The Texas Department of State Health Services has not reported an outbreak.  

Cook Children’s pediatricians Devona Martin, M.D., and Jenica Rose-Stine, D.O., say they have seen a surge in cases at their primary care clinic in Willow Park, Texas.  

“Over the past few months, we have noticed a big increase in the number of cases of salmonella,” Dr. Martin said. “This usually presents as diarrhea that has blood or mucus and fever. Each case is reported to the Health Department to try to track down a cause, but a common source has not been identified.”  

Since July, the Emergency Department at Cook Children’s Medical Center – Fort Worth has also reported increased numbers of patients with salmonella.  

“In the ED, we usually see less than 20 patients per month with a diarrheal illness caused by salmonella,” said Stephanie Felton, D.O., associate medical director of the Cook Children’s Emergency Department. “In the month of July, we had 43 positive cases. We had 59 in August, 71 in September, and 74 in October.”  

Last week at Cook Children’s, 11 out of 229 patients tested for Salmonella were positive, resulting in a 5% positivity rate.  

Dr. Felton, Dr. Martin, and Dr. Rose-Stine provide answers to commonly asked questions about Salmonella.  

What is salmonella?  

Salmonella is a bacteria that can cause gastrointestinal illness and fever called salmonellosis. It is one of the most common causes of foodborne illness in the United States.  

What is the difference between salmonella and E. coli?  

Although salmonella and E. coli cause similar illnesses, they are different kinds of bacteria. E. coli more commonly produces a toxin that can lead to kidney damage, a condition called hemolytic uremic syndrome. This isn’t seen as often with salmonella.  

What are the symptoms of a salmonella infection?  

Symptoms of salmonellosis are diarrhea with blood and/or mucus, vomiting, abdominal cramps, and fever. 

How do children contract salmonellosis?  

Salmonella infection can be contracted by consuming contaminated food products, including poultry, eggs, produce, infant formula, and water. It can also be spread through contact with infected animals, like reptiles and birds, or other people who are infected if strict hand hygiene isn’t followed.  

Is salmonella contagious?  

Yes, salmonella is contagious and can be spread by person-to-person contact or by touching contaminated surfaces. The incubation period usually is between eight and 72 hours following exposure. You may be asymptomatic during this time.  

Salmonella is not as contagious as the viral stomach bugs we often see.  

How can parents and caregivers prevent infection?  

We can prevent infection with proper hand washing, especially before eating and after touching animals. Make sure that your counter spaces and sinks are clear of any bottles, sippy cups, or dishware before washing any fruits or vegetables. Cook and prepare all poultry and meat products appropriately. 

Only use FDA-approved formulas for your infants. Thoroughly clean all bottles, pacifiers, and toys before handing them to your children.  

How are salmonella infections treated?  

Treatment primarily involves rehydration and rest. Infants less than three months old or children with moderate to severe illness may receive antibiotics. These infections usually clear on their own.  

What should parents do if they think their child has a salmonella infection?  

If you are worried about your child having salmonella, please contact your primary care physician. He or she can run stool studies to confirm the diagnosis.  

Unless your child has blood, mucus, or fever with their diarrheal illness, it’s likely a stomach virus and not salmonella. Keep your child at home and make sure they hydrate!  

If your child is acutely ill or if you are concerned about dehydration or prolonged fevers (100.4 degrees Fahrenheit for five days or greater) please bring your child to the Emergency Department for an evaluation.  

Parents may be wondering if they should get their children vaccinated. Vaccines are the best way to prevent serious illness in people of all ages, including children. 

Based on available data, our health care providers and pediatricians at Cook Children’s strongly recommend that parents get children vaccinated as soon as they are eligible.

“It is important to keep our children safe now and in the future," said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. "This is one way to safely protect your children AND protect people who they might expose from catching SARS-CoV-2."

We asked Dr. Whitworth to answer some of the big questions and shed a little light on the subject.

Why should my child get the COVID vaccine? 

Children are at risk to get sick from COVID-19 disease, requiring hospitalization, and in rare cases, dying from the infection.  More commonly they will get a mild infection and recover quickly. But while they are contagious they can spread this to others such as vulnerable grandparents.

How do we know it’s safe for children 5 and under?  

The children who participated in the vaccine research had no serious adverse events and we know that the FDA is extremely cautious and will review the data quite carefully before approving this.

Should parents get their children vaccinated, even if their child recently had COVID?  

Yes. Those who have been infected with this virus can get infected again. This second infection may be the same, milder, or more severe – and they are able to transmit SARS-CoV-2 to those who are more vulnerable.

What about if I live in an area with a low number of cases?  

SARS-CoV-2 will not be eradicated.  We will have this infection with us for years to come, just like influenza.  Low numbers now are something to enjoy, but we will all be exposed at some point in the future. 

What should parents do if they have more questions?

Talk to your pediatrician. They have your child’s medical history and are the best source of information for this topic. They have the latest information available and want to help you make an informed decision. 

If your child is eligible for the COVID-19 vaccine, please contact your local pediatrician's office to schedule an appointment.

RELATED: BioNTech Asks the Food and Drug Administration to Authorize COVID-19 Vaccine for Children Under 5

There have been 118 outbreaks reported and more than 22 million birds have been affected since January, according to the CDC.

So what does this all mean for children? Nicholas Rister, M.D., of the Cook Children's Infectious Disease team is here to break down what the bird flu is and share what parents and caregivers need to know.

What is the avian flu and can people be infected by it?

The influenza virus circulates around the world through a variety of human and animal hosts. Generally, the virus tends to stay within the same animal groups (ie, bird/avian flu infects birds and pig/swine flu infects pigs) but since the influenza virus is very good at mutating on a regular basis, it is able to jump from one type of animal to another from time-to-time. 

In particular, bird and pig influenza viruses are known to jump between each other and human hosts. When these jumps happen, the virus is often quite a bit different from the last time human hosts saw it, so our immune system may not be as well prepared (ie, worse infection, easier spread). 

The major four global influenza pandemics in the 20^th century all occurred with an avian influenza jumping back to humans. But that is four pandemics in 100 years, so while we see lots of avian influenza viruses, they don’t all turn into pandemics. We also have flu vaccines made yearly that try to predict which viruses are most likely to emerge and provide so protection ahead of time.

What should parents and caregivers know about the avian flu?

Avian influenza in children presents like many respiratory viruses – fever, cough, congestion, fatigue, rash. In most cases, these symptoms will not become severe enough to require medical attention, but if a parent feels their child is having difficulty breathing or has altered mental status, they should certainly seek medical care. Very similar recommendations to many common illnesses. 

Additionally, the yearly influenza vaccine provides some protection each year against these infections. There are also anti-viral treatments (such as Tamiflu) available for patients that are found to have early infections with influenza to reduce the length of illness although many patients do not get ill enough to present for testing.

Why are zoos removing birds from exhibits?

This is out of an abundance of caution. Coming out of an era of COVID-19 pandemic planning, there is a lot of concern for any potential disease spread. 

The majority of documented cases of avian-swine-human influenza spread occurs at sites with consistent and prolonged interaction with animals. Think pig farms, outdoor butchers/food markers in developing nations, zoo workers. In all likelihood, no one was going to acquire a pandemic bird influenza from visiting a zoo exhibit but adjusting them may alleviate lots of concern with everyone on higher alert for respiratory viruses right now.

Should I be concerned about feeding my child poultry and eggs?

No. The virus spreads through close contact with the animals when they are alive or recently killed. Not from the food you would obtain at the store. However, be sure to cook and prepare all meat/poultry products appropriately since other concerns such as Salmonella always remain.

Should I be concerned about my child interacting with birds, such as feeding the ducks or through bird feeders at home?

Not in particular. While interacting with birds is how humans get avian flu, the conditions for transmission usually require a lot of persistent interaction as mentioned above. Routine interaction with ducks, small birds, outdoor feeders, is very unlikely to contribute much to the spread of avian flu.

Nine of those drownings in the stretch from January through middle March occurred in swimming pools. Three occurred in bathtubs. The children ranged in age from infancy through 9 years. 

Sharon Evans, trauma injury prevention coordinator at Cook Children’s, pointed out that drownings typically peak between Memorial Day and Labor Day but can occur any time of year. 

“If you have water, there's not an off-season,” she said. “A lot of these seem to happen on the weekends when the weather's nice and people go outside working in the yard. The child falls in the pool or somehow gains access.”

Data from Cook Children’s show two or fewer drownings in January-February each year from 2018 to 2021. The trend this year is unusual and concerning to Evans, who urges parents and caretakers to take precautions and stay vigilant to guard against accidental drowning injuries.

Last year, more than 60% of drownings treated at Cook Children’s occurred during unplanned swim time. This is when parents didn’t expect their child to be in or around the water. Parents can put barriers in place to help prevent a child from accessing the water or make it more difficult to access when an adult is not present.

Those barriers – such as locks, alarms and fencing – can help keep unsupervised young children from getting into swimming pools.

“We always talk about those layers of protection. They're not guaranteed to prevent a drowning, but they do slow the child down as far as gaining access,” Evans said. “Toddlers are just curious. They're going to explore and see what they can figure out. As parents, we have to make sure they are safe.”

Sometimes the child who drowns in a backyard pool was playing outdoors with older siblings. Other times, the parent doesn’t realize the child left the house through an unlocked door or doggie door. Ice chests, mop buckets and horse troughs can also present hazards if they hold more than an inch of water, Evans said.

One rule prevails when it comes to bathtubs: Never leave the child alone … not to answer the doorbell, not to pick up the phone, not even for a second.

“I often say with injury prevention across the board, there is no do-over,” Evans said. “Just be alert.”

Cook Children’s initiated a drowning prevention campaign called Lifeguard Your Child in 2015 in response to a high number of drowning injuries treated in the Emergency Department and medical center that year. The Lifeguard Your Child campaign is spread through the Safe Kids North Texas Coalition, which is based in Fort Worth and led by Cook Children’s.

Dana Walraven, manager of community health outreach for the Center for Children’s Health, led by Cook Children’s, said partners across 11 counties share education, access to swim lessons, safety videos, resources and social media with a consistent theme: Lifeguard Your Child.

“Knowing social media messages alone have reached millions, the messages and awareness are making a difference for a safer community,” Walraven said.

The campaign’s strategies include Cook Children’s Loaner Life Jacket Stations at many lake entry points across the region. Families can go to the stations to find U.S. Coast Guard-approved life jackets in a variety of sizes with easy tips for a proper fit.

Safety tips for home swimming pools: 
• Restrict access by installing door locks high out of children’s reach. Door and window alarms can signal if someone leaves the house. 
• Install four-sided fencing around pools with a self-latching gate that only opens out. The fence should be at least 4 feet (preferably 5 feet) high. 
• Remove all toys and floats from the pool area so children are not tempted to get close to the water. 
• For above-ground pools, make sure the ladder is removed and not accessible when it’s not swim time. 
• Consider a pool surface alarm to alert if anyone/anything falls into the water. 

Safety tips for the bathtub: 
• An adult must stay at the side of the tub in reach of the child. 
• Pay attention. This is not the time for multitasking. 
• Ignore distractions like the doorbell or phone calls. 
• Drain the tub after each use. 
For more information about drowning prevention, go to www.lifeguardyourchild.org. 

"I honestly had never thought about it before because there are so few of us, that’s always been my reality," Bowen-Jallow told "Good Morning America." "You’re just used to that."

Dr. Bowen-Jallow attained her undergraduate degree from Texas A&M University and earned a medical degree from the University of Texas Medical Branch.

"I wanted to be a cardiothoracic surgeon and then I desired to be a neurosurgeon," Dr. Bowen-Jallow remembered. "Right before I decided to go into pediatric surgery, I wanted to be a plastic surgeon."

She said becoming a pediatric surgeon was an accident, but it was the best accident that could've happened. She also believes it was worth enduring all 17 years of higher education.

"I'd committed to doing plastic surgery and was lining up interviews," she said. "As I signed up for my acting internship (AI), I wanted to do general surgery and was informed there were no more spots available. My only option was pediatric surgery, and within three days I'd changed my career path. I knew pediatric surgery was what I wanted to do for the rest of my life."

"Working with children is instant gratification," Dr. Bowen-Jallow explained. "If you perform a good operation, perfect your technique and pay attention to detail. Children will recover well."

Kevin Greene, assistant vice president of Cook Children’s - Prosper, recruited Dr. Bowen-Jallow.

"She’s a great surgeon, she comes from great training and she’s really been able to inspire and connect with families," he told GMA. "She's someone who personally wants to provide the best care for every child that steps foot on our campus."

Read the full story here.

Generally, I’m not too concerned about the exact number of your child’s temperature. “Felt warm” is usually more than enough for me to know my kid has a fever.

But, like many things in medicine, that has changed in the world of COVID-19.

Many of the protocols for screening and testing have been developed based upon knowing if you or your child has fever.

So, now more than ever, knowing which type of thermometer and the best way to take your temperature is crucial.

Here is a look at 7 different types of thermometers (and a bonus one that many of you swear by) and how to decide if they are right for your family:

1. Forehead strips

Ahh…the allure of not having to wake your baby up to know their temperature. Sounds nice, right? And it might even offer you some peace of mind. But is that peace of mind false? Probably. There aren’t many studies on the use of strip thermometers but most recognize the accuracy of detecting fever at around 35 to 50 percent. What does that mean? If you don’t want to touch your child and wake them up to see if they have a fever, just flip a coin…Heads=fever, Tails=no fever.

2. Wearable thermometers

Trying to one up the forehead strips is the wearable thermometer. In theory, it will notify you via an app if your child’s temperature reaches a fever. Like the forehead strips, the accuracy of these is suspect. On top of that, if you’ve read anything I’ve written about fever before (like this post about fever myths), you might know that I don’t think it’s important to know your child’s temperature every second of the night.

3. Pacifier thermometers

Just plain “Nope.” They don’t work. Save your money.

4. Ear thermometers (tympanic)

Now we’re getting into the more common and reliable ways of checking your child’s temperature. While not my favorite, some parents like the relative ease of the tympanic thermometer. This thermometer is placed in the ear. A few important points: 1) It can’t be used in children under 6 months. 2) Placement in the canal matters. Read the directions and follow them. 3) Excess earwax can cause an incorrect reading.

5. Forehead thermometers (temporal)

This is the preferred method for most kids 3 months and over, particularly for screening when you can’t or prefer not to do a rectal temperature. That’s why you’ll find most doctor’s offices using them at check-in. Once again, the placement and the way you move it matters so follow the directions included. If you are getting a reading that doesn’t make sense, check it a few more times until you are getting consistent readings. Another nice thing about these thermometers is that they can be used for screening even before 3 months of age…before you go to take a rectal temperature.

6. Digital thermometers

A nice digital thermometer is good to have because it can be used throughout age ranges, provides accurate readings, and it's cheap.

At any age, you can use a digital thermometer under the arm and add 1 degree to get a general sense of what the true temperature might be (just don’t count on that as 100-percent reliable.)

Before age 3, the most accurate temperature will be a rectal temperature, in the bottom (see below for how to take a rectal temperature). Anything over 100.4 taken rectally is a fever. After age 4 or 5, you can start to take the temperature in the mouth (see below for how to take an oral temperature). I general consider 101.4 or above to be a fever when taken orally.

7. Non-contact Infrared Thermometers

With the recent events related to COVID-19, I've gotten a lot of questions about these thermometers. They are an option for you because they are accurate, can be used for screening at your home or office and they don't require touch.

Bonus: Mom’s hand or lips

“He feels about like the oven which is set at 350 degree.” Actual phone call. Actual quote.

Ok, this is not an actual thermometer, but I thought it deserved a mention. While touching the child might give you an idea that you should check a temp, mom’s hand is not a reliable way to determine the child’s temperature. Now grandma’s hand…I find it best not to argue with grandmas. “It felt like 102…yes ma’am.” But seriously, use an thermometer that works.

Hopefully this article will provide you some guidance for the next time you need to replace your thermometer. You have a few solid options and a few terrible ones. Some are basic but work just fine. Some have fancier features that might be useful. Others have stuff which prove that the solution to fever is not always more (cow)bells and whistles.

How to take a rectal temperature

• Clean the thermometer with soap and water.
• Place a small amount of petroleum jelly on the end.
• Place your baby across your lap face down or on their back on a firm surface.
• Gently place the thermometer about ½ inch into the anus.
• Place your entire hand around the child’s bottom, holding the thermometer in place between your fingers.
• Hold in place for about 1 minute or until you hear the beep.

How to take an oral temperature

• Wait 10-15 minutes after the child has had a drink.
• Clean the thermometer with soap and water.
• Turn the thermometer on and place under the tongue toward the back of the mouth.
• Wait for 1 minute or until you hear the beep.

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

Just a quick reminder of my big fever rules. Click the links to learn more:

1. You don’t always have to rush off to the ER for a fever. No matter how high.

2. In a well-appearing child, it’s OK to watch fever at home, even up to 5 days.

3. You only have to treat fever to keep the child comfortable. Don’t treat the thermometer.

But what if your little one has a fever and it doesn’t seem to be going away? What should you be worried about?

Let me just start by saying this…this article is intended for children 6 months to 3 years who are fully vaccinated and are otherwise acting pretty normal. Why?

• Older kids are usually much better about telling us if something hurts.
• In children who haven’t received all of their vaccinations, we have to consider some other infections that have otherwise pretty much gone away.
• If a child isn’t acting normal (is lethargic, not drinking and peeing or has other concerning symptoms), they should be taken in for care (probably to the ER).

Sometimes it’s really obvious where the fever is coming from but other times it’s not. Here are some infections we think about when it’s not really clear:

1. Ear infection – Often kids with ear infections will have fever, fussiness, runny nose/cough and will be pulling at their ears but other times it might not be so clear.

2. Pneumonia – Most children with pneumonia will have symptoms such as rapid breathing or difficulty breathing but not always.

3. Urinary tract infection – This is actually one of the most common reasons for kids to have fever without symptoms in this age group. They just can’t tell you that it hurts when they pee.

4. Meningitis – The younger you are, the more likely a child is to have meningitis only presenting with fever.

5. “Viruses” – This might be the answer you don’t like to hear but, besides ear infections, it’s probably the one you want to have. Sometimes a child will present with just fever or fever and very little else until a few days into the illness when viral symptoms like runny nose, cough or rash become more prominent.

So, if your baby’s fever doesn’t go away after 3-4 days, what should you expect?

Your doctor should take a thorough history and do a full physical. If the diagnosis isn’t clear, here are the tests that are likely to be run:

1. Blood work – A blood count and some markers of inflammation will help determine if the infection is more like viral or bacterial.

2. Urine sample – Even though it’s not fun because urine catheterization in this age is no fun for anyone, getting a urine sample is critical because UTI is such a common cause.

3. Chest X-ray – Due to the fact that pneumonia can be a cause, getting a chest x-ray will usually be necessary.

4. Other – Depending on the baby’s story, physical exam and the results of the initial lab work, further testing may be necessary.

When your little one has a fever, it can be really scary. Keep in mind that most fevers have obvious causes or go away quickly on their own. But when they don’t, now you’ll know what to expect.

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

Fever has been recognized as being around for thousands of years. And yet it’s never gone away. We’ve just not evolved it away. Which must mean it benefits us, right?

The process of a fever, simplified/Dr. Diane-ified:

1. A germ (virus or bacteria) enters your body. One of your immune cells floating around notices it. It freaks out. It makes a whole bunch of chemicals to freak everybody else out. HIGH ALERT, EVERYONE!

2. The chemicals reach your brain (the hypothalamus, in particular). The hypothalamus says OK GUYS, GET THE ARMY OUT THERE, STAT. DO YOUR THANG. I'LL MAKE THIS PLACE REAL HOT TO HELP OUT!

3. The brain thermostat is set at a new number. Instead of 98 F, he’s now gonna re-set at 102 F.

4. Heart rate speeds up. Breathing speeds up. Blood vessels open, flush. The body is physically pushing the blood around faster, to get the white blood cells there quicker.

5. Muscles shiver, generating heat. You start making more immune cells. They travel around faster. They talk to each other more effectively. They “stick” to the bad guys better.

6. You feel cold, because your new “set” thermostat wants you to be 102F. You're not there yet, so your body is trying to get you there. You shiver. Your muscles ache.

7. Soon, the germ can’t replicate as much as it wants to. It can't divide and conquer. Maybe even its protective coating starts to break down a little bit.

After a few days of fever, you beat the germ! Thank you, glorious fever and fabulous immune system!

Studies have shown (in rats and iguanas) that there is even a higher success rate at overcoming a virus or bacteria if a fever is allowed to burn rather than when they're given medications to bring it down.

Oh my gosh. Aren’t our bodies amazing? And are you feeling a teeny bit better about that number on the thermometer?

Most of the time, fever is just a sign that the body is fighting something, and you just need to try to keep your kiddo hydrated and comfortable.

You do not have to run to the ER, or my office, at the very first sign of a fever if your child is over age 3 months.

But sometimes, fever isn't OK.

My son once woke up with a fever of 105.7F. I remember the day clearly. I totally freaked out, just like you do. Then I asked myself – what do I tell my patient families to do?

Once I tried a few different thermometers and they all read the same number, I gave him a dose of ibuprofen and put him in a warm bath (NOT cold – warm) and let him play.

I watched him closely. I made sure he was breathing OK, and able to drink. He seemed fine, just super grumpy.

After about 45 minutes, I re-checked his temp. It was 102F. He was sitting on the couch, drinking water and talking comfortably. I was OK with this. And he did fine. He had a fever for three days, and a runny nose and a little cough, and it went away. He had a virus, and his body took care of it.

6 Types of Thermometers:

1. Thermometer forehead “strips”, pacifier thermometers, and wearable thermometers - don’t buy them. Save your money. 

2. Forehead “temporal” thermometers – they’re OK. We use this kind in the office. Good days and bad days, and I think they’re usually as accurate as the ear ones.

3. Tympanic (ear) ones – easy to use. Pretty accurate. Don't use under 6 months, ear canals too tiny.

4. Rectal - most accurate (good luck)

5. Oral - second most accurate, if they can hold their mouths shut

6. Armpit - least accurate

Yes, you add one degree to the armpit temp measurements. Although again, I dislike the math.

But what I want to drive home is: if the child looks fine otherwise, the number often doesn’t matter too much to me.

Febrile seizures:

Something like 2-4 percent of kids between the ages of 6 months and 5 years have febrile seizures. This means they may have a seizure when they have a high fever spike. They usually stop by age 5.

These are super scary, but actually don’t cause any brain damage. The child should be rolled onto his side, and watched closely. Don’t stick anything into his mouth.

VERY rarely, unrelenting and long febrile seizures may indicate a bigger problem like something neurologic or genetic going on. But again, this is super rare.

Febrile seizures may run in families. If the seizure lasts longer than 5 minutes, call an ambulance. Again, these are rare, and usually very benign.

Whew. OK. I hope this helps you understand fevers better!

Education is empowerment in your child's health! The more you know, the better you feel!

Want even more on beautiful science of fever? It's all laid out here, with lots of big words and acronyms.

Have a great day, friends!

Dr. Diane

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.

Is it strep or the flu? Maybe, both?

Strep and flu are two very different things, although they may have similar symptoms at times.

First, let’s distinguish between the two.

The flu is a viral infection that impacts the nose, throat and lungs. A flu, or cold, can make the throat sore and scratchy

Strep is a bacterial infection. Strep causes the throat to be very sore and it becomes very painful to swallow and they typically don’t eat, or only eat very soft things. With a cold or flu, children usually eat fine or if not the reason is appetite not pain with swallowing.

They both can cause a fever, sore throat, chills, muscle aches and even nausea.

So how do you tell the difference?

Even for a pediatrician, it’s difficult to distinguish strep from the flu by a quick look inside a child’s throat. Studies have been done that shows that without the proper tests, physicians can’t tell the difference half the time.

Strep can cause white spots, but rarely does. Usually the throat is somewhat red and can have the red spots which are petechia. The body aches in strep are also less severe in strep and one of the defining symptoms of flu.

The only accurate way to diagnose strep is through a strep screen or a throat culture.

Strep throat symptoms include:

• Red, sore throat with white patches
• Headache
• Swollen, sore glands in the neck
• Fever
• Red spots on the roof of the mouth
• Painful, difficult swallowing
• Chills
• Fatigue
• Nausea and possibly vomiting
• Decreased appetite
• Rash
• Muscle aches, especially in the neck, and abdominal pains, especially in younger children
• Swelling in back of mouth

We will take more tests to confirm the diagnosis that may include a throat culture, rapid DNA test or rapid antigen strep throat.

Most strep will get better in about a week to 10 days.

Your doctor will prescribe antibiotics to treat the infection. Although the symptoms may fade, the infection may remain. Please make sure to take all the antibiotics prescribed.

You may be surprised to find out that about 30 percent of people have strep in their throat at all times and it does not cause symptoms. To help reduce your child’s chances of strep, follow these tips:

• Wash your hands
• Don’t share food or drink
• Avoid exposure to other people with strep
• Replace your child’s toothbrush after starting antibiotics

Flu symptoms include:

• Fever
• Cough
• Sore throat
• Runny or stuffy nose
• Body aches
• Headache
• Chills
• Fatigue
• Sometimes diarrhea and vomiting

We advise everyone to get the flu shot. However, if you or your child are sick with the flu, stay home, rest and avoid contact with other people. The Centers for Disease Control and Prevention recommends staying home for at least 24 hours after the fever is gone (except for medical care or other necessities). The fever should be gone without the use of fever-reducing medicine.

In some cases of the flu, you may be prescribed antiviral drugs that are prescription medicines. These aren’t sold over-the-counter and you can only get them with a prescription. The drugs aren’t antibiotics which fight against bacterial infections (strep for instance), but they fight against the virus.

You may hear someone say that their child got strep and flu at the same time. This can happen, but it’s very uncommon. Both are increase in the winter months, and symptoms such as sore throat, fever, etc. can overlap, which is likely why children are being treated for both.

Strep and flu two are entirely different things. Colds and flu always cause a sore throat, but strep is never the cause of cold symptoms.

So if your child has cold symptoms and a sore throat and gets tested for strep, it could be a false positive or it could just be a coincidence. For instance if your child has a cold or flu, then they go to the doctor or to school and are exposed to someone with strep throat. Now he or she has both. But they aren’t related.

And remember because they are different, they would each have to be treated differently and separately.

I hope this helps. We’ve been asked a lot about it lately. Stay healthy.

Dr. Bradley Mercer is pediatrician at Cook Children's Pediatrics (Fort Worth). To learn more about him and his practice, click here.

For most of her 20 years, Shanley Stuteville has been a patient at Cook Children’s.

She came to the medical center at the age of 3 after she began having seizures. Even as an adult, she continues to be seen by the Neurosciences team. After receiving care for so long, Shanley knows better than most how overwhelming a hospital stay can be, especially for younger kids.

“I was in the hospital last summer for my second phase [of testing], and my nurses were mentioning they were really glad I was older because a lot of the younger kids get scared,” Shanley said. “After that, my mom suggested I should write a book to help them.”

After years of testing and needles, Shanley has a wealth of empathy for younger patients. She recalls her initial feelings of fear of the unknown, but they were quickly lost when she realized her hospital was unlike any other.

Shanley began to write in July 2018, while scheduled to undergo testing at Cook Children's Neurology Epilepsy Monitoring Unit (EMU), where she would be watched 24/7 for four days to see what the source of her seizures was. The book became a family interest when her aunt began to illustrate Shanley’s medical team and created an animated world where leads, IVs and MRI machines weren’t so scary after all.

“Soon an IV was applied to my hand. Their magical spray made it something I could stand,” Shanley wrote. “It took away the pain and for that I was glad. It did not hurt, not even a tad.”

Shanley donated 50 copies of her children’s book to the Epilepsy Unit, but despite her appointments and hospital stays she’s found other ways to give back to her medical team. As a student leader at her university, Shanley completes a lot of service hours, but her service project last year was a hospital-sized treat.

As a “thank you” to her medical team, Shanley baked over 900 cookies for the Dodson Specialty Clinic staff. It took her a period of several school semesters to complete, but she delivered homemade cookies to each floor.

Although she spends an ample amount of time at Cook Children’s trying to figure out why she has seizures, it’s not uncommon for patients with epilepsy to have periods of time without seizures. Shanley would occasionally go 100 days without seizures, and even celebrated with a cake with her nearly lifelong doctor, Howard Kelfer, M.D., a Cook Children’s neurologist. However a life without seizures was never permanent.

“She’d go long periods of time without having a seizure and then one would come back around so it was really discouraging for them because they thought she was going to be over it,” Dr. Kelfer said. “It eventually became very clear that her seizures weren’t responding just to medications. It was always, ‘well she went this long without a seizure, maybe she’ll go longer this next time.”

Shanley was eventually determined as a surgical candidate after her time in the EMU last summer. Her surgery in May 2019 removed a portion of the front lobe in her brain. While she has not had a seizure since, it will take a year of no seizure activity before it can be deemed a success.

Shanley is now able to sleep through the night, a small comfort she didn’t have before her surgery. Her surgeons were also careful in the placement of her scar, which will be hidden by her hair when it begins to grow back.

“I have to say that I wouldn’t mind if it did [show],” Shanley said. “It will always be a reminder of the wonderful men and women at Cook, as well as hopefully provide an example to other children that they can walk through this and recover too.”

Shanley remains an advocate for younger patients, and is recovering quickly after her brain surgery. Her passion for patients inside the medical center has shaped her life for the last 17 years, and she is hopeful to make it a lifelong expression of gratitude.

“Shanley and her family come to all the family support groups and they’re willing to volunteer to talk to other families,” Dr. Kelfer said. “Shanley is extremely motivated to not allow her seizures define who she is.”

Following her surgery last month, Shanley will return to school this fall where she is studying to become a pediatric occupational therapist.

With so many people out on the road, it means more opportunity for danger.

From Dec. 20 to Dec. 31, 2018, the Trauma Department at Cook Children's reports 17 children were admitted at the Medical Center for injuries related to motor vehicle crashes and an additional 29 children were treated and released after a visit to the Cook Children's Emergency Department. One wreck during that time frame included a fatality and a total of three children died during the entire month of December.

“Unfortunately, we've seen children die around the holidays," said Debbie Wheeler, a Child Life specialist for the Emergency Department at Cook Children's. "With other traumas, we’ve seen young kids live by the grace of being properly restrained in the correct car seat. I really want to encourage parents to travel safely this holiday season, especially for everyone in the vehicle to be buckled up appropriately. It is really sad to see a patient hurt and have injuries that could possibly have been prevented if they were in a car seat, a proper car seat, or a seat belt.”

Motor vehicle injuries are the leading cause of death among children in the United States. Many of those deaths could have been avoided if parents took the extra time to make sure their children were properly restrained.

Sharon Evans, Trauma/Injury Prevention outreach coordinator at Cook Children’s, says it’s extremely frustrating because she has seen wrecks where one child who was properly restrained lived and the other child not buckled died.

“Honestly, it’s just so infuriating,” Evans said. “These crashes are preventable. It’s because the adults in the car aren’t doing something that could save their child’s life. I don’t think people think it can happen to them. But it can happen to anyone. It breaks my heart because these are deaths that shouldn’t occur if people would just place their kid in the proper car seat and buckle them up with a seat belt."

Holiday Injuries Treated at Cook Children's (Dec. 20-31, 2018)

The Centers for Disease Control and Prevention (CDC) found that in one year more than 618,000 children ages 0-12 rode in vehicles without the use of a child safety seat or booster seat or a seat belt at least some of the time. Statistics show this is especially a problem for Hispanics in the community. Ninety percent of the ejections that have occurred since April 2015 were Hispanic.

“I think a lot of it has to do with our culture,” said Magdalena Santillan, Trauma Injury Prevention Specialist at Cook Children’s. “These are people who love their kids, and they want to hold their baby. A lot don’t want to hear their baby cry, and so it’s easier to hold their baby in the car. They are showing love, but the consequences are too high and can be a deadly mistake.”

Texas law states that “all children younger than 8 years old, unless taller than 4’9”, are required to be in the appropriate child safety seat system wherever they ride in a passenger vehicle. The safety seat MUST be installed according to the manufacturer’s instructions.”

That means that when a child reaches his or her eighth birthday – no matter their height, it is legal for the child to use only the adult safety belt in the passenger vehicle.

However, the Texas Department of Public Safety states on its website that best safety practice is: “if the child is not yet 4’9”, they are better protected if they continue to use the appropriate child safety seat system until they can fit properly in the adult safety belt.”

“From a safety standpoint, I encourage parents to follow the best safety practice guidelines,” Evans said. “Graduating to a seat belt too early does keep children in the car if they crash, but when the seat belt doesn’t fit properly, it can cause serious injuries. That is something else we are seeing right now at Cook Children’s – children in a halo brace for severe neck injuries because they were in seat belts too young and too early.”

Call 682-885-2634 to set up a FREE car seat checkup to ensure your seat is properly installed.

What The Flu Is

The flu is a respiratory illness.

The flu happens every year. It hits hard from December through March (and other months, but those primarily). There are deaths every year. Kids, healthy people, old people, babies and folks with chronic illness die every year. This year we're trending lower at Cook Children's than in previous seasons. I really, really, really hope it stays that way.

Overall, remember that the flu is usually a "mild" illness (I mean, you feel like you've been hit by a truck, but we call that "mild" in medicine, ha).

It hits fast and fevers can go high, which is worrisome. But with a lot of rest, fluids, pain and fever reducers, things usually get better after 3-5 days. The cough and congestion can last for 2 weeks.

Sometimes, rarely, it can get bad. Really bad. The flu can cause: Pneumonia. Sinusitis. Ear infections. Brain inflammation (encephalitis). Heart inflammation (myocarditis). Asthma attacks in asthmatics. Death. That escalated quickly.

You hear us talk a lot about Flu A and Flu B. They are just two different strains of influenza. They are the two types that circulate the globe each year. In the states, Flu A usually arrives first and in general is considered the more severe strain. But overall, there is little difference in how they present clinically and we can’t really tell them apart without a flu test.

What The Flu Isn’t

The flu is not a stomach bug. There is no "stomach flu." That's called gastroenteritis. Your child is throwing up, but doesn't have a runny nose or cough? It's not the flu.

How Do You Prevent The Flu?

Scared to vaccinate? Hear stories? Hate shots? Have an uncle who loves to talk up a good conspiracy theory? Know this: some years, you can still get the flu even if you get the flu vaccine. It depends on how well we predict what strains of the flu will be circulating the globe that year. And some years, it's not a good match.

BUT it's usually milder, if you do get it. It GREATLY reduces your chance for hospitalization and death. I get it every year for my kids and my family. If you ask any pediatrician or ICU doc what viruses put fear into their hearts, I'll bet you influenza tops that list. I always tell my patients, even if it’s a "bad match" year, isn't a 30 percent effective seatbelt better than no seatbelt at all?

We can't know how good of a match the vaccine was until the flu season is over in April. So ignore the dramatic news reports.

Tamiflu can help make it less severe sometimes, for some people.

WASH YOUR HANDS! The flu can live on some surfaces up to 24 hours in cold weather! Think about all those door handles you touch! The cash you get handed back from the cashier! The snot that flies from every person's sneeze can cover a 6 foot radius around them! Wash. Those. Hands!

How Long Are You Contagious?

You are contagious with the flu 1-2 days BEFORE you start showing symptoms. How sneaky is that?

You are contagious 5-7 days after you start to show symptoms. Your KIDS can be contagious up to 10 DAYS after they start to show symptoms.

You should keep your kids out of school for at LEAST 24 hours after their last fever. This means fever without the use of meds to keep it down. If it's financially feasible for you, I'd even try to keep your kids out at least 7 days after the first symptoms start.

When Should You Worry?

Call us (or your pediatrician) anytime if you're worried about the flu. We can walk you through what is normal and what isn't.

These are the reasons to worry:

• Fast breathing or trouble breathing
• Bluish skin color
• Not drinking enough fluids
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms that improve but then return with fever and worse cough

Stay Healthy Friends,

Dr. Diane

To Learn more about this topic:

• Infuenza/Flu Information
• Is It a Cold or the Flu?
• Pediatricians Say Kids with Egg Allergies Should Now Get The Flu Shot

I have seen so much of this over the last month at Willow Park! So much so that I did some research to better inform our patients about this "fun" rash. I want to go over a few basics with you.

Fifth disease, also known as erythema infectiosum, is a common childhood virus. I typically stick with calling it “Fifth’s” because the medical term sounds a little bit like a Harry Potter spell. It is caused specifically by parvovirus. About half of us have been infected with the virus at some point in our life. It's usually spread from person to person through contact with fluids such as saliva, sputum coughed up from the lungs and nasal mucus. Yes, it's all the gross stuff. And no, this isn't the parvovirus found in dogs and cats. Contact with those animals with a parvovirus won't make you sick.

After a child is exposed to this illness it can be 1 to 2 weeks before symptoms occur.

Usually kids will start with nonspecific viral symptoms, such as fever, headache, redness or drainage to eyes, and sometimes nausea or diarrhea. Think flu-like symptoms. The most obvious part of this illness is the rash that comes with it. Fifty percent of children will have viral symptoms 1 to 2 weeks before the rash appears, 25 percent will have symptoms 2 to 5 days before and 25 percent of children will have no symptoms prior to the rash presenting. Kiddos are contagious during the viral symptoms stage of this illness.

The rash can be pretty shocking if you are not familiar with it! It is described as a “slapped cheek” appearance and a “lacy” body rash. After the rash appears the child is no longer contagious! You will still probably get some looks when you go to the grocery store, but you’re totally safe to be around others.

The rash is not harmful, but it is frustrating. It can last for several weeks and will look worse with heat, sun, stress or warm baths. Over time it gradually fades.

It should be mentioned that Fifth disease can cause complications during pregnancy. Most women have immunity to parvovirus, but about 5 percent of women are not. If a mom is not immune, the unborn baby can develop anemia, so it is important to let your doctor know if you have another child with fifth or have been exposed otherwise. The best way to prevent fifth disease is handwashing!

I'm posting a picture for reference, but if you have questions please call your pediatrician.

Tara, NP

If you are concerned about your child, here are seven facts you need to know:

1. Monitor your child for cough, particularly if it is occurring in severe spells or they cough so hard that they vomit. The characteristic whoop of whooping cough occurs when the child is inhaling after their cough.

2. Older children and teenagers may have severe cough but usually do not have the whoop. Infants are very susceptible to pertussis and have an increased risk of hospitalization and death.

3. Be aware that the vaccination for whooping cough is not perfect. Even if your child is vaccinated, you should be on the lookout for symptoms, particularly if you live in the Grapevine-Colleyville area or know that your child has been exposed.

4. If you are concerned your child might have whooping cough, your doctor can run a test and start treatment with an appropriate antibiotic. (Even with treatment, the cough can last several weeks.)

5. Students who are diagnosed with pertussis should remain home until they have completed five days of antibiotics or until 21 days have passed since their cough started.

6. Those who live in the house of persons diagnosed with pertussis should receive treatment to prevent the infection as soon as the infection is confirmed.

7. Other close contacts (not in the house) that should receive treatment for exposure include: those at high risk for pertussis (infants and pregnant women in the third trimester), those with health conditions that put them at more risk (severe asthma or immunodeficiency), contacts of a case that have contact with a child less than 1 year of age and contacts who work in high risk settings (NICUs, childcare and maternity wards.)

If you have further questions, please contact your pediatrician.

Related articles:

• Let's Learn About Whooping Cough
• Measles, Pertussis Increase due to 'intentionally unvaccinated'
• 3 Reasons to Still Give Your Kids Whooping Cough Vaccine
• Newborns Depend On Rest of the Family To Protect Them From Whooping Cough

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

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

Age (When will my kid stop barking?)

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

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

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

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

Pathology (What makes my kid bark?)

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

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

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

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

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

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

Two take home tips:

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

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

Christian Englert was born with genetic hand tremors, like many of his family members. The tremors were never an issue, especially when he was drumming or doing school work … until he turned 15 when they helped diagnose a rare brain tumor.

At his annual physical, Christian mentioned his worsening tremors to his doctor and was quickly referred to a neurologist. As a family, they decided to go ahead with an MRI for peace of mind. Christian’s hand tremors had been the only noticeable change so there wasn’t an excessive cause for concern.

“I was with Christian at the very first MRI that we thought was just going to be routine,” Christian’s mother Shanna Englert said. “They had told us they weren’t going to be using contrast, but they came in toward the end and said they wanted to just go ahead and do it. At that point, my mommy alarm was already going off because it wasn’t what we were told originally.”

Within a few minutes, the MRI started again but Shanna was called out of the room. Christian’s neurologist was on the phone. He explained he wouldn’t normally give this news over a phone call, but the urgency was critical. There was a mass on Christian’s brain.

“There was a six week period between the MRI and Christian’s original physical,” Christian’s father Martin Englert said. “At one point we were just about to cancel the MRI because no one thought it would show anything serious. What if we hadn’t done the MRI? We could have lost him.”

The following hours after that phone call became a blur, according to Shanna. They immediately went to Cook Children’s for severe hydrocephalus, a condition caused by the tumor and resulted in too much fluid and pressure on the brain.

“When we got to the hospital everyone was confused because he didn’t have any symptoms. He wasn’t tripping, no headaches and no nausea. There was nothing on our radar saying this MRI could show something so there was no preparation on our end,” Shanna said. “I went from picking him up at school at three o’clock to him being in brain surgery the next day. His surgeon called him a ticking time bomb.”

Christian went into surgery the following morning to relieve the fluid and pressure, and take a biopsy of the tumor. Ten days later, he was diagnosed with Pineal Parenchymal Tumor with Intermediate Differentiation (PPTID), a rare form of cancer with both malignant and benign cells with only five prior diagnosed cases in the U.S. since 2000.

“The list of possibilities was so long. As a mom, that list overwhelmed me more than the actual cancer diagnosis because you have all these dreams and plans for your child,” Shanna said. “What is life going to look like after treatment? There were just so many unknowns, and as a parent to hear all of this, it was just like all these dreams came crashing down.”

With so few cases to study, Jeffrey Murray, M.D., medical director of Neuro-Oncology at Cook Children's, and John Honeycutt, M.D., Cook Children's medical director of Neurosurgery, had to research the production of a plan to safely shrink and remove Christian's tumor.

“We began creating a treatment protocol after review of the medical literature and discussions with colleagues across the country,” Dr. Murray said.

Dr. Honeycutt performed Christian’s initial surgery to relieve the pressure on his brain, as well as the tumor removal surgery three months later.

"A tumor in the pineal gland is an unusual area in the brain because it’s in the center. It’s more difficult to get to and it has a lot of important structures,” Dr. Honeycutt said. “We went in with an endoscope and navigated down to the bottom where there’s a membrane and poked a hole in it. It created a detour for the spinal fluid called an ETV.”

Christian later underwent additional surgeries to remove the tumor, insert and remove his port for chemotherapy and realign his right eye, which occurred as a result of his prior brain surgeries.

Six months later, after four total surgeries, two rounds of chemo and 30 treatments of radiation, Christian was deemed to have no evidence of disease. To this day, the tremors aren’t related to his tumor but acted as a signal that something had changed.

“Even though we’re now a part of a group that we didn’t want to be in, it’s turned out to be more of a joyful mission. Cook Children’s has become a part of our family. Dr. Murray, Dr. Honeycutt, nurses and staff that support them are people that are a part of our lives,” Martin said. “When we walk in there it does feel like a triumph, but it also feels like we have an opportunity to bring hope to the folks there. We know there are some stories that don’t end as ours did. We want to continue to be a light for others.”

Christian has now been in remission for four years. He still loves to play the drums in his spare time and has just started his sophomore year at a local university. He remains an advocate for childhood cancer awareness and the Make-A-Wish Foundation.

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's hard to turn on the news and not see a story about the dangers of e-cigarettes or vaping. 

As of Aug. 28, 2019, there have been nearly 200 reported incidents of vaping-related illness in 22 states, resulting in at least one death. 

Earlier this summer, 17-year-old Tryston spent 18 days in Cook Children's ICU, needing machines to keep him alive. He lost 30 pounds, and had to re-learn to walk normally again because he had no muscle mass in his legs anymore from being bedridden for almost three weeks. He is still coughing at times and feels tired. A clear answer for why his lungs failed him was never found, but doctors believe it was because of his vaping.  

“We don't know for sure. But there are literature reports of hypersensitivity pneumonitis from vaping. I told him no inhaling anything again, ever. We still don't know for sure what the trigger was. But it is very plausible that it could be due to his vaping,” Suzanne Whitworth, M.D., medical director of Infectious Disease at Cook Children's said.

Tryston was one of a growing number of teens who are vaping. Statistics show 45% of U.S. teens have tried it. 

While the Centers for Disease Control and Prevention (CDC) says E-Cigarettes may have the potential to benefit adult smokers if used as a complete substitute for regular cigarettes and other smokeless tobacco products, they are not safe for youth, young adults, pregnant women or adults who are currently using tobacco products. 

The CDC adds there is "a lot to learn about whether e-cigarettes are effective for quiting smoking" and "if you've never smoked or used other tobacco products or e-cigarettes, don't start."

Diane Arnaout, M.D., a Cook Children's pediatrician in Fort Worth, wrote the first story about Tryston. He was her patient and he asked Dr. Arnaout to get the word out about the potential dangers of vaping. 

"And though they claim to be a “healthier option” to regular cigarettes, I beg to differ. Inhaling chemicals is inhaling chemicals. There are over 40 different chemicals in vaping liquids. And they can cause some major damage," Dr. Arnaout wrote. "They can hurt delicate lung tissue. We are seeing more and more reports of teenagers and young adults suffering severe lung injuries and seizures coming out in the news lately.

"I’m really worried about how addictive these things are. Kids who want to quit are finding it more difficult to do so than if they’d smoked a pack a day."

Don Wilson, M.D., an endocrinologist at Cook Children's, has been speaking out about the dangers of e-cigarettes for quite some time. Dr. Wilson, who is an an Endowed Chair of Cardiovascular Health and Risk Prevention, offers this basic information for parents:

More On This Topic:

• Why Doctors Believe Vaping Landed 17 Year Old In ICU
• Surgeon General’s Advisory on E-cigarette Use Among Youth
  • Download pdf icon[PDF–572 KB]external icon
• E-cigarettes Shaped Like Flash Drives: Information for Parents, Educators, and Health Care Providers
• Teachers and Parents: That USB Stick Might Be an E-cigarette
• E-cigarettes.surgeongeneral.govexternal icon
  • Information from the Surgeon General on the risks of e-cigarettes for young people, and includes free tools such as a parent tip sheet for talking to teens about e-cigarettespdf iconexternal icon [PDF – 5.2MB].
• Teen.smokefree.govexternal icon
  • Information for teens who use tobacco products, including tips on how to quit.
• Electronic Cigarettes
  • Basic information about e-cigarettes from CDC’s Office on Smoking and Health.

As a pediatrician, I have been lucky to practice medicine in the post-vaccine era. Although I have watched kids struggle with whooping cough, meningitis, mumps and pneumonia, I am happy to say I have never seen many of the vaccine-preventable diseases. I rely upon my education and training to know about the diseases and recognize them should the need arise.

I do frequently wonder, ‘What was life like for families and children before vaccines were introduced?’ How did people manage the illnesses and anxiety that came with the disease?

For a firsthand answer, I only had to talk to the person sitting at my dining room table during a typical weekend family dinner – my mom.

It was the summer of 1949. While other children were skipping rocks and riding their bikes, my mom was lying in a hospital bed as one of many children struck down by polio.

The illness began as a fever with trouble swallowing and weakness in her left leg. The doctors quickly admitted her to the hospital for quarantine and treatment. Her most vivid memory of the time has to be of the spinal tap used to aid in her diagnosis. At the time, there were no child life specialists to comfort her. She was told to hold still and if she moved the test might kill her.

After 3 months in the hospital with only her mother allowed to stay, her symptoms seemed to be worsening. Her kind physician came into the room one day to visit and cheer up the family. His kindness unfortunately, resulted in him contracting the disease and being confined to a wheelchair for the remainder of his days. After all, back then doctors did not even realize the value of handwashing.

I asked my mom what people thought about polio in the pre-vaccine era. “Everybody was scared to death of catching it! They did not know how they got it but knew it was prevalent in the summer months. They tried to avoid the sun and swimming holes since those seemed to be related.”

We now understand the transmission of polio much better. Polio comes from a virus that is highly contagious. It is spread person to person through sneezing, coughing or contact with human feces. Before the successful introduction of the polio vaccine in the 1950s, the disease resulted in the paralysis of 15,000 people per year. Since 1979, no cases of polio have originated within the United States but cases can be brought in by travelers with the disease.

My mom was one of the lucky ones. Just as a conversation with her medical team was turning to placing her in an iron lung to support her breathing she began to recover. The impact of the illness, however, continues to this day with residual weakness in her legs that makes walking for her a constant challenge.

I asked her what she thought about vaccines as a mom and a grandmother. She responded, “I experienced polio and its effect on my life. I want all my kids and grandkids protected so they don’t have to go through what I did.”

Vaccine-preventable diseases such as polio and the re-emerging measles and mumps are not historically that far away from us. We cannot forget the tremendous impact these diseases have had on the lives of so many before the introduction of vaccines.

If you want to learn more, you can check out the CDC website on polio. 

Better yet, just look across the table on a sunny Saturday afternoon and if you are fortunate to do so, ask the folks who lived it. Their stories and experiences are powerful.

More Information On This Topic

• 'I'm Worried Too.' Pediatricians Concered As Texas' Nonmedical Vaccine Exemption Rates Hit All Time-High
• 5 Questions We Get Asked About Vaccines Answered
• Vaccines for Your Children: 9 Facts Parents Need To Know
• Vaccines and Immunizations
• Information for Parents

Earlier this summer, my 17-year-old patient Tryston just wasn’t feeling like himself.

“I was tired all the time. My energy was low. I was losing some weight.”

Then, things quickly turned downhill. He started having chills. He was feeling really exhausted all the time, was nauseous, and had some fevers.

When he started becoming short of breath and having some chest pain, he and his mother decided it was time to head to an urgent care clinic, where he was given antibiotics and flu medications.

In 24 hours, he felt worse. His breathing became more difficult. Something was definitely wrong.

He came to Cook Children’s, and the doctors and nurses quickly realized what poor shape he was in. X-rays showed something that looked like pneumonia on both sides of his chest. But the specialists were confused, because it just wasn’t obvious.

Within 48 hours however, what WAS obvious was that Tryston was getting worse.

As his Cook Children’s pediatrician, I was sent daily updates about him. I found myself holding my breath every time I opened the update – and audibly gasped the moment I realized that he was intubated.

This means a tube was stuck down into his windpipe to breathe for him.

And the tube stayed there for the next 10 days. Machines were keeping Tryston alive. He was in the ICU, where the sickest children in the hospital stay.

“I lost a lot of sleep over this kid,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. Dr. Whitworth wasn’t sure what was going on, and became very close with the family.

Was it an infection? No organism seemed to grow from cultures. Was it an autoimmune disease? The rheumatologists didn’t think so.

Even a lung biopsy – a piece of his lung which was cut out and examined under a microscope – didn’t seem to hold any clear and obvious clue as to why he was so sick. His lungs just failed, and he was in something called respiratory distress.

He was put on numerous antibiotics and antifungal medications to see if they’d help. He was needing more and more oxygen. He even needed special high-frequency ventilations (think little tiny rapid puffs of air) to keep his lungs open and working.

There’s one thing I haven’t mentioned yet. The one thing that was in the back of everyone’s minds.

One thing that Tryston mentioned to the staff of Cook Children’s before he got very ill is something I already knew, and had talked to him about the year prior.

Tryston liked to vape.

Most of you have heard about “vaping” in some way or another, but if you haven’t watched the news lately (or been in my office lately - because jeez, I am hearing more and more about it daily), “vaping” is when someone smokes an aerosolized chemical, usually from something called an e-cigarette.

Vaping is becoming VERY popular amongst teenagers. Statistics show 45% of U.S. teens have tried it. The Centers for Disease Control and Prevention is now investigating the "sudden emergence of severe lung disease linked to vaping in 14 states. Ninety-four possible cases of severe lung illness associated with vaping have been reported from the end of June to Aug. 15, the CDC reports.

Corwin Warmink, M.D., the medical director of Emergency Services at Cook Children’s, says he has seen multiple patients come through the ER and his team sees a child every week for vaping. But it’s not just teens, we are also seeing younger children, 5 and under, who have ingested vaping liquid. Scary stuff.

The most popular types look like USB devices. They’re super easy to hide. They have different “fun flavors” like mango, crème brulee and fruit medley. Some of the devices are even cute, with teddy bears on them.

They are more addictive than cigarettes. One Juul pod (currently the most popular brand) has the same amount of nicotine as an entire pack of cigarettes! “And I know lots of kids smoking 2 or 3 pods a week,” Tryston told me.

And though they claim to be a “healthier option” to regular cigarettes, I beg to differ. Inhaling chemicals is inhaling chemicals. There are over 40 different chemicals in vaping liquids. And they can cause some major damage.

They can hurt delicate lung tissue. We are seeing more and more reports of teenagers and young adults suffering severe lung injuries and seizures coming out in the news lately.

I’m really worried about how addictive these things are. Kids who want to quit are finding it more difficult to do so than if they’d smoked a pack a day.

Want to know why you should quit?

Tryston spent 18 days at Cook Children’s.

He lost almost 30 pounds. He is re-learning how to walk normally again. He has no muscle mass in his legs anymore from being bedridden for almost three weeks. He is still coughing at times. He feels very tired.

A clear answer for why his lungs failed him was never found.

“We don't know for sure. But there are literature reports of hypersensitivity pneumonitis from vaping. I told him no inhaling anything again, ever. We still don't know for sure what the trigger was. But it is very plausible that it could be due to his vaping,” Dr. Whitworth said.

The general consensus was that his lungs were severely injured, and I believe his vaping habits had a lot to do with it.

Two days after going home, he walked into my office for a follow-up visit. We had a very real, very brutal heart-to-heart.

I said, “Tryston, buddy…you know you could have died, right?” and he looked me in the eye and said “I’ll never touch the stuff again, Dr. Diane. And I want everyone to know that. I want to tell my story. And if I can just keep one kid from going through what I did, it’ll all be worth it.”

So here I am, telling you his story. Tryston is a great kid with a great heart. He made a mistake, one that LOTS of kids are making, because they assume e-cigarettes are “healthier” than regular cigarettes.

And Tryston wants us all to learn from it. Do me a favor and do what he has asked: print this out, and give it to your teenage son or daughter. Ask them to read it.

Let them know it’s just not worth it.

Learn More About This Topic:

• Vaping, Juuling, Dabbing (AAP Environmental Health) - Source for statistics in article
• New York Times: Dozens of Young People Hospitalized for Breathing and Lung Problems After Vaping
• Huffington Post: CDC Launches Probe Into Surge of Severe Lung Disease Cases Linked To Vaping
• Juul, Other E-Cigarettes Called an 'Epidemic' By FDA Chief
• E-Cigarettes Exposes Teens to Cancer-Causing Chemicals, Future Cigarette Smoking
• Adding flavors to e-cigarette liquids changes chemistry, creates irritants (Duke University)
• Tobacco Use Increases By More Than 38 Percent Among High School Students

Regardless of statistics, research or science, some parents will never change their minds.

But for the vaccine-hesitant parents who are truly trying to make the most informed decision for their child, let’s take a look at some of the most commonly asked questions and concerns we read on social.

The responses to these questions are based on extensive research conducted by the Cook Children’s Vaccine Clinical Guideline teams, comprised of primary care and specialists in their field. The team cited 99 different sources during their research and their work was approved by the Cook Children’s Medical Center’s Clinical Excellence Committee.

We hope this helps to answer some of your questions.

1. Do vaccines work?

Immunizations are considered to be one of the greatest accomplishments of modern medicine. Compared to pre-vaccine statistics, we’ve seen a reduction in the number of cases of measles by 99.9%, mumps by 95.9%, pertussis by 92.2% and rubella by 99.9%.

This is important because many vaccine-preventable diseases require high vaccination rates to maintain community immunity. For most of the vaccines that are currently available, there must be a population immunization rate for at least 90% to ensure consistent community immunity and some diseases that are highly contagious, such as pertussis or measles, require population immunization rates of at least 95%.

The maintenance of community immunity protects people who received the vaccine but were unable to generate a lasting immune response to the illness, as well as those individuals who are too young to receive a vaccine or have medical reasons that prevent them from receiving a vaccine.

2. Do vaccines cause autism?

This is a most difficult subject to approach because some parents make the direct link to their child’s autism to the vaccines they received.

Because MMR is one of the vaccines that is given to children between 12-18 months and signs of developmental conditions such as autism develop around the same time, it’s easy to see why families would perceive a cause and effect relationship between the two.

This argument was strengthened when Andrew Wakefield published an article in The Lancet in 1998 that claimed a link between the MMR vaccine and autism. Since his initial article was published, investigations have found that Wakefield’s study was flawed by research misconduct, conflicts of interest and lies. This ultimately led the Lancet to retract his original article. In 2010, Wakefield was barred from practicing medicine in Britain.

Dozens of studies have been conducted to look for any possible link between vaccines and autism and these studies continue to confirm no link exists, and that vaccines are safe and effective.

3. If children receive too many vaccines, can it overload their system?

While the number of vaccines that children are given has increased over time, children are actually being exposed to fewer antigens than they had been previously – thanks in large part to the increased purity of the pertussis vaccine.

Some parents may have concerns that vaccines can overwhelm a child’s immune system, but this simply isn’t true. When a child is born, they leave a relatively sterile environment and within hours their GI tract becomes heavily colonized with bacteria. They begin to produce what’s called a specific secretory IgA against these bacteria within the first weeks of life. A 2002 study, published in Pediatrics, states that an infant has a theoretical capacity for up to 10,000 vaccines at any one time.

Multiple studies have been done that show vaccines do not cause an increased risk of infection for children. One study even found that children who received vaccines had a lower rate of infections from vaccine-related and unrelated pathogens. There is also no evidence to support the idea that vaccines lead to increased risk of SIDS. Research has found that vaccines significantly reduced the risk of SIDS.

Children with severe immunodeficiencies who receive live viral vaccines may be at risk for developing an infection or disseminated disease. The biggest concern would be children with T-cell immune deficiencies receiving live virus vaccines. Fortunately these immune deficiencies are usually diagnosed around 6-8 months well before the first live virus vaccines are scheduled (12 months). 

With all that being said, many children with immunodeficiencies can receive vaccines safely, such as certain children with HIV or certain children with malignancies.

4. Is it really hygiene and better nutrition that caused disease reduction and not vaccines?

Statements like this are commonly found in anti-vaccination literature and it implies that vaccines are ineffective and unnecessary. While better hygiene and nutrition have certainly helped to improve the health of our population, it ignores the dramatic effects of vaccination.

If hygiene and nutrition were responsible for disease reduction, you would expect all disease incidence to decrease at around the same time, but this is not what we have seen. Instead, we have seen a recurrent pattern of disease reduction shortly after a vaccine against that disease has become available.

For example, while there was yearly variation in rates of measles, it wasn’t until a vaccine was released and widely distributed in 1963 that we saw a permanent drop in measles cases. Another example is Haemophilus influenza type b, which remained prevalent until the early 1990s when a vaccine that could be used in infants was developed.

Another way of debunking this myth can be to look at individual countries who saw a decrease in their immunization rates. Great Britain saw a dramatic drop in their immunization rates for pertussis in 1974, which was followed by a pertussis epidemic with more than 100,000 cases and 36 deaths by 1978.

In Japan, a drop in pertussis vaccine rates around that time from 70% to below 40% resulted in an increase of pertussis cases from 393 in 1974, to 13,000 in 1979.

5. If your child is vaccinated, why do you care if my child isn’t?

The increasing prevalence of vaccination acts to prevent the circulation of an infectious organism within the community provides benefit to everyone, even those who aren’t vaccinated. This is referred to as community immunity. Community immunity is an important means of protecting the elderly, the young and those with medical conditions that prevent them from receiving vaccines.

For most of the vaccines that are currently available, there must be a population immunization rate of at least 90% to ensure consistent community immunity and some diseases that are highly contagious, such as pertussis or measles, require population immunizations rates of at least 95%.

The maintenance of community immunity is important to protect those individuals who received the vaccine but were unable to generate a lasting immune response to the illness, as well as those individuals who are too young to receive a vaccine or have medical reasons that prevent them from receiving a vaccine.

More on This Topic:

• Vaccines for Your Children: 9 Facts Parents Need To Know
• Vaccines and Immunizations
• Information for Parents
• Immunization Collaboration of Tarrant County
• Childhood Vaccine Assessment Tool (CDC)
• American Cancer Society and HPV
• Centers for Disease Control and Prevention
• Vaccinate Your Family
• Voices for Vaccines
• Allied Vaccine Group
• Texas Department of State Health Services

Making a school “seizure ready” can entail a number of steps and it is important to get started on these as soon as possible. M. Scott Perry, M.D., medical director of Neurology and an epileptologist at  Cook Children's, offers the following advice.

Step 1: Does your child have a seizure action plan?

One of the most important components of being prepared for the school year is having a plan in place should a seizure occur. A seizure action plan is a form provided by your medical team which describes the types of seizures a child has and what to do if one occurs. The plan covers the key components of seizure first aid, as well as for instructions on how and when to use rescue medications for the child’s seizures. A standard form is provided by the Epilepsy Foundation and is commonly used.

Click here for a Seizure Action Plan from the Epilepsy Foundation.

For future reference, I encourage parents to begin requesting updated Seizure Action Plans at least a month before the school year starts, as many clinics get thousands of requests before the start of school and completing them may take time.

Step 2: Is your child’s rescue medication appropriate for their current age and weight?

Rescue medications are commonly prescribed to patients with epilepsy and are most often used for seizures that are prolonged or occur in clusters. Each patient will have unique circumstances for which a rescue medication may be appropriate. Some patients may not have a rescue medication as part of their Seizure Action Plan – for example, if their seizures are rare, well-controlled, and typically very brief.

A variety of rescue medications are available. For prolonged seizures, particularly convulsive type, patients may use rectal diazepam or intranasal midazolam. These medications are favored because they can be absorbed quickly for rapid treatment of the seizure and they don’t require putting anything into the mouth of the person that is seizing. Rectal diazepam comes ready to use for the age/weight of the child. Currently, nasal midazolam will have to be measured out by school staff before administration, but a new ready-to-use formulation has been approved by the FDA and should be available soon.

For patients with clusters of brief seizures, rescue medications such as clonazepam can be given by mouth between seizures. Several other medications, such as diazepam, midazolam, and lorazepam, also come in oral formulations that might be swallowed or put between the gum and cheek of a patient for effect.

It is very important that parents and their providers make sure the rescue medication prescribed for the child is appropriate for their age and weight. As a child grows, the dosing of medications will change. For those patients that have rare seizures and rarely require rescue medications, it is possible that the dose prescribed years ago may no longer be appropriate and therefore, may be less likely to work if the dose is too low.

Step 3: Can your child’s school administer the rescue medications provided?

It is important to know what medications your school is able and willing to give. While rectal diazepam is commonly used in schools, there are some school districts in the U.S. that only allow the medication to be given by a school nurse or similar medical personnel, even though the drug was designed to be administered by laypeople. If your school does not have a full-time nurse, there may be times when the medication cannot be given and an alternative rescue plan may be needed. Likewise, some school districts will not administer nasal midazolam because this formulation of the drug is not FDA approved to be utilized in this manner, though in the medical profession, we’ve used it this way for many years. Talk to your school about the seizure action plan recommended by your medical team. If they are unable to give rescue medications suggested, talk to your team to see if there are alternatives or if training can be provided to the school to ensure the rescue plan is followed.

Step 4: Is your child’s school “seizure ready”?

Probably the most important step in making sure your child is safe at school is making sure the people caring for them during the day are prepared to recognize and treat seizures. Despite how common epilepsy is, many people are only familiar with one type of seizure – tonic clonic (previously referred to as “grand mal”).

It is important that teachers and staff understand what seizures look like for each child with epilepsy, so they can recognize when rescue treatments may be needed, but also to keep parents informed if seizures are occurring frequently and may require a visit to the doctor to discuss treatment changes.

Some seizures, such as absence and partial seizures, may only manifest as staring or decreased response. For these cases, it is important that staff are aware so they can recognize seizures and don’t confuse these behaviors with simply ignoring instructions or bad behavior. Finally, for some children, their first seizure may occur at school and it is important that staff be able to recognize seizures in those who may have no prior history.

There are a number of ways for school personnel to become educated about epilepsy. The Epilepsy Foundation provides many resources including online and in-person training of school nurses and staff on seizure recognition and first aid.

Click below for a couple of great tools:

Managing Students with Epilepsy – school personnel and school nurse training

Seizure Training for School Personnel

The Epilepsy Foundation will also provide an ECHO course for school nurses starting October 2019. This is an online, interactive course for school nurses that includes instruction from epilepsy experts and allows for collaborative case presentations to discuss seizure recognition, first aid, and rescue treatments. Information for this course will be available on www.epilepsy.com in the near future. A helpful Seizure First Aid poster can be found by clicking here.

Finally, the Epilepsy Foundation will host a webinar from 7-8 p.m. CST on Wednesday, Sept. 25, 2019, on rescue therapies are open for anyone to attend.

Resources For Parents:

• Cook Chidren's Comprehensive Epilepsy Program
• Epilepsy
• Sam's Law
• Seizure Action Plan
• Seizure First Aid
• Seizure Training for School Personnel
• Managing Students with Epilepsy - School Personnell and School Nurse Training

This may not be one of the questions you expect to hear from a pediatrician during a well-child visit, but it’s always on the checklist for Vanessa Charette, M.D., a Cook Children’s pediatrician in Fort Worth.

Dr. Charette asks this question for a few reasons. For one, she’s genuinely interested and she’s even gotten some great recommendations of books to read to her children.

“I also ask because I want your child to know that adults around them think reading is important and I am hoping this small question may help them grow up with a love for reading,” Dr. Charette said.

It’s never too early to begin reading to your child.

Ear and brain structures for listening begin working between 25-39 weeks of gestation. At about 28-30 weeks, connections between the brain and the ear start happening.

“For the auditory brain to develop, babies need to listen to language, music and all different kind of sounds,” wrote Becky Clem, an education coordinator for Rehab Services and a speech-language pathologist and listening-spoken language specialist. “Reading aloud is a great way to help children learn to listen and talk. Reading aloud to that growing baby in utero is a jump start to listening, talking and future reading. Reading aloud to children of all ages has huge benefits.”

Clem said the first three years of a child’s life is the most important time for learning. Reading aloud to children boosts their vocabulary, listening and talking skills.

Research on reading aloud to children tells us that it:

• Is the single most important thing to help a child get ready to read and learn.
• Helps a child learn more, unique words. Children who know more words do better when starting kindergarten.
• Helps a child’s brain develop. Language development is vitally important from birth to 3 years.
• Helps a child love to read.
• Helps a child learn.
• Helps parents bond with their child.
• Sets an example for children that reading is important and fun.

Of course, your toddler won’t sit still, but Dr. Charette says parents shouldn’t worry about reading the entire story to them. “Look at the pictures, point things out on the pages, have them find things on the pages,” She said. “The Richard Scarry books are great for this and we read them over and over when my kids were this age.”

For the school-age child that maybe doesn't love reading yet: Dr. Charette suggests getting them books on topics they love. Does your child love Legos? Then Lego® books it is. Do they love animals? Then try National Geographic kids’ animal fact books. They have lots of pictures and fun, short reading sections. Is your kid funny? Then try a joke book. But Dr. Charette warns as only a mom can: "This leads to the most ridiculous knock-knock jokes being read aloud to you.”

“For your older school-age or teen child: Be a two-person book club,” Dr. Charette added. “I have done this a few times as my children became older and they loved it when I read a book at the same time they were reading it. It allows them to talk to me about the story. They were so excited to share with another person what is happening with the characters and what may happen next.”

Clem understands that families lead busy lives in today’s world, but she offers these tips for reading aloud into your day and week:

Some ideas for fitting reading aloud into your day and week:

• Visit your local library. Get a free library card for you and your child. Check out books weekly. It’s FREE!
• Visit read aloud storytime at the library.
• Read aloud at breakfast time.
• Keep books in the car to read while waiting at appointments.
• Make bedtime book reading a family tradition.
• Have a family storytime every week.
• Keep waterproof books in the bathtub for a quick read during bath time.
• Read together as a family every day.
• Have older siblings read aloud to younger siblings.

For more on this topic, read Becky Clem's blog, "Raising Bookworms."

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.

Recently, Dr. Justin Smith talked about things to remember before your child heads back to school. He specifically mentioned you and your child’s anxiety as back to school approaches. It is true that pediatricians experience first-hand the anxiety that the transition back to school can create. Working in the emergency room as a child life specialist, offers a front row seat to the same pressures and stress. We often see a wave of kids struggling with anxiety and having a difficult time coping as they go back to school. As parents, we are often struggling too. Getting back in the swing of things and managing our kids’ emotions can feel overwhelming and often disheartening.

I want to challenge you, though, as parents and caregivers to enter into this time of transition with some tools in your back pocket ready to combat the stress and anxiety that back to school can bring. As a child life specialist, we are on the hospital side offering kids normalcy in the midst of a stressful situation. We are creating space for kids to learn to cope and develop tools that they can use throughout their lifetime – not just during hospitalization. As parents we need to create this same space in our homes. Here’s a few tips for creating space to cope during this transition. Remember that not every family and schedule can look the same. As you read, think of ideas that fit into these tips but also fit into your family’s culture.

1. Celebrate!!! Instead of back to school being a bummer, make it a celebration. Have traditions around the first day of school. We always have cinnamon rolls on special days so the first day of school is no different in our family. I usually write my girls a special note to commemorate the day and have a Dollar Store goody sitting at their spot for breakfast. I have all girls, so we have a tradition of getting nails done before school starts. School supply shopping day usually includes a lunch or dinner out to eat at a favorite place. You could go to their favorite restaurant or make a special date for a fun activity. These are just a few ways we celebrate, but there are LOTS of ways to celebrate a new school year, the end of the school year and all the things inbetween!
2. Create a routine. Often during the summer, our routine is gone or at best inconsistent. Going to school can provide the opportunity to revamp your routines and boundaries. In our home, there is no screen time before school, no matter how early you get up. There is an order to our mornings that include breakfast, getting dressed, brushing teeth, packing backpacks - all while music is playing in the background. My kids know what to expect each day when they wake up. We also have afternoon routines- a few minutes for a show when they get home, quiet/homework time before dinner and always set aside time for reading. While routines need to include the mundane things, it’s also good to include FUN in your routines. We have fun weekly routines and traditions. We get ice cream after school every Wednesday. We often have movie/pizza nights on Fridays or Saturdays. This year we will be adding a weekly job for our girls to accomplish also. Setting expectations and boundaries for kids sets them up for success. My kids know when to expect screen time, ice cream and family activities, and they can look forward to it without always asking for the next thing.
3. Be nosy! What does that mean? Well, you are the parent. You get to know ALL the things simply because you are the parent. Just because your kiddo is away from you for 7 hours a day or more, you still get to know what is happening in those hours. Ask your kids about their day with open-ended questions - stay away from yes or no questions. Get to know the people at school…your kids’ teachers, principal, even cafeteria workers. Take time to honor them so that they can know and respect you. Get to know your child’s friends and ask who they are eating with, playing with, etc.? Know the other parents in your kids’ class so when the stories don’t quite line up, you can get some more details. Know your kids’ teacher. While you want to be respectful of their time, it is important to address things that come up for your kids during the year. Don’t be afraid to ask questions to know more. Send the email to clear up confusion. Make the phone call when you see a red flag. The more you know, the more you can engage your child. Plan to eat lunch with your child regularly. That might be once a month, but your presence in that space matters…mostly to your child. Volunteer in your child’s classroom or at the school or offer to do things from home. This allows you to know what to ask and to advocate when and where there is a need. You don’t have to be an infamous “helicopter parent,” but being present (and a little nosy) creates space for your kids to trust you and know that you are with them and for them no matter what.
4. Focus on character. So often much of school feels centered around grades, testing, and measured successes. Often those are measured against other kids and expectations are high. While it is incredibly important for kids to master subjects and advance academically, their character will take them through all of life ~ all the challenges that they will face. And while math facts are super important, they won’t teach them how to be a good friend or show respect. I try to assess what character quality my kids need encouragement in and spend time fostering it. Whether it be self-control, patience, humility or the many others, we take time as a family to talk about these things. One thing I do for my kids is start a notebook at the beginning of the year that goes in their lunch box. I focus on character and encouragement in that notebook. I write a note or draw a picture each day that hopefully reminds and encourages them in that character trait. I also always let them know they are loved. I remind them at the beginning of each day, usually on the way to school, to choose others before themselves and treat others as they would like to be treated. We encourage trying over perfection, kindness over being right, and gratefulness when things aren’t going your way. The work will always be there, the vocabulary and math facts, but I don’t want my kids to get so lost in those facts that they forget about being human.

We want our kids to feel prepared and ready for this next year. Preparation alleviates some anxiety while creating space to teach them how to cope with the inevitable stress that comes with this transition. Celebrating, establishing routine, being present (aka a little nosy) and focusing on their character are all ways that you can help your children cope and combat the stress and anxiety of going back to school.

For most of us, a snake bite of any type would send us directly into a panic. However, when Ray was bitten while working in his lawn, he was hesitant to go to the doctor. He didn’t want to overreact. He wasn’t even sure he’d been bitten because of the heavy gloves he wore outside.

“Initially I knew it wasn’t good, the numbness and tingling. I told my wife that I thought I got bit by a snake but I never saw it because I was trimming the shrubs,” Ray said. “I actually called the Emergency Department at Cook Children’s and talked to one of the physicians I work with, and he advised that I go into my local ER to get some labs.”

While Ray was on the phone with the doctor, his wife went to the front yard where he was bit, found the snake and killed it. Later, poison control confirmed the snake hiding in their shrubs was, in fact, a venomous copperhead.

Ray went to Texas Health Resources for testing and bloodwork, and eventually started Crofab (an anti-venom) in the following hours. He spent the next four days in the hospital, receiving additional doses of antivenom while waiting to regain use of his left hand.

Providers aren’t immune to the fear of the unknown that patients often experience. It was in that same unease that he began to sympathize with his own patients.

“Going from a caregiver and being placed into the role of a patient is something I’m going to take away from this,” Ray said. ”I was really anxious in the waiting room because of the swelling, I even knew the science behind it all, but it was still a source of anxiety for me so for children to be a patient, it’s even harder on them.”

Now fully recovered, Ray’s experience has given him a deeper level of empathy for his patients and has made him a better provider for children with anxiety.

“Seeing the compassion of the other physicians and the nurses is something that is going to make me a better provider going forward,” Ray said. “This experience is going to make me more compassionate. I think whenever a provider is forced into the role of a patient it can create more empathy for their future patients.”

Related Topic:

• After the Bite: When and Why Antivenom is Used at Cook Children's
• 1 Year Old Bitten By Rattlesnake Recovering At Cook Children's
• Patients Bitten By Snakes
• What Are The 4 Venomous Snakes Found in Texas?

Sadly, these heartbreaking occurrences no longer shock us. But that doesn’t make these events any easier to talk about with our children, especially as they occur more and more often.

So, where do we go from here and how do we make sense of any of this?

Lena Zettler, director of Psychology at Cook Children’s, says parents should spend time listening and watching their kids after tragedies such as what took place over the weekend. When talking to your children, Zettler encourages parents to focus on what makes their kids safe.

“I know it seems more difficult to do, especially when something like a shooting is close to home or in our same state, but our job as parents is to reassure our kids about the ways they are safe,” Zettler said. “Sadly in this day and age, that means talking about the drills our children perform in school to protect themselves. Maybe, as a family, you have your own safety plan. Remind your children of the safe people in the world who are looking out for them, such as their parents, grandparents, teachers, police or other relatives or close family friends. A good idea, may be to sit with your child and make a list of all the safe people they know in the world.”

When talking to your children, Zettler encourages parents to focus on what makes them safe, based on their child’s specific fears. She suggest parents ask opened ended questions before providing information. For instance, with the El Paso shooting, we are hearing that racism and targeting immigrants played a role. However, don’t assume that kids have made the connection between race and this incident. Find out what they know and what scares them and address those specific issues.

“Focus on what things make your children safe, based on their fears,” Zettler said. “Respond with your eyes, body language and words when kids express their fears. Anytime we are scared, our brains read body language and facial expressions more than words. Kids may express these fears verbally or behaviorally. Pay attention and provide reassurance when you see they need it.”

Lisa Elliott, a licensed psychologist and clinic manager of Cook Children’s Psychology Clinic, said the events of the weekend came up during most of her sessions on Monday. She reminded the children to focus what Mr. Rogers’ mother taught him, “To this day, especially in times of 'disaster,' I remember my mother's words and I am always comforted by realizing that there are still so many helpers ― so many caring people in this world.”

“There are always helpers in crisis and there are more helpers than there are people who do hurtful things,” Elliott said. “Today, this was once again helpful for each one of the kiddos who brought this up. We actually did an exercise where the kids looked up all the stories of those who helped people.”

Joy Crabtree, Psy.D, a licensed psychologist for Cook Children’s Behavioral Health in Southlake, said parents must set the example for their children to follow. Crabtree encourages a discussion of the events, but only if your youngest children have learned about the incident elsewhere. If they haven’t heard about it, don’t share information with them. If they already know about it, answer their questions and most importantly, reassure them as best you can.

For example, talk about the good people like the first responders who took care of the people who were hurt and everyone who worked together to make sure people were safe.

“Parents have to stay calm and cannot be glued to the TV,” Crabtree said. “If you have an elementary-aged child, and they haven’t learned the news, there’s certainly no reason to sit down with them and show them the story. There’s no need to cause fear in your children. By the time children are 7 or 8 years old, they can distinguish fact from fiction and will understand the consequences of what they are watching. If they have heard about it, take as much time as needed to sit down with them and have a discussion/answer session, providing reassurance and support. Answer their questions, but only their questions. There’s no need to add more information that may scare them even more.”

For older children, such as those in middle school and high school, Crabtree encourages parents to again determine if their child is mature enough to handle the information. If parents feel they can handle it, use the DVR as your friend during the news. Watch it with your child and pause the TV to answer questions. Gauge your child’s emotions and turn the TV off if your child becomes too emotional or the news is too intense.

The psychologists we talked to agree the recent tragedies may also be a good time to promote speaking up when your kids see a peer who is in distress. “They are not tattling. If they see a peer who is acting out things or talking about violence, speak up to a trusted adult,” Zettler said.

“It is definitely important for children and teens to speak up and say something if they have a concern, or feel someone may be making a threat, either toward themselves or someone else,” Crabtree added. “And sadly in the times we live in now, it’s also important to have general situational awareness, no matter where you are.”

For a great resource on how to speak up, visit sandyhookpromise.org.

Kids, even teens, look to parents for reassurance. Parents can express their feelings about these events, but do not make this about your feelings. Model resiliency and good coping (calming, grounded practices that could include praying, meditating, deep breathing, laughing, yoga, and exercise for instance).

After listening, ask the child what they need: it may just be a hug for now. Reach out to professionals for help if fears persist more than a few weeks.

Crabtree advises parents to watch and see if their children restrict activity. For instance, they may not want to go to school or to the playground because it is too far away from home, or simply because they are afraid. Also, notice if your child becomes withdrawn or more clingy than usual, and constantly wants to sleep in your bed. For older kids, if you see them avoiding social events or larger gatherings, that might be something to discuss.

“It is common for children to have a mild fear, but if you see an overwhelming fear, it’s important to start by talking to their pediatrician,” Crabtree said. “If it continues to be a concern, then it may be time to get professional help.”

For more on this topic:

• Sandy Hook Promise
• Cook Children's Behavioral Health
• Cook Children's Psychology
• Individual and family therapy
• Parent Education and Support
• Diagnostic Testing

"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."

It was reported by the American Academy of Pediatric Dentistry that sports accidents account for 10-39 percent of all dental injuries in children! These injuries can happen to a child’s face and teeth from falls, collisions, contact with hard surfaces and sports equipment. Activities such as riding a bike, skateboarding, hover boarding and jumping on a trampoline can result in injuries that affect the teeth and the face. The upper lip, gums and front teeth are more prone to injury. These teeth are subject to fracture, nerve damage, becoming loose and even falling out.

Not all sports-related injuries can be avoided, but most of them can be prevented! Wearing helmets, facemasks and mouthguards have been shown to greatly reduce the severity of dental and facial trauma. The National Federation of State and High School Associations only mandate mouthguard use for certain sports such as football, ice/field hockey, lacrosse and wrestlers wearing braces. But it is very important that proper protective equipment and mouthguards be worn for all sports that have the risk of injury (baseball, softball, basketball, soccer, volleyball, gymnastics to name just a few).

A mouthguard is made to protect the lips, gums and teeth from damage. They work by absorbing the energy from an impact and dissipating the remaining energy. There are many different types of mouthguards and if you are thinking of getting a mouthguard for your child, it is important that you visit your dentist. The best mouthguards are the ones that are custom made at the dental office. A mold is taken of the teeth and a mouthguard is made that is the right fit and comfortable for your child. If a custom mouthguard is not feasible for you, then there are many other mouthguards that are available over the counter. Even though they may not be a perfect fit, they will still provide offer some protection.

Bottom line, please protect your child’s face and teeth with the proper protective equipment while they are playing sports and having fun!

While these popular summer spots are a great way to beat the summer heat, they can pose a danger to anyone not wearing shoes.

“Children often forget that the pavement is hot because they are wet and they aren’t feeling the heat as much, but any dry pavement that is out in the sun is a potential place for children’s feet to get burned quickly,” said Kara Starnes, D.O., medical director of Urgent Care at Cook Children’s.

Dr. Starnes says she’s seen patients who’ve suffered burns on their feet and suggests children wear water shoes while swimming so that if they step on hot pavement, their feet will be protected.

She’s also seen children injured from playing outside at home.

“If your children are like most, they like to run outside to play without a thought about shoes,” Dr. Starnes said. “An option to protect your children’s feet, especially at home, is to place interlocking foam pads down over pavement on patios or other areas where your children commonly play. While these pads do still get hot, it is not typically enough to cause a burn.”

So how do you know when burns are bad enough to seek medical attention? Dr. Starnes advises parents to seek treatment for burns on your child’s feet:

• If there are blisters forming on the bottom of the feet.
• If simple measures such as Tylenol or ibuprofen, aloe to the area or sunburn pain relieving sprays do not relieve symptoms.

Children initially begin to walk between the ages of 12 and 15 months. In the early stages of walking, you may notice your child “waddling” with their feet wide and their arms out like an airplane. Once a child has become more comfortable with walking, you may notice them becoming “brave” and attempting to walk fast or even run. As a child goes through these stages of development, you may find your him or her falling several times during the day.

It’s normal for children to fall frequently as they are learning to walk. In the early stages of walking/running, a child is learning to plan movements, find their balance and explore new-found independence.

As children gain more control of their body, you will find they begin to walk with a narrower base and their arms are at their side. A child will walk/run with decreased hesitance and you should notice less falls. This will occur within the first 2-3 years of learning to walk.

When should you be concerned about your child’s falling? There are many different reasons why children lose their balance throughout the day.

• Pay attention to when your child is falling and ask yourself a few simple questions:

• Did the type of shoe he or she is wearing change? Often times children have difficulty finding their foot placement with new shoes, especially ones that are heavy (such as a boot) or non-supportive (such as a sandal or slip-on shoe.

• Are they only falling when reaching a curb or changing surfaces? Sometimes vision can play a big role in a child’s ability to maintain balance with walking and running. If you suspect a visual deficit, you should contact an eye care specialist.

• Does your child only fall when playing with peers their age? Children have to think constantly about their next move when walking/running during play. You may find that they will trip or fall when attempting to keep up with peers their age. This could be the cause of decreased coordination, meaning they are having a difficult time organizing movements during play, causing them to fall.

• Try to pay attention to how your child is falling, sometimes a child may have a difficult time clearing their toes when walking/running and will fall. This would be good to mention to your pediatrician for possible referral to a physical therapist.

If your child is falling more than 10 times per day and doesn’t fit into the above categories, it may be beneficial to talk to your pediatrician about a physical therapy evaluation to assess your child’s needs.

About the author

Morgan Hubbard, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield. If you would like to schedule an appointment or speak to our staff, please call 682-885-4063.

My question to you is...what in the world am I talking about? Our children’s vocabulary is very important, and if we use words such as “this” and “that,” we lose out on opportunities to teach our kids new words. I took a course recently that said that children between the ages of 4 and 5 demonstrate the most significant growth in vocabularies.

A child the age of 4 has a vocabulary of about 1,200 words, but a child the age of 5 has a vocabulary of 5,000 words. That is a HUGE growth in words.

Your child's vocabulary is so important. Think of each skill your child develops as building blocks. Starting from infancy, your child begins by cooing, which turns into babbling that then turns into words and eventually sentences. Research shows that children with higher vocabulary results in better decoding abilities. All that to say that their reading skills will benefit from having better vocabulary.

So what can I do to help my child?

1.Be specific when talking to your children. If I changed the story above to something more like this, it would all make sense…..

The other day I went on vacation. We went to South Padre Island. I enjoyed it because we went parasailing and fishing. My son caught a fish but his line got tangled with someone else’s. We couldn’t stop laughing, but eventually we helped him untangle the line and get it on the boat.

Now isn’t that so much better.

2. Try teaching your child new words or even different variations of the same word. For example: “The elephant is big” can turn into “The elephant is gigantic.” or even “The elephant is enormous.”

3. Use the same word in many different ways. Think about the word “run." The dog ran fast. I ran next to him, but I could not run as fast. My brother tried to run, but he fell down. After I ran, I was really tired. Running is fun.

4 .Make learning new words fun. Instead of doing flash cards (snooze), find something that is interesting to your child and think of words based on the activity. If your child likes playing with farm animals, think of several words you could teach your child involving farm animals. As you play, introduce those words you wrote down.

5. Read books to your child. Books offer so many new and wonderful opportunities for learning words. You don’t have to necessarily read all the words, just talk about the pictures. Try thinking of words you can use multiple times throughout the book.

Vocabulary development is critical for children. It helps with building sentences and it’s important for reading as well. Markus Zusak put it well when he said, “The words. Why did they have to exist? Without them, there wouldn’t be any of this."

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

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

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

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

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

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

What topics did we miss?

Related To This Topic:

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

I spend a good portion of my day asking my daughter to give my son a little space; sister loves hard!

Recently, my son was playing in the kitchen (right next to me) when my daughter suddenly came in, sat behind him and looked like she was doing the Heimlich on him. As I was telling her to back away slowly, I noticed he was trying to put something in his mouth and wasn’t able to due to her pestering... and then I wanted to throw up. It was a button battery. A tiny battery that he could have swallowed without difficulty, and without me ever knowing it.

Last year, more than 470 children visited the Cook Children's Emergency Department after swallowing a "foreign body." Most objects that children ingest can be passed without much concern, but a battery is not one of those things. A battery lodged in the esophagus is a medical emergency. Essentially it can erode the lining of the esophagus. They are very dangerous and can be deadly without treatment.

As a previous pediatric ICU nurse and currently a primary care nurse practitioner at the Willow Park office, I knew this. I warn others of this danger. So how did it almost happen 2 feet from me?

I suddenly remembered my daughter was wearing a headband that lit up the day before, and she accidentally pulled the back off spilling the batteries. I thought I had picked up all the batteries, but one was hiding under the kitchen mat.

After thanking my daughter for her brother obsession, I went on a mission to locate all the button batteries in the house.

Keeping these babies safe is a hard job, for ALL of us! Doing a quick scan of the house to make sure no batteries they could easily swallow are in their reach is a good step towards safety.

-Sperry, NP

For more on this topic, read:

• Number of Kids Seen in ER for Swallowing Small Objects Doubles Over Past Two Decades
• Button Battery Injury Prevention Safe Kids
• Choosing Safe Baby Products
• Is Your Home Safe for Baby?
• Is This an Emergency?

We’ve gotten a lot of requests to write a post about nosebleeds so I thought I would cover some of the basics. As we’re going along remember this: While scary and annoying, most nosebleeds don't point toward anything concerning.

What causes nosebleeds?

If you are like me, nosebleeds will never be the same after Eleven and Stranger Things. But don't get things upside down on the actual cause of your child's bloody nose.

The nose has tons of blood vessels that go to it...and the tissue inside the nose is very fragile and can easily crack and bleed.

Anything that causes the tissue to be dry can lead to increased risk for nosebleeds, especially dry and very cool or warm air (winter and summer). Conditions which lead to nasal inflammation (especially nasal allergies) can also be a factor.

Ultimately, the most common trigger to a bleeding is nose picking but extreme heat, activity and stress can also be a factor. Yes, your kids pick their nose. Every kid picks their nose. I promise. Other common triggers are blowing and suctioning.

There are a few more unusual causes of nosebleeds that should be considered if the nose bleeds are consistent over time:

1. Structural problems - An abnormal bump or growth can be more prone to injury.
2. Bleeding problems - Children who have problems with blood clotting can be more prone nosebleeds.
3. Object stuck in the nose - Sometimes kids put stuff in their nose. Symptoms are usually one sided bleeding and a foul smell from the nostril.

How do you stop a nosebleed?

Pinch it. Pack it. Head up. Head down. What is the right thing to do?

There's no reason to tilt the head back or to lie down. This only increases the amount of blood that is traveling down the back of the throat and can lead to coughing or vomiting blood later.

• Have your child sit or stand and slightly lean forward and breathe through their mouth.
• Firmly pinch your child nose in the soft part just below the bony ridge.
• Hold pressure at that location for 10 minutes. Don't check. Seriously, if you're reading this now, don't check.
• If the bleeding does not stop, repeat again for 10 minutes.
• If the bleeding does not stop, continue holding pressure but get ready to head in to be checked out by a doctor.

When should you be concerned about nosebleeds?

It can be difficult to know what is normal and what is concerning with nosebleeds.

Here are some indications that you should probably see your doctor:

1. An individual nosebleed that doesn't resolve after  two attempts to control bleeding for 10 minutes.
2. Nosebleeds are happening more than 2-3 times per week or are significantly increasing in frequency.
3. There are other associated symptoms such as bruising or easy bleeding, fever, weight loss or rash.
4. Nosebleeds are consistently occurring from one nostril.
5. You should always seek care sooner if your child has an underlying medical condition.

How can I prevent nosebleeds?

In children who have frequent nosebleeds, there are some steps that you can take to help prevent them.

• Keep your child's nails clipped.
• Run the humidifier in the room with your child overnight.
• Apply nasal saline spray to the nose a few times per day. If this doesn't seem to be enough, saline gels or vaseline may also be an option but talk with your doctor.
• Seek medical care for underlying conditions, especially allergies and be consistent with your allergy regimen.

As I was writing this, I received a bunch of emails I plan to answer in a followup, but for now I'm going back to watching Stranger Things.

The National Weather Service in Fort Worth has issued a heat advisory from 1 p.m. Tuesday through 8 p.m. Wednesday. According to the Star-Telegram, it could feel as hot as 111 degrees in parts of our region.

The range of the heat-related incidents seen at the ER has included children left in hot cars to kids being treated for heat exhaustion after working out.

"As the outside temperature rises, your family's risk of heat stroke rises right along with it," Corwin Warmink, M.D., medical director of Emergency Services, said. "On 100-degree days, it's best to stay inside when it gets that hot. If temperatures exceed 90 degrees, stay in the shade and keep an extra eye on the kids."

Children today are spending increasing amounts of time in air conditioned environments, lured indoors by the constant upkeep of social media accounts and online gaming. Studies show the average American child spends 4 to 7 minutes a day in unstructured play outdoors, compared to more than 7 hours a day in front of a screen.

"The more you're out in the heat, the more your body gets used to it, or 'acclimatizes,'" Dr. Warmink said. "Children who are always inside are more prone to heat exhaustion and heatstroke than those who are frequently outdoors and active."

Play it cool

But don't mistake what Dr. Warmink is saying. Too much time out in the heat can cause heat-related illnessess such as heat exhaustion and heatstroke.

Lack of acclimatization has led to an uptick in heat illness among children in recent years, according to Dr. Warmink. Most incidents occur during the first two weeks of school athletics training when kids begin cross country, football, cheerleading or band practice.

"More is being demanded of young athletes during the late summer months," Dr. Warmink said. "Kids who spend all summer indoors and then go out for training in August are setting themselves up for heat illness."

For more information on this topic:

• Tips for Preventing Heat-Related Illness - CDC
• Heat Exhaustion and Heat Stroke
• Child Safety Center
• Vehicle/Car Safety
• Drowning Prevention

Over the past five years, the Cook Children’s Emergency Department has seen over 50 fall-related injuries and more than 20 drownings during the July Fourth weekend. Parties, lake trips and higher amounts of people on the road are often the sources of injuries in children around the Fourth of July. With more distraction comes more risk of accidents such as motor vehicle, ATV/golf carts and snake bites. Many of these injuries are preventable and can be avoided with proper safety equipment and watchful eyes of parents.

In 2018, there were five drownings associated with the July Fourth weekend alone. Children in or around water should be watched by a responsible adult using the mindset of a lifeguard.

Corwin Warmink, M.D., medical director of Emergency Services, says adults should be within arm’s reach of young swimmers, especially in open water.

“The lakes are jam-packed and people are celebrating and not always using their best judgment. Overloading of boats is a recurring theme, everyone in a boat should have a life jacket within hands reach if not on,” Dr. Warmink said. “Letting children swim or out on open water during the Fourth of July is inviting trouble. We’ve had multiple injuries and deaths from people struck by boats while in the water and on kayaks or jet skis.”

In comparison, over the past five years, Cook Children’s has only seen three burns related to fireworks during the holiday weekend. Still, these injuries can be harmful and painful to a child. Dr. Warmink warns parents to be attentive especially during down times when activities are finished. Many injuries and deaths are preventable but can happen to anyone in 30 seconds or less of distraction.

“Fireworks rarely cause death but we often do see serious burns and occasionally injuries that could cause loss of an eye, finger or hand,” Dr. Warmink said. “Every year we have at least one tragic story that ruins not just a family's holiday, but their entire life.”

Top Injuries Seen at Cook Children’s During July Fourth Weekend

For More On This Topic:

• Lifeguard Your Child (Drowning Prevention)
• Aim For Safety (Protecting Our Children From Firearm Accidents)
• Vehicle/Car Safety
• Firework Safety Tips from SafeKids
• Is This an Emergency?

While this is the plot of a new movie, it’s based on  fact.  Sudden Cardiac Arrest (SCA) is the leading cause of death in young athletes. The Fort Worth based movie, The Last Whistle, takes a look at what happens when no one knows what to do after a high school football star collapses and dies at practice from sudden cardiac arrest.

Sarah Thieroff, Project ADAM Texas Coordinator at Cook Children’s, hopes The Last Whistle brings awareness to not only SCA, but also how to be prepared for such an event.

“Every school does a fire drill, but the last time a student died in a school fire was 1950. On the other hand, a young competitive athlete dies suddenly every three days. This is something we need to make people aware of and I hope The Last Whistle will do that,” Thieroff said.

Thieroff says that 20% of our population goes to school each day, and parents assume they’re healthy and safe, but there is always the chance for sudden cardiac arrest, which is why Project ADAM is so important.

The reality is that parents and staff often don’t realize their school keeps an AED on site for situations like the one portrayed in The Last Whistle, or with the Cook Children’s programs namesake, Adam Lemel. In 1999, Adam, who was 17 years old at the time, collapsed during a basketball game and died from sudden cardiac arrest. Like in The Last Whistle, knowing where there is an AED on site and how to use it could have saved his life. 

There are now 20 Project ADAM programs in 16 states, and 150 lives have been saved to date nationwide. These 150 lives saved are because students and staff were properly trained on how to react to sudden cardiac arrest, Thieroff says.

Currently in the Texas Project ADAM program there are 414 Heart Safe Schools and 14 Heart Safe School districts. In 2018 eight lives were saved in Project ADAM Texas schools. It is the hope that through movies like The Last Whistle and stories like Adam’s that people will be encouraged to learn what to do in the case a sudden cardiac arrest occurs.

Prevention

Pre-screening is an essential component of prevention. In Texas, the University Interscholastic League (UIL) requires a Pre-participation Physical Evaluation prior to student involvement in sports for grades (7-12). The physical may help determine whether a student athlete is physically capable of certain exercise, and may determine the need for further evaluation should warning signs be present.

However, athletes are not the only ones at risk, and not all children are athletes, many are active and some may have underlying heart conditions. 

Sign and symptoms

Pediatric heart disease has warning signs and symptoms that can go unnoticed. It is important to recognize the following:

• Fainting or near-fainting during or after exercise, emotion or surprise
• Dizziness or lightheadedness
• Extreme fatigue associated with exercise
• Extreme shortness of breath associated with exercise
• Discomfort, pain or pressure in chest during or after exercise
• Skipping or racing heartbeats
• High blood pressure
• Congenital heart abnormality
• Family history of sudden death prior to age 50 or known heart abnormalities

Not all episodes of sudden cardiac arrest are preventable because many of the kids do not have symptoms until they have the episode. For this reason, secondary prevention strategies are important.

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.

Well, you might be surprised to hear that over-the-counter medications like Advil and Tylenol might actually be what’s triggering the headache in the first place. According to Ellie Corbin, M.D., pediatric neurologist at Cook Children’s, taking these medications on a regular basis can lead to something called ‘medication overuse headaches.’

Even if your child isn’t exceeding the prescribed daily dosage, Dr. Corbin says consistently taking several doses of these medicines over a long period of time can be harmful.

Overuse headaches are far more common than people realize, Dr. Corbin says. Close to 50% of her patients who come in with headache complaints inadvertently put themselves in this situation, by overusing headache medicine. Instead of the medicine relieving the headaches, it made them worse.

The International Classification of Headache Disorders defines medication overuse headaches as:

• A headache that occurs on more than 15 days a month, in patients with pre-existing headache conditions (migraines, or tension headaches).
• The regular overuse of headache medication like: Tylenol, Advil or Ibuprofen for more than three months.

Dr. Corbin diagnoses medication overuse headaches by asking two simple questions: how long and how often have you been taking the medication? These two questions are enough for her to know if her patient is suffering from too much medication. The only form of treatment is to immediately stop taking these medicines all together and use alternative measures the next time a headache develops.

One alternative Dr. Corbin encourages her patients to do is hydrate with fluids that have electrolytes, like Gatorade and Powerade, when their headaches start, instead of taking medicine. Preventative medicine is prescribed to the majority of children with overuse headaches during the “washout” period of over-the-counter medications, Dr. Corbin says. During this “washout” period, your child doesn’t have to suffer. A form of therapy known as “bridge therapy” is used. This is when other means are used to make your child comfortable while their body adjusts to the withdrawal of headache medicine, it usually comes in the form of steroids.

Once a patient has stopped taking over-the-counter pain medicines, relapse is rare. Dr. Corbin emphasizes that reducing the use over-the-counter medication might result in headaches at first, but in the long run, it will likely mean less pain for your child.

“A lot of patients are scared to go back after the washout period,” Dr. Corbin said. “They’re afraid that if they take these medicines again the medication overuse headaches will come back. There is the chance that a chronic headache condition is so severe that a relapse happens.”

- By Libby Collins

Over the course of a week, there were three different auto pedestrian injuries, where a child was hit by a car and ended up in Cook Children’s Pediatric Intensive Care Unit.

Once the school year ends, Sharon Evans, Trauma Injury Prevention coordinator, calls this time of year “the 100 deadly days of summer” because kids are so much at risk. They are spending more time on their own or with friends and often times without adult supervision.

"Kids are out because they are playing with their friends, going to the ice cream truck or riding their bike. In other words, it’s just kids being kids. But that’s also when children are getting hurt," Evans said. “We are asking parents to make sure their child knows how to cross the street, mainly that they wait until the driver actually motions to them to cross the road. Just because you think the driver is looking at you doesn’t actually mean they ‘see’ you.' These days everyone is so busy or distracted, even while behind the wheel, you can’t take anything for granted."

Studies show children don’t have the cognitive ability to safely cross the street until they are 10 years old.

So even though they can ride a bike and do multiplication tables doesn’t mean they can safely cross the street, Evans said. While they may ride or walk on the sidewalks, you still have the danger of cars backing out and/or turning into driveways. During the summer, Evans said the medical staff at Cook Children’s sees an increase in backovers. 

“With our larger cars and SUVs, you often can’t see the child and that’s where the backovers happen as you are leaving,” she said. “Of course this disaster is even worse because the injury is usually caused by a parent or family member.”

Evans asks parents to be extra aware that kids are out during this time of year and to be on the lookout for them. She adds distracted driving plays into this too.

“Drivers need to be extra aware that kids are out and about,” Evans said. “It’s up to us, as the adults, to be on the lookout for them. Of course, distracted driving plays into this too. We also need to make sure we are all driving the speed limit or below the limit in neighborhoods, around parks or just anywhere kids may be outside and playing. Really it’s up to all of us to be careful and watch out for kids."

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.”

Jakera wasn’t in pain but her mom, Tiffany Ferguson, noticed her little girl had lost range of motion on her right side.

“She couldn’t open her hands, she couldn’t lift her arms. I immediately called her doctor and told her that Jakera couldn’t move anything on right side. She told me it sounded like a stroke and to call 911,” Tiffany said.

An ambulance rushed Jakera to Cook Children’s where she was treated for a stroke and diagnosed with moyamoya, a more serious disorder that developed from her sickle cell disease. Moyamoya can occur when sickled red blood cells cause repeated damage to the blood vessels in the brain. The blood vessels begin to tangle and create a “puff of smoke” appearance on an MRI.

Moyamoya can lead to more stroke activity and typically requires surgical intervention to improve blood flow around damaged blood vessels. Jakera’s medical team decided to intervene before another stroke could occur.

Jakera had revascularization surgery in February 2019, a procedure where surgeons flipped the protective covering on top of the brain (the dura) to encourage the main artery there, the middle meningeal artery, to create new collateral arteries into the brain.

Following the surgery, Jakera now receives blood transfusions every four to six weeks.

Along with interventions such as blood transfusions, sickle cell disease is also managed by medications and potentially a stem cell transplant for long term success against the disease. But finding a donor can be seemingly never ending. Physicians will look to find a match from siblings and family first before trying to find an unrelated donor, according to Cook Children’s physician Clarissa Johnson, M.D. Jakera has not yet had a stem cell transplant, but her family remains hopeful she’ll find her match.

“A stem cell transplant is a cure for sickle cell disease because you’re basically putting new stem cells in the body,” Dr. Johnson said. “Red blood cells are made from stem cells so if you put new stem cells in the body that don’t contain Hemoglobin S, you are creating a situation where you no longer have stem cells that make sickle cells.”

With sickle cell, stroke and moyamoya, Jakera has endured her share of hardships, but it wasn’t until she was diagnosed with Bow hunter’s Syndrome that she was affected by just the turn of the head.

“She started blacking out three to four times a day. It happens [when she turns] like a bow and arrow hunter when they have to turn their head to the side to aim,” Tiffany said. “She was born right handed but when she turns her body to the right, it cuts off the circulation to her brain so she actually switched hand dominance to the left.”

Jakera had a spinal fuse from the back of her neck down to her shoulders to limit the amount she can physically turn. She can no longer turn more than 90 degrees to ensure there is enough blood reaching her brain. While this is not a cure, her physicians believe it will relieve the loss of consciousness.

Jakera is not the only one in her family impacted by sickle cell disease. Her father also faces medical difficulties.

“There were days where I was running from Cook Children’s to Harris and back to Cook Children’s so that I could be with both of them during their crises,” Tiffany said. “Everyone in the family is learning to deal with it because we know it isn’t going to go anywhere right now, but they understand the most important thing is making sure they [Jakera and her father] are OK.”

Four major diagnoses and two surgeries in five years could seem daunting to most, but Jakera has flown through it all with ease, and has even made the local cheerleading squad.

“She’s like a little woman,” Tiffany said. “She takes it and keeps on moving. The stroke limited her a lot but the squad has been so good to her. She always pushes through.”

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.

Alice Phillips, M.D., a Cook Children’s pediatrician in Fort Worth – Cityview, hears the worry in the voices of many of her patient families. They’re afraid their child may contract measles or some other contagious disease.

“I like to reassure them,” Dr. Phillips said. “And currently, I can say there is no indication of a major outbreak threatening the health of their children in our area. But I understand their apprehension and I admit I’m worried too.”

Measles cases have hit a 25-year high in the United States, and Texas already has reported 15 confirmed cases of measles in 2019, six more than in all of 2018.

And yet as the number of cases have gone up, Texas vaccine exemption rates have reached an all-time high. According to a report in the Texas Tribune, “the number of individuals who have had at least one vaccine exemption affidavit requested on their behalf has grown more than tenfold, to more than 70,000 in the 2018 fiscal year.”

Texas is one of 16 states to provide vaccine exemptions for conscientious, philosophical and/or religious beliefs. In our state, kindergartners must have 10 immunizations to be enrolled in school. The Tribune found that since 2006, when Texas first started reporting data, the exemption rate for kindergartners has risen from 0.3% for the 2005-2006 school year to 2.15% for the 2018-2019 year.

“I’m very concerned by these numbers,” Dr. Phillips said. “I truly believe vaccinations are the greatest public health advancement seen in my lifetime. This trend toward opting out of vaccines threatens the health of all of our children.”

The Texas Tribune article allows readers to type in their school district and see the vaccine exemption rates for kindergartners, those who aren’t receiving vaccines by claiming a conscientious exemption (along with citing medical or religious concerns). The story mentions that Alliance Christian Academy had the second highest vaccine exemption rate by percentage in the state last year with 40.6% of their students (13 of their 32 kids).

In Fort Worth ISD, 1.39% of kindergartners (84 of 6,031) received non-medical vaccine exemptions. Dr. Phillips knows that some will say that’s only 84 kids in Fort Worth or 13 at Alliance Christian, but those numbers add up.

“You may say only 2% of the population isn’t vaccinated, but that 2% is often times happening in clusters,” Dr. Phillips said. “We have seen those areas with clusters of a population are where we are especially primed and ready for an outbreak. That’s what we’ve seen recently in New York City. There was a cluster of people who didn’t vaccinate. I worry that’s what we are at risk for in Texas.”

Dr. Phillips hopes healthy people who can receive immunizations take that responsibility seriously. Community-wide protection depends upon a high percentage of the entire population receiving vaccines in order to protect children who are immune compromised and or can’t receive vaccines for health reasons.

“Those children rely on us to protect them,” she said. “They can’t have the vaccine, so they rely on the rest of us to stand up and protect them and keep these illnesses from them. That’s the herd immunity. That’s simply not happening as much as it should in this country. The measles cases in this country are startlingly high.”

With so much misinformation on the Internet or even among their friends, Dr. Phillips welcomes a conversation with her patient families. She said her job is to listen to concerned parents in a respectful way to try to provide facts and calm their fears.

“I try to answer them with what my experiences as a practitioner have been. I tell them not only what I’ve seen as a physician and explain all the science supporting immunization, but what I’ve done as a mom. My children are vaccinated. I believe in vaccines. Many times, a parent just needs kindness, compassion and assurance that they are making the right decision for their child. I truly want them to know that receiving a vaccine is the right decision for your child.”

For more on this topic:

• The Texas Tribune Story: Texas vaccine exemption rates have reached an all-time high. Did Texas make it too easy for parents to opt out?
• Vaccines and Immunizations
• Common Questions About Immunizations
• Measles
• Immunization Schedule
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know