The Cook Children's Fostering Health Program serves more than 2,000 children from across North Texas and as far west as Stephenville. In March, the Clinic helped more than 200 children, a record number for the program.

“Our clinic functions as a primary care medical home and offers complete health care for children in foster care through age 21,” said Brittany Schoonover, pediatric nurse practitioner for the Fostering Health Program.

It begins with trauma-informed care.

“We recognize when a child is removed from a home that in itself is trauma,” explained Keirsten Velez, LMSW, a social worker for the Fostering Health Program. “Sometimes we see the child the day after it happens, so our goal is to empower the child.”

That empowerment includes involving children in their own health journey while helping caregivers navigate the foster care system.

“There are a lot of nuances that come with providing medical care for a kiddo in foster care,” said Velez. “For example, most agencies require the foster parent to have a nine-page form completely filled out and signed at the end of every medical visit.”

Even before the first exam, the team works to fill the gaps in a child’s medical history by tracking down records from schools, hospitals and previous pediatricians.

“Often times we find fragmented care where the child had initial medical exams but often not follow up care,” explained Schoonover. “Our clinic is helpful to connect the dots and put the puzzle pieces together to be able to provide the best care for the child.”

Velez noted often placements occur with limited time or funds for foster parents to prepare for the child’s arrival. The team strives to address immediate needs, providing patients with essentials such as clothes, toys, and diapers, while also serving as a bridge to long-term support through Cook Children’s and community support.

“We try to make navigating the system easier for the caregivers,” said Velez, “We're kind of advocating alongside of them for what they may need.”

The support does not end when a child’s case closes. Schoonover and the team ensure continuity of care by providing families with information about new pediatricians and specialists.

“We’ll send over whatever they need to the new doctor, we want to keep the continuity of care that they have had here in their medical home,” said Velez.

It’s a dose of antibodies that works right away to help fight off severe RSV infection for at least five months. Getting the shot in October – just before RSV season -- provides an infant with extra antibodies to build their immunity during the fall and winter months.  

In November 2023, Cook Children’s saw a spike in RSV at our Urgent Care centers and Emergency Departments, the highest volume of cases in recent years.   

“RSV is one of the most common winter viruses. All of us catch RSV in the first couple of years of life," said Mary Suzanne Whitworth, M.D., Medical Director of Pediatric Infectious Diseases at Cook Children’s.

In older children, RSV typically causes cold-like symptoms such as cough and runny nose. But babies under 12 months don’t have fully developed immune systems, Dr. Whitworth said. They tend to get sicker with RSV, a leading cause for wintertime hospitalization in infants.

Severe RSV in infants tends to impact the lungs. Infants should be seen by a doctor if they’re struggling to breathe. If your baby is sick, Dr. Whitworth said, watch for rapid breathing, flared nostrils, airway congestion, wheezing or a rattle you can hear or feel in their chest. Other concerning signs are excessive sleepiness, lack of appetite and trouble feeding.

The Food and Drug Administration (FDA) approved the preventive medication, called nirsevimab, in 2023 after clinical trials showed it reduces the risk of hospitalization for RSV by 75%.

Every infant under age 1 needs the medication ahead of RSV season, Dr. Whitworth said. Some older babies need the shot too if they have certain underlying health conditions. Here’s the breakdown. 

Stopping RSV Two Ways

The first option Pfizer's Abrysvo, given during weeks 32-36 of pregnancy.  Maternal antibodies are passed to your baby and protect against RSV for about six months after birth.   

Infants who don’t have maternal antibodies should get a dose of nirsevimab shortly before the RSV season. Infants born from October to March should receive the medication within one week of birth, according to the U.S. Centers for Disease Control and Prevention (CDC).

The CDC also recommends nirsevimab for certain young children shortly before their second RSV season. This higher-risk group includes children who were preemies, or those with chronic lung disease, compromised immune systems or cystic fibrosis.

The injection delivers safe and effective antibodies, Dr. Whitworth said, and the most common side effect is soreness from the needle stick. She encourages parents to ask their baby’s pediatrician for the shot in October, before hospitalizations for RSV start climbing in infants.

“They are going to be exposed to RSV. It is a virus we are exposed to regularly all winter long.” she said. “The immediate benefits of the shot are huge.”

Cook Children’s has the RSV shot available at our seven Neighborhood Health Centers in the Fort Worth area and more than 40 pediatric offices from Aledo to Willow Park.

Additionally, the Tarrant County Health Department is offering this product to infants ages 2 – 8 months with state-funded insurance or no insurance and infants 8 – 19 months with a qualifying diagnosis.   

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Physicians Say New Antibody Shot Could Be Game Changer
Medication to Prevent RSV

“If your child needs emergency care treatment, our Emergency Department is here for you. That’s why we’re here,” said Natalie Carpenter, director of Emergency Services at Cook Children's. “But please don’t come to the emergency department for a simple COVID test.”

Carpenter said many parents have come to Cook Children’s ED in a panic because their child was exposed to a classmate at school who tested positive for COVID-19. The parents often bring younger siblings too, so that the whole family can be tested in the ED. High volumes of non-emergency patients puts unnecessary strain on the department.

“It pulls away staffing from the critically-injured and ill and it takes away bed space,” she said. 

As an example, Carpenter said, of the 361 patients seen in the ED on Tuesday, almost half were considered less urgent or non-emergent. Many of the patients could have been seen at a pediatrician’s office or clinic.

 The U.S. Centers for Disease Control and Prevention (CDC) lists these COVID-19 symptoms requiring emergency care:

• Trouble breathing
• Persistent pain or pressure in the chest
• New confusion
• Inability to wake or stay awake
• Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

With schools reopening and COVID-19 cases on the rise, parents should encourage their children and teens to wear masks, social distance, wash their hands frequently, and follow guidance for quarantining. Carpenter encouraged parents who suspect their child might have COVID-19, and are not exhibiting symptoms, to get tested at drive-thru centers or other designated testing facilities. 

It’s important to know that Cook Children’s urgent care clinics are unable to perform rapid COVID-19 testing on a child who doesn’t show symptoms. Cook Children’s does have drive-thru testing sites, but those appointments are scheduled only through a Cook Children’s pediatrician and for specific times and locations.

Kara Starnes, D.O., medical director of Cook Children’s Urgent Care, said patient numbers and wait times have dramatically increased recently. Dr. Starnes said 737 patients came to urgent care on Tuesday – compared to a previous maximum of about 650 patients.

“The usual surge that comes when school starts is usually about two to four weeks post back-to-school,” she said. “We’re seeing strep infections, common colds and pink eye as well as the expected substantial increase in COVID cases as kids are now congregating together at school, often without masks.”

Where do you go when your child needs to be seen by a doctor? Here’s a guide:

• Go to the emergency room if your child has trouble breathing, unusual sleepiness or confusion, poison ingestion, head injury with vomiting, serious burn or another life-threatening condition.

• Call your health care provider if your child has ear pain, sore throat, diarrhea or vomiting, rash, cough or other non-urgent health concerns. The pediatrician ’s office can help you decide what steps to take.

• If you can’t get to your provider’s office or it’s after hours, go to an urgent care center. Urgent care centers manage the same problems as your regular health care provider plus services such as X-rays, stitches and splints.

For more information, visit www.cookchildrens.org/coronavirus.

On Monday, Nov. 18, our staff saw 567 patients in the emergency room, which is equivalent to a patient checking in every 2.5 minutes for 24 hours straight. That’s nearly double the number of patients we typically see in the ED.

What’s causing the high census rate?

Hospitals across Dallas/Fort Worth and the state are experiencing similar situations right now due to a variety of bugs making their way around the region. Respiratory illnesses like RSV and croup are being seen in high numbers. We’re also seeing the first wave of flu cases, along with a range of gastrointestinal illnesses.

What does this mean for you?

If you’re planning to come to Cook Children’s Emergency Department with non-emergent issues, be prepared to wait.

“If your child is experiencing cough, fever or vomiting, you should contact your primary care physician first to make sure the ED is the right place to take your child,” said Corwin Warmink, M.D., medical director of Cook Children’s Emergency Department. “Wait times are going to be much higher than normal, and patients may have to wait several hours to be seen if they are not suffering from a life-threatening emergency.”

If you are going to the ED, please limit the number of people you bring with you (if possible).

“The waiting room at the emergency department is so full that Cook Children’s staff have brought out folding chairs to accommodate as many people as possible,” said Dr. Warmink. “We are working as quickly as we can to get patients into rooms, while still providing quality medical care to each child. We know it’s frustrating for families to be stuck in the waiting room, but we ask for patience.”

Also, be aware that anyone who comes into the ED is at a high risk of being exposed to and contracting an illness. The following groups of people have the highest risk of infection:

• Pregnant women
• Infants and young children particularly under age 2
• People of any age with certain chronic health conditions (including asthma or lung disease, heart disease, diabetes, kidney disease or some neurological conditions).
• People with severely compromised immune systems.

What other options are there besides the Emergency Department?

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

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

Cook Children’s has seven urgent care locations that provide services that are both convenient and comfortable for your child during the evenings and on the weekends, including two brand new locations in west Fort Worth and Prosper. Many of these locations are also experiencing a high number of patients, but not nearly as high as the emergency department.

If you’re not sure whether your child’s issue can be seen at an urgent care, click here to see a quick list of conditions and where to go for each.

What else should parents know?

The best way to keep yourself and your child out of the emergency room with seasonal illnesses is to wash your hands frequently. This means before, during and after preparing food, before eating, after using the restroom, after blowing your nose or sneezing. The Centers for Disease Control and Prevention suggests scrubbing your hands for 20 seconds, or hum the ‘Happy Birthday’ song from beginning to end twice. This will greatly reduce your chance of getting sick and spreading bugs to others.

And if you haven’t already done so, get your flu shot! It’s not too late, in fact, flu season is just beginning to ramp up. An annual seasonal flu vaccine is the best way to protect against the flu and reduce the risk of hospitalizations and deaths.

Learn more:

• State Confirms Rio Grande Valley Site of First Pediatric Flu-Related Death, 74 Cases of Flu Last Week at Cook Children's
• Let's Learn About Fevers
• https://www.checkupnewsroom.com/lets-learn-about-fevers/
• ER or Urgent Care? How to Decide Where to Go When Your Child Needs Immediate Medical Attention

The Centers for Disease Control and Prevention (CDC) found that nearly half of all people who enter an urgent care center, or walk-in clinic, with symptoms of a cold or flu leave with a prescription for an antibiotic.

The study found that 46 percent of urgent care patients were prescribed antibiotics for conditions, compared with 24 percent at emergency rooms and 17 percent at medical offices.

Educating families and staff on antibiotic overuse has become a focus of Parul Martin, M.D., medical director of Cook Children’s Urgent Care Centers. She joins the national movement on this topic to improve antibiotic stewardship and has highlighted this topic of concern in her presentations for the Urgent Care Association (UCA).  Additionally, the Cook Children’s Urgent Care Quality Improvement and Research Council is collaborating with the UCA to improve antibiotic prescribing practices nationally.

“Cook Children’s proudly supports a culture of clinical excellence,” Dr. Martin said. “Our practice standards are very high. We follow the American Academy of Pediatrics guidelines and we follow evidence-based medicine across the board, including our primary care offices, our specialties, our Emergency Department and our Urgent Care Centers. Everyone is held to those same high standards. We are continually educating our providers about antibiotics and the treatment of viral illnesses. But we also have to continue to educate the families we treat about the proper use of antibiotics.”

Many families don’t want to leave a doctor’s office without an antibiotic. But Dr. Martin said it’s important that doctors explain to families that too much antibiotic use can be harmful to a child. Education is the key to reaching a long term solution to the current crisis.

“We’re a little more proactive on this issue than some of the other Urgent Care Centers or walk-in clinics you may take your children to if they are sick,” Dr. Martin said. “We don’t have the same pressures that they do to stay in business based on volume. If families aren’t prescribed an antibiotic they may go somewhere else. That’s a tough position to be in because if those clinics don’t satisfy the families, they aren’t going to stay in business. That’s part of what has led us to this antibiotic crisis we are in right now. As caregivers, we have to be unified and responsible about only giving this medication when it’s absolutely necessary.”

For viruses that cause illnesses such as the common cold, also known as an upper respiratory tract infection, antibiotics aren’t effective. Antibiotics don’t stop viruses. They only kill bacteria.

The CDC estimates 47 million unnecessary antibiotic prescriptions are written in doctor’s offices, emergency rooms and hospital-based clinics each year. Furthermore, they estimate up to one-third to one-half of antibiotic use in humans is either unnecessary or inappropriate.

Using antibiotics the wrong way can cause bacteria to grow into superbugs and this could mean a problem for your child.

“Antibiotics are drugs used to treat bacterial infections,” said Marc Mazade, M.D., a pediatrician who specializes in Infectious Diseases at Cook Children’s. “Over prescribing or using antibiotics the wrong way can lead to antibiotic-resistant infections. This means the next time your child is sick, the next infection could be much harder to treat when he or she really needs an antibiotic.”

If you are unsure if you or your child needs an antibiotic, ask your health care provider these 5 questions:

1. “Do I really need an antibiotic?”

2. “Can I get better without this antibiotic?”

3. “What side effects or drug interactions can I expect?”

4. “What side effects should I report to you?”

5. “How do you know what kind of infection I have? I understand that antibiotics won’t work for viral infections.”

Each year in the United States, at least 2 million people get serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections. At least 23,000 people die each year as a direct result of these antibiotic infections, according to the CDC.

“I think what happens sometimes is that health care providers feel pressured to give antibiotics from their patients or in a child’s case, the patient’s family,” Dr. Mazade said. “The parents feel they are doing what is right for their child, but the reality is that they may be causing long-term harm to him or her. If they overuse antibiotics, the next time children need the drug to fight off an infection, antibiotic resistance may make the antibiotic useless.”

Antibiotic resistance happens when bacteria change in a way that reduces or eliminates the ability of antibiotics to kill the bacteria.

You do not need antibiotics for:

• Colds also known as upper respiratory tract infections (URI)
• Most coughs and bronchitis
• Sore throats not caused by strep bacteria
• Runny noses, stuffy noses and nasal congestion
• Seasonal Allergies
• Most earaches
• Bug bites by themselves
• Most Diarrhea
• Most Rashes
• Uncomplicated flu infection and RSV infections

The screaming-leg-hanger-on-er

I know there are parents who are terrified of how their child will do on their first day of school. They are picturing their children crying and hanging on to a leg shouting, “Mommy! Don’t leave me here!” My heart goes out to those families because that must be really difficult. It seems painful for the child and is probably the most painful on mom or dad who is attempting to pry themselves away. Then, they have to spend the whole day worrying if their child is OK or building a need for therapy from their mounting sense of abandonment.

Here are some tips:

1. This behavior might be demonstrating some separation anxiety Talk through the drop-off period and the day with your child until you are both sick of talking about it. One of the best methods for combatting anxiety is to be prepared.
2. If possible, send the parent who is less likely to cause this reaction early on. Sometimes it’s mom and sometimes it’s dad. If your child can make an easy break with one, but not the other, let that parent try to help during those early days until the child sees that school isn’t such a terrible place.
3. Make a quick break. Trying to coerce children to say they love you and give you 1,000 kisses only makes things worse. A quick goodbye and we’ll see you soon should suffice.

A quick note of support: Ultimately, you may do everything right and this may still happen to you. Try to remember that their behavior at this extremely stressful moment does not define your ability as a parent. Teachers are used to seeing this. Most of them probably see it every single year in a child or two.

The quiet, but compliant child

I would bet that many kids fall into this category. They aren’t exactly sure what to think about school. They are a little annoyed about their first day of school outfit and a little more annoyed about the fact that they had to take pictures wearing it, holding a sign that says “First Day of School.” (What’s Instagram mom?) They are not openly upset about you leaving them, but they may seem a little anxious.

Here are some tips:

1. They might appreciate it if you walk them into class the first few days and see what they have been up to for a minute or two.
2. Let them know what they are feeling is normal. “It’s OK to be afraid. But every day you go, it will get easier.”
3. This is another instance where a quick, clean break is good. After the child is settled in, say goodbye and leave. No need to make every drop off day sappy … just treat it like it is no big deal.

The “see you later, dad; or not. Whatever it’s cool” child

My child might fall into the previous category, but I have a pretty strong feeling he will fit here. He seems really excited about school and I hope that is actually the case on the day of. I plan to give him lots of latitude to change his mind that day because with 5 year olds, you never know what to expect.

For this child, these tips are more for mom and dad:

1. Keep it together yourself, if you can. Your big boy or girl is growing up and independent. That is actually the goal of parenting. No one wants their college age child to be holding onto their leg at the dorm so you can check that off your parenting accomplishment list.
2. Don’t take it personally. They still love you (for now) and still want you around (occasionally).

There are many more first day of school personalities that your child could show, these are just a sampling. The best advice I can give from hearing back to school stories for years is to be flexible. Come back next week to see if I can follow my own advice. I’ll try not to cry the first day he asks me to stay in the truck while he walks in …

About the author

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