RSV has arrived at Cook Children's.

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

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

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

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

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

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

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

What are the symptoms of bronchiolitis?

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

How do we treat bronchiolitis?

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

Who goes to the hospital?

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

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

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

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

Summary

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

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

Most children transition out of their crib between 18 months and 3 years … sooner if they are climbing out, later if they are perfectly happy in the crib. There are some bad times to make the transition: surrounding a move (new rooms are already scary) and when potty training (one big change at a time).

Some children handle the transition with no problems, others might have more trouble.

Here are some types of children you might find a little more challenging and how you can help them:

1)The Manipulator/Negotiator

“One more story … one more stuffed animal … lay down for one more minute …”

Next thing you know, your bed time routine is two hours long and everyone is exhausted, plus you missed the window to vote for “The Voice.”

Set the expectations early. “We will read two stories; have two stuffed animals and two minutes of lay-down time.” When the bargaining starts, be firm and consistent and don’t give in.

2)The Screamer/Crier

The bedtime routine went smoothly, all was well but as you start to wrap up, you can see the anxiety building. As soon as you close the door … uncontrollable crying and screaming.

It is OK to go back in and reassure. Most of the time you can tell if they are truly scared. Stay a few minutes longer, and then try again. If this is every night, you might want to reconsider if this is truly a good time for the transition.

3)The Creeper/Sneaker

You hear little steps sneaking down the hallway or, you wake up in the morning with a child in your bed and wonder, “How did they get here?”

I recommend putting a child’s gate at the door of their room. Having a gate allows you to be in control of getting the child back to bed. You can walk to the gate and ask them to get back in bed without even going in their room. Make their room completely child proof so that if they get down and roam, they will be safe.

Hopefully your child’s transition to a toddler bed will be easy. If not, talk to your friends about how they did it or ask your pediatrician. They might have some helpful tips.

About the author

Justin Smith is a pediatrician and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. His interest in communications started when he realized that his parents were relying more on the internet for medical information. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” is set to open in Trophy Club in 2017.

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.

My wife nudges me. It’s 2 a.m.

“Hey babe, did you hear that? Who is coughing? Can you go check on them? Take your stethoscope.”

That’s what an Emergency Room visit looks like in our house in the middle of the night. This time of year, many of you might wish you were married to a pediatrician … but, alas, Mrs. Doc Smitty is one of the few with that privilege.

We at Cook Children’s, and hospitals around the nation, have seen a significant rise in the use of our Emergency Departments and Urgent Care Centers over the past few weeks. Not only are we seeing more kids, many of those kids are more complex and more sick than we have seen in previous years. We are seeing RSV, flu, vomiting/diarrhea and just about every other pediatric illness you can imagine. It’s all going around.

Not only do we find ourselves servicing our local area, we are accepting transfers from most of North Texas in an effort to provide service to very ill patients who need the level of care that Cook Children’s can provide. This responsibility is based on Cook Children’s promise that every child’s life is sacred.

But that important commitment to helping so many children means helping a lot of kids. Here’s what we know that means to you.

We know that wait times are longer than usual right now.

We follow the trends in wait time closely – both at our medical center and in our region. All across Dallas-Fort Worth, hospitals are experiencing this surge in visits and we are hearing about increased wait times at emergency rooms throughout the area.

We are working to address this issue. We are increasing the number of providers ready to work in the ED. These are not our regular ED physicians but physicians who will be available to help out with patient surges after their “day jobs.” We are working to educate our families about other locations where they can receive care. Unfortunately, once a patient is checked in at the ED, we cannot ask that they leave to receive care elsewhere. Asking them to leave would be a violation of a law known as EMTALA.

Another issue we are facing is limited space. Hospital beds are filled with sick children that are not ready for discharge. This requires that children who need admission remain in our ED as they wait for a room in the hospital.

Space in the ED is already limited based on the fact that it was built to accommodate 45,000 visits per year but is currently seeing more than 120,000. Much of this problem will be addressed when our new Emergency Department opens, but, for now, we have to work to maximize the use of the space that we have.

Therefore, increasing providers will not cut your wait time down to zero but we will do our best to shorten it as much as possible.

You can help by utilizing our various other ways to care for your child’s medical issues addressed. Do not hear this as a lecture to not go to the ER; that is not the point of this post. We are working hard to provide other means that might help you by addressing the problem more quickly. Consider calling your Cook Children’s pediatrician. Even if they are not open, you can get advice from our outstanding pediatric nurses who can take your phone calls overnight. If your issue requires a visit but the ER seems like too much, check out one of the four Cook Children’s Urgent Care Centers throughout the Fort Worth area.

We know that waiting is terrible.

Doctors are some of the most impatient people I know. I don’t like to wait for anything. I get antsy and frustrated and become very difficult to deal with. If the radiology report or the lab result takes longer than expected, our anxiety level goes up. When we know our patients are suffering and we need those results to relieve suffering, we become even more frustrated. We hope you don’t sense our frustrations as frustrations with you. We just hate to see kids sick and to see more of them sick than usual makes us all sad.

You can hear the frustration in this brief interview with Corwin Wormink, M.D., Cook Children's Assistant Medical Director of Emergency Services.

We are working to address this issue. We are working to speed up all the processes associated with caring for your children so that our providers can be as efficient as possible. We are working to support providers (doctors, nurses and all other staff) so that they can be energized (physically and emotionally) to continue to provide excellent care for your child.

We know that waiting with a sick child is even worse.

We hate it that you are waiting hours to be seen in our ER. When our providers walk into the room and see that you’ve been waiting, our heart hurts about the time you’ve spent sitting in an uncomfortable chair trying to corral your sick child (often with their siblings). We know that you are worried about your child because he or she is sick. You’ve been scared to go to the bathroom, afraid you might miss your name being called out and that you are hungry and tired.

We are working to address this issue. We are looking to staff volunteers in the waiting rooms to help you get to where you need to be, to provide distractions for your children and to do anything they can to help you while you wait. We also are looking to increase our use of text and other notifications to update you on the status of your wait times, need for vital sign checks and other issues. Even when you are waiting, unable to be seen by a doctor, our triage nurses are checking and re-checking your child’s vital signs to make sure that your child’s medical condition is not changing, requiring them to be moved up in line to be seen sooner.

Your child is important to us.

Despite the fact that the numbers of children in the ED are high, we want to continue to provide the best care for your child. No matter how long your wait, we want you to feel like your concerns and questions have been addressed and that you have received the personal care your child deserves. If at any point, you do not feel like you have received that level of care, feel free to reach out to us at 682-885-6698.

You may not have a pediatrician lying next to you in bed for a quick ER check in the middle of the night but we do want you to know that we are here for your child in many other ways. Start by picking up the phone and calling your pediatrician or nurse triage line. If you decide your child needs to be seen, think about trying one of our Urgent Care Centers or in an emergency, our Emergency Department.

Our providers in each area are ready to provide the best care for your child.

Previous articles, related to this topic:

• Sicker kids means longer wait time in ED
• More flu, longer waits in the ED
• Emergency? 6 signs from an ER doc
• Cook Children's to build new South Tower on main campus
• Is it RSV?
• 8 flu myths I wish would go away

With each injury, parents commonly find themselves asking each other, “Do you think it’s broken?”

Broken bones are one of the most common types of injuries in children that need treatment.

They most commonly occur in the arms.

They can be the result of direct contact with something but are also common with falls where the child tries to catch themselves with their hands.

A common quote, “Well, he could move it so I know it wasn’t broken.”

If only it were that easy.

Here are some signs that your child might have a broken bone (we’ll start with the obvious and move to the less obvious):

• The bone is sticking out of the skin.
• The extremity is crooked.
• There is severe swelling or pain (if leg injury, is not able to put weight on it).
• The pain is not severe but does not steadily improve over a few days.

If you find yourself unsure or you have questions, give your Cook Children’s pediatrician a call. They can do an exam to determine if an x-ray is necessary and get your child the treatment they need.

In the year 2000, measles were declared eliminated from the United States. This occurred because there was a 12-month period where no measles cases were contracted here, making the disease no longer native to the United States.

I hear this question often in my office and its logical based on the fact that measles was eliminated:

“We haven’t seen outbreaks of these diseases for years. Do we really need to continue vaccinating for them?”

The answer is yes and it's exactly because of what we've seen in the past two weeks. Measles are only a plane ride away. We live in a society with global mobility. People fly in and out of countries where measles continue to be a huge problem and then fly back to the United States. Measles are highly contagious via droplets from coughs and sneezes. In addition, people are contagious before they start to show symptoms. (Contrast that with another infectious disease we dealt with recently (Ebola) that requires blood or body fluid contact and is not contagious until there are significant symptoms.)

Continued vaccination programs protect our citizens when they travel abroad. It protects our citizens when travelers return to the United States. It helps to control outbreaks when they do occur.

Another common questions centers around the severity of these diseases.

I pulled this quote from an interview with The Today Show in Australia and Dr. Sherri Tenpenny:

“I don’t believe that measles, mumps, rubella or chicken pox are routinely fatal illnesses. If you ask any person over the age of 50…they had all those illnesses when they were children and growing up.”

There are so many false assumptions mixed in with this statement:

1. You cannot ask a person in their 50s that died from one of these diseases how serious it is.

2. Even if not fatal, the complications associated with these diseases can be very serious.

3. This completely discredits the suffering of any family member of someone who experienced complications from these diseases.

Just look at the stats. In the United States, prior to the introduction of measles vaccine in 1963:

• 3-4 million people had measles each year
• 400-500 died
• 48,000 were hospitalized
• 4000 developed encephalitis (brain swelling)

These complications don’t happen as much in the United States, but do continue to occur in areas where vaccination rates are not as high. There were 145,700 measles deaths worldwide last year. This is a 75-percent drop since 2000 due to efforts to make vaccinations available to children all over the world.

Continuing to vaccinate for measles is important because measles are serious and only a flight away ... and lately, even in our own backyard. 

This is part 2 of Dr. Smith’s series on measles. For more information about measles vaccination and herd immunity, click here.

About the author

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.

I won’t be thankful that I can’t sleep in due to my 3-year-old alarm clock.

I will be thankful for extended breakfast with that 3 year old and big smiles for the blueberry bagel.

I won’t be thankful for traveling in a car with 3 children (under 5) who won’t sleep by my plans.

I will be thankful that when we get there they will be with family that loves them (and for the human hurdle):

I won’t be thankful for battles over eating new and different foods.

I will be thankful for three healthy children whose business and spunkiness brighten every day.

How can you survive this week?

• Be flexible.
• Allow a little extra screen time.
• Don’t stress if they don’t eat all their food.
• Remember that a few days off their nap schedule won’t ruin their chances at Harvard.
• What are you thankful for this week?

Parenting presents many challenges and sometimes it takes a little extra effort to remember those things that we can be thankful for.

Start with some simple things…

• Health - If you child is healthy, start with that. If your child is sick this holiday season, we pray for quick healing.
• Time - Extra time sometimes means extra conflict. Your kids don’t want perfection, they want you present, so just be present.
• Fun - With added stress due to family visits, it’s easy to lose the fun for your kids. Plan an activity for them, play a game or start in impromptu dance party.

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.

Oh, there she is, over there checking out Facebook.

Are you nervous every time her kid climbs up the ladder he might fall down and injure himself?

She’s still playing Candy Crush. Ok, let me rescue her kid from the top of the slide.

There’s new evidence to suggest that there may be some truth to your concern.

A recent study from Yale Economics professor Craig Paulson showed that, from 2005-2012, unintentional injuries in children aged 0-5 increased. He was able to correlate the increase in injuries with the expansion of 3G cellular networks across the country. Many of these injuries occurred during times of parental supervision (not day care or with other caregivers). There was no similar increase in injuries of children aged 6-10.

This trend is the opposite of the overwhelming decrease in unintentional childhood injuries since the 1970s.

While there could be other explanations of this trend, clearly distracted parenting is becoming more of a problem in today’s world.

Here are some things to think about:

1. You will underestimate how long you will be looking at your screen. Even if you look away for one task, that task will take longer than you think and you are likely to get sidetracked by something else.
2. Injuries in children often take mere seconds to develop. There may be no build up from independent play to dangerous predicament in the time it takes to read and respond to a text.

In any situation, you should be aware of how much time you are spending with your smartphone.

“Hey bud, how did you get that BAND-AID^®?”

“I just climbed up on this and got it (from the medicine cabinet).”

Those are 2 conversations that happen frequently and just yesterday, respectively, in my house.

A study released this month in Pediatrics (the journal of the American Academy of Pediatrics) looked at out-of-hospital medication errors in patients less than 6 years of age.

There were many questions that the study looked to answer:

How common are medication errors?

Almost 700,000 errors in these children over the 10 year period, that is equal to 1 error every 8 minutes.

Many of these were minor and required no medical care, but there were almost 2,000 children who required intensive care and 25 death due to medication errors.

What type of medications were associated with more errors?

Liquid medications were the most common, accounting for 81.9% of the errors. These kids are more likely to be taking liquid medications so this might be expected but it’s still a good reminder we need to be cautious.

Where do the ingestions occur?

The child’s own home was the location of the ingestions 96.9% of the time.

What errors were the most common?

The 5 most common errors were:

1. Medication accidentally given twice.
2. Confused the units of measure (1  milliliters (mL) vs 1 teaspoon (tsp).
3. Wrong medication taken/given.
4. Medication given too soon.
5. Accidentally was given or took someone else’s medicine.

So what can you do to protect your child?

1. Be aware. These errors are common and we need to be aware.
2. Be cautious with liquid medications. Kids can find and ingest them more easily and dosing errors are more common.
3. Protect your own home. Make sure that medications are locked away in a safe place.
4. Double, triple and quadruple check your dosing. You know the saying measure twice and cut once? For meds it should be measure 5x and give once.
5. Assign a primary medication giver for the house. If anyone else is giving meds, run it through them first.