As pediatric experts, Cook Children’s Health Care System know that protecting a child's health is about preventing emergency room visits just as much as treating illness. Ahead of the major soccer tournament, the system launched "World Cup Wednesday," a weekly healthcare series providing local and international visitors with essential resources on injury prevention, heat safety, water safety and guidance on when to utilize urgent care versus the emergency department.

The hottest time of the year in Texas is here, with temperatures regularly ranging from 80-100 degrees between June and August. Medical experts from Cook Children’s Health Care System advise caregivers and parents on what to know before attending outdoor activities or fan watch parties.

“Children can't cool off the body as well as adults,” said Monica Herrera, M.D., a pediatrician at Cook Children’s Pediatrics Windhaven, “it's important that we keep them hydrated.”

Dr. Herrera emphasizes that hydration is key during these months, as well as protecting children's skin from the sun and mosquitoes.

Learn the signs of heat-related illnesses

Spending too much time in the heat without proper hydration can lead to heat exhaustion and heatstroke. Dr. Herrera said learning the signs for heat-related illness is important, so caregivers know when to seek medical attention.

Symptoms include:

• Feeling faint or confused: A child may begin acting disoriented.
• Walking unsteadily and losing coordination.
• Headache
• Abnormally warm skin: Feels hot to the touch.
• Lack of urination: No wet diapers or bathroom use in eight hours.
• Nauseous and vomiting
• Shallow breathes: The body uses shallow breathing to try to shed excess heat.
• Muscle cramps: A child may complain that their legs hurt.
• Numbness

If a child exhibits these symptoms, seek immediate medical attention.

Preparedness is the number one way to avoid heat-related illness and Dr. Herrera says it starts with hydration.

Hydration Tips

Babies under 6 months old should generally be kept indoors. However, if an infant is outside, Dr. Herrera recommends they stay hydrated with formula or breastmilk. Babies under 6 months should not be given water.

“The breast milk has everything that the baby needs as does formula,” said Dr. Herrera. “If you're outside for a prolonged period they really need to be drinking every 20 minutes.”

As children get older water becomes the priority for hydration, but there are other tricks if your little one isn’t fond of H20. While water is best, other caffeine-free fluids and water-rich foods can help count toward hydration.

“Fluids don’t always come in the form of liquid,” said Dr. Herrera.

Alternative hydration sources:

• Ice cream
• Popsicles
• Snow cones
• Crushed Ice
• Fruits (Watermelon, grapes and cantaloupe) are an excellent source of hydration
• Soft liquids (such as yogurt, applesauce)

How do you know if your child is hydrated?

Check their urine. Urine is the best indicator of hydration status for both children and adults. A well-hydrated child's or adult’s urine should be clear to a light yellow, similar to a light lemonade color. If the urine is dark yellow or tea-colored, dark orange, more fluids are needed.

Sun protection

While hydration is critical, protecting a child’s skin is a close second. Dr. Herrera explained that children’s skin is sensitive and can burn when exposed to the sun for a prolonged period. While sunblock Sun Protection Factor (SPF) ratings range in coverage from SPF 10 to 80, Dr. Herrera recommends choosing products with two active ingredients: zinc oxide or titanium dioxide and use a sunblock of SPF 30.

Babies under 6 months of age should not have sunblock applied. Instead, keep them in the shade and dress them in a wide-brimmed hat.

Sunblock recommendations for 6 months and older:

• Choose a mineral-based sunscreen.
• Use SPF 30
• Apply 15 to 30 minutes prior to going outside.
• Reapply every two hours.
• Avoid sunscreens containing oxybenzone.
• Choose lotions over aerosol sprays to ensure total skin coverage.

Staying Cool in the Sun

• Dress children in light-colored, loose-fitting clothing.
• Choose breathable, absorbent materials.
• Avoid sitting directly in the sun. Seek shade when possible.
• Use cool mist sprays for quick relief.

Mosquitos

Summer heat in Texas also brings mosquitoes, which thrive around stagnant water and in hot, humid climates.

“Mosquitoes, as we know, can carry viruses which can cause severe infections and serious complications,” said Dr. Herrera. “We want to avoid mosquito bites if at all possible.”

The most effective line of defense is insect repellent.

Finding the best repellent:

• DEET is the most effective option.
• For infants up to 2 years of age, use a maximum of 10% DEET.
• For children older than 2, a maximum of 30% DEET.
• Apply repellent only to exposed skin or on top of clothing. Do not apply it underneath clothing.
• If concerned about applying directly on the skin, apply repellent on clothing instead.

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Let’s talk about the satisfaction of avoiding the world’s most annoying bug (and most devastating disease vector).

So…what is the best mosquito repellent out there?

Answer: DEET. (But you’ve got options.)

I’ve said it before and I’ll say it again: DEET may not be the most natural thing on the planet, but you know what is natural? Disease. Like Dengue fever. Malaria. West Nile Virus. Chikungunya. Zika. All carried and passed by mosquitos. Super natural.

Few things I want you to know (all backed by evidence – see my links below if you wanna read more):

1. There is no product out there that is as effective or lasts as long as DEET when it comes to repelling mosquitos, chiggers, fleas, and ticks.
2. DEET comes in all kinds of concentrations – from 10% to over 75%.
3. DEET is safe. This has been proven time and again in numerous studies. It doesn't cause cancer.
4. However - it doesn’t mean that it can’t be sometimes irritating to our skin and airways, and you should be cautious with it. It can cause numb or burning lips, nausea, and headaches. But it causes more problems if ingested than just if on skin. And some people are allergic to DEET.
5. More on safety: There have only been roughly 20 cases in the world of severe DEET reactions, like a seizure or brain encephalopathy. They were due to massive ingestion of DEET (think a small kid drinking a large bottle of it).
6. DEET is safe to use as young as age 2 months. Yes, you read that correctly.
7. If your baby is 2 months or older, spray the DEET spray on your hands, and wipe it onto their body. Don’t put it on their hands or face. Use a DEET concentration somewhere between 10-30%.
8. 10% DEET lasts about 2 hours. 24% lasts about 5 hours. Sweat, rain, wiping, and swimming all make it not last as long.
9. If you need to put on both sunscreen and DEET, apply the sunscreen first, let it soak in for 15 minutes, then spray on the DEET.
10. What do I think you should use if DEET is not an option for you? Picaridin!
11. Picaridin is plant-based and almost as effective as DEET, but you need higher concentrations of it typically and it usually doesn’t last as long. Still though – a good option.
12. DEET is better than Picaridin when it comes to tick protection in particular, but both work.
13. Picaridin is often tolerated a little better by people (and clothing). It’s less stinky and not greasy, and it doesn’t irritate the skin as much.
14. Lemon Eucalyptus oil (PMD) is about one-half as effective as DEET in studies (for example, 30% lemon eucalyptus oil works about as well and as long as 15% DEET). Still more studies needed though. Don’t use this on hands or face of kiddos either; it can irritate the skin and eyes.
15. Citronella is meh.
16. The bracelets just don’t work. Don’t waste your money.
17.  Botanical oils (sandalwood, lemongrass, citronella, geranium, soybean oils) and essential oils are way inferior to DEET, Picaridin, and lemon eucalyptus. They are well tolerated with less irritation, but I don’t think I’d use these until more studies prove they work.
18. There are a lot of theories out there as to why some people get bitten more than others. Those theories include:

• Blood type
• The kinds of bacteria living on our skin
• Pregnancy
• The amount of carbon dioxide we exhale (my husband does think i'm full of hot air....)
• If you’ve recently had a beer (!!)

I use DEET on my kids and don't really think twice about it. I use somewhere between 10-20% and spray it on my hands, and then rub it on them. I avoid the hands and face. And we take a bath once we've come inside (less chance for skin irritation if it's not on the skin all night).

Hope this helps you navigate your fight against these beasts.

Dr. Diane

Below is the evidence I promised: 

• Efficacy of DEET and lemon eucalyptus compared to other products
• Efficacy of DEET
• DEET Safety in Infants and Lactating/Pregnant Women
• Applying DEET to skin does not harm fetuses
• PMD/Lemon Eucalyptus efficacy
• Picaridin efficacy
• Poor Efficacy of Citronella and most wearable bands
• Comprehensive look at plant-based insect repellents

I remember last year as story after story reported our cities varying counter assaults against West Nile, I looked at my husband and said, “This is really going to freak people out.” My stepson, with his patented perfect timing, walked into the room scratching a red bump on his arm and announced, “Hey something bit me.”

My stomach dropped. While I went in search of an antihistamine in our medicine cabinet, I reminded myself that usually only a small percentage of mosquitos in any area where carrier mosquitos have been found are infected with the West Nile virus. According to the CDC, 80 percent of people bitten by a mosquito infected with West Nile virus never develop symptoms.

Among those who are bitten and infected 1 in 5 develop mild flu-like symptoms such as fever, headache, body aches sometimes skin rash. These symptoms may last for a few days and are easily managed with over the counter medications.

Less than 1 in 100 (that is less than 1 percent) of those infected develop a severe illness with West Nile meningitis or encephalitis (swelling of the brain and surrounding tissue.) Armed with the facts I breathed a sigh of relief and reassured my stepson he would be fine.

What can we do this summer to protect ourselves and our kids? We need to prevent the mosquitoes from biting and make sure we do not have areas around our homes that invite mosquito to breed. We need to use the Four Dʼs: Drain, Dress, Dusk, DEET.

1. Drain all free standing water. Mosquito LOVE free standing water. The murkier the better. It is their favorite breeding ground. Check flower pots, bird baths, swimming pools, gutters, drain pipes. Drain or clean out anywhere water collects.
2. Dress in long sleeves and long pants. Easier said than done in 100 degree Texas heat but the reality is mosquitos only bite skin they can reach. Maybe opt for longer shorts and wear socks and tennis shoes instead of sandals.
3. Dusk (and Dawn) is the mosquito's’ favorite time of day so take extra precautions if the kids go outside during these times of the day.
4. DEET Use insect repellant. DEET has been tested and approved by the Environmental Protection Agency (EPA). Remember you only want to apply repellants to exposed skin or clothing and avoid contact with your eyes and mouth. DEET concentrations vary from product to product from less than 10 to more than 30 percent. The higher the concentration the longer lasting the repellant.

Safety has not been related to concentration. We do not recommend DEET products under 2 months of age. Instead you could try mosquito netting over your infant carrier.

You can also use repellants with picaridin or biopesticide repellants like Oil of Lemon Eucalyptus (ages 3 and up). Regardless of the type of repellant used; remember to wash the product completely off your child’s skin once you are indoors.

If despite your best efforts your child does get a bite you can give him or her an over the counter oral antihistamine or apply topical 1 percent hydrocortisone cream to help relieve the itch. As with all medicines, if you are not sure about the dose check with your pharmacist or pediatrician. If your child develops high fever, body aches or headaches it is time for a visit to your pediatrician.

Remember severe West Nile virus infection is extremely rare and armed with the Four Dʼs we can fight back the terror and, hopefully, take the bite out of this summer.