Federal safety officials have recalled the Fisher-Price Snuga Swings and revised their standard for nursing pillows, two moves intended to guard infants against unsafe sleep spaces.

The U.S. Consumer Product Safety Commission (CPSC) and Fisher-Price announced the Snuga Swings recall in October 2024. The swings aren’t designed for sleep. According to the CPSC, the deaths of five babies were reported from 2012-2022 when the swings were being used for sleep. Bedding such as blankets had been added to the swing in most of those fatalities.   

In September 2024, the CPSC issued a new safety standard for nursing pillows to prevent sleeping infants from suffocation, entrapment and falls. The commission knows of 154 infant deaths and 64 injuries from 2010-2022 associated with nursing pillows.

“Your child should be sleeping on a flat, non-inclined mattress,” said Sharon Evans, Cook Children’s Trauma Injury Prevention Coordinator. “Any more than a 10% incline poses a suffocation risk to your baby.  They can get in the chin-to-chest position and have a difficult time breathing. Swings, bouncers, or propping them up in a pillow is unsafe for sleep.”

The U.S. Centers for Disease Control and Prevention (CDC) reported about 3,700 infants younger than one died due to sudden unexpected infant deaths (SUID) in 2022. The report indicates that 28 percent of those deaths were due to accidental suffocation and strangulation in bed. 

Through early November, nine sleep-related deaths were recorded at Cook Children’s in 2024. In the past three years, Cook Children’s has seen several infant fatalities due to sleeping on a nursing pillow.

The safest way for babies to sleep is on their back, on a firm surface with a tight-fitted sheet, in a crib or bassinet, or pack ‘n play with no pillows, blankets, bumper pads, or toys. No other children or adults should share the sleep space.

Evans said caregivers should lay their babies down in a safe sleep environment – not the couch, swing, car seat, or an adult bed – when it’s time for sleep.

“There’s just as much risk to your baby when they are taking a nap as when they sleep overnight,” Evans said. “Every sleep time needs to follow safe sleep practices.”

The new CPSC safety standard for nursing pillows relates to labeling, firmness, seam strength, and restraints. It applies to pillows designed to position and support an infant while feeding. The rule is scheduled to take effect in April 2025.

“Nursing pillows are intended to be used for feeding when both the infant and the caregiver are awake, and the caregiver can ensure that the infant’s airways are not covered by the pillow,” according to the CPSC. Injuries occur when a sleeping infant rolls face down on the pillow or their neck falls forward or back, preventing their ability to breathe.

The new standard adds this statement to the label: “Move baby to an infant sleep product, like a crib or bassinet, if baby falls asleep or if you feel drowsy.” 

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Written by Ashley Antle. 

All babies are special, but 16-week-old twin sisters JamieLynn Rae and AmieLynn Rose Finley are making history in one of the most unique ways possible. On Monday, they became the first conjoined twins ever to be separated at Cook Children’s Medical Center in an 11-hour procedure months in the making.

Conjoined twins are estimated to occur in only 1-in-200,000 live births. JamieLynn and AmieLynn are omphalopagus twins, meaning they are joined at the abdomen and share one or more internal organs. In their case, it’s a liver.

“As far as conjoined twins that reach and stay viable after birth, at least for the first few days, there's really only about five to eight of those per year on the entire planet, so it is very rare,” said Jose Iglesias, M.D., Cook Children’s medical director of pediatric surgery.

Even so, the girls’ story begins like many others.

James Finley and Amanda Arciniega of Saginaw, Texas, wanted to add one more baby to their family of five. The youngest of their three children at the time, 7-year-old James, was elated at the prospect. He’s always wanted a younger sibling and playmate.

Little did any of them know — or expect —their hope for one more would become a gift of two.

“She said that's the baby's head,” Finley said, describing how their obstetrician shared the unexpected news of twins at their 10-week ultrasound. “I was like, ‘What is that?’ and she said, ‘That's the other baby's head.’ And I was like, ‘What?’”

Double Blessing

The revelation of the twins' connection came early in the pregnancy. The 10-week ultrasound showed the babies had little to no separation between them. Images taken at the following appointment confirmed the babies were conjoined. Suddenly, the family’s excitement for welcoming two new additions was covered by a cloud of questions, uncertainty and fear. 

“I would not have thought in a million years that I would have twins,” Arciniega said. “And then conjoined twins on top of that.”

In the months that followed Arciniega enjoyed an easy and uncomplicated pregnancy, save for the many appointments with specialists across the state to determine who best to deliver the twins and what hospital was most capable to care for them after birth.

The couple settled on maternal-fetal specialist Bannie Tabor, M.D., whose practice is located at Texas Health Harris Methodist Hospital Fort Worth in Fort Worth, Texas. He is also the medical director for Cook Children’s Fetal Center. In his 32-year career of caring for high-risk pregnancies, Dr. Tabor has delivered more than 5,000 babies.

Soon after taking Arciniega and her unborn babies as patients, Dr. Tabor reached out to Dr. Iglesias, a longtime colleague, to review the case and discuss the possibility of separation.

“It was a big surprise when I got the first phone call from Dr. Tabor saying he had conjoined twins that he was starting to follow,” Dr. Iglesias said. “At that time they really didn't know the babies’ anatomy specifically. So I said there is a big range of possibilities and we need to see what happened with the initial MRI to make some plans from there.”

Many conjoined twins die in utero or do not survive long after birth because of the nature of their joining and the organs they share. But scans showed JamieLynn and AmieLynn each had their own heart and heart sac, increasing their chance of survival and making them candidates for future separation.

“I think the key thing when we first met the family was they had a lot of anxiety about the situation, what the options were and what they could do,” Dr. Tabor said. “I think I gave them the confidence that, while I could not promise everything would work out, we would do everything that we could and, with everybody involved — from me to the neonatologists to the surgeons — they were in the right place.”

Family Ties

Texas Health Harris Methodist Hospital Fort Worth and Cook Children’s Medical Center have a long history of physical and professional collaboration. Both facilities are located in the heart of Fort Worth’s Medical District along a historical stretch of Pennsylvania Avenue that cattle barons once called home. The two facilities are joined by a skywalk and, in Cook Children’s early days, even shared some utilities. Local neonatologists practice at both hospitals’ neonatal intensive care units (NICUs) and many Texas Health Fort Worth obstetricians, including Dr. Tabor, regularly consult with Cook Children’s pediatric specialists.

“The working relationship between the whole team, that's made possible by the close relationship of the hospitals, allows us to be the center that can provide this type of highly advanced service to North Texas so families don’t have to go halfway across the state or halfway across the country or even to Dallas for care,” Dr. Tabor said.

Early in the pregnancy, Finley and Arciniega also consulted Ben Gbulie, M.D., F.A.C.S, of Posh Plastic and Reconstructive Surgery in Mansfield, Texas, and a member of the plastic surgery faculty at Cook Children’s. They learned of Dr. Gbulie through Finley's mother, whose friend told her of a local plastic surgeon with experience in multiple conjoined twin separation surgeries.

After long discussions with the couple, he pointed them toward Cook Children’s Medical Center.

“I explained to them that traveling for surgery is not a problem, and a lot of people do that,” Dr. Gbulie said. “But if you can get the same quality of care where you live, it's always better because you want to be able to have long-term follow-up. While this is a major, complex operation, it is not something that is beyond what I felt Cook Children’s could do.”

Finley and Arciniega were relieved to hear Dr. Gbulie’s recommendation. The family lives less than 30 minutes from Cook Children’s. To know that they could stay close to home, close to their other children and close to their support system was comforting.

Cook Children’s was also familiar. Two of the couple’s older children have received care at the medical center. Their daughter, Aaliyah, 13, spent weeks in Cook Children’s pediatric intensive care unit (PICU) when she was 7 for a nearly deadly bacterial infection called Bartonella henselae. It’s commonly known as cat scratch fever and can be acquired when scratched by a cat. Big brother, James, is a frequent visitor to Cook Children’s as he manages sickle cell disease. 

“Sometimes we come in here and I’m like, ‘Hey, I’ve seen you before,’ to a doctor that has been around our son or Aaliyah, and they’re like, ‘Hey, I’ve noticed you, too,’” Arciniega said. “So it’s kind of like we’re family here.”

“Everybody’s always treated us nice,” Finley added. “It takes a lot of pressure and anxiety off when you know your kid is going to be taken care of.”

Delivery Day

As the babies grew in utero, Dr. Tabor closely monitored their progress and, together with a team of doctors from both hospitals, prepared a delivery and post-natal game plan. During Arciniega’s third trimester, Dr. Tabor became concerned with the slow growth rate of the babies and determined it was best to deliver them early.

On Oct. 3, 2022, at 34 weeks gestation, JamieLynn and AmieLynn were delivered via C-section at 10:40 a.m. at Texas Health Fort Worth. Arciniega required a vertical incision over the traditional horizontal approach to delivering the babies safely. Both weighed 4 pounds, 7.8 ounces. JamieLynn was the longer of the two, measuring 16.9 inches to AmieLynn’s 16.5 inches.

“It wasn’t an easy delivery, but we made it look easy,” Dr. Tabor said reflecting on that day.

Upon delivery, neonatologists Chad Barber, M.D. and Mary Frances Lynch, M.D., took over the babies’ care in Texas Health Fort Worth’s NICU. Like with any set of identical twins, telling them apart can be tricky and, if mistaken, dangerous in the hospital setting. To help keep their identities straight, Dr. Barber and Dr. Lynch chose a favored color for each girl, purple for JamieLynn and green for AmieLynn, and used Sharpies to mark each baby’s color on one of their nails.

After a month, the girls were transferred to the NICU at Cook Children’s Medical Center where they remain today, still under the care of Dr. Barber and Dr. Lynch who practice at both Texas Health Fort Worth and Cook Children’s. The girls’ color codes followed them there, too, and are used as an additional layer of safety when identifying the babies for medication administration, feedings and individual care needs. They even inspired the purple and green crayon costumes the girls sported for Halloween.

Home Away From Home

In the NICU room, which has been their babies’ home since November 2022, Finley and Arciniega attend to their infants like many other parents of twins — together. It takes two to pick them up, especially considering how they must navigate the tubes and wires that monitor the babies’ vitals and deliver nutritional support. Scripted signs handmade by the NICU nurses hang on the wall, making their private NICU room look a little more like a sweetly appointed home nursery.

The girls lay face-to-face on their sides, carefully and frequently repositioned from one end of their shared crib to the other in order to give equal time on each side. Although currently the smaller of the two, JamieLynn is wide-eyed and alert. Her gaze fixes on and follows those that enter the room. She’s feisty and makes sure everyone knows when she is unhappy. Sister, AmieLynn, is more reserved. She’s often the calmer and more chill of the two.

Together, the beloved girls evoke the attention of their parents who make sure there are enough cuddles and kisses to go around, especially from their protective dad. He’s already planning ahead for the days when young men come calling for any one of his three daughters.

“Every window will have a rose bush underneath,” Finley said with a laugh, but only half kidding.

Their days in the NICU are filled with feedings, naps, diaper changes, baths and a number of therapies to help with mobility, strength and eating. The girls respond especially well to music therapy and love it when Grandma sings to them during her visits. Their siblings, brother Isaiah, 15, Aaliyah and James, visit regularly, too. James loves to entertain them, and the girls respond with delight.

Their face-to-face positioning makes feedings and diaper changes a challenge, but nurses have developed creative workarounds to accomplish both. Most of the time they can be bottle-fed one at a time by a single caregiver, with AmieLynn often waiting patiently until sister is satisfied. When patience runs out, feeding is a two-person job.

The older they get, the more they move their limbs. It’s not uncommon for one to unintentionally punch and sometimes anger the other. The girls wear mittens to protect each other from scratches.

All the while doctors monitor their progress, study their anatomy and plan for the enormous task of separation. 

Journey to Separation

The timing of conjoined twin division varies from case to case and primarily depends on how complicated the anatomy is. In the girls’ case, their anatomy and growth support a surgery date sooner rather than later.

While the girls are thriving in the NICU, they are not growing at the same rate, partly because they share some blood supply.

“One is stealing groceries from the other, basically,” Dr. Barber said.

AmieLynn is beginning to develop scoliosis. Feedings are becoming more and more challenging with their size, mobility and face-to-face proximity. While separate, their hearts are exceedingly close together and grow ever closer as the girls age.

“They're pretty much at their maximal, I like to say, baby stretchability,” Dr. Iglesias said. “So their skin is pretty stretchy. Their abdominal walls are stretchy. We've got the benefits of using that. By separating early, they're not going to be as used to the loss of having essentially part of you that is different, so hopefully, that transition will be better. There are not very many more benefits to waiting longer versus doing it now.” 

At nearly 4-months-old, the time is right.

It’s taken months of planning and collaboration. Countless hours have been spent building a comprehensive medical team, studying scans of the girls, building models of their anatomy, mapping out potential surgical solutions, identifying the what-ifs, troubleshooting potential problems, inventorying equipment needed to accomplish the surgery, preparing the operating room (OR) and rehearsing the carefully choreographed surgical production. Dr. Barber estimates there have been at least 100 medical professionals, from physicians to nurses to therapists and other clinical specialists, intimately involved in the girls’ care and surgical planning.

“I think the teamwork is a great point to bring up because it's everything,” Dr. Iglesias said. “It takes a huge team to get all of this working as smoothly as you can make it, given the unknowns that we'll have. Having everybody open and honest talking to each other regardless of their position, that's the definition of teamwork.”

The surgery comes with great risk and a number of unknowns. Because they must dissect the liver, an extremely vascular organ, bleeding is a concern. A significant risk of infection also exists, for which the twins will be monitored weeks into recovery. Doctors are unsure of how the babies’ hearts will respond to their new anatomic position as the girls lay on their backs for the first time in their lives. Then there are questions about how to best close the abdominal wall, many of which can not be fully answered until separation is accomplished. The girls may require additional surgeries to complete closure and reconstruction.

“In order to prepare for this, it's a lot of practice, practice, practice and more practice, trying to really think of every possible scenario so that we're not surprised by anything,” Dr. Barber said. “There's always going to be unexpected things, but if you're prepared for the worst possibilities and the most unlikely outcomes, then you can hopefully not get too caught off guard.”

For their part, mom and dad pray, leaning on the same faith in God that carried them through when their older children faced medical crises.

Separation Day

Monday, Jan. 23, 2023. JamieLynn and AmieLynn are ready for their big day. Thanks to their NICU nurse, they’re sporting fresh mani-pedis in their signature purple and green to help identify them in the OR.

Before the sun rises, family and members of the medical team gather in the girls’ NICU room. It’s calm and quiet as mom and dad steal a few final pre-surgery kisses from their babies. Grandma sings softly. Others pray. The girls are awake, content and comfortable. Just before 7:30 a.m., they begin their journey to the OR.

Inside the OR is a sea of medical professionals: three anesthesiologists, four pediatric surgeons, two plastic surgeons and about a dozen other clinical professionals. They are separated into two teams, one for each girl. Those in purple scrub hats belong to JamieLynn’s squad, while Team AmieLynn dons the green. Everyone will work together until the babies are separated, then each team will focus solely on their assigned baby.

“The reason that's important is because you need focus,” Dr. Gbulie said. “You want to minimize room for errors and the risk of confusion. So little things like color-coding everyone and everything minimizes the risk of giving the wrong medication on either side. It's truly a community effort that involves a multi-specialty team.”

The first few hours involve inserting central lines for delivering anesthesia and placing breathing tubes. Then, sedation begins. The process is slow and methodical.

“When we're talking about taking care of conjoined twins compared to taking care of just a single baby, one of the biggest questions is what is shared, and there does seem to be some shared circulation between the girls,” said Chandra Reynolds, M.D., the lead Cook Children’s anesthesiologist on the surgical team. “What is the response going to be for baby B when we give baby A certain medication? It’s a very slow and stepwise approach until we better understand what happens to one when the other receives medication. The key thing is to give one baby a certain amount of medication, watch and wait for a while to see how things are going and, based on that response, we can give her sister a certain amount as well.”

Once the girls are safely asleep, the surgeons begin marking incision lines. At 12:28 p.m., the separation officially begins. Guided by plastic surgeons, they are careful to make cuts that give the girls’ abdomens the best chance of closure.

First, surgeons open the abdominal wall and dissect the lower part of the sternum and the liver. A little under two hours in, the family receives word that the girls’ shared liver is separated. The private waiting area where the family anxiously awaits news of progress erupts with cheers. Finley and Arciniega embrace.

Surgeons painstakingly work layer-by-intricate-layer until they reach the backside of the abdominal wall where they complete the dissection.

The update everyone’s been waiting for comes at 3 p.m. JamieLynn and AmieLynn are officially separated and on their backs. Tears and shouts of praise flow from family and friends in the room. Their relief is palpable.

“I want to tell you that all of the people in there taking care of them cheered even louder than this,” said the nurse delivering the news, followed by laughter from the family.

There is still a long way to go.

“Once the babies are finally physically separated, then we have to initially look for other additional anomalies and see if there is anything else going on,” Dr. Iglesias said. “We transfer one baby to the other bed where one surgeon will follow and an additional surgeon will pick up with the other and continue to do the evaluation.”

Once each baby is ready for closure, their assigned pediatric surgeons, Dr. Iglesias for JamieLynn and Marty Knott, D.O, for AmieLynn, begin closing the chest and abdomen. Plastic surgeons Dr. Gbulie and Eric Hubli, M.D., Cook Children’s Surgeon in Chief and medical director of craniofacial and cleft surgery, assist with skin closure.

By 6 p.m., the surgery is complete. This time Dr. Iglesias, Dr. Gbulie and Dr. Knott deliver the news to the family.

“We did it,” Finley said in response. “I don’t know what I did, but we did it.”

To this Dr. Iglesias replies, “You trusted us. That’s what you did.”

All the while, neonatologists Dr. Barber and Dr. Lynch stand by for the girls’ post-surgery return to the NICU.

One by one, the sisters exit the OR on their way back to their familiar home away from home in the NICU. For the first time in their lives, they lay on their backs, each in their own crib. The family gets a momentary glimpse from afar as the girls are wheeled past the waiting room, and cheer them on as they pass. About an hour later, mom and dad are able to join the girls in the NICU.

The first look at their twins in separate beds brings a wave of emotion. For the first time, they must divide their attention between the two. They start with JamieLynn. Arciniega places her pinky finger in her baby’s hand.

“It’s OK, Mommy’s here,” she whispers.

Then to AmieLynn. Finley gushes about her strength and how proud he is of his quiet fighter.

It’s a monumental moment, but none of the physicians are ready to say “mission accomplished.”

“The challenges the girls may face after surgery are very difficult to fully prepare for,” Dr. Lynch explained. “We do still have some unknowns as far as how their shared vasculature and their shared anatomy and positioning over these last three months will affect them. As Dr. Barber alluded to earlier, we have to prepare for many different scenarios. The things that will worry us and that we’ll be the most focused on in the first few days are going to be breathing support and pain control. As you can imagine, this is an incredibly big surgery and pain control will be at the top of our list.” 

They’ll be watching for signs of infection, too.

“The soft tissue usually swells over the first two to three days,” Dr. Gbulie said. “If you get through those two to three days, you're usually OK. That being said, we are going to be going through potentially some bowel and definitely the liver, so there is a relatively higher risk of wound infection and that usually shows up at about five to 10 days.”

Road to Recovery

Recovery is best described as slow.

“I'm sure mom and dad are going to think we're moving in slow motion,” Dr. Iglesias said. “The first steps are going to be healing of the very large incision that is required to separate them. We have to wait for their gut to start to work before we start allowing nutrition to move through their intestines. Some of these things may require staged procedures so the family's ready that the abdominal closure may take more than one operation. We're hopeful it won’t, but that's a possibility.”

They’ll need extensive rehabilitation, too, which will include nutritionists, physical therapists, occupational therapists, speech therapists and more.

Doctors say they’re optimistic but will continue to hold their collective breath until they are waving goodbye to the girls as they leave Cook Children’s for their first ride home.

“I'm very hopeful that they're going to have a good recovery and lead healthy lives in the future,” Dr. Iglesias said. “They're going to have a bit of a ramp up from the recovery, but I think they're going to be able to get there eventually, and very close to normal if not completely normal.”

Until that chapter of this story begins, JamieLynn’s sassy spirit and AmieLynn’s sweet smile remain on full display as their NICU team continues to care for their daily medical, physical and emotional needs. This time, together, but separate.

Cook Children’s is a not-for-profit organization. Donations to Cook Children’s Health Foundation allow us to care for our families when and how they need us. Give today to support patient families like Jamie and Amie. Go here. To donate items at the Medical Center for Jamie and Amie, email AandJ@cookchildrens.org.

Finding infant formula on store shelves can still be tricky if you’re shopping for specialized types made for premature infants or babies with digestive complications.

Nutritional experts at Cook Children’s say some patient families are struggling even though formula availability generally has improved in recent months. The 2022 shortages have been blamed on a manufacturing recall and supply chain disruptions.

Brand options tend to be limited for preemies, who require formulas with higher calcium, phosphorous and protein for their bone and brain development. Likewise, infants who undergo surgery on their stomach or intestines might need certain easy-to-digest formulas.  

We spoke with three registered dietitians – from the Cook Children’s Neonatal Intensive Care Unit (NICU), the N.E.S.T. Clinic, and the Gastrointestinal Clinic – about tips and support for parents when the formula their baby takes is out of stock.

Their advice? Consider switching to another appropriate brand. Use the imported formulas that received approval from the U.S. Food and Drug Administration. Ask your pediatrician for samples. Don’t dilute formula or make your own version. And don’t give up.  

“I still see grocery stores with formula shelves that look about half empty or less,” said Hayley Spinks, a clinical dietitian in the NICU. “If you’re looking for a specific formula, it doesn’t really matter if the shortage is getting better overall. If you can’t find the formula that your baby needs, it’s really a big deal.”

One resource the dietitians share is a substitution list they created to help families know which brands fall in categories for particular needs. The substitutions list includes standard formulas, premature formulas, reduced lactose formulas and more. Go here to view the formula substitution chart.

The shortage continues to cause challenges and frustration, but dietitians are working to help parents find solutions. Here are their viewpoints.

In the NICU

Dietitians in the NICU monitor growth of the smallest babies, who sometimes need fortifiers added to their feeding regimen. When a preemie product runs out of stock, Spinks said, they turn to alternatives with the right nutritional components that the infant can tolerate. Signs of formula intolerance may include diarrhea, vomiting and belly bloating.

Before patients are discharged, Spinks and her colleague in the NICU like to ask the parents whether they’ve been able to find the formula they need. “Some moms are telling me that they’ve looked and they can’t find the formula that their baby is on,” she said. Others tell her they’ve enlisted relatives and friends to help search the stores.

Spinks makes a habit of checking the formula aisle when she’s shopping. She also belongs to formula finder groups on social media. “I’m always trying to keep my eye on the situation of what we can expect,” she said.

She encourages parents to have confidence in the safety of formulas that have been imported since May to relieve the shortage in the United States. But she cautioned that the measurements might differ (milliliters versus fluid ounces). Always follow the recipe on the can.

In the N.E.S.T. Clinic

The Cook Children's N.E.S.T. Developmental Follow-up Center (cookchildrens.org) provides support, interventions and care coordination for NICU babies as they transition home.

 “A majority of our patients require specialized formula either to meet their increased nutrient needs from prematurity or to improve their tolerance and absorption,” said registered dietitian Kayla Harrell.

Harrell said the shortage has forced some patients to change formula multiple times, incurring the risk of tummy distress, allergic reactions and other symptoms of intolerance. She has seen some improvement in availability. But parents tell her stories of driving up to two hours to track down formula or shipping it from out of state.    

For children with medically complex dietary situations, Harrell said, the formula hunt can be difficult and heartbreaking.

“You are not alone,” she said. “We are always here to help find the best solution for your precious child.”

In the GI Clinic

Gastrointestinal conditions can include bleeding, inflammatory bowel disease, chronic liver disease, swallowing dysfunction and nutrition absorption disorders. Some patients require formula fed through gastrostomy tubes called G-buttons.

Chelsea Barrow, a registered dietitian, said many children with GI problems have significant allergies, growth failure or reflux that causes them to rely on highly specialized formulas delivered from medical supply companies. Some of these formulas have gone in and out of stock, causing shipments to be delayed or partially fulfilled, Barrow said.

“Families are telling us they are driving around everywhere to find formulas,” she said. “They’re unable to find formula on the shelves or online. There’s limited access to grocery stores and pharmacies in their small rural towns. Families are asking if anyone has formula to spare or looking to social media for options.”

Barrow said it’s important to communicate with your health provider regarding brand substitutions. Not all formulas are interchangeable for individual patients, and mixing instructions can vary between brands. She urges patience as the dietitians navigate the inconsistent formula availability by adjusting orders, communicating with medical supply companies, fielding phone calls and continuing to see a full clinic load.

“There is indeed a light at the end of the tunnel with the return of many specialized formulas,” she said. “We are all working very hard and long hours to ensure families have something safe to feed their child.”

RELATED: Two Cook Children’s pediatricians shared their guidance on the infant formula shortage. Click here to watch videos in English and Spanish. 

This week, SMA was added to the list of required medical screenings every baby in Texas receives at birth. Without newborn screening, many children escape the diagnosis until after permanent neuromuscular damage has occurred. Early recognition and treatment can mean the difference between a near normal life or suffering many skeletal deformities and being unable to breathe without a ventilator.

“The hope and thought is that it’s going to change the lives of patients and their families,” said Stephanie Acord, M.D., a pediatric neurologist at Cook Children’s Jane and John Justin Neurosciences Center. “Without treatment, these kids and those who care for them are significantly affected. The earlier you treat SMA, the better.”

Dr. Acord directs the multi-disciplinary Muscular Dystrophy Association (MDA) Clinic at Cook Children’s Jane and John Justin Neurosciences Center where she and Warren Marks, M.D., medical director of movement disorders at the center, specialize in the treatment of SMA. Dr. Acord shared with us what every expectant parent needs to know about the disorder and the new screening.

What is SMA?

Spinal muscular atrophy is a genetic disorder in which the nerves within the brainstem and spinal cord, called alpha motor neurons, break down and lose the ability to send signals from the brain to the muscles. Without those signals, the muscles grow weak from lack of use and affect a baby’s ability to hold up and control their head, sit up, crawl, walk, swallow, speak and breathe. If left untreated, a child will eventually require a feeding tube and respiratory support, such as a ventilator. Untreated SMA is among the leading genetic causes of death of infants and children.

Spinal muscular atrophy can be passed to a child if both parents have a defective survival motor neuron (SMN1) gene. Parents do not have the disease or signs of the disease and do not usually know they carry an abnormal gene. The faulty gene inhibits the production of the protein that fuels these motor neurons and, without it, the nerves die. There is a back-up copy, the SMN2 gene, but it doesn’t work as well as the SMN1 gene.

It is estimated that about 100 children born in Texas each year have the disorder. Many newborns will not show signs of SMA for months. By that point, you’ve lost valuable treatment time and the ability to give a child with SMA a better life. This is why newborn screening is so important.

What are the signs and symptoms of SMA?

There are several types of SMA. Symptoms vary depending on the type, but muscle weakness and loss of muscle control that worsens over time are general indicators. It is important to note that SMA is not a cognitive disorder, but a muscular one.

Type 0 is the rarest and most severe form of the disorder. Babies born with Type 0 SMA have breathing problems very early on and typically do not survive.

Type 1 is the most common form of SMA and also considered severe. Infants will begin showing signs within six months of life. They have poor head control, do not sit independently and have difficulty sucking and swallowing. Even though cognitively they are normal, they are unable to speak due to weakness. Without treatment they will need assistance with breathing, feeding, communicating, sitting and walking.

Type 2 is a more moderate form of the disorder. Symptoms will become evident between six months to 18 months of life. Infants with Type 2 will have difficulty controlling their lower limbs. They may be able to sit independently and crawl but struggle with walking.

Type 3 is a milder form of SMA. Symptoms such as mild muscle weakness, difficulty walking or frequent respiratory illness do not appear until after 18 months of life. Some people may not experience symptoms until early adulthood.

Type 4 is adult onset SMA. It is rare, progresses slowly and typically doesn’t appear until the early 30s. Most people maintain mobility and are able to manage their symptoms without much interruption to their lives.

What treatment is available for SMA?

The Federal Drug Administration (FDA) approved the first treatment for SMA in December 2016.

“It used to be a diagnosis in which there was very little treatment and little hope,” Dr. Acord said. “But the treatment now available for these patients is completely different than it was just five years ago.”

Today, there are three FDA-approved treatments. Two—Spinraza® and Evrysdi®—are drug therapies that help stimulate the production of a more functional SMN2 protein. These two treatments require ongoing administration of medication at various time intervals. The other—Zolgensma®—is a gene-replacement therapy administered once through an IV that delivers a normal functioning copy of the SMN1 gene.

The treatments have varying degrees of success, but all work to improve the strength and function of muscles through healthier neurons. They help to prolong the amount of time a child can live without additional support such as equipment to help them breathe more comfortably, as well as increase their ability to speak with their voice and to eat to some extent by mouth. The most critical part of any of the treatments is to start as soon as possible following diagnosis.

How will my newborn be screened for SMA?

As of June 1, 2021, SMA is one of 55 disorders on Texas’ list of required newborn screenings. It does not require an additional test. It’s simply bundled into the routine screenings already performed on newborns via blood test.

What happens if my newborn is positive for SMA?

If your newborn’s screening is positive for SMA, it is recommended that they be referred to a specialist, either a pediatric neurologist or a pediatric neurogeneticist, within 24 hours. A specialist will most likely conduct additional testing to confirm the diagnosis and develop a treatment plan.

“Parents need to advocate getting their child to a specialist as quickly as possible,” Dr. Acord said about receiving a positive SMA screen.

Pediatric neurologists at Cook Children’s Medical Center are able to conduct many SMA assessments virtually via telemedicine, which is helping parents and children in parts of the state without specialists get access to care from the comfort of their home.

Click here to learn more about the Muscular Dystrophy Association Clinic at Cook Children’s and for contact information for clinic staff.

Charlee was diagnosed in utero with congenital hyperinsulinism (CHI)—a rare genetic disease of the pancreas. Although there are several forms of the disorder, hyperinsulinism is a condition in which the pancreas produces too much insulin, driving blood sugar levels dangerously low and depriving the brain of important fuels it needs to function.

"Hyperinsulinism is a rare condition affecting about 1 in 20,000 to 30,000 newborn babies each year," said Paul Thornton, M.D., medical director of the Cook Children's Hyperinsulinism Center. "However, it is the most common cause of severe hypoglycemia in the newborn. Despite this, unfortunately today, there are still patients who have delays in diagnosis. This can be very damaging as this form of hypoglycemia puts babies at a high risk of brain damage."

The Perkins are no strangers to the disorder as their 11-year-old daughter, Ava, was also born with CHI. Even so, the pandemic made the somewhat familiar situation much more challenging.

Babies born with CHI need a quick and correct diagnosis and immediate intervention with medication to increase blood sugar levels. Without these measures, they can suffer seizures, brain damage or even death for a disease that can be managed with various therapies and, in some cases, even cured with surgery. An amniocentesis revealed Charlee’s CHI prior to his birth, giving the family important information they needed to prepare for his arrival.

The first major hurdle was to determine where to deliver Charlee. He would need care at a medical facility with a center specializing in CHI. Only two of those exist in the U.S.—one at the Children’s Hospital of Philadelphia (CHOP) and the other at Cook Children’s Medical Center in Fort Worth. The Perkins were familiar with the center in Philadelphia as that is where Ava received treatment shortly after her birth, but the pandemic made traveling that far from home complicated. They needed something closer, preferably a facility a reasonable car ride away.

An internet search led the Perkins to Cook Children’s where they were put in touch with Dr. Thornton who trained at CHOP and is considered a world-renowned expert on the disorder.

“I was impressed whenever Dr. Thornton called me and talked on the phone with me for close to an hour,” Perkins said. “I know he's a very busy man. So, we decided to go ahead and cancel our plan to go to Philadelphia.”

The Perkins worked together with a multidisciplinary team of obstetricians from Texas Health Harris Methodist Hospital and CHI experts from Cook Children’s to develop a game plan for Charlee’s birth.

"From the first moment I met with Mrs. Perkins and we talked about how we could help her prepare for the birth of her child with a rare disorder, I was impressed with her determination to ensure the best possible care for her baby from the moment of his birth," Dr. Thornton said. "Her sacrifice to leave her family and travel to Cook Children's so that she would be able to deliver her baby where our team was ready to treat him from birth was the best choice she could make."

But in the months that followed things went awry for Laurie. Preeclampsia and placenta abruption made for an early and dramatic delivery, throwing Charlee’s care team into action much sooner than originally anticipated. Charlee was born at 32 weeks gestation on July 7. As expected, his blood sugar was dangerously low. He was immediately transferred to Cook Children's and given medication to increase his blood sugar levels.

"By being prepared for a baby with severe hyperinsulinism we were able to have him stabilized within 30 minutes after birth," Dr. Thronton said. "This gave us the best possible ability to get a good long-term outcome for Charlee."

A Chance for Charlee

The Perkins had two treatment choices for Charlee. Either subject him to a lifetime of feeding tubes and continuous feeds to keep his blood sugar from dropping too low or have surgery to remove most of his pancreas. The latter would mean Charlee, like his big sister, would be a diabetic and dependent on insulin injections to regulate his blood sugar.

This time, the familiar made choosing the surgical option for their baby much easier. Charlee and big sister Ava have the exact same form of CHI. Ava’s pancreas was removed as an infant and, with the help of her family, she has been able to successfully manage the resulting diabetes. Even as an 11-year-old, she knows how to check her blood sugar, can read her glucose monitor and can change her cordless insulin pump. Nothing stops her from enjoying all of the activities in which kids her age take part. The Perkins knew they could instill the same knowledge, independence and confidence in Charlee as they have Ava.

Before they could do surgery, Charlee had to overcome the challenges of prematurity while in the NICU.

“Not only did he have CHI, but he had to beat all of the early preemie baby stuff to even be able to sustain surgery,” Perkins said. “He was born on July 7th at 32 weeks and was ready to rock and roll for major surgery on July 31.”

Meeting A Milestone

The Perkins family found Cook Children’s Hyperinsulinism Center in a milestone year, as 2020 marked the center’s 10th anniversary of serving children who come from all over the country to receive the very specialized care the center offers.

"The treatment of congenital hyperinsulinism is very complex," Dr. Thornton said. "It's really important that patients with rare diseases have access to multidisciplinary teams such as are at Cook Children's Hyperinsulinism Center where the approach and the experience of the team members caring for these patients results in better outcomes with shorter lengths of stay, getting the patient's home to their families as fast as possible."

Hayden Hood has been a Cook Children’s Hyperinsulinism Center patient since its inception. Doctors discovered Hood’s hyperinsulinism just weeks after his birth in 2000.

“Hayden was so sick when he was born that it took them a matter of days to figure out the problem,” said Davelyn Hood, M.D., Hayden’s mother and a family practice physician in San Antonio, Texas. “You hate to say that you’re grateful that your child is sick but, because he was so sick, they were able to diagnose him early. That’s why he’s had better outcomes than could have been.”

Most of Hayden’s pancreas was removed when he was two weeks old but the problem persisted. After struggling to manage his disease for the first 19 months of his life, the Hoods decided to travel from their home in South Texas to CHOP as it was the only HI center in the U.S. at that time. That’s where they met Dr.Thornton.

“Dr. Thornton helped us come up with a new treatment plan for Hayden, something that we could do to help stabilize his hyperinsulinism condition,” Dr. Hood said. “It was a real roller coaster in those days, and Dr. Thornton was a big part of helping get things on a more stable track for us.”

In what Hayden’s mom describes as a divine turn of events for their family, Dr. Thornton was recruited by Cook Children’s Medical Center in 2002 to join the medical staff as the medical director of endocrinology. The move meant the Hoods would no longer have to travel out-of-state for Hayden’s care.

Dr. Thornton spent eight years growing the Cook Children’s endocrinology program and, in 2010 set his sights on launching the nation’s second HI clinic at the medical center.

“Every child’s HI management is different. It’s a very personalized experience,” Hayden’s mom said. “I think that’s an important distinction. They don’t just have a one-size fits all treatment. At Cook Children’s they’re really able to tailor their care, and I think that’s why families feel heard and like they are getting care that works for them. That’s something extra special about the Cook Children’s center.”

Breaking Barriers

Like most rare disorders, there are few resources for information and support for families with HI, so the Perkins and Hoods led the way in building a few.

Laurie Perkins organized a support group in their parish called Sweet Heroes for children with diabetes so that Charlee and Ava can spend time with other kids who face a similar fate.

Dr. Hood parlayed her medical knowledge into an advocacy role as the president of the board for Congenital HI International, a nonprofit dedicated to improving the lives of those with HI. She is also a principal investigator for the HI global registry which collects data and feedback from HI patients across the globe in order to learn more about the HI experience. Dr. Thornton is active with this organization and endeavor as well.

Living with a rare disorder hasn’t stopped Hayden from pursuing his dreams. And, if his big sister is any indication, it won’t stop Charlee Perkins either.

“I always felt like a normal kid,” Hayden said. “I did every normal thing a kid can do and didn’t feel held back at all. I know I am one of the lucky ones with this disease. So I really do try to take everything as a blessing.”

Hayden went on to become a long snapper for the Texas Tech Red Raiders during his first year of college. Today, he has his sights set on creating a career path that allows him to nurture his love for hunting and ranching. He even started a small hunting guide business with a friend. Now a young adult, Hayden is able to manage his HI with diet, exercise and paying close attention to how his body feels.

"One of the best parts of being an endocrinologist and working in a single institution for a long time is getting to guide our patients from diagnosis all the way up to adulthood and seeing them become successful adults," Dr. Thornton said. "It's even more fun when the families follow you from one institution to another. The big advantage of seeing a child from diagnosis to adulthood is that you come to understand the lifelong impacts of a disease on a child and their family and this makes you a better doctor at the end of the day."

As for little Charlee, his days are full of kisses and cuddles from mom, dad and sister. He is meeting all of his milestones, loves to smile, is sitting up and will be crawling in no time.

For more than six years, Cook Children’s online newsroom has provided the latest in pediatric health news to more than 16 million people in 230 different countries.

But during all that time, the team behind the scenes felt they had more to accomplish. At the top of their list was creating an online Spanish language presence. This month, they reached their goal with the publication of Checkup Newsroom En Español.

This new newsroom is in Spanish, with content written and approved by Cook Children’s pediatricians and health care providers.

“We know the importance of sharing up-to-date and evidence-based information with our patients and their families,” said Bianka Soria-Olmos, D.O., a Cook Children’s pediatrician and primary contributor to the webpage. “Checkup Newsroom is hugely important for getting out timely and relevant health information. With our community being so diverse, we realize making this information available in Spanish is necessary.”

The addition of the Spanish-language newsroom builds on Cook Children’s ‘Promise’ to improve the health of every child through the prevention and treatment of illness, disease and injury.

The COVID-19 pandemic has highlighted the need for credible health information in the Hispanic community. According to Tarrant County Public Health, 27% of COVID-19 cases are among Hispanics, making it the most affected group by race and ethnicity. Further, Texas’ Hispanic population has grown by more than 2 million since 2010 and the state's demographer predicts that Hispanics will be the state's largest population group by mid-2021.

“We are so happy that Cook Children’s is making so many efforts to be inclusive,” said Vicki Kelley, Family-Centered Care Program Manager, who oversees the Hispanic Family Advisory Council at Cook Children’s. “All parents want to do what’s best for their children. Having an online presence such as Checkup Newsroom gives parents a great resource to find helpful and accurate information for their kids.”

“The publication of our Spanish newsroom is a great next step in our diversity and inclusion efforts at Cook Children’s,” Wini King said. “We’ve talked about making this happen for many years, but were limited in time and resources. The timing just felt right, and with the COVID-19 pandemic, we know this information is needed now more than ever.”

Being a new parent is hard.

Being a new parent today is even harder.

With the limitation of visitors, changes to doctor’s offices, and lack of ability to get out of the house (among many other challenges), being a parent in COVID-times is causing new parents to feel even more isolated and ill-equipped.

But, when can you have visitors over to meet your newborn?

Like most things COVID-related, it’s not a simple question.

It’s also a decision that, given all the same information, two families might make very different choices.

Even in “normal” times, I believe that babies under 2 months should have a pretty tight circle drawn around them, which can relax more with each round of shots at 4 and 6 months. COVID has just heightened my desire to protect them even more.

It appears that infants less than 1 year are at a higher risk of severe illness than other kids.. Because of the upfront, face-to-face nature of caring for them, they may be at higher risk for exposure from a caregiver. When considering this decision, it’s essential to keep in mind the reverse (and perhaps more significant) risk to the person entering the house. Many grandparents and other family members might fall into higher-risk categories based on age or medical conditions.

But that doesn’t mean you have to go it alone.

Here are three factors to consider:

1. The purpose of the visit.
2. The behavior of the visitor.
3. The activity at the visit.

The purpose of the visit.

The first time this comes up is at the time of delivery. If you have an older child at home, they need to be taken care, of and you should have the opportunity to have someone to support you at delivery. This one is easy. Ask the grandparent or other caregiver to take caution with social distancing, masking and other precautions around 36 weeks so that they can be as safe as possible entering the home.

After the initial delivery phase, some parents may need ongoing support from a close family member. When a parent has to go back to work or doesn't have a lot of experience with babies, they may need ongoing support. The safest way to do this is to ensure that the person entering your home has been following guidelines for at least 2 weeks before the visit. If possible, they should plan to come and stay as much as possible rather than coming and going frequently. Staying put limits their number of contacts and lowers the risk for everyone.

Purely social visits are probably the riskiest. Having any number of visitors drop in to say hi significantly increases the baby's risk because of the number of possible contacts and the lack of control over their behavior and exposures. Some parents might feel comfortable with a very close friend or family member. Still, we all must recognize the risk of doing so.

The behavior of the visitor.

There are many different approaches and mindsets concerning coronavirus. While I wish everyone took a cautious approach, that’s not the case. And while you may have family members who argue they have the right to make their own decisions regarding social distancing, mask-wearing and the like not everyone has the right to make their own decisions AND get to spend time with your baby.

If you have a close friend or family member you trust is taking an extremely cautious approach, you may feel more comfortable inviting them come over to meet your baby. Remember that you get to make your own decisions about what makes you comfortable. If you decide to take a more conservative route than your family appreciates, feel free to blame your pediatrician (especially if it's me). I promise we’re cool with that.

The activity at the visit

Once you’ve decided you’re going to see family, there are still questions about what will happen at the visit. Of course, at a baseline, we’re going to do all the usual things we would ask anyone to do when visiting a newborn.

1. No one comes over who has possible symptoms, such as a cough, runny nose, (obviously) fever, etc.
2. No one holds the baby without washing hands first.
3. No one kisses the baby period.

Extra precautions you might consider in the context of COVID would be (in decreasing order of safety): drive-by only visits, patio/outside visit, no-holding/across the room visit or a masked visitor visit.

Be gracious with yourself and others

Remember again that every parent and family will make different decisions and have different comfort levels. Be kind to yourself and your fears. Consider the impact of not having visitors vs. having visitors and what that means for your level of stress because it might affect each parent differently. If you are the potential visitor, be kind, and understand if the new parents in your life ask you to stay away

We're all in this together for the long haul, and they are dealing with enough stress as it is.

It’s a common question to ask your pediatrician. "What is the daily calorie need of your infant or child?"

Here’s a chart that covers the normal daily calorie need to sustain healthy growth. Average weight and lengths are listed for reference for infants. Base the calorie needs of your growing infant more off of their weight and height, rather than their age, until age 2. Also listed is the approximate number of ounces of breastmilk or formula your infant should consume to obtain the daily necessary calories (for a solely breastfed or formula fed infant, it does not take into account the calories from pureed baby foods).

These daily calorie counts are a general guideline, but other factors such as chronic medical conditions, medications, and extreme physical activity can change what your child actually requires in a day. If you are concerned your child is not eating enough, or is eating too many calories in a day, schedule an appointment with your pediatrician.

Most people develop some redness and itching after a mosquito bite. Unfortunately, some children will have what’s known as a large local reaction, or “Skeeter syndrome.” This happens due to an allergy to mosquito saliva. These patients develop redness and swelling within hours of a mosquito bite. The swelling can be very large (like an entire arm or leg) and typically worsens over 1-2 days. In the worse reactions there can be bruising and even blistering!

It’s not always easy even for your doctor to tell the difference between “Skeeter syndrome” and a skin infection. One of the big differences is the timeline. Skin infections usually happen several days after a bite or an injury, but “Skeeter syndrome” usually starts within a few hours of a bite. Most often children with a large local reaction will complain about intense itching. Only in the more severe cases are pain and fever seen with allergy. It’s not common, but some even develop severe allergic reactions to mosquito bites that lead to difficulty breathing.

Large local reactions are best treated with oral antihistamines (Benadryl or Zyrtec) and topical over-the-counter steroid cream (hydrocortisone 1 percent). Fingernails need to be trimmed very short, because scratching causes local skin damage that can become infected. Cold compresses several times a day help alleviate some of the discomfort. In patients who have a history of this type of reaction, I recommend daily antihistamines such as Zyrtec during the time of the year when bites are difficult to avoid. This doesn’t totally prevent the reaction, but can help keep the swelling from being as extreme. I don’t recommend topical antihistamines (Benadryl cream) because some people develop a contact allergy that actually worsens the problem

So, when should you come to the doctor? 

Any child with significant eyelid swelling or swelling that is limiting activity or skin blistering deserves an office visit because they require further evaluation and sometimes even need oral steroids or more potent prescription topical steroids. Red/swollen/hot areas of skin that are associated with pain or fever should also be examined to rule out a bacterial infection.

Tick bites don’t usually cause itching like mosquitos, but are more of a concern due to infections they can transmit. Ticks are predicted to be more prevalent this summer due to the winter being relatively warm. Ticks can transmit several infections with Lyme being one that is often discussed.

If you find a tick on your child it should be removed with tweezers by grasping the tick as close to the skin as possible and pulling straight up. Different types of ticks spread different infections. For example, infected deer ticks can spread Lyme after being attached for 36 hours or longer. Certain areas of the country have a much higher rate of local tick infection than others. Texas is not a part of that area, but cases of Lyme do occur every year.

It is best if children bathe after coming in from playing outside to wash off ticks prior to attachment. It’s a good idea to look in hidden areas such as behind the ears and on the scalp. Remove ticks if you find them and watch for a rash. Certainly, a rash that looks like a bull’s eye or a target (erythema migrans) is concerning for Lyme infection and needs to be seen for further testing.

Insect bite avoidance is important (and hard)! The large local reactions are definitely very uncomfortable, but infections transmitted by mosquitos such as West Nile or Lyme from ticks are potentially very dangerous. Using DEET containing insect repellant and wearing long sleeves during peak mosquito times are helpful.

As always, see your pediatrician if you are worried about a bite or rash and we are happy to help.

Related:

• The deets on DEET from a pediatrician
• Protecting Your Child From Ticks

In the United States the Census takes place every 10 years. By now we hope you have heard that the Census is taking place this year. The goal of each census is to count each person in the US. Why does the census matter? This information helps determine how billions of dollars get spent on things like schools, roads, hospitals and community resources.

The Census has been well underway now since the beginning of this year. Around March of 2020 the US Census Bureau began sending US households instructions on ways to participate. It has never been easier to participate, the following methods to respond include:

• Online - via any mobile or computer device with internet access
• By mail (just drop off the completed census form in the nearest mailbox)
• By phone (quick and easy by answering several questions).

By August 10, 2020, the US Census Bureau estimates that 64.5% of Tarrant County households had already responded to the survey. This is great news! That response rate is better than the overall estimated rate for Texas of 58.3%. However we know we can do better than that. Although the Census Bureau is planning on visiting households that have not yet responded this has become a bit problematic due to the COVID-19 pandemic, which has led to an extension period. Self responses are still being accepted in the forms listed above will be accepted through September 30th, 2020.

North Texas is one of the fastest growing areas in the country. The growth of the our communities leads to more needs for programs and services for growing families and especially children. When completing your survey please remember to include ALL people that live in your home (including newborns to adults). It is estimated that in the last census (2010) almost 2 million children under the age of 5 were NOT counted. If we don’t count everyone, especially children between ages of 0-5 then the programs that provide services to these children may be reduced or eliminated as a result.

If you have not yet responded to the 2020 Census, please visit www.2020census.gov and compete the survey today. Remember it only takes a few moments and all the information is kept confidential. Let’s work together to makes sure all kids get counted, tell friends and family about how important it is to complete the census.

Making sure #EveryChildCounts in the 2020 Census!

And I thought we should end with a word from our friends at Sesame Street about the Census.

Being a pediatrician is a special job. You get involved in not only a child’s life, but become a part of the entire family. I was diagnosed with asthma at the age of 4, and this is the reason I became a pediatrician. My pediatrician growing up was so wonderful and caring of both myself and my parents, I wanted to be just like her, providing compassionate care to children.

Our delightful environment in North Texas tends to allow for year ‘round allergies, which can exacerbate asthma and wheezing.

So when should you take your child to the doctor to check their cough or wheezing?

The answer is, any time you are concerned and your normal medications aren’t enough. Some asthma is seasonal when allergens are worse in the air, some asthma is activity-induced, and your child will require an as-needed emergency inhaler called Albuterol. When Albuterol is needed more than once or twice a week for cough, wheezing, or difficulty breathing, it’s time to talk to your pediatrician about starting an inhaled steroid maintenance inhaler.

This is taken every day, and the inhaled steroid lessens the likelihood you’ll need to use the emergency inhaler. There is also a commonly prescribed chewable or swallowed pill called Singulair that is helpful in keeping allergies and asthma symptoms better controlled. When your child has worsening night time cough, trouble keeping up with peers during physical activity, or wheezing, it’s time to schedule an appointment with the pediatrician to discuss increasing or changing medications.

During an acute asthma exacerbation from whatever cause (viral illness, change in seasons, allergy flare, etc), the doctor will often prescribe a short course of oral steroids, around the clock albuterol nebulizer treatments or inhaler use, and perhaps a round of antibiotics if they are deemed necessary. It is critical to take all medications as prescribed. Just because your child feels “better”, doesn’t mean that it is time to stop daily asthma medications. They are better because the medications are working, and stopping any maintenance medicines can cause irreparable damage to their lungs. Let’s keep our children at their best by coming to the doctor at the first sign of respiratory distress, and quickly managing asthma and wheezing.

When is it asthma, and when is it something else?

It's hard to think about right now, but it only a couple of months we will see cooler weather and winter will be here before you know it. Winter season brings on LOTS of cold viruses, all 847 of them, and several can cause wheezing or trouble breathing, also known as reactive airway disease.

Especially known is the dreaded RSV, but other viruses can affect the lungs too, and require extra support from nebulizer treatments to even oxygen given in the hospital. Some children are highly susceptible to every common cold virus spiraling into a reactive airway disease/ asthma/ wheezing episode, and require a doctor visit every 1-2 weeks it can seem. So when it is just “asthma”, and when should the pediatrician and parent confirm it’s not something worse?

When something doesn’t feel right, come in and talk to your doctor. It may be nothing. It may be just another cold and cough virus. But maybe, and it’s a very small chance, but maybe it is something more. And you as the parent deserve to be listened to, to have your concerns validated and heard. And we as the Pediatrician, promise to do right by your child and not only treat in the moment, but plan for further investigation if necessary. Don’t ever feel awkward or hesitant coming in to the office to check the cough or snotty nose virus; I’d rather reassure you that it’s a simple virus and not something more.

Listen to your gut, and I’ll listen with my ears and my heart.

Over the past few months, most of us have thought of nothing more than the COVID-19 pandemic and everything that comes along with it: keeping your kids safe, keeping your kids entertained and keeping your kids from destroying your home.

And while we still need to focus on doing all we can to protect ourselves from the coronavirus, we need to make sure we continue to monitor other aspects of our children’s health.

If I haven’t seen you for a while, I look forward to welcoming you and your children back for a well-child visit. At Cook Children’s, we are taking many precautions to make sure you are safe when you walk into our office. You will notice our masks and eye protection. We’ve always taken extra steps to make sure we separate well-child and sick visits, spacing them out over the course of a day.

We are doing everything we can to make sure you will be safe and one of the main reasons we are doing this is because we believe that maintaining your child’s well-child schedule is important. Here are a few reasons why:

1. It’s important to not get behind on vaccines. Vaccines work and a schedule helps prevent many types of diseases, including measles, mumps, rubella, the flu … and more.
2. It’s important to monitor your child’s growth as this can be a key to a patient’s overall health. Children grow fast, especially when they are younger. We want to keep up with your child’s height, weight and head circumference – all important aspects of your child’s medical records. Their growth allows us to see how your child is progressing and to catch, and prevent, any issues early.
3. To evaluate the physical and emotional well-being of your child. Even before the pandemic, pediatricians were placing a greater emphasis on your child’s emotions and mental health. We now screen for things like depression and that’s wonderful. This is especially important with everything going on in the world with the pandemic and everything we’ve seen in the news lately. A child may be more inclined to talk to their pediatrician than with parents or even friends.
4. To identify any developmental concerns as early detection is important. Sometimes, we think of a well-child visit as just about keeping up with a child’s shot record, but it’s so much more. The visit allows pediatricians to see how your child’s functioning. We look at their communication, behavior and social skills. Plus, we evaluate their interaction with others, motor and sensory skills and adaptive abilities.
5. It helps to identify if there is a need to evaluate for certain conditions such as anemia, high cholesterol, diabetes, thyroid conditions, etc. I know that sentence can be scary for parents. But the important thing to remember is that the earlier a condition is diagnosed the quicker we can begin treatment.

And my final reason for the importance of asking you to schedule a well-child visit is a bit of a selfish one. I miss you and I look forward to seeing you and your child walk back into my office for the next well-child visit.

Sickle Cell Disease (SCD) causes an abnormal shape of the red blood cells. The red blood cells are shaped like crescents instead of circles. They don’t last long and they can get stuck in the blood vessels, which blocks the blood flow, often resulting in pain and organ damage.

SCD is a group of inherited red blood disorders affecting an important protein in the red blood cell. This protein is called hemoglobin. Hemoglobin helps the red blood cell to carry oxygen to all the different parts of the body. In sickle cell disease, the body produces one or more abnormal types of hemoglobin. This means that the ability of the red blood cell to carry oxygen to all parts of the body is changed. Sickle Cell Disease is a lifelong illness that can result in serious health problems.

There are different forms of Sickle cell disease which are named depending on whether a person inherits a sickle cell trait from each parent or if the person inherits sickle cell trait from one parent and a different abnormal hemoglobin trait from the other parent. Some common types of sickle cell disease include SS disease also known as Sickle Cell Anemia, Sickle Hemoglobin C disease, and Sickle Beta Thalassemia.

Sickle cell disease affects about 100,000 people nationwide. Among the many misconceptions of SCD, African Americans are not the only race affected by the disease. While the African American race makes up a reported 60 to 80 percent of Americans diagnosed, people of East Indian, Middle Eastern, Hispanic and Mediterranean descent may also be affected.

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

Donating bone marrow requires less than 5% of bone marrow cells and is typically taken from the hip of the donor or through a non-surgical procedure in which it is collected through an IV.

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

The Sickle Cell Program at Cook Children's Sickle Cell Center serves more than 400 children annually across northern Texas and adjoining states. The program offers testing, diagnosis and treatment for the many types of sickle cell disease. Research is also an important part of the program as the team seeks new ways to treat and prevent the many complications that can occur as a result of this disease. Click here to learn more.

Cook Children's Hematology and Oncology Center is actively involved in sickle cell disease research, including stem cell transplantation. The recognized team of researchers work with leading organizations across the U.S. and around the globe to find solutions to treating, preventing and curing the disease. As a research facility, Cook Children's also has a number of clinical trials available and we are able to match our patients to trials at other facilities. 

Other resources on this topic:

• Sickle Cell Disease
• Hematopietic Stem Cell Transplantation
• Clinical Trial Drug Reduces Pain Of Sickle Cell Patients
• Brotherly Love: Siblings Receive Bone Marros Transplant From Older Brothers
• 'She Takes It and Keeps On Moving.' Child Battles Four Major Diagnosis and Two Surgeries in 5 Years
• The Greatest Gift: Bone Marrow Donors Tell Their Stories
• 4 Reasons Why Pediatricians Recommend Public Cord Banking
• Warning Signs of Pediatric Stroke
• Living With Sickle Cell

COVID-19 has now been associated with a syndrome in children known as pediatric multi-system inflammatory syndrome. This condition is similar in nature to two pediatric conditions known as Kawasaki disease and Toxic Shock Syndrome.

While we still don’t know a lot about the COVID-19 related syndrome, let’s take a look at Kawasaki disease.

Kawasaki disease is a syndrome in children which is characterized by fever over 5 days with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye without drainage or mattering
• Swollen lymph nodes of the neck

In addition, children are commonly very irritable with Kawasaki disease. It is significant because the level of inflammation can affect multiple organs (most notably the heart) and lead to very severe illness.

While it’s still not a common condition, even with the newfound association with COVID-19, parents should be aware if their children display persistent fever with any of the associated symptoms.

The cause of Kawasaki disease is unknown. Some evidence suggests there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of Kawasaki disease involve the heart and can be inflammation of the lining or muscles of the heart, or dilation of the arteries that supply the heart.Toxic Shock Syndrome can present in the same way as Kawasaki Disease but the patient has low blood pressure and is significantly more ill.

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

The good news is that children with Kawasaki's disease and Toxic Shock Syndrome, usually return to normal and don't suffer complications.

For more on this topic:

• Kawasaki disease (cookchildrens.org)
• Pediatric multi-system inflammatory syndrome
• COVID-19 and Pediatric Multi-System Inflammatory Syndrome (AAP)
• Kawasaki disease
• Toxic Shock Syndrome
• My Child's Fever Isn't Going Away. Should I Be Worried?
• Chest Pain. Is It Your Child's Heart or Something Else?

Is breastfeeding worth the possible exposure to Covid-19?

Short answer: yes.

Unfortunately, the risk of COVID-19 is everywhere in our lives right now, but the reality is your baby needs another human to survive. So regardless of the way your baby gets their nutrition, having them completely secluded from the world, or attempting to limit their exposure to you, is not only impossible; it's also not a good option for optimal health and growth as well as bonding for your baby.

As always, the way you feed your baby is a personal decision, but it doesn’t change the fact that breastmilk provides protection against many illnesses and is the best source of nutrition for most infants, even and especially during this world health emergency.

What precautions should a well mother take?

• Practice skin to skin, especially immediately after birth during the establishment of breastfeeding.
• Maintain social distancing. In the UK, this time of lockdown and isolation has shown that without the constant stream of visitors, mothers and babies have had better opportunities for uninterrupted bonding, therefor mothers have a better supply, and babies have quicker weight gain.
• Wash your hands before feeding and frequently throughout the day.
• If pumping, limit the people who feed your baby bottles.
• Routinely clean and disinfect surfaces.

But what if you are diagnosed with Covid-19?

In limited studies on breastfeeding women with COVID-19 and other corona virus infections, the virus has not been detected in breast milk; however the bigger risk is likely transmission through respiratory droplets.

With precautions in place, WHO and the CDC both agree that the benefits of breastfeeding are outweighed by the risk.

If you are sick and choose to direct breastfeed:

• Wear a facemask and wash your hands before each feeding.
• Avoid touching your or the baby’s eyes, nose and mouth.
• Continue skin to skin.

If you are sick and choose to express breast milk:

• Express breast milk to establish and maintain milk supply.
• Use a dedicated breast pump.
• Wash hands before touching any pump or bottle parts and before expressing breast milk.
• Follow CDC guidelines for proper cleaning and disinfecting recommendations of pump parts.
• Consider having someone who is well feed the expressed breast milk to the infant, if possible.

Breastfeeding is a key preventative health step, especially during a pandemic.

Talk with your pediatrician about recourses that are available for help during this time. Cook Children’s Virtual Lactation services are available: Virtual Lactation Consultation.

Previously, I covered the bascis about infant reflux. If you missed that article, please click here. 

I have a few, more specific topics I promised I would go over in my previous post. 

Should We Try a Medication for My Baby’s Reflux?

This is a tough one for me to talk to parents about, because as a doctor, I really want to “fix” things for you.

I used to prescribe medications more frequently than I do now. This is because I have read recent large studies that make me worry about the future effects of these medications (see links below):

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528619/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137535/
• https://jamanetwork.com/journals/jamapediatrics/article-abstract/2676167

If we change the pH of the gut, what are we doing to the trillions of bacteria, the natural gut biome that lives inside?

Part of the job of this gut biome is to help our body learn “friend from foe,” and a large study recently found that children under 6 months who were put on medications like Prevacid, Nexium, and Zantac (there are many meds available) or any antibiotic were found to be more prone to food allergies and asthma later in life.

Is it worth the risk? In some cases, yes. Some babies are in pain daily. Some babies even lose weight because they are fighting meals to avoid the pain. If a baby is not in daily discomfort, however, I’ll often try to talk parents into trying other methods before medicating. And we talk often about weaning it off or stopping it after a few weeks.

What Is Cow Milk Protein Intolerance and How Does It Relate to Reflux?

Cow milk protein intolerance (CMPI, also known as cow milk protein allergy) happens when a child’s immune system reacts abnormally to proteins found in cow’s milk (either in formula or mom’s diet) and soy. It is NOT the same as lactose intolerance, and it leads to injury/inflammation of the stomach and intestines.

Symptoms of CMPI usually involve the GI tract, like vomiting, abdominal pain, blood in the stool, mucousy stool and diarrhea. Prolonged issues in infants could lead to wheezing, irritability and poor growth / failure to thrive and eczema. Frankly, these are sometimes my fussiest little patients, and they often cry more than most babies do.

CMPI and reflux come hand-in-hand in a lot of kids I see. I often find that eliminating dairy and soy in a mom’s diet will help the reflux as well. Sometimes, kids need to be on special hypoallergenic or amino acid formulas.

Do I Elevate My Baby At Night So They Won’t Spit Up?

I remember many a morning looking into my son’s bassinet and seeing him sleeping peacefully in a puddle of old vomit. The guilt would overwhelm me! And it happened a lot. It was hard not to want to do something different.

But no, we don’t want you to elevate your baby when they sleep. We want you to keep them flat on their backs because this is safest.

While it may seem like elevating the head off the crib makes sense, according to the American Academy of Pediatrics, “There is no evidence that healthy babies placed on their backs are more likely to have serious or fatal choking episodes than those placed on their stomachs. But there is strong evidence that babies placed on their stomachs are at higher risk for sudden infant death syndrome (SIDS).”

There is not a need to a wedge under the mattress, or elevate the head of the bed with blankets or pillows. Studies have actually shown this doesn’t actually help reflux symptoms, anyway.

I’m hopeful that the take-home point in this two part article about reflux is clear: reflux, to some extent, is a part of every baby’s life in the first year. And in MOST kids, it completely resolves by age 12 months. Talk with your pediatrician about how you can help your baby if some of the options we’ve talked about here don’t seem to help!

Hope this helps. Remember, if you still have questions about this topic to read my first article. 

Stay safe,

Dr. Diane

Having a new baby is usually a wonderful time during those first few days full of quite a bit of emotions – usually a mixture of elation shared with celebrations with friends and family, along with some tears mainly from fatigue and hormonal fluxes.

But during the past few weeks with all the ‘shelter-in-place’ recommendations, many new moms are reporting they feel a rise in anxiety level due to indefinite periods of social isolation, unavailability of family support and more importantly fear of their children acquiring COVID-19.

The entire time of welcoming a new baby has been transformed from a warm, celebration involving family and friends overflowing with hugs and kisses, to a time where only one support person is allowed, with extensive screening and smiles are covered with masks and hugs are replaced with a 6-foot-distanced wave.

Social isolation and lack of physical and emotional support has taken a toll on mothers physically as well and mentally, creating increased anxiety and stress. Not only are new moms tackling the hardest job in the world (being a new parent), but they are doing it during the arguable most stressful time in recent history…and on NO SLEEP!!

If you are a new mom and feel overwhelmed by some of these feelings, you have every right to feel that way! And you can cry a few tears! These are unprecedented times and your hormones are crazy and you have not slept and you are scared. Reach out and call your friend, your sister, your mother or your pastor and ask for help or simply let them know how you feel. Tell your partner you need help or a nap or a drive around the block. Call your obstetrician or pediatrician and let her know you are feeling anxious. Counselors and physicians are providing telemedicine now and are able to screen for post-partum depression and anxiety if these feelings are more than you can handle at home. Here's a good resource to find therapists who may offer teletherapy during these times. 

Prioritizing Self-Care

Every time we fly, we hear the flight attendant share the Oxygen Mask Rule: “Should the cabin lose pressure, oxygen masks will drop from the overhead area. Please place the mask over your own mouth and nose before assisting others.” We know that without our oxygen mask, we will quickly lose consciousness. If we don’t make putting on our mask our first priority, we will likely not be able to help anyone. That is why as pediatricians, we address the health and well-being of our moms in order to ensure that our babies are being taken care of as well.

As a new mom prepares the nest for her baby, remember the “NEST-S principles of Self-Care” : Nutrition, Exercise, Sleep, Time for Self, and Supports! When barriers to nutrition have been placed such as a simple trip to the store, remember to ask those grandparents who want to help to place an order for a grocery or meal delivery. A walk around the house, patio or up and down the driveway can boost the mood, and the Vitamin D! Sleep is a rare commodity, so when that baby sleeps, remember to grab a nap! Take this time of isolation to read a positive quote about what a great mom you are! And investigate some innovative supports for new moms.

New resources have been developed knowing that our moms face special challenges during these times. These include the Postpartum Support International at www.postpartum.net/ , supports groups and information at www.postpartumdepression.org , virtual support groups like www.thebloomfoundation.org/mom-support-group/ and the Mom Center at https://graemeseabrook.kartra.com/page/the-mom-center .

The main point to remember is that even during this period of isolation you are not alone. Reach out and let someone know you need a boost. Know that this will end soon, and you can celebrate your baby with those you love!

Here, I’m going to address infant reflux only – for babies under 12 months of age. Kids older than this can certainly experience reflux, but I’d like to keep this specific to this age group.

I’ve literally printed your questions out, and will use them as my guide!

WHAT IS REFLUX?

Reflux is when the contents of the stomach (milk, food, stomach juices) goes up into the esophagus. Sometimes, it just stays in the esophagus and goes back down. Sometimes it comes all the way up and out the mouth (or nose).

HOW MANY BABIES HAVE REFLUX?

The books say “more than half.”

I say: All of them. All babies. 100%. I watch all babies reflux in my office daily. It’s often subtle. A little dribble of milk out the side of the mouth, hiccups, gulping. Studies show that healthy infants experience reflux “30 or more times daily.” It tends to get started around week 3-4 of life, peaks around 2-4 months, and in most kids resolves by 12-18 months.

WHAT CAUSES REFLUX?

The valve where the esophagus meets the stomach is pretty loose in infants. So stomach contents can easily come up and down. Combine that with the fact that they are laying down a lot, drinking nothing but fluids, sometimes swallow excess air during nursing or bottle-taking, and have lower muscle tone in their bodies and it’s a perfect recipe for spit-up.

WHAT ARE SIGNS OF REFLUX?

Well, spitting up is the most obvious sign. Some healthy normal kids spit up once a day. Some spit up numerous times after each meal (I had one of each – “normal” babies can be very different and there is a wide range of barfing!).

Sometimes it happens right after eating, and sometimes hours later. Sometimes it’s just a dribble out the side of the mouth, and sometimes you’re covered in puke. Sometimes it’s clear. Sometimes it’s chunky. Sometimes it’s straight up milk. Sometimes it’s acidic. Sometimes it’s not.

Other signs of reflux:

• Hiccups
• An acidic smell here and there
• Coughing, especially when laying down
• Congestion/snoring, especially after laying down
• Arching the back
• Fussing during feeds
• Gagging out of nowhere
• Gulping sounds

WHAT SHOULD I DO ABOUT MY BABY’S REFLUX?

Well, that depends on the kiddo. For the vast majority of babies, you don’t have to do anything different. It’s a laundry problem more than a medical problem! Most babies are what we call “happy spitters” – lots of spitting up, lots of mess – but growing well, happy, and thriving. Thankfully, most kids are in this category and you may just need to try:

• Frequent burping
• Being held upright for 15-30 minutes after feeds.
• A change of formula
• A change of bottle type or nipple flow
• Thickening of formula or breastmilk if other options don’t help (ask your pediatrician before you do this and we will walk you through it)

IT ALWAYS SEEMS LIKE SO MUCH MILK COMES UP! HOW IS MY BABY STILL GROWING?

Most of the time, it’s less milk than you think. I always tell parents, “A stain on your shirt the size of a dinner plate is one ounce.” That’s pretty impressive, right? Talk to your pediatrician about whether s/he believes your child is gaining weight adequately at checkups to assure your baby is keeping enough in.

WHEN SHOULD I WORRY?

I worry if an infant is not gaining weight. I worry if the reflux causes consistent and constant refusal to feed, or disruption of feeds. I worry if an infant seems to be in pain MOST days (all babies have a bad day here and there). I also worry if:

• The vomit looks dark green
• The child’s vomiting is getting more consistently large and forceful
• The baby has fever
• The baby develops pneumonia (VERY rarely reflux can cause lung issues like wheezing and pneumonias)
• There's blood in the stools, or very stringy mucus-y stools.
• The child cries most of the day
• The baby isn’t urinating at least every 6-8 hours

If any of these things are going on, please contact your pediatrician!

Sometimes, it takes more than just those simple methods above to help your child with reflux. It may take a medication or a change in a breastfeeding mom’s diet to improve symptoms. We also need to talk about safe sleep for a child with reflux.

All of this is addressed in Part 2!

There is currently no vaccine available for COVID-19. Studies are currently underway, but they are in the very early stages and there is no clear timeline for when it will be available.

Treatment for COVID-19 in children is mostly supportive. Making sure that they are drinking well and not having trouble breathing are the two major things you can do to help your child. Novel treatments such as antivirals and other medications are being studied, but it is not clear when those will be available for treatment-especially in children.

One of the first things I like to know when ascertaining the seriousness of a child’s condition is whether the child is playing, smiling eating or drinking. If a complaint is brought up regularly, interferes with play or a child really cries, parents should consult a physician.

High Fever

New parents might find the recommendations for when to seek treatment for a fever daunting, but it gets easier with time.

For infants 3 months and younger, any fever is serious and parents should see a physician’s help immediately.

For children older than 3 months, a high fever combined with symptoms such as lethargy, changes in fluid and/or difficulty breathing require prompt medical attention.

Children who are 3 months or older with fevers of 102 degrees Fahrenheit or higher that don’t respond to fever-reducing medicine should see a doctor.

Fevers up to 101 can often by managed with fever-reducing medicine, fluids and rest. However, if your child also has a harsh cough – which may indicate croup – you need to consult a doctor.

Stomach Hurts

If your child has a stomachache, there are three red flags that may warn parents of a serious illness such as appendicitis:

1. Your child has a tummy ache and a fever.
2. Your child can point with one finger to where it hurts.
3. Your child has been vomiting.

Children don’t need to have all three symptoms for parents to seek help because any one of these symptoms can indicate that appendicitis might be a possible diagnosis. Parents should also not wait too long. If symptoms worsen in six to eight hours, consult a doctor.

My Head Hurts

Headaches and even migraines can occur in children as young as 3 years of age. Parents can give their child a nonsteroidal anti-inflammatory medicine, such as ibuprofen, or eliminate headache pain caused by hunger, fatigue or dehydration with food, rest or fluids.

Talk to your pediatrician about his or her treatment recommendations, particularly if you’ve never treated your child’s headache before.

If headaches occur at the same time each day, parents should consult their pediatrician. Headaches can occur with the flu or fever, but we become concerned if a headache is serious enough to make a child cry, interferes with play or is so bad the child is vomiting.

Related Topics:

• Let's Learn About Fevers
• Is It Strep Throat or the Flu?
• Let's Learn About the Flu
• Probiotics for Tummy Bugs: Do They Help Your Chlid?
• My Child Poops Every Day. How Can They Be Constipated?
• Is Over-The-Counter Medication Causing Your Child's Headaches?
• When It Comes To Your Kids, It's Never Just a Virus

Antibiotics have been one of the most amazing advances in medicine, preventing countless deaths and relieving suffering for conditions that historically had no treatment.

While antibiotics are critically necessary in particular infections, doctors must evaluate their necessity on a case by case basis. Bacterial infections often require antibiotics, but some infections (such as ear infections) that were once thought to require them, may be able to resolve on their own. Viral infections do not respond to antibiotics and thus should not be treated with them.

Two studies released in the past few months suggest that the use of antibiotics in infancy likely increases the risk of allergic disease in childhood. The research found the use of a particular type of antibiotic during the first trimester of pregnancy  (macrolides such as azithromycin), increases the risk of congenital anomalies.

Each year, thousands of kids flood the Cook Children's Emergency Department with bronchiolitis. Bronchiolitis is one of the most common illnesses pediatricians see. Lots of viruses can cause bronchiolitis, but the most well known is RSV.  In the past, doctors have tried breathing treatments like albuterol, steroid medicine, cough and cold medicine, and even sometimes antibiotics. We now know that these things don’t help and can make things worse.

"Antibiotics treat bacterial infections, not viruses like bronchiolitis. Giving your child antibiotics when they aren’t needed may cause diarrhea, and over time can cause bacteria to become resistant to antibiotics," Stacey VanVliet, M.D., wrote in her about post about this topic.

Even with more and more information warning against overuse of antibiotics, I hear from parents all the time wondering why I didn't prescribe them to their child.

So when should you give your child an antibiotic? Let's take a look.

What common bacterial conditions require antibiotics? The list is surprisingly short:

• Strep throat
• Whooping cough
• Urinary tract infection

The conditions require antibiotics, either for treating the infection or treating potential complications that can arise when they are not treated (or both). If you suspect your child has one of these conditions, it is important to have them evaluated.

Some common conditions for which antibiotics are often prescribed but could resolve on their own:

• Ear infections
• Sinus infections
• Bronchitis

For certain ear infections, antibiotics can be avoided. It is essential to talk with your doctor about your desire for this if you are interested. Many children with ear infections will get better without antibiotic treatment. Similarly, sinus infections can be both viral and bacterial. Talk with your doctor about whether treatment with antibiotics is necessary.

Bronchitis in kids is almost always a viral infection. It can be treated by treating the symptoms and allowing the passage of time.

There are some standard conditions for which treatment with antibiotics is not indicated. These infections are caused by viruses such as:

• Common cold
• Viral sore throat

Being cautious with antibiotic use is important for preventing unnecessary complications and side effects for you and your children. If you’re not sure, ask your doctor. The CDC provides a helpul guide on when antibiotics are necessary. Here's a quick version for you:

If you want to learn more about these or any other conditions, Cook Children's offers a great service "Ask a Librarian." Click here to learn more, but a Cook Children's librarian can send you information that is up to date and most importantly from reliable sources.

We've also written a ton on this topic for the newsroom:

• Does My Child Really Need An Antibiotic?
• What Is Cook Children's Doing About the 'Antibiotic Crisis'?
• Too many antibiotics not helpful, could cause harm
• 3 Myths About Antibiotic Use Every Parent Should Know
• Probiotics for Tummy Bugs: Do they Help Your Child?
• Is It Strep Throat or the Flu?
• Is It Croup or Whoop?
• Let's Learn About Whooping Cough?
• When It Comes to Your Kid's It's Never Just a Virus

There are certain posts that we write that are guaranteed to cause a reaction…vaccines, raw milk and essential oils are some of the ones that have really brought on the comments. The usual comments don’t surprise me…from “you don’t know what you’re talking about” to “but ____________ really worked for me and my family.”

But, I try to not to worry too much and I try to do my research to present to you the best possible information available, ignoring whatever the response might or might not be.

I suspect the topic of MTHFR gene mutations will soon be added to my list of topics that bring on controversy because a consistent response to the other hot topics is…“But, what about people with MTHFR gene mutations?”

So, you might call MTHFR mutations the controversial topic of the controversial topics…the uber-controversy…or meta-controversy.

What is the MTHFR enzyme?

MTHFR (or 5,10-methylenetetrahydrofolate reductase for long) is an enzyme that, according to the American College of Medical Genetics and Genomics practice guideline on the topic, “catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-5-methyltetrahydrofolate, the primary circulatory form of folate, and a cosubstrate for homocysteine remethylation to methionine.” Easy, right?

MTHFR is an enzyme. An enzyme is a substance that speeds up chemical reactions. Enzymes help almost every chemical reaction in our body. The efficiency of an enzyme can be sped up or slowed down by many different factors. MTHFR matters because the last product in its pathway, methionine, is converted to another product that can donate something called methyl groups. Methyl groups can be donated to many different parts of the cell and play an important role in the function of DNA and proteins.

What happens if MTHFR doesn’t work?

In instances when mutations in MTHFR cause the enzyme activity to be severely impaired, it can lead to elevated level of an amino acid (the building blocks of protein) called homocysteine. Buildup of this amino acid may increase the risk of blood clotting and heart disease.

Recent studies have cast doubt on this association and have shown that treating the elevated levels of homocysteine may not decrease the incidence of heart attacks but we know that homocysteine does activate blood vessels and make them more likely to form clots. Mutations that do not affect homocysteine level have not been proven to cause disease. Many variations exist at the gene level which do not appear to affect the activity of the enzyme. Without further confirmation that these cause problems, they should probably be thought of as normal variations (like eye color).

Studies have attempted to link mutations in MTHFR to over 600 different medical conditions. There have been 1000s of publications and no doubt more that went unpublished. Yet, only one condition has been definitely shown to be an increased risk in children with MTHFR mutations: women with a variant known as C677T have a slightly increased risk of delivering a child with a neural tube defect (like spina bifida).

Individual studies have shown other associations but, for each condition, there are conflicting studies that argue against MTHFR being a cause.

At this point, the American College of Medical Genetics and Genomics does not recommend routine testing of MTHFR for patients with blood clots, for women with recurrent pregnancy loss or for any other condition.

So, what’s all the buzz about?

There are a handful of doctors and naturopathic providers out there recommending MTHFR genetic testing for just about any condition under the sun. They generally recommend testing and then having the genome analyzed by a second company (often this second company is run by or provides financial kickbacks to the referring provider). After this, the treatment plans often involve supplements and other therapies. These treatments can be very expensive.

The providers of these services often tout their extensive research. The research may include some of the scientific studies that have suggested a link between MTHFR and the condition at hand, but they often ignore the other published evidence (often of stronger quality) that fail to show the same link. Other research published on their websites show collections of anecdotal stories, even down to the level of collections of blog posts, which report improvement in symptoms after having completed MTHFR testing and diet or supplement modification.

What are others saying?

As I mentioned before, the American College of Medical Genetics and Genomics practice guideline does not recommend MTHFR testing for evaluation of increased blood clotting, recurrent pregnancy loss or at-risk family members despite the fact that these are the most plausible diseases which would be caused by MTHFR mutations. No other medical societies have endorsed MTHFR mutation testing.

I think the most telling evidence comes from this post and summary of the topic from the 23andMeBlog. 23 and Me is a company that offers the genome sequencing (for $149) which is necessary for starting the workup for MTHFR mutations. So, they have 149 reasons for you to want to investigate your MTHFR status. But, what is their summary?

“Based on the existing data, scientists at 23andMe have concluded that people should not interpret their genotypes at the common MTHFR variants as having an effect on their health. In order for a connection between a genetic variant and a health condition to be considered real and clinically meaningful, well-run scientific studies need to show convincing and consistent evidence for that association.”

So, if no diseases have been definitively proven to be caused by MTHFR mutations, no major medical society endorses MTHFR evaluations and the company that can sell you the evaluation says it’s not worth it…maybe we should really think twice before going down this pathway except in very specific cases.

Your questions:

Does having a mutation on the gene for MTHFR absolutely mean that you will have problems because of it?

Unfortunately, it’s not that straightforward. Variations on the gene are very common. I have seen figures up to 40-60% to have some type of change. But, those changes do not necessarily mean that a person will have increased risk of disease because of them. Many of these changes could be (and probably are) normal variants. Based on our current knowledge, if levels of homocysteine are normal, it does not appear that the mutations are clinically significant.

Think about something like eye color. Around 55% of the population have brown eyes, but that doesn’t mean that everyone else will have poor vision. How do we test for vision? With a vision test, not by checking the genes for eye color.

How do you check for MTHFR function? With homocysteine levels. It is possible that there might be other and better ways of testing for MTHFR function to be discovered, but I cannot find studies or recommendations for how to do so at this time.

Should vaccines be delayed or deferred in children with MTHFR mutations?

I can only find one study that looks at the relationship between vaccine side effects and MTHFR mutations. This study was looking at side effects of giving small pox vaccination in a population of ~125 patients. Those that had MTHFR mutations did show an increase in adverse events. The adverse events listed were both local (larger mark at the site) and systemic (fever, rashes and lymph node swelling). They did not report any further or long-term side effects.

I saw one of the major writers about MTHFR talk about how the mercury in vaccines combined with a patient with MTHFR mutations might have problem processing the mercury. The problem with that specific theory is that mercury is no longer included in vaccines except for multi-dose flu vaccines vials. For discussion of other heavy metals, see the question on the topic later.

I think it is very possible that, over time, we will discover that children may have differing responses to vaccines based on their genetics. The differences may be in side effects or effectiveness of the vaccines and will likely only affect an extremely small percentage of children. The problem is that we currently don’t have any information to inform those decisions. Further research is necessary and anyone who claims to know the secret link should have their claims evaluated with extreme caution. In addition, because differences in MTHFR genes are so common, it is hard to imagine that it will play a significant role in vaccine reactions. If they were, I would expect reactions to be much more common than they are.

Is there an association between MTHFR and autism?

There has been a few studies that have shown a connection between a slight increase in autism risk and a particular change known as C677T. A large study that combined the results of multiple studies (our favorite kind of study, known as a meta-analysis) showing something very interesting: “C677T polymorphism was found to be associated with ASD only in children from countries without food fortification.” The association between this mutation and autism disappears in countries where foods are fortified with folic acid.

There are no other significant studies that show a link between MTHFR and autism symptoms. While many of the MTHFR experts claim that high percentages of kids with autism have MTHFR mutations/variations, so do people without autistic traits. Proving it as anything more than coincidence would require that the number of mutations be higher in children with autism than neurotypical children.

Is there an association between MTHFR and processing toxins or metals?

This question is difficult to answer because the definition of what is a toxin is very hard to pin down. Pretty much anything we come into contact with can be a toxin if the exposure level is high enough. Almost every substance in nature is harmless if we aren’t exposed to too much. So, the ability to process toxins is vague and would be hard to define or study.

The discussion of metals is a little bit different. One of the most studied metals in association with MTHFR mutations is lead. One study suggested that moms who have mutations in the MTHFR may make their child more susceptible to developmental problems if they are exposed to significant amounts of lead before age 2. Other metals have not been studied as well although you could theoretically see how similar results might be obtained.

Can people with MTHFR mutations have trouble when they are given acetaminophen or other medications?

Acetaminophen causes depletion of glutathione which is an antioxidant that prevents protects damage to many parts of our cells. This has been implicated to cause a role in several different diseases-most commonly asthma and making asthma worse. Other studies have linked acetaminophen use to other problems, including use during pregnancy also causing autism. MTHFR mutations work on a related pathway and thus, people with decreased functionality of the enzyme could be at increased risk for these effects.

While firm treatment recommendations have not been changed as a results of these studies, I think it is prudent to decrease the use of and reliance on medications for most symptoms where possible. Some of the common scenarios where I see overuse of acetaminophen are: teething (kids don’t having teething symptoms for weeks), “low-grade” fevers and routine/scheduled acetaminophen after vaccines. I would be happy if my patients (MTHFR or not), never received treatment for these symptoms.

The most likely scenario where MTHFR mutations do have effects on the use of medications is in those conditions where treatment with parts of the same pathway are involved. Chemotherapeutic agents used for cancer and auto-immune disease (rheumatoid arthritis for example) often work on parts of the same pathway. We should use caution and continue to study the effect of MTHFR mutations in patients who need to receive these types of medications.

Is there a relationship between MTHFR mutations and tongue ties, stork bites, sacral dimples or other physical findings?

Yes, I’ve seen the graphic. But, is there a relationship between MTHFR mutations and tongue ties, stork bites, sacral dimples or other midline defects?

Stork bites are a common red mark found on the back of the neck. Sugar bugs are a prominent blue vein found on the nose. They have been a concern in Chinese medicine for ages and supposedly indicate a tendency towards a sensitivity to sugar. Tongue-ties are also fairly common and most are also normal variants. Sacral dimples are also a common finding. They are little bumps at the base of the spine, usually just above or in-between the crack of the bottom. They can be the mildest form of spina bifida. While most are not concerning, the doctor should look for the base of the dimple as well as the size and then be on the lookout for symptoms that could be signs of spina bifida.

I have searched the literature for any connected between these findings and MTHFR mutations. No studies exist. Because studies that fail to show a positive correlation are not often published, it is difficult to know if they have not been done or if they have been done, failed to show a correlation and thus were not submitted for publication.

What’s next for MTHFR mutations?

More research! We need to have more high quality studies performed before we can definitely say what the various mutations mean.

As with most findings from whole genome studies, because they only recently became available and cheap, we still need to learn what the various mutations mean. Only when we know what they mean can we reliably recommend treatment recommendations that make sense. Until then, recommendations will be based on theory alone and may or may not prove to be worthwhile. In fact, it’s often theoretical treatments that can end up being harmful.

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 am reminded of a very festive party I had for my kid a year or two ago. I served cupcakes with blue frosting. What followed was a week of worried messages from friends. “Something’s wrong with his poop”. “I don’t know if he ate anything different recently, it’s so bright green!” Ha. I brought that one on myself.

So what colors of poop make a pediatrician worry? Well, mostly – black, white and red. I’ll explain. Let’s dive into the different colors. So to speak. 

GREEN – super common with food dyes that are green and blue (like…. blue cupcakes). Also very common when breastfeeding infants drink a lot of foremilk (rather than a mix of foremilk and hindmilk), or kids drink formula. Taking antibiotics. Eating grass. Eating a lot of dark leafy green veggies like kale and spinach. Having a tummy bug (gastroenteritis, which causes vomiting and diarrhea sometimes).

BLUE – mostly food dyes. Blueberries.

ANY SHADE OF BROWN – Normal. Yes, tan is okay. Light brown. Greenish brown. All fine.

RED – Sometimes cause for concern. Could mean bleeding in the lower half of the intestinal tract. Could be Cow Milk Protein Intolerance. However, I’ve seen red stools with certain foods like beets and cranberries, too. The antibiotic Cefdinir (and other meds) can make stools red or orange. Your doctor can test a red stool to see if it’s actually blood or something different.

ORANGE – usually normal with foods like carrots and sweet potatoes. Medications like Cefdinir can cause orange stools too.

BLACK – Sometimes worrisome, sometimes not. Newborn babies have dark black tarry stools at birth and for a few days following. Pepto Bismol, licorice, and iron supplements can cause black stools. Can be due to blood from higher part of intestinal tract. If persistent and your kiddo isn’t taking meds, would see your doc.

YELLOW – totally normal in breastfed babies. Can sometimes happen with diarrheal illnesses in kids.

WHITE/PALE – I think this is okay if it’s an isolated 1 day event. I see it sometimes with diarrhea illnesses. However if it persists past 1 or 2 poops, time to talk to your doctor about possible liver disease.

This list is in reference to kids only. Adults have different-colored poops for similar, but not always the same, reasons.

Call your doc if you feel like your kiddo’s stools are any of the concerning colors above.

Know your babies' limits and plan ahead when making a trip outside so you can keep them well this winter.

Bundle Up

Before infants head outdoors, make sure they are wearing fresh diapers and are insulated against the cold and wet. 

"A good rule of thumb is to dress newborns in as many layers as you're wearing," said Diane Arnaout, M.D., FAAP, a Cook Children's pediatrician in Willow Park. "That includes covering their heads, hands and feet. Those areas can lose a lot of heat and be harder to keep warm."

As a mom of young children, Dr. Arnaout has first-hand experience in facing area winters with a newborn. She recomends using socks to keep tiny hands and feet warm, knit hats for infant heads and sunglasses to keep the bright winter sun out of little eyes.

Pay Attention

It's important to regularly check on newborns while you're together outdoors. Babies tend to fuss when they're uncomfortable, so if they are crying or restless while you're out and about, it may be time to move outside. 

To see if infants are getting too cold, check their ears, nose, hands and feet regularly. If your own nose or ears are cold or your lips and becoming chapped, odds and it's too cold outside for babies.

Blue skin, shivering and a cool chest and stomach are signs that children may be dangerously cold. If you see these signs, take action immediately to get kids out the cold. Seek immediate medical attention if you're not able to warm the body.

About the source

Dr. Diane Arnaout joined the Cook Children's Willow Park practice in 2011. Dr. Arnaout was born and raised in the Dallas-Fort Worth area. She served as a leader on the medical education committees during her internship and residency in pediatrics at the University of Texas Health Science Center in the Texas Medical Center at Houston, Texas.

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

We received this question recently. Let's discuss.

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

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

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

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

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

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

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

Doc Smitty

But choosing the best place to go for your child's care  can be a difficult one for some parents. After all, Cook Children's offers several options within its system, ranging from primary care, urgent care, the neighborhood clinics and the emergency department.

So how do you know where to go? To begin with, visit the handy infographic to the right or click here.

"Every patient who comes into our Emergency Department is important to us. However, some patients may be able to receive the care they need from their primary care physician, a neighborhood clinic or an urgent care center," said Corwin Warmink, M.D., medical director of Cook Children's Emergency Department. "The best thing a parent can do is know what constitutes an emergency, so they know where to go when that time comes."

When it comes to choosing where to go, Kara Starnes, D.O. medical director of Urgent Care at Cook Children's, advises parents to think about the severity of the issue.

For instance, your child's Cook Children's pediatrician can see a number of ailments, including allergies, the flu, migraines, pink eye, sprains and vomiting.

During times when your pediatrician's office is not available, the Urgent Care Centers at Cook Children's can handle the same ailments, along with most fractures (broken bones) and cuts. Fractures with severe deformities or open fractures should not come to the Urgent Care but instead should go to the Emergency Department (ED). The ED has more equipment to handle the most severe cases, and the child can be admitted quickly to the medical center for continuing care.

If your child has multiple injuries, neck injuries or head injuries with loss of consciousness and/or vomiting, they should go to the ER. These kids typically need the ER because the UCC is not as equipped in imaging and other sophisticated tests available at the medical center.

"Possible surgery, such as appendicitis, is tough for parents to determine because most of the time, abdominal pain is caused by something simple like constipation," Dr. Starnes said. "But severe abdominal pain, testicular pain or swelling, bleeding when vomiting or severe bleeding with bowel movements are reasons to go to the ER."

You should visit the ED with your child in case of a medical problem that could cause death or permanent injury if not treated right away.

Daniel Guzman, M.D., a Cook Children's Emergency Department physician, adds “when in doubt of the severity, always visit the higher level of care such as the Emergency Department” and if immediate attention is required call 911.

And of course, we are right in the middle of flu season. Last week (Jan. 5 to Jan. 11, 2020), 837 kids were tested for the flu. Of those kids, 141 tested positive for Influenza A, 187 for Influenza B and another 102 for RSV. 

For those kids, Cook Children’s has a variety of options for care including the primary care offices, neighborhood clinics and urgent care locations.

“If your child is over 3 months old and has a fever, even a high one, it’s OK to see your pediatrician as long as they are breathing comfortably and drinking well,” said Diane Arnaout, M.D., a pediatrician at Cook Children’s Forest Park. “If your child has mild wheezing, we can give breathing treatments in the primary care offices. If you’re not sure whether your child’s issue is an emergency, our nurses can talk to you over the phone about symptoms and help you decide between the ER, urgent care and a primary care visit.”

Texas flu activity continues to rise and is at an above-average level, per the week’s DSHS flu report.

At Cook Children’s Medical Center, the lab tested 529 children for the flu during the week of Nov. 10-16, 2019. A total of 74 kids tested positive for the flu (63 with Influenza B and 11 with Influenza A) and 152 more were confirmed to have RSV.

“For more than 50 years, hundreds of millions of Americans have safely received season flu shots,” the agency wrote in its tweet.

“The flu vaccine is still the best form of protection we have to fight off getting sick,” said Justin Smith, M.D., a pediatrician at Cook Children’s in Trophy Club. “The vaccine is especially important for children aged 6 months to 5 years. They are at the highest risk for serious flu-related complications, including death. Even if you do get the flu, people who are vaccinated generally get a milder and less dangerous form of the illness.”

Two types of flu vaccine are available for the 2019-2020 flu season. Both protect against four types of influenza viruses: Influenza A (H1N1), Influenza A (H3N2) and two influenza B viruses.

You may remember the spray shot wasn’t previously available for children because it didn’t work as well. The newer versions appear to work as well as the shot. So either vaccine can be given this year, depending on the child’s age and general health.

The nasal spray is approved for use in people 2 years through 49 years of age. People who are pregnant or have certain medical conditions (such as asthma) should not receive the nasal spray influenza vaccine.

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

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

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

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

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

For now, here’s what we do know:

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

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

You grab your phone and type in a few keywords and are immediately overwhelmed with the wealth of information on the internet.

So, how do you know where to look and, more importantly in this age of "fake news," what's accurate?

"It's so important for today's physicians to make sure they use digital platforms to reach parents and provide helpful and accurate information," said Justin Smith, M.D., medical director of digital health and a pediatrician at Cook Children's. "Parents are so busy these days, and sometimes it's difficult to make sure what you are reading online is accurate. Trusting internet sources for you or your child's health without verifying their accuracy can be dangerous.

The problem for most of us is distinguishing trusted sources of information from misleading or altogether "fake" health news.

"Type 'RSV' into a search engine, and you'll come up with millions of hits," said Barbara Steffensen, MSLIS, family librarian at Cook Children's. "You have to figure out which results are authoritative, which are commercial and which would apply to children rather than adults. Filtering all of those options can be a complex task for parents who want reliable information quickly."

A few tips can help you simplify your search and find information that you can trust.

Consider the source

A website's domain name can tell you a lot about its credibility. Nonprofit, nongovernmental research, advocacy, education and health professional organizations are generally excellent resources that tend to have ".org" endings.

The sites with ".gov" means you are visiting a United States government site. Colleges and universities also can be excellent sources; identify their websites by looking for ".edu." at the end.

So what about checkupnewsroom.com, the site you are reading this on right now? We are an online newsroom run by Cook Children's Medical Center in Fort Worth, Texas. We publish a story almost daily, but not until it goes through an approval process. The articles on this site are either written by or approved by the sources of the story before published. The same is true when you visit the Cook Children's website, cookchildrens.org.

Otherwise, domain names ending in ".com" or ".net" can be tricky. Online encyclopedias and for-profit websites are acceptable to use for the most basic information and a place to start your search, such as finding the definition of a disease but shouldn't be consulted for much else.

Dig deep

A well-designed website can mask flawed information. Before you dive into the material, read the site's "About Us" tab or an equivalent to learn about the organization behind the digital portal. Be careful. These sites may have a hidden agenda.

"Recently, I was searching for information online about a health topic," Steffensen said. "I found a page that looked promising, but when I checked into it, I found a law firm produced it."

Look for red flags

If you open a website and find it difficult to see past the explosion of advertisements, it's time to hit the "back" button.

"Lots of ads are a sure sign that a website isn't a good resource," Steffensen said. "If the site has ads all over the place, endorsements from pharmaceutical companies or solicitations for donations, searchers should be concerned, even if the material looks credible."

Read the fine print

Comb articles you can find online for easy-to-miss details that are essential clues to reliability. Is the author a medical professional? When did he or she write the essay? Was the piece reviewed by such an individual, and how recently?

Many families want to know as much as they can about their child's health and wellness, and becoming more health literate is great. What would be better still is for parents and caregivers to have peace of mind in knowing the information they gather is trustworthy.

Read what the National Library of Medicine suggests about web surfing and search wisely.

For more information

Need accurate health information that you can trust? Visit Cook Children's Education Resources page. Do you have questions about an illness or condition? About how to keep your child healthy and safe? Let us help. Click here to learn about the Matustik Family Health Library, located inside Cook Children's Medical Center.

Cook Children's approved health resources for you:

• Health Education and Resources
• Ask a Librarian Health Information
• Procedure Information
• Condition Information
• Medication Information
• Parent Center
• Teen Center
• Kid Center
• Community Education Events

"Heavy metals in baby foods leading to lower IQs"

You might have seen these headlines in the past few weeks as a result of the report, "What's in my baby's food?" from the Healthy Babies, Bright Futures initiative.

The report looked at a variety of foods for four different heavy metals: arsenic, lead, cadmium, and mercury. Each of these heavy metals can be linked to developmental delays and loss of IQ points over time.

But, the tricky part is that these metals are present in many different substances, foods, even the dirt that your child eats on the playground. So, it's not just the fact that the metals are there but how much and how often they are ingested that matter.

And despite what you read in the headlines, it's not possible to avoid these exposures by switching to organic or by changing to baby-led weaning or homemade purees. Because these heavy metals are present in our soil, they are taken up by plants as they grow. Even the report goes on to say, "Organic standards do not address these contaminants, and foods beyond the baby food aisle are equally affected." So, moving away from jarred baby food doesn't eliminate the risk of your baby having exposure.

While we'd love to eliminate any risk and should continue to do so, is there a real risk to your baby?

The report spends significant time discussing lead exposure and it's a risk to babies. Interestingly, many pediatric offices (including mine) run a screening lead level at age 1 and 2 but we do not see a significant number of children who test at a detectable level and even fewer who fall above the level of 5 at which a child is considered at risk for problems. We do not routinely screen for the levels of the other chemicals but, likely, those would not be present in a significant number of babies either.

The headlines and articles have spent significant time discussing the 11 million IQ points that have been lost due to exposure of heavy metals, but what does that mean to YOUR baby. Probably not much. First of all, those lost IQ points are based on the known IQ loss from excessive exposure and many other assumptions to calculate the total loss. And, while it's not clear from the reports, the assumption is those IQ points were a cumulative loss over all children from 0-24 months which when averaged out over all those children work out to a fraction of a point per child which would mean nothing to an individual baby.

So, what should we do?

Of course, the baby food and agricultural industry should continue to work to provide a sustainable source of healthy nutrition for all of us (including our babies). Subtle changes, like searching for soils that have less heavy metal exposure for root vegetables (like carrots and sweet potatoes which absorb more heavy metals from the soil) might be beneficial. The food processing industry should continue to make as many gains as possible in decreasing the steps that might lead to an increase in heavy metals in our foods.

Here are some tips for parents that you can make to minimize your child's exposure:

1. Remember that switching to organic or providing homemade purees will not reduce risk. So, if you wouldn't otherwise, there's no need to make that change now.
2. Avoid higher risk foods, especially those that contain no other nutritional benefits. Rice cereal, teething biscuits, puff snacks (rice-based) and apple juice are some of the riskiest foods and have little to no benefit.
3. Provide a variety of foods regularly. Sweet potatoes and carrots can be an important part of your baby's diet but should be given in with a mix of a variety of other foods.

Even as the summer was winding down, every member of the Emergency Department knew a fatal drowning could still happen at any moment. Tragically, that moment came over the weekend when two sisters were found unresponsive in a Haltom City apartment swimming pool. News agencies report the girls were taken to Cook Children’s where they both died.

“Drownings occur year-round and there is no ‘drowning season,’ especially in Texas,” said Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s. “You can’t get comfortable and complacent with children and water, no matter the time of year.”

Before this weekend’s pool drownings, three children had died from drowning at Cook Children’s in 2019 – two separate incidents in bathtubs in March and one child in open water in May.

Even in the month of September, the warm Texas weather means kids are getting in the pool. From 2014 to 2018, there have been a total of  16 drownings (13 in a pool and 3 in open water) during the month of September, with two being fatal.

“I worry that with the end of the summer and kids being back in school that people will relax a bit,” said Dana Walraven, community health outreach manager for Cook Children’s. “But we can’t let our guard down even for a little bit. The temperatures are still warm and there’s plenty of time left for kids to be in the water. All the same rules apply to keep our kids safe.”

It was also during this time that measles showed up in Texas and when I received my second MMR.

My sister had been in San Antonio with my mother for two months receiving care at a Bone Marrow Transplant center. While she had no memory of her twenty-third birthday, I saw pictures of the nurses and doctors surrounding her with a cake.

Later when she returned home, she commented on this nice shirt she had found in her suitcase as she had not seen it previously. I did not have the heart to tell her that it had been a gift from me for her birthday, she just had been so ill she did not remember.

As the number of measles cases in Texas were climbing, her doctors became fairly insistent that I receive a second MMR. They really didn’t want me to be around her without being protected.

Some may feel that wasn’t their decision to make. However, those doctors were not only scientifically correct but they cared deeply for my family. They knew me well enough to know that if I gave anything to my sister that would have hurt her, I likely would have never recovered from that guilt.

While measles can harm anyone, it likely would have been a death sentence for my sister. Initially, my mother was concerned about any possibility of me developing measles after the vaccine and giving it to my sister. The doctors reassured her and said the only way to protect her was to protect me. My mom had to make so many difficult decisions that year. Sometimes she did what the physicians recommended and sometimes not. Her goal everyday was to advocate and protect her daughter. So I was vaccinated based on the new two dose MMR policy.

Then I was able to be with my sister. I was with her when they told her that cancer returned. I was there to watch my platelets infuse into her weak body. I was there on the morning she died. Holding her hand. It would have been too risky during the measles outbreak for me to be around her that summer if I had not received that vaccine. While I grieve the loss of her beautiful mind and spirit still after almost 30 years, I realize that experience inspired me to enter medicine and advocate for children.

It is so unfortunate that the discussion around vaccination has become so volatile. Like my mom, parents are just trying to make the best and safest decisions for their children. They have to navigate a much more complex world of information available to them. At my clinic, we spend a good amount of time discussing questions and concerns regarding vaccines. While I try to work with families and guide them, in the final discussion, vaccinating children is the healthiest choice for them. Not just for their own disease prevention but for all of those who cannot receive certain vaccines through age or medical condition.

Honestly, I was a bit nervous writing this realizing potential backlash from those not agreeing with vaccinations. Yet as I was looking through my closet the other day, I saw that shirt I gave my sister. It made me smile remembering her wearing it and it reminded me of how all of us had to be brave in different ways that year. In her memory, I will continue to try and be brave.

Vaccinate. It saves lives.

"There are a lot of patients who need specialized care or even higher levels of care and it’s really important that in this rapidly growing community that we have that available to these families," said Dr. Hogan, pediatricitian at Cook Children's Pediatrics Prosper Trail.

Dr. Hogan is one of 24 Cook Children's pediatricians currently treating patients in this region of North Texas. She says patients like hers need a place to access specialized and emergency pediatric care without having to drive 30 minutes to an hour away from home.

"A lot families have hardships and are not able to drive that far, or take off work all the time to go to these visits, and having this inpatient hospital and specialized care right her will make it easier for all the families," Dr. Hogan explained.

Construction of Cook Children's Medical Center North is in the initial phases with plans to have a full service hospital completed in 2022. The new hospital will be located on a 23-acre site in Prosper at Windsong Parkway and Highway 380. Having started in October of last year, phase one is already underway with plans to open a primary and urgent care clinic in the fall. An outpatient surgery center and specialty clinic with imaging and lab services will open in 2020.

"I'm really excited about the hospital opening up and being able to refer my patients to specialists, right here in Prosper, and being able to send my patients to get the specialized care that they need, having higher levels of care right across town," said Dr. Hogan. "I think that is going to be really wonderful for the families here."

Currently, Cook Children’s operates eight primary care offices in and around the Town of Prosper. The expansion near Windsong Ranch marks the first time in Cook Children's 101 year history that a full-service hospital has been built outside of Fort Worth.

"Just like the Town of Prosper is family, a close knit community, so is Cook Children’s," said Dr. Hogan. "We are all here wanting your children to be healthy and do better in life and be able to get the care they need to grow up to be happy and healthy adults."

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.

So before your child arrives, it’s important try to be as prepared as possible.

Prior to Delivery

1. Every mother should get a Tdap vaccine in the third trimester of pregnancy to protect her baby against whooping cough. Any other family members who will be spending time with your newborn should also get a Tdap vaccination. If it’s flu season, family members should also receive the flu vaccine to protect your child from getting the flu, since babies are unable to receive the flu vaccine themselves until they are 6 months old.
2. Pack a to-go bag for the hospital with clothes, toiletries, and a camera (or at least have your phone charged and ready to go), as well as anything that you may want to have during delivery such as soothing music. Formula, diapers and wipes are readily available in the hospital and do not need to be packed. Don’t forget to bring your baby’s car seat, as your family won’t be allowed to leave the hospital without having one.
3. If possible, before delivery, ensure that car seat/car seat base is installed tightly. If it can be moved more than an inch side to side or front to back, it’s not tight enough. All infants and toddlers should ride in a rear-facing car seat for as long as possible, until they reach the highest weight or height allowed by the car seat manufacturer, which is usually about 40 pounds. Most children can stay rear-facing until after 2 years old. Rear-facing is the safest way for babies/toddlers to ride.
4. Make sure your baby has a safe sleeping space at home. This may be a crib or bassinet with a firm, flat surface for your baby to sleep on. Besides a tight-fitting sheet over a mattress, there should not be anything else in the crib/bassinet. No loose blankets, stuffed animals/toys, pillows or bumpers in the sleep space. It’s recommended that babies share a room with parents. The bassinet or crib should be close to your bed for at least the first 6 months of life, but preferably the first year of life. This has been shown to decrease the risk of SIDS.

After Delivery

1. After delivery, your child will be examined by a pediatrician within the first 24 hours of life, and then each day your baby is in the hospital.
2. Every baby will receive a vitamin K shot and erythromycin eye ointment soon after they are born.
3. After your baby is born, he or she should be fed on demand, which is usually every 2-3 hours. Every baby loses weight in the first week of life, and then usually gains back to their birth weight by about 2 weeks of life. Until that time moms, be prepared to feed at least every 3 hours.
4. Breastfeeding: In the first few days after birth, a mother’s body will produce nutrient rich colostrum for her baby. Breast milk usually comes in 3-5 days after the birth. It’s helpful to breastfeed often to stimulate milk production. Breastfeeding is a learning process for both mother and baby. It’s very helpful to utilize lactation consultants in the hospital. They are a wonderful resource for parents.
5. Babies should receive their first hepatitis B vaccine prior to discharge from the hospital. Babies will also have a hearing screen, congenital heart screen, and newborn screen done prior to discharge from the hospital.
6. When placing your baby in the car seat after leaving hospital: Harnesses should be at or below the baby’s shoulders. When testing the harness strap over your baby’s shoulders, you should not be able to pinch any slack between your fingers. The harness chest clip should be at the center of the chest, even with your baby’s armpits.
7. Your baby should have a follow-up appointment with your pediatrician 2-3 days after discharge from the hospital, or sooner if needed.
8. Keep the umbilical cord clean and dry. Only give sponge baths until the umbilical cord has fallen off. If there is any redness/swelling or foul smelling discharge, call your pediatrician.
9. Try to keep yourself and your baby away from people who are sick. Wash your hands with soap and warm water often. If you are not near water, use an alcohol-based hand cleaner. Call your pediatrician if your baby has a fever, which is 100.4 degrees F. The most accurate way to check a baby’s temperature is rectally.

Argh! I know. It seems like a lot. But by taking a few precautionary steps now, you will have more time to enjoy your baby and this exciting time in your lives!

So let’s talk about it, and what you can do to help it go away.

Baby eye tear ducts don’t work well sometimes.

Pull down your bottom eyelid and look in a mirror. See that little dot towards your nose? That’s part of the tear drainage system. Tears wash over our eyes daily then drain down that teeny tube into our nose.

Baby’s tubes just don’t work well sometimes, and get sticky, stuck, and blocked.

Parents often complain that one or both of their baby’s eyes are full of tears or have yellow crusts or drainage.

Tears (which are clear) almost always dry to a yellow color, by the way.

As long as the white part of the eye isn’t red or pink, it’s not pink eye (but if it is red or pink, see your pediatrician. Sometimes drops are needed).

This common problem is called nasolacrimal duct obstruction, and it’s nothing to worry about.

You often just have to wipe the tears/goo away, and with time, it’ll go away.

Sometimes we recommend a nasolacrimal massage. It’s also called the “Crigler massage.”

Take a warm washcloth and wrap it around your finger, like in my super-glamorous picture to the right.

Massage up and down a few times with the washcloth to help the duct open and the tear sac (inside the tissues in that area) loosen up. Do this maybe 1-2 times a day when the eye has been acting up.

The problem will often come and go a few times in a child’s first few months.

Very rarely, if it continues after 6-7 months of life, I’ll send kiddos to an ophthalmologist. There is an in-office procedure they can do that’ll fix the problem. I’d say maybe 1-2 out of 100 kids need this done.

The first death occurred in Providence Village on Thursday, June 24, 2019. CBS11 reports the 4-year-old boy was found outside a home just before 5 p.m. when temperatures were in the mid-90s.

The second tragedy occurred on Sunday, June 23, when an 18-month-old was left inside a car for five hours outside of a restaurant in Galveston. 

The deaths were the first two of the year in Texas and the thirteenth pediatric vehicular heatstroke deaths nationwide.

The peaking 100 degree temperatures are dangerous, especially for children, whose body temperatures rise three to five times faster than adults. There have already been 11 pediatric hyperthermia (heat stroke) deaths this year in the United States from children being left alone in cars.

Although there have not yet been any recorded in Texas, this state typically leads in hot car related deaths. Since 2010 there have been 60 juvenile deaths in Texas from children being left alone in a hot car.

Most cases of child heat stroke deaths in cars are accidental. There was a change in mom or dad’s routine, and the child was unintentionally left in the back seat. Like drowning, it is quick and it can happen to anyone.

“We do get a very small amount of people who leave the child in the car intentionally, but the majority is when you just totally forget,” Cook Children’s Injury Prevention Coordinator Sharon Evans said. “There is no socio-economic, no educational or cultural factors. It can be anyone.”

Evans and her team have partnered with Safe Kids Worldwide to develop a Texas Hyperthermia Board to educate Texans about how and why this can be preventable. The task force has changed legislation in 2016 to require birthing hospitals to educate new parents about hyperthermia and car seat checks.

“The biggest problem with injury prevention is everyone thinks it won’t happen to them,” Evans said. “We hear lots of people saying, ‘Oh, that’s just a horrible parent. How could they forget?’ Today’s world is so technologically driven, and people give more time than ever to their cellphones. If you can forget your phone somewhere, you can forget your child in the backseat.”

Outdoor temperatures don’t have to be sweltering for heat stroke to occur. The first vehicle-related heat stroke death this year occurred in April with 79 degree weather. The temperature in a car can rise nearly 19 degrees in ten minutes. Heat stroke can occur when a body temperature rises above 104 degrees and body organs begin to shut down near 107 degrees.

There have been many instances where people walk through the grocery store parking lot, see a child alone in the car and do not act for fear of prosecution if they damage the car. Texas released Texas House Bill 478 (HB 478) in 2017 to protect Good Samaritans and potentially save children from heat stroke.

HB 478 allows citizens to rescue a vulnerable child under the age of seven if there is no reasonable method for the child to exit the vehicle without assistance and if the Good Samaritan has reasonable belief that entry into the car is necessary to avoid imminent harm to the child. HB 478 also requires law enforcement must be notified and the citizen must not use more force than necessary to enter the vehicle.

Child car-related heat strokes are preventable, but can happen to anyone. It’s important to take measures in educating adults and children about the dangers of a closed car door. The effects could ultimately last a lifetime.

“It doesn’t matter how good of a parent you are. It’s just a tragic accident,” Evans said. “Being vigilant could save a life.”

In his veto statement, Gov. Abbott called the bill “an unnecessary invasion of parental rights and an unfortunate example of over-criminalization.”

Texas law already requires children younger than 8 years old or shorter than 57 inches to be secured in a car seat and that the car seat be installed according to the manufacturer's instructions. The current law does not specifically mention car safety guidelines for children under 2 years old.

Following the veto, Chris Turner, D-Grand Prairie, who authored the bill said to The Dallas Morning News: “The governor’s veto sends the irresponsible message that it doesn’t matter if a child under age 2 is rear-facing. It does matter, because it is proven to save young lives.”

In much of the medical community, the talk among experts has shifted away from the age of the children to simply keeping them safely in a rear-facing car seat as long as possible. In 2018, the American Academy Of Pediatrics updated its recommendations on car seats for children. The AAP recommends children remain in a rear-facing car safety seat until they reach the highest weight or height allowed.

Benjamin Hoffman, M.D., FAA, the lead author of the policy statement and chair of the AAP Council on Injury, Violence and Poison Prevention, said newer car seats allow children to remain rear-facing until they weigh 40 pounds or more, meaning most kids can remain rear-facing past their second birthday.

“It’s best to keep your child rear-facing as long as possible. This is still the safest way for children to ride,” Dr. Hoffman said. “Car seats are awesome at protecting children in a crash, and they are the reason deaths and injuries to children in motor vehicle crashes have decreased. But that also means we just don’t have a large enough set of data to determine with certainty at what age it is safest to turn children to be forward-facing. If you have a choice, keeping your child rear-facing as long as possible is the best way to keep safe.”

Nationally, car crashes remain a leading cause of death for children. The American Academy of Pediatrics states that over the last 10 years, 4 children under 14 died each day.

Last year at Cook Children’s, 37 kids, who were 2 years of age and under, were involved in motor vehicle crashes, including five deaths (the most in at least five years). According to Cook Children's Trauma team, there have been 205 children in that age range invovled in wrecks and 12 deaths since 2014.

Spinal cord injury is a major concern for children who have transitioned from rear-facing to forward-facing or booster seat too soon. Melodie Davis, director of the Pediatric ICU, Transitional Care Unit and Rehabilitation Care Unit at Cook Children’s, said a young child’s head is so heavy as a toddler that it whips and causes damage.

“Properly used car seats protect children from injury and death,” Davis said. “Infants and toddlers are at risk for head, neck, and spine injuries during car crashes because their heads are large and heavy compared to their bodies. When placed rear-facing, the car seat can better support these high-risk areas because the seat is able to absorb the force of the crash. Unfortunately, we see significant neck injuries with cord damage in incorrectly used car seats. Another common injury includes traumatic brain injuries because of the force of the crash. Following proper car seat use guidelines can significantly decrease injuries and death in children.”

Using the right car safety seat or booster seat lowers the risk of death or serious injury by more than 70 percent, according to the AAP. Parents are suggested to check the instruction manual and the labels on a car safety seat to find the manufacturer’s weight and height limits. When a child is approaching the limit, it’s time to think about transitioning to the next stage.

“We hope that by helping parents and caregivers use the right car safety seat for each and every ride that we can better protect kids, and prevent tragedies,” said Dr. Hoffman.

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

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

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

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

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

2. Transition to a cup before 15 months.

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

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

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

4. Decide on a plan for your transition.

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

5. Try not to stress too much about this.

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

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

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

I hate that phrase and I know it never gives parents comfort when they hear it from doctors.

Doctors (I’ll admit I’ve said it too) usually say “it’s just a virus” to let parents know we don’t see anything that suggests a bacterial infection so your child doesn’t need antibiotics or other specific treatment. This is an infection caused by a virus and should go away over time. It’s meant to comfort mom and dad.

Then the appointment usually ends with “if things don’t get better to let me know.”

But it’s never JUST a virus when it’s your child, is it? As parents we know that viruses aren’t always simple and that kids can be VERY miserable and even get VERY sick.

RSV and flu still strike fear in the hearts of many parents. So much so that they’ll choose to have me test for them, even if I assure them it won’t change the treatment either way. But sometimes, the knowledge and the ability to put a name to it provides some level of comfort or the negative test gives them the ability to take a deep breath and relax (even though a no-name virus can be as scary as a named one).

We should take viruses seriously, after all they’ve been the cause of many of the most serious conditions the medical community has ever faced. Like I said earlier, once you catch a virus there’s not a whole lot doctors can do. We have to wait it out, try to treat the symptoms as we can and simply let things run its course.

That’s why the advancements that have been made in vaccines have been so essential. They were created to prevent the viruses before your child caught them or to lessen their severity if they did.

We don’t often think that these very serious conditions are viruses, but fortunately we have a vaccine for them:

• Polio which for many children might cause no symptoms at all or a mild upper respiratory illness, can also lead to devastating, permanent paralysis.

• Measles which for many children cause a syndrome with fever, rash and upper respiratory symptoms, can also cause pneumonia, death and a severe neurologic disease called SSPE which develops 5-10 years after the infection.

• Mumps which for many children caused fever, muscle aches and headache, can also cause infertility in males, meningitis and hearing loss.

• Hepatitis B which many believe to be a disease of adults (because it can be sexually transmitted and needle-borne) actually caused many infections in babies who contracted it from their mothers. Hepatitis B was less likely to be cleared by children which led to a 40 percent chance of liver cirrhosis and liver cancer.

Fortunately, for these viruses along with the flu, chicken pox and Hepatitis A, we can now protect kids with vaccines. We can protect them, not only from the suffering associated with the illness but also the devastating complications that can arise as a result of them.

How would it have felt to live in a time when these viruses were common?

Think about how you feel when you read stories about the polio-like illness that has been spreading across the country or how you feel when you hear that there are cases of measles in your community. Then imagine that you know someone or at least know someone who knows someone who has suffered from one of these disease personally.

Terrifying.

Imagine a doctor telling a family it’s “just a virus” in this environment. It wouldn’t fly.

I promise I’ll try to avoid saying “just a virus” but I’m thankful that it’s easier for me to get away with it today … thanks to vaccines.

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

Let’s look at some of the most common:

1. When is it OK to start a pacifier?

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

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

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

2. When should we stop using a pacifier?

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

3. Do pacifiers actually work to calm a baby?

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

4. Do pacifiers prevent SIDS?

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

5. What kind of pacifier is best?

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

6. Should I put something on the pacifier?

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

7. When should I replace or change pacifiers?

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

8. Should I use a pacifier-attached lovie?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“This news is frustrating to physicians and other health care providers because measles is a disease once thought to be all but gone from the planet. It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning. In 2000, the United States declared that measles was eliminated from this country. Now, more and more kids aren’t getting immunized and diseases like measles have returned. Measles is very serious and can cause pneumonia. Children under the age of 5 have a higher risk of hospitalization.”

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

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

Learn more:

Measles

Vaccines and Immunizations

Frequently Asked Questions About Immunizations

Immunization Schedule

Maybe not and that’s OK, at least for your baby. You, on the other hand, may need some rest.

Let's start with your baby. Does their lack of sleep pose any risk to their health or development?

A recent study in Pediatrics looked at the percentage of babies who were sleeping through the night (6 to 8 hours of uninterrupted sleep). The study went on to further explore the relationship between sleeping through the night and future development.

The bad news

At 6 months, about 4 out of 10 babies are still not sleeping 6 consecutive, uninterrupted hours. At 12 months, it’s still close to 3 out of 10 babies that are not sleeping 6 straight hours.

If you change the definition of “sleeping through the night” to 8 hours, the numbers get even worse.

So, if you have a newborn or you’re expecting soon…prepare yourself for the possibility that you won’t be getting a great night’s sleep for a while.

The good news

The study also didn't find an association between maternal mood and baby’s sleep.

This contradicts two potential misconceptions about sleep and a mother’s moods:

1. Mom’s mood can be affected by lack of sleep. While this might be true for an individual mom, the study did not show it across the study population.
2. Mom’s mood could be affecting the baby’s ability to sleep.

The best news

One of the major concerns about babies who don’t sleep well has been whether it has any effect on their development. Results showed that the lack of sleeping through the night had no effect on their later mental development. So, while it may be frustrating and exhausting, at least you don’t have to worry about negative effects in development later in life.

But what about you?

So if your baby isn't sleeping through the night, how are you doing? You're already exhausted from taking care of your newborn, now you just want to get some rest. Here are 5 tips that might help you when your baby isn’t sleeping through the night:

1. Do your best to rest or sleep when your baby is sleeping during the day. Sometimes this isn’t possible because of older siblings or housework, but it saves a lot of frustration during those long nights when you can.
2. Don’t rescue your baby at the first stirring. Give them a second to calm themselves down. They might just surprise you.
3. After your baby is established in their growth, you don’t have to feed them for every nighttime awakening.
4. Get help. If it’s a partner, grandparent or friend-having a one night break from getting up can seem like a life saver for an exhausted parent.
5. Turn off your monitor, if your baby is close enough for you to hear if they get really upset. Having the monitor turned off (or at least down), so that you don’t wake up to their every stirring can also help you get a better night’s sleep ... even if they aren’t sleeping through the night.

In the meantime, here are some things you can do to help.

Suction, suction, suction. Your old friend the bulb suction (aka nasal aspirator or booger-sucker) is the best thing you have against congestion. Many times people tell me they don’t get anything out when they use it but that is usually because they aren’t doing it right. Depress the bulb, push the tip in the nose until you have a seal on the nostril and then release. Repeat for each side. There are other devices that you can use to accomplish the same goal. I’ve seen a mom place her mouth directly over the nose and suck (yeah, wow) and there’s also the battery operated device. The other one that I have a handful of families using is the Nose Frida. This device allows you to suck mucous out of baby’s nose with a tube that has a filter in it. Seems kinda weird to me but my families who use it swear by it.

My two main recommendations about suction are that you should stop whenever you are no longer getting anything and that you shouldn’t suction thousands of times a day. If you continue to suction without production, you are only causing swelling in the nasal passage and making the problem worse. If the child is happy and noisy, there is no reason to suction them. Reserve your suction times to before meals and at bedtime. If they are just noisy, it is bothering you more than it is bothering them.

Nasal saline drops-putting some nasal saline drops in the nose can be very helpful with that hard to reach congestion in the back of the nose and when the congestion seems to be thickening such that it cannot be extracted with suction. Just place a few drops to each side of the nose and then pull with suction to get a little more snot out.

Humidity-keeping the nose nice and moist actually helps to smooth the air flow as it goes from the nose to the trachea and into the lungs. This helps the babies breathing stay comfortable. I get asked all the time about whether it should be warm or cool mist and I frankly don’t care. If you have child have bad congestion/coughing, getting the bathroom with the shower going can be helpful as well.

So, these are my helpful tips for congestion.

Any one else have anything that they have used out there? Any one used the Nose Frida?

It’s always nice to see future moms and dads come in with their list of recommendations they get online or from talking to other parents about what they should ask the pediatrician.

So when the parents come in for that initial visit, we first go over some basics. I introduce myself. We talk about the sex of the baby and the due date. Then I usually launch into my spiel.

The main thing I go over at the interview is not to panic about breastfeeding right after the birth of your baby. I explain to moms to watch for certain interested cues and if the nurse makes you wake the baby up to feed the baby, it’s probably not going to work. And if it doesn’t work, don’t worry.

During those first couple of days, moms please get your rest. The nursing will happen. Your baby isn’t going to starve and only requires the colostrum (early milk rich in antibodies to help the baby’s immunity) in the first three or four days.

I let mom know I will be at the hospital every day that the baby is in the hospital. Usually it is two days for regular vaginal delivery and usually a C-section requires a little longer stay. We have everyone back in the office two days after you go home to check the baby for jaundice. Then when your baby is 2 weeks of age, you come back to make sure he or she has gained back the birth weight.

We go over the checkup schedule – 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months and then again when the child is 2 years old. From that point on, barring sickness or injury, I will see you once a year. Often times, I see the child through college.

I like to go over the behavioral aspects of raising kids and how much they change in that first two years because 2 year olds are very different than 18 month olds, 18 month olds are very different than 9 month olds and 9 month olds are very different than 4 month olds. Part of my job is to help prepare parents for those changes and one of the things is to prepare them for the behavioral things.

I then go over our office schedule. We are open from 8 a.m. to 5 p.m. during the week. We are closed on weekends, as well as Thanksgiving, Christmas, New Year’s Day, Easter Sunday, Memorial Day, Labor Day and Fourth of July.

Then we discuss when to call our office and our after-hours, nurse triage phone line.

If after hours, parents should call if it is a serious issue and you think there is cause for concern. If it’s something like cold symptoms or rash that’s not really bothering your child, I ask parents to wait. It’s Ok to call, just wait until the next day.

If parents think it’s important or even serious, they need to call and the triage nurses will call back. The nurse will then give you home care instructions or recommend that you call the office in the morning. However, if the child sounds like he or she is seriously dehydrated, the nurse will recommend going to the Cook Children’s Emergency Department.

Then it’s time for questions.

Usually, I’m asked about our waiting room situation. Do we have a room for the sick kids and one for the well kids? We usually separate our well ones and our sick ones by time. We see well ones early in the morning and early in the afternoon and sick ones later in the morning and later in the afternoon and that’s how we try to keep them separate.

But all bets are off when it comes to our toddlers. They are crawling on the floor and chewing everything.

Some people ask about antibiotic use. I treat bacterial infections with antibiotics. If the baby looks real sick, I get a blood count at our office. If I find a high white blood count and I can’t identify a source then sometimes I start them on antibiotics. I communicate with the parents what it is I’m treating. Really I’m treating the white blood cell count.

I’m often asked about immunizations. I can’t overstate the importance of immunizations and how passionate I am about taking care of your child. If I thought for a second that immunizations harmed your child, I would not recommend them. But I do believe in immunizations and believe they are crucial in keeping your child, and all other children, healthy.

We give a little booklet that goes over what the immunizations are for and how often they should be administered. Occasionally, a parent expresses concern about immunizations. I try to talk to them about how there is no evidence that immunizations do anything but save lives right and left, but if they are adamant that they aren’t ever going to give their baby immunizations I say, “you know what I may not be the doctor for you.” If I get someone that wants a different schedule or that sort of thing I’ll work with them. But if they don’t want to get any at all, I can’t in good conscience take care of your child. You are putting every other child in our clinic and at their school in danger.

I care about all of the kids I see and I want what’s best for every child. I don’t want to take responsibility for treating a child who has not been immunized. Plus, children who have not received their vaccinations place my other patients at risk for getting illnesses that are preventable with immunization.

I can’t in good faith do that for children. So it’s not out of arrogance, but out of caring that I expect parents to take my advice. Sometimes I have parents who don’t listen to me and they still come in for their visits. I wonder why. They may get their healthy kid stamp of approval, but they don’t get any of the other benefits I think I can give whether it’s behavioral issues, sleeping issues or eating issues. Parents should trust their pediatrician enough to take their advice, otherwise it’s frustrating and a waste of time for everyone involved.

You are paying for the advice. You might as well take it.

All the questions and information parents receive is important in choosing a pediatrician, but usually it comes down to the physician’s personality. It’s really important to take time to meet the person who, if chosen, will be taking care of your child into his or her teens.

More Resources For You

• Cook Children's Newborn Center
• Preparing For Parenthood
• Your Pregnancy
• Childbirth
• Newborn Care

Commonly recommended ways to prevent constipation are to drink water, exercise, and eat fruits, vegetables and fiber-rich foods. Yet even when we use these techniques, our children still sometimes get constipated. Whether its contributing to stomach ache, delayed toilet training, bedwetting, or missed school, constipation is no laughing matter.

“But my child poops every day! My child can’t be constipated!”

Even if your child stools every day, he or she may be constipated. Think about your office desk; you may clear papers off regularly, but if you are not clearing as many papers as are building up, you will soon have a messy desk. Children may poop every day and still not be fully emptying their intestines. When constipation develops, the extra stool causes the intestines to stretch. Once this happens, the intestines may not be able to move as well, which leads to more constipation, and it becomes a vicious cycle. In infants constipation can be particularly hard to recognize because in this age group it is can be normal to have less than one stool per day.  Parents should look for a change in the frequency of stools along with firm stools when considering constipation. 

“What now?”

The good news is that constipation can often be treated with dietary changes. The key to making the treatment stick is continuing it long enough. If you stop too soon, the intestines have not had time to heal, and the constipation returns. As a physician who often sees this condition, I recommend treating constipation for as long as it has been a problem. For example, if constipation has been an ongoing problem for one month, treatment typically lasts at least one month. Treatment also depends on your child’s age.

• For infants over the age of two months, ask your pediatrician about giving small amounts of prune juice or pear juice.
• For a toddler, in addition to pear, apple, or prune juice, consider adding high fiber foods such as pears, peaches, and whole-grain cereals to his or her diet.
• School age children or teenagers can learn about which foods will help improve their symptoms and can then get involved in choosing foods that are fiber-rich and appealing to them.
• In cases that do not respond to dietary changes or are more severe, your pediatrician may recommend a medication to help treat the problem.

Contact your child’s doctor if you have any questions or concerns about your child and constipation.

Normally, tears are produced all the time to keep our eyes moist and those tears are drained by the nasolacrimal duct. If this duct is obstructed, or clogged, the tears flow out of our eyes causing clear drainage. When tears sit for long periods it can form crusting or ‘gunk’ near the eye and eyelashes. This type of obstruction occurs in around 6 percent of all newborns and is a common topic discussed in our pediatric office.

When a pediatrician diagnoses nasolacrimal duct obstruction, we ask parents to massage the area gently several times each day. This technique, called Crigler massage, is thought to help relieve the obstruction and encourage the duct to function normally. The technique is easy to do at home, effective and, best of all, costs nothing. See the video below at the end of this blog demonstrating this technique.

We also ask parents to keep the area clean with a soft, damp wash cloth.

The good news is that most cases of nasolacrimal duct obstruction go away over time. In fact, approximately 90 percent of all cases will resolve by 6 months of age. After 6 months, there is still a two-thirds chance the problem will resolve, but after 12 months the problem will need treatment by an eye doctor (ophthalmologist).

If a child is referred to the ophthalmologist, the treatment usually involves inserting a small probe into the duct to clear the obstruction.

Nasolacrimal duct obstruction is not the only reason for an infant to have eye discharge. It is important to speak to your doctor if the eye becomes red, is causing the baby discomfort, has pus-like discharge or the baby has a fever.

So if your newborn has a watery eye, talk to your pediatrician. With their help, some gentle massage at home and a bit of patience, the problem will likely go away on its own.

Here is a video demonstrating Crigler massage: 

From the beginning, it was clear that my body didn’t like being pregnant. My husband, Shawn, and I worked on getting pregnant for a little over a year and were finally successful after seeing a fertility specialist. I can honestly say that I didn’t really have one day during my pregnancy where I could just enjoy being pregnant. Whether it was being really nauseous, increased problems with my asthma or dealing with high blood pressure.

This new chapter of our lives began on March 13 when I called the doctor with an exceptionally high blood pressure reading. I’d been battling high blood pressure since week six of my pregnancy but it had been controlled with medication. I remember thinking to myself before I called the doctor that morning that I was probably just overreacting. Two hours later, I was in a helicopter being taken from Harris Southwest to Harris downtown. The whole feeling was completely surreal. I didn’t really feel that bad so why were people acting like I was so sick?

I was told that I was being transported to Harris downtown so we could be closer to Cook Children’s in case I needed to deliver. Deliver?? I was only 26 weeks; there was no way I could deliver yet. I wasn’t ready. She wasn’t ready. But, less than 48 hours later, at 8:33 p.m. on Friday, March 14, Avery Leigh Wooley came into this world via a C-section, weighing 1 pound, 5 ounces. The doctors had diagnosed me with preeclampsia and decided it was just too dangerous for me and her to stay pregnant any longer.

Being in the operating room for the C-section was another surreal experience. Shawn just kept telling me to “stay Avery strong!” That has now become our battle cry. We’ve even printed up bracelets that say “I am Avery strong” for friends and family to wear.

We are on day 14 of being in the NICU. Overall, she has done really well. She is experiencing all the normal things that a premature baby at 26 weeks would but nothing out of the ordinary. You never know what news could be lurking around the corner so we’ve really focused on taking it one day at a time. We celebrate the good news, try not to focus too much on her setbacks and try not to think too far in advance. This is definitely a marathon, not a sprint. They say to plan on her being her until her due date, which was June 20.

The care that we’ve received here in the NICU has been incredible. There is nowhere else, except in my belly, that I would rather Avery be right now. All her nurses and doctors show incredible empathy and do a great job of comforting me on a daily basis. It’s not just a job for these people, it’s a calling. They do it because they love it. They’ve taught me so many new terms and do a great job at explaining things in plain English.

The amount of guilt I have for not being able to carry Avery to term is overwhelming. I feel like I failed at my first act of motherhood. I will spend the rest of my life trying to make it up to her. For right now, I am trying to do that by being here with her as long and often as I can and giving her my breast milk to make her grow big and strong, so she can be Avery strong!

Avery's Journey Continued:

• Avery's Journey - Part 2
• Avery's Journey - Part 3
• Avery's Journey - Part 4
• Avery's Journey - Part 5
• Avery's Journey - Part 6
• Avery's Journey - Part 7
• Avery Goes Home! - Part 8
• Thankful to be Home - Part 9
• Avery turns 1 - Part 10
• Independence Day- Part 11
• An Autism Spectrum Diagnosis - Part 12
• NICU Parents Suffering from Post-Traumatic Stress Disorder - Part 13