trained therapist/counselor to visit child’s class and siblings’ classes to answer questions and provide grief counseling.

Bereavement Programs offered to families include:

• An annual Remembrance Ceremony.
• Camp Morning Star- A weekend camp for families who have lost a child that was treated at Cook Children’s. The camp is held annually at Camp John Marc in Meridian, Texas. Parents and children have a chance to enjoy being together as a family and also participate in therapeutic activates to help them cope with their loss.
• Sib Shop- Sib Shop is a national organization that is focused on helping meet the needs of siblings of kids with chronic illness. This group is led be a trained Sib Shop facilitator and Child Life staff from Cook Children’s. This is a specific group for siblings who have lost a brother or sister at Cook Children’s. They meet quarterly now but could increase this number with more funding.
• Referrals to appropriate grief family retreats and camps local and national.

When your child looks and acts healthy, it’s hard to understand how they could have a condition that, without proper treatment, could cause them to have a heart attack or stroke before the age of 50. Maria Gutierrez found herself in this situation when she received a life-changing phone call from Don Wilson, M.D., an endocrinologist and medical director of the REACH Clinic at Cook Children’s to discuss her daughter Kate.

When Kate was 4 years old, doctors told Maria that Kate was overweight and might be developing thyroid issues. Maria encouraged Kate to be more active and eat healthier. Her daughter’s change of lifestyle seemed to be the answer and by age 7 Kate was no longer overweight.

“Kate is always very hyper, very active. She eats vegetables! She loves cucumbers, lemons, loves fruits, loves everything,” Maria said. “Why would doctors call now to suggest blood tests when she’s healthy?”

According to the REACH (Risk Evaluation to Achieve Cardiovascular Health) Clinic, ideal total cholesterol levels should be less than 170 mg/dL, or LDL cholesterol levels (sometimes called “bad cholesterol”) less than 130 mg/dL. Kate’s lab work showed her cholesterol levels at 250 mg/dL, and she was diagnosed with hypercholesterolemia.

Hypercholesterolemia is a condition characterized by high levels of cholesterol in the blood. The condition is frequently caused by a genetic condition and kids can be at risk even when they are living a healthy, active lifestyle. The good news is that with early detection made possible by a routine blood test and medication to lower the cholesterol to safe levels, children with high levels of cholesterol can avoid serious health issues such as a heart attack or stroke when they become adults. But for children with genetic causes of high cholesterol, a healthy lifestyle is not enough.

Maria realized that Kate’s levels matched that of her husband’s, Roberto Macedo, who is diabetic. Dr. Wilson decided to test Kate to see if she had a genetic condition that would cause her cholesterol to be high. When she tested positive, Maria brought in her older son Brandon, 10, too. Brandon also tested positive for the gene. Brandon’s Vitamin K levels were also extremely high, putting him at risk of blood clots.

Both Kate and Brandon take medicine daily to treat their high cholesterol. Their schedules for lab work vary depending on how well they respond to their medication. It’s been two years since their diagnoses.

Right now, Brandon is coming in monthly to monitor his Vitamin K levels. If his medicines do not improve his condition, his dosages will have to be changed. Fortunately, with medication both children have achieved a healthy level of blood cholesterol. Like virtually all children treated with cholesterol medication, Dr. Wilson notes that none of the children have experienced side effects, and all have shown normal growth and development.

Everyday decisions, like what’s for dinner, are potential health risks for Brandon and Kate. They’re kids, so of course they want treats every once in a while. Maria says for her family “if they want a burger, they have to eat really healthy during the week and they can have just one hamburger at the end of the week, but with lettuce and tomato. It’s all about the balance.”

What’s hardest for Maria is knowing that there currently isn’t any cure for her children’s conditions. “I feel really bad because there is no way I can help them. The only way I can help is with what they eat, get plenty of exercise and make sure they take their medicine every day,” said Maria.

What’s even more difficult for her is the fact that not everyone believes Maria when she explains her kids have high cholesterol. She hears this a lot, “They aren’t fat, how can they have high cholesterol?” Maria explains that it’s genetic, and there isn’t much they can do other than to make sure her kids take their medicine, eat healthy and stay active.

But Maria’s children aren't alone. Genetic causes of high cholesterol affects 1 out of every 250 children, and it is one of the most frequent health concerns that affect children. For kids with genetic causes of high cholesterol, early treatment with cholesterol lowering medication is readily available, inexpensive, and most importantly, has proven to be safe and effective.

“It’s hard to understand that little kids can have this issue. They look fine, but they could become diabetic if their levels don’t go down. Or be at risk of having a heart attack or stroke when they’re adults” Maria said.

According to Dr. Wilson, left untreated, 50 percent of men and 30 percent of women with this condition will experience a heart attack by age 50.

Hypercholesterolemia is a challenge that Kate and Brandon face every day, yet an outsider could easily never notice. Maria hopes to bring awareness to her children’s conditions; she wants others whose children appear healthy but face health issues to know that they aren’t alone.

View this video  to learn about high cholesterol.

These are common problems in the lives of a child.

But thanks to cyberbullying, the pressure to make it into college and a desperate need to fit in, anxiety has reached near epidemic proportions.

More than 40 million Americans suffer from Anxiety. According to the annual national survey by the American College Health Association, one in six college students has been treated for or diagnosed with anxiety in the past year.

For many of the kids at Cook Children’s, chronic pain only adds to that sense of stress and anxiety.

“Chronic pain affects every relationship in a child’s life. There’s a lot of bullying that can take place. They lose a lot. They lose their ability to play soccer or stay on the football team or they find themselves not being able to go to school regularly and some of our kids can’t go to school at all due to pain,” said Barbara Deleon, Pain Management Services coordinator at Cook Children’s. “So then they lose some of their friends. They lose those relationships that are important to children.”

To help the children who suffer from chronic pain, Pain Management Services uses many different types of therapies to help their patients including acupuncture, acupressure, aroma therapy, massage therapy and different types of physical therapies.

But yoga has always been at the top of the list to add to their pain management tools.

Two years ago, the Pain Management team wrote a proposal to bring a yoga program to Cook Children’s and they received the funding this year. Then the search was on for the right person to lead and teach yoga to the variety of patients dealing with pain and anxiety at Cook Children’s.

Tatiana Miller was that person. Miller brings with her a ton of expertise with hundreds of hours of yoga instruction, as well as a cognitive behavioral therapy practitioner, a stress management life coach and a health counselor.

She is also a wife and mother of two who lives in Fort Worth. Immediately, she knew this job at Cook Children’s was the one for her.

“When they called me in to meet with the Pain Management department I thought, ‘Oh my gosh this is divine. This is more than meant to be. All the knowledge I’ve gained, all the experience I have was for this moment. It was for this department. We’re taking these children and giving them these tools that they had not been given before. These kids are missing school because of their pain. They aren’t able to catch up on reading or math, but they also can’t catch up with just wanting to have a good life. To get their life back. If you don’t have the tools to cope with this pain, you can’t catch up to feeling depressed or angry or frustrated. Anxiety is paralyzing and these kids that once had normal lives aren’t able to do life anymore because of their pain and the anxiety that comes with it.”

The yoga instruction at Cook Children’s provides tools to make it easier for patients to cope with the challenges they may face, including:

• Anxiety
• Post-traumatic stress disorder
• Chronic headaches
• Sleep disorders
• Pain
• Grief
• Depression

The yoga is designed to accommodate all ages and fitness levels, based on 5 principles:

• Stillness – learn to quiet the mind and body, become self-aware and develop sensitivity, self-control and self-regulation.
• Listening – tune in to what your heart, mind and body have to say.
• Grounding – discover how to be physically present in your body and develop a sense of competence, physical safety and security.
• Strength – develop physical, mental and emotional strength.
• Community – enjoy a fun-loving environment where you can explore yoga through the use of movement, breathing and games.

Miller takes the principles with her to help her patients, but these are kids and no two sessions are the same.

“Part of the yoga therapy approach is meeting patients where they are at,” she said. “So I can’t show up with a plan because I might have a teenager and a toddler in a class or all teenagers for all toddlers. The kids may be very active or very tired. So my approach is to show up and to read them. That’s where I start off. I talk to them to make them feel safe. I try to connect to each participant in a way they can relate.”

For all of her training and expertise, Miller said any progress begins with one simple truth: “They have to like me. Because if they don’t, they aren’t going to participate and they aren’t going to listen to what I have to say.”

Miller walks into a room and scans for body language, where the kids are located in the room and their social cues such as are they looking her in the eye.

From there, she begins to reach into her bag of tricks to hook their attention. She may bring out a focus ball to help the kids with their breathing. She teaches them what breathing should feel like and how to slow down their breath.

“If I can get them to slow down their breathing, their nervous system says things are good. We can calm down,” Miller said. “The first goal is to get them in a happy place in their nervous system.”

From there, depending on age and the physical makeup of the class, students may do as many as 15 yoga poses.

But Miller works on more than just the physical during yoga. She works on their self-esteem. She talks to them about feeling empowered and feeling like a leader.

“The true understanding of yoga is the ability to be still and listen. That’s it. Yoga is not body postures. Yoga is not meditation. Yoga is not breathing. Yoga is the ability to be still and listen and not let external circumstances affect your internal state,” Miller said. “A crisis is any time your internal tools can’t keep up with the external demand. That’s why most teenagers live in crisis, which is anxiety, because they don’t have the internal tools to meet the external demands.

“If you teach them to be in the world but have the capacity to come back into themselves and say, ‘Is this real or is it in my head? My thoughts? My emotions? Can I do this? Is this right for me? That relationship within themselves … That’s the stillness and the listening.”

Miller is just beginning the program, but it is catching on throughout the medical center. She has taught children in Pain Management, Rehabilitation, Psychiatry and more is planned, including going to individual rooms for yoga therapy.

Yoga is a way to help the patients at Cook Children’s feel better about themselves. It’s one way to help kids who have lost control either physically or emotional to gain some control back.

“Pain is very physical and yoga can be physical,” Deleon said. “With pain, there is a mind, body connection and in yoga there is a mind, body connection. So the relationship between yoga and helping with their pain is very beneficial to our patients.”

Other than the commemorative labels on them, nothing about these two bricks stands out too much. That is until you sit down and spend time with Bobby Moore.

Then you will learn that Moore, who is 68 years old, plans to pass on one of those bricks to his daughter and the other one "will be in the casket with me."

So why would two old, dusty bricks mean so much to a man?

Because they once held up the building then known as Fort Worth Children's Hospital and it was there where corrective surgery saved him from a life in a wheelchair.

Moore was born in Alvarado, Texas at Dr. John Falk's medical clinic. Shortly after his birth, Moore's parents were told there was something wrong with their son's legs. Dr. Falk helped to schedule an appointment with Cuvier Lipscomb, M.D., an area surgeon and one of the founders of the Fort Worth Bone and Joint Clinic.

At 18 months old, Moore began seeing Dr. Lipscomb. Dr. Lipscomb tried braces, corrective shoes and Moore says "just about everything you could think of" to help his legs get better.

"I was extremely pigeon toed. Evidently the bones weren't developing below my knees," Moore said. "When I was about 12 years old, I was having lots of problems. Dr. Lipscomb said, 'I've done this procedure on a boy from Weatherford and it helped him a lot. I think it's something we need to do on you because if we don't, by the time you are 20, 25 years old, you aren't going to be walking."

Dr. Lipscomb went in below the knee, cut the bones and rotated Moore's feet until they were straight. He placed a cast on both of Moore's feet from the tips of his toes to his waist. He wore that cast from May 31 to Oct. 1.

Moore was wheelchair bound at that point. He and his family lived across the street from the school. He remembers kids bringing his books and homework to him every day at the end of school and then picking up his work the next morning.

In October, the casts came off of Moore. He went through physical therapy and started school on crutches. In February 1964, Moore went back to Dr. Lipscomb for another surgery. This time, staples held the bones together and kept them straight. Those staples are still in there to this day.

Moore couldn't play sports because of his legs, but he worked through high school and all of his adult life.

"You miss a lot, just not going to school my eighth grade year," Moore said. "I only made two six week periods the whole year. But with the help of the other students bringing my books to me, I was still able to pass my eighth grade year doing that."

Moore said he was too young to realize the serious nature of his condition.

"My brother tells me he can remember when we would go see Dr. Lipscomb," Moore said. "He remembers telling my dad, 'This kid won't walk by the time he's 15 years old if we don't do something for him.'

"What they were saying really didn't sink into my head. Even while I was sitting there with casts on my legs. I really didn't realize what was going on. The gravity of it all. But I'm very thankful there were people like Dr. Lipscomb who took the initiative and cared for patients."

Perhaps the moment that hurt Moore the most occurred when he was drafted to join the military. He went to Dallas for a physical, but was rejected because of his legs. Moore went to Fort Worth to have Dr. Lipscomb send paper work to explain the scars and how he thought he could hold up to military life. But he still was not accepted.

Moore knows without Dr. Lipscomb's care, he would probably be in a wheelchair by now.

"As a matter of fact, when I was 18 and the Army turned me down, Dr. Lipscomb told me, "Let me put you on 100 percent disability because I don't think you'll ever be able to work, using your feet and legs very much. He didn't realize how good a job he did on them. Up until 2004 when I started having knee problems, I hadn't had any trouble with them at all.

I was an auto mechanic for 15 years and I worked at a nuclear power plant for 34 years before I retired."

It's funny the things that stick with someone 50 years later.

A glimmer returns to Moore's eyes as he remembers the names of the other patients at the hospital. He also remembers his trips through the underground tunnel from the Fort Worth Children's Hospital to Harris Hospital for X-rays and physical therapy.

However, not all the memories are fun.

"The worst part was trying to recover," Moore said. "It wasn't necessarily the physical part of it, but the self-confidence part of it. You go to a ballgame and you see all these kids playing ball. You have to get up on a pair of crutches to walk, trying to get out of the building and you wonder if people are watching. Are they looking at you? I've always been self-conscious about walking because you don't ... I'm just very lucky that Dr. Lipscomb was the man that he was and the doctor that he was that got me through everything."

Today, Moore speaks with pride about his time at Fort Worth Children's and the part his family has played in the Cook Children's legacy.

His daughter Kim Epperson is the director of Telehealth at Cook Children's and his granddaughter Ashley has been a patient at Cook Children's and interned at the medical center during the summer.

"I'm very proud of Kim," Moore said. "When she first told me she applied to Cook Children's, I told her that's a good place to go because people like you can make a difference. When you are dealing with children and people that are scared and don't know what's going on, you need someone like Kim that cares about people and wants to make a difference. I'm very proud of her for doing that at Cook Children's."

Epperson said it wasn't until she was older that she realized what all her dad went through as a child. He and her mom, Janelle, were the parents she still strives to be every day. Moore was the softball coach and always outside playing with his kids in the yard.

"It's pretty miraculous to me. I think it's one of those things in your life where you make a decision. I'm either going to find the blessing in this or the curse. We've all benefitted from that generation after generation. He rides bicycles with us, his grandchildren, our children ... All the things that could have been so different, if a different decision had been made years ago."

"My dad has definitely influenced me. Before they tore down the old Fort Worth Children's Hospital, he came up one day and we went inside. He took me exactly where his room was when he was a child. He could describe the sounds. He knew that Dr. Lipscomb was coming by the sounds of his shoes (he always wore big wing-tipped ones) down the hallway. That left a really big impression on me because that's what we're still doing for children every day. To be a small piece of that puzzle is a big deal. Even though I'm not involved in direct patient care, we all have a small part to play in this experience for a child. They are going to remember what they heard, who they met and what they saw."

Epperson had other opportunities to work at other health care providers, but she wanted to come to Cook Children's enough to interview here on three separate occasions until she got the job.

"This is the type of place that transforms lives for generations," she said.

New bricks make up the walls of Cook Children's, but Moore knows the same care remains for kids today.

"There are good medical facilities all over Fort Worth," Moore said. "All over the Metroplex. But this is one of the places that really makes the differences in people's lives. They makes life-changing events for little children every day."

In The Media

At 2 p.m. CST on Tuesday, Jan. 8, 2019, Jamye Coffman, M.D., will be a featured expert on Munchausen Syndrome by Proxy on 'The Dr. Oz Show.' The episode will explore the case of Gypsy Rose Blanchard, whose mother (Dee Dee Blanchard) claimed she was terminally ill and wheelchair-bound since childhood. Blanchard pleaded guilty to second-degree murder in the death of Dee Dee and is serving a 10-year prison sentence.

Anyone who has ever heard of Munchausen syndrome by proxy has probably asked themselves the same questions:

Why in the world would a mother want to hurt her own child?

And how does a child end up receiving unnecessary medical procedures? Don’t doctors know when a patient is really sick?

The answers are complicated. But each year, experts in Tarrant County get a little better at understanding how to spot these abusers and bring them to justice.

What is medical child abuse?

You may have heard about the HBO documentary ‘Mommy Dead and Dearest’ about the 2015 murder of Dee Dee Blancharge. Her daughter, Gypsy Rose, pleaded guilty to second-degree murder and is serving a 10-year sentence for her death. The trial uncovered a number of unknowns about the relationship between Dee Dee and Gypsy.

To everyone who knew Gypsy, she was believed to have been wheelchair bound and have a myriad of medical problems. It turns out those issues were largely fictitious and now, at 25 years old, Gypsy is arguably one of the most notorious victims of medical child abuse.

Medical child abuse is the diagnosis given to a child whose parent or guardian is suspected of lying about their medical history, leading to unnecessary treatments and procedures. This condition was formerly known as Munchausen syndrome by proxy. The abuser has what’s known as factitious disorder imposed on another.

“Anyone who has worked in pediatrics for very long has run across these kids. The question is whether or not you recognize it because it is so difficult to diagnose,” said Jamye Coffman, M.D., medical director of the Child Advocacy Resources and Evaluation (CARE) team at Cook Children’s. “We call it medical child abuse because in all of the other names, abuse is nowhere in it. But it’s abuse. And it’s medical, because we are the weapon.”

Few people may realize just how experienced experts in Tarrant County have become with this disturbing crime.

Since January 2009, the Tarrant County District Attorney’s office has investigated 19 reports of medical child abuse. Of the eight prosecutable cases, five were reported to Child Protective Services (CPS) by attending physicians at Cook Children’s. In each case, the abuser was the child’s mother.

“Tarrant County is pretty good at identifying and handling these cases,” said Michael Weber, a Tarrant County investigator who specializes in medical child abuse. “We have a system in place that is better than most counties in America.”

That system heavily relies on information provided by the medical community.

They’re using us to harm their child

In the medical field, the Hippocratic Oath is sacred. At the beginning of a physician’s career, they make a promise to ‘do no harm.’ But when a parent gives a doctor false information, they may unintentionally end up breaking the oath by providing procedures the child did not really need.

“The most common unnecessary surgery is placement of a feeding tube, or G-tube,” said Dr. Coffman. “That’s because there are very few tests that tell us if a child needs a G-tube. We are dependent on a history showing a failure to gain weight.”

The inability to gain weight is one of the top symptoms in medical child abuse cases. The abuser may withhold food and water from the child to make it seem as though there is a medical issue preventing weight gain. Besides inducing symptoms, abusers may also exaggerate and even fabricate symptoms.

“The parent may say their child threw up seven times in 12 hours, but they really threw up once. Or, if they are fabricating symptoms, they may say a child threw up seven times but there was never any vomiting at all,” said Dr. Coffman.

The severity of these cases can vary, and some symptom fabrications that seem mild may actually end up being life threatening.

For instance, a parent may tell a physician their child has been diagnosed with sleep apnea. Due to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), physicians cannot access another hospital’s records unless they have written permission from a parent or guardian. Without approval to access information protected by HIPAA, the physician has no way of knowing if the parent is being truthful about the apnea diagnosis. Once admitted to the hospital, the parent may actually suffocate their child in order to set off alarms, thus inducing symptoms.

“We’ve seen kids in wheelchairs who said they could not walk, even though there was no problem with their ability to walk. We’ve had parents tamper with lab tests and falsify records. Abusers have even gone as far as injecting feces into a feeding tube or IV line to make a patient septic,” said Dr. Coffman.

“In most cases, the abuse has been going on for many, many years. It’s psychological manipulation, physical manipulation and total control of the child by the parent,” said Weber.

It may seem baffling that children, who would be perfectly healthy otherwise, end up in these situations.

“You have to remember that ninety-nine point nine percent of our parents are good parents giving us accurate information,” said Dr. Coffman. “But if all an abuser has to do is say their child is vomiting and they’re secretly withholding food from them, how are we supposed to know that? We are depending on parents to tell the truth.”

Hiding in the spotlight

Identifying medical child abuse cases can be difficult for a number of reasons. The medical team is usually being lied to by the abuser, patients may be too young to speak for themselves or they may have been conditioned to lie as well.

Also challenging is the fact that the person harming the child is often the last person anyone would suspect.

“You may have a mother who seems like the best parent ever. The medical staff loves them, they are extremely concerned about their child, and they have a lot of medical savvy,” said Dr. Coffman. “We used to think these people had a medical background, but now with the internet, that’s not necessarily the case.”

According to Weber, Google and social media are key to the investigation.

“When we are building a case, we take all of the child’s medical records and dump it into a spreadsheet with social media posts and internet search history. When arranged by date, we can see the abuse pattern, and the lies,” said Weber.

He says in one case, a mother falsely told a doctor that she took her child to an emergency room the night before. Then later, she made posts on her Facebook page about her child being admitted to the hospital, though that never happened.

“She had numerous Facebook posts that were all lies,” said Weber. “Social media is a huge part of these cases.”

When the hero is the villain

One of the biggest mysteries surrounding medical child abuse cases is ‘why.’

For Dr. Coffman, that’s not something she spends time worrying about.

“We don’t have to know the reason why. Just like I don’t understand why a pedophile is sexually attracted to a child, I don’t have to understand why a parent is doing this.”

Instead, she says she needs to know if a parent is exaggerating, fabricating or lying about a child’s symptoms. Then, a report can be made to CPS.

“I do believe it’s a compulsive behavior that creates some sort of internal gain for them. They like to be the hero,” Dr. Coffman said.

That doesn’t mean they can’t control their actions, she said.

“They know what they are doing, and they know it’s wrong. It’s premeditated.”

Both Dr. Coffman and Weber say anyone who suspects a child is being subjected to unnecessary medical care should report their concerns to CPS.

“If you suspect it, report it,” says Weber. “It’s no different from physical or sexual abuse.”

I was just about three and a half years out of college and clueless about a lot, mostly relying on my willingness to learn and my ability to take my time to learn those essential skills that I needed. But while I tried to climb and hoist myself up that steep leaving curve, I learned one thing almost immediately: I love what I do because I get to serve a purpose and a cause that I believe in. I learned that I love and serve our nurses and clinical staff by empowering them with knowledge to care for critically ill children in our community. I love my purpose because most of us, if not all of us, are eventually touched by medicine in ways that can be healing or devastating. Whether it is our loved ones or us that are affected, I would want to be within reach of a healthcare provider that was cared for by their leaders.

Whose leaders equipped them with the proper tools to serve with compassion, grace, and humility? Not just knowledge. Not just skill. But who encouraged them to listen by role modeling that concept? I would want to be within reach of staff whose leaders cared for them so that they could properly care for my loved one or for me.

However, I have come to understand that being a leader in health care isn’t easy and I feel obligated to tell you a secret: my confidence is sometimes clouded by self-doubt and there are times that my purpose gets lost in the noise of day to day distractions. Even coining myself as a “leader” is something I still struggle with on a day to day basis because I still equate this term with “expert,” and that’s not a title I confidently own. And you see, this can be quite an obstacle when you are trying to be an agency for change and a role model for good. But what I’ve learned from surrounding myself with compassionate, knowledgeable, confident, and empathetic leaders is this: there’s no such thing as a perfect leader and the best thing that a leader can do is to live in a space that forces growth, openness and commitment to the obligation you have to those that look to you for solutions. Here is what I want to share in the hopes of encouraging someone navigating this same space.

Don’t Sacrifice Outcome for the Sake of Your Insecurity

In my experience, any new start I’ve had in life came with a call to “prove” myself (whether it was self-inflicted or not). However, I’ve come to realize that as long as the patient or the staff member receives what they need, it doesn’t matter who was able to support them. I’ve learned that celebrating my colleagues’ or staff members’ talents are more important than feeding the need to prove something to myself or to others just because of my fears. Growth means knowing your resources and acknowledging that somebody else may be better suited to fulfill that job and celebrating their successes and positive outcomes that benefit the patient. In fact, the greatest joy I have found within my role is the growth that I am able to observe in others both clinically and professionally.

You Can’t Please Everyone

Eventually, whether it has happened for you already or not, someone is going to be unhappy with a decision you’ve made. The questions that I ask myself when this happens are usually the following:

• Did I make this decision to the best of my ability using the information I was provided?
• Did I ask the appropriate questions and do the proper research to arrive to this decision?
• Did I evaluate and analyze all possibilities?
• Did I arrive at this decision reflectively and not in a reactionary way?
• Did I objectively evaluate the information I was given?
• Am I functioning from my core values and does this decision reflect those values?

If I was able to answer yes to all these questions, then I have to have confidence that I did the best that I could to address the situation at hand. Of all these questions, the most important is the last. I highly value respect, collaboration, and caring. If any decision I consider acting upon doesn’t align with those values, I often need more time to evaluate or reflect or seek assistance to reach alternative solutions.

Conversely, you’re going to make mistakes. When this happens, own up to it. Apologize if you need to. Learn from it and remedy it if you can. Move on.

Nothing That Was Ever Worth it Started Out Comfortable

Many people that have met me in adulthood are surprised to learn that I was painfully shy and noncommunicative growing up, especially because I earn a living constantly communicating with others and where the level of my effectiveness highly depends on how well I communicate. But I didn’t wake up one day and decide “today, I’m not going to be shy anymore.” This took years of stepping into uncomfortable spaces that would traditionally terrify the type of introvert I am: speaking up in any classroom despite the fact that English was my second language, auditioning for the lead in the musical in 5^th grade, singing in my middle school talent show in the 8^th grade (by myself!), trying out for section leader in band in high school, starting a club in college that forced me to talk in front of 200 students each week, starting a job in a medical unit that terrified me, and becoming a clinical educator.

The decision to step into these uncomfortable spaces has forced me towards the most important concept in my growth as a leader: I need to ask for help. Because I love my job and respect the responsibility that it entails, I have sought out mentors and participated in professional coaching. I read books. I practice crucial conversations with someone better equipped to handle them than I am. I hope to maintain the level of humility and openness that I had when I began this journey. I recognize my weaknesses. I constantly remind myself to listen more, speak less. I remind myself that this type of learning will never be done—that in my heart I am glad to be this type of novice. And the reason for that is that people are dynamic. You can’t master people. You can learn and grow with people and that means that our leaders must be dynamic as well.

Give it Time

In this day and age we want to be the expert now. We want to be the best now. And no one knows this better than me (raise your hand if you’re a perfectionist, overbearing, overachieving millennial!). But what I’ve come to appreciate is to look back on my time since starting out as a clinical educator and valuing my trajectory. I value the times that I told myself “I’m not ready” and how I gave myself grace to grow during that period. I have appreciated the patience that I have given myself to do a serious job for our staff nurses and our patients. I appreciated the times that I fumbled the most because it gave me a chance to build my professional resilience and gave me an opportunity to rise to the occasion.

End

I want to state a disclaimer that the content of this article was just as much a reminder to myself as it was information sharing to an audience. This hasn’t been easy, but nothing that was worth it ever was. I want to be the type of leader that I often see: caring, committed, humble while simultaneously innovative, solution oriented, and creative. No, I don’t have to be perfect. But the people I serve deserve that type of ownership and commitment and so do our patients, families, and overarching community. I am so appreciative of this opportunity to serve and to grow. It’s the best challenge I’ve ever taken on.

“She was very athletic. When the pain began in her knee, we chalked it up to a sports injury,” said Abby Jackson, Danakah’s grandmother.

It was 2016 and Danakah was living with her grandparents in Covington, Texas. She was in the ninth grade and, like most teens, couldn’t wait to get her driver’s license. She was a normal kid, but within a matter of months her life would be turned upside down.

“In February, she started complaining about her back hurting. I took her to the doctor and he put her on some pain pills,” said Abby. “We figured she twisted it or pulled a muscle.”

Then Danakah began losing weight. She lost 15 pounds in less than 10 days. It also became difficult for her to breathe. Her doctor knew something was going on and ordered a round of scans. An MRI examined her lower back and a CT scan offered a glimpse into her chest. There it was in black and white – a tumor was clinging onto Danakah’s spine.

“We knew she had cancer. When the CT of her chest came back, they found eight different tumors in her lungs,” Abby explained.

The next day, Danakah and her family made the hour drive to Cook Children’s Medical Center in Fort Worth, Texas. She was admitted to the hospital immediately. Her new doctor, Karen Albritton, M.D., medical director of the Adolescent and Young Adult (AYA) program at the Hematology and Oncology Center, wasted no time getting to work.

“They did a biopsy of a bump on the top of her head. They also found more tumors. There was one under her left eye, one beside her right eye and one in her right leg,” said Abby.

The tumor in Danakah’s leg stretched all the way from her knee cap to her hip bone. Abby suspects it had been growing since her granddaughter first mentioned her knee pain back in the fall.

“It was so much easier to say where the cancer wasn’t. It wasn’t in her brain. It wasn’t in her heart or her colon or her intestines, but she was, head to toe, eat up with it,” said Abby.

Sadly, the cancer was in her blood stream and her bone marrow. Danakah was diagnosed with Ewing Sarcoma and started chemotherapy. She spent most of 2017 in the hospital. Even though she was missing her friends and school, Danakah was able to keep a positive attitude – something her nurses say helped draw them close to her.

“I was fairly new to my job when Danakah was diagnosed,” said Johanna Sargent, Hematology and Oncology nurse. “She was my first teenage girl to take care of and she was so full of life.”

Johanna and fellow nurse Aly Norris spent a lot of time with Danakah during the course of her treatment. They would play ping pong with her in the AYA lounge, walk laps with her around the unit or just spend time talking about her friends, family and hopes for the future.

“She was so funny. Sometimes, in the middle of the night, she would come over to the nurses’ station and show us magic tricks with a deck of cards,” remembers Aly. “She always had us laughing. Danakah was such a light.”

It wasn’t long before the chemo took its toll on Dankah’s hair. While most teenage girls couldn’t imagine going bald, Danakah took it in stride. According to her grandmother, Danakah insisted she wasn’t going to wake up each morning looking at the hair that had fallen out on her pillow. She decided to shave her head instead.

“I remember the day she walked out of her room and she was like ‘look!’” said Johanna. “I went over to her and started rubbing her head and telling her how much I loved it. I think she was a little apprehensive to do it but once it was done, she was so happy.”

Aly remembers when a Child Life specialist brought craft supplies to the floor. Danakah insisted that Aly participate, which she says is ‘just like Danakah.’

“I came to her room and she had two canvases and she told me we were each going to paint a word. She had decided the word would be ‘Daly’ because it was a combination of our names,” said Aly.

Despite her cancer, Danakah was always looking ahead. She was optimistic and sure she was going to get better and get her driver’s license. But by Christmas, her health had taken a turn for the worse.

“We almost had her lungs completely clear when three more tumors popped up,” said Abby.

One of the tumors caused bleeding near her lungs so a chest tube had to be inserted to remove the blood. Danakah was very sick and placed in the Pediatric Intensive Care Unit (PICU).

“She always had a happy attitude about everything but she was in pain,” said Abby.

Abby left her granddaughter around 11:30 p.m. on Jan. 24, 2018 to sleep in her room on the H/O floor. She told her to rest and she would be back soon. In a matter of hours, Abby was awoken by a phone call.

“They told me they had to put Danakah on a ventilator. We lost her at 1:30 that morning,” said Abby.

Danakah remained on the ventilator while the rest of her family traveled to Fort Worth. There were about 30 people in her room when she was removed from the breathing machine. She died on Friday, Jan. 26.

Among those who came to came to say their goodbyes was Ralph, her favorite therapy dog.

“She and Ralph had a special bond. I have a picture of them, both with their mouths open. They were so happy. That’s the photo we used in her memorial,” said Abby.

Johanna was also able to say her goodbyes. While in the PICU with Danakah’s family, someone handed her a bracelet asking it be returned to Aly.

Originally a gift from Aly, Danakah had been wearing the bracelet when she passed.

“On one of her last days on the H/O floor, Danakah asked to have something to remember me by. I said ‘let’s not talk like that’ and she ‘no, if we have something of each other’s then we can be together wherever we go,” explained Aly.

That night Aly went home and found two bracelets. One for her and one for Danakah.

“I keep her bracelet on my key chain as a reminder of her and why I’m a nurse,” said Aly.

Both Aly and Johanna say it’s often uncomfortable when people ask what they do for a living. Most people think being a nurse in a pediatric cancer unit is ‘depressing’ but neither see their careers that way.

“Honestly, our kids bring so much joy into our lives. It’s an honor to be able to be there for these families during such an intimate time,” said Aly. “Being a nurse is more than just medicine. It’s also about loving the kids and helping their families along the way.”

Johanna agrees, saying “I know people are afraid of what we do because they think it’s sad, but it’s not sad. You develop relationships with the patients and their families. Every single one of those kids leaves a mark on you.”

While it’s been nothing short of a difficult journey for Abby and her family, she says she’s thankful for all who cared for Danakah through her illness, especially the nurses.

“It takes someone special to work with children, and to work with children with cancer is even harder. They never let the situation get to them. Every nurse on the H/O floor deserves a raise. They are just wonderful people. We were blessed to have Danakah as long as we did.”

While flu always receives a lot of attention, I thought this would be a great time to talk about RSV. Of the 273 kids tested last week at Cook Children's, 78 tested positive for RSV at Cook Children's, while only two tested positive for Influenza A. 

Each year, thousands of kids flood the Cook Children’s Emergency Department with bronchiolitis, and countless more are seen by their pediatrician. Children with bronchiolitis may have a stuffy nose, cough, wheezing, fever, or fast and hard breathing.

So what is bronchiolitis, you ask? It is an infection of the small airway tubes in the lungs caused by a virus. It mostly affects children under 2 years old. The small airway tubes in these young children become swollen and fill with mucus.

The viruses that cause bronchiolitis live on surfaces. Your child may touch a surface contaminated with the virus at daycare, at the park, or even at the grocery store. The best way to prevent the spread of the virus is to wash your hands. We also know that children around cigarette smoke may become sicker from the virus because their airways are already irritated, so it is best to not smoke around your child.

Bronchiolitis is a frustrating illness for parents and doctors too. Children with bronchiolitis don’t sleep well due to stuffy nose and cough causing frequent nighttime wake ups. Your child’s snot can feel like a constant faucet. Unfortunately, there isn’t much we can do as parents or doctors to make it better.

The virus has been around for many years, which has given doctors lots of time to try out different medicines to try to make it better. 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. Breathing treatments are good for asthma, but the wheezing caused by bronchiolitis is different than the wheezing caused by asthma. Unnecessary breathing treatments can make children feel jittery and can make their heart beat too fast. Cough and cold medicines do not work either, and have dangerous side effects in children. The American Association of Pediatrics advises that children under 4 do not get these medicines.

Your doctor can listen to your child with a stethoscope and tell if they have bronchiolitis. A chest X ray is not needed, and doctors try to make sure that we never expose children to radiation from X rays when it is not needed. There are some tests that can tell if your child has a virus like RSV. These tests involve putting a swab in your child’s nose. Unfortunately, proving a child has a virus does not help us treat them better or change the way we manage their illness. For this reason, doctors will probably choose not to put your child through this uncomfortable test when it won’t make a difference.

The best way to treat bronchiolitis is to support your child and let their immune system do the work. This means making sure they have plenty of fluids and sleep. You also can help them clear out the mucus by using a cool mist humidifier and loosening up the mucus with saline drops in the nose. Do not use water.

Children under 2 have a hard time blowing their nose. You can help suck out the mucus in a couple of ways. One is the bulb suction that you likely received when your child was first born. There are also several new suction devices in stores that are easy and work well. One is called Nose Frieda. You should try to suck out the nose if your child is sounding very congested and before they eat.

You should call your doctor if your child is breathing very fast, using extra muscles between the ribs to breathe, is difficult to wake up to eat, will not calm down and is very irritable, or if you are worried about their fever. Tylenol can be used for fever, and ibuprofen can be used if your child is older than 6 months. If your child is younger than 2 months old and has a fever, you probably need to see a doctor right away.

You should head straight to the doctor’s office or emergency room if your child is blue around the lips or face, is struggling for each breath, or is limp and floppy. These are signs of serious illness. Thankfully, most of the time bronchiolitis is much more mild. Even mild symptoms can be scary for parents. Always talk to your doctor if you are worried or have a question that is specific to your child’s illness.

What is a Hospitalist?

Dr. VanVliet is a hospitalist at Cook Cook Children's. Cook Children's Hospitalist Group is a team of board eligible and certified pediatricians who specialize in caring for patients while they are admitted to Cook Children's Medical Center. One of the hospitalists will see your child daily and is available 24 hours a day to manage any urgent medical needs of hospitalized children. Click to learn more about them and how they care for your child.

Well, the fact is…that is most of what they do. And we need them to keep right on doing it.

While we can roll our eyes or scoff, the reality is it’s those meetings that keep our practices going and our hospital making money which keeps us in business and allows us to take good care of patients without worrying so much about all the other stuff.

We can avoid meetings like the plague and survive. But, like it or not, there will be times where we need to attend meetings in order to thrive in a healthcare system.

Here are 4 mistakes that doctors make in regards to meeting…and what you can do about them.

1. We don’t realize their value.

If you talk about your administrators spending all their day in meetings and roll your eyes, you probably won’t be ready to engage in one when you need to. But, the problem is, if you want to affect change anywhere beyond interactions with individual patients, you will have to participate in meetings. Now, don’t get me wrong, it will inevitably take twice as many meetings as it probably should and it’s possible that you won’t have to be present for all of them but it’s important to listen to those times when your presence is necessary. Are you hearing chatter that suggests the initiative might be facing opposition or losing traction? That’s when you have to be there. An advocate can cover the rest.

2. We don’t appreciate the importance of an agenda or preparation.

If you are running a meeting, one of the most important things you can do is to prepare and have an agenda. Meetings with agendas get more accomplished in a shorter amount of time and will lead to a lot less frustration. If you send the agenda out ahead of time, it’s much more likely that the people you need to attend will come. Sometimes the calendar invite doesn’t quite sum up what is going to happen in a way that lets everyone know whose attendance is optional and whose is mandatory. During the meeting, it keeps everyone on track and minimizes fruitless chatter.

3. We don’t understand or aren’t used to conflict.

Most doctors are used to working in environments where their word is the final say. Meetings with admins don’t always work that way…and it’s a good thing. Conflict in a meeting helps us challenge our thoughts and beliefs in a way that could lead to bigger and better ideas. If you attend a meeting where everyone pats you on the back or simply agrees, you didn’t have a meeting, you gave a presentation and it probably should have been done through email.

4. We don’t perceive how our presence affects the meeting.

When you go to a meeting you change the dynamics. It’s often difficult for members of other departments to speak up to or share idea with doctors. They may be used to speaking freely and sharing opinions but they may be more cautious around you because they don’t know you as well or are afraid how your will take their thoughts (maybe even criticisms). It’s important to set the ground rules early, let everyone know that you want to hear their thoughts and then respond well when they give them. Make sure everyone has a chance to speak up. If someone isn’t contributing, seek their opinion directly.

So, go ahead, roll your eyes but roll into your meeting with energy and preparation and they will feel a lot more productive.

When searching for a pediatrician, I realized how much I never considered before becoming pregnant with twins.

There were several things I looked for when searching for a pediatrician. I wanted someone with a great bedside manner who would be engaging and personable with the twins. It was also very important that the doctor’s office would be able to schedule back-to-back well child visits so I wouldn’t have to bring the girls up on separate days or separate times.

I haven’t even had the girls yet but trust me, you don’t want to be lugging both babies up to the doctor’s office at different times, especially in those first six months when you see your pediatrician so frequently!

It was important to me that my pediatrician had experience with twins, since there are certain situations and issues that can arise from having multiples. Ramon Kinloch, M.D., a pediatrician at Cook Children’s Forest Park office, met all of those qualifications for me and we are so excited to have him as the girls’ pediatrician.

“When looking for a pediatrician, I think it is extremely important that the doctor is patient. This is especially true for new parents and parents of multiples,” Dr. Kinloch said. “There may be a lot of questions or concerns that you have, and sometimes feel that they are either too silly or bothersome to ask. However, a great pediatrician is understanding and willing to listen to all of your concerns to ensure that you are comfortable taking care of your little one(s).”

I’ve had so many questions and as I draw closer to the birth of our twins, I still have so many more that will be answered over the next few days, months and years to come.

Being pregnant is such an exciting, scary, overwhelming, exhausting and beautiful journey but being pregnant with twins comes with a lot of special circumstances. I wanted to share my story of how I became pregnant, my twin pregnancy journey up until now and also some of the differences I’ve noticed between a singleton pregnancy and a multiples. Please keep in my mind that this is just my experience. Every woman and every pregnancy is so different, including twin pregnancies. I hope that by sharing my story, those of you who are pregnant with twins will feel more prepared for what’s to come. I know when I first found out I was pregnant with twins I scoured the Internet reading so many articles about what to expect and it was comforting, albeit sometimes a little terrifying.

‘A Threatened Miscarriage’

The first trimester of my twin pregnancy was filled with a lot of scary and traumatizing moments. I found out fairly early on that I was RH negative (read more about that here), had a septate uterus, which upped my chances of a miscarriage and worst of all I developed a subchorionic hemorrhage.

When I was 8 weeks and 4 days, I woke up to blood gushing out me in bed. My husband had already left for the day, and I immediately jumped up and ran to the bathroom. It felt like a nightmare and I remember chanting, “No, no, no, no, please no” as I struggled to call my husband and my mom. After attempting to calm down, I called my doctor’s office and they told me to come in immediately and they would do an ultrasound to check on the babies.

Thankfully, they were fine and doing well with strong heartbeats, which was such a relief. My doctor told me bleeding in the first trimester is fairly common and I had what she referred to as a “threatened miscarriage.” She told me to go home and take it easy for the next 2-3 days and that there was really nothing I could do to either help or hurt the situation. I remember feeling numb and helpless, completely out of control within my own body. I was convinced that I had miscarried and we were going to lose our babies that we had wanted for so long.

Everything was fine for a few weeks until I woke up around 11 weeks to another bleed. Cue the panic and fear all over again, the crying phone calls to my mom and my doctor. I went in for an ultrasound and again the babies were fine. This time, my doctor told me I had what looked like a subchorionic hemorrhage in my uterus.

According to heathline.com, “Subchorionic bleeding occurs when the placenta detaches from the original site of implantation. This is called a subchorionic hemorrhage or hematoma. It affects the chorionic membranes. These lift apart and form another sac between the placenta and the uterus. The movement and resulting clots are what cause this type of bleeding.” While this sounded scary, it helped to finally have a name for what was happening to me. My doctor told me again to go home, stay off my feet and take it easy. Ultimately, if my body decided to reject the pregnancies there was little I could do about it. That was both helpful and frustrating as you can imagine.

Unfortunately only four days later I would have a bleed so bad that I ended up in the ER on Mother’s Day. It was the worst night of my entire life, sitting in a hospital bed for five hours with my family. No one could tell us anything and I was certain this time that I had lost the babies because of the massive amount of blood. By some miracle, the twins were alive and well, both with strong heartbeats. They were already little fighters and I’m still in awe of how strong they are! Thankfully, that was my last bleed and by the time I was about 17 weeks pregnant my hemorrhage had all but disappeared. During that time I researched, read articles and watched videos about subchorionic hemorrhages and how many women experienced them during their pregnancies. I am so grateful everything turned out okay in my case and that my babies are still growing inside me today.

Relatively Smooth Sailing

After that, everything was relatively smooth sailing despite the typical pregnancy symptoms. I experienced severe nausea and exhaustion from weeks 8-16, so much so that I had to be put on anti-nausea medicine just to be able to come into work. I remember coming home from the office and collapsing on the couch, unable to do anything but sleep. I survived off soup and bread; I rarely was hungry but knew I needed to eat to help my stomach. The medicine helped but also made me even more tired than I already was. My doctor told me this was normal especially with multiples as I had such a large amount of hormones in my body.

I know not everyone suffers from morning sickness and exhaustion, but I have heard from many other twin moms that they too suffered from this their first trimester. Just know for most women, it will get better! By week 14 I could see the light at the end of the tunnel and by week 16 my nausea and exhaustion had noticeably decreased. Unfortunately, as soon as I got over those symptoms my body decided to gift me with pregnancy headaches! In some ways this was worse than the nausea because I really couldn’t take anything but Tylenol, which rarely helped. I was back to coming home from work and falling asleep, this time to escape the constant pounding in my head. After about four weeks of this, I finally linked it to my blood sugar being low, and became vigilant about eating every couple of hours and making sure I was getting enough food in my stomach at meal times.

Now that I’m 26 weeks pregnant, most of my symptoms have turned to just aches and pains as my body grows to accommodate two babies! For most women pregnant with one baby, this is referred to as the “honeymoon trimester.” Your first trimester nausea is over, but you aren’t physically uncomfortable yet; many women with singleton pregnancies say they feel the most like themselves during the second trimester. For me, by about 22 weeks I started to experience round ligament pain in my legs and hips and noticed that my sleep was getting worse. I started having to get up in the night to go to the bathroom, and rolling over in bed became a process. Moving from a seated or reclined position started to require effort and by the end of each day I was feeling sore and achy. To help with this, I try to take a warm bath with Epsom salts and have generally taken it easy my entire pregnancy. I don’t work out and since I have a desk job I don’t have to do too much walking around. I notice when I do, my body will let me know I overdid it the next day, big time. With a multiples pregnancy it is so important not to push yourself or overdo it. Of course, you know your body and its limits better than anyone but do not feel bad about taking it easy- this is such a short phase in your life and the most important thing is making sure the babies are healthy and growing!

I know that being pregnant with twins, especially at the beginning, can seem daunting and overwhelming. It doesn’t help that even family and friends will tell you, “I just couldn’t imagine having twins I don’t know how you’re going to do it!” Don’t let anyone stress you out! I truly believe we are given twins for a reason. You will make it work and survive because that is the only option. While a twin pregnancy can be more complicated and intense than a singleton, focus on the fact that at the end of it you get to bring home two babies to love and care for and that no matter how scared you are, you will make it through! I hope my story helped some of you, whether you are trying to get pregnant, are pregnant with twins or are just curious about what a twin pregnancy is like. I would love to hear from you if you are a twin mom what your pregnancy was like and what your experience has been as a twin mom!

Read the story here.

So when he complained that he “felt funny,” his parents took notice.

It was late in the summer, a few weeks before school, and Landyn was at football practice in Arlington, Texas. He was involved in a pileup during a play and someone accidentally stepped on his side.

Following practice, Landyn told his parents he didn’t feel well. When he got home, he went upstairs and threw up before going to bed. His family thought maybe it was the rough day of football or the way he guzzled water at the end of practice.

The next morning, Landyn’s father, Kirk, went to work. He’s a truck driver and had a delivery to make in Longview. Landyn’s stepmother, Angela, felt like she should stay home from work just in case it was something else.

“I got a call from my wife. Thank God she didn’t go to work that day,” Kirk said. “She told me Landyn had used the bathroom and when he peed, it was straight blood. It was black.”

Angela told Kirk she was going to take him to a nearby Arlington hospital. As she went upstairs to get Landyn, she was shocked at what she saw.

“He was throwing up everywhere,” Kirk said. “Landyn was projectile vomiting. I didn’t see the room right after, but my wife said it looked like a murder scene. She told me, ‘Baby you don’t want to see this.’ It was scary.”

At the hospital, Landyn complained of abdominal pain. His urinalysis looked like a cup of ink because the blood was so dark. Doctors ran an abdominal CT scan with contrast. It showed the renal vein thrombosis and inferior vena cava thrombosis: blood clots were occluding (obstructing) them.

“It was the scariest moment of my life,” Kirk said. “You’re the protector of your child and when something comes around and you are helpless … It was so scary.”

Adding to Kirk’s fear was Landyn’s family history. Landyn’s birth mother died as a result of clots in the lungs. But this was happening to an 11-year-old boy.

The doctors told the family that Landyn needed to be taken to Cook Children’s where they specialize in pediatrics. Landyn was rushed to the medical center in an ambulance with his father in the back.

Landyn was admitted to the Pediatric Intensive Care Unit at Cook Children’s and Hematology and Interventional Radiology were then brought in to treat the young patient.

The decision was to start heparin (blood thinner medication) overnight and to proceed with Interventional Radiology thrombolysis the following morning,” said Marcela Torres, M.D., a pediatric hematologist and co- medical director of the Stroke and Thrombosis Program at Cook Children's. She discussed the case with Adeka McIntosh, M.D., one of the interventional radiologists at Cook Children’s, and formulated a careful plan to treat Landyn.

Pediatric Interventional Radiology (IR) at Cook Children's offers minimally invasive, image-guided diagnoses, treatments and therapies designed especially for kids.

Thanks to advanced technologies, many disease and injury assessments and treatments no longer require invasive surgeries. Today, many of the diseases and injuries that once required extensive surgery can be treated with minimal risk, less pain and faster recovery times.

The team’s board certified interventional radiologists have extensive training in interventional radiology with specialization in the pediatric population. In addition, there is a team of nurses and technicians also specialized in intervention radiology procedures in pediatrics and even our equipment is designed to meet the needs of children.

While clots have been considered primarily an adult diagnosis, the doctors at Cook Children’s have seen an increase in pediatric thromboembolic events.

The procedure was successful in Landyn’s case and most of the clot was gone by the time the catheters were removed. Landyn was transitioned to heparin (blood thinner), which was given intravenously and once his renal function improved and the bleeding stopped, he was transitioned to Lovenox (another type of blood thinner) which is given as an injection.

“These are some of my favorite cases to treat because we can, almost immediately, make a difference in the patients’ lives. This is as close to instant gratification as I get in my practice and I really love it,” Dr. McIntosh said.

After another week of that treatment, Landyn was discharged to go home on blood thinners and his family was taught about the risks and complications of blood thinners.

Landyn cannot compete again in full contact sports due to the use of blood thinners, but he is back to school and enjoying a full active life, playing in his band and able to participate in sports that do not involve full contact.

Given Landyn’s family history, an inherited condition was suspected. He was studied for the multiple conditions of the blood that can increase his risk for thrombosis. He was found to have Protein S deficiency. People with this condition have a greater risk of developing abnormal blood clots than most of us.

Landyn’s risk for having blood clots, will always be higher because of his inherited condition. Doctors say it’s extremely important for him to avoid situations that can increase his risk of developing blood clots even more, such as : Dehydration, prolonged immobilization, long surgeries (specially orthopedic procedures) obesity, long trips by car or plane (longer than four hours), smoking. His hematologist had told the family that it is probable that Landyn will need to be on blood thinners in the future or in specific situations with high risk for clotting.

A year later, Landyn is doing well. He’s followed doctors’ orders and is currently off all medication. It’s amazing all that’s happened during the course of a year in his young life.

“We can’t thank Cook Children’s enough,” Kirk said. “They saved Landyn’s life. They took care of him. That’s all we could ask. The doctors, nurses and everyone involved in Landyn’s care were top notch. They worked with him and for him. They worked with us too. They taught us ways to take care of him. We had to give him shots when he first got home. I’m afraid of needles. The fact that they helped me give him a shot, is unbelievable. A friend of mine has a grandson that lives outside of Fort Worth, I told him to bypass everyone and go to Fort Worth.”

Then with a laugh Kirk adds, “I’m a grown man and I wish I could go to Cook Children’s.”

I watched in horror as her dad carried her down the hallway and into one of the exam rooms. She looked stiff. She looked like she was in pain. Her face was grimaced. What in the world? Why was this very healthy 4-year-old being carried in? My stomach sank.

Something was very wrong with Elizabeth.

This was in June 2018. I’d seen her a few days before, during her little brother’s checkup. I couldn’t help but notice how quiet she was being. She sat still, in a corner. This was a child that usually loved to bop all over the room.

“Elizabeth, kiddo, you feeling okay?”

“She’s not feeling well. She’s had a little fever and seems under the weather,” said her mom Heather.

I checked her out, looking in her mouth and ears, and listened to her heart and lungs. She looked fine.

“I think this is something viral. Why don’t you let her rest this weekend and let me know how she’s doing next week?”

Little did I know that “next week” meant three days later, and that her dad would be carrying her in like a limp, broken doll into our office.

Nurse practitioner Tara Haraldson and I ran right behind them into the exam room.

She screamed in pain whenever her head was turned. Her neck was stiff, rigid. She hadn’t been eating much and wouldn’t drink. She was having a hard time talking. I was really worried she had meningitis. She was in so much pain she had to lay on the floor of her parent’s car to get to the office.

“Things got much worse yesterday. We took her to the ER earlier this weekend but they thought maybe it was just pneumonia so they tried antibiotics. Her neck pain started that night and has only gotten worse. She can’t turn her head and she’s hurting so much we can barely move her.”

I sent her to Cook Children’s Emergency Room via ambulance. I called the ER doctor to let them know she was coming. That physician also thought it was likely meningitis. We agreed she needed a brain MRI and a spinal tap right away.

Barely one hour later, the ER doctor called me – “It’s acute flaccid myelitis.”

“WHAT?!”  I nearly spit out my drink.

This was almost a myth. A pediatric rarity. "The rare polio-like illness that's affecting kids across the country". A disease that affected less than 1 child in a million. I’d only read about this in medical journals. What in the world was it doing in my office – heck, in my city…. in my state?

A 'Polio-type Illness'

The words rang in my head for hours after I got the phone call. I struggled to remember what I had learned about this rare disease in years past. I had certainly never seen it in person – nor had any doctor I knew.

Elizabeth’s AFM was found via her brain MRI. They wheeled her into the ER and took her straight to the MRI machine. The radiologist watched as the images loaded on the screen. She had color changes on it, spanning from the bottom of her brain (the brainstem) all the way down her spinal cord. The radiologist knew what it was in a matter of minutes, and called the ER doctor immediately.

As I sat in my office staring into space that afternoon, I’d remembered that there was an outbreak of this disease in Colorado in 2014. The headlines were splashed all over the front of my medical journals as a warning. Watch out for this, pediatricians! Keep your eyes peeled for this awful polio-like illness. Thankfully, the cases had slowly vanished and I hadn’t heard about it for awhile. Until now.

Why do we keep calling it a “polio-type illness”? Well… because this disease looks exactly like polio. Except, it’s not polio. It’s a brother of polio – not a cousin, or a distant relative – a brother. And it is a terrifying reminder of what polio used to be (and hopefully will never be again).

Polio, caused by the poliovirus, is in the enterovirus family. There are hundreds of enteroviruses. Stay with me.

The heroine of my story

Back to Elizabeth, the heroine of my story. While in the ER, they noticed she couldn't stand without severe dizziness. And that her right arm wasn't working very well. Her face was drooping on one side.

Her mother later told me that in the ER, the doctor said that she may never walk again. She may need a breathing machine for the rest of her life. She may not live. They were absolutely terrified.

Her parents ran frantic Google searches, and called families across the state. I dug up every study I could find on the 2014 outbreak and read until my eyes crossed. What could we do to help her?

She was wheeled up to the Cook Children’s Pediatric Intensive Care Unit for extremely close observation. They were worried her breathing muscles might become weak, or her brain function might continue to decline.

I don’t think I slept more than 20 minutes that night. I know Elizabeth’s parents didn’t.

We were waiting to see what would happen to Elizabeth’s body. And there was nothing the ICU doctors, the infectious disease doctors, or the neurologists could do to stop this. Steroids, antibiotics, antiviral medications, other forms of therapy – all were deemed useless over the past few years. We were helpless.

So we watched.

(This is the end of part 1. Read the conclusion to the story tomorrow.)

Watch the story by clicking here. 

Two children tested positive for the Influenza A virus from the week of Sept. 16 through Sept. 22, 2018, according to Laboratory results from Cook Children's.

For the week, 85 children were tested for the flu, with 83 tests coming back negative. Interestingly, the first case of the flu was confirmed during the same (Sept. 21) in 2017.

The goods news is that flu vaccines are available at our Cook Children’s pediatrician's offices now.

Getting the flu vaccine is one of the most important things you can do for your child this time of year. Yes, hand washing and avoiding ill contacts are good ideas but that’s not going to be what ultimately protects your child from flu.

No one likes getting a flu shot, kids and parents included, but it’s essential to your child’s health. Here are 5 important facts about the flu shot you should know:

1. Get your child the shot. The American Academy of Pediatrics is recommending flu shots for every child over 6 months of age. Children and elderly adults are the most at risk for serious illness, hospitalization and death from the flu. Children under 2 and those with chronic medical conditions are at higher risk, but healthy children are hospitalized and die from the flu every year!
2. Get your own flu shot. Getting yourself protected helps to prevent the spread of flu in your house. It will decrease the risk of you contracting it, even if someone in your house gets it … and taking care of sick kids while you are sick is one of the hardest things I’ve ever done as a parent. If you have a child under 6 months with whom you have frequent contact (who cannot receive the vaccination) it is extremely important.
3. Ignore any early data about the effectiveness of the flu vaccine. Last year, early data about flu vaccine effectiveness caused many to skip their shot. But, at the end of the year, protection rates ended up being average (and any protection is better than none). Just get it done.
4. Choose the injectable vaccine. Nasal flu vaccines will be available again at some offices this year. However, based on past years, I am strongly recommending that patients get the injectable vaccine. After giving nasal flu vaccine for years before studies showed it wasn’t working, I’m not taking that risk with my children or my patients until we know more about how it’s working over the next few years.
5. Go ahead and get your child scheduled. Pediatric studies have not shown a decrease in effectiveness during a flu season because of getting the shot done early. Getting the vaccine at least 2 weeks before the season starts is critical to making sure they are protected and we never know what vaccine supplies will be when the season hits.

All About the Flu

• Influenza (flu)
• Is it a cold or the flu?
• Is the flu vaccine a good idea for your family?
• Frequently asked questions about immunizations
• How can I comfort my baby during shots?
• Immunization schedule
• Is the Flu vaccine a good idea for your family?
• Your child's immunizations: influenza vaccine

 "Hutson turned 3 and started having several unsettling symptoms all together that I didn't feel were right," Hutson's mother Heather Liles said. "We asked for a blood test up front, and our [primary] doctor never ordered one. We were told his leg pain was just growing pains, bruises were just bruises and that his swollen face was just because of allergies."

Heather pushed for more answers because she knew something wasn't right. Hutson was finally sent for a blood test.

"His swollen lymph nodes were 'fine,'" Heather said. "But something in my heart told something was wrong."

With his mother's intuition guiding his way, Hutson's diagnosis was confirmed, along with his parents' worst suspicions.

"After generic blood tests ordered by his doctor, we came to Cook Children's to have new blood work done and received the diagnosis that same day," Hutson's father Bo Liles said.

Hutson is diagnosed with B-Lymphoblastic Leukemia, and although his life is centered around treatments, his parents still make time for him to still be a kid.

"Being in treatment is a new routine, one that is based around medicine and keeping ourselves and our surroundings ordered and germ free," Bo said. "But mostly, we want him to be a three year-old boy; to play with his hot wheels and dinosaurs, to eat French fries on car rides and ice cream cones. We stay focused on treatment because he deserves a great summer as he beats cancer."

Hutson has found a love for his hat collection throughout his battle with cancer, and his parents love that he has a piece of his life he can choose and control.

"Hutson has a lot of hats," Bo said. "He loves picking his own hats out, which we know will serve us well at various stages of treatment."

Despite spending so much time at Cook Children's during treatment, the Liles family has found comfort in their nurses and doctors.

"We have been absolutely blessed to have the Cook Children's community to surround us and guide us through this treatment as a family from day one," Bo said. "Grateful is just the beginning of how we feel, from our amazing doctor, Dr. Lauren Akers, to Hutson's favorite nurse, Allie Barnes, every step from in-patient to his clinic visits are full of patience, positive vibes and thoroughness!"

- Story written by Ashely Parrott

We worry about them because kids get hurt in them sometimes. It’s also because they actually don’t encourage walking –they hinder the natural neuromuscular development that needs to happen for walking to occur.

Just to be clear - the walkers I speak of are the ones that you sit your child down into. There is a seat into which you slide their legs, and there are usually wheels on the bottom.

A recent study by the American Academy of Pediatrics found that from 1990-2014, over 230,000 kids visited ERs across the country because of injuries related to infant walkers.

The majority of the kiddos in the study ranged from age 7-10 months. Most of the children suffered head and neck injuries (90%). Almost 75 percent were injured by going down stairs in the walker.

I’ve also seen kids get neck and chest injuries from being whipped around by an older sibling. And some even get finger injuries from gripping the sides of the walker and then slamming into a wall!

The study states that “walker–related injuries can be severe and can include skull fracture, brain injury, burns, poisoning, and drowning” and that “from 2004 to 2008, infant walkers were associated with 8 pediatric fatalities”. This is absolutely eye-opening to me.

Another thing that is troublesome about walkers is that they keep kids from doing that very thing: walking.

If you sling a child’s pelvis in a sack, it lifts the child’s weight for them while they pull along the ground with their toes/feet. It doesn’t force the kiddo to lift his own weight. It keeps certain hip and pelvic muscles from developing the strength and coordination they need to actually learn the process of walking. This is the reason physical therapists have disliked walkers for a long time.

This article does not apply to the “push walkers” that kids stand up and push. We actually like those more, because there are less injuries involved with these devices, and kids are lifting and moving their own weight properly.

My advice is to throw out your sit-in infant walker. It seems they’re even more dangerous than we initially thought, and to me, the fun freedom of movement is just not worth it. Throw that sweet kiddo on a soft rug or blanket, spread out some toys on the ground and on the couch, and watch that child learn how to move on his own.

Sounds fun, right?

But the U.S. Food and Drug Administration has sent out an alert of the “potential for serious injury from eating, drinking, or handling products prepared by adding liquid nitrogen at the point of sale, immediately before consumption.”

If you aren’t familiar with the product’s names, you’ve probably seen them at malls, food courts, kiosks, state or local fairs, and other food retailers. They are food and drinks prepared by adding liquid nitrogen immediately before consumption. The products may include liquid nitrogen-infused colorful cereal or cheese puffs that releases a misty or smoke-like vapor.

The concern is that the liquid nitrogen, although non-toxic, can cause severe damage to skin and internal organs if mishandled or accidently ingested due to the extremely low temperatures it can maintain. The alert from the FDA advises consumers to avoid eating, drinking or handling foods prepared using liquid nitrogen at point of sale and immediately before consumption, due to injury.

A particular worry is for people asthma patients. The FDA says “inhaling the vapor released by a food or drink prepared by adding liquid nitrogen immediately before consumption may also cause breathing difficulty.”

The FDA stated that the organization is aware of severe – and in some cases, life-threatening – injuries, such as damage to skin and internal organs caused by liquid nitrogen still present in the food or drink.

Karen Schultz, M.D., medical director of Pulmonology at Cook Children’s, said this warning is definitely a concern for young asthma patients.

“Inhaling cold air is a known trigger for asthma and, in fact, is used to help determine if someone has asthma (called a ‘cold air challenge’)," Dr. Schultz said.

Worsening signs of asthma include breathing that is hard and fast, trouble talking or walking, inability to work or play, constant coughing, or a color change in the lips and/or nail beds. At this point, rescue medications should be given and the family should seek immediate care.

"General signs of initial worsening of asthma include some difficulty breathing, coughing and wheezing, problems working or playing, or waking up at night coughing," Dr. Schultz said. "At this point families should start using their rescue medications as instructed by their physician. Families should call their physician if their child has required three extra treatments in a 24 hour periods or they need them more frequently than every four hours."

Consumers who have experienced an injury because of handling or eating products prepared with liquid nitrogen at the point of sale, immediately before consumption, should consult their healthcare professional. Consumers should also consider reporting their injury to MedWatch. The FDA encourages consumers with questions about food safety to Submit An Inquiry, or to visit www.fda.gov/fcic for additional information.

* Photo Courtesy of the Food and Drug Administration. Read Alert from FDA.

Related Articles

• Cook Children's Pulmonology
• Appointments and Referrals
• Asthma Information
• What Is an Asthma Emergency?
• Innovative Program Keeps Kids with Asthma in Class and out of the ER
• 'My Child Can't Play Sports. He Has Asthma.'

Doctors agree that nothing fights off the flu better than the vaccine, including all children 6 months and older.

And thanks to  recommendations, based on research, that includes children who are allergic to eggs.

A study by the Centers for Disease Control and Prevention (CDC) found the rate of anaphylaxis after all vaccines is 1.31 per one million doses given.

Based on guidelines from the CDC and the American Academy of Pediatrics, people with egg allergies no longer need to be observed for an allergic reaction for 30 minutes after receiving a flu vaccine. It is now recommended that people with a history of severe allergic reaction to egg (any symptom other than hives) can now be vaccinated in an inpatient or outpatient medical setting, under the supervision of a health care provider who is able to recognize and manage severe allergic conditions.

"All children with egg allergy of any severity can receive an influenza vaccine without any additional precautions beyond those recommended for all vaccines," the AAP wrote in the September 2018 edition of Pediatrics as part of its "Recommendations for Prevention and Control of Influenza in Children, 2018-2019."

Backing up the AAP and CDC, is new research in the Annals of Allergy, Asthma and Immunology, which found the flu shot to be safe and recommended its use for people who are allergic to eggs.

Jason Terk, M.D., a Cook Children’s pediatrician, said previous recommendations on egg-allergic individuals not receiving a flu vaccine were based on the fact that most of the flu vaccine currently available is created from viral cultures in chicken embryos. Experts theorized there was a risk because of the concern that small amounts of the egg that the viral cultures come from could end up in the vaccine.

“After years of study and observation, it was found that no significant increased risk for reactions occur in egg-allergic people,” Dr. Terk said. “The recommendation to avoid flu vaccine for egg-allergic people has been removed. No medical intervention is without risk. But the risk of influenza and the complications arising from it far exceed the infinitesimal risk of influenza vaccination.”

If you have concerns, Dr. Terk said your pediatrician should be happy to answer questions about your child and why the flu vaccination should be given.

The Star-Telegram reports that Tarrant County Public Health officials are working to identify any Texas Christian University students who may have been exposed to the mumps. Currently, no other cases have been reported, but symptoms can take as long as 25 days to develop after exposure.

This is another reminder about the value of vaccination in preventing what can be serious illness. Mumps cases decreased 99 percent after the introduction of a successful strategy for vaccination.

Mumps can be prevented with the MMR vaccine (measles, mumps and rubella). The Centers for Disease Control and Prevention (CDC) recommends children get two doses of MMR vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Teens and adults should also be up to date on their MMR vaccination.

Health officials hope that no other cases will occur because of the TCU campus' high vaccination rate.

The CDC states that a "mumps outbreak can occur any time of year. A major factor contributing to outbreaks is being in a crowded environment, such as attending the same class, playing on the same sports team, or living in a dormitory with a person who has the mumps. Also, certain behaviors that result in exchanging saliva, such as kissing or sharing utensils, cups, lips balm or cigarettes, migh increase spread of the virus. in some years, there are more cases of mumps that usual because of outbreaks."

Here's a quick look at mumps cases over the years according to the CDC:

*Case count is preliminary and subject to change

** Cases as of Jan. 27, 2018 Case count is preliminary and subject to change

For More Information:

• Tarrant County Public Health Department
• CDC Mumps Cases and Outbreaks
• About Mumps (CDC)
• Mumps Vaccination

Struggling to make it in the music industry, he gains notoriety when he has a seizure on stage and the video of the event goes viral. The portrayal of the seizure itself is inaccurate, but more troubling is the way the film chooses to make the diagnosis of epilepsy comedic.

Fans of the rapper begin to refer to him as “seizure boy” and even create a ridiculous dance to mock the seizure he had on stage. The official website for the film states “the young rapper with big dreams has one night to bounce back from major embarrassment.”

The fact they label the event of having a seizure in public as an embarrassment only feeds further bias and ridicule for those that suffer from epilepsy. Given 1 in 26 people will suffer from epilepsy in their lifetime, it is a diagnosis every person should be familiar with. It is unfortunate in this day and age, there is still so much misunderstanding, misrepresentation, and stigma for those with epilepsy. Media has the power to educate and raise awareness on a scale unlike any other, yet media has a long history of feeding bias, fear, and confusion about epilepsy.

What is the history of epilepsy in media?

Epilepsy and people with seizures have been represented in film for many years. An analysis of characters with epilepsy since the 1950s show that most characters are portrayed as sad, damaged individuals that are feared and often linked to psychiatric disease.⁽¹⁾ 

The seizures shown on film are almost always convulsive type and violent, though that represents only a small subtype of seizures. This inaccurate portrayal has not improved with time. An analysis of epilepsy in film since 2004 showed almost all seizures depicted remained convulsive type and most were uncontrolled, yet in reality 70 percent of patients gain control of their seizures with medication.⁽²⁾

When simple seizure first aid was delivered in film, 96 percent was performed by a healthcare professional, yet inappropriately provided in 57 percent of the cases. In 97 percent of the portrayals, the cause of the epilepsy was known, though in reality only about 30 percent of epilepsy has a defined cause. These inaccurate depictions set unrealistic expectations for patients, but more importantly teach inappropriate behaviors for those that may be called on to help a person having a seizure in public.

Print media doesn’t fare much better. Newspapers covering neurological conditions were found to utilize stigmatizing language in 21 percent of their stories, and epilepsy represented the most commonly represented diagnosis (30 percent). ⁽³⁾

The advent of social media has taken the ability to marginalize those with epilepsy to another level. Consider this, the internet has become to “go-to” source for medical knowledge with  more than 60 percent of adults reporting they search for medical information on the web – many people using social media sites like Twitter, YouTube, and Facebook to find information.

One would hope user generated information on these platforms would be more accurate and sympathetic, but is it? A seven day analysis of “tweets” related to seizure(s) found over 10,000 tweets.⁽⁴⁾ Of these, nearly 10 percent were written specifically to ridicule and over a third were metaphorical – that is comparing abnormal movements to “seizures” much like the way the “seizure dance” is portrayed in “The After Party.” Overall, 41 percent of tweets were considered derogatory. YouTube videos suffer from inaccuracy as well, with up to a third of videos labeled to depict seizures clearly depicting non-epileptic events – again spreading misinformation. ⁽⁵⁾ In addition, up to 10 percent of videos related to epilepsy/seizures can been labeled as inaccurate or derogatory. ⁽⁶⁾

So much work remains to raise epilepsy awareness throughout the world. Media presents a unique and powerful resource to educate the public on this common condition, its varied presentations, the availability of treatments, and the appropriate response to a person having a seizure. Increased awareness will hopefully erase fear, inaccuracies, and bias towards those with epilepsy.

When films like “The After Party” are created in the name of “entertainment”, they do nothing more than increase the stigma for those with epilepsy, erasing all we in the epilepsy community work to alleviate each day.

References

1. Kerson JF, Kerson TS, Kerson LA. The Depiction of Seizures in Film. Epilepsia 1999 40(8):1163-1167.
2. Moeller AD, Moeller JJ, Rahey SR, Sadler RM. Depiction of Seizure First Aid Management in Medical Television Dramas. Can J Neurol Sci 2011 38(5):723-7.
3. Caspermeyer JJ, Sylvester EF, Drazkowski JF, Watson GL, Sirven JI. Evaluation of Stigmatizing Language and Medical Errors in Neurology Coverage by US Newspapers. Mayo Clin Proc 2006 81(3):300-6.
4. McNeil K, Brna PM, Gordon KE. Epilepsy in the Twitter Era: A Need to Re-Tweet the Way We Think About Seizures. Epilepsy Behav 2012 23(2):127-30.
5. Brna PM, Dooley JM, Esser MJ, Perry MS, Gordon KE. Are YouTube Seizure Videos Misleading? Neurologists Do Not Always Agree. Epilepsy Behav 2013 29(2):305-7.
6. Wong VS, Stevenson M, Selwa L. The Presentation of Seizures and Epilepsy in YouTube Videos. Epilepsy Behav 2013 27(1):247-50.

The policy statement from the AAP “provides 5 evidence-based recommendations for best practices to optimize safety in passenger vehicles for all children, from birth through adolescence.”

The policy statement from the AAP gives these five recommendations:

1. All infants and toddlers should ride in a rear-facing car safety seat (CSS) as long as possible, until they reach the highest weight or height allowed by their CSS’s manufacturer. Most convertible seats have limits that will permit children to ride rear-facing for 2 years or more.
2. All children who have outgrown the rear-facing weight or height limit for their CSS should use a forward-facing CSS with a harness for as long as possible, up to the highest weight or height allowed by their CSS’s manufacturer.
3. All children whose weight or height is above the forward-facing limit for their CSS should use a belt-positioning booster seat until the vehicle lap and shoulder seat belt fits properly, typically when they have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.
4. When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection.
5. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

Resources For Parents

• Child Passenger Safety Guidelines from AAP
• Vehicle/Car Safety
• The Ultimate Car Seat Guide
• Road Rules for Little Passengers
• Child Passenger Safety Considerations For Organizations Transporting Children

The parents don’t know the child’s social security number or even date a birth, but no one thinks twice because this is so normal to them.

This is part of the Cook Children’s Fostering Health program.

“Limited access to medical care is common among children entering the foster care system,” said Sharon Johnson, a nurse practitioner in the Fostering Health Program. “The goal of the Fostering Health program is to provide medical care using a trauma informed lens. We understand that removals are often due to a combination of trauma experiences and that even a visit to the doctor is unusual. Children in foster care are a very unique patient population that require unique care.”

The team follows the American Academy of Pediatrics’ health care recommendations to provide a health screening within three business days and a well-child checkup within 30 days of removal. During these visits, the team will assess behavioral, developmental and chronic health care needs. The staff also will partner with case managers to help coordinate care with required specialists and act as a continued resource for the children and biological parents.”

The Parents

On their very first date, they talked about adoption.

As Christians, the young couple felt their faith compelled them to take care of the orphaned, those who didn’t have a home or were less fortunate.

Time moved on and the couple married and they adopted their first child.

While their calling was to help children, they knew they could not afford another adoption.

“We looked into becoming foster parents,” “Janet” said. “There’s such a need and so many kids are in the foster care program. We both knew plenty of people aren’t called for it. We were.”

The couple have now been foster parents to three children. Their latest foster child is the first to have been seen by the Fostering Health program at Cook Children’s.

Raising foster children brings a new set of challenges, both logistically and emotionally. They have to:

• Be vetted legally through CPS and the foster care system.
• Be CPR and first-aid trained.
• Go through background checks and be finger printed.
• Make sure anyone who would baby sit or watch their children, also go through a similar process.

The husband and wife say they have seen children come out of very sad situations, where both the birth parents and sometimes even grandparents have a history with CPS. The children are often removed from the birth parents’ homes.

One or both of the birth parents sometimes are battling criminal charges, mental health issues or drug problems.

And then there’s always a chance, the birth family could get their life straightened out the child returns to them and leaves the foster parents.

The couple are currently fostering a daughter a little under a year old after the child’s mother was found to be unfit to care for her child because of psychiatric health care issues as well as the fact that she was homeless.

The child was brought to Cook Children’s Foster Care Program for an initial three-day evaluation. They found the concerns for the child included lack of prenatal care and possibly premature birth (estimated gestational age 36 weeks). The child was seen 10 days later for a weight check and a newborn screening and then two months later for another well-child exam.

The foster parents of the child say the experience at Cook Children’s Foster Care program was much different than previous visits to a pediatrician’s office. In the past, the staff in other pediatric offices didn’t always understand or appreciate the unique needs and concerns of the foster parents and their children. The family spoken to for this story said previous foster well-child visits might take as few as 20 minutes and the staff couldn’t understand that this child was new to the foster parents. They weren’t sure of common questions asked of birth parents such as if the child’s immunization record was updated or different behavioral aspects of the child.

“Previously, the doctor would take less than 20 minutes looking at our child,” “Janet” said. “At Cook Children’s Fostering Health program they spent well over an hour checking her. I just appreciated their understanding of our situation. We didn’t know the things most parents know. It’s not like the child came out me. We didn’t know the family history. We didn’t know anything about this baby.”

The foster mom said she vividly remembers crying on her way home following the first two placement, well-child visits.

“I tried to explain to them, I don’t know the children. I got them less than 24 hours ago,” Janet said. “There are so many elements that’s simply out of control of the foster care parents. We don’t even know the social security number, the birth mom’s name … sometimes they don’t tell you the basic things. I just appreciated the humility of the whole office. They were all walking around oohing and awing. It is a Foster care clinic. They get it like no one else does. I really loved going to Cook Children’s.”

Services provided from the Cook Children’s Fostering Health program include:

• Providing care coordination between foster and primary care physicians, specialists, therapists and behavioral health
• Helping establish a primary care medical home
• Providing sick and well-child visits
• Coordinating with Department of Family and Protective Services and child placement agencies

To schedule an appointment with Cook Children’s Fostering Health program, call 682-885-3953. The team can combine the three-day required visit and the appointment for hair follicle drug testing if the drug test is ordered by Child Protective Services.

The program provides a medical screening within three business days of removal to:

• Assess the child’s overall health and confirm that there is no evidence of abuse
• Find out if child should be taking routine medicines and help with refills if necessary
• Document behavior changes
• Provide a well-child checkup (Texas Health Steps) within 30 days of removal
• Reduce preventable hospitalizations and Emergency Department visits
• Connect children to services such as physical and occupational therapy, behavioral health and specialists visits
• Help foster parents access health care services

To Schedule an Appointment

Caregivers, Child Protective Services representatives and providers can call 682-885-3953 and ask for the fostering health care coordinator or email fosteringhealth@cookchildrens.org.

Stress, the negative influences upon our daily lives, and anxiety, the worry and mental energy directed toward stress, are part of every human life from infancy through adulthood.

One particular stress or worry can be addressed, but it will inevitably be replaced by another. Teaching our children how to deal with the stress and anxiety of life is one of the more important things we can do as parents.

Given a person’s age, developmental level, personality, etc. anxiety can manifest in many ways. Classically, stranger and separation anxiety emerge around 6+ months of age. This represents a normal developmental milestone of learning how some people and situations are part of the “family universe” and some are not; and how a child learns a sense of “self.” As children grow, anxiety can begin to show itself in ways less obvious than just crying, such as elevated heart rate, nervous tics, tantrums, inattention or difficulty focusing, complaints of pain (tummy aches, headaches), etc.

Studies have shown that anxiety is highly inheritable. If a child is very anxious, not uncommonly, there will be a parent who has struggled with anxiety. Furthermore, recent evidence shows that not only is anxiety genetic, it actually may be even more of a learned predisposition. Children mirror their anxious parents. This actually is encouraging news, however. It means there can be a significant impact from teaching our children how they can effectively deal with stress and anxiety.

STRATEGIES FOR CHILDREN:

DISTRACTION: It is the most effective strategy for infants and very young toddlers but it can also be very useful for older children. For instance, instead of discussing immunizations/shots extensively, talk more about what prizes are to be had afterward or other positive things about the day. If you look for the good, you will find it. Help your child find it.

JUST BREATHE: As we become anxious, our “fight-or-flight” system, our sympathetic nervous system, kicks in increasing our heart rate, respiration rate, etc. As our minds subconsciously recognize this, it increases our anxiety further. Luckily, we can mindfully break this feedback loop by concentrating on our breathing. For kids, a timer is especially useful. You instruct a child to slowly breathe in through the nose for 4-5 seconds, then slowly out through the nose for 4-5 seconds. Watching the timer the entire time, trying to make the in and out of one breath to be about 10 seconds, and repeating continuously for just a few minutes can be remarkably calming. Doing it with them can also calm us. Breathing techniques can be adapted for the age of the child - such as “blowing out candles slowly” (use fingers for pretend) for younger kids and guided imagery - imagining a calm, peaceful place while breathing slowly - for older children.

BUILDING SAFE AWARENESS AND SUPPORT: The personal recognition of when and how anxiety hits is fundamental to dealing with it and a hallmark of Cognitive Behavioral Therapy (CBT), the most well studied treatment of anxiety. Once a child can learn to identify the onset of anxious thoughts, they can also start using their personal breathing/calming techniques, refer to personal, home-made cards with positive self-talk on them (“when I feel nervous, I remember that Mommy loves me no matter what”, etc).

EXPLORE WITH ART: It can be very helpful for younger children to draw their fears. This can help the parents understand particulars, help them discuss it, and actually serves to lessen the child’s fears. Older kids can benefit from journaling their anxiety. Interspersed with their written worries, written affirmations and strategies can help.

PROFESSIONAL HELP

A simplistic, but nonetheless helpful, dictum used in the primary care field as it pertains to mental health conditions is that when a particular problem - anxiety, inattention, sadness, etc. - becomes significant to interfere with “normal” life, professional help should be sought. For younger children and for those with mild problems, the information in this packet and resources listed herein may be sufficient. Play or talk therapy may be an adjunct. For older children with more severe problems, Cognitive Behavioral Therapy holds the most promise.

Medication can sometimes be indicated for severe anxiety. However, it should not be seen as a cure. Patients who just take medication don’t fare as well with anxiety disorders as those who take medication and teach the mind to deal with inevitable stress and anxiety of life.

You may be even more surprised to learn that while GBS is rare (incidence is about 2 per 100,000 cases), Cook Children's neurologists see between 6 to 10 cases per year. 

To learn more about GBS, we spoke to Stephanie Acord, M.D., a neurologist at Jane and John Justin Neurosciences Center. 

1. What is GBS?

It is an auto-immune process in which your immune system starts attacking the myelin which is the protective coating that surrounds your nerves. As a result, the information needing to get down the nerve to communicate with other parts of the body is slowed or unable to occur.

2. What are the causes?

Most common cause is almost always post-infectious, either viral or bacterial. Most common bacterial cause is Campylobacter jejuni which causes a gastrointestinal illness. It is not an infection itself and is not contagious. Symptoms usually start within a few weeks of the illness. Occasionally, it can be associated with vaccinations or post surgically.

3. What are the symptoms?

Symptom onset is usually relatively rapid and can include: progressive, ascending weakness (starts in feet and maybe hands and spreads gradually up the legs, arms and trunk), abnormal sensations such as pain, tingling, numbness and pins and needles, and autonomic instability (abnormal heart rate, blood pressure, temperature stability, breathing rate)

In more severe cases, difficulty breathing, facial weakness, trouble swallowing, and bowel/bladder dysfunction.

Peak of symptoms is usually within 2-3 weeks after onset.

4. What is the treatment?

IVIG is the treatment of choice and in more severe cases may require plasmapheresis. The sooner treatment is initiated the better the outcome. We prefer for treatment to start within 7-10 days of onset of symptoms.

Definition of IVIG: Immunoglobulins are special proteins in the blood. They fight infections. Some white blood cells make them. They are also known as antibodies. They are part of the immune system. With immunoglobulin therapy (IVIg), these proteins are donated from a healthy person. They are then given to you through an IV.

5. Is there an age range when you are more susceptible to it?

Peak age for onset of GBS is 38-40 years of age, but any age may be affected.

6. Does it impact children differently than adults?

The type of symptoms and response to treat is usually similar in children and adults

7. When should you see a doctor?

Any quick onset of abnormal sensations and/or weakness that is worsening needs to be evaluated. If the weakness is progressing quickly, may need to be evaluated in emergency department. Many times, people have difficulty with ambulating.

8. Are there different types of GBS?

There are axonal variants such as AMAN (acute motor axonal neuropathy) and AMSAN (acute motor and sensory axonal neuropathy) in which the immune system is attacking the membrane of the nerve itself not the protective coating. With AMAN, you do not usually have sensory disturbances associated with the disease. AMSAN can look very similar to GBS and there has been some debate in the past if they are the same or different diseases. AMSAN usually has a more rapid progression of symptoms over days and can take longer to recover.

Miller Fisher syndrome is onset of weakness that usually starts in the face and includes difficulty with moving the eye muscles leading to droopy eyelids and double vision, ataxia which is unsteadiness and incoordination, and decrease in your reflexes. Weakness can spread to rest of body in a more of a descending pattern. This should not be confused with botulism which is also a descending weakness but usually also affects the pupils.

There is also tick paralysis which can look like GBS so need to also look for tics on the body if have similar symptoms.

9. How rare is it to get it later in like like Travis Frederick?

It is common to get it in the adult age. Peak age for onset of GBS is 38-40 years of age.

10. Once you’ve had it, can it recur? Is it something that lasts forever?

There is a chronic form of GBS called CIDP or chronic inflammatory demyelinating polyradiculoneuropathy in which progression of symptoms continues at least 8 weeks and can be more difficult to treat. Most of the time, GBS is an illness you only develop once. If symptoms recur, then again, it may be that you have the chronic form that will need long term immunosuppressive or immunomodulating medications.

Most people have full or near full recovery of symptoms but this can take months or for more severe cases even years.

The products, marketed and sold by King Bio online and in local health food stores, have been recalled due to “microbial contamination.”

According to the company, “the use of drugs products with microbial contamination could potentially result in increased infections that may require medical intervention, and could result in infections that could be life threatening to certain individuals.”

No injuries or illnesses have been reported to date.

While this recall is alarming, the names of some of the medications also got my attention:

• DK Attention and Learning Enhance
• Chicken Pox Symptoms Relief
• Children’s Appetite and Weight
• Children’s Appetite Enhance
• Children’s Growth and Development
• DK Teething
• DK Colic
• Kids Stress and Anxiety

For the full list of medications involved see the FDA release.

While I love looking for non-traditional and less invasive treatment approaches for my patients, I think it's always important to evaluate new or different medications with a skeptical eye.

(For more on this approach, see: Honey for cough. Skipping antibiotics for ear infections. I’ve researched essenital oils, milk alternatives and many other topics trying to find the best information about alternative approaches for my patients and my kids.)

Weighing the risk of a medication against the benefit is an important part of what I do every day in pediatrics. When a medication is clearly indicated and will clearly give the child relief, we can tolerate a very small risk of an allergic reaction or other side effect. But, if the medication doesn’t have clear benefit, any risk is too much.

King Bio makes homeopathic medicines. You can read a full description of homeopathic medications and how they are made here. The summary is this: homeopathic medicine subscribes to the idea that you can give substances which would normally cause disease at very low level to prevent the same diseases that they cause. Homeopathic medications are super-diluted and by the time they reach the bottle that is shipped out, they will most likely not even contain a single substance that would matter. They are mostly water.

So, can they be effective? No. Unless you believe that a syringe of water is an effective treatment for anything, but a tiny bit of thirst, there is no logical reason to believe they would work.

Look at the conditions that King Bio proposes that they can treat. Teething and colic are notoriously hard to understand because it’s unclear if they cause any of the symptoms that have been attributed to them in the past. I’m really uncomfortable with supplements that propose to increase appetite or weight gain. Most developmentally normal kids will eat and grow if food is available. If there are true feeding problems, they need to be addressed. If something works for ADHD, it is affecting your child’s brain. There’s no other mechanism for it to work. Even if it did work, I’d be very scared to give it to my children based on the limited information available.

So… return your items to King Bio (or better yet, you can just throw them out) and if you were considering buying this product or something similar, think about it seriously and ask your doctor if you’d like more information.

Get to know Justin Smith, M.D., aka The Doc Smitty

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

 

He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” open now. Click to learn more. To make an appointment, call 817-347-8100.

As one of the worst drowning seasons in Cook Children's history continues, Dr. Olsson is trying again. 

Dr. Olsson said it has been a "rough season" on his staff and it can be frustrating because so much effort has been placed on awareness, they will continue to do all they can to educate families in hope of preventing another drowning.

"There are tragedies we see that can be life changing for families and a drowning is one of those," Dr. Olsson said. "What’s difficult for us as staff is that these are usually healthy kids leading up to this. It’s a very quick change in a family’s life from that point on."

Twelve children have died from swimming-related drowning causes this year at Cook Children's, the most in at least six years.  

After going through the Emergency Department, many of the children who are treated at Cook Children's spend time in the Pediatric Intensive Care Unit. The PICU team says the impact of a drowning lasts long after the child is no longer at the medical center.

"Drownings are tough for us because you have children who the day before or hours before were playing or they  had their pictures taken," said Rachel Hayes, a registered nurse in the PICU. "Their parents were celebrating, maybe going out for dinner or going out to barbecue in the backyard. So it’s knowing that those children had a beautifully healthy life and suddenly at the drop of a hat (she snaps her fingers) their lives are changed forever. The family’s life is changed forever. The neighbors’ lives are changed forever. So I think that’s part of what it makes it so challenging is just that we can relate to these kids as our children."

Dr. Olsson said the staff is specially trained to give the children who enter the PICU the best possible care, but it never stops being difficult for the caregiver.

"Dealing with the families and their emotions and walking with them is a struggle for us sometimes," Dr. Olsson said. "And there’s always the battle of us transposing that on ourselves and our own family and our own children,  thinking of those situations and what it would be like to be in those situations. And often times we do. Often times  as much as we approach it in a professional way, we are human and we have emotions and feelings. Sometimes we have to cry with the families and sometimes we have to cry with each other and support each other in that. Our Pastoral Care department helps us in those situations."

"Even if you do come to terms with, 'OK we dealt with that one. I’m at peace with that one.' Then the next week another kid comes in with same story," Hayes said. "The same thing happens. So you don’t get to let go of it in that aspect. Yeah, definitely, it’s very emotional and it sticks with you."

And while much is made of the drowning deaths, the staff in the PICU stress that just because a child makes it out alive, it doesn't guarantee the best of results.

"There’s a heartbreak to it that nothing else can come close to and it's heart-wrenching because it's 100 percent preventable," said Cammie Bonahoon, a registered nurse in the PICU. "The child may have come back out of that pool alive, with a pulse and with blood pressure, but they aren’t going to be the same child that went into that pool."

That’s the concern of many of the state’s physicians based on new numbers from the Texas Health and Human Services department.

In its Annual Report of Immunization Status, 56,738 kindergarten through 12^th grade students were reported as having a conscientious exemption on file at the school. This number represents 1.07 percent of the number of students reported enrolled by schools in the survey.

This is on top of a recent report by the Centers for Disease Control and Prevention that states that Texas is one of 21 states that is currently being monitored for the spread of measles. The CDC says there has been 107 cases reported this year and that the majority of those cases weren’t vaccinated.

The amount of children who aren’t receiving at least one vaccination for a nonmedical reasons has been steadily on the rise since Texas lawmakers passed what’s known as conscientious exemption in 2003. Parents and legal guardians can choose for their child not to receive an otherwise required immunization for their child because of reasons of conscience, including religious beliefs.

Fifteen years ago, about 2,300 students opted out of at least one vaccine.

In an editorial in the Star-Telegram that urged parents to provide immunization for their children, Dr. Peter Hotez warned that “we are extremely vulnerable to a measles outbreak in Texas.”

Dr. Hotez, who is director of the Texas Children’s Hospital Center for Vaccine Development, recently co-authored a study on vaccine exemptions published by the Public Library of Science Journal of Medicine.

Texas was named one of 18 states that allows non-medical exemptions, and identified Tarrant County and Fort Worth as national “hot spots” for a potential outbreak. The study found that parents of at least 518 kindergartners in Tarrant County schools last year opted to not get preventive shots for their children.

“These numbers are very concerning,” said Justin Smith, M.D., a pediatrician and Medical Advisor for Digital Health at Cook Children’s. “In 2000, the United States declared that measles was eliminated from this country. Now, more and more kids aren’t getting immunized and diseases like measles has returned to this country. I don’t think that’s a coincidence. Measles is very serious. Measles can cause pneumonia and children under the age of 5 have a higher risk of hospitalization.”

Dr. Hotez’s study found that children not given the measles, mumps and rubella vaccine are 35 times more likely to contract measles than a vaccinated child.

Keeping vaccination rates relatively high (somewhere around 90 percent) actually helps protect all children (vaccinated or not) from diseases, Dr. Smith said. In addition, when outbreaks occur, even children who are vaccinated become at risk for contracting disease due to the number of possible exposures.

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

What follows are Dr. Ben's Top 10 areas of focus to promote good mental health for your soon-to-be adults.

1. Sleep - As a person goes through the teenage years, it's normal to have a harder time falling asleep early and harder to get up in the morning. Good sleep can be promoted by trying to keep weekday and weekend awakenings and sleep at around the same time (within an hour or two at least). Try to walk away from screens an hour or so before bedtime and rid the bedroom of screens as best you can. This is hard but doable. Strive to get eight hours or more sleep most nights. If you find yourself unable to consistently fall asleep quickly at bedtime or wake up consistently at night, talk to your parents or pediatrician. 

2. Unplug - To be a kid today is to have computerized screens as a central part of your education, entertainment and socialization. Being constantly connected, or just feeling like you have to be, is not mentally healthy. While it would be almost impossible to function today without them, it's important to realize that heavy screen use has been associated with poor mental health.

3. Exercise - If you are not involved in a sport, it's easy to have physical activity become less and less of a priority. However, studies have shown that adolescents who get regular exercise generally sleep better, perform better academically and are happier than their non-exercising peers. Finding some way to move your body with vigor, getting a bit out of breath and sweaty, can really improve your happiness level. 

4. Outside - Human beings have spent millennia evolving, which, until the last couple hundred years, necessarily involved spending a large degree of time outside. Now, some people's only time outside for days on end can be walking to and from a car into home, school or activity. Exercising outside, doing homework outside or simply going for a walk outdoors can boost happiness.

5. Play - Growing up necessarily means increasing responsibilities and pressures. It becomes easy to lose track of plain ol' FUN! Doing something joyful and "non-productive" can be rejuvenating. Baking cookies for somebody, going bowling or playing a board game be a great source of stress relief. Have fun. It's one of the things that makes life worth living. 

6. Mastery - The teenage years are actually the time in which certain areas of brain performance are at their absolute max. Developing what psychologists call a "growth mind-set" is a great tool for happiness. Instead of "I can't do it," think and say "I can't do it - YET." You are a human becoming and you can accomplish all wonder of things with persistence and grit.

7. Connection - During these years, it's normal to become more and more connected to your peers and rely less on your parents. Forging many relationships, different relationships (with classmates in different social spheres, people at church, camp or sports, etc.) can be a source of great mental strength. Forging these bonds away from screens is a good idea. Including others can make not only the other person happier, but can make you feel good too. Nobody feels good when someone is left out. 

8. Mindfulness - Although the term is in danger of becoming fuzzy from overuse, a good definition is "paying attention on purpose, non-judgmentally and with intention." Unfortunately, the screen in our lives promote the opposite of this. Many resources such as books, websites and apps (such as Headspace, Insight Timer, Aura, etc.) exist and cultivating mindfulness can play a tremendous role in increasing happiness.

9. Kindness - As you get older, it's easier to note the imperfections of others - classmates, siblings, teachers and especially parents. However, making a point to be kind to all of those around you not only makes others happier, it can remarkably improve your own happiness. EVERYBODY responds well to kindness. 

10. Gratitude - Although it may seem silly, finding things to be grateful for can have a big impact on happiness. Keeping a gratitude journal, saying "thank you" often, or writing notes of gratitude can be very positive. Striving to do this even more in times of stress is especially important. The things themselves that we can be grateful for can be large and small; it is the process of finding them, savoring them and remembering them that's important.

Watch the full story by clicking here.

I have a few tricks up my sleeve: fun toys, silly pictures, asking them about something they brought in or something they are wearing. When I’m asked to evaluate a child who isn’t talking, I begin with some easy tasks like pointing to things or naming familiar items. Most kids begin to warm up in a short amount of time and I frequently have to steer them back toward our speech activities because there is so much more they want to talk about.

But sometimes a child won’t talk to me. Week after week, they won’t talk to me.

Parents tell me that he talks a lot at home, A LOT, but rarely to other people or away from home. This is more than being shy. When the parent describes what the child says at home, I learn that they use a variety of words and usually talks in full sentences. Sometimes, I’m able to determine that the child doesn’t even have a speech problem. They may have an anxiety disorder called Selective Mutism.

Selective Mutism is a childhood social communication anxiety disorder. It occurs when children do not speak for at least 1 month in certain social settings, but are able to speak in other settings. (Important note: this does not include kids that refuse to speak during the first month of school or children learning a new language.) The inability to speak is not related to a speech delay or disorder and is not the result of other medical or psychological problems that interfere with speech.

When it comes to talking or engaging with people, some kids experience an extreme level of fear and anxiety causing them to be silent, or mute. Maybe they are afraid to engage with other people or afraid they will embarrass themselves when they speak. In the moment, no amount of reassurance or pressure will help them bring words out. They are frozen.

Some studies estimate that this happens to 1 in 1,000 children*. However, several researchers have stated they believe this is largely underestimated. Selective Mutism is slightly more common in girls than boys. Most kids are diagnosed around the age of 5, but parents report difficulty starting years earlier. Selective Mutism may last for months or years. It may even extend into adulthood if left untreated.

What should parents do?

Never try to force or bribe a child to speak.

Talk to your doctor or a psychologist. They will likely gather a team to help diagnose your child’s difficulty and develop a plan of care:

• Are there hearing problems?
• Does she have difficulty speaking or being understood?
• Has there been a recent traumatic event?
• Does she express fear about talking or other things?

Frequently there are other underlying issues that have led to the anxiety disorder.

A psychologist or counselor can help your child understand their fears and work through them using play therapy, family counseling and behavioral or cognitive strategies.

Many times a speech language pathologist is called in to help. I know this seems unusual as we have just said there is not a speech problem, but an anxiety disorder. However, speech language pathologists  are able to set up activities in a nonstressful manner with low expectations for talking.

Let’s start with playing with a train set. The therapist helps the child build the train track and continues to make comments about the activity, train sounds and try to engage in taking turns with the child creating a fun shared activity.

The next level may include asking the child to point to a picture of the train car they want to put on the track first. Recently, a child I was seeing began saying the color as they were touching the picture. I smiled and continued playing, not making a big deal about them speaking.

Slowly, week after week, the therapist helps the child build success and confidence.

We set up activities that include more people and work with parents to design practice activities they can do between therapy visits. As we provide more challenging activities, we always have a backup plan ready if the child begins to feel unsure.

With older children, once we build trust, we can help them identify challenges in speaking or socializing. We can build on skills they already have and gain confidence in communicating with others. We will also help them problem solve specific situations that cause stress.

If you suspect your child has difficulty speaking, whether it be due to anxiety or other speech skills, please talk to your pediatrician to seek help.

* Estimate from Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

For starters:

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

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

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

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

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

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

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

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

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

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

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

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

Hope this helps!

Hugs,

Dr. Diane

Harper was born with a rare genetic disorder called familial chylomicronemia syndrome (FCS) that causes a build-up of dietary fats, often resulting in pancreatitis, acute inflammation of the pancreas and severe abdominal pain. FCS is so rare estimates vary; but experts believe about one to two per million are likely to have the syndrome.

"It was really crazy at first because I went from breastfeeding to having to get formula, and it wasn't your everyday formula," Harper's mother Kendra Braughton said. "This was our first baby, too, so we didn't even really know what to expect."

Many people who have FCS live with severe pain for years as they receive misdiagnosis after misdiagnosis. Although Harper's condition was diagnosed at nine months, she still encountered a fair share of medical missteps.

"When we first took her to a specialist in Dallas, we actually took her to a cardiologist on the recommendation of our pediatrician," Harper's father Chris Braughton said. "After she put her on flaxseed oil, Harper ended up getting hospitalized with pancreatitis . Unbeknownst to us, it was because her body can't tolerate fat."

It wasn't until her hospitalization that Harper's family knew they had to dig deeper to find an answer that would give them an unfamiliar diagnosis, and would lead them to the Cook Children's Endocrinology Program.

Kendra's mother works for a Dr. Dennis Canon in Canyon, Texas. She spoke to the physician about Harper's condition. He did some research and found information he thought matched Harper's symptoms. Dr. Canon emailed Don P. Wilson, M.D., a Cook Children's endocrinologist, to ask for help.

Despite the rarity of the syndrome, Dr. Wilson is nationally known for treating patients with FCS. Dr. Wilson and his team currently care for 12 patients from around the nation, including six from Texas.

"Receiving such a rare diagnosis was shocking at first, but once Dr. Wilson explained what it was and how to manage it, and that it was really going to change us more than her, we realized we could do this," Chris said.

Normal triglyceride levels in a healthy person are typically less than 150 mg, however patients with FCS can reach levels of 10 times that amount. With a correct diagnosis, Harper could now be treated for her condition.

Dr. Wilson orders a lipid profile and Harper's triglyceride levels are closely monitored every six months to ensure she doesn't fall into another case of pancreatitis. Her triglyceride levels have remained around 700, which may seem high but is within a healthy range for a FCS patient.

"High triglycerides can destroy the pancreas, which would lead to problems absorbing nutrients and could cause her to have diabetes. Particularly in her [Harper] case dietary restrictions are necessary to avoid pancreatitis," Dr. Wilson said.

Patients with FCS are usually diagnosed due to debilitating symptoms such as severe abdominal pain, numbness or tingling, impaired cognition or blood with the consistency of milk, but at nine months old Harper was diagnosed due to her pink blood.

"Harper had high triglycerides and had little fat bubbles under her skin that looked like little pimples almost," Chris said. "One time we took her to get blood tests and her blood came out pink because it was so full of fat. The lab technicians actually thought they had messed up the test so they took her in for a second one and she broke the test again [due to inconclusive results]."

While there is no cure for FCS, patients are encouraged to meet with a dietician to maintain a lifestyle with extremely low levels of fat and the importance of avoiding excess carbohydrates.

"The only thing we have to watch is her fat intake," Chris said. "She eats a very low fat diet, we typically try to keep it between 7 or 8 grams per day. She eats very healthy, but otherwise we don't limit her. We try to keep her day as normal as her friends' would be."

While most 5 year olds are concerned with getting a piece of cake with the most icing, Harper is thankful on her "cheat days" and understands her daily restrictions.

"FCS requires a strict and rigid diet, and that's the problem especially with young children," Dr. Wilson said. "Everyone will grow up and be tempted to eat things that we shouldn't be eating, but when a child cannot always participate in birthday parties and other treats it can ostracize them."

Despite her dietary limitations, Harper has now lived five years with FCS and her healthy lifestyle is her definition of normal.

"Harper doesn't know anything else besides this type of lifestyle," Kendra said. "It seems like her body can tell when she does eat too much fat because she doesn't feel well and needs to eat something different."

Harper's parents quickly realized if she was aware of her diagnosis their daily lives would be easier to manage.

"We're very open with her about limiting her and why we're limiting her," Chris said. "She's very conscious of it. I think that's really the key for parents with kids who have dietary restrictions. That's your kid, and you have to let them have their cheat days and fun with their friends, but you also have to explain why you can only do that every so often. It really does help."

I have been very fortunate to find a clinic that has built my confidence and allowed me to grow as a provider. From our first encounter the physicians felt like friends. I knew it was meant to be when our first meeting was at a bakery. Cookies always lighten the mood. Since that time, they have taken me under their wing, taught me what they know, and encouraged me through the entire process. I have not once felt like I was under them or not equal. It is truly a refreshing relationship! These women have trusted me with their patients, even their own children, judgement free. We also enjoy each other outside of work. We make it a point to invest in each other’s lives personally. Whether it is dinner, yoga, cooking classes, or kid’s birthday parties, we truly like being around one another!

I have spoken with several of my advanced practice provider colleagues, some of which I worked with in my nursing career prior to becoming a nurse practitioner. I asked for insight and thoughts on their relationship with physicians they work with. I was overwhelmed with all the positive responses. Everyone who responded mentioned having at least one physician who was willing to put in the effort to mentor them into becoming a better provider. The term “collaborative practice” was a collective theme. One of my favorite conversations was with a nurse practitioner who retired last year. Her statement resonated with me, “Be friendly, kind, and make sure you know what you don’t know. As long as you can put egos aside and work together, you will have a good relationship”.

There will always be some difficult situations when you are the middle person. We are in a group of our own; no longer practicing as nurses, but not physicians. I believe this is where there can be strain on the advanced practice provider and physician relationship. We are often performing similar jobs and functions with the same expectations, but at times with different levels of respect or notoriety. This can be mentally challenging for advanced practice providers. I have learned over the years to remind myself why I chose this path. I absolutely love what I do! I was able to go through nurse practitioner school while having children (two while in school, because I’m an overachiever) and working. These would be difficult tasks had I chosen the path of medical school.

In nursing school we are taught to put the physician on a pedestal. Everything they do and say goes. Nurses follow orders and only question if it seems to be life-threatening. Looking back, I am surprised that was so engrained. I think this is where we can come into relationship issues with physicians as advanced practice providers. We need to realize we are a healthcare team and we all have value. We have a common goal of treating and caring for our patients to the best of our abilities. Here are a few tips I have found that have helped me to strengthen the relationship and bond I have with the physicians I work with.

• Communicate frequently and clearly. Whether it is as simple as asking how your day is going or discussing office issues, communication is important to maintaining a good relationship.
• Define your role as an advanced practice provider early in the relationship. Expectations should be defined and possibly redefined over time.
• Know what you don’t know. Some of the best advice I’ve ever been given. It is important to put your pride aside when you’re unsure how to manage or help a patient. Sometimes my colleagues are unsure as well (hello, weird rash), but we work as a team to make a plan.
• Care about each other on a personal level. This has by far been the key to our success as an office. We are friends outside of work, and truly look out for everyone’s best interest.

In the end it’s not a “them” and “us” situation. We’re all people, not one better than another, doing our best to take care of our patients together!

Parents worry SO much when I hear one in their kiddo's chest and I tell them about it.

But I am here to help you not freak out!

I feel like I need to add "Parental Freak-Out Support and Management" to my resume. Maybe underneath "Office Donut Day Coordination Specialist"?

...

I hear heart murmurs in kids Every. Single. Day. Sometimes numerous times a day. We're deep into school physicals this time of year and that's when many doctors will find a heart murmur on exam.

They're really common.

I have read that anywhere from 30-70 percent of children and adults have a heart murmur at some point in their lives.

A heart murmur is a whooshy sound I hear in between the heart's little beats. So instead of "bum-bum, bum-bum," I hear something like "WHOOSH-bum, WHOOSH-bum".

Lots of things cause heart murmurs. A heart murmur can show up at any time in a child's life. And just because it wasn't heard before doesn't mean something bad has happened or is happening.

Anemia can cause murmurs. Dehydration can. Illness in general can.

Fevers are a common cause of murmurs. I can't tell you how many times one of my little patients goes to urgent care at night and a parent is told, "you should know your child has a heart murmur." And then of course they worry! When really, it was your poor kiddo's 102F temp that caused it.

Sometimes it's just the shape and size of your kiddo's heart at that time in their life. A "Still's Murmur" is something I often hear anywhere from age 2 to 6. It can come and go and causes no problems. It just has to do with the way the blood sounds whooshing through the valves and rooms in the heart.

Pediatricians have heard thousands of heart beats. We are pretty good at knowing which murmur sounds okay, and which murmur doesn't. And we will send you to a pediatric cardiologist if we are concerned or just wanna see why the sound is there.

So when do I worry a little more about a murmur?

• Any murmur heard in a newborn to 6 month old (these are more likely to be a structure problem in the heart that they were born with, and we need to investigate those further).
• Any murmur accompanied by other symptoms of heart problems, like: Skin that appears ashen or blue from poor circulation (cyanosis), pale skin, heavy or rapid breathing, a rapid heart rate, tiredness, difficulty feeding or poor growth.
• If your child has a murmur and you tell me that they can't keep up with their friends when playing sports, or have chest pain or tightness related to activity.
• If you have a family history of sudden and early cardiac death (think young people under 40 who suffer a heart attack during play).

If any of these are happening, more studies (like an EKG or heart echo) are usually needed.

I hope this helps you understand murmurs a little better!

As always, if you're concerned, just ask your pediatrician to explain things a little more if they mention your child has a murmur.

Have a great day!

Dr. Diane❤️