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.

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

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

The slippery assumptions of oil supporters

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now we can move on to some research…

The Research on Essential Oils in Kids

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

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

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

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

Lavender

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

Tea tree oil

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

Chamomile

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

Peppermint Oil

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

Eucalyptus

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

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

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

Other Sources

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

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

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

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

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

Summary of Research

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

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

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.

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

In an interview with Billboard published October 8, she reveals that her time her away was a consequence of scary health scare, following the diagnosis and subsequent treatment for lupus.

Fortunately, Gomez is doing well. Her lupus is in remission and she is set to appear in an upcoming movie and her newest album, Revival, will be released October 9.

Here are 8 facts about lupus that will help you understand the disease and explain it to your children if they ask:

1. Lupus is a disease where your body’s immune system (which usually helps you fight off infections) starts to attack your own cells (it falls into a group of diseases call auto-immune diseases).
2. Symptoms of lupus vary from person to person but can include: fever, swollen/painful joints, facial rash, tiredness, body swelling, sun sensitivity and mouth ulcers.
3. Lupus is diagnosed through a combination of symptoms and lab testing. It is often difficult to make because it can look like many other disease s and there is not one specific test to confirm or deny the diagnosis.
4. Lupus is not a contagious illness. The exact cause is not known but is thought to be a combination of hormones, genetics and environment.
5. Lupus most commonly affects women 15-44 years of age but can affect younger children and boys as well.
6. When severe, lupus can cause anemia. It can also cause excessive blood clotting which can lead to strokes and other complications.
7. Pediatric specialists known as rheumatologists treat lupus in children.
8. Treatment of lupus includes use of medicines to treat inflammation, steroids, anti-malarial medications and occasionally stronger medicines, which are used to decrease the activity of the immune system.

For more information about lupus, you can read more from the Lupus Foundation of America at lupus.org.
 

*Photo from SelenaGomez.com.

“Making New Year’s resolutions can be very beneficial for children because it teaches them the importance of setting goals and following through,” said Lizy Varughese, M.D., pediatrician with Cook Children’s in Lewisville. “Not only can goals be applied to a child’s eating habits and physical activities, but they also help teach important life lessons about the benefits of planning ahead and the success that comes from it.”

For many parents, taking time to sit down and discuss with a child the lessons learned during the past year, both good and bad, can serve as valuable, teachable moments and deepen family bonds. Because societal factors such as TV, friends and the Internet can strongly influence a young child’s behaviors, it’s crucial that parents help young ones map out and focus on a few simple, healthy resolutions that can later translate into positive behaviors as children grow and develop.

Keeping It Real

While it may be tempting as a parent to jump ahead and make a list of New Year’s resolutions for your children rather than waiting for them to develop a list on their own, empowering your kids to creatively embrace this time-honored tradition can be filled with good times and great memories.

Encourage children to start with a list of broader, bigger goals such as eating less junk food, spending less time playing video games, picking up their toys or making better grades. No matter how far-fetched goals may seem at first glance, parents should stay open-minded and flexible, resisting the urge to criticize their child’s resolutions. Remember, keeping the mood light and enthusiastic makes goal setting seem less like work and more like fun.

From there, Dr. Varughese suggests children break down their resolutions into small bites by using journaling as a method to help solidify goals.

“Begin the new year by writing down specific goals for eating and participating in sports and exercise activities,” Dr. Varughese said. “Children are more likely to complete a task if it’s written down and there is accountability for their progress. It’s also important to be flexible so the parent can help kids form a more attainable goal if a particular goal is not met or seems difficult for the child.”

Basic resolutions for the entire family may include:

• Eating meals at the table as a family at least four times a week.
• Preparing more meals at home.
• Limiting fast food and takeout.
• Packing lunches for school and work.
• Planting a garden.
• Going for a family bike ride, walk, swim or hike two times a week.

Lead By Example

According to the Centers for Disease Control and Prevention, children begin to copy their parent’s behavior by age 3.

The greatest impact a parent can have on his or her child is by being a good example,” Dr. Varughese said. “Parents can make their own resolutions with their children and even participate in physical activities together. Taking an evening walk with them is not only a great health benefit, but it can also deepen the emotional bond they share.”

Read these New Year's tips from the American Academy of Pediatrics for children and youth for preschoolers, 5-12 and 13 and older. 

About the source

Lizy Varughese, M.D., attended Texas A&M University and received a B.S. in Biomedical Sciences. Dr. Varughese attended medical school at the University of Texas Health Science Center in Houston, Texas and completed her residency at Stony Brook University Hospital, Long Island, New York. She was then appointed Clinical Professor of Pediatrics from 2005-2006. After that, she joined a private practice in New Jersey for five years. She moved back to her hometown of Dallas, Texas, and joined Cook Children's Physician Network in Lewisville in 2013.

She is married to Dr. Shane Varughese and has two children, Noah and Sarah. Dr. Varughese enjoys photography, cooking, and church activities. Her passion in life is taking care of children and educating families on preventative care and battling childhood obesity.

Cases of RSV (respiratory syncytial virus) infections in North Texas commonly increase in the winter. But this year, it's arrived earlier than usual. During the week of Nov. 20, 2016, 47 Cook Children’s patients tested positive for RSV. During this same time frame in 2015, only 9 kids had tested postive and the number was 18 in 2014.

A simple cold can quickly progress to bronchiolitis caused by the RSV virus, especially in kids under 2 years old. As a parent, here are a few things you need to know about RSV.

1. What is RSV?

RSV is a virus that impacts the respiratory tract, including both the upper and lower airways. It usually starts with cold-like symptoms, such as a stuffy nose and sneezing, but could progress to include a cough, fever or wheezing.

2. How does my child get RSV? Is it contagious?

The virus is spread through droplets caused by coughing and sneezing that linger in the air or land on surfaces. This virus can live on surfaces for about six hours and survive in the air for about 30 minutes.

3. How long does the illness last?

Illness can begin between four and six days after exposure to the virus, and can last for a week or two. Symptoms may continue longer in infants or patients with weakened immune systems.

4. How is it treated?

In most cases, supportive care is all that is necessary. This includes elevating the head of the bed, running a cool mist humidifier and using a nasal bulb for suctioning to clear secretions. Some children develop wheezing, in which case treatment with prescription albuterol through a nebulizer may be helpful. In more severe cases, deep suctioning, supplemental oxygen and hospitalization may be necessary.

5. When should I be concerned?

If your child is having difficult or labored breathing, as evidenced by retractions (tugging of the muscles around the ribs and abdomen), nasal flaring or shallow breaths, they need to be evaluated by your pediatrician.

6. How do I prevent it?

As with any other airborne disease, it is important to cover coughs and sneezes to prevent spread of the virus. Kids should avoid touching faces with unwashed hands, practice good hand-washing techniques and avoid contact with sick individuals. Parents should keep surfaces, like crib railings and toys, sanitized regularly and use disinfectant sprays. There is a vaccine available for certain premature babies or babies with underlying diseases. Talk to your pediatrician to see if your child qualifies for the vaccine.

In the absence of complications, RSV can usually be handled at home with supportive care and kids will feel better fairly quickly. If your child’s symptoms concern you or they show signs of difficulty breathing or dehydration, see your pediatrician right away.

Just in time for the holidays a reader wrote in with this question:

“My friend...was told by her grandson’s pediatrician that her grandchildren who are vaccinated should never be around any unvaccinated children. Well, the parents of her other grandchildren do not want to vaccinate their small children…As a result there are no more family gathering with all grandchildren. They have to spend holidays on separate days. My question is: Why would the pediatrician say this? If the children who are vaccinated and the children are not showing symptoms what’s the problem?”

This is definitely a sad and tricky situation and one that we should use extreme care when discussing.

One thing I will say is that no matter what one’s choice about vaccinating is, parents believe they are making the choice in the best interest of their child. Of course, I have strong opinions about how important it is, but this discussion is not for the faint of heart.

There are probably some doctors that would tell you it’s no big deal and you shouldn’t worry about it (I would disagree with them). There are other doctors that would say you should never have your child around children who are unvaccinated regardless of your child’s health (I recognize this is not reasonable in many situations).

Here are the questions to consider:

1. How old is the child? The younger the child, the more vulnerable they will be to infection. They cannot receive protection for chicken pox or measles before 1 year. Older children who are fully vaccinated have a significant amount of protection and they likely encounter an unvaccinated child at school every day.
2. Who isn’t vaccinated? This question is about family members which makes transmission of infectious diseases more likely than if you just walked by someone on the street and were not interacting with for longer periods of time.
3. Can you have an open conversation with those involved? The discussion is clearly more complicated than simple medical advice as it broaches on several tricky areas including family dynamics and vaccination.

The easy (get out of having to make a committed answer) is that there is no one answer to the question. The family should talk with their doctor about their specific concerns and make a decision with their counsel.

Should I stop the blog post there? Not so fast.

Instead, I want to give you a framework for having that discussion with your doctor.

What diseases should I be worried about?

I believe that all vaccines are important, period. But there are 3 diseases that jump to the top of my list when considering this issue:

1. Flu

Flu season is predictable in that it comes every single year at roughly the same time. It is unpredictable in that we never know how widespread it will be and how severe the cases will be when it does come around. Flu is particularly dangerous in babies and they cannot be vaccinated until they are 6 months old. Remember that the flu vaccine isn’t perfect, so I’m not saying that everything’s cool if we all have flu vaccines but it would seem logical to get as much protection surrounding the baby as possible.

2. Pertussis

Pertussis, or whooping cough, is still common and is a very serious disease for anyone who gets it. In children, teenagers and adults it tends to cause a very rough and painful cough that lasts for weeks to months. I know of adults who have had broken ribs because the coughing is so hard. The real danger for pertussis comes in small babies (less than 3-4 months). These babies commonly have spells of coughing that cause them to stop breathing; leading to ICU stays for intubation and unfortunately, death. Babies are vaccinated against pertussis at 2, 4 and 6 months which increases the number of children who are protected with each shot but they go on to get another vaccine at 4 and 11 years as well. So, when are they fully protected? It’s impossible to say. In addition, vaccines are not perfect so even vaccinated infants who are exposed could develop pertussis. Pertussis still occurs commonly in the United States and is generally carried by older children and adults who are coughing but do not know that they have pertussis. Just like flu, having the vaccine does not prevent disease 100% and I still feel that we need to do something better with the pertussis vaccine but again, it would seem logical to increase protection as much as possible.

3. Measles

Measles is another disease that still occurs in the United States. In 2014, there was a record number of 667 confirmed measles cases reported to the Center for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases (NCIRD). That’s the highest number of cases since measles elimination was documented in the U.S. in 2000. Measles can cause pneumonia and have a higher risk of hospitalization in children under 5. Children receive their first measles vaccine at 1 year of age, but they have no protection from measles until then.

What criteria should I use for being around others?

1. If your baby is under 6 months, use extreme caution. Many babies do not have full protection until after the 6 months shots. In addition, they cannot receive a flu vaccine until 6 months.
2. If your baby is under 1 year, I would also use caution. Your baby cannot be vaccinated against measles or chicken pox until 1 year.
3. After your child is vaccinated at 4 years, they have much of the protection that they need to protect themselves against the vaccine preventable diseases.
4. Babies or children who may not have a normal immune system-such as those with chronic illness or who were born premature deserve extra caution.
5. Anyone with symptoms of illness, especially fever, cough, congestion or rash, should not be around your baby or child regardless of your contacts’ vaccination status.

Can you get a definitive answer about when your baby can be around unvaccinated children? No, but you at least have some information to make an informed decision.

After you’ve discussed your plan with your pediatrician how do you handle the conversation with friends and family?

Here are some thoughts about some things you might say:

1. Our baby/child doesn’t have protection against many very dangerous diseases and we do not feel comfortable having her around people who could spread them to her.
2. Our baby/child has already been through so much, we can’t risk putting her through another medical problem. Especially something that we could have avoided.​
3. The doctor was emphatic that we cannot be out around anyone (especially someone who is not vaccinated or you could leave that out) until __________. (I’m fine with a family placing the “blame” completely on me.)

Those words haunt me. I do not remember what was said next, mainly because a wave of fear and dread engulfed my body. The day I was diagnosed with breast cancer my life changed, forever. The greatest change, the greatest loss, is the sense of invulnerability you have when you are healthy, when you are not in pain.

What followed was a rapid fire series of tests, decisions, surgery, chemotherapy. The speed at which I felt my "normal self" being consumed by the world of cancer was overwhelming. Through it all, I kept thinking of all my patients and their families who have battled cancer through the years. I relived every moment of those cancer conversations. The anticipatory nausea I had prior to walking into a room to deliver the results every parent dreads. The shock and tears and anger that followed the horrific news I had just given.

And every time, I watched my sweet patients and their families turn and face their battle with a grace and dignity that astounded me.

Now that I am a cancer patient, I am even more astounded. I am lucky. I have breast cancer. I knew going into treatment that my cancer, Breast Cancer, receives the highest proportion of research funding by both the government and the private sector.

I knew that although my particular type of cancer tends to be aggressive, because of the hundreds of millions of dollars poured into breast cancer research each year that new chemotherapeutic, hormonal, immunologic and targeted agents now exist that raised my survival rate to 99 percent at 10 years. I also knew that amazing new medications exist for adults that make the side effects of chemotherapy far more tolerable than they were previously.Children with cancer are not as fortunate. Pediatric cancer is grossly underfunded. Last year alone, the National Cancer Institute (NCI) spent 96 percent of its budget on adult cancer and only 4 percent on childhood cancers.

The NCI funded $584 million for breast cancer and only $26.4 million for ALL pediatric cancers combined. This doesn't even begin to take into account private sector and pharmacologic company sponsored funding, which largely goes to support adult cancer research. In fact, research and development of new drugs from pharmaceutical companies makes up more than 60 percent of funding for adult cancer drugs and almost zero for pediatric cancers.

Because of this lack of funding, in the past TWENTY YEARS there have only been two chemotherapeutic agents approved by the FDA for the use in children. More than half of the chemotherapies used in children are over 25 years old. I cannot begin to imagine the COURAGE it would take to fight a cancer battle armed with the knowledge that my best weapons are more than 25 years old.Some people argue adults get cancer more frequently than children and that's why the funding is greater. But when you stop to consider productive years lost by a cancer diagnosis, the effects aren't even close to equivocal.

The average age for adult cancer diagnosis is 67 with an average number of years lost to cancer of 15. The average age of diagnosis for a child is 6 with the average number of years lost to cancer of 71 years.

SEVENTY-ONE years lost.

Imagine if we could have the HEART to change those numbers. Children with cancer could grow up, fall in love, and have their own children. Imagine if we used our BRAINS to find new ways to fund childhood cancer research. These young cancer survivors could go to college, create beautiful art, make new discoveries that could change our world and perhaps find a cure for cancer.

It's October and in case you haven't noticed the world has turned pink for Breast Cancer Awareness month. I am a breast cancer survivor. This message is for all the women in my life. My patients, their Mommies, my colleagues, friends and family. And, for all the women in their lives. One in eight of you will get breast cancer.

Many women think that because there has not been a case of breast cancer in their Family they do not need to be concerned. This is not true. Only 20 percent of breast cancers are familial. You are at risk for breast cancer if you have breasts. 

If you would like to donate to Cook Children's, please visit this page. Learn how Cook Children's is helping to fight cancer.

About the author

Sandra Peak, M.D., is a Cook Children's pediatrician in Lewisville. She earned a B.A. degree in English and psychology from Baylor University, which helps her communicate with the children she treats today. After Baylor, she followed her passion and attended medical school at University of Texas Health Science Center in San Antonio. Her pediatric residency was at Arkansas Children’s Hospital in Little Rock, where she participated in Angel One emergency helicopter transport service. While there, she also received the Jocelyn Elders Award for excellence in community service. Dr. Peaks returned to her home town of Dallas in 1998 and established a Pediatric Practice in neighboring Carrollton, Texas. She joined Cook Children's Physician Network in Lewisville in 2004.

Every kid goes though it and yet, it’s universally misunderstood. Poor teething. It gets blamed for just about everything and probably causes very few symptoms.

I thought I would clear up some of these misconceptions and I asked Sheela Patel, D.D.S, a pediatric dentist at CookChildren’s to lend her expertise.

Teething Myth No. 1- Teething causes fever (or maybe you’ve heard it blamed for congestion, sleep disturbance, decreased appetite, diaper rash, diarrhea or vomiting).

It doesn’t. Right, Dr. Patel?

“Despite what you may have heard, teething doesn’t directly cause a high fever or even diarrhea,” Dr. Patel said. “Babies tend to put everything in their mouth in an effort to massage their gums, so they may pick up bacteria.”

Here are some symptoms that have been found to be statistically associated with teething:

• Mild temperature increase
• Sleep disturbance
• Salivation
• Rash
• Runny nose
• Appetite loss
• Irritability

You’re thinking, “See, I told you it does cause fever!”

Not so fast.

First of all, the temperature increase was noted to be 0.12 degrees Fahrenheit on the day that the tooth erupted. I’ll leave it up to you to decide if you think having a temperature of 98.6 vs. 98.72 actually makes a difference…

Second, the increase in temperature and the rest of the symptoms associated were found to be present on the day the tooth came and the day after. This was not a 2 week (or 2 month) process leading up to the teeth popping through.

The issue is that all kids teeth. In addition, all kids have occasional sleep disturbances, drool and have runny noses. Trying to determine if the teething causes these symptoms in a particular child is pretty difficult.

Teething Myth No. 2 - It’s too early for them to cut teeth.

The average age for the bottom middle teeth to come out is 4-6 months, but some children teeth before or after.

Some children are born with teeth, called natal teeth. If the teeth are stable in the mouth, nothing needs to be done. There may need to be some extra special care with breastfeeding moms to make sure their latch is not painful, especially during those early feeding days. If the teeth are wiggly, sometimes the pediatrician will pull it or recommend that you see a pediatric dentist to have it pulled.

Teeth can otherwise erupt any time after birth. But remember that the “symptoms of teething” that occur for two months before a tooth erupts are not likely due to teething at all.

Teething Myth No. 3 - They are too old to not have any teeth.

“He still doesn’t have any teeth.” I get this comment all the way from 6 months to 1 year. The right answer, “That’s OK.”

It is exceedingly rare for children to not have any teeth or to have teeth, but for them to never come out. A handful of babies don’t have teeth at their one year check-up but, I promise, they’re coming.

Teething Myth No. 4 - Teething must be treated.

The understanding of teething has changed a lot over time. Infant death used to be commonly associated with teething. Think about it, if a 6-12 month old child died for unexpected reasons, chances are they had a tooth coming in. Because of this, teething used to be treated with things as invasive as lancing the gums in order help them come through.

While we’ve come far enough to know that isn’t necessary. Parents still attribute a significant amount of normal fussiness or waking up at night to teething and treat based on this idea. What’s the problem? Everything we do has potential risks…from teething gels, to essential oils and even Tylenol^® or Motrin^®, while options, should be used with caution. (While I’m on my soapbox, just because something is the “natural” or “organic” variety, doesn’t mean it’s safe.)

For treatment of teething, Dr. Patel recommends that you “provide a firm rubber teething ring to chew on, but avoid the ones that are filled with liquid. Try giving your child a cool, wet washcloth to chew on. You can wet a washcloth, ring out the excess water and place it in the freezer. Make sure to wash it before each use. Give your child cool, softer foods such as applesauce or yogurt.”

Don’t let these common teething myths fool you. If your child has severe symptoms, don’t attribute them to teething. Don’t treat normal behavior with medication. Don’t assume that teething treatments are without risk.

About Sheela Patel, D.D.S

Dr. Patel is a dentist at Cook Children's Neighborhood Clinic on 2600 E. Berry Street in Fort Worth Texas, 76105. Dr. Patel received her dental degree in 2009 from University of Nebraska-Medical Center in Lincoln, Neb. She completed her pediatric residency in 2011 from the Baylor College of Dentistry in Dallas. Dr. Patel is board certified by the American Academy of Pediatric Dentistry. The Neighborhood Clinic offers a dental home for patients from 6-18 years of age the clinic and most CHIP, Medicaid, and commercial insurance plans are accepted. The staff speaks English and Spanish. To learn more, click here or call 817-347-4600.

I collect snow globes of cities I love. When my stepson, Sage, was little he would love to watch us shake them and watch the snow swirl violently around settling gently on the miniature cities. Shortly after starting kindergarten, I found Sage sitting on our couch holding a snow globe and looking really sad.

When I asked him what was wrong he held up the globe he was holding and shook it and in the softest voice said, "Look Sand... It's 9/11." I sat down next to him, took the Globe with the pre9/11 New York City skyline and sat it on the table. He put his hand in mine and we sat there watching the snow swirl around the miniature city.

I realized he thought the snow was paper and that he must have seen footage of that day somewhere. We have to talk to our children about 9/11.This day makes us feel sad and angry. Our hearts ache. The images haunt us. The pain is still so fresh.

How do we possibly explain this day to our children, most of whom weren’t even born when the towers fell. We want to protect our children and shield them from evil. But, no matter how hard we try, it is there. It will ALWAYS be there. The planes crashing. The towers falling. Our illusion of safety demolished.

First we must listen. Children are taught about 9/11 in school as a part of national history. They may want to express their thoughts and feelings. Let them talk. Listen to what they have to say.As you talk to your children, be age appropriate in your discussions. You do not need to tell your children graphic details.

Be honest. Answer the questions they ask. Correct any misperceptions they have.Try to focus your discussion on stories of resilience and hope. Talk about how the entire world responded to our country with support and love. Talk about the heroes of 9/11. If you lost a family member on that day, tell stories about how wonderful that person was and their importance in your life.Children want to know they are safe. Remind them about all the changes that have been made to make sure we are safe.

For younger children; it is important their world feel secure.Monitor TV and the Internet. On the anniversary of 9/11, many news outlets will show memorial coverage. Try to limit the coverage they see. There are many graphic images on the Internet as well. If your child sees an image that is upsetting, let them talk to you about their feelings. Tell them it upsets you as well. Remind them it is Ok not to watch or look at things that make them feel sad. Again, reassure them that they are safe.Discuss with your children that today should be about reflection and remembering, but also a day to tell those we love how much they mean to us. Take a moment today to reach out to others and teach your children to do the same.Walk in peace today and give thanks to those who are protecting us.

We will never forget.

About the author

Sandra Peak, M.D., joined Cook Childrens Physician Network in Lewisville in 2004. Dr. Peak enjoys gardening, yoga, and boating and in her spare time can be found at the lake with her husband Jay, stepson Sage and the world’s most amazing Lab, Sugar Mae.

That’s how I remembered this:

Blood, frogs, lice, flies, disease, boils, hail, locusts, darkness, death.

You might ask, why was I learning the order of the plagues? Obviously, for a bible quiz game we used to play in Sunday school. Because I’m ultra-competitive, even when it comes to Sunday school.

The recent weather in North Texas has many questioning if we are witnessing plagues or if the Apocalypse is upon us.

Fortunately, it looks like the worst of the drenching rain (and hopefully the flooding as well) are behind us. As the waters recede, the rising threat will be mosquitoes and mosquito borne illness.

What’s the big deal with standing water?

Standing water is the breeding ground for mosquitoes. There are four stages of life for mosquitoes. The adult flying stage is the only one that does not rely upon water for survival. The eggs, larva and pupal stages must live in standing water.

Any standing water - water in a bird bath, pond or standing water from improper drainage can be a place for mosquitoes to breed.

Why do mosquitoes bite?

Female mosquitoes bite because they need a source of protein before they can produce eggs. Otherwise, like males, they can feed on nectar or sap.

When females bite, their long mouthpart breaks through the skin and gets into the small blood vessels just underneath. They also inject a small amount of saliva into the wound to make entry easier and to keep the blood from clotting.

What harm do bites cause our children?

Local reaction - While not technically an allergy, some kids will have a large local reaction with swelling and redness at the site of mosquito bites. These can be itchy and cause distraction in school or lack of sleep when severe.

Local infection – It’s not uncommon to see local infection in kids who have scratched mosquito bites, leaving a gap in skin, which can lead to infection. If the swelling worsens after the first few days or if there is significant warmth from the site of the bites, you should see your pediatrician to see if antibiotics are necessary.

General infection - Because mosquitoes can carry diseases, bites from mosquitoes can transmit infection that can affect the entire body. Mosquito borne illnesses cause over one million deaths world wide, most commonly from malaria. Two other diseases that we have seen in Texas associated with mosquitos are West Nile Virus and Chikungunya.

Given the amount of rain and the season, mosquitoes will be inevitable this summer season. Read more here about the many different ways you can reduce your child’s risk of discomfort and serious illness: How to fight (and) win against mosquitoes.

Aside from flu, I can’t think of any other disease for which we vaccinate where we are excited if only a few outbreaks happen here and there. Yet, despite relatively high vaccination rates at recommended times, we continued to see outbreaks of pertussis occur across the country.

A recent study, published early online for Pediatrics showed that the effectiveness of the new vaccine might even be worse than I thought. The study looked at the medical records of children diagnosed with pertussis. They looked to see if they had the newer, acellular vaccine as children and how long it had been since they received their Tdap (Tetanus, diphtheria and pertusiss) booster. This booster is usually given at age 11.

The most striking statements in the article is how quickly immunity from the vaccine decreases over just a few years after receiving the Tdap booster. The first year yields about 69 percent effectiveness. The second through fourth years decrease like this: 57 percent, 25 percent and 9 percent. We only give boosters for Tdap every 10 years.

The effectiveness was so bad that the authors concluded the study by saying: “We expect future pertussis epidemics to be larger as the cohort that has only received acellular pertussis vaccines ages. The results in this study raise serious questions regarding the benefits of routinely administering a single dose of Tdap to every adolescent aged 11 or 12 years.”

Will I stop giving pertussis vaccines to my 11 year olds? Would I skip it for my kids?

The answer to both of these questions, for now, is “No.”

Here are 3 reasons why:

1.There are very smart members of a group called the Advisory Committee on Immunization Practices (ACIP) that review vaccines and make new recommendations every year. These folks understand vaccines and the statistics surrounding their effectiveness better than anyone else in the country. They are not afraid to make changes that are based on very minute details (like whether you can be vaccinated with different brands of vaccines over time and they still work). There is no question they will review this study.

2.We have another disease for which we continue to vaccinate even though the vaccine strategy isn’t perfect and we continue to prevent thousands of severe cases and death from flu every year. Do we continue to look for better strategies and products for vaccination for both flu and pertussis? Yes. Do we throw out what we have because it isn’t perfect? No.

3.Even if the vaccine effectiveness wanes quickly, that one year of protection could be important for specific populations. Pregnant moms not only need to be protected from contracting the disease, they pass antibodies to their babies if the vaccine is given at the right time during pregnancy. Because of this, it is now recommended that pregnant moms receive the vaccine with each pregnancy. Perhaps we should consider giving a booster shot to all close contacts with the baby no matter when their last booster was given.

Reading this study and the subsequent articles I saw was disheartening. I have seen babies struggling to breathe and subsequently die from pertussis. It’s awful.

Undoubtedly, we need a better vaccine and strategy. For now, I’ll continue to do the best I can until we have something better.

I have to start with an apology.

It’s not that I didn’t care, or wasn’t concerned.

I asked about feedings and dirty diapers. I asked about sleep positioning. I asked about your plans for vaccination. I educated on how to take a temperature and what a fever is, whom you should call when you are concerned.

I know a lot about your baby from our little time together.

But, I often forgot to ask about you.

Sometimes, if you looked particularly tearful, concerned … I don’t know, maybe distraught, I asked how you were doing. You might have said “fine” and I probably left it that.

Recent news reports reminded me that I should be doing better.

Depression affects about 30 percent of women between 18 and 44 years of age. I don’t want to get bogged down with more stats, but about 15 percent of women in their reproductive years take antidepressants. Most experts agree that untreated depression carries much more risk to babies than medications for depression. Studies have shown mixed results with most indicating that they are safe and others indicating a slight increase in risk for birth defects.

A special US Preventative Service Task Force report stated that all adults should be screened for depression but placed particular emphasis on the importance of screening pregnant and new moms. They conclude that screening should be implemented “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”

If new moms should be screened for depression, who is going to do it if I don’t? Many don’t go back to their obstetricians until six weeks. What doctor are they seeing in the mean time? Who is going to screen them for postpartum depression? It has to be me.

Many pediatricians do this very well. They have built a system in place and screening has been part of their process for years.

Those of us who didn’t have many reasons…

Other priorities took over.

Checkup times are too short.

We’re not sure what we would do when we identified someone with postpartum depression.

But none of those are good excuses.

Because of this, I promise to work to develop a system that works.

I have to.

For you and for your baby.

I will report back with more soon.

Sincerely,

PS. Symptoms of postpartum depression can include:

• Increased irritability
• Loss of patience
• Quick mood changes
• Excessive energy or extreme fatigue
• A sense of feeling hopeless or overwhelmed

If you are someone you know is suffering from these symptoms, please ask for help from someone. Start with a friend or a doctor but do not suffer in silence. There are resources available.

Don’t get me wrong, I’m glad he had his baby vaccinated for his baby’s sake, but I don’t want it to affect your decision to vaccinate at all.

I don’t want your vaccine decisions to be based on what a celebrity does, even if that celebrity is one of the most brilliant guys around.

Why?

Because some other really smart person will choose next week to skip vaccines and then where will we be? No better off than getting vaccine information from celebrities like Justin Timberlake or Jenny McCarthy.

If you vaccinate, you are not alone.

Studies show that over 95 percent of you have chosen to vaccinate your children.

Does it feel like that to you?

Does the media portray it that way?

Does your social media stream reflect that vaccination is the overwhelming majority?

The answer, I believe, is no.

But, why?

Maybe it’s not cool or politically correct to vaccinate you child, or at least to say that you do.

Maybe it’s because you are afraid of the comments you will receive if you support vaccines or report that your child just received some.

Maybe you worry what would happen if you question that thousandth share of some 2012 Italian court case. (P.S. That decision, which was made in some really low level court in Italy, was thrown out by a higher court so just stop already with Italian court decision memes.)

I promise you the world wouldn’t end if you do. If you get a comment that is rude, it’s OK to ignore it. If you have an answer, answer. If you don’t know, get advice from someone who might know. Tag me.

So, I don’t care that it was Mark Zuckerberg who chose to vaccinate his child. But, I do appreciate when anyone speaks up to say, “I vaccinate my child because I believe it is what is best for them.”

Let’s start something today:

Share this post that you are reading right now and say, “Thanks for sharing Mark. I #vaccinate too."

Currently, I am the lone survivor of the war on Smith-Summertime-Flu-Like-Illness-2015.

You name the symptom and someone in my family has had it: fever, cough, runny nose, congestion, headache, sore throat, vomiting ... I could go on.

All of these symptoms are annoying. Running to grab the “puke bowl” when your 4 year old is “frowing up” is not my idea of a fun nor peaceful Wednesday evening. Trying to discern if his “headache” is really a headache, or fever or the early stages of some terrible bout with meningitis is not good for this pediatrician’s soul (nor his wife’s after she read this. It’s not meningitis, babe, I promise).

But the most annoying of all these symptoms for me is cough. When I have a cough, I generally try my best to keep it in for as long as I can, and let it go just before I feel like I’m going to drown in post-nasal drip. When my 6 year old has a cough, I’m pretty sure he feels like it is his duty to release that cough every five seconds. I think he does this just to remind me that he’s not feeling well and I haven’t given him anything to help.

Why don’t I give my kids cough medicines?

I don’t give cough medicine to my kids because they don’t work.

They really don’t.

Really.

The hard thing about this fact is that they were a staple of pediatric care for decades. Cough and cold medicines were first approved for use in children in 1976. There were no studies done to determine if they worked or what the appropriate dosing should be. I think the process back then went something like this:

“Why not give half the adult dose for children 5-12 and a quarter for the adult dose for children age 2-5?”

“Sounds good to me, let’s do this.” (Or maybe “Right on!” or “Groovy!” I don’t know, it was the 1970s.)

Since 1976 there have been several studies looking at the use of cough and cold medicines. The most recent review of the 25 best studies done stated this as a conclusion: “There is no good evidence for or against the effectiveness of OTC (over the counter) medicines for acute cough.”

I don’t give cough medicine to my kids because they can cause problems.

Side effects, even serious, even fatal ones, can occur as a result of giving kids (especially those under 6) cough medicines.

If you want to read some scary stories read these case reports from Pediatrics:

1. 3 year old ends up in ICU after becoming lethargic, having a slow heart rate, fast breathing and high blood pressure. Diagnosed with toxicity from Dimetapp (in this one we don’t know how much mom gave-could have been too much).

2. 3 year old being treated for pneumonia develops a fast heart rate, so fast that it start to interfere with the heart’s ability to work right. Parents were thinking they were giving Tylenol but ends up they were giving Tylenol Cold (acetaminophen, chlorpheniramine and dextromethorphan).

3. 9 month old boy is discharged from the ER with a diagnosis of pneumonia, doing well. Returns 12 hours later after being found cold, blue and not breathing. Unfortunately he dies after he is unable to be resuscitated. Toxicology on autopsy finds acetaminophen, pseudoephedrine, chlorpheniramine and dextromethorphan in the blood and heart tissue.

It is estimated that about 7.000 children are treated nationwide for toxicity related to cough and cold medicines and 64 percent of those are children under 6 years of age.

Everything in medicine is about weighing whether something works and if it could be harmful.

Cough medicines do not work and could cause harm, so my kids will pass.

P.S.

So will my patients because I don’t prescribe them either.

• You will be awake during hours of the night you didn’t even know existed.
• You will begin to interpret everything as a smile.
• You will allow words like spit up and poop become normal dinner conversation.

As you talk about poop, you will uncover something you will be concerned about or at least something that gets your attention. So, here are some weird things you might find in a baby’s diapers:

1. No poop - Babies need to poop in the first day or two after birth to prove that they can. After that, skipping a day or two shouldn’t concern you.
2. Lots of poop - Infrequent stools can be normal but so can pooping all day long every day. It’s also not uncommon for babies to poop every meal with a few stuck in the middle. So much poop, you literally can’t even.
3. All the colors - Pretty much any color stool can be normal. Yellow, green and brown are the most common. In the first few days, it will be black. But there is one color that should get your attention…
4. White or clay-colored poop – This is the one poop color that should prompt an immediate visit to the doctor. Do not pass Go, do not collect $200. It can point toward a rare, but serious liver condition and the baby needs to be seen.
5. Seeds in poop – These little flecks are common in breastfed babies and won’t grow breast milk trees if planted although that would be cool.
6. Blood or mucous poop – This could be a sign that your child is allergic to the protein in their milk. Call your doctor.
7. Red specks in pee – These little red crystals are not blood but are actually urate crystals. They are common and normal.
8. Swollen scrotum – If your little boy has one sided scrotum swelling or both sides are increasing in size, it could be a hernia. This is much more of an emergency if the baby seems to be in pain or there is redness of the skin.
9. Diaper rashes – Most of these are just general irritation from stool. For those, large amounts of thick cream, keep stool off the skin and allow it to heal (you probably aren’t using enough).
10. Bloody or clear/white vaginal discharge – This discharge is very common and is the result of hormonal changes that occur after birth and nothing to worry about.

There are plenty of other weird things your baby will show you, even some more in the diaper area. Some of these are more severe abnormalities that should have been picked up by the doctor before you left the hospital. Hopefully by reading this, you can avoid having to talk about if your baby’s poop is normal tonight. Have a great dinner!

Because societal factors such as TV, school, friends and the Internet can strongly influence a young child’s behaviors, it’s important that parents help young ones map out and focus on a few simple, healthy resolutions that can later translate into positive behaviors as children grow and develop.

“Making New Year’s resolutions can be very beneficial for children because it teaches them the importance of setting goals and following through,” said Lizy Varughese, M.D., a pediatrician with Cook Children’s in Lewisville. “Not only can goals be applied to a child’s eating habits and physical activities, but they also teach important life lessons about the benefits of planning ahead and the success that comes from it.”

While it may be tempting as a parent to jump ahead and make a list of New Year’s resolutions for your child rather than waiting for them to develop a list on their own, empowering your kids to creatively embrace this time-honored tradition can be filled with good times and great memories.

Encourage children to start with a list of broader, bigger goals such as eating less junk food, picking up their toys or making better grades. No matter how far-fetched the goals may seem at first glance, parents should stay open-minded and flexible, resisting the urge to criticize their child’s resolutions. Remember, keeping the mood light and enthusiastic makes goal setting seem less like work and more like fun.

From there, Dr. Varughese suggests children break down their resolutions into small bites by using journaling as a method to solidify goals.

“Begin the new year by writing down specific goals for eating and participating in sports and exercise activities,” Dr. Varughese said. “Children are more likely to complete a task if it’s written down and there is accountability for their progress. It’s also important to be flexible so the parent can help kids for a more attainable goal if a particular goal is not met or seems difficult for the child.”

About the source

Dr. Varughese attended Texas A&M University and received a B.S. in Biomedical Sciences. She attended medical school at the University of Texas Health Science Center in Houston, Texas and completed her residency at Stony Brook University Hospital, Long Island, New York. She was then appointed Clinical Professor of Pediatrics from 2005-2006. After that, she joined a private practice in New Jersey for five years. She moved back to her hometown of Dallas, Texas, and joined Cook Children's Physician Network in Lewisville in 2013.

She is married to Dr. Shane Varughese and has two children, Noah and Sarah. Dr. Varughese enjoys photography, cooking, and church activities. Her passion in life is taking care of children and educating families on preventative care and battling childhood obesity.

Last week, a Plano CPS agent responded to a different type of call after a Facebook post inviting parents to bring their children over to be exposed to chickenpox was reported

What is a pox party?

Pox parties were more common prior to the introduction of the chickenpox vaccine in 1995. The general feeling was that, if your child was going to get chickenpox at some point anyway, you might as well get it out of the way. It seemed like a rite of passage that everyone should go through. Because most people survived chickenpox with a few days of itchy annoying rash, there are some that ask me if the vaccine is necessary. “Wouldn’t it be better for us to just get the disease?”

Why do we vaccinate for chickenpox?

Most children with chickenpox develop fever, sore throat and loss of appetite which is followed by the classic rash. I was taught that the rash was like “dew drops on a rose petal” because of the clear, fluid-filled bumps that form on a red base. The rash would then crust over with the crusts lasting one or two weeks before falling off.

It was a memorable disease but not dangerous for most. I happen to remember riding around in the floorboard of my dad’s gas truck (it was a different time for lots of reasons) while I was recuperating, not able to go to school because our local farmer’s couldn’t wait for my rash to heal to have gas for their tractors.

Unfortunately, not all children with chickenpox have a simple course. Here is a list of possible complications that can arise from chickenpox:

1. Skin infections-These could be simple and treated with antibiotics but also can be deeper and involve muscle or other tissues. This would be more dangerous now that we see more antibiotic resistant bacteria.

2. Neurologic complications-Infection of the tissue around the brain could lead to confusion and infection of a particular part of the brain lead to a loss of coordination, both complications lead to hospitalization.

3. Less frequent complications-Pneumonia and hepatitis (liver infection) can also occur but do so less commonly.

Prior to the vaccination, there were 11,000 hospitalizations and 100 deaths from varicella yearly. About three children out of 1000 infected required hospitalization. Since 1996, hospitalizations and deaths have fallen significantly (70 and 88 percent).

Is there anything wrong with having a pox party?

As best as I can tell (I am not a lawyer), there is nothing illegal about throwing a pox party. One thing is clear, sending lollipops through the mail (even pox parties want to be the next Uber) to infect others is. There is also a picture that has been shared around the internet which reportedly quotes the mom from the Plano area pox party as saying, “I had to open my husband’s shingles blister and swab their mouths.” I have a feeling most of those out there who would throw or go to a pox party would consider this a little much.

Should CPS have been called?

I have to say when I first read this story; I thought that the call to CPS was a little overboard. CPS is busy as it is. Investigating pox parties is probably not the best use of their time. I have served on local CPS boards and the things that we talked about needed the full attention of a staff that was already stretched thin.

Secondly, the likelihood of serious harm resulting from contracting chickenpox is overall pretty low. Should CPS be called for every parenting infraction that minutely increases the risk of harm to children? No. That would mean I should report every family that turns their child’s car seat around at 21 months or that allows their baby to sleep on their stomachs. While I disagree with those decisions, I choose to educate as best as I can but don’t log on and report them to CPS.

My only pause in this case came from what I admit is a slippery slope argument but stick with me for just a second. What if one of these children ended up seriously harmed as a result of contracting chickenpox at this party?

Seeing children suffer from vaccine preventable diseases (pertussis is the most common which admittedly occurs in both vaccinated and unvaccinated babies) is hard. If I saw a child suffering from a complication of chickenpox only to discover that the child had contracted chickenpox intentionally at a pox party, this would be even harder.

How can we prevent against chickenpox?

The most effective and best way is through vaccination. Vaccination at age 1 and 4 years protects against 90 percent of chickenpox disease and 99 percent against severe disease. Rarely, children can get chickenpox after they have been vaccinated but the cases seem to be milder.

If you have a child with ADHD and have chosen to go for a non-medical route, more power to you, and if it is working well for you, that is awesome. However, I also have families that have stressed for years because of something they have heard in the media or from their friends and they and their child suffered because they didn't want to place their child on medicine for whatever reason.

Won't They Get Addicted to the Medicine?

Children on ADHD medicines are not addicted and are not more likely to have addictions later in life.

Here is the definition of addiction: "compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly  : persistent compulsive use of a substance known by the user to be harmful."

ADHD medicine do not form compulsions in children who actually need them and they are not habit forming. Just like any other medicine, parents and kids will forget from time to time and the only effect they see from missing a dose is that their child's behavior is not as good that day. There are no other side effects.

Tolerance is the effect where a person develops a bigger and bigger need for a substance in order to develop the desired effect. While there are times when I do have to increase a dose of medicine it is typically more related to the size of the child increasing and the changing stressors (increasing difficulty, etc) at school that require the increase. Changes are often necessary around puberty as well.

Finally, there are no withdrawal symptoms when a person comes off their stimulant ADHD medicines. In fact, the child “comes off” their medicine every night and can take weekends or summers off without developing symptoms (other than being more hyperactive). By definition, this means that there is no withdrawal.

So, without compulsion and habit, tolerance or withdrawal, there is no single characteristic about these medicines that make them addictive.

As for the question about children with ADHD going on to have more addictions later in life, it seems that this is more related to the ADHD than the medicine and adequate treatment may actually help prevent some of these later behaviors.

I Don't Want Them to Act Like a Zombie!

I hear this complaint or concern with just about every consult that I see. Understandably, parents don't want their children to act differently or have a change in personality because they are on medication. Guess what? Me neither. If I were to see personality changes in my patients, I would change their medicine or come up with other treatment strategies. However, this is a very uncommon complaint when families actually start medication. In my 6 years of practice, I have heard this complaint only twice and both of the parents were extremely worried about it prior to starting medicines, which makes me wonder if they weren't looking too hard for it in the first place.

It is my opinion, this was a bigger problem before with the short acting medicines (like Ritalin). Because they needed to be dosed more twice in the day, the children may have experienced the change in their blood level throughout the day which led to more drastic behavior changes.

Will This Stunt My Child's Growth?

While there have been some studies showing a slight decrease in weight and height growth over the first year of starting a medicine, these differences disappear when you recheck the children at 2 and 3 years out from starting medicine.

What are the Common Side Effects?

The most common side effects I see from the ADHD medication (primarily stimulants) are loss of appetite and difficulty going to sleep.

Loss of appetite-We usually see this problem just after starting medication and it certainly can improve over time. The child usually has the biggest problem with lunch time as that is the when the medicine is at its highest level in the blood stream. Usually, you can make up for this problem by making sure the child eats a good breakfast and dinner and eats what they can at lunch. I follow my patients’ weights closely especially when there is a concern about the child's appetite.

Difficulty with sleep-Occasionally, we will have a child who has a difficult time going to sleep. Like appetite, this is most common right after starting the medication. My first treatment for this is to make sure that are taking care of doing the right things to help themselves go to sleep: no food or drink with 1-2 hours of bed time, no screens on in the room 1 hour prior to bed time, etc. If that doesn't work we can do a trial of melatonin. Other options are available if this doesn't work.

Some more rare side effects that I want to discuss are mood instability and tics.

Some of the medicines are worse that others about this but we will sometimes have a child who is very emotional and tearful when first starting the medicines. This typically happens in the afternoon or evening as the medication is wearing off. Usually, with just a period of observation, this will improve after about 1 week on the medicine so I first have my families continue trying for a bit and monitoring closely to see what happens.

Tics are involuntary movement disorders that result in a short jerking of the head, lip smacking or some other short, quick motion. These medicines do not cause tics, but in a child who is already predisposed to them for some reason can cause them to become much more obvious and frequent. If the tics are disruptive or concerning, we will usually need to switch medicine to something else as this does not usually improve over time.

Summary

1. Children do not become addicts because of ADHD medicines.
2. Children do not become zombies because of ADHD medicines.
3. Children do not become short because of ADHD medicines.
4. Children should be watched closely for loss of appetite or difficulty sleeping when starting ADHD medicines.

For more information

Visit our Checkup newsroom resource page to learn more about ADHD. 

New research published this week in the Journal of Clinical Psychiatry may challenge that stereotype or at least require us to broaden what we think ADHD “looks like.”

The research looked at the overall rate of ADHD comparing surveys of parents completed in 2003 and 2011. It might not surprise you to learn that the overall diagnosis of ADHD increased during that time. But you may not have heard that increases were found across all racial/ethnic groups, with the largest increase in Hispanics (83 percent). Perhaps another surprise was the fact that the increase in girls was greater than the increase in boys (55 vs. 40 percent).

Symptoms of ADHD can include difficulty paying attention, hyperactivity and impulsivity. Diagnosis is based upon a conversation you can have with your pediatrician or a psychologist and usually involves a screening questionnaire to be completed by a parent and teacher. Treatment starts with behavioral and parenting strategies to help children cope with symptoms but can require medication when these are not successful.

The study showing this increasing number of children diagnosed with ADHD certainly grabbed my attention. As someone who generally does not like medication for kids, I worry that this means the number of children on medications for ADHD is also increasing. As with all medications (and more than most), treatments for ADHD do not come without risk.

I do have some theories as to why the number of children diagnosed is increasing:

Theory No. 1 - Parents and teachers are more aware of the signs of ADHD.

Many hyperactive and impulsive children were previously labeled as trouble-makers and ended up spending lots of time in detention and in school suspension. Many inattentive children slowly started to have more trouble as classes got harder and parents and teachers eventually gave up on them as someone who just “wasn’t made for school.” Now we are realizing that those hyperactive/impulsive kids can’t simply “just sit still” and that those kids who were previously doing well shouldn’t be failing just because they can’t listen to lectures or get their paperwork turned in on time.

This particularly accounts for the increased rates of diagnosis in children of Hispanic and African-American descent. Previously, the stigma associated with all mental health conditions (including ADHD) prevented parents from seeking help. Also, because many girls are inattentive, rather than hyperactive and always in trouble, they could also go undiagnosed.

Theory No. 2 - Physicians are increasingly giving in to parent demand to “fix” their child.

This is by far my least favorite, but I just believe it is something we should at least consider. In a world where the expectation is that a pill can cure just about anything right now, parents increasingly want something today that will resolve their child’s behavior problems. Long term treatment plans that involve behavioral techniques and maybe even counseling aren’t as popular for all parents. However, we should fight against this as the diagnosis of ADHD and decision to start treatment should not be based on demand from a parent.

Theory No. 3 – The expectations and demands on children are changing.

Children are learning to read and do more intense math earlier and earlier. Homework was virtually non-existent when I was growing up until second or third grade. This is not necessarily the schools or teachers fault so don’t call up and gripe at your child’s teacher. Many of the requirements for what they teach and when they teach it come from above them. The simple fact is that, in trying to keep up with the success of other countries, we have decided to accelerate curriculum and to challenge students. It’s not always a bad thing, but it can be if you have a hard time sitting still for long periods or can’t keep yourself organized.

Theory No. 4 - New medications with less side effects have made parents more likely to seek treatment.

No one wants to see their child “turn into a zombie.” It’s still the number one concern I hear when starting treatment for ADHD. Fortunately, with newer medications, the side effects are much less severe and much less common. Loss of appetite and difficulty falling asleep are now the most common side effects I see, even those are not that frequent.

Keep in mind, each of these things are theories based on my experience. We will need to continue investigating why we are seeing this increase in the rate of ADHD. We all need to be observing our children for signs and symptoms, particularly if they are struggling with school but parents and teachers need to be careful not to attribute all school struggles to ADHD.

For more information, read: 

Are we there yet? “No. 5 more minutes.”

Are we there yet? “No. I will tell you when we get there!”

Did anyone hear this or something like it last week?

We’ve been asking a similar question to our favorite Cook Children’s microbiologist, Morgan Pence, Ph.D.

Is it here yet? No.

Flu season should be just around the corner, but it’s not here yet. Currently, there are only two regions showing Influenza activity across the state of Texas. Tarrant County is not one of those regions.

Flu season usually starts sometime in late October or November but occasionally we have later seasons. It appears that we are going to (knock on wood) make it till December before we see our first case at Cook Children’s this year.

There are few theories about why flu follows a seasonal pattern:

1.As weather gets colder and people are trapped indoors, the virus can more easily spread from person to person.

2.Colder temperatures lead to drier air. Dry air causes our noses to be drier which may make their defense against flu weaker.

3.Cold temperatures may allow the flu virus to live longer on surfaces.

Based on these theories, it’s possible that our warmer fall has caused a delay in the onset of flu season. With the colder temperatures last week, we may be reporting our first case soon.

Dr. Pence reports that our lab tested 74 specimens last week but none were positive for flu. She states, “Currently we are mostly seeing children with rhinovirus and RSV.” Rhinovirus causes the common cold. RSV can cause cold-like symptoms as well, but can be more severe in babies, especially those who were born premature.

What does this mean for you and your child?

1.If you haven’t yet, there’s still time to get your flu shot. (Even if the year starts late, it could still be a bad one).

2.Continue to teach your children to cover coughs and to wash hands.

3.Be aware if your child tests positive with a rapid flu screen, it may not be correct until flu activity is higher.

For now, Dr. Pence will still have to play the role of lab-mom.

Is it here yet? “No.”

Is it here yet? “No, probably 2-3 more weeks.”

Is it here yet? “No, but you’ll be the first to know!”

It could be that amoxicillin prescription that your child took last week.

Antibiotics have been one of the greatest advances in medicine. People used to die frequently from diseases that we now view as simple because antibiotics are readily available. However, the ease of use of antibiotics, combined with what seems to be a low risk associated with them has created a huge and growing problem.

I believe that the biggest reasons why antibiotics are overprescribed deal with several myths surrounding antibiotic use:

Myth No. 1: Parents always want antibiotics.

This myth is one that physicians frequently believe. You would like to think that it doesn’t influence their behavior but it does. A study from 1999 showed that physicians prescribed antibiotics for viral infections 62 percent of the time when they believed that parents wanted them and only 7 percent of the time when they didn’t. Hopefully we’ve gotten better and this gap is closing but still, WOW. The interesting thing about this study is that the physicians often thought that parents wanted antibiotics when, in fact, they did not.

So, this one falls on us. We need to ask more questions about what parents goals are and we need to educate rather than prescribe when antibiotics are not what is best.

Parents if you want to help your doctor understand when you would prefer not to use antibiotics, read this post: Does my child really need an antibiotic?

Myth No. 2: All infections will get better with antibiotics.

Some infections in kids require antibiotics for improvement. Strep throat, urinary tract infections and skin infections will need antibiotics to treat and prevent worsening of the symptoms.

Ear infections don’t always need antibiotics. In older children with less severe disease, a period of waiting can allow the infection to go away without treatment.

Many infections in children are caused by viruses. Flu, colds, sore throats that aren’t strep and many other infections in children simply need a little time and TLC. Mary Suzanne Whitworth, M.D., medical director of Cook Children’s Infectious Diseases adds, “Most viral upper respiratory tract infections start with clear runny nose, maybe fever, and maybe a cough. After a few days the nose drainage is green and then after a few more days it goes away on its own. Antibiotics are not needed for these viral illnesses. The child might have bacterial sinusitis and need antibiotics if the green runny nose lasts for over 7 to 10 or if symptoms worsen after a few days.”

Myth No. 3: There’s no harm in giving antibiotics.

While you might not have ever seen side effects or dangerous reactions to antibiotics, I see them almost every day. Children can have severe, even life threatening, allergic reactions (even if they have taken that antibiotic before and been fine). Because these are rare, they are not a reason to avoid antibiotics when necessary but they are a reason to use caution when antibiotics are not the right treatment in the first place.

Antibiotics can also cause other side effects, most commonly diarrhea. This diarrhea can last weeks and can be quite severe. If the diarrhea is severe (especially if blood or mucous is present) your doctor might have to consider testing for C. difficile which is a potentially serious infection that can be the result of antibiotic use.

Finally, we are beginning to see an increase in the number of infections caused by bacteria that do not respond to the antibiotics we have traditionally used for them. This requires us to use stronger antibiotics which can often cause more side effects. You can see why people are concerned if we continue along the same path but fast-forward 25 or 50 years. What types of bacteria would emerge? This is why we must use extreme caution.

Dr. Whitworth adds, “Antibiotics are important and often life-saving. But each time they are used there needs to be a conscious decision made about exactly why they are indicated, what the best choice is for patient compliance, and what the risks and benefits are. They should not be used just because they are expected or requested.”

Parents and doctors all play a role in decreasing the unnecessary use of antibiotics. Open conversation about the child’s condition, the parents’ expectations and the possible risks and benefits of antibiotics treatment are all important parts of each decision regarding antibiotics.

Poisoned candy?

We’ve heard these scary tales since we were little kids. Parents make sure you check your kids’ candy before they begin munching on their treats, but know that many of the stories you’ve heard are meant to scare your little brother.

Are there some particular dangers you should be aware of for the last day in October? Yes! Here are a couple of other Halloween treat issues you should know:

Food allergies

Children with food allergies can have a particularly challenging time during all holidays, including Halloween. Their desire to feel included in the rite of passage that is trick-or-treating doesn’t always mesh well with the risk of getting food that could harm them.

Many of the most common food allergies are frequent ingredients in Halloween treats (nuts, milk, egg, soy and wheat).

Over the past few years, there has been a movement towards providing non-food options for trick-or-treaters. You can designate your house a food-allergy friendly house by painting a pumpkin teal or for those of you are aren’t as crafty (or are just too lazy or don’t have enough time), you can print out this flyer and tape it to your door.

Listeria in caramel apples

Besides being a risk for ripping my front teeth out, caramel apples can harbor Listeria. Remember Listeria, you guys? It’s why I haven’t had Blue Bell in months. According to a recent study from the American Society for Microbiology, it seems that when the apple is punctured by the popsicle stick, the small amount of juice that comes out can become infected with Listeria.

Listeria is a particular concern for pregnant moms, the elderly and newborns so please don’t let your newborn munch on a caramel apple.

Some stores are pulling caramel apples off the shelves in response to this study.

Halloween can be a great time of fun for all kids.

For more information, check out our Halloween safety page.

What if you then found out that you had been lied to about that day care’s license?

In fact, they didn’t have a license at all.

Fortunately cases like this are rare.

But what about a more common case where your child is bitten once or a few times at day care? What if your child is the one who is biting?

I reviewed the Texas Department of Family and Protective Services Minimum Standards for Child-Care Centers. Here is what I found:

• Parents should be notified about minor injuries when the child is picked up from day care (biting is included in this category).
• Relevant ongoing education is required for employees (and specifically mentions biting).
• Decisions about child/caregiver ratio must take into account situations where there are tricky situations. For biting, it suggests that a caregiver be assigned with training in redirection or that an extra caregiver be assigned.
• Biting is specifically prohibited as a means of discipline for a child (day care workers cannot use the old “just bite them back” techniques for biting).

What can you do?

Three tips if your child is being bit:

1. If it’s a one-time thing, try your best to let it go. I know this is hard but biting does happen and can happen in the blink of an eye even in very closely supervised environments.
2. If you start to notice bites over time, mention your concerns and assess what the day care is doing to prevent the issue.
3. If the bites are severe or very frequent, I would feel very confident suggesting that your child’s day care follow the steps as outlined in the Child Care Guidelines. This might mean that the day care needs a specialized or extra caregiver for the “problem” room.

Three tips if your child is the biter:

1. Do not feel guilty. Sometimes the day care will make it seem like your parenting is the problem. The reality is that you cannot do anything at home to teach a toddler to not bite at day care. Discipline in the toddler age does not work that way.
2. Discuss your child’s triggers with the day care. Biting usually occurs in predictable situations for children. You might be able to help them prevent biting in the first place.
3. Learn what works to distract your child. Children need to be distracted when they are biting. It’s clear from studies that direct punishment does not work well with toddlers. Teach the day care what strategies they can use.

You can read my earlier posts on the symptoms of teething and my outright forbidding the use of teething gels.

After these, I think I have many of my readers wondering what in the world they are supposed to do when their child seems to be teething.

There are a select few of you out there who think you have found a loophole … their children are walking around sporting brownish yellow bling around their necks, are as happy as can be at all times and are sleeping through the night like little angels. Right?

Do amber teething necklaces work? If so, how?

Websites selling amber necklaces are all over the place when discussing how they might work to control symptoms that are commonly associated with teething.

They tend to center around three main concepts:

• Magnetism, energy or natural flow of energy

• Thyroid gland stimulation to control drooling

• Succinic acid released causing anti-inflammatory and pain relieving

Magnetism, energy or natural flow of energy

I found this quote in one of the top-ranking articles regarding how amber teething necklaces might treat teething pain:

“The unfavorable environmental conditions prevailing today block the natural flow of energy-related processes in cells. Blocks affect cellular metabolism and significantly weaken the immune system, but the natural energy of amber is able to stimulate its renewal.”

Thyroid gland stimulation to control drooling (or other symptoms)

The thyroid gland makes thyroid hormone which increases metabolism. This results in a whole list of changes inside our bodies, including:

• Increasing body temperature
• Faster, stronger heart beat
• Brain development and growth in children

Slowing drooling is not a function of the thyroid; thus stimulating it would not result in less drooling.

Stimulating the thyroid could result in increased body temperature (which is, ironically, often one of the symptoms of teething that people are trying to treat).

Succinic acid release causing anti-inflammatory and pain relieving

Perhaps the MOST logical explanation (and most often referenced) for why amber teething necklaces might work for teething pain is that amber contains 3-8 percent succinic acid.

Succinic acid is a chemical that is found naturally in the body and is involved in an energy producing chemical cycle known as the Krebs cycle. The basis of the reasoning behind why succinic acid treats teething symptoms is that it is reported to have anti-inflammatory properties.

Let’s look at a few problems with the assumption:

1. I can only find one study that even shows succinic acid to have anti-inflammatory effects. It is almost 30 years old and was published in a journal I have never heard of, in Russian.

2. Assuming succinic acid does treat pain associated with teething, how does the succinic acid get into the child’s body? Amber is fossilized tree resin which is formed under extreme heat and pressure. The Wikipedia article on amber states, “Exposure to sunlight, rain and temperate extremes tends to desintegrate resin, and the process is assisted by micoorganisms such as bacteria and fungi. For resin to survive long enough to become amber, it must be resistent to such forces or be produced under conditions that exlude these." How is it, all of the sudden, that amber decides to release succinic acid in response to 98.6* temperatures and gentle pressure from your child's neck? Seems unlikely.

3. Let’s assume that 1 and 2 are wrong and that succinic does treat pain associated with teething and will absorb into the child’s body from the necklace. How much is absorbed? Medication applied to skin is notoriously unreliable with children.

Let’s flip this around. Say an established drug company comes up with a treatment for a common condition that is not dangerous but may cause some discomfort. The drug rep comes to my office to promote the drug…

Me: Ok, this all sounds great? So, what is the dose? How does the dose change as the child gets older?

Drug rep: Ummmm, we don’t know really. We haven’t really looked into “dosing.”

Me: So, how do you know this works?

Drug rep: Well, it’s actually been around a long time, we just put it in a different package so we’re pretty sure it works and is safe.

Despite the fact that on the surface it seems plausible, I don’t think the succinic acid claim holds up as a mechanism where amber necklaces could work for teething.

Is it a choking hazard?

We have to address these necklaces as a choking hazard. It’s interesting. People say they aren’t a strangulation hazard because they break. Ok. But then they say they aren’t a choking hazard because the beads are tied individually.

I say, you can’t have it both ways. If they break, they have to break somewhere and a bead has to get loose. And if you’ve seen the size of these beads … looks like a choking hazard to me.

So, why do amber teething necklaces “work?”

It’s really based on three points…

1. Teething symptoms are vague and most are only mythically related to teething.

2. Teething symptoms go away on their own 100 percent of the time.

3. Parents are desperate to help when they assume their kids are in pain.

Studies are pretty clear that teething symptoms really only last a day or two around the day that the teeth erupt. Many of the symptoms commonly associated with teething may actually be normal developmental issues-drooling, waking up at night, etc.

Knowing whether a specific treatment for “teething symptoms” works or not is almost impossible. But, for parents who had concerns and tried amber teething necklaces, the results seems magical. Doing something is often thought to be better than doing nothing. It’s certainly easier to brag about.

I have yet to see a Facebook post that says, “My kid was MISERABLE with teething last week but look at him today!! I found the miracle cure - I did absolutely NOTHING! You should try it too.”

I’m coming into a place where I’m not sure treating teething with anything makes sense, even your typical pain relievers. For this reason and because I cannot find a plausible explanation for why they work, I think parents should save their money when it comes to amber teething necklaces.

The first line of treatment for children with ADHD are behavioral options. I never ask (or let) a family jump first to medication if they haven't first tried some of the techniques I’m going to describe below.

What are the goals of treatment?

1. Improved interaction with parents, teacher, classmates and siblings

2. Improved grades

In my opinion, the goals are simple and should be taken in that order. It is important to consider these goals and re-evaluate them frequently during the treatment course. Perfection should not be the goal.

I recommend these behavioral techniques before medication for all children, especially those who are young or who have milder ADHD:

1. Make a schedule daily. All kids have difficulty and waste time with transitions. Children with ADHD do this to the 1000th degree. If these transitions are scheduled and the child knows what comes next it might speed up the transition. Things that should be included on the schedule are homework time, daily chores and self-care items (shower, brushing teeth, etc).

2. Make separate areas in the house for necessary tasks. Keep toys and video games out of the space where homework needs to be completed. This helps limit the child’s distractions so that they can finish the task at hand.

3. Set small goals that are attainable. Don’t ask the child who is failing to make the A honor roll in the next six weeks. Start with turning all assignments in and that they are complete, then slight increases in grades, etc.

4. Use charts and checklists. Children with ADHD are often very visual and concrete. If you can put a list in front of them that can be checked off, they are much more likely to complete what needs to be done. I find this to be helpful for me as well ...

5. Keep choices to a minimum. Don’t tell them to go to the closet in the morning and pick out something to wear. This is a sure way to start a huge fight as they stand in front of the closet for hours while you are trying to wrestle them out the door. Pick out two options ahead of time for them to choose from.

6. Don’t discipline them impulsively. Remember that one of their biggest problems is that they don’t stop to think about consequences before they act. If your discipline follows the same pattern, how can we expect them to learn to act differently? Plan out your discipline plan in advance and be consistent. As tempting as it may be, corporal punishment is rarely effective. I’m not going to get into a spank your child or not debate here, but timeouts and restriction of privileges seem to be more effective for children with ADHD.

7. Help your child with organizational skills. Developing a system that helps them keep track of all the papers is a way to keep them from getting thrown away, having them sit in the floorboard of the car or (more infamously) avoiding having the dog eat them. If you need some help establishing this system, check out this amazing book called That Crumpled Paper Was Due Last Week.

8. Get help. Raising a child with ADHD can be very frustrating and quite exhausting. There will be lots of times when you will feel like there is nothing left to do to help. If your child continues to struggle, talk with your pediatrician about options for treatment, including medication options. Find a family counselor that can work with your child but, maybe even more importantly, that can help you develop a plan for your child and help you cope with the struggles you will face.

I hope that you find these tips helpful as you begin to think about how you can help your child with ADHD.

As you walk through the process keep in mind that your goal should be function, not perfection.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

Along with this goal of each child’s attendance, we have to balance the goal of keeping others safe from infectious diseases. Our contagious students need to stay home when they are sick to keep the rest of their classmates safe. (This is why I don’t really care for perfect attendance bike raffles. I prefer responsible attendance.)

Balancing these tensions is often hard for the parent, the school and the pediatrician because we often don’t know exactly when a child is no longer contagious. This is why I got so geeky excited last week to see a new study released in the Pediatric Infectious Disease Journal about the contagiousness of strep throat.

The study looked at 111 children with strep throat over two days.

Day 1: Children who tested positive for strep were given their first dose of amoxicillin before 5 p.m. (They also had cultures taken which allow to see if bacteria will grow from a swab of their throats.)

Day 2: Children were retested and cultured for strep in the morning to determine if they still carried the bacteria in their throats.

Here is what they found:

• 101 children tested negative for strep on the morning of day 2.
• 7 children had significantly decreased growth of bacteria from their throat cultures.
• 2 children continued to have high loads of bacteria.

The author’s conclusion: “all children treated with amoxicillin for streptococcal pharyngitis (strep throat) by 5 p.m. can, if afebrile (fever free) and improved, may be permitted to return to attend school on day 2.”

I’m pretty sure you’re not as excited as I am, but THIS IS HUGE!

Based on current guidelines, children must be treated for 24 hours before being allowed to return to school. If we treated according to the results of this study, it would allow for the child to be back in school and for the parent to be back at work a whole day earlier.

I feel like there is a lot of work to be done in this area and this type of study, along with other models of health care delivery, are good examples of the work that will be necessary.

Because I value education and our school districts so much, I want to be constantly thinking about ways we can do this better. As a general pediatrician, I can really boil down the goals of my job to these:

1.Keep kids growing and healthy.

2.Keep kids developing and learning.

Early in your baby’s life, this looks like frequent checkups for preventing illness, monitoring growth (and talking about diet) and teaching ways that parents can help their child with development. (Read: Everyone should homeschool.)

As your child gets older and starts school, my role changes a little bit. I don’t ask my elementary age patients about fractions or my high school students about “The Great Gatsby.” Instead, I might ask, “How is school going?” “Any problems I need to know about?” “Any way I can help?”

On a practical level, this means offering school aged children after school appointments when possible. It means getting sick kids in the same day so that we can start treatment and get them back in their desks as soon as possible.

In the future, this may mean totally different modes of delivering health care and working with the school and school nurses in order to decrease missed class time.

But I’m getting ahead of my geeky self again. I’ll save that discussion for later.

So why did the Tarrant County Health Department just announce that there is a case of rubella in a Texas Christian University student?

Unfortunately, the student returned from a part of the world where rubella continues to be an ongoing concern. The World Health Organization states that rubella continues to cause infection in Africa, the Eastern Mediterranean and Southeast Asia. Despite the fact that rubella is no longer transmitted in the United States, an average of 10 cases of rubella are diagnosed here each year from travelers who bring it back from affected areas.

Don’t get me wrong, rubella is a big deal. Prior to the vaccination, it used to cause millions of cases per year around the world. The most severe complication from rubella is congenital rubella syndrome (CRS) which can affect the babies of women who contract rubella during the first three months of their pregnancy. Children born with CRS are at risk for growth problems, developmental delays and other birth defects.

We should definitely be aware that there is a case of rubella in our area, but I’m advising parents not to panic about their children getting rubella.

Here are the 2 main reasons why I’m choosing not to panic:

1. Rubella is a mild illness in children. It can start with a mild fever (but often doesn’t) and then causes a rash that starts on the face and spreads downward. Other complications from rubella are very rare and are more likely to happen in teenagers and adults.

2. Rubella vaccine works very well. After the first dose of the rubella vaccine (given at 1 year), 90-95 percent of children are protected. After the 4-year booster dose, protection gets much closer to 100 percent. If your child is vaccinated, they are most likely protected. As with anything, the vaccination is not perfect so we are relying on each individual person getting vaccinated to help protect their neighbors from an outbreak. Despite the fact that cases of rubella have been imported into the United States, no outbreaks have occurred, thanks to our relatively high immunization levels.

Children (or adults) who are infected by rubella can spread the disease via droplets spread by sneezing or coughing. We recommend all children be vaccinated against rubella. The vaccination helps prevent children from getting the disease and it also helps protect anyone they may come in contact with, including pregnant women.

Pregnant women with rubella run the risk of potentially having a baby with congenital rubella syndrome.

As always, if you are pregnant (especially in the first three months), use caution around sick individuals especially those with a rash. If you already have a baby, you were likely checked for rubella immunity at the delivery and your doctor should have the results of that test. If you are thinking about becoming pregnant, a doctor can check your immunity level now so that you can be vaccinated prior to getting pregnant.

Let’s not panic about rubella at TCU. If your child is starting classes there, feel free to send them on (I’ll be on campus for a meeting today if that gives you any peace of mind). Let’s be aware. We’ll follow the story and notify you if there are any updates or new reasons to be concerned.

More resources:

• Rubella
• Frequently asked questions about immunization
• Measles: Just a plane ride away
• Should you immunize?

Articles and news reports about infectious diseases and their impact on our children keep me up at night. Tonight, it’s not an article about an outbreak of disease that has me up typing away at 11:30 on the night before I come home from vacation.

Tonight, at least in the United States, there’s no large ongoing outbreak.

Tonight, my concern isn’t so much about those parents who choose not to vaccinate. I’ve been down that road before.

Tonight, I’m concerned about parents who are choosing to vaccinate their child, but then also choose (often unknowingly) to send them to a school where the low vaccination rates put even their fully vaccinated child at risk.

We know that families who choose not to vaccinate tend to cluster in geographic regions because studies have shown this. I have proposed the theory before that perhaps clusters of unvaccinated children in our area might be more based on ideology (faith-based or otherwise).

Why does this matter?

Herd immunity.

Keeping vaccination rates relatively high (somewhere around 90 percent) actually helps protect all children (vaccinated or not) from diseases. In addition, when outbreaks occur (which is much more likely when herd immunity breaks down), even children who are vaccinated become at risk for contracting disease due to the number of possible exposures. (If you are about to say, “If your child is vaccinated, why do you care if mine is?” read the post above.)

NBC 5 Investigates released a really enlightening (frightening) report this week on vaccination rates in local school districts. They highlighted the growing number of vaccine exemptions in three public school districts (Frisco, Plano and Lewisville).

At first glance it may not seem that concerning. If you look at an individual school or district, the percentage of vaccinated children in those districts is still really high.

My bigger concern, and what keeps me up at night, is in the schools where unvaccinated children, for some reason, are clustered together.

Take a look at what’s happening in our area:

• 30 schools in the DFW area have vaccination rates below 96 percent.
• 5 schools in the DFW area have vaccination rates below 90 percent.
• The highest unvaccinated rate in our area is around 13 percent. The highest in the state is near 50 percent.

Why does it matter?

If you read the names of the schools that fall into the categories above, you’ll see a trend. They are private schools. They are schools that have a high likelihood of having people go overseas for mission trips or other opportunities.

Traveling to countries where diseases are more common increases the likelihood of bringing a disease back to school. Waiting at school are their unvaccinated friends and their vaccinated friends who could even be at risk as the number of cases rise. Outbreaks are possible.

Do you think this is far-fetched?

The Tarrant County measles outbreak from 2013 basically had all the characteristics that I am describing. A large group of unvaccinated people, grouped together based on their faith that contracted measles from a visitor who brought measles into the United States after traveling overseas.

What can you do?

• Get the best start to protection by vaccinating your child.
• Be aware of the vaccination percentages of your child’s school, your church and your social community.
• Be especially cautious when your child’s unvaccinated contacts return from overseas travel. If they are sick, stay away.

School physical season is one of my favorite times of the year for many reasons:

• It’s really fun to see kids grow up and get big over time.
• I love watching my patients’ personalities mature.
• I love that the visits become progressively more about my relationship with the child in addition to my relationship with their parents.
• For the most part everyone is healthy and happy.
• For most children, the promise of a new school year and new beginnings is exciting.

I have a few things on my agenda for each back-to-school checkup.

I want to talk about diet, exercise and sleep. I want to talk about how school went last year and what the plans are for the upcoming year.

But checkups are more than just about what I want. In order for the checkup to be a success, it must meet the goals of the child and parent. Parents are all over the place when it comes to their expectations for physicals.

Here are just a few examples:

1.“Let me get out my list.”

Whether your weapon of choice is a spiral-bound notebook or long thumb-scrolling iPhone lists, you know who you are. And frankly, I love you. Having a guide that directs the visit through any questions and concerns that you have is beyond helpful. It keeps me from having to talk about stuff that’s not important to you and wasting both of our time. So, bring it on, Listers, and I promise not to roll my eyes.

2.“I’m just here to get my form signed.”

No worries. That may be all you need and that’s great. In the meantime I can provide a quick screen for height, weight, body mass index, high blood pressure, heart murmurs, risk for sudden cardiac death, hearing and vision (and much more). I can also screen for drug/alcohol abuse, depression, attention problems and other school issues. “Here’s your form, thanks for coming in.”

But seriously, even in those children who come in with no apparent concerns or complaints, we do pick up health problems that need to be addressed to maximize your child’s ability to function well in school or compete at their best in their chosen activity.

3.“I’m not worried, but __________ wanted me to ask about __________.”

This is a tricky one. I’m totally cool with it, but it can be hard to get at exactly what the concerns is if that person isn’t there to ask questions. My advice … if that person is close enough to be providing this type of advice, they could probably come to the appointment. If the concern is coming from the child’s teacher, a quick note explaining what is going on can be really helpful.

Just don’t leave it up to chance that we can figure out what the problem is, especially if you don’t quite understand why they are concerned. Get specific information about the concern or have them come along.

I’m sure there are many more ways that parents think about their children’s checkup, but these are some common ones I notice.

No matter what, regular checkups are an important part of helping you maintain your child’s health. Good health increases their ability to be present for and to participate fully at school and extracurricular activities.

Which category do you fall in? Is there a different one you think I should include?

Sports EKGs are free through the month of August at specific locations in Arlington and Fort Worth. Cook Children's offers a $25 Sports EKG (electrocardiogram) screening test at our Cardiology offices in Mansfield, Southlake and Denton. Adding a sports EKG to your child’s physical can help detect most heart conditions that may lead to sudden cardiac arrest. Click to learn more. 

For school physicals, visit your local Cook Children's pediatrician. Click to find one near you. 

You decide to seek out some information online and you find this:

“Although data to make specific recommendations as to when it is safe for infants to sleep in the prone or side position are lacking, studies that have established prone and side sleeping as risk factors for SIDS include infants up to 1 year of age. Therefore, infants should continue to be placed supine until 1 year of age. Once an infant can roll from supine to prone and from prone to supine, the infant can be allowed to remain in the sleep position that he or she assumes.”

AAP SIDS and Safe Sleep Guidelines

“Heh?”

Hopefully none of us really talk this way, but I have a feeling sometimes it’s close. Doctors have a notoriously bad rap for their handwriting; fortunately, we’ve mostly fixed that with electronic records. Unfortunately, some of us aren’t known for our amazing verbal communication skills, either.

A study released in Pediatrics this week highlighted this fact. The authors surveyed mothers of 4-6 months old babies about the education they received from their doctor when their baby was a newborn.

They asked the mom if they received advice on the following topics: vaccination, breastfeeding, sleep position, sleep location and pacifier use.

All of these seem like pretty basic newborn information. Most doctors would want to cover them during that time frame. They all are included in very specific guidelines with clear instructions for how the American Academy of Pediatrics wants us to educate our patients?

How did the doctors do? The following percentages reflect the number of mother’s who reported receiving correct advice for the respective topics:

1. Does it seem like we’re speaking in a foreign language?

For many cases, the study showed that either the doctors failed to mention some pretty important topics or they weren’t presented in a way that parents understood or remembered.

One of the reasons I love to write is that it forces me to have clear thoughts about the medical issues I deal with every day and to focus on clear strategies for communicating those thoughts to patients. Of course, I’m not perfect. Here are some of the communication mistakes I (and from the results of this study, other doctors) make and some strategies for the way things should go (with help from you of course):

Some people describe the first few years of medical school as being more or less a foreign language study. During those years, medical students learn terms that most people don’t need to know. We use them as a way to communicate with other doctors as we begin to learn from “real” patients in the later years. The problem is we sometimes forget that we can’t talk that way all the time if we want to be understood by our families.

How can you help us while we work to get better?

Don’t be afraid to ask questions or to stop us if you don’t understand. Your child’s health is important to us. We know that you have to understand our instructions if we want to have any chance to help your child stay healthy or get better when they are sick. Ask us to slow down or to re-explain a certain concept again if what we say doesn’t make sense.

2. Have we given you the best opportunity to hear us?

This newborn study is a perfect example of this. A newborn mom is tired and stressed and getting health advice from the nurse, the doctor, their family and the Internet, so what usually ends up happening? We rush right through with the messages that are important to us and hope that mom gets them in 5 minutes.

Thanks for coming in. Good luck, mom!

Other examples are when we deliver bad news or just simply have a baby with an ear infection that is screaming in pain while we get louder and louder to make sure we are “heard.”

How can you help us while we work to get better?

Some are easier than others. When we’ve delivered bad news, there’s probably nothing either of us can do to help in that situation. But we should definitely slow down and wait a minute to let you think before we plow through into “next steps.”

If your baby is fussy and you can’t concentrate, feel free to ask if a nurse could come help for a second while we talk. Even if the baby stays in the room, just having them out of your arms makes it easier to listen. During those newborn visits when you are sleep deprived, ask for resources that you can take home and read when your mind is a little more clear (if that every actually happens for any of us with newborns).

3. We try to cover everything, but did we focus on what you want to learn?

This has another medical school analogy. Some people refer to the first few years of medical school as “trying to drink from a firehose.” There is so much information coming so quickly, you have to learn how to decide what is important enough to waste brain space on and what can be discarded (or “Googled”) later. So, when it comes to giving advice, we assume that you can do the same. The other assumption we make is that you actually care about the things that are important to us.

How can you help us while we work to get better?

First and foremost, please bring a list of questions. This helps us to focus on the things that are important to you, which are the things that you are going to remember anyway. As I get to know my “listers” better, I tend to grab (nicely) the list out of their hands and start writing the answers down (in ugly doctor scrawl) as we go along.

This is another time when asking for resources can be really helpful. Ask us to highlight or point out sections that are related to what you have talked about in the visit. Now, for this strategy to work, the resources have to come out of the diaper bag before they get formula and other baby fluids spilled on them - better yet, maybe they can just be pulled up on your phone …

I work hard to avoid these mistakes. But as I said, I’m not perfect. Communication is vital between a pediatrician and a parent. In the medical community, it looks like we have a lot of work to do.

Fortunately, we have some great examples at Cook Children’s to learn from.

But we can all get better with your help and feedback.

Watch the video below for five key facts about diarrhea that every parent needs to know in only a minute. 

In today's video, Doc Smitty explains:

1. What are the common causes?
2. How long can it last?
3. When are the symptoms more than a stomach bug?
4. When do you call your pediatrician?
5. What are the biggest risks?

Learn the answers to these questions. It only takes a minute.

Asthma is a big problem across the country with about 25 percent of children age 9 diagnosed. Children ages 6-9 are three times more likely to have asthma than others in the state of Texas.

Fortunately, most of those cases are mild and require only rare treatments with albuterol inhalers. However, some of those cases can be severe and can result in significant issues for families.

The social complications of asthma are costly:

1. Missed school for doctor visits, emergency room and hospital stays.
2. Missed work for families.
3. Decreased activity level resulting in other poor health outcomes.

There are times where these complications might be unavoidable. But these should be very, very rare cases.

I don’t believe that any general pediatrician should use physical activity restriction as a means to manage a child’s asthma.

Why? Most cases of asthma can be managed by the pediatrician and involve the following treatments:

Avoid Triggers

Allergies - If the child has allergies, make sure that he or she is on adequate treatment using a step approach to include antihistamines up to nasal steroid sprays.

Viral infections -Train your children to wash their hands frequently especially during winter months. Get your child a flu shot every year.

Stop smoking - If you are smoking, you do not get to tell your child that they cannot participate in sports. It’s hard to quit smoking, but it’s harder to be a child who wants to do an activity but can’t because their parent’s smoking makes their asthma too severe.

Develop a Treatment Plan

Treatment plans for asthma are called “asthma action plans.” Children with have asthma need one.

Treatment for asthma generally starts with albuterol on an as needed basis. This might be the case in a child who has rare symptoms or who only wheezes once or twice a year when they get a bad cold.

Treatment for asthma should include some type of daily medication for control if either of the following is present:

• Symptoms more than twice a week or a limitation in activities due to asthma
• Symptoms at night more than twice a month (waking up coughing or with difficulty breathing).

Refer to a pulmonologist

If you and your general pediatrician cannot seem to get a handle on your child’s asthma, request a referral to a pulmonologist or allergist before telling your child that he or she cannot participate in physical activity.

Here are a few guidelines based on current asthma severity that might help when you are managing asthma and physical activity:

• Children with well-controlled asthma who are symptom free should not be restricted in any way. They don’t get to run less or skip out if they are feeling well.

• Children who are having mild symptoms (cough from an upper respiratory infection) may need to be modified but sometimes do not need to be completely sedentary. (They can walk around the gym if everyone else is running.)

• Children with moderate to severe symptoms should be receiving medical care by the school nurse or their pediatrician. Asthma can be serious, even deadly so don’t wait to call if you are concerned.

Children with asthma can and should participate in physical activity. I do not believe that they should be restricted based on the recommendation of a general pediatrician alone.

Everything should be done to allow them to play first: avoiding triggers, treating aggressively, even to seeing a pulmonologist.

For more information about what is being done in our area to help prevent and treat asthma, check out the report from The Center for Children’s Health’s Asthma Think Tank-Childhood Asthma: A Guide to Action.

“Mom, my legs hurt.”

It wouldn’t be so concerning except that it’s happening four nights a week, for months. Right?

So, what do you do?

Watch The Doc Smitty in Cook Children's latest My Kid Minute video on growing pains:

To learn more about growing pains from The Doc Smitty, read his blog on the topic.

Here's why:

There has been an outbreak of severe flu among dogs in the Midwest. Cases of the H3N2 strain have now been seen in dogs in Texas.

Most dogs have cough, runny nose and fever, but it has been severe and resulted in death in some.

So you may be wondering, “Is my child at risk if our dog has this flu?”

The answer, according to the CDC:

“To date, there is no evidence of transmission of canine influenza viruses from dogs to people and there has not been a single reported case of human infection with a canine influenza virus.”

That’s fortunate, but what are some health dangers associated with pets?

Bites

I’ve seen too many severe dog bites in my training to not mention bites first. The most common statement I hear about the dogs who bite is, “We just never thought he/she would do that.”

Dogs can be a great addition to a family but use caution:

• Be careful of rough play. Even a playful snip can be dangerous if it happens near the eye or a fingertip.

• Stay away from dogs when they are likely to be defensive: when they are eating, sleeping or taking care of puppies.

• Stay away from unfamiliar dogs or dogs that seems scared or anxious.

Here are some more tips from the ASPCA on how to avoid dog bites.

Allergies/Asthma

This is actually one of the most common questions I get regarding animals. It’s very intuitive. People can be allergic to dogs and cats, so wouldn’t owning one increase my child’s risk for allergies?

I have seen several studies that suggest the exact opposite. Often by having animals in the house early, kids may have slightly decreased risk of developing allergies. That said, if your child has frequent allergy and asthma symptoms, it may be reasonable to attempt to isolate the animal from the child for a bit to see if symptoms improve.

Infections

Infectious diseases are transmitted through animals frequently; think about the number of diseases that tics and mosquitoes can carry. Although it can happen, they are less frequently transmitted from pets.

Here is a list of pets and some of the diseases they can transmit:

Cats

Cat-scratch fever:

This disease is caused by bacterial infection (Bartonella) of an open wound or a bite that results in the breaking of skin. It is more commonly transmitted by kittens than older cats. Symptoms of the infection in humans are fever, headache and fatigue. There is often a large and tender lymph node near the site of the bite.

Toxoplasma:

Toxoplasma is usually a foodborne illness, but can be transmitted from cat feces. In people with normal immune systems, there are often no symptoms of toxoplasmosis. Pregnant women (and fetuses) are especially susceptible and, for that reason, should not handle cat litter boxes.

Dogs

Hookworms:

Dogs infected with hookworms can have bloody stools; which in severe cases can lead to anemia. Humans are infected by walking barefoot on contaminated soil and develop an interesting rash which consists of red, squiggly lines where the larvae have migrated under the skin.

Reptiles

Salmonella:

Salmonella is one of the most common pet-associated infections. It is estimated that 70,000 people will contract salmonella from pet reptiles. Salmonella generally causes bloody stools but in children and in people with weakened immune systems can be serious. The CDC recommends that houses with children less than 5 and with any household members with weakened immune systems not own reptiles as pets.

Many Animals

Campylobacter:

Ingesting food contaminated with the bacteria transmits most infections of campylobacter, but cases can occur from the handling of dog or cat feces. The main symptom of campylobacter infections is diarrhea (which can be bloody) and usually lasts about one week.

Ringworm:

The fungus that causes can be transmitted from many different animals but most commonly occurs from puppies and kittens. The appearance of the rash on human skin is a circular rash with a raised edge. It can be difficult to distinguish from eczema which sometimes causes circular patches as well.

Pets can be great additions to your family and, in most cases, will not cause any harm to your children. Be aware of the specific risks associated with certain types of pets and take caution to protect your children when appropriate.

A disturbing trend on social media, the #kyliejennerchallenge, has left some teenagers in pain and not the look they were hoping for … to say the least.

So what is the challenge?”

“Kids suck into a container, often a shot glass, to increase blood flow to the lips, giving them a temporarily fuller, more pouty look,” said Justin Smith, M.D., a pediatrician and medical advisor for digital health at Cook Children’s.

Why should you tell your teenager not to do it? Dr. Smith has a few reasons:

• Pain
• Bruising
• Chapping/cracking – any cracking can lead to infection
• Cuts (some severe) from shattered glass

About the source

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . View more from The Doc Smitty at his Facebook page. He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

We cannot give into fear. We need to be prepared. Know the signs. Have a plan.

Before the storms even start it is important that you have a plan for your family’s safety.

You need to pick a safe room in your home where your family can gather. The safest place is a basement or storm cellar but these are pretty rare in North Texas so you need to pick an interior space in your house on the bottom floor like a closet, bathroom or hallway where there are no windows. You want to put as many walls between you and the storm. The biggest source of injury in a tornado occur from being struck with flying debris so if you can pull a mattress into your shelter space or cover with heavy blankets or sleeping bags you will increase your protection. Contrary to popular belief you do not have to pick an area in the southwest corner of your house. Just pick the safest area in your house. Also you do not have to open or crack windows to equalize the pressure in your house. You are just increasing your risk of getting hit by flying debris.

If you live in a mobile home get out! People are 15 times more likely to die in a mobile home than any other location. Try to take shelter in a permanent structure if you can. As a last resort if you cannot find a permanent structure for shelter then go to a low lying area like a ditch and cover your head.

If you are at work, take shelter in an interior room, stairwell, or bathroom on the first floor and away from windows. Your office should have an inclement weather plan and remind employees of it twice a year.

If your child is at school they will be instructed to follow the school’s tornado plan. Schools will go on lockdown mode and move the children to the safest area possible. Follow your school’s tornado and inclement weather plan. It is the best way to ensure your child’s safety as well as your own. Your child has gone through numerous safety drills at school and knows to follow the schools plan. Reassure them that this is the safest thing to do. Remind your children to follow what their teachers have taught them. The best way to reassure your child is to help them understand the importance of following the direction of the adults who are caring for them.

If you are outside, try to find shelter in a permanent location. If you cannot find structural shelter get in a low lying area and cover your head with your hands and arms. Try to pick a spot away from trees and other potential projectiles.

If you are in your car and cannot get to a structural shelter, the American Red Cross recommends staying in your car. They recommend pulling off the road. Leave your seat belt on and crouch down away from the windows. Try to cover your face and head with a coat or blanket is possible. They do not recommend trying to take shelter under an overpass or bridge. Do not try to flee a tornado that is moving toward you. They also note if your car is near a low-lying ditch or culvert it may be safer to leave your vehicle and get to the lowest point possible. Always remember to cover your head with your hands and arms.

It is important to know the difference between a TORNADO WATCH and a TORNADO WARNING.

TORNADO WATCHThis means that the conditions are present that make a tornado possible over the next several hours. This does not mean a tornado is about to occur. It is a caution to be vigilant as you go through your day.

TORNADO WARNING

This means an actual tornado has been spotted or that meteorologists have picked up rotation on their Doppler radar. Your city’s safety alert siren will sound if a tornado warning is occurring. This is a sign to go to your safe area.

I highly recommend you get the American Red Cross app for your phone. This is a free app that will alert you if a TORNADO WARNING is occurring in your area. It also has excellent tips about tornado preparedness and the ability to set up a blast message you can send to friends and family to let them know that you are safe. It will send the message via email, Message, Twitter, and Facebook.

It is a good idea to create an emergency- preparedness kit. The American Red Cross recommends you include the following basics:

• Water – at least a 3-day supply. One gallon per person per day.
• Food – at least a 3 day supply of nonperishable easy to prepare food
• Flashlight with batteries
• Battery powered or hand crank radio
• First aid kit
• 7 day supply of all necessary medications
• Copies of personal documents
• Family and emergency contact information
• Extra set of clothing and study shoes
• Sanitation and personal hygiene items

You have a Plan.You know the signs. Be safe. Have Faith.

Sandra C. Peak, M.D.

Learn what you shouldn't do during a tornado here.

Advocating for breastfeeding is a big part of a pediatrician’s job in the first few months of life. We state the benefits of breastfeeding. We encourage families who are struggling and provide help with troubleshooting issues. We point them towards lactation consultants and other resources that can help when things are not going well.

But, is there a point where “breast is not best?”

Does all the conversation about breastfeeding pressure moms to seek out breast milk from other sources when they choose not to breastfeed or when breastfeeding does not work for them?

The answer is: Yes.

Breast milk donation can be used to provide much needed breast milk to premature babies. Many of these babies would otherwise not receive breast milk. This provides an amazing service to a vulnerable population. I strongly encourage moms who are interested and have extra breast milk to look into donating their milk to one of these organizations.

There are other means of exchanging breast milk that I am not as excited about. Families can buy and sell breast milk online via websites that link buyers and sellers (often called “communities” or “societies”).

But, is this method of obtaining breast milk safe?

A recent study showed that out of 102 samples of breast milk bought online, 10 of those samples contained more than 10 percent cow’s milk. This shows that at least some sellers are mixing cow’s milk with their breast milk, most likely to increase volume and income from their breast milk sale.

Why is this dangerous?

It is dangerous because previous studies have shown that 20 percent of online breast milk buyers are buying milk because of a medical condition in their child - many of those are listed as formula intolerance. Introduction of cow’s milk into the breast milk increases the odds that these children could have a reaction or problem with the purchased milk especially if they have a true allergy to cow’s milk.

While this risk is not insignificant, I feel the danger is much greater. I believe that the real danger lies more in the motivation of the sellers. If they are willing to actively deceive buyers by adding cow’s milk, what else are they willing to lie about in order to find a buyer for their milk? Anyone ever thought of why we do not pay blood donors or allow for payment for organ donation? The motivations matter.

Here are some other potential issues with breast milk sold online that you should be aware of:

1. Storage and bacterial contamination

Safe storage of breast milk is not as simple as just throwing it into the freezer. Transportation of sold milk also creates another potential source for unsafe storage. The same group of researchers showed in a previous study that 74 percent of the milk they bought online contained enough bacteria to question their safety for infants.

2. Medications/drugs/alcohol

Many of the sellers’ listings make a point to say that the milk is free of substances or that the donor did not engage in risky behavior. In fact, sellers who made such claims (in addition to claims for clean handling and infectious disease screening) were 6 times more likely to sell their milk than those who did not make those claims. Does this encourage honesty?

3. Infectious diseases

You would hope that donors would be honest about their infectious disease history because many diseases can be transmitted via breast milk. Also, there are some transmitted diseases that the donor may not be aware of at the time they pumped the milk.

Of course, I advocate for breastfeeding for moms who can. But, let’s be real. Formulas have come a long way since the days where it was practically evaporated milk. So, let’s be realistic about the lengths we will go to in order to provide our child breast milk.

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer

If you want to start, visit Cook Children's guide to choosing a pediatrician. Then, go check out your doctor on healthgrades.com or vitals.com or any of the other rating sites you can find. What you’ll likely find is a sampling of a small handful of raters. These sites are a sample size and can be heavily skewed by one great (if you like your pediatrician, let people know) or one terrible one. 

So, where else can you go for advice?

Friends

Ask your friends who have kids what doctors they use. This especially works well if you have friends that are similar in belief systems, medical philosophy and personality. If they like their doctor and you’re similar to them, chances are you’ll like them too. Good old fashioned word of mouth (it’s actually more commonly via Facebook or what I like to call “word of mouse") is still probably the best way to learn about the doctors in your area.

Practice websites

Practice websites are helpful in determining the practical aspects of the practice you are considering. Look at office hours and availability of care after hours via phone, etc. If having a doctor that is up to date with latest medical knowledge and technology is important to you, make sure that their website looks professional and is updated. This is also a place where you can find a little bit about the doctor’s personality (from their bio) and see their picture but these often become pretty predictable. Everyone likes to spend time with their family and has a few particular interests in pediatrics like obesity or development. They also went to medical school and residency somewhere (in case you were wondering).

Ranking websites

There are several of these out there. Some of the most popular ones are healthgrades.com and vitals.com. I like vitals.com because it allows people to leave narrative comments and not just rate with stars. Some of those comments can really give some insight into what the doctor is like. These website are not without fault-because the number of reviewers is often small, they can be skewed heavily by someone who has a negative experience (this is a good reason to go over and rate your doctor that you like).

So, how do you know if your doctor is the best?

The right question is this: How do you know if your doctor is the best for you?

I think this comes down to two basic questions:

1. Can you ask your doctor any questions without fear of judgment or feeling silly?

2. Do you trust the doctor’s answers to your questions?

If you can answer a resound YES to both of these questions, then you are in the right place. If not, you should probably be looking elsewhere.

He’s not hurt and had a presumably bright future in the NFL.

Why did he retire?

In light of the recent focus on repetitive trauma, concussion and brain injury, he decided that it was in his best interest to stop playing football.

Consider it this way: After years of playing football, starting a very young age, succeeding in high school and later at the University of Wisconsin, he reached the pinnacle of his sport and decided it was better to walk away than to keep playing. Granted, he’s only one player and many, many more will continue to make the decision to go back to training camp in July.

Most football players will never reach that point where they’ll have to decide if the NFL is right for them. I played junior high football, but didn’t move on to high school. I like to tell myself that I was making sure I was protected from injury for tennis season (truth was, I was probably a little scared of being small and getting hit by bigger high school kids. Sorry for lying, Coach West).

If you look at the research,  it seems like cumulative trauma is the issue. The older and bigger you get and the longer you play, the number and the force of the traumas increase. The rules are changing in an attempt to make the sport safer. But, I’m sure many of you read this and worry about your young football players.

My sons haven’t asked to play football yet. At 5 and 3, I think the level of risk for concussion is higher when I pick them up and throw them as high as I can in the air barely grabbing them before they crash into the ground. But living in the middle of Texas, football countr,y and having an older son built like a perfect tight end and having little brother with a canon for an arm, I am sure that is a conversation we will have some day.

I wonder if someday we’ll look back on the days when football was played and think, “I can’t believe that they used to do that to themselves.” Or, will the sport look so different that we will barely recognize it?

What about you? Do you have concerns about your sons playing football?

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

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

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

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

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

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

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

In the state of Texas, it's illegal for anyone under 18 years of age to use an indoor UV tanning facility, even with a parent's permission. But recent studies show that the use of tanning beds can become an obsession and parents need to make sure their child is not finding a way to work around the law.

Why?

The dangers of cancer:

• Ultra-violet (UV) light in tanning bed is known to cause cancer.
• Every year, more than 170,000 cases of skin cancer related to indoor tanning are diagnosed.
• One indoor tanning session increases your risk of getting melanoma skin cancer by 20 percent.
• Melanoma is the second most common type of invasive cancer in teens and young adults and is the leading cause of cancer death in women ages 25 to 30.
• One indoor session increase your riks of getting squamous cell carinoma by 67 percent.

"While all tanning is bad, tanning bed usage exposes people to ultraviolet A rays," said Sandra Peak, M.D., a Cook Children's pediatrician in Lewisville. "UVB rays cause sunburn, but UVA rays penetrate much deeper into the skin."

Other icky health risks may also be found at your local tanning salon, including bacteria that can lead to staph infection. Regular trips to the tanning bed can also change skin texture and cause sunspots, which probably aren't what your teen is after.

So what if your child begs you to go? It's time to talk.

"Parents should sit down and discuss the risks of indoor tanning with their children," Dr. Peak said. "Melanoma has become the cancer of young people."

Instead encourage your children to use a self tanner to get that summer glow, and urge them to always apply a broad-spectrum sunscreen with a minimum sun protection factor of 15 before heading outdoors, even during winter months. Dr. Peak recommends staying away from spray tans, since the chemicals can damage delicate mucus membranes.

About the author

Sandra Peak, M.D., joined Cook Childrens Physician Network in Lewisville in 2004. Dr. Peak enjoys gardening, yoga, and boating and in her spare time can be found at the lake with her husband Jay, stepson Sage and the world’s most amazing Lab, Sugar Mae.

When people think of homelessness, they commonly think of someone living in a park or on the street with no structure to sleep under but the effects of homelessness are felt by many in less dire circumstances. There are various classifications of homelessness which include homelessness without shelter but also include the following:

1. Homelessness with shelter - Living in a supervised private or public shelter.
2. Imminent homelessness - A chance that the primary residence will be lost in 14 days.
3. Youth/family instability

In survey data from 2012, the Cook Children’s Center for Children’s Health show than 7.5 out of 1000 kids in Tarrant and the surrounding counties had spent the night in an emergency shelter or with family/friends due to homelessness. Because of the nature of the study, my suspicion is that this number is likely understated. Despite the fact that it is more common in low socioeconomic areas, it is not restricted there. An example of this might include a child who is kicked out of the home for various reasons.

What are the effects of homelessness youth and children?

1. 97 percent have moved more than once in the last year.
2. Interrupted or ineffective school participation
3. 22 percent have been witnesses to domestic violence
4. 50 percent of homeless teenagers have depression or anxiety
5. More likely to have severe asthma, malnutrition, ear infections, exposure to toxins
6. More likely to have mental health and substance abuse issues
7. More like to engage in dangerous sexual activity leading to STDs and unintended pregnancies
8. 7 times more likely to be victims of violent crime

All of these issues can be categorized under the heading “toxic stress.” Toxic stress occurs when a child experiences strong, frequent and prolonged adversity. Studies show that these experiences can have significant effects on the development of the brain and other organs which can lead to increased risk for negative mental and physical health outcomes. These problems can persist well into the adult years, even when the stressful situations have resolved.

What can you do?

1. Be aware - One of the biggest problems with addressing homelessness is that many people are not aware that it is even an issue in their area.
2. Donate time - There are many programs available in our area where you can serve as a mentor to children in schools. Children going through toxic stress benefit greatly from having an adult who spends time with them and with whom they can process their experiences.
3. Donate financial resources - Many homeless shelters struggle to survive financially. They have a hard time providing healthy nutritional options and, certain times of year, even enough beds to house all those in need.

Learn more about homeless in Tarrant County here. 

We have been trained to assume that chest pain is caused by the heart and an emergency, which is right in adults. But, one of the basic principles of pediatrics is that children are not “just little adults.”

Chest pain is a perfect example.

What are some common causes of chest pain in children?

1. Muscular or rib pain - This is the most common cause of chest pain in children. Pain can be caused by a bruise, muscle strain or after repetitive coughing.

2. Lungs - Asthma and pneumonia are two common lung causes of chest pain.

3. Stomach - Reflux can cause chest pain (think “heartburn”).

4. Psychological - Stress, anxiety and panic attacks frequently show up as chest pain.

If most chest pain in children is not an emergency, when does it become one?

1. The pain is severe, especially if it has the classic findings of heart pain (crushing pain, under the breastbone, moving to the left arm or up the jaw).

2. The pain is associated with difficulty breathing.

3. The pain has is associated with other symptoms (fever, nausea/vomiting for example).

What are some other findings that suggest the heart is the cause of chest pain?

1. The pain is associated with exercise or limits the child’s ability to exercise.

2. The child has lightheadedness, dizziness or faints with exercise.

3. There is a family history of heart problems or sudden death, especially if early in life.

If your child has any chest pain, a visit to your doctor is important so that they can ask you questions and perform an exam on your child to determine the cause and right treatment.