Fears regarding COVID-19 have increased the amount of hand sanitizer and other disinfectants in homes, giving children more access to ingest these products. While hand sanitizer is beneficial for killing germs on our hands, it can be toxic if swallowed or misused.

“The biggest concern with hand sanitizer ingestion in kids is alcohol intoxication that can lead to low blood sugar, which can cause coma and seizures,” said Justin Smith, M.D., pediatrician at Cook Children’s Pediatrics Trophy Club. “Less serious symptoms can include nausea and vomiting.” 

Earlier this month, the U.S. Food & Drug Administration (FDA) issued a warning for a voluntary recall from Ashtel Studios due to hand sanitizer that is packaged “in containers resembling a food and drink pouch.” The appearance of the product is similar to applesauce and fruit packets and marketed with popular children’s characters, like PAW Patrol and Barbie. 

“It’s important that we remember that hand sanitizers should be kept out of the reach of small children, especially those under 5 years old. While keeping our children safe from COVID-19 is very important, we don’t want to let our guard down against other risks,” said Dr. Smith. “And please don’t buy sanitizer in containers that could look like food or could otherwise be more attractive to kids.”

As the coronavirus pandemic continues and flu season arrives, parents need to be more careful than ever to store hand sanitizer out of the reach of children. For more information on poison prevention, visit our website.

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

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

Who needs to be tested for COVID?

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

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

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

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

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

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

When can my child go back to school?

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

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

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

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

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

The quick answer is, No.

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

Summary

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

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

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

Let’s get started.

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

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

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

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

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

And ...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How do you help with the guilt:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Childcare and Other Resources

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

Medical

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

School

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

Educational

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

Social and Emotional Needs

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

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

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

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

For more on this topic:

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

So, when can we get back to sports?

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

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

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

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

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

Now. If and when it can be done safely.

Here’s how to keep your child safe:

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

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

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

But many parents are still asking the question, 'Should I take my child to daycare?'

Of course, there's no one clear answer for all families. The bottom line is that everyone should consider carefully whether taking their child to daycare is the right decision for them.

The first consideration is whether you think your child’s daycare center is ready to open.

The Center for Disease Control (CDC) has issued some guidance for child care opening. Before I sent my child back, I would ensure that they are at a minimum following their recommendations that daycare centers should only open when:

• They can be compliant with local and state orders, are ready to protect high risk children and employees, and can screen children and employees on arrival.
• The following health and safety actions are in place: promote hygiene practice such as handwashing with employees wearing masks, intensified cleaning, encouraged social distancing when feasible, adjust activities to limit sharing of toys/supplies and training all employees.
• Ongoing monitoring is in place. Children and employees should have a process for checking for signs and symptoms upon arrival, sick employees should be allowed to stay home and a plan should be in place should employees or children get sick.

Once daycare center readiness has been determined, each family will still need to make a determination for when their child should go back. Here are some factors to consider:

1. Child’s medical history - This may seem obvious but children with chronic conditions are who are immunosuppressed would be at higher risk with returning to day care.
2. Child’s age - Children 2 and older will likely be asked to wear a mask but the younger kids are, the harder it will be. It might be easier for children who aren’t mobile to be separated. Toddlers will be the trickiest as they are mobile and can’t wear masks.
3. Family medical history - At risk family or household members will be at risk for contracting disease from asymptomatic children who bring infection home.
4. Family work situation - As offices open up, many parents will not have a choice. Even parents who work from home may face increasing pressure to be more productive as the economy begins to open up. Parents need to be able to provide for their family and maintain insurance coverage in a time where work insecurity is a real issue.

While each parent will have a choice to make in regards to taking their kids back to daycare, hopefully these considerations will help you make the best decision for you and your children.

We miss you and your sweet kids!

What a crazy time the last few months have been. Our entire lives have been changed-work, school, family and free time-they are all different.

During this time, we, your Cook Children’s pediatricians, have learned a lot about COVID-19. We have been following what’s happening all over our country and the world. Fortunately, Cook Children’s supported us through this time so that we could make the safest, best decisions for your family.

While we learned, we made an immediate switch to do as much as we could via telemedicine but continued to do checkups under age 2. We have slowly started to incorporate more visits as we grew more comfortable with our ability to keep you and your family safe and now, we are ready to see your child for their checkups!

What do you need to know about your upcoming check-up?

Safety is our primary concern

Changes to clinic workflows and traffic patterns in the office will ensure that your family is able to maintain social distancing.

Scheduling will be modified to keep well and sick children in the office at separate times of day.

Masks will be worn by staff at all times. In addition, we ask that you and your children over age 2 also wear a mask while in the office.

Rigorous cleaning of all surfaces throughout the clinic will continue between each patient encounter. This includes surfaces in the room and common areas.

Regular checkups are important for your child’s health

Assessing children for growth and development helps us act quickly when things aren’t going well. Diagnoses of growth hormone deficiency, autism, anxiety and depression frequently are recognized during well child care.

Vaccine schedules are designed to allow shots to be given at the most critical time. Waiting for long periods, often leaves them vulnerable during the times when they need protection the most.

Physical exams during well care often pick up dangerous conditions such as scoliosis and even cancer. Neuroblastoma (cancer in the adrenal gland above the kidney) and testicular cancer in teenage boys are often diagnosed during well child care.

Cook Children’s Pediatric offices will be reaching out to patients in need of checkups, but you don’t have to wait, give your office a call to schedule their visit.

But as a pediatrician, let’s talk first about what’s most important to me and you: our kids.

Fortunately, we have not seen any cases of COVID-19 (coronavirus) at Cook Children's. The other good news is based on confirmed cases of COVID-19 from around the world, kids have been relatively protected from serious illnesses. According to the Centers for Disease Control and Prevention, children are less likely to get Novel coronavirus infections (COVID-19) than adults. And the good news is if they do get it, it’s usually a mild case.

In a study of more than 72,000 patients by the Centers for Disease Control in China, only about 400 cases occurred in children under age 9 with zero deaths.

Most of the kids who caught COVID-19 had mild symptoms, including a fever, runny nose and cough. 

"These limited reports suggest that children with confirmed COVID-19 have generally presented with mild symptoms, and though severe complications (acute respiratory distress syndrome, septic shock) have been reported, they appear to be uncommon," the CDC wrote.

The CDC adds, "However, as with other respiratory illnesses, certain populations of children may be at increased risk of severe infection, such as children with underlying conditions."

So now let’s get to some of the basics you may be wondering about.

What is the “Coronavirus?”

COVID-19 is a novel respiratory coronavirus which most often presents with symptoms of fever, coughing and shortness of breath. The rapid spread throughout China (and now outside of China) as well the significant percentage of cases that result in severe illness is what makes COVID-19 a particular concern.

Where can I find the latest?

I highly recommend checking out Tarrant County Public Health’s website for the latest on COVID-19 (Coronavirus). The site tracks the total cases confirmed worldwide, including deaths.

The Texas Department of Health and Human Services (DSHS) also has a COVID-19 webpage with information for the public, travelers, health care professionals, public health partners and others.

How do I take care of myself and my kids?

Currently, there is no vaccine to prevent COVID-19. So for now, the best way to prevent infection is to take the following precautions:

• Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing or sneezing. If soap and water are not available, use an alcohol-based hand sanitizer with at least 60 percent alcohol.
• Avoid touching your eyes, nose and mouth with unwashed hands.
• Avoid close contact with people who are sick.
• Stay home when you are sick.
• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
• Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.

To add to the previous bullet, the World Health Organization states that “there are some chemical disinfectants that can kill the 2019-nCOV on surfaces. These include bleach/chlorine based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform.” Click here for the EPA's registered antimicrobial products for use against Novel Coronavirus report. 

But it’s important to add: “However, they have little or no impact on the virus if you put them on the skin or under your nose. It can even be dangerous to put these chemicals on your skin.

I know you’ve probably heard a ton about the Coronavirus disease (COVID-19) as far as what will and won’t work. Check out the WHO’s myth busters section for some great advice for the public.

What about masks?

We have been asked so much about masks. Should you wear one or not wear one? The CDC doesn’t recommend the routine use of respirators (or masks) outside of workplace settings (in the community).

“Most often, spread of respiratory viruses from person-to-person happens among close contacts (within 6 feet). CDC recommends everyday preventive actions to prevent the spread of respiratory viruses, such as avoiding people who are sick, avoiding touching your eyes or nose, and covering your cough or sneeze with a tissue. People who are sick should stay home and not go into crowded public places or visit people in hospitals. Workers who are sick should follow CDC guidelines and stay home when they are sick.”

So, what can we do to prepare? 

Preparation is good advice in general for any new and emerging infectious disease, and not just dealing with the novel coronavirus. Preparation and thinking around the status of coronavirus could be divided into three categories:

Preparation Right Now 

Based on the current status, the following suggestions can be universally applied at relatively low cost. They could prevent problems down the road should an outbreak occur.

1. Gather medical supplies and prescriptions that you might need in advance. Children with chronic medical conditions should have enough supplies to last a few weeks in case local spread develops rapidly, and doctors or pharmacies are overwhelmed. Parents of children with chronic respiratory conditions such as asthma should especially consider this option.
2. Having some non-perishable food on hand to minimize trips outside is something relatively easy to do. At the same time, we wait to see what develops.
3. Reinforce with your children hand-washing, cough and sneeze hygiene and continue to develop good habits of staying home while sick.
4. Healthcare workers should discuss with their institution the efforts that are taking place to protect them from spread should their medical center have cases.

What to do in case of a community spread of the novel coronavirus

If one of the local populations of COVID-19 infections includes your area, some other things might help or be asked of you:

1. Schools, churches, employers and other places where people gather in large numbers should have preparation for allowing individuals who can have the ability to work from home. If the virus is spreading throughout a community, minimizing contact between community members may be a strategy employed.
2. Reach out to your health care providers if you think you or your child might have COVID-19 so that they can guide you to the right place and prepare for your visit. In the case of local spread, a non-essential visit to health care facilities may be postponed, so call ahead.
3. Use common sense when evaluating claims of products on the market for treatment or prevention of disease. Unfortunately, many will use this vulnerable time to take advantage of scared members of their community.
4. The local public health departments (Tarrant County for us) will be the ultimate source of the best information regarding the spread of the virus and recommendations regarding novel coronavirus.

What to do in case of a widespread outbreak of the novel coronavirus

Should the number of cases expand rapidly or broadly, further precautions will be undertaken. Remember, this is felt to be an unlikely scenario for the United States.

1. Minimize contact with others whenever possible to help avoid the spread of the virus.
2. Follow the CDC guidance for infection precautions and treatment. In the case of a widespread outbreak, they would be working with local health departments and healthcare facilities to address coronavirus.

I hope this helps ease your mind. We will continue to update you as needed and also provide the latest information from our friends at Tarrant County Public Health.

Stay well,

Doc Smitty

Note: Thank you to Tarrant County Public Health, Alice Phillips, M.D., Mary Whitworth, M.D., and Corwin Warmink, M.D., in putting this article together.

Resources:

• Tarrant County Public Health's COVID-19 (Coronavirus) Page
• Texas Department of State Health Services' Coranvirus Page
• Coronavirus Disease (COVID-19) and Children
• Centers for Disease Control and Prevention's Coronavirus DIsease Page
• How COVID-19 Spreads (CDC)
• Symptoms (CDC)
• Prevention & Treatment (CDC)
• What to Do If You Are Sick With Coronavirus Disease 2019 (CDC)
• World Health Organization's Coronavirus Page
• EPA's Registered Antimicrobial Products for Use Against Novel Coronvavirus SARS-CoV-2, the Cause of COVID-19

In the wake a baby is dead and her mom has been charged with her murder. In addition, the baby’s dad has been charged with aggravated battery and cruelty to a child for diluting their baby’s breast milk with water, then refusing to take the child for medical care.

By the time they did take her to the hospital, she was already dead.

Unfortunately, this is not uncommon. I remember a similar case from years ago in which a child’s family was desperate for money and thought they could use extra water to make their formula last longer. In a study from Clinical Pediatrics, up to 25 percent of families considered “food-insecure” admitted to using various methods to make their formula last longer.

The problem is that extra water is not safe for babies. It causes the sodium level in their blood to drop. Low sodium will lead to brain swelling which can cause poor feeding, lethargy, seizure and eventually death.

Giving free water to babies is not just an issue of formula stretching. Families commonly ask during the summer months if their babies need extra water due to the heat. The answer is NO!

Some reasons babies don’t need water:

• Breast milk and formula is mostly water (80-90 percent). Babies don’t get thirsty. Their diet is primarily liquid.
• Water does not have nutrition or electrolytes babies need. If a baby is going to be drinking something, why not make it be something that can help them grow?

Babies can safely start to drink some water after six months but they still don’t need a lot. They can get one to three ounces during their meals if parents want to introduce and practice with a sippy cup.

1. They don't leave enough time for their commute. Even if the roads get mildly slippery and you were born and raised in North Dakota, keep in mind that us native Texans pretty much absolutely freak out about winter weather. We'll either be taking it too slow or driving like a maniac. Give yourself some extra time to get the kids to school.
2. They leave their kids puffy coats on in the car. Car seats are not meant to be buckled around big puffy jackets. Take them off and use them as a blanket before you take off. Read more about this here. Give your child an extra second to put it back on in the school drop off line. (Yet another reason to see No. 1 above).
3. They forget to take care of their kid's skin. Get outside and play in the cold weather, but remember that sun and snow can still cause significant sunburns. Apply sunscreen like you're at the beach. Cold wind can also lead to dry, red cheeks in children of all ages. Apply some vaseline to the cheeks after being outside and at the first sign of irritation.
4. They ran out of their child's albuterol. Weather change can be a significant risk factor for children with asthma. A sharp drop in temperature often bring the wheezers into the office in droves. Make sure you have inhalers or albuterol for your nebulizer on hand (and not expired).
5. They worry about things that don't really matter. "Cover their head so they won't catch a cold." "Don't let them outside with a wet head." Here is more information about these and many other Winter Wives' Tales.

Now that you know some of my big tips for keeping your child safe when the weather turns cold, stay safe and enjoy the winter while you can!

“Wear shoes outside.”

“Put on your hat.”

Does any of this really matter? Is any of it true?

Between well-meaning friends and family members and the wealth of websites devoted to health, parents are bombarded with tips and tricks to keep their kids healthy year round, but especially during the winter. This can make separating fact from fiction difficult.

Not all old wives’ tales are fictitious – some are grounded in truth. However, if you have questions or hear health advice that doesn’t make sense to you, always ask your children’s pediatrician before acting on the information or simply believing a statement is true.

Let’s take a look at the facts on these weather health myths.

Myth 1: Sudden changes in the weather make you sick

One day you are wearing shorts and the next day you are dragging out all of your winter gear. Welcome to Texas. So doe the fluctuating weather make you sick? In general terms, the answer is no. I know no matter how much science I use in my answer, many of you won't believe me. The truth is there's no scientific proof that changes in the weather will make you sick or keep you from getting better. 

But as usual there are exceptions. The changes in the weather can be really hard on your child's skin. Moisturizing children's skin during the winter is important and that includes wearing protective lip balm. Also, make sure your child uses sunscreen when playing outside whether it's cold or hot outside. 

The other concern would be kids with asthma. People have different triggers for their asthma. The most common ones tend to be weather changes, viral infections and exposure to certain allergens. Cold, dry air can cause bad flare-ups and viral infections are the most common trigger this time of year. Parents should stress to their children the importance of handwashing, especially this time of year.

Myth 2: If children go outside with wet hair or without shoes, they’ll get sick.

Many people believe that cold temperatures are responsible for the spike in illness that typically occurs during late fall and the winter months. People get sick in the winter because they spend more time in close proximity to one another, not because they’ve been exposed to cold weather.

The truth is it’s not really going to matter that much if your kids go outside without socks and shoes – except maybe if you don’t want dirty feet or if it’s extremely cold, your child runs the risk of frostbite.

It’s true we do see more colds, flu and flu-like viruses during the winter. Both the life cycle of common viruses and the fact that people are more likely to be clustered inside their homes and schools when it’s cold outside, which causes viruses to circulate, contribute to this increase.

Myth 3: People lose most of their body heat throughout their heads, so children should wear hats while playing outside in cold weather.

This tale originated in response to several studies conducted by the United States Army in the 1950s. Further research has since debunked this claim, but it’s true that your face, chest and head get colder faster when you’re exposed to winter weather.

Your face is particularly sensitive to the cold. If your children’s faces are cold while playing outside, they should wear warmer clothes. But colds come from germs – not cold temperatures – so children aren’t going to get sick if they don’t wear a hat.”

Myth 4: Feed a cold and starve a fever.

We’ve all heard this and probably most of us can’t even keep the saying straight. But there’s no scientific evidence to support the idea that children should fast when running a fever. Children who are sick should eat when they feel up to it and drink plenty of fluids to prevent dehydration.

Even if children don’t feel hungry, we ask parents to encourage their kids to drink as many liquids as they can. I’ve also heard an old wives’ tale that says you shouldn’t drink milk if you’re running a fever, but milk works as well as other fluids when it comes to keeping kids hydrated. Other good choices include water, Pedialyte and Gatorade.

Myth 5: All fevers should be treated with medicine because high fevers are dangerous.

As parents, it’s only natural to rush to the medicine cabinet at the first sign of a high temperature, but fevers aren’t always a cause for concern. In fact, they help your child’s body fight infection. According to the American Academy of Pediatrics, children’s demeanors are often better indicators of illness severity than the numbers on the thermometer. If children aren’t fussy or complaining of feeling badly, there’s no need to treat a fever unless their doctor says otherwise.

Myth 6: You can’t prevent your child from catching a cold.

While there’s no cure for the common cold, you can take steps that will reduce your child’s risk. In this case, grandma is right. These are the same steps she told you. Wash your hands after you sneeze. Wash your hands after you blow your nose. Wash your hands after you eat. See a theme? Children should sneeze into the crook of their elbow and not their hands. They should blow their nose to get rid of the mucus. For children too young to blow their noses, parents should use a blue bulb syringe and drain the child’s nose with salines. If a cold lasts longer than a week, bring your child in to see his or her pediatrician. It could possibly be a sign of acute sinusitis and may need to be treated differently than the common cold.

Don’t buy into the weather myths. Here are some tips for preventing health issues:

• Help your child eat healthy and get good sleep.
• Get your child up and active in some way every day.
• Teach your child to wash their hand and cover their coughs.
• Get your child a flu shot (it’s still not too late).

1. The Centers for Disease Control and Prevention (CDC) is closely monitoring the current outbreak caused by a novel (new) coronavirus first identified in Wuhan, Hubei Province, China.
2. Coronaviruses are a highly contagious type of respiratory virus that will sometimes cause outbreaks in regional areas (if you remember SARS, think along those terms).
3. Human coronaviruses are common throughout the world. The CDC states there are seven different coronaviruses that scientists know of, that can make infect people and make them sick.
4. A current strain of the coronavirus caused hundreds of cases in China. Symptoms typically are runny nose, cough, sore throat and fever.
5. Because the virus replicates and causes high levels of infection in the lungs, it can spread rapidly to a large number of people.
6. Because it’s so new, there’s no specific treatment for coronavirus, but exposed individuals should be monitored for upper respiratory symptoms and worsening breathing problems.
7. For now, most of us in the U.S. are at low risk for coronavirus, but care should be exercised for anyone traveling to or from the impacted areas of China.

We will continue to monitor the CDC and other health organizations. If there’s something new to report, we will be sure to let you know.

*Image Credit: NIAID

When should you be worried? The biggest issue is context. You can read the other posts to see all about that.

Another reason you should be more concerned with fever is if it is lasting more than 5 days. Of course, if you end up with a diagnosis where fever is known to last more then 5 days, no big deal, but otherwise, most fevers should be gone by then.

This situation is called fever without a source.

There are many different definitions of fever without a source but I use: fever greater than 101 for eight days in a child in whom there is no obvious source of the fever through the patient’s story or physical exam.

Because children can often have back-to-back viral infections, it is important that this fever be present daily or near daily. For instance, it doesn’t count if they had fever for 3 days then were better for 2 days and then had fever again for 3 days.

The different things to think about are all over the place and can range from very serious to the “no-big-deal.”

Infections - The most common diagnosis in this instance is “unknown” but the fever goes away on its own. While often not intellectually satisfying (to either me or the parent who wants to know what is going on), this is probably the best outcome for the patient. Most of those are probably viruses for which we don’t have or don’t think to run specific tests. Bacterial infections can also cause long-standing fever.

Rheumatologic - Less commonly, children with prolonged fever can have rheumatologic causes, an example is juvenile rheumatoid arthritis. Often these children will have exam findings like swollen, painful joints or swollen lymph nodes that will help point towards their diagnosis.

Malignancy - Fortunately, this is a very rare cause of prolonged fever but it does happen so we all need to keep it in the back of our mind. The most common type of cancer in children is leukemia.

The workup for fever without a source involves a few things:

1. Repeat histories and physical exams - Often things are discovered over time.
2. Preliminary screening labs - Check these in just about all kids with it.
3. Specific tailored labs and exams - Check some of these based on a child’s story or exam.

Kawasaki disease

One specific cause of fever over five days deserves specific attention. Because many parents are not aware of it and because the diagnosis can be tricky, I thought it deserved its own specific mentions.

Kawasaki disease (KD) is characterized by the characteristic fever over 5 days along with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye
• Swollen lymph nodes of the neck

One of the other things to note with KD is that these children are very, very irritable. Not kinda irritable, but noticeably irritable even to a pediatrician who hears crying babies and children all day long irritable.

The cause of KD is unknown. There is some evidence to suggest that there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of KD involve the heart and can be inflammation or the lining or muscles of the heart or dilation of the arteries that supply the heart.

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

The good news is that children with Kawasaki's disease, like the child in the photos with this blog, usually return to normal and don't suffer complications.

"What happens if my child eats all of my adult vitamins?"

We received this question recently. Let's discuss.

Just like any adult medication, vitamins should be locked away so that kids can't get to them. Vitamins are particularly risky because, while they may seem harmless, ingestion of multiple vitamins can be dangerous. In addition, vitamins are colorful and often made in forms that kids love to eat (chewables and gummies).

Vitamin toxicity can occur if a child is taking a few extra vitamins per day or if a child ingests a large amount of vitamins in one sitting.

The most dangerous vitamins ingested by kids are the fat soluble vitamins (A, D, E and K) and iron. Other vitamins and minerals can cause problems as well, but many are passed in the child’s urine without concern.

If you suspect your child has ingested a large amount of any vitamin, call Poison Control at 1-800-222-1222.

They can help you asses the amount that the child ingested and what the risk is.

Most commonly your child will have some stomach upset with or without vomiting. Severe toxicity can occur with Vitamin A and iron, which can lead to multiple problems and ultimately lead to death.

Hope this helps. Just remember to keep all medications locked away and out of reach of your kids. 

Doc Smitty

Man…this is a tough one.

Remember when your child was a toddler, and you taught them to poop on the potty? It was all leading up to this moment. Everything we have taught them along the way was an effort to allow them to become more independent.

But, now that they are, why does it hurt so much?

This time can be painful and confusing, but it can be handled with grace on both sides.

Unfortunately, it’s not always easy.

Here are 8 mistakes that parents make when their child starts to pull away:

1. Holding on too tight. Not allowing your child to spread their wings can create resentment and frustration. Yes, they are your baby, but they don’t want to be treated like one. It’s OK to let them try new things and make mistakes. Be there to help them learn from them.

2. Not holding on tight enough. Even though they seem more independent and don’t seem to want you around, they are still immature and still need someone to protect them from the big mistakes. Monitoring their technology use and being aware of their friends are essential examples.

3. Taking this transition time personally. They might act as they hate you…they might even say that they hate you…but they probably don’t actually hate you. While you might get your feelings hurt from time to time, it’s important to remember that this transition is healthy and not a reflection on your parenting skills.

4. Making judgments too quickly. If your teen starts to tell you something about their life or feelings, they can see right through your judgy looks. Practice in the mirror…whatever it takes. Just listen without (apparent) judgment.

5. Giving up too quickly on family time and family plans. You’re going to get shot down over and over. It’s OK to make family dinners a requirement as often as you think it fits your family best. Also, make a point to involve your teen in planning family time. If they choose the activity, they are more likely to be a willing participant. You can also leverage that to say, “Remember when we all played Fortnite together? Now it’s your sister’s turn to plan.”

6. Trying to have serious and deep conversations all at once and face-to-face. These are awkward and unlikely to meet their desired goals. Talk about the issues in small chunks. Use the car ride or some physical activity time (playing catch).

7. Dominating conversations. Say anything that smells of “I-told-you-so” or involves a long drawn out lecture, and you’re actually doing more to push your child away.

8. Not recognizing warning signs that it’s more than just standard teenager stuff. Unfortunately, teens and pre-teens do get depressed, and significantly withdrawing can be a sign. Look for the following:

• Significant abrupt changes in interaction.
• Severe withdrawal (not coming out from arriving at home until school the next day).
• Moving away from activities that they used to enjoy.
• Loss or gain of appetite/sleep.

Growing up can be difficult. Don't forget that. We've all been there before. But normally, things will get better and they will come back to you soon enough.

But when the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, treatment with an acid reduction medication is considered.

One common medication is a group of acid reducers known as H2-blockers, with the most common example containing ranitidine.

Ranitidine is in the news right now because the FDA recently reported that they had found small amount of a potentially cancer causing chemical in brand name and generic Zantac (ranitidine) products.

CVS Pharmacy has stopped selling products which contain ranitidine (Zantac as well as its generic version of the heartburn medication) until further notice.

According to the FDA, Zantac has potential cancer-causing chemicals. But those are found in anything else we eat, breathe, sleep, live on.

For now, here’s what we do know:

1. There are likely many babies who have been placed on ranitidine unnecessarily for what is normal fussiness or normal spit up.
2. There are also likely many babies and children who have been started on Zantac but no longer need the medication and have been passively continued on it.

We don’t know the long-term effects, but this is your baby we are talking about. So, even if the risk is minimal it would be reasonable to consider your baby's case and have a conversation with your doctor about whether coming off the medication might be the right thing to do anyway.

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

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

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

Age (When will my kid stop barking?)

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

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

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

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

Pathology (What makes my kid bark?)

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

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

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

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

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

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

Two take home tips:

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

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

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

And here are 5 other common causes of chest pain:

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

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

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

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

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

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

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

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

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

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

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

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

More On This Topic:

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

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

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

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

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

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

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

Effectiveness/General Use

Do they really work or is it a mind over matter thing?

I think that there are probably some uses for oils that will be studied and proven to work. I think these will be pretty rare and only a small fraction of the claims that are currently made.

So, is it mind of matter (placebo)? Here are some of the most common uses I see for oils in kids:

Teething - It’s not even clear what symptoms teething causes …fussiness, fever, runny nose, etc have all come into question. But, if you give an oil and a symptom goes away, does that mean the oil fixed it? Not likely.

Fever - Fevers come and go during the day with illness, even without medication.

Cough/congestion - The regimens I see where children have oils placed frequently basically make it impossible to know if they do anything for these symptoms. Cough/congestion will be worse at certain times of day and better at others treatment or no.

How close are we to having actual research on the use of oils?

I still think we are quite some time away. Those that are currently doing research are often biased, are not doing high-quality studies and are using small sample sizes.

Marketing

Why are they sold through multi-level marketing (MLM)?

It’s a fast way to get a product out there and make a lot of money. Since I’ve been on social media, I’ve seen several of these types of MLM ideas crop up. The difference with these is I have some specific knowledge about the conditions they are being used for and specific concerns about how their use could harm a population of people that I care very much about. I know very little about bags and good smelling wax that can be melted with a light-bulb so I haven’t gotten involved until now.

In many ways, it protects the big company because they are not the ones out there making claims about the oils and what they can do. That falls to their independent distributors. If someone were to have a bad outcome because of their use of essential oils, who is responsible? If I prescribe a medicine that someone is allergic to, that responsibility falls squarely on my shoulders, not the makers of amoxicillin. If I prescribe the wrong medicine for a kids asthma and something bad happens, that responsibility falls to me.

Are they an increasingly popular trend or just something I was not aware of?

I’m not sure but it certainly does feel like they are gaining in popularity. Social media makes it seem that way at least.

Do you believe the claim that certain brands of oils are superior to others?

I’m sure there are differences but since we don’t even know what they do for the most part, it’s hard to answer this question.

Philosophy/Opinion

Regarding writing about essential oils: Are you mad, man?

Yes, in fact, I think I must be.

What’s the number one reason you see parents using oils instead of medicine?

In general, people are becoming less trusting of experts and organized institutions. Medicine and doctors are no different. The gap between what a doctor knows and what patients know shrinks every day. People can find out information about their conditions and know basically the treatment options that exist. People are looking to live more natural lives and most who use them feel that oils fit within that idea. When you combine these two issues, right or wrong, essential oils seem to step in the gap.

What is a good way to communicate with your doctor about your use of essential oils (for specific conditions and generally)?

I think it’s important to be honest with you doctor about your use of essential oils. As new information is uncovered it would be important for your doctor to be able to show you new research etc, especially if something shows a particular oil to be unsafe. They can only do this if they know about your use of them. Also, as doctors are prescribing medications, we need to know anything you might be on that could cause a drug interaction.

What is your take on the potential political barriers to the study of essential oils given that they are not backed by super profitable pharmaceutical companies?

Young Living is a very profitable company. They are big and profitable and will only continue to be more profitable. There is no reason that they could not start testing their own products or set up independent testing.

After your research as a pediatrician, would you use them on your children?

People will read all of this information or even do further research and come to different conclusions from me but here are two reasons I won’t:

1. I do not treat my kids with unnecessary medications. Since they are recommended for symptoms and given with the hopes of reliving those symptoms, I consider these oils to be medication.

2. I believe that, due to the lack of good studies, the use of them in children should be considered experimental at this point.

Summary

• The use of essential oils seems to be growing.
• The evidence for their use in children is slim.
• Talk with your doctor about the products you are using so that they can be aware of potential safety issues and medication interactions. 

Previous articles on this topic:

• New York Times Report: Are Essential Oils Safe For Kids?
• Essential oils and their use on children
• How safe are essential oils for children?

My interest began with a report from the Tennesee poison center that said reports of toxic exposures to oils doubled from 2011 to 2015. Of those reported cases, four out of every five were in children.

As I began my research on essential oils, I asked what you guys wanted to know. I asked on Facebook what you all wanted to know and you guys had some great questions.

Most indicated that they “really wanted to hear my opinion.”

I will take the questions and try to divide them up by category as best as I can.

I feel like I owe it to you, and your children, to give my candid answers on the subject.

Safety

Q: What harm have you seen from patients choosing oils over modern medicine?

A: I’ve seen two examples of this. The first were parents using oils for their child’s eczema. They came to me after one month of attempts (including multiple different regimens) to treat with oils and the child ended up having a secondary staph infection of their eczema because the skin was open. In fairness, severe eczema happens and secondary skin infections happen, but most of my patients with eczema do not get that severe with the medications I typically recommend. The second patient was one who had an upper respiratory infection that led to croup (noisy, barky cough). The parents were trying oils at home for three days (again multiple different attempts to get the “right” oil) before they ended up in the emergency room and admitted for two days for difficulty breathing. The theme here has three components:

1.The oil itself did not hurt the child.

2.The ambiguity as to which oil should be used led to multiple different regimens and oils being tried.

3.The biggest problem with these two is the delay in receiving appropriate care.

Q: What is the best way to explain proper dilution to others?

A: Ummmm…I don’t know. Based on what I have seen regarding research this has not truly been studied, at least in children.

Q: Are there any that are harmful for use topically?

A: There are case reports of severe toxicity with topica application that uses eucalyptus and tea tree oil from those that I studied. These are mainly due to extensive application. Toxicity to any treatment is always related to dose. The more area you cover, the more likely it is to be toxic. There are also some reports of reactions with very small applications. The other concern I have (for which we don’t know the answer yet) is how does the toxicity change when these oils are being applied hourly (as I’ve seen recommended) or when multiple oils are being used at once.

Q: Can I use them in my child with asthma?

There are no studies that show effectiveness for asthma. Any inhaled substance with a small particle size that can get into the lungs could theoretically lead the airways to constrict which would actually cause more problem in children with asthma.

Q: What happens when oil are ingested (purposefully or accidental)?

Even most pro-oil websites don’t recommend ingestion of oils in children and to use extreme caution in adults. Because we do not have studies that evaluate the safety and appropriate dosing for ingestion by children, this is the one hard line I take with my patients who are using them. Please do not use them in this way.

Q: Have you seen allergic reactions?

The allergic reactions I have seen are mostly related to the skin. Application of anything topically can flare a child who has eczema or cause contact irritation of the skin.

Q: Are they really good for you or are you you doing more harm than good?

I don’t think we know the answer to this question on a global scale. If they do have all the anti-bacterial, anti-viral and all other properties, and will actually work for those uses (which are not proven in humans), would we go on to see essential oil-resistant-bacteria? I believe we would. Especially with the way they are currently being used. Basically applying whatever oil for whatever infection (I am basing this on the fact that anytime I see someone requesting help with which oil to use, they routinely get 5-10 suggestions). That is exactly the way resistance to antibiotics occurs - too many antibiotics for non-specific indications and next thing you know a certain antibiotics doesn’t work for certain infection any longer.

Q: Is it safe to use oils along with modern medicines?

We know that these oils can affect the liver and cause the liver to metabolize other medications faster or slower. This could lead to medications not being as effective or potentially be more toxic. Some information is being gathered in adults to try to figure this out but kids are not “little adults” and we’ll likely need research in children before we can answer this for sure.

More from Doc Smitty on this topic:

New York Times Report: Are Essential Oils Safe For Kids?

Essential oils and their use on children

Essential oils and children - more questions answered

Believe it or not, summer’s almost over and the new school year will begin before you know it.

Are you ready? Or are you like a certain dad I know who usually waits until the last minute? Last year, this dad forgot:

• To book his child's physicals so he had to scramble to get checkups before flu shots.
• His daughter has some pretty significant fears about going into school the first day and he didn’t take the time to properly prepare her.
• To get his son's asthma inhalers refilled and the forms on file so that he could have it at school (until April when he was having a flare).

Don't be like me…here are 10 steps you can take to make sure you and your child are ready for back to school.

1. Vaccines - Make sure that your child is up to date on vaccines. As your kids get older, your school might prevent them from enrolling in classes or other benefits, which might make it difficult to get their classes scheduled, etc. Vaccines are routinely scheduled at 4 years old (measles, whooping cough and polio among others), 11-12 (whooping cough and meningitis) and 16 (meningitis). At Cook Children's, we also recommend the HPV vaccination starting at age 11.
2. Physicals - If your child plans to participate in a sport or marching band they may need a sports physical form to be completed by your child's doctor. This requirement is required by the UIL before junior high, ninth and eleventh grade but many schools ask for it each year. The marching band requirement is new so not as many parents are aware. I expect we'll be doing a lot of those in the first few weeks of August. Students who are attending private schools or participating in sports that aren’t governed by the UIL may have other physical exam requirements. Many of these kids are already out in the heat working hard preparing for their upcoming season, so I recommend getting these as soon as possible.
3. Forms - Don't be that parent who realized in April that their child doesn't have his inhaler or the form required to take it at school (ahem ... me). Here are some common medications your child might take which might need to be administered at school: inhalers/nebulizers for asthma, insulin, ADHD medications and pain reducers.
4. Sleep - Transitioning back to a sleep schedule that works for school might be the most difficult transition in prepping for back to school. The older your child, the more likely they are to be going to bed too late and sleeping in. Start making subtle changes in their bedtime over the next few weeks. Rolling bedtime back 30 minutes at a time can make the transition to early morning easier.
5. Screen time - Just like sleep, screen time can get away from us a bit over the summer (Fortnite! I’m looking at you). An immediate drop off in daily screen time can be a struggle so starting to make changes now can help your screen junkies detox a bit before they go back to school.
6. Your child’s back to school fear or anxiety - Many children deal with some fears about going back to school. These fears can be mild or they can be more severe, almost debilitating. Helping your child prepare for the transition by talking them through their day, setting up a play date with classmates ahead of time or taking a tour of the school can orient (or re-orient them) back to school in a way that can be helpful. If the anxiety is more severe, consider talking with your pediatrician or a play therapist in advance to help them and you prepare.
7. Your back to school fear or anxiety - Getting yourself prepared for back to school is almost as important as preparing your child. Some parents will kick their kids out the door and drive off to their gym class without a second thought. For others, the transition can be just as hard on the parent as the child. Begin now to prepare yourself for what it will feel like those first few days at drop off. Showing emotions with your child is certainly OK, but a prolonged, tearful drop off can make things harder on your child.
8. Supplies - Get your child ready for back to school by buying their school supplies in advance whenever possible. Whether you buy the prepared packet from school or enjoy the process of shopping for individual supplies doesn't matter, just make sure your child is well prepared with what they need to start the year off right. Buy some extra tissues or hand sanitizer to help the teacher out.
9. Set goals - My favorite part of a new school year is the fresh start that kids can get. Whether last year was amazing or a huge struggle, it's a great opportunity to help our kids realize that they can always work on something to make themselves better. Using last year as a guide, help them set some goals that focus both on their strengths and challenges.
10. Attend meet the teacher night - Sometimes these events occur before school and sometimes they occur a little after school starts. Use meet the teacher night strategically to help frame your child in a positive light. This can go a long way to helping your child accomplish their goals for the year.

Whether you're counting the hours until you can send the kids back or dreading the return of early mornings, hopefully, these tips will help you think through some of the things you need to consider. I know it did for me.

What topics did we miss?

Related To This Topic:

• Vaccines and Immunizations
• Immunization Schedule
• Common Questions About Immunizations
• Knowing Your Child's Medical History
• Sleep Center
• Your Kids Are Ready For School. But Are You?
• 5 Questions Every Parent Should Ask Their Child's Teacher
• 6 Ways You Can Help The Teacher Understand Your Child

But when it comes to newborns, forget everything I’ve always taught you about fever. If an infant has a fever, it is a sign something is wrong and a serious cause for concern

In older children, fever is almost never an emergency, the exact degree of the temperature doesn't really concern me and unless there are other reasons to do so, a workup isn't indicated.

In babies up to 3 months of age, the opposites are true.

Fever in a newborn is an emergency. When a newborn has a fever, parents should have a sense of urgency.

An accurate temperature really matters for newborns. You don't need to go around checking your baby for fever randomly. But if they feel warm, are not eating well or you're otherwise worried, we recommend taking a rectal temperature. Rectal temperature is important because it's the most accurate way to determine the temperature and the studies that tell us what to do with your baby are based on rectal temperatures.

Once you have an accurate temperature, I recommend that you call your doctor with any temperature over 100 degrees. Technically fever is anything over 100.4, but it's good to let us know so we can coach you on what you should be looking for. It also helps us decide what should prompt a visit to the emergency room if it rises overnight.

Fever is such an emergency in babies because they can be an early sign of serious, even life threatening infections and babies can't tell us if something hurts. Babies can have blood stream infections, meningitis or urinary tract infections with little other symptoms. They also can get all the other things that older kids get too like stomach bugs, flu and other viruses but we would rather be safe than sorry.

Because of these risks, babies with fever will typically receive some type of lab work to determine if infection is present. This can include blood work, urine test and possibly a spinal tap to rule out meningitis.

While it's scary and no one wants to think of your baby needing this work-up, the fear of missing one of these serious infections or leaving them untreated, even for a short period, is even scarier.

Most babies with fever will be started on antibiotics while we wait in results from the test. This prevents babies from getting worse while we wait for results to come back.

So, as you can see, fever in newborns is a LOT different.

But, the important thing to remember is to call your doctor if the fever is over 100 and we'll help you keep your baby safe from there.

Related Topics:

• My Child's Fever Isn't Going Away. Should I Be Worried?
• 7 Types of Thermometers and to what Degree You Should Trust Them
• My Child has a Fever. Should We Go to The ER?
• 5 Days of Fever. Now What Should I Do?
• When It Comes to Your Kids It's Never Just a Virus
• Let's Learn About Fevers
• 4 Reasons Why This Pediatrician Doesn't Alternate Tylenol and Motrin for His Kids

They can be very ugly. They can cause pain if they’re in a tough spot. They can last forever.

Because of this, I’ve seen families try just about anything and everything to treat them.

But what actually works?

Many warts will go away on their own over time. Studies have shown about 80% of warts are gone after four years … but sometimes we can’t wait that long, especially when it’s your child in pain.

Here’s a look at some of the alternative and conventional treatment options for treating warts, along with my thoughts on if they are worth your time:

1. Apple cider vinegar – There are limited studies that show mixed results for using apple cider vinegar. It can be very irritating to the skin for some children. It’s OK to try but I wouldn’t get my hopes up.
2. Salicylic acid – Yes, this is a cream typically used for acne, but salicylic acid has been shown in some studies to effectively treat warts. The skin irritation associated is common and expected, but it has a better chance of working than apple cider vinegar…so it might be worth it.
3. Tea tree oil – While tea tree oil has been studied (and actually works for a few pediatric skin issues), warts are not one of them.
4. Crushing aspirin or Vitamin C and applying – No on these as well. No evidence that they are effective and it sounds like a lot of work.
5. Aloe vera – While unlikely to cause any problems, aloe vera is not effective treatment.
6. Duct tape – One small study showed that covering a wart with duct tape led to resolution of the wart. Later studies were done which showed it didn’t work, but the researchers used clear tape instead of silver duct tape. So, right now we’re in a sticky situation (sorry) where we don’t know if it works or not. I would use the silver if I wanted to try it. It has been suggested to combine it with the salicylic acid treatment.
7. Freezing – The most standard treatment is freezing. Freezing works well, but might require retreatment after a few weeks if it doesn’t completely go away. Freezing can be difficult for warts on the feet or hands because the underlying nerves can be damaged.
8. Surgical removal – If all else fails, a physician can provide local anesthesia and remove the warts.

So there are lots of alternatives to try, but a conversation with your pediatrician is a great place to start. From there, you may be referred to our Dermatology team or to Pediatric Surgery. 

But for the most part, the best weapon against warts is patience.

Related To This Topic:

• Plantar Warts
• Molluscum Contagiosum: The Most Common Rash You Never Knew About
• 7 Skin Conditions Young Athletes Need To Know About
• 5 Common Medical Conditions That No One Shares On Instagram

They were doing great, breastfeeding or taking a bottle and eating some solids but now what?!??! You're expected to change everything. First off, remember that if you plan to continue to breastfeed (which is awesome if that’s your choice!), some of this won’t apply to you but some of it will.

With everything else going on, I’m here to tell you it doesn’t have to be that complicated.

Here are my 5 simple rules for transitioning to milk at 1 year of age (and only two low-stress choices for you to make):

1. Remember that there’s nothing magical about milk.

Cow’s milk is an easy source of calcium, calories, and protein but if they are eating those things then they actually don’t have to drink milk at all. Especially keep that in mind when you make the change if their milk intake falls off. It’s OK. I generally recommend 18-24 ounces per day. This should be enough to get your baby some extra calories, but not be so much that it can lead to constipation. Also remember that yogurt and cheese have similar nutritional content so they can be included in the total as well.

2. Transition to a cup before 15 months.

The closer to 1 year that you can transition to a cup, the better. Hopefully you’ve been offering some water at meal times with a cup for a while. Don’t buy any large quantities of a cup until you find out what your baby likes. Put the cup in front of them, they’ll eventually drink.

3. Decide on a milk. You have some choices.

Remembering rule  No. 1, it’s OK to give yourself some flexibility in the milk that you choose. I’m not worried about cow’s milk or dairy intake as a general rule. Depending on baby’s weight, I am Ok with either whole milk or 2% milk. Talk to your doctor about which might work for your child. There are a few milk alternatives that closely resemble cow’s milk in nutritional content (pea and soy milk are examples) but there are others that are basically water (almond milk). I don’t routinely recommend toddler formula unless medical indicated or recommended by your doctor.

4. Decide on a plan for your transition.

I’ve seen families make the change cold turkey the first day it was possible. I’ve seen families slowly transition by adding in milk alternating bottles with formula. I’ve also seen families mix some formula and some milk in individual cups. I haven’t seen any one particular strategy work better than another. I think most babies would do fine with a quick transition or cold turkey swap…but every baby is different.

5. Try not to stress too much about this.

There are plenty of things to worry about in parenting. Deciding what to give them to eat and drink shouldn’t add to your stress. Provide them plenty of fruits and vegetables. Decide on your milk choice and your method of transition and don’t stress the rest.

They will have good days and bad days (just like us).

But, I promise everything is going to be OK in the end.

To identify the hot spots, researchers from the University of Texas at Austin and Johns Hopkins University looked at each area’s volume of international travel from foreign countries with large measles outbreaks and the prevalence of nonmedical exemptions from childhood vaccinations.

The same researchers previously predicted outbreaks in Washington, Oregon and New York which are all experiencing an influx of measles cases.

“For measles, most experts believe that there will be one to two deaths per 1,000 cases, most likely infants. We are set to see over 1,000 cases in the U.S. in 2019. So, for the first time since the 1980s, we may expect infant deaths from measles in the U.S.,” said the study’s lead author, Sahotra Sarkar, a philosophy and integrative biology professor at UT Austin and an expert on public health, in UT news. “We have long known that vaccine avoidance is a critical public health issue in the U.S. and Europe. Our results show how travel from regions elsewhere compounds this risk.”

The Texas Department of Public Safety has confirmed 15 measles cases in Texas this year, including one in each: Tarrant, Dallas and Denton counties and two in Collin County. Comparatively, Texas had nine measles cases in 2018 and only one in 2017.

Already this year, more than 760 cases of measles have been confirmed in the United States, the highest number in decades.

Physicians at Cook Children’s call this news frustrating because measles is a disease once thought to be all but gone from the planet. Texas has one of the highest rates of unvaccinated children in the U.S., partly due to a 2003 state law allowing parents to opt out of getting their children immunized for reasons of conscience.

“It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning.”

Measles is a highly contagious respiratory illness spread by contact with an infected person through coughing and sneezing. Measles is so contagious that if someone has it, 90 percent of the people around that person who are not immune will become infected.

The Centers for Disease Control and Prevention (CDC) recommends children who are older than 12 months 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.

Two doses of the MMR vaccine are about 97% effective at preventing measles; one dose is about 93% effective.

"Populations who choose to not follow the recommended vaccine schedule 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," said Jason Terk, M.D., a Cook Children's pediatrician.

Other Texas counties to make the Top 25 were Harris at No. 9 and Travis at No. 22.

To learn more about where you can receive vaccines in the Tarrant County area, visit the Immunization Collaboration of Tarrant County website.

For More on This Topic:

• 25 U.S. Counties Identified as Most at Risk for Measles Outbreaks
• Vaccines and Immunizations
• Immunization Collaboration of Tarrant County
• Common Questions About Immunizations
• Why Children Like Olivia Need You to Immunize
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know

Popular rocking sleepers have been in the news lately for all the wrong reasons. 

Last week, Kids2 recalled all of its rocking sleeping models after reports that say five children have died in its sleeper since they were introduced in March 2012. 

Approximately 700,000 products were sold at major retailers including Walmart and Target. The brand names of the sleepers included Disey Baby, Bright Starts and Ingenuity.

Earlier in the month, Fischer-Price chose to recall its Rock ‘n Play Sleeper after 32 infant deaths associated with the product. Fisher-Price chose to recall approximately 4.7 million of the units on April 12, following a report from the U.S. Consumer Product Safety Commission (CPSC).

Less than two weeks later, two class action lawsuits have been filed against Fischer-Price and its parent company Mattel.

While there were claims that the deaths were only associated with the unsafe use of the device, the CPSC stated the deaths occurred “after the infants rolled from their back to their stomach or side while unrestrained, or under other circumstances.”

“And our concern doesn't stop with only the Rock 'n Play or the Kids2 products,” said Justin Smith, M.D., medical advisor of Digital Health at Cook Children’s. “Other sleep aid devices such as hammocks, nests and wedges also can put babies at risk for both suffocation (where a baby turns into a soft surface and rebreathes their own breath) and positional asphyxiation (where a baby's airway is squeezed off by flexion at the neck).”

“It's clear that the safest position in which a baby should sleep is on their back, on their own in a boring, flat surface.”

So what do you do with a baby that never slept well anywhere else? We talked to Dr. Smith and Diane Arnaout, M.D., a Cook Children’s Pediatrician at Forest Park to get some ideas.

Dr. Smith: First of all, we want to say that we know the idea of making this transition away from a sleep device or the idea of having another baby without one (when your first baby only slept in one) is scary and overwhelming.

We hear you.

And, believe me, if we could recommend something magical that would help your baby sleep, we would tell you all about it. No one needs to sleep more than pediatricians, especially pediatricians who are parents.

Here are some tips that might help you survive with a baby who is a poor sleeper:

Give your baby their best chance to sleep by maximizing their environment.

Dr. Arnaout: Try to mimic the womb environment. What happened in the uterus? It was a dark, warm, noisy place. A baby is looking for that same type of environment outside of the womb.

Some adjustments that you can make that might help:

• Use a sleep sack that is snug but not tight (if you choose to swaddle make sure that you are stopping after two months)

• Turn on a sound machine to provide some white noise-this mimics the sounds of the blood vessels in mom's tummy.

• Allow your baby to use a pacifier once breastfeeding is established - not only does it help with sleep, it's also protective for SIDS.

• Help your baby go down to sleep drowsy but not asleep, this will help them make those transitions at night when they enter lighter sleep stages.

• Practice, practice, practice - use your sleep routine (or at least an abbreviated version) with every sleep, this helps your baby understand when it's time to go down.

Remember the bottom line is that babies should be sleeping alone in their own crib, staring on their back, with no blankets or pillows.

Dr. Arnaout: "I know this seems out of the blue and unrelated, but - It’s really important to make sure your baby is getting "full feeds". This doesn’t mean any particular number of ounces or minutes of nursing - this just means discouraging “snacking”. I tell parents daily that babies who snack all day are gonna snack all night. Babies who are encouraged to empty both breasts, or fill up on as many ounces as possible during a bottle feed, are able to go longer between feeds and are able to fast for longer periods at night."

We know that the transition out of the Rock N Play is going to be brutal. But you were going to have to make that transition at some point, this probably just accelerated the timeline (or kept you from having to make one at all). So, expect some rough nights and do your best to prepare.

Seek help when you need it. It's more than OK. It's necessary.

Dr. Smith: It's particularly hard to shoulder this burden of poor sleep when you feel like you're on an island. And I know there are parents out there who struggle to get help. But this is a situation where a tired baby, makes for a tired parent and a tired parent doesn't have the same patience to work with a fussy baby to help them through this transition.

I know that sometimes partners need to go to work the next day and feel like they can't work on shortened sleep. But, keep in mind, that staying home and parenting after no sleep is no walk in the park either. Find creative ways to share the burden. It's amazing what one good night of sleep will do to prepare you for a few difficult nights.

If both parents are working and your baby isn't sleeping well, seek out friends or family who might be willing to take a night or even just a few hours for you. Friends and family, when you hear that mom and dad are struggling to get sleep...don't ask what you can do to help, ask what night they want you to come over.

Dr. Arnaout: I think one of the hardest things for me to realize with my first baby was that we were gonna have good nights and bad nights, and one day…I’d sleep full nights again.

Dr. Smith: I think it’s important for parents to know that safe sleep is accessible for all babies. What doesn’t work one night may work the next, as the child grows and develops. And kids’ sleep is phasic - you’re gonna have weeks where they rock it, and nights when you’re totally questioning your life decisions.

Recognize your exhaustion as temporary! It will get better!

The more weight your baby puts on and the more self-calming mechanisms they develop as they grow will both help you climb out of the early infant months well-rested and feeling confident your child is safe while they sleep! And as always - if you need help - ask your pediatrician! We are honored to be a part of your “village” and have helped thousands of families during this trying time.

We know that this topic is one that inspires a lot of passion. No one wants to make a family feel guilty who has used the Rock n’ Play in the past or who are currently struggling with what to do. But, the reality is, that new information is almost always a good thing. And this information says that these devices are not safe. While we'd love to compromise, we can't advocate for using a device that causes infant death, especially when used as directed.

What about babies with reflux?

Dr. Arnaout: "One morning, I woke up to find that my first baby, who experienced pretty bad reflux, had barfed all over the place sometime in the night. It was everywhere - in his hair, his ears, and soaked into his sheet and sleep sack. I felt horribly guilty for not hearing it or being there to help - even though I was laying in bed right next to his bassinette. I was an exhausted mom, and looking back, I needed to forgive myself. I was worried that morning - what if he had choked? Aspirated? But then I remembered all the protective reflexes babies have to protect their lungs - namely, gagging and coughing - that gets it all out, and allows them to breathe again.

There is some thought that tucking a blanket or wedge under the mattress to elevate the baby might help, but lately, research has proven that elevation may not really help: "The supine sleep position does not increase the risk of choking and aspiration in infants, even those with gastroesophageal reflux, because infants have airway anatomy and mechanisms that protect against aspiration.”

What do you think about baby monitors?

Dr. Arnaout: I think monitors are both helpful and not helpful. The AAP says babies are most safe in the parents’ room in the first year, in their own sleep space (crib). But my kids were noisy little people - and I am a light sleeper who would jump up at every single noise. I’ve eventually used monitors with both of my kids when I moved them to their own room and depended on them to let me know when my baby wasn’t feeling well or was hungry. But I always turned the volume on low, and it only alerted me if the baby was yelling pretty loud. I did this because all babies make noises while they sleep: snort, sigh, cough. Refluxy kiddos are honky and loud sometimes when they sleep because the tummy acid juices and milk sometimes irritate the back of the nose as it goes up and down.

And, I’m pretty sure my freshly minted 10 year old will soon be asking about his own Twitter, Instagram or YouTube account soon. I realize this is a tricky situation. Especially since I’m the medical advisor for Digital Health at Cook Children’s and I’m active on social media.

Trust me I see the irony … or maybe the hypocrisy.

But Right now I’m planning to hold off AS.LONG.AS.I.CAN.

Why?

Because I’m a parent. I worry about my kids like everyone else and I want them to be safe and protected

I’m also a pediatrician and I talk to too many kids in my office who are dealing with the negative fall-out of social media. I also see way too many studies addressing how social media has caused harm.

Social media can lead to:

• A fear of missing out. I wasn’t cool in high school (this may shock you and if it doesn’t just stay quiet) but I really didn’t know what I was missing out on. Everyone partied on the weekend but didn’t say much to me about it on Monday. If there had been pictures and posts from the weekends, I would’ve understood how left out I probably was.
• Inappropriate expectations of appearance. We don’t look like the celebrities we follow on social media and we probably never will. Sometimes though it’s important to remember the celebrities don’t look like the celebrities when they are on social media either. They are photoshopped and edited many times. But still, our kids are left to compare themselves to people who taking professional photos or using editing software to make everything look perfect. It’s their job after all. Unfortunately, that doesn’t keep many of us from feeling jealous or feeling like we’ve fallen short when we don’t.
• Bullying. Anonymous or even semi-anonymous (or “behind the screen”) empowered bullying can cause isolation and fear. And it doesn’t stop when you go home from school like it did when I was a kid/teen.
• A lack of ability to process our feelings. The constant ding of dopamine we get from the amount of likes on our posts enables us to continue posting to get our fix rather than process and dive into our sadness.
• Oversharing and shame. Teenagers and preteens don’t understand the significance of oversharing and what can happen later when those details (or pictures) get shared to a wider audience.

So what should we do as parents?

Here’s what I recommend:

• Keep your child off social media as long as possible. I know. I hear it too with my three kids. But the longer you can keep them away from it, the more time you have to talk to your kids about this issue and let them mature to handle what will inevitably come their way.
• When they get on, you get copies of their passwords and connect with their accounts. You can have privacy when you are out from under my roof. Oh man, I’m starting to sound more and more like my dad. But until then, sorry kids, I’m doing everything in my power to protect you.
• You reserve the right to delete the account and take their phone at any time. I paid for it and I can take it away.

I hope this helps. Just know I’m dealing with it too and would love to hear your thoughts. Again for irony … on social media.

When I first started practicing medicine, this line rolled right off my tongue, “Don’t give nuts, eggs or fish until 1 year of age.” The classic teaching was that by avoiding these foods we would prevent the development of food allergies.

But, several studies have been released during the last 10 years that have significantly challenged and changed the advice I have been providing patients.

The new theory is that by exposing babies to new and different foods, they will develop tolerance for those foods and be less likely to present with allergies later on.

Last week, the American Academy of Pediatrics released further guidelines that support the new and emerging science.

Here’s what you need to know about the new guidelines:

1. There’s no evidence that delaying foods will prevent allergies. In fact, it probably causes more harm than good.
2. All children benefit from the introduction of highly allergenic foods before one year of age. And these foods should not be restricted, but fed according to family and cultural preference.
3. Children with higher risk for allergic disease (severe eczema or egg allergy) SHOULD have peanuts introduced between 4 and 6 months and other allergenic foods introduced around 6 months.

I know parenting is never easy, but hopefully the new guidelines will help ease your mind when it's time to introduce your baby to new foods. 

Here are a few of my thoughts that will hopefully make you feel better. And who knows? This actually could turn out to be good thing for all of us (myself included) on what it means to be a good parent.

1. I don’t think it’s real. Despite all the drama and buzz. I can’t find anything that proves this is really happening. It appears to be a hoax  and this isn’t the first time this same story has circulated.

2. It’s motivating parents to reconsider their child’s media consumption. MoMo challenge or not, unsupervised browsing of user-generated video content is a terrible idea (even if that platform is labeled “kids"). Watch what your kids are watching with them. Censor. Protect. That’s what we we’re supposed to do. But we’ve gotten lazy because it’s easier to let the algorithm decide than to actually sit and watch and guide.

3. You get to have a hard conversation with your kids. If you decide to take an app off their device for their protection, you can explain that their safety trumps any momentary joy they might get from watching videos on a screen. You care too much about them to put them at risk.

4. You get to ask your child deep questions so that you might learn about their deepest fears. Because even if this thing isn’t real, some kids are really scared by what they’ve seen and heard. Simple questions like, “Have you seen anything in your device this week that scared you?” “Have your friends been talking about anything that gets you worried?” “How can I help?”

5. Because even if this turns out to be a hoax (which it seems to be), the fact that kids are scared and talking about it is heartbreaking. The fact that someone thought spreading this would be funny at the expense of our kids feeling safe is infuriating. You don’t have to validate the fears to ask about them but you should ask.

Don’t let your kid live in fear without knowing you’re looking out for them.

Here are a few articles about the Momo Challenge you might find helpful:

• Parents, please stop freaking out over the Momo Challenge
• Momo Is Not Trying to Kill Children
• The 'Momo challenge' isnt' a viral danger to children online. But it sure is viral.
• What Is The Momo Challenge?

Whatever you call it, parents have lots of questions about pacifier use.

Let’s look at some of the most common:

1. When is it OK to start a pacifier?

A pacifier can be a life-saver for the baby that doesn’t need to feed at the moment, but desperately wants to suck.

The classic teaching for breastfeeding moms is to wait 3 to 4 weeks for breastfeeding to be established prior to introducing a pacifier. But, I think the most important thing is to make sure you feel confident in your baby’s latch and nursing before introducing a pacifier (or bottle for that matter). If your baby can latch, it’s OK to give him or her a pacifier. This will help your baby’s need to suck and your need to sleep and get a break from the constant nursing.

So day 1, probably not, but you don’t necessarily have to wait 3-4 weeks if you have a baby who is latching and nursing well.

2. When should we stop using a pacifier?

Prolonged pacifier use can primarily lead to two problems: Interference with speech development and dental issues. To prevent these problems from occurring, I recommend changing your strategy for pacifier use to nap and sleep times only after one year of age and starting to wean completely by 18 months with a goal of having them gone entirely by age 2.

3. Do pacifiers actually work to calm a baby?

Yes. Babies have a desire and drive to suck and it’s not always limited to feedings. Some babies never really take to it but for others, it can be a life-saver. Be careful not to jump to the pacifier for every fuss, learn your baby’s other needs and check for those before using the pacifier. But using the pacifier for everyone to get some sleep is perfectly fine when all of your baby’s other needs have been taken care of.

4. Do pacifiers prevent SIDS?

Way below some of the other more significant risk factors for infant death like sleeping on the back, no smoking in the house and other significant findings, pacifier use may be protective for SIDS. Is it a direct and absolute reason to use one? Probably not. But it doesn’t hurt and may actually help.

5. What kind of pacifier is best?

Babies will like all different kinds of pacifiers so don’t buy a whole bunch of one type until you know your baby’s preference. Pacifiers that are single piece may be preferable because they are unlikely to break and turn into a choking hazard. At the very least, pay attention to multiple part pacifiers to make sure they are in good shape. Pacifiers that are easily cleaned and simple seem to make the most sense.

6. Should I put something on the pacifier?

No. The practice of putting sugar or honey on pacifiers is unnecessary and potentially harmful. They can both accelerate the damage to teeth and honey has been known to cause a severe infection known as botulism in infants.

7. When should I replace or change pacifiers?

Pacifiers that are damaged or have been chewed should be thrown away. Small pieces can dislodge and become a choking hazard. In addition, throw away a pacifier when a child can put the whole thing in his or her mouth.

8. Should I use a pacifier-attached lovie?

This might be the most controversial (or at least unwelcome) advice in this whole post but using a lovie attached to pacifier particularly at sleep times could be just as dangerous as having a large blanket or pillow in bed with the child and shouldn’t be used.

9. How should I clean my baby’s pacifier?

Use warm water to rinse a baby’s pacifier. Some are dishwasher safe. Soap can be used intermittently and some can be placed in boiling water. Can you clean them with your mouth? Yes and there have been studies that show it might decrease your child’s risk of allergies but can also spread germs.

I hope this helps. What other questions do you have about pacifiers? Respond in the comments and we’ll get back with you.

According to The Washington Post, the number of confirmed cases have been steadily rising from a handful last week to 23 cases on Tuesday, Jan. 22.

“The vast majority of those who had have fallen ill had not been immunized,” the Washington Post wrote.

While this news is alarming to health care officials, it does not come as a surprise. The World Health Organization (WHO) says the number of measles cases has grown 30 percent worldwide and that “vaccine hesitancy” is one of the top 10 threats to global health in 2019.

The WHO defines vaccine hesitancy as “the reluctance or refusal to vaccinate despite the availability of vaccines.”

The organization says vaccine hesitancy threatens to reverse progress made in tackling vaccine-preventable diseases that currently prevents 2-3 million deaths a year. But the WHO states a further 1.5 million could be avoided if global coverage of vaccines improved.

In New York, NBC News reports that an outbreak among Orthodox Jews has led to 177 cases. The Centers for Disease Control and Prevention states that 349 cases of measles were confirmed in 26 states in 2018, making last year the second-worst year for measles since 2000.

“Almost none of the cases had been vaccinated against measles,” NBC reports.

Measles is one of the most infectious viruses known to man and will infect 90 percent of unimmunized people who breathe it in. What frustrates health care providers is that the spread of this highly contagious disease can be contained.

And while the vaccine has been found to provide about 95 percent protection, a recent poll of Texas parents found 13 percent say they believe the risks of vaccines outweigh the benefits and 16 percent say they should be able to opt out of vaccinating their children.

Texas has one of the highest rates of unvaccinated children in the U.S., partly due to a 2003 state law allowing parents to opt out of getting their children immunized for medical reasons or conscientious and religious beliefs.

In an editorial in the Fort Worth Star-Telegram, Peter Hotez, M.D., director of the Texas Children’s Hospital Center for Vaccine Development, urged parents to provide immunization for their children, Dr. Hotez warned that “we are extremely vulnerable to a measles outbreak in Texas.”

Dr. Hotez identified Tarrant County and Fort Worth as national “hot spots” for a potential outbreak. A study co-authored by Dr. Hotez found that parents of at least 518 kindergartners in Tarrant County schools last year opted to not get preventive shots for their children.

“This news is frustrating to physicians and other health care providers because measles is a disease once thought to be all but gone from the planet. It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning. 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 have returned. Measles is very serious and can cause pneumonia. Children under the age of 5 have a higher risk of hospitalization.”

Keeping vaccination rates relatively high (somewhere around 90 percent) 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 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.

Learn more:

Measles

Vaccines and Immunizations

Frequently Asked Questions About Immunizations

Immunization Schedule

And yes folks, that means Q-tips. Look at what our medical director of Emergency Services has to say:

“Q-tips and cotton-tip swabs cause numerous ER injuries we see at Cook Children’s,” Corwin Warmink, M.D., medical director of Emergency Services said. “I know people hear this all the time, but children should not be putting cotton-tip swabs in their ears. They can cause damage and sometimes the damage can be severe.”

Natalie Roberge, M.D., an Ear, Nose and Throat specialist at Cook Children’s, says problems from placing cotton-tip swabs in the ear can include:

1. Pushing the wax further into the ear canal causing impaction.
2. Laceration/bleeding of the ear canal.
3. Increased risk of otitis externa from the trauma. It's called swimmer's ear, but really any trauma to the ear canal can lead to otitis externa.
4. Perforation of the ear drum. Some will not heal and require surgery. Rarely the middle ear ossicles will also be damaged.

So how do you get earwax out of your child's ear? 

Well maybe you don't.

Earwax is a normal, protective coating to the ear. Some kids make more than others.It doesn't need to be removed except in extreme circumstances and should not be removed by parents.

If you can see some earwax on the outside, it's OK to clean it off but there's never a need to place something in the ear canal to remove it.

Even if I see a lot of earwax during a checkup, I don't clean it out unless there is a concern for infection, a problem with hearing or there is discomfort from the wax.When it is time to remove it, we have a few options:

1. Drops to break down the wax. These can be bought over the counter but should not be used in patients that have a history of tubes or who might have an ear drum rupture.
2. Ear flushing - In the office, we can use a flushing of fluids to remove the wax from the ear.
3. Ear curettage - The most common and my preferred method is to use an ear currette to pull the wax out of the ear. This is done with extreme care because the child must be older or held properly to make sure they are safe.

I get asked a lot about earwax from parents. I hope this advice helps. 

Related to this topic:

• What's Earwax?
• Let's Learn Something: Ear Infections and Tubes
• 7 Ear Infection Myths Every Parent Should Know
• Another Ear Ache. Is It Time To See An ENT?

But, does your child have a cold or allergies?

After all, the mountain cedar pollen count is the highest it's been all season in North Texas and is in the "very high" category for the first time since January 2017. 

We're also in the middle of the cold and flu season. 

Determining the difference between colds and allergies can be very difficult, but knowing which it is can be helpful for treatment, expectations for how long it should last and for determining if your child is contagious.

Colds are caused by viral infections which are spread from person to person. They can occur year round but are going to be more common in winter months. Symptoms usually last 3 days to 2 weeks but remember that kids can get several colds per year so it’s possible for them to be sick for long periods if they catch a few colds back to back.

Allergies are caused by an overreaction of the immune system to allergens. Dust, pollen or molds can all be potential triggers. Allergies can occur year-round depending on what your child is sensitive to. Usually fall and spring are busy allergy seasons but pollen counts were moderate to high many days in December.

So, how can you tell the difference?

Symptoms with a cold usually build up over a few days but allergic symptoms can start quickly after the child is exposed to the substance they are allergic to.

Here are some of the symptoms that can be present and whether they are more likely a cold or allergies:

This time of year, if your child has cold symptoms but also have significant body aches or high fever, you should also consider if they might have flu (because they probably do).

Treatment for colds is treating the symptoms. Nasal saline and suction for babies. Honey for kids over 1. Make sure they are drinking plenty of fluids and getting rest.

Treatment for allergies should usually start with a long acting antihistamine like Zyrtec or Claritin. If that doesn’t seem to be helping, talk with your doctor.

“My baby never spits up, but seems like they are fussy all the time."

I know this sounds like reflux, but the truth is spitting up can be normal. Even if it’s with every feed, even if it seems really bad.

Maybe you just have a happy spitter.

I call babies who spit up a lot but still gain weight and who aren't fussy with feeds “happy spitters.” They present more of a laundry problem (their clothes, your clothes, sheets, burp cloths, couch cushions…) than a medical problem.

The passage of milk and stomach contents into a baby’s esophagus is a normal process and can even result in VERY frequent, VERY large amount of spitting up and still be normal. It happens because the muscle that sits on top of the stomach is relaxing off and on all day long. If the pressure inside the stomach is higher than the resistance provided by that muscle, the baby can spit up.

But when is it a problem?

I consider reflux a problem if one of two things are happening:

1. The baby seems fussy after feeds or they are fussy when they spit up.
2. The baby is having significant spit up and is not growing well.

Fussiness after feeds is particularly concerning for reflux if the baby is arching their back or starting to refuse their feeds once they start. 

Because pressure is a big player in the spit-up/reflux process, there are some simple things you can do:

1. Make sure you are not overfeeding the baby. Babies who are overfed and spit up can seem hungry after, but that only makes the problem worse.
2. Avoid laying the baby down immediately after feeds when possible. Keeping a baby upright 20 minutes after feeds can help the milk to move further down and be less likely to come back up.

So when do we need to consider medication for reflux?

When the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, despite limiting overfeeding and keeping the baby upright, we consider treatment with an acid reduction medication.

One common medication is a group of acid reducers known as H2-blockers, the most common example is ranitidine. Another group of acid reducers are known as PPIs, such as lansoprazole.

It’s important to keep in mind that the medications don’t do anything to keep the milk down, so it’s likely that the baby will continue to spit up hopefully without being fussy and gaining weight (and another good reason not to treat a “happy spitter”).

Here are 12 day-ngers of Christmas:

1. Fireplace - Lighting a fire is one of my favorite winter time activities but it can be very dangerous for kids. Young children should always be supervised when around the fire and you should have them inspected regularly to prevent potential problems.
2. Candles – If you’re anything like my wife, the first thing you want to do when you get home is light a candle. The smells can really put you in the Christmas spirit but little hands love to explore flames and hot wax can be just as dangerous.
3. Small decorations – Small decorations (manger scenes or small tree ornaments) can be a significant choking hazard this time of year. Because they are often colorful and shiny, they can be spotted from across the house and crawling babies will find them.
4. Glass decorations – Little feet and crawling knees get glass in them frequently this time of year. A solid barrier around the tree and keeping fragile ornaments up high can help.
5. Stocking holders – Heavy stocking hangers can be a risk for kids as they reach up to pull down on the stocking and the heavy holder can cause skull fractures and bruises. Use lighter hooks, tape or otherwise secure the holders in some other way. It could even knock out your child’s two front teeth.
6. Tree allergies – Kids can be allergic to trees and this is the only time of year where we bring in a gigantic live allergen into our homes. If you are an allergic type family, think about an artificial tree; especially if your kid always end up miserable around Christmas-time.
7. Christmas tree water – Yes, kids will drink water anywhere they find it. The Christmas tree base is the perfect height for a crawling baby to lap it right up. Find kid safe tree nutrients or make sure that they are kept away from the base.
8. Holly/mistletoe berries – The old time fear of poinsettias may be true if your child ingests several flowers which can lead to abdominal cramping but the real risk is holly berries. Ingestion can cause severe stomach cramps and diarrhea from even just a berry or two.
9. Unstable tree base – Make sure that your tree is properly installed and the base is broad enough to prevent tip over if a child decides to do some indoor tree climbing practice or is rockin' around it.
10. Ladders – The process of decorating can be just as enjoyable as the decorations themselves. But ladder falls are common …your child doesn’t need to see you toppling over so be careful amateurs. Also be sure and put them away after each use so that little kids don’t decide that they can “help” later.
11. Electrical outlets – This time of year new things need to be plugged in and unplugged but don’t forget about your plug covers and electrical safety. Keep the cover nearby and replace it each time you unplug that tree or other decoration.
12. Hot drinks – Decorating and celebrating Christmas means more hot chocolate and apple cider but wandering little hands are eager to see what’s in that colorful mug…

This time of year can be amazing as a family…but stay alert.

When your baby is in a new house or environment be extra vigilant.

Take precautions as you deck the halls to prepare for safety at home.

Have a Merry Christmas!

RSV has arrived at Cook Children's.

Last week, 178 kids tested positive for RSV, compared to only two who tested positive for Influenza A.

RSV is a virus. It’s short for respiratory syncytial virus. It causes a disease in young children (especially those less than 2 years) called bronchiolitis. The RSV season usually begins around mid-August and runs through March.

Bronchiolitis is a disease of the lower respiratory tract which causes children to wheeze. They are wheezy because their small airways have swelling and junk (mucous and cells from the lining of the airway) in them.

The smaller airways are similar to the area where a child with asthma has issues (which is why they wheeze). The difference is that children with asthma have a squeezing down of the walls of the airway (which is what a breathing treatment reverses). This is why breathing treatments in children with bronchiolitis usually don’t work.

Bronchiolitis is not just caused by RSV. There is a long list of viruses that can cause the same symptoms:

• RSV
• Rhinovirus (usually a cause of the common cold)
• Parainfluenza
• Human metapneumovirus
• Influenza (Flu)
• Coronavirus
• Human bocavirus
• Human polyomavirus

Here are some answers to the most common questions I hear from parents:

What are the symptoms of bronchiolitis?

Typically the child starts with runny nose and cough. This will progressively worsen over a few days and possibly develop into difficulty breathing and difficulty with eating. The symptoms typically last a total of about 5-7 days with the worst day being the day in the middle. It is not uncommon for the cough and runny nose from bronchiolitis to last 2-3 weeks.

How do we treat bronchiolitis?

In most children, treatment is done at home and consists of sucking snot (click here for more advice on this) and counting wet diapers. This isn’t very fancy but, unfortunately, until someone invents TamiRSV we don’t have anything more specific. As far as wet diapers go…I am looking for a wet diaper about every 6 hours.

Who goes to the hospital?

Getting admitted for bronchiolitis is usually based on: dehydration, severe difficulty breathing or low oxygen levels.

Children who can’t eat because they are breathing fast and are puking because of all the mucous draining into their belly are at risk for dehydration. Unfortunately, the only way to fix this is to put them in the hospital for intravenous (IV) fluids until they are able to drink better.

A child who is having severe difficulty breathing also needs to be observed in the hospital. Unfortunately, babies with severe bronchiolitis can get tired from all the heavy breathing they are doing and this can progress to needing ICU care. It is best to have those babies who are breathing that hard in the hospital so that they can be monitored closely by people who know what they are looking for…

Babies with bronchiolitis often need extra help keeping their oxygen level up by getting extra oxygen. We monitor these babies closely and I put them on oxygen for severe difficulty breathing or if their oxygen level is less than 90 percent.

Summary

1. Bronchiolitis stinks, it makes kids sick and I don’t have much to offer.
2. Whether it’s RSV or not often doesn’t matter.
3. Watch for difficulty breathing and decreased wet diapers.

For more information on bronchiolitis and RSV, read this post from one of our hospitalists.

“Well, umm, uhhh, ummm, yeah I guess that is what I’m saying….And, now that I think about it, I will definitely be calling it that for the rest of my career.”

Group A beta-hemolytic stroptoccal pharyngitis is probably something you have heard of before…well, you might have heard it called strep throat.

But, what you probably didn’t know is that that same bacteria can cause other infections. One of the most common is an infection of the skin just around a child’s anus.

The infection can cause significant pain, itching and when you look you will see a bright red, moist rash right around the anus. You can also sometimes see some blood in the stool from scratching and skin breakdown. Some parents confuse it with a really severe form of diaper rash.

The infection is most common in children 6 months through elementary school. How do kids get it? Spoiler alert: they often scratch and touch themselves…so, if they are around someone with strep throat, they can get it on their hands and infect themselves.

If you believe your child has perianal streptococcus, your baby should be seen by a pediatrician because prescription antibiotics are required.

Related:

Is it Strep Throat or the Flu?

I tell you that not to freak you out, but to let you know how common it is. Most cases are typically mild. When we see sever disease, it's often in immunocompromised patients and those cases are uncommon.

What's important to remember is the children who died in New Jersey were all medically fragile and had weakened immune systems.

I know this kind of news can be scary, so I thought I would take some time to answer a few questions you may have.

What is adenovirus?

For most children, adenovirus causes mild symptoms. Sore throat, pink eye, fever and common cold symptoms are the most frequent. The symptoms are typically similar to but much less severe than influenza and can also be mistaken for strep throat. Like most viruses, the initial symptoms go away on their own in a few days but upper respiratory symptoms such as cough and congestion can last up to two weeks.

There are multiple different types of adenovirus, some cause more severe disease than others. They are all spread by close personal contact and by droplets spread by coughing and sneezing. In addition, adenovirus is pretty resilient and can live on surfaces. It can also continue to be spread by people with weakened immune systems, even after the symptoms have resolved.

Should you be worried?

Because adenovirus is usually a mild illness, most parents don't have to worry about the virus. The situation in New Jersey is a tragic combination of factors that led to this terrible outcome. Multiple children who are medically fragile living in close quarters. In addition the type of adenovirus which affected the children is known to be one that causes more serious disease.

So, what if my child is medically fragile?

If your child lives or will spend time in a group rehabilitation home investigate their cleaning practices. There is little evidence to suggest that this rehabilitation center has made significant mistakes that caused the outbreak, but you can never be too careful.

Otherwise, keep you child away from illness as much as possible. If they are sick with upper respiratory symptoms, monitor them closely for sign of difficulty breathing and seek help quickly

For the rest of us, it's important to remember to keep our kids home when they are sick so that we do not put other children at risk.

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

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

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

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

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

Here’s how the debate usually goes:

“Please vaccinate your children.”

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

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

So why do I care?

There are two reasons.

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

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

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

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

How does it work?

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

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

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

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

Scenario No.1:

Scenario No. 2:

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

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

So, in scenario No. 2:

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

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

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

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

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

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

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

We’re likely to share a cute video of our children blowing out their birthday candles or a picture of our kids in their baseball uniforms.

There are plenty of things that parents and kids go through that no one feels the need to post. Some of them are thought of as “gross” or “weird.”

But even celebrities aren’t immune to gross and weird. America’s cutest couple recently went through a battle with pinworms … it was so memorable that Kristen Bell felt the need to share it with everyone with a Netflix subscription when she went on the Joel McHale show and shared about her family’s experience with pinworms.

Here are 5 common medical conditions that no one (except maybe Kristen Bell) shares on Instagram:

Pinworms

Pinworms are an annoying cause of anal itching. Kids (usually elementary age) get them from touching and ingesting the eggs from foods on contaminated surfaces. You can usually diagnosis pinworms with the story alone but if you see a moving worm on the stool or toilet paper, you know what’s going on. Treatment is a medicine that you take twice, one immediately and one 2-3 weeks later depending on the type of medication.

For more information, read our full post on pinworms: 4 Things Every Parent Should Know about Pinworms

Molluscum

One of the most common skin problems that no one seems to know about is molluscum. Molluscum contagiosum is a viral rash that causes little flesh-colored bumps that can look like they have clear fluid inside. They are similar to warts in that they can spread from child to child and a child can spread them to other parts of their bodies. They tend to go away on their own but they can be frozen or removed if they are bothersome or are in tricky parts of the body. They are not concerning but one of the most annoying conditions we see in pediatrics.

For more information, read our full post on molluscum: The most common rash you never knew about

Scabies

Although less common than some of the other topics on the list, scabies is another condition that we see frequently but you’d never know it. Scabies is an infection with a parasite that causes itchy red rash all over but is most present in the spaces between the fingers and toes. The condition is not necessarily related to cleanliness, although this is a common misconception. Treatment is a topical cream that is applied neck to toes and repeated in a week.

For more information read this post about scabies (and cooties): Eww, cooties: The Doc Smitty on lice, scabies and yes, cooties

Lice

Oh, the dreaded email from the school, “There has been a case of lice in your child’s classroom.” Lice is sooooo common. Almost every child will have a case at some point during their school-age years. The diagnosis is made after the discovery of live lice or nits (which are eggs) on the scalp. The child will commonly be itching their scalp. The treatment is a shampoo that kills the nits or a treatment to remove the nits and prevent re-infestation.

Treatment for lice has become more complicated because of lice that are resistant to standard treatments. Here’s an article that explains what you need to know: 4 Ways to Fight Against Super Lice

Bedwetting

No one talks about this…but 15 percent of 5 year olds still wet the bed… 5 percent of 10 year olds…

Almost every bedwetter has another bedwetter that sits with them in class every day.

There are some subtle things you can do to help. But, most of all, children outgrow their bedwetting on their own time with bladder maturity and not often because parents find the magic fix. There are solutions that can be explored for sleep-overs and overnight camps.

There are some warning signs that might warrant further concern or investigation. Read more here: Bedwetting: When should you be concerned?

So what should you remember?

1. Get kids and do weird stuff (these and many others) that no one talks about.
2. It’s ok to keep it to yourself or share.
3. Even if you choose not to share, remember that you’re probably not alone.

So, are gluten free foods better for your child?

The answer is…

Complicated. It depends on your child.

Gluten is a protein found in wheat, rye and barley. The protein works as a “glue” to hold the foods together. It is often found in foods that might be unexpected or surprising.

Are gluten-free kid’s foods healthier for my child with celiac disease?

Yes. Definitely, absolutely yes.

Celiac disease is a genetic condition in which people have a severe auto-immune reaction to gluten that leads to damage of the small intestine. It can be difficult to diagnose because the symptoms are wide and varied but often include abdominal pain, bloating, diarrhea, stool changes and behavioral changes. Diagnosis can be tricky but involves lab testing and usually a visit with a gastroenterologist.

Avoidance of gluten is the primary treatment for children with celiac disease.

Are gluten-free kid’s foods healthier for my child with gluten intolerance (non-celiac)?

First of all, you have be very careful to determine if there is something to this. Because many of the proposed symptoms of gluten intolerance are vague and not specific (there are many doctors who question if it is a true condition). Whatever you believe, it can be easy to attribute normal child stuff to a sensitivity to foods.

Because of this, I highly recommend a long conversation with a pediatric, GI doctor or allergist before making the changes to your diet. Studies have shown that it is more difficult to obtain adequate calories and nutrition for kids on gluten free diets. Thus, it’s not without risk to decide to eliminate gluten from your child’s diet.

Are gluten-free kid’s foods healthier for my healthy child?

The answer to this is categorically no. In fact, they could be less healthy.

A recent study compared food for kids based on whether those foods were advertised as gluten free or not. The results might surprise you.

Gluten free supermarket foods were found to be nutritionally similar to regular child-targeted foods. One change was that 80 percent of gluten free kid foods had higher sugar content than non gluten free kid foods. Previous studies have shown that gluten free products have similar total calories but less protein and fiber.

Bottom line, if your child has a medical need, gluten free foods are important. Otherwise I’d save my money and skip them.

"I swear he looked worse when I called."

"She hasn't been this active in days."

"She felt so hot when we left the house."

I get it. I've always tried to understand when I hear parents say these kind of things and this week I was personally reminded how this happens.

After getting a worried text from my wife, I left a Cook Children's Physician Network board meeting and hurried home to rush my daughter off to urgent care. After a few minutes there and a trip to the bathroom...we were as good as new. Back to asking a million questions. Back to telling me to look at the screen to see the same scenes in the same movies we've been watching for years. Back to getting on the table, climbing off the table.

Has this happened to you? Most likely, yes.

But, we got our results back, everything checked out great and we were on our way.

Why does this happen? Maybe no one knows.

Here are my 5 suggested possibilities:

1. Time has passed. Kids can get rapidly better and rapidly worse. That's one of the amazing (and absolutely terrifying) things about working in pediatrics. Kids often get better within hours. So, it's possible they were just due for some improvement after you called for the appointment.

2. Your child's medicine has had time to kick in. Kids can look terrible when they have fever and can pretty much bounce right back to normal when it goes down. If their fever is down, they are going to look much, much better.

3. You're in the presence of trusted professionals. (all modesty aside) When you're really scared, it's nice to have anyone around. Having that someone be a pediatrician who's trained for years to handle just this situation might make them look "better."

4. Kids often look better in the daytime. If you were worried about your child at night but bring the child in the next morning, they often look much better. Viral illnesses often look worse at night. Also, when you are tired, you might be more prone to worry and less able to put your fears in context.

5. I have always joked with my parents that we have a magic spray in the waiting room that decreases fever, fussiness and otherwise just makes kids look better before they get back to the room. What I learned from posting about my experience with my daughter is that I'm not the only pediatrician who does so...some of them call it magic pixie dust, some magic spray but apparently we all have something that does the same thing.

Ironically, there were many other pediatricians who responded by saying that their kids often did the same thing. I wasn't alone.

So, the next time your child looks tragically ill at home and perfectly fine in the office, you can rest comfortable knowing that your doctor has probably experienced the same thing.

The CDC recommends people not eat this cereal and retailers not sell any Kellogg’s Honey Smacks cereal at this time because it might be contaminated with salmonella and could make people sick.

Justin Smith, M.D., a pediatrician at Cook Children’s Trophy Club office, said that salmonella is one of the most common bacterial causes of infections he sees in his office and it is a “fairly frequent cause” of severe diarrhea and abdominal pain in children.

Symptoms that might alert parents they should call a doctor include:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever of more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that lasts more than one week.

“If you suspect your child has salmonella, your pediatrician can run stool studies to confirm the diagnosis,” Dr. Smith said. “This may not be necessary if there are known cases that the child has been exposed to. The infection will typically go away on its own in seven days or less. Most healthy children do not require antibiotics. I do not routinely recommend anti-diarrheal medications in children because they can prolong symptoms with some infections.”

If you suspect your child has one of these infections, Dr. Smith said parents should consult with their doctor and keep them out of daycare until the pediatrician is sure they will not put other children are risk.

The Kellogg Company recalled all Honey Smacks products that were on the market within the cereal’s one-year shelf-life on June 14, 2018. The CDC stated that even products with earlier dates could also potentially be contaminated.

In its press release, Kellogg Company states that none of their other products are impacted by the recall. “Kellogg launched an investigation with the third-party manufacturer who produces Honey Smacks immediately after being contacted by the Food & Drug Administration (FDA) and Centers for Disease Control (CDC) regarding reported illnesses,” Kellogg wrote in its release.

The CDC has this advice for consumers and retailers:

• Do not eat any Kellogg’s Honey Smacks cereal, regardless of package size or best-by date. Check your home for it and throw it away, or return it to the place of purchase for a refund. The Kellogg Company recalled the cereal on June 14, 2018.

• Retailers should not sell or serve Kellogg’s Honey Smacks cereal.

• Even if some of the cereal has been eaten and no one got sick, throw the rest of it away or return it for a refund.

• If you store cereal that looks like Kellogg’s Honey Smacks in a container without the packaging and don’t remember the brand or type, throw it away.

• Thoroughly wash the container with warm, soapy water before using it again, to remove harmful germs that could contaminate other food.

Illnesses due to the outbreak have been reported from March 3, 2018 to July 2, 2018. Ill people range in age from less than 1 year to 94. No deaths have been reported.

The FDA said the products were currently available, but that “supply levels may vary across wholesalers and pharmacies.”

"Based on the information provided by the manufacturer, the FDA anticipates the EpiPen shortage to be short-term," an FDA spokesperson said.

The advocacy group Food Allergy Research and Education (FARE) called on the FDA to act swiftly on the growing national shortage of epinephrine auto-injectors.

“Epinephrine is the first-line treatment for anaphylaxis, a serious and potentially life-threatening allergic reaction associated with severe food allergies,” the organization wrote in a press release. “Delayed use of epinephrine during an anaphylactic reaction can lead to death.”

FARE stated the shortage has been felt by patients in almost the entire country, and was not necessarily a “spot shortage.”

So what should you do if your child has an EpiPen need?

Justin Smith, M.D., a pediatrician at Cook Children’s recommends the following:

1. Check to see if your prescription is at or near expiring.
2. Check multiple pharmacies in your area as some may have it and some may not.
3. Check with your pediatrician for alternatives if you can’t find it.

Did you know the American Academy of Pediatrics (AAP) actually has an official stance encouraging pediatricians to talk with their families about the importance of daily, out-loud reading to your children (Literacy Promotion: An Essential Component of Pediatric Primary Care Practice).

Sometimes, when the AAP releases statements like this, that seem like common sense, I have to resist the urge to roll my eyes and tell myself, “Ok, thanks for stating the obvious.”

This one, while perhaps common sense, is very important. 

Why?

Despite the fact that I think most parents would agree with the importance of reading to your children, studies show that only about half of children are read to aloud every day. In addition, reading to children sets the stage for their speech development which helps them do better in school. So what are the reasons for not reading to your child?

1. I don’t have time.

We aren’t asking that you read “War and Peace” every night with your 6 month old. I’m hoping for about 5-10 minutes of reading (1-2 short books). Ultimately, if you don’t have that much time then just read for the amount of time that you can, any amount is better than none. Our kids really like to read during meal times as well, it tends to keep them eating and moving and keep their fighting about food to a minimum. If you routinely watch TV during meals, it’s a much better alternative.

2. If they don’t understand, it doesn’t matter.

Reading to your children even before they are speaking is an important part of teaching them language. Babies learn the sounds of language long before they know any words. The number of words a child hears before they start kindergarten is a strong predictor of how well they will do in school. This is why it’s not only important to read to them, you should also spend time talking with them all throughout the day.

3. It’s so boring.

This one I can really sympathize with. There are nights where I feel like I deserve an Oscar for my dramatic performances … but there are also nights where I drone on in monotone and doze off between pages. It’s important to really engage your children as best you can, based upon their age. Have them help you count objects, letters or words on the page. If it’s a book you’ve read 1,000 times, read the wrong word and let them correct you (“Ohhhh … daaaadd, you’re so silly!”). You can be selfish here. Do whatever it takes to make it interesting for you, it will make it easier for you to do it and it’s likely that your child will enjoy it more as well.

4. They don’t even seem to enjoy it.

Let’s face it … sometimes they don’t even seem like they care. Your 12 month old is crying because he or she is tired but doesn’t want to go to bed. My youngest would rather chew on a book than have you read it. My oldest child would often rather be reading his own book than listening to me. But, I press on. Reading is not only beneficial for the language development, but studies show that it helps to develop more nurturing parent-child relationships. Perhaps more importantly, is what it does for me. After a hard day at work, getting home to referee the boys fight for 2 hours, it’s nice to have some one-on-one time with each child to remember that I still like them.

5. No one ever told me it was important.

Well, you can’t use this one anymore can you? Just in case you missed the message, it’s important.

Start by making a plan to read to your child every day for the next month.

Get a calendar out and mark off the days. 

I promise it will benefit your child for years to come.

Resources For Families

• AAP Tips for Families for Early Reading and Literacy
• Is Your Child Ready to Read?
• 5 Ways Parents Can Improve Their Child's Vocabulary
• The Unique Challenges of Raising a Highly Gifted Child

On a recent interview with the Joel McHale Show, Kristen Bell described an episode in her family that highlights one common cause: pinworms.

If you haven’t seen the video, I highly recommend you watch it because, it’s actually pretty accurate; and, despite the fact that she uses a word near the end that’s a little too mature for Anna, she somehow manages to make having pinworms adorable in a way that only Kristen Bell can.

How do children get pinworms?

Kids usually get pinworms from eating foods or touching contaminated surfaces and then placing their hands in their mouths. The eggs are small enough to become airborne and swallowed.

So, like she says in the video, they are highly contagious.

How do you know if you or your child has pinworms?

Most infections with pinworms don’t cause symptoms (especially in adults) but the most common symptom is anal itching. Kids will sometimes itch so badly at night that they don’t sleep very well. Other sites of infection can occur and there can be enough worms to cause abdominal pain but these are both rare.

How do we diagnose pinworms?

Pinworms are formally diagnosed when the symptoms are present and the worm is seen - either around the anal area, on the outside of the stool or toilet paper. The worm are about ¼ inch long and thin like a piece of thread-but are often moving.

If you see the worms or the child has a known exposure to someone with pinworms and is showing symptoms, it’s reasonable to assume that they have them and proceed with treatment.

If you’re not sure, and you want a test to check, some recommend placing a piece of clear tape around the anal area first thing in the morning in an attempt to collect some eggs or worms-the Scotch tape test.

How do we treat pinworms?

The easiest, cheapest means of treating pinworms for kids over 2 years of age is pyrantel pamoate. It is available over the counter and is given in doses, one dose now and another dose in 2 weeks. If your child is under 2, consult your doctor.

Household members and caregivers of the child should also be treated. Avoid co-bathing during the 2 week period. Taking a daily shower and washing clothes in hot water can help prevent reinfection.

The Dallas Morning News reports that person from another state who had mumps traveled to Dallas for the National Cheerleaders Association All-Star National Championship, which took place Feb. 23-25 at the Kay Bailey Hutchison Convention Center. 

At this point no Texas residents have developed mumps in connection with the case, but people are urged to watch for symptoms. 

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.

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