There’s been a ton of surprises related to the COVID pandemic and skipping flu season last year was another one I never saw coming.

Masks and social distancing definitely played a role but the absolute lack of cases was still shocking.

So, will we get lucky again this year?

I doubt it.

And here’s 3 reasons why:

1. Social distancing and masking are going away or gone. And we all want to get to that place…but it does mean we’re likely to have flu cases spread among classmates and families.
2. Skipping a flu season last year may make individuals more vulnerable to flu this year. Our bodies haven’t seen flu for almost two years. And just like our other colds went wild in kids this fall, flu could do the same this winter.
3. A mild or absent flu season last year may make people more likely to skip their flu shot this year. “Do we really need one after last year?” is a common question I have been asked.

What can you do to protect your child and their friends?

Get them their flu shot. Now’s not the time to get cute. Just do it.

Start to work with your child on hand-washing and covering their coughs. We need to protect ourselves and others.

Keep your child home if they are sick. If something seems to be brewing, give it a day to develop at home.

But, driving to work the last few weeks and seeing all the standing water already starts to make my skin itch. Mosquitos are on the way. And I suspect it’s going to be a terrible year.

Mosquitos can cause a variety of problems:

1. Simple itching and discomfort-small bites which can lead to infection when scratched
2. Large local reactions-which can be very itchy, even quite painful (See more at Skeeter Syndrome).
3. Serious systemic illness such as West Nile Virus, Zika virus or Chikungunya.

But our kids don’t have to suffer. There are great options for preventing mosquito bites and warding off some of these miserable consequences.

DEET

N,N-Diethyl-meta-toluamide sounds like a little bit of a scary name for a chemical we can put on babies as young as two months. But DEET has been extensively studied and consistently shown to the safe and effective as a mosquito repellant in children. Recommended concentrations of 10-30% provide great protection with 30% lasting around five hours.

Picardin or Lemon Eucalyptus Oils

Multiple alternatives to DEET have been tried. Studies have shown that these two alteratives can be as effective as 10% DEET and thus last around two hours. Reapplication will be important if there are plans to be outside longer than two hours.

Here are some important facts about applying insect repellant:

1. Spray a thin layer over clothes and exposed skin. Thick layers do not make it more effective.
2. Use your hands to apply repellant to the face rather than directly spraying.
3. Spray in open areas to avoid ongoing inhalation.
4. Assist young children with application to ensure coverage and safety.
5. Avoid combination sunscreen products because reapplication of sunscreen needs to be done more frequently.

Having a healthy and fun summer should include TONS of outdoor play. Keeping your child safe from mosquitos is one part of making sure nothing spoils the fun.

Read more: 

'Skeeter Syndrome': Is My Kid's Bug Bite Infected?

An Infectious Disease Pediatrician Explains Differences and Similarities between West Nile and COVID-19

Everything You Need To Know About DEET and Protecting Your Kids From Mosquitos

Why Do Mosquitoes Bite Me and Not You?

 Chiggers Myths Parents Need To Know

And while I’m confident that we’ll get through it together, I need your help.

Ruling out COVID-19 for kids with symptoms (some mild, some more severe) has become the biggest reason for kids visiting our office. We’ve already seen kids getting sick as they go back to school and that makes me nervous about what the upcoming flu season is going to look like.

Because the symptoms of flu overlap with COVID-19 so much, it’s going to be difficult to tell whether flu or COVID-19 is causing your child’s flu-like illness. And, there’s no guarantee that a child can’t get both at the same time.

So with the flu season nearing, you probably have a lot of questions that need to be answered about this possibility:

• Does every child with flu-like illness need to be tested for both?
  • Probably.
• Does getting COVID-19 and the flu at the same time mean your child will be more at risk for severe illness?
  • Probably.
• Will we have enough COVID-19 testing available to continue avoiding unnecessary quarantines?
  • I hope so, but every time we test a child for COVID-19 because they have flu-like illness, we have fewer tests available.

Here are some things you can do to help your child and yourself (and me):

1. Get your child their flu shot. ASAP. The effectiveness of the flu shot does vary from year to year. It’s not perfect. But, it’s the best we have. And even decreasing the amount of flu by 60% this year will change the lives of those children: Avoiding not one but two tests. Avoiding the worrying during the waiting time and wondering if your child has flu, COVID-19 or something else.
    
2. Start practicing hand washing. Children need to be taught to wash their hands adequately and often.
    
3. Wear your mask, even in situations where you think it might not be necessary. It will not only protect against COVID-19, it will protect against the flu as well. We, as a health care provider and a society, cannot afford to have a terrible flu season this year.
    
4. Keep yourself and your child home if you are sick. This is important…every…single…year. But it is especially important this year. Don’t be the family that knocks over the first domino. Even if you aren’t seen by a doctor, waiting a day can be helpful to see if your simple symptoms progress or go away.

Let’s all do our part.

We can do this!

It smells like strawberry Laffy Taffy.

This strategy works like a charm to get a strawberry flavored popsicle stick into a little one’s mouth, but in today’s world of COVID-19, they might have a new use as well.

New data from adults suggest that the anosmia, or the loss of the sense of smell, might be a sign more specific for COVID-19. This could be helpful in the middle of cold and allergy season when everyone seems to have cough and congestion. According to researchers, it's possible that between 30 and 60 percent of COVID-19 patients have a significant loss of smell. This seems to occur both before sypmtoms arise and along with other symptoms. 

While it might be difficult to assess with young children, parents and providers could be able to use loss of smell as an indication that COVID-19 might be more likely.

One important thing to keep in mind is that a lack of smell is likely to be significant if the child does not have nasal congestion, which would otherwise explain the symptom. 

According to the U.S. Centers for Disease Control and Prevention, the most common COVID-19 symptoms include fever, cough and shortness of breath. Some patients also report digestive issues like diarrhea.

Related Articles

• COVID-19 Testing Guidelines: Why Every Patient Won’t Be Tested For COVID-19 At Cook Children’s
• New Visitation Rules at Cook Children's Medical Center in Response to COVID-19
• Don’t rush to the doctor’s office. Here’s what to do if you suspect your child has COVID-19
• What Parents Need to Know About the Coronavirus
• COVID-19 (Coronavirus) Information
• Información sobre el COVID-19 (Coronavirus)
• How to Prepare for the COVID-19 (CDC)

When should you be worried? The biggest issue is context. You can read the other posts to see all about that.

Another reason you should be more concerned with fever is if it is lasting more than 5 days. Of course, if you end up with a diagnosis where fever is known to last more then 5 days, no big deal, but otherwise, most fevers should be gone by then.

This situation is called fever without a source.

There are many different definitions of fever without a source but I use: fever greater than 101 for eight days in a child in whom there is no obvious source of the fever through the patient’s story or physical exam.

Because children can often have back-to-back viral infections, it is important that this fever be present daily or near daily. For instance, it doesn’t count if they had fever for 3 days then were better for 2 days and then had fever again for 3 days.

The different things to think about are all over the place and can range from very serious to the “no-big-deal.”

Infections - The most common diagnosis in this instance is “unknown” but the fever goes away on its own. While often not intellectually satisfying (to either me or the parent who wants to know what is going on), this is probably the best outcome for the patient. Most of those are probably viruses for which we don’t have or don’t think to run specific tests. Bacterial infections can also cause long-standing fever.

Rheumatologic - Less commonly, children with prolonged fever can have rheumatologic causes, an example is juvenile rheumatoid arthritis. Often these children will have exam findings like swollen, painful joints or swollen lymph nodes that will help point towards their diagnosis.

Malignancy - Fortunately, this is a very rare cause of prolonged fever but it does happen so we all need to keep it in the back of our mind. The most common type of cancer in children is leukemia.

The workup for fever without a source involves a few things:

1. Repeat histories and physical exams - Often things are discovered over time.
2. Preliminary screening labs - Check these in just about all kids with it.
3. Specific tailored labs and exams - Check some of these based on a child’s story or exam.

Kawasaki disease

One specific cause of fever over five days deserves specific attention. Because many parents are not aware of it and because the diagnosis can be tricky, I thought it deserved its own specific mentions.

Kawasaki disease (KD) is characterized by the characteristic fever over 5 days along with some of the following findings:

• Swelling or redness of the hands and feet, followed by peeling of the tips of the toes or fingers
• Red rash all over
• Redness and crusting of the lips or redness of the tongue (like a strawberry)
• Severe pink eye
• Swollen lymph nodes of the neck

One of the other things to note with KD is that these children are very, very irritable. Not kinda irritable, but noticeably irritable even to a pediatrician who hears crying babies and children all day long irritable.

The cause of KD is unknown. There is some evidence to suggest that there might be an infection involved. The symptoms and complications associated with it are a result of inflammation of small to medium sized arteries throughout the body.

The most commonly known complications of KD involve the heart and can be inflammation or the lining or muscles of the heart or dilation of the arteries that supply the heart.

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

The good news is that children with Kawasaki's disease, like the child in the photos with this blog, usually return to normal and don't suffer complications.

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

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

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

1)The Manipulator/Negotiator

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

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

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

2)The Screamer/Crier

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

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

3)The Creeper/Sneaker

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

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

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

About the author

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

You can read my earlier posts on the symptoms of teething and my outright forbidding the use of teething gels.

After these, I think I have many of my readers wondering what in the world they are supposed to do when their child seems to be teething.

There are a select few of you out there who think you have found a loophole … their children are walking around sporting brownish yellow bling around their necks, are as happy as can be at all times and are sleeping through the night like little angels. Right?

Do amber teething necklaces work? If so, how?

Websites selling amber necklaces are all over the place when discussing how they might work to control symptoms that are commonly associated with teething.

They tend to center around three main concepts:

• Magnetism, energy or natural flow of energy

• Thyroid gland stimulation to control drooling

• Succinic acid released causing anti-inflammatory and pain relieving

Magnetism, energy or natural flow of energy

I found this quote in one of the top-ranking articles regarding how amber teething necklaces might treat teething pain:

“The unfavorable environmental conditions prevailing today block the natural flow of energy-related processes in cells. Blocks affect cellular metabolism and significantly weaken the immune system, but the natural energy of amber is able to stimulate its renewal.”

Thyroid gland stimulation to control drooling (or other symptoms)

The thyroid gland makes thyroid hormone which increases metabolism. This results in a whole list of changes inside our bodies, including:

• Increasing body temperature
• Faster, stronger heart beat
• Brain development and growth in children

Slowing drooling is not a function of the thyroid; thus stimulating it would not result in less drooling.

Stimulating the thyroid could result in increased body temperature (which is, ironically, often one of the symptoms of teething that people are trying to treat).

Succinic acid release causing anti-inflammatory and pain relieving

Perhaps the MOST logical explanation (and most often referenced) for why amber teething necklaces might work for teething pain is that amber contains 3-8 percent succinic acid.

Succinic acid is a chemical that is found naturally in the body and is involved in an energy producing chemical cycle known as the Krebs cycle. The basis of the reasoning behind why succinic acid treats teething symptoms is that it is reported to have anti-inflammatory properties.

Let’s look at a few problems with the assumption:

1. I can only find one study that even shows succinic acid to have anti-inflammatory effects. It is almost 30 years old and was published in a journal I have never heard of, in Russian.

2. Assuming succinic acid does treat pain associated with teething, how does the succinic acid get into the child’s body? Amber is fossilized tree resin which is formed under extreme heat and pressure. The Wikipedia article on amber states, “Exposure to sunlight, rain and temperate extremes tends to desintegrate resin, and the process is assisted by micoorganisms such as bacteria and fungi. For resin to survive long enough to become amber, it must be resistent to such forces or be produced under conditions that exlude these." How is it, all of the sudden, that amber decides to release succinic acid in response to 98.6* temperatures and gentle pressure from your child's neck? Seems unlikely.

3. Let’s assume that 1 and 2 are wrong and that succinic does treat pain associated with teething and will absorb into the child’s body from the necklace. How much is absorbed? Medication applied to skin is notoriously unreliable with children.

Let’s flip this around. Say an established drug company comes up with a treatment for a common condition that is not dangerous but may cause some discomfort. The drug rep comes to my office to promote the drug…

Me: Ok, this all sounds great? So, what is the dose? How does the dose change as the child gets older?

Drug rep: Ummmm, we don’t know really. We haven’t really looked into “dosing.”

Me: So, how do you know this works?

Drug rep: Well, it’s actually been around a long time, we just put it in a different package so we’re pretty sure it works and is safe.

Despite the fact that on the surface it seems plausible, I don’t think the succinic acid claim holds up as a mechanism where amber necklaces could work for teething.

Is it a choking hazard?

We have to address these necklaces as a choking hazard. It’s interesting. People say they aren’t a strangulation hazard because they break. Ok. But then they say they aren’t a choking hazard because the beads are tied individually.

I say, you can’t have it both ways. If they break, they have to break somewhere and a bead has to get loose. And if you’ve seen the size of these beads … looks like a choking hazard to me.

So, why do amber teething necklaces “work?”

It’s really based on three points…

1. Teething symptoms are vague and most are only mythically related to teething.

2. Teething symptoms go away on their own 100 percent of the time.

3. Parents are desperate to help when they assume their kids are in pain.

Studies are pretty clear that teething symptoms really only last a day or two around the day that the teeth erupt. Many of the symptoms commonly associated with teething may actually be normal developmental issues-drooling, waking up at night, etc.

Knowing whether a specific treatment for “teething symptoms” works or not is almost impossible. But, for parents who had concerns and tried amber teething necklaces, the results seems magical. Doing something is often thought to be better than doing nothing. It’s certainly easier to brag about.

I have yet to see a Facebook post that says, “My kid was MISERABLE with teething last week but look at him today!! I found the miracle cure - I did absolutely NOTHING! You should try it too.”

I’m coming into a place where I’m not sure treating teething with anything makes sense, even your typical pain relievers. For this reason and because I cannot find a plausible explanation for why they work, I think parents should save their money when it comes to amber teething necklaces.

The numerous health benefits of breastfeeding cannot be denied. Some of them might be overstated at times but, all in all, I believe that breastfeeding is best.

I know there are times when, for whatever reason, moms cannot or choose not to breastfeed. Fortunately, we have come a long way from the old days of evaporated milk formulas of the 1920s to where formula feeding is a very reasonable alternative for those moms. I believe that families should be properly educated and supported in their feeding decision no matter what it is.

If you chose to formula feed or plan to, you can stop reading now. This is not one of those articles meant to shame someone for their choice. This post is a message in support of moms and families who choose to breastfeed and need a little help to determine if everything is going OK.

“Seven percent is average, over 10 percent I start to get worried.”

Most moms know (or read or were taught) that babies lose weight in their first few days of life. If not, that one week checkup is pretty emotional when they place their babies on the scale and the number is lower than their birth weight. Think about it, a 10-pound baby can drop to as low as 9 pounds and still be considered normal weight loss, but you would certainly worry from the time the baby was weighed until I came in the room to tell you everything is OK.

I have been quoting this 7 percent/10 percent mantra since I started practice. It’s partially wrong, at least for breast fed babies. Why? They can actually lose more and still be normal.

A study released in Pediatrics in December showed that breastfed babies could lose more than 10 percent and still be normal, especially babies born via caesarean section. The graphs enable a pediatrician to look at a baby’s weight loss day-by-day and determine if the weight loss is excessive. The bottoms of the weight loss peak occur on day six for both vaginal and c-section but the peaks occur at 11 percent and 12 percent respectively.

Why does this matter?

Any mom who has had trouble getting their baby to grow on breastmilk knows the pressure to start formula that can be applied by doctor, nurses or family members. While, I don’t believe that having mom give formula when appropriate ruins her chances of breastfeeding, I certainly don’t want to be pushing families to supplement when it isn’t necessary. Therefore, I plan to start implementing these guidelines into my practice so that I can best support breastfeeding moms in their effort to breastfeed.

If you are having a baby and are planning to breastfeed, it might be helpful for you to be aware of them as well.

They are not caused by holding (or kissing) frogs but, instead, are caused by viruses.

The virus that causes warts is contagious, but that does not necessarily mean that if your child touches a wart they will get one.

Warts will go away on their own without treatment (Say it with me now.). It never feels like that when it’s your own child, but I promise they will. It may take 6 months to 2 years but they will go away.

There are many strategies for taking care of warts at home. 

Over-the-counter (OTC) Meds

1. Bath or shower
2. Use an emery board to file the dead skin on the surface
3. Apply the topical wart remover
4. Cover the wart with a band-aid

Duct Tape

Place a strip (or ring if on the finger/toe) over the wart. This strategy may take weeks or months of coverage to work, but it does work (studies even show it)

Wart removal can be done, but I only recommend it for warts that are painful or in a location that makes activities (writing, etc) difficult. 

The most common types of removal are freezing and laser therapy.

About the author

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

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.

It’s that inevitable time of year where I see news story after news story where children are rewarded Oprah-style for their awesome record of perfect attendance:

“You get a bike and you get a bike and you get a bike.”

Yeah!!  It’s pretty heart-warming and exciting, right?

There are kids (and families) that blew their perfect attendance the first week of school and didn’t think twice about it, but there are some that are holding out hope that maybe this year will be their year to win the drawing for $100 or an iPad or a trip to Hawaii (I haven’t actually seen this one, but I want my kids to go to that school) or whatever their school dreams up.

I do have a question though. Is perfect attendance really the point?

You need to be at school to learn. I get that. Missing school for frivolous reasons is harmful to the student and the school. So incentives to get kids to school make sense from that standpoint. But, at what cost?

There is a tension going on right now in the minds of parents throughout our community. It might go something like this:

“He’s only coughing a little bit.  He did get a few hours sleep last night. His fever is only 101 and if I give him Tylenol® maybe he won’t have fever at school.”

Does this sound right?

Has this line of thought ever happened in your house?

Do you think it really happens at other houses?

I can assure you it does. Parents say something like this all the time, “Well, he was having fever last night, but I gave him some Motrin® this morning so he hopefully wouldn’t have one at school. But sure enough, he did and the nurse called me to pick him up.”

This clearly misunderstands the whole point of not wanting your child at school if he has fever. Not having fever is not the goal. Keeping your child away from others when they are sick is the goal. Whether your child’s fever is masked by medicine or not doesn’t make them less contagious.

What can we do about it?

What if we changed the goal from perfect attendance to responsible attendance?

Perfect attendance implies that you go to school no matter what.

Responsible attendance implies that you go to school when it is appropriate and don’t when it isn’t.

Perfect attendance puts your child’s classmates health at risk.

Responsible attendance puts your child’s and their classmate’s health above another goal.

I am an optimist, but not unrealistic. I’m pretty sure that we can’t change the school’s policies regarding perfect attendance awards.  Besides, how would you reward responsible attendance anyway?  But, we can make a decision to practice responsible attendance with our kids and teach them to do the same.