Summertime is the best time of year (in my opinion!). Schedules can sometimes be looser, we can be outside more and it’s great to have a break from schoolwork! It is common to be more relaxed with the bedtime routine.

As a parent myself, I am happy to let a strict bedtime for the school year fade away. However, a late bedtime and waking up late can end up being troublesome during this time of year when we know we have to return to a more regular schedule.

It isn’t “bad” for kids to go to bed late and awaken late, as long as they are getting the total number of hours of sleep recommended for their age. I have met a few kids that go to bed late but also wake up early so they are tired in the daytime, which can impact their behavior.

Our middle school kids are programmed to go to bed late and awaken late -- this change to the clock inside your brain is part of the pubertal process. Therefore, it can be hard to fight the return to an early morning wake-up in August.

How should you do it? Here is one method. Once a person has been going to bed late for a longer period of time, the brain becomes accustomed to that. So simply getting in bed early won’t mean that a person gets to sleep early.

It’s best to continue with the late bedtime, but get up a bit earlier (like 1 hour earlier) than usual. It’s hard to do but using sunlight exposure (sun to the face) and encouraging breakfast can help. Then kids will be naturally tired earlier the following evening since they arose earlier that morning. Some parents use melatonin (dose of 1-3 mg) given 1 hour earlier than the late bedtime to help with falling asleep as well.

Watching caffeine intake, aiming for calm play in the hours before bedtime and keeping lighting low can also help with resetting bedtime. Screen use (TV, phones, computer monitors, and video game consoles) should stop around 1 hour before the desired bedtime as well.

Remember that bright artificial light (from screens) can trick your brain into thinking it is daytime. Try not to allow afternoon naps, so kids build up their sleepiness- aiming for a reasonable bedtime.

Sometimes writing down the plan for bedtime/waketime change can help. Kids can be an ally here so involve them in the process.

Good luck with the new school year!

By Lauren Bridge, MS, CCLS, AYA Child Life Specialist at Cook Children’s Hematology and Oncology Center

Most often, the title “child life specialist” resonates with toddler, preschool and school-aged children. However, our scope of practice spans through young adulthood. I am Lauren, our Oncology Adolescent and Young Adult (AYA) child life specialist. The AYA population includes those diagnosed with cancer ranging from ages 15 to 39.

How is this role similar to other child life specialists?

As a child life specialist, I still provide diagnosis education, procedure preparation, procedural support and general emotional support for coping. All of that education and support is customized to meet the developmental needs of a teenager or young adult.

The medical environment can still be very confusing for our older population and the educational background of a child life specialist allows for breaking down information in easier-to-understand terms.

Let’s not forget play. Play is an integral part of a child life specialist’s role and imperative to coping well in the hospital environment.

What are the unique needs of AYAs?

First, let’s look at the developmental needs of adolescents without a chronic illness. During this stage of development, teens are seeking autonomy, making self-discoveries, learning about their changing bodies and acquiring their own set of values and morals all while their social life becomes a priority.

Throw in a cancer diagnosis and suddenly these developmental needs become increasingly difficult. Autonomy is difficult as caregivers and medical staff are constantly near with instruction, invading personal space. Cancer adds to the confusion of self-discovery. How much of their identity lies in diagnosis or not?

Changes in their body increase as hair is lost, weight fluctuates, menstrual cycles are paused and illness affects their physical well-being. Social life is put on the backburner as immune systems become low, energy decreases and feelings of self-consciousness set in. The sense of invincibility is shattered and many adolescents and young adults question their values and faith during this time.

Looking beyond the age of 18, as AYAs enter young adulthood, developmental needs continue and grow. Young adults continue to seek autonomy and self-discovery, are entering more schooling or the workforce, have increasingly more financial independence and responsibility, are exploring their sexuality, are forming intimate relationships and in some cases are starting families.

Cancer turns these developmental needs upside down. Autonomy is stunted by hospitalizations and the need for help. School or work are disrupted or put on hold. Body consciousness and side effects of chemotherapy become more prominent making exploring sexuality a struggle. As the immune system weakens, emotions run high and the body’s physical exhaustion, many find themselves isolated. Collectively making forming deep relationships challenging.

How can Child Life help?

As an AYA child life specialist, my goal is to help adolescents and young adults cope with new challenges, express emotions, meet developmental milestones and maintain a sense of normalcy.

Recognizing the importance of autonomy, I offer patients as many choices as possible. I, along with our AYA multidisciplinary team, want to give the AYA population a say in what is done to their body. Allowing our patients to share what comforts them, people they want present when ill, how much medical intervention they wish to have and end-of-life wishes give them control in a powerless circumstance.

Most often I can be found holding space in a patient’s room offering a safe place for expression, providing port education prior to the procedure, creating a coping plan with a patient, debating who will win a game of pool, exchanging jokes, giving choices for space and autonomy, validating emotions, creating art and having some deep conversations.

Building trust with the adolescent and young adult population is not always simple. For this reason, I follow the AYA patients inpatient, outpatient and in the ICU. I have to earn my space in their room. I strive to show up consistently and genuinely. It is with a true sense of honor that these amazing young people allow me to be a part of their care. I am forever grateful for this unique population and their trust in me to serve as their child life specialist.

They grow up so fast. One minute you’re rocking your baby in your arms and breathing in their sweet baby smell from the top of their head, and the next you’re carting them off to the doctor for their teen physical and wellness check.

In many ways, for both parents and kids, it feels like an altogether different experience from their yearly infant and child well-checks. But, in reality, it’s not different at all, save for the fact that your baby has matured into a teen who now values a certain level of modesty and privacy when it comes to their bodies. This can make the routine check of the genital area which is a part of every physical a bit “cringey,” as your teen might say. Let’s face it, it’s uncomfortable for parents, too, as they come to terms with their child’s increasing independence.

“I think parents think they're different and I think the only reason that they feel it's different is that, of course, the teenager at this point now does a lot of stuff on their own, meaning they have their privacy,” explained Bianka Soria-Olmos, D.O., Medical Advisor for Digital Health. “The parent isn't in full knowledge of things like bowel habits or genital development and abnormalities because they’re not changing a diaper or helping with bath time every day.” 

What to Expect

When Dr. Soria-Olmos examines the genitals during a patient wellness check — be it for a baby, child or teen — she says she is inspecting for the same things. Is the child following a normal developmental path? Are they entering puberty too early? Are there any visible abnormalities of the genitalia? These exams are general visual inspections. Nothing invasive.

For boys, pediatricians examine the penis, testicles and scrotum. When inspecting the scrotum, they may ask your child to turn their head and cough as the pediatrician feels the scrotal sac.  This helps reveal inguinal hernias or tumors. Slightly embarrassing for your teen? Yes, but absolutely necessary. Undetected inguinal hernias can rupture and be very painful, or even dangerous, for your teen.

Inguinal hernias are particularly dangerous for teen boys playing sports, as a direct blow to the genitalia could lead to hernia rupture. This is why most teen boys are required by their school to have physicals prior to playing contact sports, but they’re important even if your kiddo isn’t suiting up each week for Friday night football.

“I remind my parents of kiddos who say, ‘I'm not playing sports, so I don't need that check,’ that we still need to make sure that we have a normal anatomy and that we don't have a hernia,” Dr. Soria-Olmos cautioned. “Because an undiagnosed hernia, even if not playing sports, can be dangerous.”

Girls will also undergo a visual exam of their genitals to make sure their development is coming along at a normal pace. Unless there is a complaint of pain or other concern, Dr. Soria-Olmos says teen girls do not need an internal gynecological exam. The American College of Obstetricians and Gynocologists recommends women begin having regular Pap smears at age 21.

Alleviating Embarrassment

You can help your teen gain some level of comfort with these exams by talking to them prior to their physical about what to expect and why these checks are necessary. Dr. Soria-Olmos makes this discussion a regular part of her patients’ yearly wellness checks as they grow and mature. She also uses it as a springboard to talk about body safety and the difference between an appropriate medical exam under the consent and supervision of their guardian versus inappropriate touching.

In addition to a genital exam, all of the normal body system checks occur, too — ears, eyes, nose, throat, mouth, abdomen, back, legs, arms and thyroid glands. You’ll hear the same questions about your teen’s nutrition, sleeping habits and physical activity as you did when they were younger. If mom or dad has expressed concerns or the doctor detects any red flags about mental health, sexual activity, alcohol use, drug use, smoking, signs of an eating disorder or other risky behaviors, your pediatrician may broach these subjects with you and your teen.

“We only talk about this when the physical is done,” Dr. Soria-Olmos said. “And then always gauging the parent’s comfort for allowing their teen to have a conversation with or without the parent in the room.”

If you have a concern about your teen, or feel they may be more comfortable talking to the doctor about an issue, it’s okay to alert your pediatrician ahead of time so that they are aware your teen might have something they want to discuss.

“Ideally, I try to foster this type of open communication,” Dr. Soria Olmos said. “We are all here together to help the child. It’s important that mom, dad and doctor are all on the same page about what is going on with their teen.”

While this new phase of life may be tricky to navigate and, at times, uncomfortable for both you and your teenager, it shouldn’t deter either of you from getting these important health checks. In addition to protecting their health, it teaches your teen to be responsible for taking care of their bodies as they move out from under your wings and into adulthood.

By Ashley Pagenkopf, MS, CCLS, Child Life Specialist at Cook Children's

The last few years have been filled with collective challenges. The pandemic seemed to touch every single person in some way. It was the first experience of my lifetime that seemed to affect every single person I know.

We seem to be coming out of the grief and fog, but some lasting changes and effects will forever remind us of this time. Yet, in the middle of a pandemic, life continued to happen. Babies were born. Family members received new diagnoses. Some of us said goodbye to those closest to us. Joy and sadness shared space just like they always have and always will. 

When 2022 began, I filled out my yearly “dream guide” and walked into this year with joy and excitement to leave the intensity of the past two years behind. I wanted a break from the hard and literal constant changes. For our family, this year was a mile-marker year. My husband and I celebrated 15 years of marriage, and I entered my fourth decade of life. I was ready – ready to celebrate at every turn and really enjoy this year.

Grief and Grace

At the end of March, our world changed yet again. My middle daughter had a seizure and was diagnosed with a brain tumor. Time stood very, very still. Only a week after her first seizure, my grandfather (who I truly believed would live forever), died unexpectedly. We found out about her tumor two days before my grandfather’s funeral. 

I’ve never really known grief like I knew that weekend. It was physically painful. I remember wondering if the pain would ever subside or if it was going to be my new normal. There were many moments I could not breathe. My girls were devastated over the death of their great-grandfather, and we still had to tell them about a tumor. I just thought that pandemic was hard. This was a new level.

For the next several months, my daughter endured tests and imaging, and we talked to countless doctors to decide our next steps. We spent the summer in many, many consults and trying to make huge decisions.

At the beginning of August on our way to our summer vacation, I found myself completely void of any hope. I was shutting down. The moment I realized I was not okay was in the security line at the airport with the unkindest person that ever existed. 

After several very difficult shifts in the ER where many families lost their precious babies coupled with the intense decisions we were making for my daughter, the one lady working security caused me to completely fall apart. I wondered if she had recently lost someone or watched someone else grieve their child or if her child had a new diagnosis… I had to ask myself this so maybe I could give her some grace. I really had nothing left, though. 

I sobbed as I put my shoes on. My kids stared as I didn’t even try to hold it together. My husband was angrier than ever. I made my way to Starbucks, barely able to catch my breath and not even attempting to hide my hot, alligator tears. Once on the airplane, I proceeded to sit on my coffee that I had set down to put a bag away. Things felt completely hopeless. Life felt unraveled.

Have you looked at this past year and wished it would just end? Have you had one too many phone calls from the school with your kid as the subject? Has your kiddo been diagnosed with a new illness? Did you think that you were done with treatment, only to find yourself back in hard? Has your job felt like it is robbing you of all your energy and sanity? Have you lost someone dear to you this year? Has your world felt like it was ending, and you couldn’t see a way to stop it? Have you had a moment like mine in the airport where you had nothing left for the mean person and then you sat on your coffee?

Embrace Hope Now

I’ve heard a lot of people say recently that they are ready to have 2022 in their rearview mirror. I would be lying if I said I didn’t feel the same way. But I’ve spent a lot of time thinking about this. I am the first to embrace new beginnings. I love the New Year – new goals, new resolutions, new starts. But I have been reminded often that hope is here, now. It is at this very moment. In my desperate desire to leave this year behind and start over, I may miss the very moment where hope meets me now.

Literally, in every hard moment of this year, something beautiful has shared space with it. That something beautiful has often reminded me that hope is here. Hope is defined as “confident expectation” or “forward-looking faith.” Hope reminds us that there is good coming and beauty to be had.

Yet, this year, what I’ve always hoped for has met me in every hard moment. The hope for people who would support me, the hope for strength to shine in my kids in the face of adversity, the hope that I would be able to be present for my family when we faced pain and the hope that I could still find comfort and peace amid grief… All those hopes have been real this year. Thank goodness for those few sips of Starbucks before I sat on it. (Starbucks has provided a great deal of hope in the middle of hard this year.)

While on the said vacation, a wonderful photographer captured our family on the beach of Lake Tahoe. Hope that we could still smile and laugh and find joy met me in those moments. When tears streamed down people’s faces as they shared their prayers and hopes for our family, hope met me there. When my Cook Children’s family extravagantly showered our family with gifts and love, hope was tangible. When my very best friends drove seven hours for my daughter’s surgery and surprised me, hope met me. With every letter and encouragement and tear, I met hope.

What would happen if we could embrace hope now? Hope – the beauty that is to be had – doesn’t have to be next year. Hope is here, now. 

You can be hope to someone, and you can find hope in the simple. You can hand that bag of essentials out the window to the next man or woman you see on the corner and offer them hope. You can pay for the car behind you in the drive-thru and be hope for them. You can smile and ask your cashier how their day is and be hope for them at that moment. 

You can offer the beauty that is to be had – the hope – to those around you. And you can find hope in your next cup of coffee that warms you up. You can see hope in your kiddo that chooses kindness towards their sibling. You can experience hope in the next phone call or text message or next hug that comes your way. You can experience hope the next time your kiddo is brave like you never knew. You can see hope in the way that one tiny candle lights up the darkest room. Hope is here, now.

We all know sleep is important, but that doesn’t mean we get enough. And when it comes to kids, sleep is especially critical for their development and mental health.

So what should you do if your child has trouble sleeping? Hilary Pearson, M.D., is the medical director of the Sleep Center at Cook Children’s Medical Center. On this episode of Raising Joy, Dr. Pearson talks to us about sleep aids, the impact of electronics on sleep and when you should seek help for your child from a medical professional.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

Join us for the first LIVE recording of the Raising Joy podcast on Thursday, September 29 at the historic Downtown Cowtown at the Isis Theater in the Fort Worth Stockyards.

This event, which is being hosted in partnership with The Center for Children’s Health led by Cook Children's, will bring mental health leaders in the community together to hear an inspiring talk by author and renowned speaker Andrew Solomon, Ph.D. Solomon is a Pulitzer Prize finalist, National Book Award winner, TedTalk presenter, as well as a professor of Clinical Psychology at Columbia University.

Registration is required to attend. Click here to register! 

As summer draws to a close, one mother, Dana Gage, is sharing her journey to making her son’s tragic drowning death matter.

On Aug. 31, 2012, Dana's son, Connor, left for a friend’s birthday party at a rented lakehouse. Little did either of them know, it would be the last time Dana would see what she calls her son’s “1000-watt smile.”

Hours later, Connor drowned in a swimming incident that was 100% preventable. He was 15 years old.

In the 10 years since Connor’s death, Dana and her family established The LV Project, to raise awareness about drowning prevention and advocate for the use of life vests on lakes. We asked Dana to share with us how Connor inspired what has become her life's work since his death.

What is one of your favorite memories of Connor?

I spent my career in marketing and advertising. One of my favorite memories is sitting with Connor and watching TV. An ad would come on and he’d say, “Mom, that’s a really good commercial.” Then, in great detail, he’d proceed to tell me why. And he was always spot on. I remember thinking, how on earth does this little kid have the ability to discern between good advertising and bad advertising? How does he deconstruct these ads down to the nuances that result in a great commercial?  But he did, and it was fun. For me, it was sort of like having a pint-sized work buddy at home. 

At a very young age, Connor seemed to understand that connecting with people emotionally is the way to get people to think, and hopefully, act. On one of his school assignments, Connor was asked what he would do with his life. He wrote, “I’ll probably go into advertising or something.” In many ways, he has, as we share his story in hopes of preventing drowning deaths.

As you reach the 10-year mark of Connor's death, what do you want people to know about his legacy and remember about his life?

It’s taken every bit of the last 10 years to pry my broken momma heart loose from the magnetic force of lament mode and force myself into joy mode. It’s like weightlifting. It’s a constant struggle not to be crushed under the loss. There are many days I am still on the floor, in a heap of grief. But I get up. I fall down. Then I get up. After 10 years, as my grief muscle continues to develop, I find that I’m getting up more quickly, and I’m falling down less. 

I’m trying not to dwell in the lament of what Connor could have been and, instead, genuinely celebrate what Connor was. A happy kid who enjoyed his life. I guess when people think of Connor, they’re naturally going to remember the boy who died. But what I truly hope is that they remember the boy who LIVED. Connor lived joyfully, happily, buoyantly. He made his 15 years count far beyond his 15 years. There are no guarantees in this life, and there are no do-overs. Connor made his count.

We remember his buoyant spirit. We remember his smile, and we remember that come what may, we can keep going.

How does Connor's life inspire the work of The LV Project?

I started The LV Project in November 2012, just two months after we lost our boy. Why? Honestly, because it was the only alternative to losing my mind. I had to do something. Doing nothing wasn’t an option.

On that awful day, Riley lost his only sibling and his best friend. Brett and I lost our family, our dreams, our hearts, our future. It was too horrible to be true. Yet, it WAS true. My baby DID die. This WAS now my life. And I had no idea how to face it. Broken open, shattered in a million pieces, sitting in the rubble, I spent my days walking in literal circles over and over inside my house. From the living room to the kitchen to the dining room and repeat. Groaning and walking. Walking and groaning. I guess you could say, all those circles led straight to The LV Project.

Most people think of LV’s mission as drowning prevention, but in reality, it’s heartbreak prevention and hope. We’re in the buoyancy business. That’s true on water and in life. No mom, dad, brother or sister should feel the way Brett, Riley and I do every day. Not when it can be prevented. And the thing is, it really is possible to end these tragedies. Drowning really is a problem we can fix. The LV Project is where we make our suffering matter. If you live long enough, you’re going to suffer. We have to make it count. Because suffering without meaning is just despair. That’s why The LV Project isn’t just about how Connor died. It’s about how he lived. And Connor lived buoyantly.

Why is it important that parents, health professionals, lawmakers and anyone responsible for a child's safety and life understand The X Effect?

The seeds for The X Effect were planted pretty quickly after Connor’s death, though we didn’t know it at the time. In the weeks that followed, we were surrounded by the loving support, but also stunned by how few people mentioned the fact that the boys weren’t wearing life vests at the lake party where he died. No one brought it up. The blame seemed to fall on Connor. It was chalked up to “boys will be boys” and “reckless teenage behavior” or just “a terrible accident.”  That sickened me. Still does. Terrible it was, but accident it wasn’t. Connor’s death was not some random, unstoppable event. It was preventable.

Even more shocking was how little people understood the dangers of open water. If my underage son had died in a car because the driver didn’t require seat belts there would’ve been shock and rage at the carelessness. If Connor had been killed by a drunk driver there would’ve been a certain fury at the recklessness. But very few people seemed to understand that allowing a kid to swim after sunset and jump from high places in an unfamiliar lake without a life vest is every bit as dangerous. 

There was a time when people didn’t wear seat belts. And there was a time when people drove while drinking alcohol. But, unnecessary deaths—deaths like Connor’s—created the change necessary to save lives. Now is the time for people to understand that knowing how to swim does NOT make a kid drown-proof. Now is the time for people to understand that a life vest in a lake is like a seat belt in a car. Now is the time for people to understand that it’s our responsibility to protect those at the highest risk—teenagers age 15 to 19—from drowning in open water.

What everyone needs to understand is this: you can’t out-water the water. The water always wins. We hope The X Effect opens a lot of eyes to the reality of drowning for ALL kids—little and big.

What do you think is the biggest misconception about teens and drowning?

Absolutely the biggest misconception is that people think good swimmers are drown-proof. Nothing could be further from the truth, especially in open water.

There were many factors that contributed to my son’s death. Paramount is the fact that I did not ensure that my son would be required to wear a life vest, nor did the host family require the boys to wear them. That was a recipe for disaster. The five boys at this party were given permission to swim very late in the day. Connor went under at 8:15 pm. The sun had set that day at 7:55 p.m. It was entirely too late to be in the water. It’s impossible to see anything in lake water at high noon, much less after sunset. We have a saying, “When the sun’s low, the kids gotta go.” Low light conditions can turn an already risky situation deadly.

The other challenge is our life vest laws which, I believe, work against us. The law in Texas says life vests only need to be worn by kids 12 and under, and only in boats. That leads most parents and kids to a false sense of security. The irony is that in Texas, 80% of open-water drownings happen beyond the boat, meaning in open water settings such as shorelines or simply swimming in the lake. So, there’s this presumed assumption of safety because the law says you don’t need a life vest when you’re 13 or older. Meanwhile, our strong swimmers are drowning. Per the CDC, open water drownings triple at age 15, and the drowning rates remain elevated through adulthood. So as the life vests come off, the drowning rates spike.

But the most important thing is to know the numbers. In open water, more teens and adults drown than small children. We love our littles. We love our bigs. We have to protect them both by making life vests a must.

What work still needs to be done when it comes to action and awareness of this issue?

Raising the current mandatory life jacket wear age from 12 to 16 as a law would be an amazing first step. That would save a lot of lives, and also serve as an effective signal to parents and their teens that good swimmers can drown and do.

Secondly, everyone should have the opportunity to learn how to swim. Getting swim lessons into our school curriculums as a basic life skill would be a fundamental lifesaver. In those lessons, bridging the gap between pools and open water is important. Swim lesson instructors should plant the seeds early about the differences between closed and open water so the safety measures continue as the kids age into adolescence.

Lastly, just like every young parent learns how to keep their kid safe when they’re babies with car seats, poison control and more, we need to educate our young moms and dads about the reality of teenage drowning. Water safety goes beyond learning how to swim. It’s the second leading cause of death, after automobile accidents, for kids ages 15 to 19. I’m sure if more adults knew that, requiring teenagers to wear a life vest wouldn’t be a maybe, it would be a must.

Lifeguard Your Child

Lifeguard Your Child offers parents these tips for keeping their kids safe in open water:

• Life vests should be “US Coast Guard Approved (USGA).” Check the inside label for this stamp of approval. They should also be worn inside the boat or in the water, as most drowning fatalities in natural water are non-boating related.
• Know before you go. The water conditions of lakes, rivers and oceans can change daily, from clear to murky and calm to rough. Be aware of the conditions before you get in and know that there may be harmful debris under the surface that you can’t see.
• Children, whether toddlers or teens, should be watched by an adult when in or near the water. Teens are often fearless and unaware of danger. They need responsible adults to help them avoid risky behavior.
• Have a safety plan in case of an emergency. Learn CPR so that you can administer rescue procedures while EMS is in route.

For more information about keeping children and teens safe in and around water, check out www.lifeguardyourchild.org, a program of The Center for Children’s Health, led by Cook Children’s.

Our relationships with our parents during childhood have a wide-reaching influence over the course of our lives. On this episode of Raising Joy, we talk to one of the leading experts in this field of research, known as attachment theory.

Casey Call, Ph.D., LPC, is the associate director of education at the Karyn Purvis Institute of Child Development at Texas Christian University in Fort Worth, Texas. She tells us how her background as an educator led to her passion for improving systems of care for children. We also explore how different attachment styles impact our children and ourselves.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

In June 2018, Payton Singh arrived via ambulance to Cook Children’s Emergency Department in a barrage of flashing lights and sirens. She was just 12 years old and decided to end her short life while her parents were away from home.

Payton and her family returned to Cook Children’s this week to reunite with her medical care team who saved her on her darkest day.

“I can’t even explain the emotion and the panic that sets in as a parent,” said Brandy Lumbert, Payton’s mother. “After getting the call, I remember running into the emergency room - they knew exactly who I was. And then she flat-lined right in front of me. As a parent, you want to jump in and tell the doctors and nurses to move faster, but you’re just standing there, helpless.”

Payton and the Lumberts also shared their story on the latest episode of our Raising Joy podcast.

Payton’s brother, Kegan, found her unconscious in her room and took action well beyond his years. Though he was just 8 years old, he had the wherewithal to call 911, put the family’s dogs outside and notify his parents that help was on the way.

 When officers arrived at the Lumbert’s home in Keller, Texas, they believed Payton had been without oxygen for 12 minutes.

 “Doctors told us, ‘She’s alive but she’s not showing any brain activity,” said Nick Lumbert, Payton’s stepfather.

 The medical team was able to stabilize Payton and moved her to the pediatric intensive care unit (PICU).

 “Every day in the ICU, we’d stare at the breathing machine to see how many breaths she was taking on her own,” said Nick. “It was very hard to go through that.”

Soon after being admitted to the hospital, Payton’s neurologist pulled the Lumberts aside to show them the scans of her brain. They revealed four small spots, an encouraging sign that the damage wasn’t as dire as it could have been. Still, it was unknown if she’d ever walk or talk again.  

On day five in the PICU, something unexpected happened.

“I remember walking through the doors and we hear all of the alarms going off and we take off running to her room,” said Brandy. “She had stood up next to the bed and was ripping everything off. She looked right at us and I was flabbergasted!”

And just like that, hope began to shine on the Lumbert family.

Soon after, Payton was transferred to Cook Children’s rehabilitation unit where she embarked on the long road to recovery. Over the next six months, she underwent treatment at three different hospitals across Texas.

Now, four years later, she is returning to Cook Children’s to say ‘thank you’ to the people who saved her life.

 On Thursday, September 1, 2022, Payton and her family were reunited with the doctors, nurses, and care team members who cared for her at Cook Children’s. This emotional reunion was requested by Payton, who is now a 17-year-old high school senior. She has a job, drives a car and is planning to pursue a career as a veterinarian.

The Lumberts recently shared their story on the Raising Joy podcast in hopes of encouraging other families who may find themselves in a similar situation.

 When asked what message she has for kids and teens who are struggling with their mental health, Payton said “Get help.”

 Their episode is now available on all major podcast platforms including Apple, Google and Spotify.

 September is Suicide Prevention Awareness Month.

 Here are some signs to be aware of – though not every suicide attempt will display signs. This is why it’s important to talk to children and teens about suicide, whether you suspect they are suicidal or not. 

1. Preoccupied with death (writing, drawings)
2. Talking about feelings of hopelessness
3. Talking about being a burden to others
4. Telling loved ones goodbye
5. Decline in performance
6. Giving prized possessions away
7. Isolating and withdrawing
8. Acting highly anxious or agitated
9. Acting reckless and taking risks
10. Rages
11. Changes in sleeping and/or eating
12. Use of alcohol/drugs
13. Dramatic changes in personality and/or appearance

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you. You can also address your concerns with your child’s pediatrician, psychologist or therapist.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) offers 24/7 call, text and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

One day your baby is securely nestled into their rear-facing car seat with a five-point harness. The next, they’re 16 and climbing into the driver’s seat eager to conquer the open road. For parents, it’s a moment of both pride and sheer terror.

Will they drive carefully and obey traffic laws? Will they pay attention? Will they know how to react when seconds count? Will they make it home safely?

Parents have a good reason for concern. The National Highway Traffic Safety Administration (NHTSA) reports that 2,042 people were killed in crashes involving teen drivers in 2019. In March, six high school girls, one of them the driver, lost their lives in a tragic car accident that made national news. The investigation into the cause of the accident is ongoing.

The summer months are the deadliest for teens in cars. No school means more unstructured time for young drivers and their friends to roam the roads. The AAA Foundation for Traffic Safety labeled the period between Memorial Day and Labor Day the “100 deadliest days” because there are more daily deaths during this time due to accidents involving teen drivers than at any other time of the year.  

Sharon Evans is the trauma injury prevention coordinator at Cook Children’s Medical Center where she spends her days educating patients and staff about how to stay safe. She is also a National Child Passenger Safety (CPS) Certification instructor and was the first in Texas certified to instruct the CPS course for special needs children called Safe Travel for All Children. Evans knows what it takes to keep kids safe in the car.

It’s not uncommon for teenagers to think they know everything. In reality, their brains are not fully developed. They lack the judgment skills that come with age and maturity, like the ability to assess risk. It’s why teens are prone to risky behavior in general.

“Teen brains aren't developed to the point where they can look at the situation and predict what's going to happen, good or bad,” Evans said. “They need time to grow to that before they can handle distractions like having more people in the car, or have the reaction time they need to drive I-635.”

Teens are also easily distracted and easily influenced. A young driver is more likely to mirror the behavior of their teen passengers, even if it takes their focus off the road. According to NHTSA, the more teenagers in a car with a teen driver, the higher the risk of a fatal crash. In Texas, new drivers under 18 aren’t allowed to have more than one non-familial passenger younger than 21 in the vehicle.

Even without multiple passengers, distractions are aplenty. Texting and talking on the phone, eating a drive-thru breakfast, or applying makeup while in a school rush — all have the potential to lead to a deadly disaster, even for the most experienced driver.

Giving new drivers the time to gain experience and maturity is the point behind the graduated driver licensing system. All 50 states and the District of Columbia have enacted some form of this three-stage licensing system for new drivers to minimize high-risk situations, such as driving at night or with multiple unrelated passengers.

But Evans says teen driver training starts long before a child turns 15 and enters the permitted driving stage.

“I truly believe setting safety expectations and good driving habits starts way back when they're a year old,” Evans said. “Kids are watching their parents. So when they see the parents on the phone while driving, you’ve basically just told them through your actions that it's OK.”

The same goes for seat belt wearing. Properly wearing their seat belt was never a choice for Evans’ kids. It was a given that turned into a habit and, eventually, an automatic reflex — one that paid off when her teens became drivers.

“I felt much better the first time one of my 16-year-olds drove away knowing that they were in the habit of always wearing their seat belt,” Evans said. “I at least felt they would always have it on because that was the norm for them.”’

Evans suggests a few other steps to prepare your teen driver to take the wheel:

• Have the hard conversations. Talk about the dangers of driving under the influence of drugs and alcohol and the potential aftermath of being distracted by the phone. Be open and honest about what can happen.
• Walk through the “what ifs.” What do you do when you have a flat tire? If your car breaks down on the side of the road should you get out or stay in the vehicle until help arrives?
• “Preparing for all of those little ‘hope they don’t happen’ things, really makes a difference,” Evans said.
• Be clear about the rules. No alcohol. No speeding. No texting while driving. Where can they go and when? What highways and byways are off-limits? Who can be in the car when they are driving? Who can and can’t they ride with? You know your child best. If they’ve fulfilled state licensing requirements but you know they’re not ready to be let loose of certain restrictions, slow their roll.
• Practice. Practice. Practice. It takes nerves of steel to be a parent in the passenger seat while your kid is behind the wheel, but that permitted driving stage is essential. Novice drivers need to encounter different driving situations and gain experience responding to them while under the watchful eye of a skilled driver.
• “It can be unnerving, but drive with them,” Evans said. “Let them get lots of experience during that permit time so they can encounter different situations while you are there to help and instruct. Drive with them as much as possible before they’re truly out on their own.”

For more information about teen driver safety, or how to keep children safe in the car at every stage, click here.

Ashley Igo was just 8 years old when her world changed forever. She was riding in an Amtrak train car when a semi-truck tried to speed through the crossing. She lost her mother, two friends, a niece and her right foot in the traumatic accident. For years, Ashley suffered from severe anxiety later diagnosed with PTSD. Today, she is a licensed psychologist and registered play therapist, and is passionate about early intervention after trauma.

Learn more about Ashley and the charitable work she does through the Beautifully Flawed Foundation and the Lauren Scruggs Kennedy Foundation here.

Ashley is our guest for episode 7 of the Raising Joy podcast. Here is her conversation with Wini King, Chief of Communications, Inclusion, Equity and Diversity at Cook Children’s. and Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s :

Wini (00:05):

Stress, anxiety and depression are skyrocketing among children and teens and Cook Children's Health Care System is on a mission to bring these topics into the light. I'm Wini King.

Dr. Pyrc (00:16):

And I'm Dr. Kristen Pyrc. If you have kiddos in the room, now is the time to put on those headphones. Some of the topics we'll be discussing will not be suited for young years. This is Raising Joy.

Wini (00:32):

Hello, and welcome back. We're so glad to have you back on this episode of Raising Joy. One of our first episodes dealt with trauma and how childhood trauma messes can sometimes mess with mental and physical health. It really kind of throws the equilibrium off of the health.

Dr. Pyrc (00:56):

Absolutely. And we talked about the ACEs study with Dr. Hood Patterson and I just thought she did had a really good job of explaining that to us. And I think that there are all different kinds of trauma. She had lost her dad in her front yard. And that totally changed her life as a teenager. But I think that there are other kinds of trauma that we see and I think that there is some trauma in our society right now just watching the news.

Wini (01:22):

We're seeing it now, as you watch the events of Ukraine open up and just unfold. And now the photos and the video it's becoming so much more graphic. And while of course, my trauma is not their trauma by no stretch of the imagination. It is something that if I look yet long enough, I feel the effect. And so trauma is something that we tend to push down, push down, push down, but that stuff can bubble up and come back. And when we talk about ACEs, I didn't even realize I had about five or six of them.

Dr. Pyrc (02:00):

A lot of people are learning that.

Wini (02:02):

You're like ‘I got to keep my head down, I have to do this. I got to make sure I do that.’ And so you wanna push it down. Today, we are joined by someone I would like to just refer to as a trauma survivor who embodies the word resilient.

Dr. Pyrc (02:21):

Absolutely. So Ashley was just 8 years old when her life changed forever. It set her on a course to help countless others. Ashley, thank you for being here.

Ashley (02:32):

Thank y'all for having me.

Wini (02:32):

Thank you so much. So now that we've set this up, trauma lives around you or has been a part of your life. Tell us about that day.

Ashley (02:43):

The day of the accident, so a little bit of background. A big deal for 8-year-olds and adolescents is the American Girl concept. So my friends and I were obsessed with the American Girl series and so my mom had me and then her best friend had three girls. And so they planned a spring break trip to Chicago to the American Girl store. It was amazing. And instead of taking traditional transportation, we took an Amtrack train and that was cool and exciting. And kind of all the things that go along with new experiences. So it was a really, really cool trip. We spent a week there exploring Chicago and going to the American Girl store.

(03:34):

On the way back, we were headed back from Chicago on our way home to Memphis, which is where I'm from. An 18-wheeler tried to beat the crossing arm of the railroad track. And so, he did not make it. Our train collided with the 18-wheeler. Twelve people died in the accident, hundreds were injured. And I was the only person to survive in our sleeper car. So everyone that I was within my particular car passed away. So my mom, my two best friends and my niece all passed away and my right foot was amputated in the accident.

Dr. Pyrc (04:18):

Oh my goodness. Ashley, I'm so sorry.

Ashley (04:21):

Yeah, it was a lot for sure.

Wini (04:23):

That's a traumatizing situation for an 8-year-old girl. How did, after all that happened, how did that change and how did that affect your life?

Ashley (04:33):

Kind of to put it in a nutshell, I kind of look at healing in three different ways. Personally, first is physical healing. So after the accident kids by nature are physically resilient. I actually went to one physical therapy session. I was like, ‘this is boring.’ And I taught myself how to walk on a prosthesis.

That part kind of was pretty quick. Spiritually, my faith, it was and is still really important to me and I had a great community surrounding me. And so prayer and faith in the Lord really strengthened me during that time.

The mental health piece is something that was not cared for. Not out of, it wasn't my dad's fault, but being a single dad, he didn't really pay attention to that piece. And it was like the late ‘90s, like who cared about mental health, then?  

Wini (05:26):

OK. The physical, the spiritual that's done, onto the next.

Ashley (05:29):

Right. So everyone looked at me and assumed like, 'oh wow. She can walk. She can run. She's doing great. She's totally fine. She's healed. Let's go, let's move on with this, you know, lone survivor, powerful kid.' 

I will say my dad took me to one therapy session with an older gentleman who was not a play therapist. And I sat on his couch and he asked me some questions. I told my dad that I didn't like it. And I never went back. And so I lived with unresolved trauma for decades before it was ever addressed.

Dr. Pyrc (06:04):

I think what's hard too about your situation is its trauma and grief.

Ashley (06:08):

Mm-hmm. Exactly.

Dr. Pyrc (06:09):

I think that just makes it even more hard.

Ashley (06:12):

Exactly.

Wini (06:14):

Trauma and grief together.

Dr. Pyrc (06:16):

How did you figure out, like, ‘Hey, maybe there's something else like maybe I need,’ or how did you see the trauma kind of bubble up for you?

Ashley (06:27):

Like I said, I kind of assumed that I was healed on all fronts until really my early twenties. So, I had looked back, so the anniversaries of the train wrecks over the years were not super significant. But the 10-year anniversary, for some reason, I was like, ‘wow, it's been 10 years since this train wreck, I'm gonna go on YouTube and see if there's any coverage.’ Because I had been contacted by some news agencies out of Chicago, just kind of following up 10 years after the accident.

And since then, it's 20 years after. So I was like, let me look at just some footage and just see from that day. And so that as you're talking about imagery can be extremely triggering. And I found this YouTube montage of the accident that I was in that I had never seen before. So the imagery kind of sparked kind of flipped on this switch that I had not flipped on. And long story short, it kind of launched into this whole kind of spiral of PTSD symptoms and debilitating panic disorder.

Wini (07:37):

You’re seeing this, even from a different perspective, because you experienced the train wreck, but seeing it from a video standpoint, now you're seeing things you didn't see.

Ashley: Right.

Wini:

Things you didn't remember from a perspective that was not what you experienced, you know what I'm saying?

Ashley: Yeah.

Wini: It was different.

Ashley (07:56):

It looked honestly a lot worse on the video footage, like the fire, the flames, screaming, just the horror of it. I had survived it, but I hadn't actually seen it. And so that triggered a years-long battle with anxiety disorder.

Dr. Pyrc (08:14):

Absolutely. I could definitely see how that would trigger that. So just to help me understand a little bit, so do you think you ever had any PTSD symptoms after it happened, like nightmares or flashbacks?

Wini (08:29):

Now that you think back?

Ashley (08:30):

Yes. Now that I think back, and now that I specialize in play therapy and childhood development, I can pinpoint, ‘oh my gosh. That OCD tick that you had was a side effect of unresolved trauma and grief and anxiety.’ I mean, I definitely had OCD and panic growing up intermittently and it looks different in kids than a dozen in adults.

And so my dad, single dad now running this bed and breakfast -- that was my mom's dream. He was running it by himself because she died. He didn't see it. So I just kind of brushed everything, shoved it down, pushed it down. And now looking back, it's like, 'oh my gosh, there were so many warning signs. I didn't deal with them.'

Ashley (09:17):

And so what I've learned through my study in psychology is that, and there's this book it's called ‘The Body Keeps the Score’ is that our body holds on to experiences. Even if we don't process them verbally, trauma lives in the right hemisphere of the brain and actual neuron clusters and it takes in-depth therapy. 

In my case, I did EMDR, which is eye movement desensitization and reprocessing. It's essentially just for PTSD. I did that. I did years of it, in addition to talk therapy, in addition to medication and I would say I still struggle with anxiety and panic. I still have those thoughts, but I don't I don't become immobilized by them. They don't make my life dysfunctional anymore. So yeah, I've learned a great deal. That's why I'm a therapist.

Wini (10:11):

Wow. Did you ever go back to the, EMDR, you went back?

Ashley (10:16):

To EMDR in my twenties, yeah. So I took a decade-plus hiatus from therapy that I needed. I didn't deal with these things until I was in my early twenties.

Wini (10:28):

How did you decide this is what I wanted to do? And this was the best thing for me?

Ashley (10:33):

So I studied psychology ironically enough at SMU, so it had some kind of basic like, ‘oh, the green lights were going off’ in college. It is interesting. Then I kind of through a pathway of individuals became really interested in therapy. I knew I wanted to work with kids. And so, through my master's program at SMU, I really started kind of realizing, I was learning about myself and did research and just kind of was like, ‘OK, I need to do this specific therapy.’ And I found a therapist and kind of went from there. It was a lot of through my own education, I was kind of my best advocate from a mental health standpoint.

Dr. Pyrc (11:21):

That's amazing. Well, it's awesome. I mean, I think that whenever you have trauma and the ‘shove it down’ is survival. Like that is a survival mechanism. ‘Hey, I went through something really bad and I need to get through the day, how do I do that?’ We call it compartmentalization. Kids are experts at this, but it is just to keep going every day. And so I really applaud you for being willing to like open back up the box and be willing to have a look at what is there.

Wini (11:53):

That's painful.

Ashley (11:53):

Painful. It's painful and tough. I mean, I really got to the point where I was in therapy or I was in grad school to be a therapist. And I realized that if I did not deal with my own issues, I could not help other people. So, it was kind of, honestly, by force, I got to where I was having such horrible panic attacks that I couldn't focus. So it was like, 'OK, I've got to do this.' And I did it and it is uncomfortable. It's hard. I mean, it's not fun to feel like that and to kind of face those traumas again, because you're reliving everything. But in the end, your brain is more where we're able to integrate trauma into our lives and make it a part of our story versus just shoving it down.

Dr. Pyrc (12:41):

Absolutely. You've mentioned being a counselor and a play therapist so like how did that come about? Like how'd you figure that out?

Ashley (12:49):

Yeah. So I have always in a sense, wanted to help people and I really became passionate about early intervention when I learned about kind of my own issues and how those could have likely been prevented to some extent, with some play therapy or therapeutic approaches that were appropriate for my developmental stage. 

So I was like, ‘OK, clearly kids need prevention for, or early intervention, with the goal of prevention, essentially.’ So we want to prevent them from experiencing these debilitating issues. Let's get them early. So that's what kind of made me want to work with kids and want to work with play therapy specifically. It's kind of preventing. I would say you don't want to become me. We want you to process this as a 7-year-old versus when you're 25.

Wini (13:50):

But it seems like to me it would be so much harder to deal with a 7-year-old who can't really communicate and who really can't articulate what's going on, as opposed to a 25-year-old who can say, ‘boy, this is painful for me.’ You know, as opposed to that child. It seems to me that one, and I'm looking at Kristen like you do this every day. So it would seem to me harder to deal with as a younger child.

Ashley (14:11):

In a sense, but think about it, like if you go the same way to work every day, it's so much harder to learn a new way. Right? Whereas kids, we can teach them, we can form those neural pathways in a positive. Versus going back and trying to erase the old road and starting a new one. So as adults, we are more stubborn and it actually can take a lot longer and it's harder, to learn new skills.

But if we teach kids like, ‘Hey, it's okay that you feel this way, we accept your feeling and we reflect your emotion.’ And so I always say we accept the feeling. We do not always accept the behavior. For example, when I was growing up, my stress and anxiety came out a lot as defiance and kind of not great behaviors.

Ashley (15:02):

My dad would probably say just smart aleck. But really on the inside I was hurting. Right. I missed my mom. I was lonely. And so I wish that I had had coping skills to implement at a young age, so that those behaviors did not even present themselves. So I'm really passionate about teaching kids, coping skills early. Acknowledging that this is what you're going through and that's OK. And let's help you process through it versus let's just shove it down and make it part of your personality. Right. When you're an adult.

Dr. Pyrc (15:37):

I think that's really key, like exactly you're saying like we can create new, more positive, coping strategies because sometimes trauma and abuse can lead to really negative coping skills. I see it a lot of my practice, like lots of cutting, just horrible self-esteem and that, it just affects everything, like how they interact with the world, what they think they can do whenever they grow up, how they pick a partner, like all these kind of things.

And so I think you're absolutely right. That teaching them, ‘Hey, you have these symptoms here is how to help it.’ I think it also so helps. I think left unchecked and untalked about, the trauma gets bigger and bigger and scarier. Yeah. And harder to deal with but it's like, if, if the message from adults is, ‘Hey, actually you can do this and we're gonna help you.’ It gives the kids a sense of control. And I think that that's ultimately what they need to be successful and to feel good about themselves.

Ashley (16:33): I agree.

Wini (16:34):

Wow. Yeah.

Wini (16:35):

We were talking earlier about how, when you experienced this kind of trauma and I've said it before that I would probably curl up in the middle of the bed and you would never be able to get me out, but the fact that you were out of a space that said, ‘but I want to help, I want to do something different. I want to actually impact in a positive way.’ How does that occur? Because honestly, I know I would have a different approach. I promise you, I would, it would be something totally different, but what happens to your brain that makes you want to do something positive and to really make it better? As opposed to me just lying down and curling up in the middle of the bed?

Ashley (17:20):

Man, that's the million-dollar question. I'm not exactly sure. But  I do, again, like my faith is very important to me, so I see it as thank you Lord for your grace and, and letting me be kind of where I am today, but there's so much good and empowerment that can come in helping other people. And I think even my teenagers who are depressed, like one of them told me that she had this new thing where instead of cutting herself, she was gonna draw a pretty flower on her arm. And so I shared that with another teen who was struggling with depression, and I told the first teen whose idea it was, ‘Look, I shared your idea with somebody else. And it really helped her.’ Wow. And the, her face was it lit up. So just, it's so empowering to use your pain to help others.

Ashley (18:08):

And so I just kind of took that mentality and have been blessed enough to be able to use it in multiple areas, whether it's with amputee or mental health kind of things in my life. And so I think the Lord has given me really great opportunities to do that, but I think it also runs in family. So my mom was a super resilient person. And so I look back and think like, ‘OK, this is kind of a girl power kind of trend in our family.’ But I don't know, it's the grace of God, honestly, because it's nothing that I specifically did.

Dr. Pyrc (18:47):

Right. I have to disagree you know, because like you could have said, ‘I lost my mom’ at a time whenever girls really need it. And I'm mad, I'm frustrated and I'm gonna go the route of like every negative choice that you could make, you know? But I think what it says so much about you that you said ‘hey I’m gonna heal first and then I'm gonna help people.’ I just think that says so much about your heart and your character and resilience and being a strong person. It says to me also that your mom is amazing.

Ashley (19:21):

She was, yeah. I think she'd be pretty proud.

Wini (19:23):

I think so too.

Dr. Pyrc (19:24):

She would be so proud of you.

Wini (19:26):

She is. She is proud. She is. And, probably somewhere hovering. You know, around to kind of give you that, ‘okay, here, tapping on the shoulder, do this, do that.’

Ashley (19:36):

That. Well I have a daughter who's 14 months and she's named June after my mom. So I get to see a little bit of my mom every day.

Dr. Pyrc (19:44):

That's amazing. That is really cool.

Wini (19:47):

Tell us a little bit about the work that you're doing with amputees, because you are not a only helping the people in their mental health but you're helping others through work with other amputees.

Ashley (19:58):

Yeah. So I get to be a part of two really amazing organizations. The first is I am on the board of the Bethany Hamilton's foundation. It's called the Beautifully Flawed Foundation in Bethany Hamilton. For those who maybe not remember she's the soul surfer, shark attack victim. So she's a great friend and have gotten to know her through the years. And every year we hold a retreat in California called the Beautifully Flawed Retreat for amputee girls and women across the world. It is amazing. Wow. It's the best week of the year by far always. And so we just pull these girls together for a whole week in Delmar, California, and love on them. And we focus on kind of those three pieces, so physical, mental health and spiritual health and wellbeing. And we get to, you know, hold each other's legs and talk about prosthetic things.

Ashley (20:57):

I call it group therapy for the week. It's amazing. So there's that. And then I'm also I work with the Lauren Scruggs Kennedy Foundation. So Lauren Scruggs Kennedy is actually from the Dallas area. She was in a plane propeller accident years ago.

Wini (21:15):

I remember that too.

Ashley (21:16):

Okay. Gotcha. So she is another great friend and she, Lisa Curley and I run the LSK (Lauren Scruggs Kennedy) Foundation, which we provide, beautiful silicone coverings for girls and women also so the insurance piece does not cover anything on a prosthetic leg or arm to look real. So you're essentially getting a metal pole and self-esteem does not really allow for that. A lot of place for sure. So we pay for that. We pay for the beautiful piece of that prosthesis. So we actually have a recipient coming next week. I think it's our 13th one. We've been able to do some really amazing things.

Dr. Pyrc (21:57):

It's so cool because I've had patients, maybe not amputee, but who have gone through something that's disfiguring and it really is a huge, huge. Especially if it happens to a teenager. It is such a huge blow to their self-esteem because you're already self-conscious and now you're like, 'oh, look, now they're really gonna look at me.'

And so I feel like a lot of kids they just like turn in on themselves and like wall themselves out, like wall themselves off from the rest of the world because they don't want to be seen. But I think what's amazing about you having a therapy background is that you can say with your personal experiences, you can say, ‘Hey, I've been through this.’ You can actually say, ‘I know how you feel.’ You've been through it all. And I think that just puts you in such a unique spot to help a lot of people. It's amazing.

Ashley (22:47):

It can be really powerful. And I have a couple of girls in my practice who they have Type I diabetes. And so they wear, you know, the Dexcom and you know, I'll see on their intake form that they wear a Dexcom. And so I will intentionally wear like a dress that day or a skirt. And so they can see automatically that like, ‘Hey, there's something different about your body too.’ And so then it's a really cool bond of, ‘my sugars are really low today and it sucked.’ I'm like, ‘yeah, my leg is squeaking for no reason.’ Like, I don't know why it's doing that.

Ashley (23:17):

So it’s not to say that other people can't empathize, but there's something about kind of being in that shared experience of having something different about you. That is comforting.

Wini (23:29):

The last two years have been really hard for everybody. Have you seen anything, any trends, anything in your practice as a result of the last two years?

Ashley (23:38):

Yes. You know, in addition to the anxiety disorders that we have continued to see the depression, the kind of self-harm, just all the things. I would say the most concerning to me, just kind of looking back the last couple of years was the turn inward. Not only to just like, because they couldn't go anywhere where we were doing virtual sessions, was virtual school and everyone on their phones all the time.

And so the turning inward, the turning to their phone, the turning to comparison. Actually, I had a girl who had struggled with disordered eating in the past, but then I had seen her for virtual sessions for a year and then I saw her in person and she had lost a significant amount of weight. She hid it from me. During virtual sessions, she was wearing baggy clothes and, and that kind of thing. So looking back, it's just like wow, these things that were already really difficult for them have now been kind of exacerbated by certain things. And so yeah, I would say that for the most part, most of my cases right now are teenage and preteen girls. I really do see a lot of, kind of the disordered eating, making a, I don't even think it's a comeback, it's rearing its ugly head. I think that it's rough for self-image these days.

Wini (25:05):

And we've talked a lot about how long this is gonna take for us to unravel out of this.

Wini (25:11):

It's not like, okay, now we're through with the pandemic, take off your mask, keep going and, and it's all gonna be over. It's really gonna be an unraveling for years to come.

Ashley (25:23):

There are kids now who don't even want to take their mask off because they got to hide their acne when they wore their mask. So, I mean, it's a whole thing.  I think we're gonna be seeing kind of ripple effects for a while.

Dr. Pyrc (25:36):

I'm curious if – this is kind of a little bit of a left turn -- but what would you say to look an 8-year-old girl who came in your practice who had thing that changed their body? Like what would you tell her?

Ashley (25:51):

Hmm. So my gut would be to sit and sit with them in their discomfort. In whatever is making them have their, whatever, emotional kind of feelings. So parents always say, ‘oh, she has such big feelings.’ And so therapy 101 is ‘reflect the feeling.’ I'm not gonna try to fix it for you. We will sit and we can cry together and we can be sad about that. And we can say that this sucks. But then we, you know, I would hopefully be able to cultivate in her coping skills and positive ways to look at things in a different perspective, but I never want to just brush over things that are the in initial kind of emotional hurt that we need to sit in.

Growing up, I mean, it was uncomfortable for my dad to sit in emotions with me. And so he just tried to fix things.

Wini: And so that's what men do. 

Ashley: That's what men do. So the can got kicked down the road. So I would want to embrace that, whatever she was, you know, struggling with or dealing with reflect those feelings, sit with her and the pain. And then when she's ready to kind of move forward with coping, then that's when we start.

Dr. Pyrc (27:05):

That's amazing. And what would you tell a parent of a kid who had had some sort of like either life-altering trauma or something that changed their appearance or what would you tell the parent? How do they best support their kid?

Ashley (27:19):

Well, first I would recommend finding a therapist to help you.

Ashley (27:25):

But yeah, I mean, again, like we do a lot of parent training through therapeutic parenting skills at our practice and parents want to fix it. They want to say but it's fine. You're OK. Let's move on. And 'oh, but you're so beautiful' and ‘oh, this is great about your life,’ but kids really need to feel heard and understood.

And so we know through research and in neuroscience that if you name an emotion for somebody, it helps them to feel that emotion less intensely because someone else is sharing that kind of burden. Sometimes it is a burden. Sometimes it's not a burden, but someone else is sharing that with you. And so the first thing I teach parents is sit and reflect because sometimes the problem doesn't necessarily need to be fixed. They just need to know that someone's hearing them and sitting with them in that moment. I mean that depends on the case, but I always start there always start with reflecting the feeling.

Dr. Pyrc (28:19):

But I think that's great advice for like kids grieving any grief like if they're grieving their personal appearance, a loss of a relationship. You know, I mean that would apply to a girl who's been broken up with. You know, sit with the feeling.

Ashley (28:32):

A feeling, just sit with them and it stinks and it's uncomfortable and let's move on when you're ready. But I try to be careful not to have kids use their diagnoses as excuses for things. But you know, there's a fine line.

Dr. Pyrc (28:49):

Right, absolutely.

Wini (28:51):

Ashley, thank you so much.

Ashley (28:52):

Thank y'all for having me.

Wini (28:54):

We appreciate it. This has been so enlightening and just like we talked about at the beginning you really are resilient and it's inspiring. And I love sitting in this chair because the inspiration just doesn't stop. It keeps coming through the door.

Ashley (29:06):

You guys have a fun job.

Wini (29:08):

We're so grateful that you spent time with us today. Thank you so much.

Ashley (29:12):

Thanks for having me.

Wini (29:14):

And to our listeners. Thank you for being a part of us and all of your support being with us. Please rate, review and subscribe to help us continue to grow and reach more people with these conversations and inspirations. But until next time…

Wini & Dr. Pyrc (29:31):

Have a joyful day.

A variety of brands on the market offer the convenience of testing for COVID-19 at home. These kits can be purchased at retail stores or online as an alternative to seeking out a testing site or busy healthcare provider for a COVID-19 test.

Alice Phillips, M.D., a Cook Children’s pediatrician, explains what parents need to know about the reliability, timing and results of the at-home COVID-19 testing options approved by the U.S. Food & Drug Administration (FDA).

First, if your child is running a fever: KEEP HIM OR HER HOME.

“Any illness with fever is likely contagious, and we don’t want to spread strep, flu or even colds,” Dr. Phillips said. “If your child feels great but with mild symptoms, at-home tests provide parents with the ability to quickly screen their kids.”

As a reminder, Dr. Phillips listed some common COVID-19 symptoms: cough, congestion, sore throat, fever, diarrhea, and potentially loss of smell or taste. However, not everyone infected with the SARS-CoV-2 virus shows symptoms.

At-home rapid antigen tests look for the presence of proteins from the surface of the virus, she explained. These tests have reported ability to accurately detect disease in the 65-85% range in patients with symptoms, Dr. Phillips said. That falls to the 35-40% range if asymptomatic.

“Timing of the test is critical,” she said. “Sometimes testing too early in the illness could result in a false negative. This is why the kits include two tests.”

The U.S. Centers for Disease Control and Prevention (CDC) considers testing a critically important tool to help reduce the spread the disease. Those who have symptoms or exposure to someone with COVID-19 should be tested regardless of whether they’re vaccinated, according to the CDC. 

Type and price of at-home kits vary. Some tests require a nasal swab, while others require a saliva specimen. Antigen tests deliver results within about 15 minutes, while the more sensitive PCR test takes at least 24 hours.

The CDC website provides these tips:

• Check the expiration date. Don’t use if past-date or if the kit’s components appear damaged.
• Read the manufacturer’s instructions completely before opening the test devices.
• Clean the tabletop or surface where the test will take place. Wash your hands with soap.
• Follow the directions step by step. Otherwise, incorrect results can occur.

Dr. Phillips gives some guidance for what happens next.

The result is positive. “Believe it! I am sorry, but your child has COVID. No repeat test is needed. The good news is most kids have mild cases. Call your pediatrician for questions or perhaps set up a telemedicine visit to discuss treatment options and for your doctor to lay an eye on your kiddo in a safe way for all.”

The result is negative. Using the second test in the kit, repeat the test in 24-36 hours to confirm the finding. In the meantime “if your child has symptoms highly suspicious for COVID or fever, keep them home to help protect your community.”

The CDC points out that the results of at-home tests might come back inconclusive or invalid due to user error or a malfunction in the device. If that happens, the CDC recommends contacting the test manufacturer for assistance.

Accuracy depends in part on the quality of the nasal/saliva sample. Whether a child undergoes the test at a clinic or at home, the process of obtaining a specimen can be… interesting, in the words of Dr. Phillips.

“Have you ever wrestled an angry Tyrannosaurus Rex? This would be what it is like to push a swab up the nose of a 3-year-old with fever and cough.

“And then there is the teenager. Tired, grumpy and does not really want to go to school anyway. You eagerly describe to them that you are going to place a swab in their nose and rotate for 15 seconds on each side. Hmmm. Not a happy customer,” she described.

A positive result on an at-home COVID-19 test should be reported to the state or local health department. This helps officials to keep accurate information on transmission rates in the community. Click here to report for Tarrant County: COVID-19 (tarrantcounty.com

“She was always so happy. Everybody was her friend,” said Mary, Julia’s adoptive mother. “She did not know a stranger.”

Julia was the kind of person who trusted people easily. So years later, when a young woman reached out to her on social media, she didn’t think much about the individual wanting to be her friend. She began to correspond and eventually started meeting her at a local park where Julia liked to skateboard.

“We were so protective of her, and only started letting her go to the park by herself when she was 17,” said Mary. “Still, I would drive around to check on her. She would always say, ‘Mom, why are you always worrying?’ I would tell her, ‘That’s my job.’”

Mary was worried about the new friend in Julia’s life. Something seemed off. But, like most teenagers, Julia didn’t want to listen to her parents. After all, she had finished high school early and was working toward her dream job as a nursing assistant. Julia completed school in December, but hadn’t graduated yet. It was the week of prom when Mary last heard her daughter’s voice.

“She called me after her job interview and told me how it went, and then she said, ‘I’m going to stay with my friend for a couple of days, but I’ll be back in time to do prom stuff later this week,’” said Mary.

At the time, Julia was 18 and Mary knew she couldn’t tell her daughter what to do. Still, she didn’t like the plan.

“I said, ‘Okay, I can’t tell you not to, but I don’t want you to go,” she explained.

At 7:30 the next morning, two state troopers arrived at Mary’s home. They told her and her husband that Julia’s body had been found on a tollway in Dallas. From there, the truth about Julia’s friend unraveled. She was what law enforcement officials call a “bottom girl,” someone who manipulates and baits vulnerable victims into human trafficking. It turned out that Julia’s ‘friend’ had been paid by a human trafficking ringleader to deliver the teen for commercial sex trade. Mary believes Julia was thrown out of the vehicle when she would not comply.

Julia died on May 2, 2018, just 20 days before her graduation.

“Two hours later, my phone rang. It was the person who interviewed Julia calling to let her know she got the job,” said Mary. “That broke my heart all over again.”

This month, a grand jury in Collin County is expected to hear the case against the ringleader charged in Julia’s death. If the grand jury decides to indict, Mary says it will be the first ‘Death by Human Trafficking’ trial in Texas.

Mary and Chris are hoping their daughter’s death can save the lives of others. Working with Rep. DeWayne Burns, R-Cleburne, they’ve created a bill that, if signed into law, will require driver’s education students across Texas to be educated about human trafficking. It’s called ‘Julia’s Act.’

On April 7, Julia’s family testified in favor of the act in front of the House Committee on Licensing and Administrative Procedures. In an uncommon move, the act was voted out of the committee the same day, setting forth a high probability it will move to the full Texas House for a vote.

“People need education. They have to know that this happens. I wasn’t educated, and now I’m looking every day to see what else I can learn,” said Mary. “I felt like, if we could get it into the schools, then maybe kids would listen since it’s coming from someone else besides their parents.”

What is Human Trafficking?

A lot of confusion exists about human trafficking. It is not the same as human smuggling, and it rarely involves victims being kidnapped at random. Human trafficking is the process of “trapping people through the use of violence, deception or coercion and exploiting them for financial or personal gain.” Trafficking victims can be exploited for sex and/or labor. It occurs anytime anything of value is exchanged for sex, such as money, food, shelter or gifts.

At Cook Children’s Medical Center, the Child Advocacy Resources and Evaluation (CARE) Team treats human trafficking victims under the age of 17.

“Usually, these are kids who have already been abused. They may have a history of sexual abuse, or are runaways because they don’t have a stable home or are in foster care,” explained Stacey Henley, RN, nurse manager of the CARE Team. “We also see a lot of LGBTQ kids whose parents kicked them out because of their sexual orientation.”

Henley describes human traffickers as ‘master manipulators’ who prey on the vulnerable.

“They are really, really good at understanding human needs and behaviors,” said Henley. “I know that sounds crazy to say, but they are looking at what the person needs, whether it’s love, food or a place to live and they’re fulfilling that need.”

She says knowing how many human trafficking victims are out there is nearly impossible because it’s heavily underreported. Part of the issue is that those being exploited often don’t see themselves as victims.

“A lot of times, the victim will say the trafficker is their boyfriend. They’re being manipulated, which is part of the problem because often teachers and medical professionals are looking for someone who’s wide-eyed and mouthing, ‘Help me,’ but that’s not what happens,” Henley said. “They’re not going to say, ‘I need help, get me out of this,’ so we have to look for other clues.”

To aid with this, Henley is leading the implementation of a child sex trafficking screening tool currently in use at Cook Children’s. Her hope is that a few questions asked by clinical therapists may uncover victims hiding in plain sight.

She also points out that human trafficking is a form of child abuse and should be treated as such. Sadly, the CARE Team has seen many cases of parents trafficking their own children, usually for drugs.

“It’s really sad. The best thing we can do is get them into a stable environment and help them get the resources they need for counseling,” said Henley.

Taking Down Predators

The Human Trafficking Unit at the Tarrant County Sheriff’s Department is dedicated to taking as many predators off the streets as possible. With three investigators and a lieutenant, the unit carries out operations each month focused on helping victims and arresting human traffickers and their clients.

“When we find people who are being trafficked, we look at them as victims and set them up with an organization called Unbound Fort Worth that will help them get out of that situation,” said Detective Chris Jarvis, an investigator on the Human Trafficking Unit.

The unit also performs operations focused on the online solicitation of minors, in which they go undercover online posing as children. Detective Jarvis says they regularly catch adults who are trying to solicit sex from kids on the internet.

“Parents need to be involved with what their child is doing online,” he said. “Check their phones, make sure you’re reading their messages and know who they are talking to.”

He says some of the apps that predators use most often include:

• Facebook
• Kik
• Instagram
• Whisper
• Grindr
• Skout
• Meet me

“These are some of the biggest sites that children get on. People can go on there and talk to your child. The more experienced ones can actually find locations, even without asking,” said Detective Jarvis.

This situation is not unusual to the CARE Team at Cook Children’s. Though not always through human trafficking, young patients are frequently seen after being sexually assaulted by an adult they met online.

“I recently saw a victim who met a man on Whisper. It happens, and parents need to be looking for these apps on their kids’ phones,” said Henley.

If lured into human trafficking, Detective Jarvis says it can be extremely difficult to escape. He says traffickers isolate victims from friends and family members, take them to places that are unfamiliar and watch everything they do. They also tattoo victims as a way to brand them. Common human trafficking tattoos include bar codes, lips, cartoon characters, initials and crowns.

Life expectancy for human trafficking victims is much lower than the average person. They’re often murdered or suffer the detriments of drug use and sexually transmitted diseases. That’s why it’s so important to get victims the help they need to overcome the manipulation, which often involves long-term counseling.

A Problem Everywhere

Christi Thornhill, APRN, director of the Trauma Program at Cook Children’s travels all over Texas speaking to medical professionals about human trafficking. She says there’s not a place she’s been that hasn’t seen this problem.

“Before I speak to a group, I always Google ‘human trafficking’ and the name of the town and it never fails,” said Thornhill. “I was in Mineola, Texas, with a population of 5,000 and found an article about a bust.”

She’s also seen victims from upper-class communities like Southlake and agrees that the hardest part about this crime is the manipulation piece.

“We’ve had people from all walks of life arrested for paying for sex with young victims. Police officers, judges, coaches, doctors, clergy members, teachers. Do you really think these kids are going to tell anyone?” she said.

Thornhill points out that believing claims of sexual abuse is one of the key things that people can do to prevent a child from falling into human trafficking. She says children who are sexually abused, but not believed by their adult caretaker, stand to suffer mentally, including loss of self-esteem and self-worth, making them easy prey for traffickers.

In addition to monitoring what children and teens are doing online, parents need to know who their kids are hanging out with.

“We’ve seen cases where kids are being recruited in schools, so it’s really important to be aware of what your child is doing and who they are friends with,” said Detective Jarvis.

It’s also important to note that not all trafficking victims are runaways or missing. The CARE Team at Cook Children’s has seen cases where kids are being trafficked while still living at home with their parents.

“I’ve seen kids who have been trafficked after school, but still make it home and sleep in their own bed at night,” said Henley. “When someone is profiting from someone else having sex with a child, that’s trafficking.”

Fighting Back

You can help deter human trafficking by keeping an eye on your neighborhood. Watch for suspicious activity such as multiple cars coming and going from homes, as well as different people at all times. If you see something strange, call the police.

Red flags to watch out for in kids include:

• Missing school
• Changes in demeanor and attitude
• Odd tattoos
• Seeming like they can’t make a decision or are being controlled

“It takes a community to keep an eye out and be aware of this,” said Detective Jarvis. “We can’t do it alone.”

As for Julia’s parents, they are continuing their push for human trafficking education and hoping to extend the requirement for all state license holders. They’re also hoping to enact stiffer penalties for those convicted of human trafficking.

“The thing that really got me is that we are in a small town,” said Mary. “But going through the process and learning what I’ve learned, it doesn’t matter where you live. These people are looking for anyone willing to talk to them, and they prey on the brokenhearted.”

The past nine months have been marked by upheaval, uncertainty, isolation and change with the youngest among us feeling the weight of it all, and doctors at Cook Children’s Medical Center are sounding the alarm.

“I’ve been employed as a psychologist at Cook Children’s going on 26 plus years and never in my time have I seen such an intense number of patients with severe anxiety and depression,” said Lisa Elliott, PhD, manager of the behavioral health clinic at Cook Children’s. “It’s not uncommon for us to have high acuity patients periodically, but that’s become the norm for weeks and weeks where 70 to 80 percent of our total number of visits for anxiety and depression are severe.”

Dr. Elliott attributes the uptick, in large part, to fallout from COVID-19. 

A June 2020 survey of parents published in the medical journal “Pediatrics” revealed that, since the start of the pandemic, more than 1 in 4 parents reported a decline in their own mental health, and 1 in 7 reported worsening behavioral health in their children. Both a decline in parental mental health and child behavioral health were reported by 1 in 10 families, according to the study “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey.”

Cook Children’s mental health experts say screen time, social media, academic performance pressures and lack of sleep all stress a child’s mental and behavioral health. All of those stressors have been exacerbated this year by pandemic-induced factors such as school closings, virtual learning, social distancing and isolation, according to Kathleen Powderly, M.D., a pediatrician on the medical staff at Cook Children’s. If ignored, these pressures can be a breeding ground for anxiety and depression.

And mental health experts are bracing for what is yet to come during the holidays as it’s not uncommon to see an uptick in depression and anxiety in children this time of year, particularly when there has been a significant family change, like in the case of divorce or loss of a loved one, according to Dr. Elliott.

So what is a parent to do? How do we help our children process these pressures to protect their mental and emotional well-being?

“We have to instill hope and stay calm and reasonable about it and, at the same time, not show fear.” Dr. Elliott said. “This is critical because we are going to set the tempo for our children. We will be what they follow. So it’s critical that we are calm and follow the safety guidelines, but tell our children this is not the way it’s going to be forever.”

And what better time than the holidays to model, teach and inspire hope?

Generosity Breeds Health and Hope

As stressful as the holiday season in tandem with a pandemic can be, it also presents a unique opportunity to teach children a concept that studies show actually improves mental health. It’s long been known that generosity and giving incite the same increase in one’s happy hormones as exercising. Giving makes you feel good—emotionally and mentally.

“Research shows that in addition to eating healthy and getting quality sleep, there are three things we can do to help keep depression at bay,” Dr. Elliott said. “One of them is exercising and another is socializing because they both increase endorphins. But the one that has the most long-lasting impact is philanthropy work. Doing things for others.”

A 2018 study published in the journal “Psychosomatic Medicine: Journal of Biobehavioral Medicine” showed a correlation between giving and increased activity in parts of the brain associated with altruism, reward and parental care and behavior. It further demonstrated that acts of generosity toward a targeted, or known, individual in need resulted in reduced activity in the amygdala—a positive given the amygdala is an emotion processing brain structure that signals the fight-or-flight mode when under stress. Increased activity in the amygdala is often seen in individuals with anxiety.

In addition to the chemical reactions philanthropy produces in the brain, doing good for others can help reframe one’s focus. Seeing the pain, suffering and circumstances of others gives perspective on one’s own struggles.

“Volunteer work helps create compassion because it draws concern away from ourselves,” Dr. Elliott said. “That’s why doing for others is so valuable for children. It teaches them compassion and optimism, and helps them develop gratitude.”

It also promotes the concepts of empathy and resilience, which are important building blocks for emotional and mental strength and valuable coping skills that help children deal with other challenges that come their way, according to Dr. Elliott.

This year, the need for generosity and service to others is especially great, given the economic impact of the pandemic. COVID-19 safety guidelines may require outside-of-the-box thinking to safely, yet personally, meet a need, but don’t let that stop you. It’s a great opportunity to get creative with your child.

With the help of Cook Children’s certified child life specialist Lauren Lasrich, MS, CCLS, we’ve compiled a list of ideas to help you and your family get started.

• Pack a grocery bag full of items and ingredients needed for Thanksgiving dinner for a neighbor in need. Let your child help create the menu and shop for the items together, either online or in the store. Deliver the groceries to their doorstep with a homemade card created by your family/child.
• Gather the family to rake leaves and clean up the lawn of an elderly or disabled individual. You’ll help a friend and get some sunshine and exercise for yourself and your family at the same time. Sunshine and physical activity are mood boosters!
• Adopt a family in need for the holidays. Check with your child’s school to see if they collect Christmas gifts for students in need and offer to purchase something on the student’s/family’s wish list. Get your child involved in the shopping process, be it online or in store.
• Together with your child, research a local organization or charity that promotes a cause you connect with and find out how you can help them meet the needs of those they serve. Create a family donation jar and save change to donate to the charity.
• Organize a neighborhood food drive and collect non-perishable food items from your neighborhood to donate to a local food pantry. Let your child decorate a donation box and put it on your porch so that your neighbors can safely deliver their donations.
• The end of the year is a great time to reduce and reuse! Go through your house and collect gently used household and clothing items you no longer need/use to donate to a local charity.
• Write letters/draw pictures to deployed military members or health care workers. For information on how to do this, or other ideas for supporting our troops, check out How Can I Support the Troops? 5 Ways You Can Help Deployed Soldiers at uso.org.
• Do a drive-thru Christmas caroling tour in your neighborhood. Let your neighbors know ahead of time when you plan to be out caroling so they can step outside and enjoy the show. Decorate your car ahead of time as a festive and fun family activity.
• Make toiletry kits and donate them to a local homeless shelter.

Not only will these activities help others, but they’ll give your child a project to look forward to.

“I tell people, especially during the pandemic, you have to have one thing to look forward to,” Dr. Powderly said. “It may not be the same thing that you enjoy previously, but you have to have something to look forward to because it gives you hope, and that’s what we all kind of need a little bit more of right now is hope.”

What to Watch For

Knowing the signs and symptoms of anxiety and depression can help you help your child before things get severe. For children, look for three or more of these symptoms, according to Dr. Elliott:

• Excessive worry for more time than typical. The difference between normal worry and anxiety disorder is the severity.
• Difficulty controlling worry.
• Easily fatigued.
• Restlessness and difficulty concentrating.
• Irritability.
• Muscle tension.
• Sleep disturbances.
• Sudden change in grades and school performance.
• Disinterest in a previously loved activity.

If your child is experiencing any of these symptoms and you are concerned about their mental or behavioral health, Cook Children’s is here to help. To access any of the hospital’s behavioral health services, call 682-885-3917. For emergencies, call 911.

“We're learning more and more about coronavirus and how it affects the body in general, and particularly how it affects the heart,” said Deborah Schutte, M.D., medical director of Cardiology at Cook Children’s. “We're now learning that the virus can attack the heart much like many other viruses and kids can get what's called myocarditis, which is inflammation or swelling of the heart.”

With increasing research in this area, the American Academy of Pediatrics (AAP) recently released its recommendations for safe return to sports and activity. They suggest all children and adolescents with exposure to COVID-19 rest for a minimum of 14 days, regardless of whether or not they had any symptoms. If a child had mild symptoms (fever, cough or runny nose for less than three days), they should rest for at least 14 days after illness.

“They should talk to their pediatrician and they need to stay out of vigorous activity or sports for 14 days after they're asymptomatic or after exposure,” said Dr. Schutte.

For kids with moderate symptoms (those that last longer than three days), further examination, such as an electrocardiogram (EKG), may be required. The AAP also recommends waiting at least 14 days after the symptoms subside and obtaining clearance from a primary care physician before returning to exercise.

If a child had severe illness due to COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C), restriction from activity is recommended for three to six months.

“It's very important for us to be able to assess the patients before they return to sports,” Dr. Schutte explained. “We know from other viruses that cause myocarditis that patients who decided to participate in sports, and perhaps have had a viral infection in their heart, there can be serious consequences, even death, related to sports activities or vigorous exercise.”

While this may sound scary, Dr. Schutte says parents shouldn’t be afraid to let their kids exercise. She says physical activity is important for children and teens, especially now.

“As a parent of two boy athletes, I totally get that you're potentially scared to send your child back out on the field,” she said. “I think exercise is so important for everybody, but kids in particular. It helps combat the isolation they might be feeling right now from having to either quarantine or be socially distanced all the time. And it can also help with anxiety and depression, in addition to the physical benefits of just maintaining a healthy weight and staying fit.”

She says in most cases, the benefits of getting back out onto the field outweigh the risks. But, she adds, it’s an individual decision for each young athlete and their family.

“Parents need to take into consideration what sport it is because there are sports that are considered high-risk like football and wrestling,” she said. “You can imagine you're face-to-face with your opponents as opposed to something like soccer or volleyball, which are considered medium risk, as opposed to golf where they can safely distance themselves.”

Parents also need to consider who the athlete interacts with and whether there’s a high-risk individual in the home, like an elderly grandparent who may be more susceptible to seriousness illness if exposed to COVID-19.

“Unfortunately, it's not easy. It's a very complex decision that needs to be made within the family,” Dr. Schutte said. “But I certainly would not discourage it.”

“September of 2020 has been the highest month ever that we've seen suicidal patients admitted to our medical center,” said Kia Carter, M.D., medical director of Psychiatry at Cook Children’s. “We've seen this number rising year after year, so it's not surprising that it's this high. Suicide has become the second leading cause of death for kids and adolescents in the last year, versus two years ago when it was the third leading cause of death.”

This news comes after a near-record month in August when 29 patients were admitted for intentional suicide attempts. The patients admitted to Cook Children’s in September were between the ages of 6 and 18 years old. Dr. Carter says she feels the pandemic has played a moderate role in the increase, but that we typically see higher numbers in the fall months when kids return to school. In September of 2019, for example, Cook Children’s admitted 32 patients for suicide attempts.

“We've definitely seen this number rising in the last five years, but I do think that the amount of stress that we as a society have experienced in the last six months has caused some of our kids and adults to struggle more,” said Dr. Carter.

Virtual school may also be playing a role in mental health of kids. The Rees-Jones Behavioral Health Center at Cook Children’s has become a resource for children and teens who report feeling hopeless and not knowing how to cope with the isolation the pandemic has caused.

“I think everything in proportion is good, but when something is to this extent where some kids have had to do 100% virtual since March, it’s been very difficult,” Dr. Carter explained. “When kids have school, they have an outlet. They have other people to talk to. They have friends and social activities. Now, it’s just them, their parents and siblings.”

She says it’s important to know that some kids do very well with virtual learning, but it’s up to parents to know what works best for their child. Also, some families may have to choose virtual learning if the child or another family member falls into the high-risk category for COVID-19. In that case, parents should remember to ask for help when they need it. School counselors, nurses, teachers and their pediatrician are all great resources.

Warning Signs

Dr. Carter says the biggest thing to look for is a change in your child’s behavior, which she acknowledges can be difficult during the pandemic. She says little things like sleeping more than usual or not wanting to engage or interact in activities they used to enjoy can be signs of depression.

“Start engaging a little more and check in, like ‘Hey, are you feeling okay? I noticed you were getting a little angry at us for no reason,'” she said.

While it’s easy to write off irritation as a side effect of being a teenager, it is one of the primary symptoms of depression in children and adolescents.

Other signs to watch for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

Dr. Carter says girls are more likely to be hospitalized for attempting suicide, but boys tend to make more lethal attempts. As for age, Cook Children’s data shows 14 to 15 years old is the average for suicide attempt admissions, but more recently, the majority of patients have been around 12 to 13 years of age.

With many kids at home alone due to COVID-19, increased access to things like medication, firearms and the internet may also be contributing to the increase in patients. Dr. Carter says her team has also seen more patients participating in social media challenges where kids are hurting themselves.

“We have seen a rise in cutting behaviors, which are a form of self-injury. This is not always considered a suicide attempt but more of a maladaptive behavioral response to stress.”

She says these are things often picked up on social media, reinforcing the importance of knowing what your child is looking at and who they are talking to on the internet.

What Can Parents Do?

Get help.

If you’re concerned for the immediate safety of your child, take them to an emergency room. Trained professionals will evaluate your child to see what next steps need to be taken.

If you’re concerned about your child’s mental health (but not that they will harm themselves), you can contact your pediatrician, school nurse or counselor for a list of outpatient resources in your area.

If you feel your child may need a higher level of care (but it’s not an emergency), you can call Cook Children’s Behavioral Health Intake Department at 682-885-3917. Our team will help arrange referral for outpatient therapy and medication management, partial hospitalization day treatment options or inpatient treatment if needed.

Partial hospitalization allows children to receive treatment including medication management, family and group therapy at the Rees-Jones Behavioral Health Center during the day, while allowing them to go home at night. Children who are deemed an immediate danger to themselves may be admitted to the inpatient unit for 24/7 monitoring and treatment. The Rees-Jones Behavioral Health Center, is one of the few places in North Texas that offers inpatient psychiatric care for children between the ages of 2 and 12.

“Our biggest hope is that we can help families find the support and resources they need, and that we can educate our school systems about warning signs and screenings because they are hopefully going to come in contact with those kids before we do,” said Dr. Carter. “We don't want the numbers to continue to rise and we continue to lose our children. Remember that suicide is preventable.”

With kids going back to school, new questions are coming up on when kids should be tested for COVID-19 and when they can return to school.

Keep in mind there are some conflicting and confusing pieces of advice out there and this is only promised to be up to date as of on Sept. 25, 2020 when we are publishing this. But here are some reasonable-evidenced based approaches on testing and returning to school.

Who needs to be tested for COVID?

All patients with high risk symptoms and without another explanation should be tested for COVID before returning to school. These symptoms include:

• Fever
• Cough
• Shortness of breath
• Body aches
• Loss of taste/smell
• Headache
• Sore throat
• Sustained vomiting or diarrhea (and usually a combination of these symptoms)

If high suspicion for COVID still exists after a negative test is obtained, a second test the next day may be recommended by your doctor. If the COVID test or tests are negative, the child may be treated as they normally would for that illness (for example, returning to school after they were fever free for 24 hours).

All patients with low risk symptoms and NO known exposure to COVID can be tested before returning to school based on physician discretion. Low risk symptoms include congestion or runny nose, rash or a single episodes of vomiting or diarrhea.

If COVID is negative, the child can be treated as they normally would for that illness. Patients with low risk symptoms and no known COVID exposure may be tested, but do not necessarily need to be if their medical provider feels comfortable that their symptoms do not require it. The patient should be counseled on the high-risk symptoms to look for and they should be counseled if they do discover a possible exposure or develop high risk symptoms.

All patients with any exposure to COVID, regardless of symptoms, will need to be home on quarantine for 14 days after their last exposure to someone with COVID. They can be tested during that time if they are ill, but even if it is negative, they will need to stay home for the full 14 days. If they test positive during that time, they will need to stay home for 10 days after the onset of their own symptoms instead.

When can my child go back to school?

Children with a known close exposure to COVID must stay isolated for 14 days from exposure. Negative testing does not decrease the time of quarantine and should not be used to allow a child to return to school sooner. If continued contact with the exposed case could not be avoided ( for example you, the primary caregiver), longer duration of quarantine may be required. I recommend talking with your doctor or the health department about a safe return to school dates.

Children with a known case of COVID-19 are able to return to school:

• No sooner than 10 days after their symptoms started
• Have improvement in symptoms
• Are 24 hours without any fever while not using fever reducing medicines.

If symptoms are minimal or they are asymptomatic when they get their initial test, this 10 day period will be started at the time the test was conducted.

Does my child need a negative test to return to school or activities?

The quick answer is, No.

As long as the above guidelines are followed, negative testing should not be required to return to school. Some kids may remain positive (in testing alone but they aren’t contagious) for weeks and a sustained positive test should not prevent them from returning to school or other activities. Therefore, it does not make sense to require follow up testing in most instances.

Summary

It’s never been more important to have a sustained, quality relationship with your pediatrician. As we continue to navigate these complex decisions, having a provider who knows your child and can help you make decisions can go a long way to keeping them in school as much as possible and to ensure that their classmates are safe.

Moderate to severe asthma is a possible risk factor for severe COVID-19 disease according to the Centers for Disease Control and Prevention. But a COVID-19 infection can cause a flare up of even mild asthma. COVID-19 is a respiratory virus and contracting an infection with any respiratory virus can trigger an asthma flare-up. In fact, the most common cause of an asthma flare-up in children is a viral respiratory infection.

What does my child with asthma need to do to stay healthy during COVID-19?

The single most important thing a child with asthma can do to stay healthy during COVID-19 is to control their asthma. Here is a list of some important ways to keep your child with asthma healthy:

1. Control their asthma.
2. Wash hands frequently with soap and warm water for 20 seconds, especially before eating or drinking or touching any part of their face.
3. Avoid being around people who are sick.
4. Maintain a social distance of 6 feet outside the home.
5. Wear a face mask in public (if the child is older than 2 years of age and is able to remove the mask by themselves).
6. Absolutely no smoking or vaping inside or around a child with asthma. Now is a great time to try quitting by calling 1-800-QUITNOW!

In addition, make sure to track when the asthma medications need to be refilled so the child does not run out, as this can trigger an asthma flare-up. And keep an extra supply of the child’s quick relief medication (usually albuterol or levalbuterol) at home in addition to the one they are using.

What is “asthma control”?

Children with controlled asthma are less likely to develop an asthma flare-up when they are exposed to one of their triggers, like a viral respiratory infection. Asthma control also means almost no day-to-day asthma symptoms. The symptoms of asthma are wheezing, coughing, chest tightness and shortness of breath. Asthma is UNCONTROLLED if any of those asthma symptoms are:

1. present during the day more than just two days per week
2. OR cause any night waking
3. OR cause any physical activity limitation
4. OR require more than to quick-relief treatments per week
5. OR require systemic steroids (like oral prednisolone or prednisone) more than once in the last 12 months

The best way to control asthma is to avoid or minimize exposure to asthma triggers and take daily maintenance asthma medication (typically an inhaled steroid) as prescribed. Asthma maintenance medication should almost always be taken every day, even when the child with asthma “feels fine.” Not all children with asthma need daily maintenance medications. But, if a child’s asthma symptoms are uncontrolled, they might benefit from daily asthma maintenance medication. Now is a great time to assess your child's asthma symptoms to determine if the current plan is controlling their asthma. If the asthma isn’t controlled, call your asthma doctor to review the plan and adjust if needed.

What if my child with asthma says they “can’t breathe” or is scared while wearing the face mask?

Wearing a face mask is important for everyone going out in public at this time and is especially important for children with asthma. Many young children can be resistant to wearing them at first but with persistence and patience, this can usually be overcome. Here are a few ideas to help make masks seem less scary from the American Academy of Pediatrics:

1. Look in the mirror with the face coverings on and talk about it.
2. Put a cloth face covering on a favorite stuffed animal.
3. Decorate them so they're more personalized and fun.
4. Show your child pictures of other children wearing them.
5. Draw one on their favorite book character.
6. Practice wearing the face covering at home to help your child get used to it.

Regarding a child with asthma saying that they “can’t breathe” while wearing a face mask, it is important to make a distinction between the feeling of being short of breath and a true difficulty breathing causing a drop in the oxygen level in the blood. Only patients with very severe lung disease or who have very weak breathing muscles would have their blood oxygen levels decreased simply by wearing a face mask. If needed, this could be tested with a pulse oximeter at most physician offices. If the feeling of being short of breath is present but their blood oxygen level is normal, then it is safe for them to wear a face mask.

For more information on children and face masks from the American Academy of Pediatrics

Are steroids safe to give to treat asthma during the pandemic?

Inhaled steroids have been the daily asthma maintenance medication of choice for decades now and continue to be very safe, very effective, and very necessary for patients with persistent asthma during in the COVID-19 pandemic. A child with asthma should NEVER stop their daily inhaled steroids unless instructed to by their asthma doctor.

Systemic steroids are related to inhaled steroids but instead are much stronger and given by mouth (or injection) for short periods of time (less than 10 days) to treat asthma flare-ups. Systemic steroids can be safely given for asthma flare-up, if needed, even if that flare-up is triggered by a COVID-19 infection.

Are nebulizers safe during the pandemic?

COVID-19 (like all respiratory viruses) spreads by aerosols created when an infected person coughs or sneezes. An aerosol is a super-fine mist that floats in the air. Another person can then catch COVID-19 by breathing in these infectious aerosols. COVID-19 can also be spread if these aerosols settle on surfaces that are then touched by someone else who then touches their face. In addition to coughing or sneezing, anything that generates aerosols can spread a virus. This includes laughing, singing, loud talking and nebulization.

Nebulizers are devices for administering certain kinds of asthma medication. Nebulizers work by turning a liquid medication into an aerosol that is then breathed in by the patient. If a person infected with COVID-19 (even if they have no symptoms) uses a nebulizer, the virus can become aerosolized and pose a risk of infection to anyone nearby. Fortunately, most nebulized asthma medications can be changed to medication given by inhalers. Inhalers can be used with a mask attached to a tube (such as a spacer or valved holding chamber) in even the youngest asthmatics and cannot create infectious aerosols the way a nebulizer does. Discuss with your asthma doctor if changing from nebulizers to inhalers is right for your child.

How do I tell the difference between COVID-19 and asthma?

COVID-19 symptoms can appear two to 14 days after someone comes into contact with an infected person. COVID-19 symptoms can include fever, chills, cough, shortness of breath, trouble breathing, feeling tired and weak, muscle or body aches, headache, new loss of taste or smell, sore throat, stuffy or runny nose, diarrhea, nausea or vomiting, pinkeye, painful blue or purple lesions on toes and even hives or rashes. Many of these symptoms overlap with those of asthma, allergies, the flu or other viral respiratory infections (“colds”). Because of this overlap, being tested is the only way to know for certain if a child’s symptoms are due to COVID-19.

For more information, The Asthma and Allergy Network has a helpful chart comparing the symptoms of COVID-19, the cold, flu, allergies and asthma

What do I do if my child gets sick with asthma during the COVID-19 pandemic?

The possibility that a child with asthma’s active symptoms could be due COVID-19 infection does not change the initial treatment. I tell my patients that an asthma flare-up due to COVID-19 is still an asthma flare-up. If a child has asthma and develops any coughing, any wheezing, any shortness of breathing, any trouble breathing or any chest tightness, they should start their asthma action plan immediately.

The most common first step in an asthma plan is to treat these symptoms with their quick relief medication (usually albuterol or levalbuterol). If these symptoms do not respond or get worse, the child’s asthma doctor should be consulted immediately for additional guidance.

 When should I take my child with asthma to the doctor?

Most asthma flare-ups can be safely and effectively managed at home by following your asthma action plan and consulting your child’s asthma doctor by phone if needed. But, if the plan is not working or symptoms worsen, a change in the treatment plan or closer monitoring might be needed. Call your child’s asthma doctor if any of the following symptoms occur:

• worsening cough or wheeze
• new chest pain or back pain
• decreased ability to do usual physical activities​
• symptoms not responding to albuterol plan (but otherwise not in distress)
• needing albuterol more frequently than every 4 hours (but otherwise not in distress)
• not improving significantly after 2-3 days of increasing albuterol

Asthma flare-ups can become a life threatening emergency. If your child shows any of the following warning signs, their asthma flare-up has become a life threatening emergency. Start the emergency plan part their asthma action plan (often called “the red zone”) and call 911 or go to the nearest emergency room immediately if your child:

• can't catch their breath,
• can’t speak in full sentences
• can’t walk because of breathing difficulties
• sucking in (retractions) under the ribs or at base of neck
• abnormal movement of the belly while breathing (belly breathing)
• turning a bluish or grayish color around their mouth or fingernails
• making grunting noises
• head bobbing with each breath
• not responding to albuterol treatments
• feeling drowsy or confused

When should I take my child with asthma get tested for COVID-19?

The CDC website has a Coronavirus Self-Checker – an excellent and easy to use assessment tool to you decide if a child (older than 2 years) or adult needs to seek testing or medical care due to COVID-19. The online and mobile-friendly tool asks a series of questions, and based on your responses, provides recommended actions and resources.

If my child with asthma gets sick, when can we be around other people again?

If a child has an asthma flare-up during the COVID-19 pandemic, it is important to stay home and away from other people. Staying away from others helps stop the spread of COVID-19. You can be around others after 10 days since symptoms first appeared and at least 24 hours with no fever without the use of fever-reducing medications

For more information about COVID-19 and children with asthma from the American Academy of Pediatrics, click here.

https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Caring-for-Children-with-Asthma-During-COVID-19.aspx

For more information about COVID-19: cdc.gov

References

** Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2020. Ginaasthma.org

*** https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

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

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

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

It’s natural for parents to want to protect their children when they are distressed. But when it comes to anxiety, taking kids out of anxiety-provoking situations may not always be the right answer.

In fact, we should make a distinction between positive stress and clinical anxiety. Understand that an episode of anxiety/fearfulness/avoidance isn’t limited to a full blown clinical anxiety disorder.

Positive stress (like fears of taking a test, or going down a slide, etc.) is actually vital to normal child development and for teaching a child coping skills and the resiliency in learning to fail and then try again.

If a child’s anxious responses are expanding or not improving, however, they need to seek the help of a psychologist or therapist who can help assess the scope of the problem and craft a unique treatment plan that may include Cognitive Behavioral Therapy (CBT).

The psychologists we spoke to for this article found the parent often have an underlying anxiety disorder that may be untreated. While CBT is one very helpful treatment option (and one that is very applicable for straightforward anxiety in older teens and adults), kids are very different and there may be other factors mitigating the anxious response.

By attempting to protect your children from these situations, you may actually be enabling them to avoid and escape the situation. Then kids never learn to work through the root cause of their anxiety.

Here are 5 quick facts to remember:

Fact 1: Your child may not be happy or comfortable all of the time, and this is OK.

Fact 2: It’s difficult to see your child frustrated or disappointed, and this is also Ok.

Fact 3: Your child WILL get angry with you, and this is OK

Fact 4: Your child WILL say mean things to you, and this is also OK

Fact 5: You do not need to rush to fix it/ make it better.

Fact 6: Your child’s anxious behavior is NOT a reflection on you as a parent.

Anxiety affects 25% of children ages 13 to 18. Let untreated, anxiety can lead to depression, academic underachievement, poor social skills and substance abuse.

Sometimes, it’s difficult for parents to recognized anxiety. Kids can become easily frustrated with changes, have meltdowns, over-react, be difficult to soothe, be very reactive, struggle with transitions, be easily embarrassed, not be able to tolerate feedback/criticism, etc.

Parents (or others), may see these emotions as an anger, mood or ADHD issue, when there can be more to it, and testing can be helpful to decipher it.

One of the best treatments for anxiety is Cognitive Behavioral Therapy (CBT) from a licensed behavioral health specialist, and has proven to provide better symptom reduction than medication for most children. While licensed psychologists play an important role in behavioral health, in terms of providing psychological testing, as well as therapy, our licensed professional counselors at Cook Children’s are vital as well in providing and teaching very creative and useful coping skills every day.

When choosing a CBT therapist, make sure they use “exposure” technique. The goal of CBT is to teach people how to help themselves through anxiety-provoking situations, not to escape or avoid them.

Cognitive Behavioral Therapy will help the parent too, as a child with anxiety affects the entire family unit. There is no “cure” for anxiety, but there are resources to learn to manage it differently. Don’t take away the opportunity to experience bad things, or your child will become emotionally fragile and never be able to handle anything.

Tips:

• Teach by example and be aware of your own feelings/ actions
• Praise the effort
• Don’t reward the wrong behavior
• Plan 15-30 minutes a day of one-on-one time
• Allow 30 minutes of decompression time after school with activity the child needs: either physical activity or calm activity
• After a tantrum, talk about it, learn to problem solve
• Find something to be grateful for in a bad situation/ outcome

Much like a peanut allergy is the body’s over-sensitivity to peanuts, anxiety is an over-sensitivity to worry. Anxiety can include:

• Overestimating danger
• Expecting the worst

Physical symptoms such as palpitations, difficulty breathing, stomach upset, trouble sleeping and attempting to avoid any perceived anxiety-inducing situation.

To learn more about Cook Children's Behavioral Health services, click here.

For parents who have a child starting school in person, it’s normal to have some anxiety about the entire process, staying informed and connected may reduce these feelings and can give you a way to express concerns that you have regarding practices at your child’s school.

Consider the following if your child is set to start in-person learning and or will eventually be transitioning from virtual at-home learning to in-person learning:

Get organized and stay informed: Make sure you are aware of the safety guidelines that your school will be taking when students are back in the classroom.

Will face coverings be required for ALL children? If so ensure you have taken the last few weeks of summer to have child practice wearing their face covering or mask and encourage minimizing touching the face while putting the mask on or taking it off. Other things to consider regarding masks/face coverings:

• Ensure the mask/face covering you choose fits snugly yet comfortably against the face, covers the nose and mouth completely, and if its design is “re-usable” ensure the material allows washing and drying without damage to shape or build of the mask.
• Once you have found the type/style of mask your child is comfortable in ensure you have several available as backups.
• Tips on practice for wearing a mask (gathered from several different expert pediatricians)
• Have the child wear the mask/face covering during times likes watching a movie or playing a game. Allow them to take breaks but also praise them when they have successfully worn the mask or covering for a significant amount of time.
• For younger children needing help with wearing a mask use a favorite stuffed animal to demonstrate proper mask wearing, or find pictures of children or their favorite cartoons wearing masks.
• Modeling is very important. As a family model wearing masks/face coverings, children learn by example and this is one of the best ways to teach a child the importance of wearing a mask.
• Get in the habit of checking in with your child each morning for signs of illness. If there is ANY concern at all take the child’s temperature (if the child has a temperature of 100.4F or higher even without any other symptoms the child should NOT go to school).
• Thereafter monitor for any other symptoms: ensure your child does NOT have sore throat, cough, diarrhea/vomiting, headache or body aches.

Even if symptoms seem mild they should be recognized and taken into account in order to avoid potential spread of any infectious illness. This will remain important as the cooler weather and fall season are typical for other respiratory illnesses to arise such as influenza.

• If your child is sick and develops symptoms of COVID make sure you are aware of where you child can be tested. Also make sure you know who the school’s point of contact is for reporting illness. Find out what options for instruction/learning will be available for the child if quarantine is required. Make sure you are familiar with the school’s plan of communicating with families when a positive case or exposure to COVID-19 have occurred.
• Ensure your child is up to date on ALL recommended vaccines including the flu vaccine when it becomes available this year. We do not know how these two respiratory illness will affect severity of illness if a child or adult is co-infected.
• Review and practice proper hand washing techniques with your child at home and ensure they are aware of the options available at school for hand hygiene.
• Adjust daily before and after school routines to include the following if you had not been doing them already: remember to pack hand sanitizer and extra face coverings/masks. Have children change out of school clothes into clean set of clothes and wash hands as soon as they return home.
• Make sure the school has up to date contact information including emergency contacts as well as individuals authorized to pick up your child. If the list includes anyone who is considered high risk for developing severe illness for COVID-19 consider choosing an alternate person.
• Plan for potential school closures or quarantine periods. Consider if you will be able to take time off work should the child require quarantine at home. If the parent is unable to work from home or take time off work it is important to identify an adult who would be able to supervise the child during this time.

Stay alert: We know these times of significant change and decreased social interactions can contribute to stress and anxiety in children as well as adults.

Talk to your child about what to expect regarding how school will look different from before. For example desks may be set far apart for distancing purposes, teachers and staff will likely be using masks/face coverings and in some instances eye protection or googles, lunch time may occur at staggered times in smaller groups. Sports and other outside activities may involve different precautions than before. Be alert to changes in your child’s behavior that may indicate they are struggling with stress, anxiety or depression.

These include excessive crying or irritation, excessive worry or sadness, change in eating habits or sleep habits or difficulties concentrating among other changes in their typical behavior.

Remember there has already been a lot of stress with handling the many unknowns and issues the COVID pandemic has brought, it is important for children and adults to take breaks when necessary, get plenty of sleep, exercise and eat well and stay socially connected during this time.

Related Content:

• Returning to School During the COVID-19 Pandemic: Virtual Learning
• Regreso a la escuela durante la pandemia de COVID: Planificación para el aprendizaje en persona
• Regreso a la escuela durante la pandemia de COVID-19: Planificación para el aprendizaje virtual

As the fall semester approaches we know how hard it has been for parents and families to decide the mode of learning for their children. Some school districts have opted for a hybrid model in which the school year will start with ALL students in the remote/virtual setting gradually transitioning and providing opportunities in-person instruction.

Whichever decision or situation you choose for your student, the start of this school year will be like no other. I thought I would review a few recommendations the CDC (Center for Disease Control) has made that will help you and your family get ready for the start of the new school year.

 For those in virtual at-home instruction:

• Talk to your child about how school is going (even if they are home and involved in virtual learning), ask them about their day and about how they are feeling regarding this form of learning. It’s normal for children who are extroverts to struggle with the lack of in-person interaction while natural introverts may be more comfortable in this setting. Regardless of the situation it’s important to find out how they feel and work through the things they are struggling with.
• If you do identify behavior changes which worry you that your child may be experiencing difficulties reach out to your pediatrician to discuss these. Also find out if school has set up a plan to provide counseling or other support services during periods of virtual learning.
• Be a role model: Practice self-care. If your job or other responsibilities have you worried about how you will handle supporting your child’s learning during virtual at-home learning time seek out resources to help you find that balance (there are webinars out there currently covering this very topic).
• Consider the following to get prepared for Virtual or At-home learning:
• Get organized: Make sure you are aware of any registration deadlines, including submitting preference forms that your school districts may need. These forms will help how staff will need to prepare for when they will be offering in-person learning as well as ongoing virtual learning options.
• Review your families schedule and identify times for learning or instruction if your school has not provided a schedule for the student. Also don’t forget to schedule “recess” times in which the child can spend doing activities outside. Make sure to include breaks, waking/bedtimes, and unstructured “free time.”
• Attempt to schedule family oriented physical activity as your schedule allows (such as walks in the evening, water activities outside)
• A family calendar if you don’t use one yet may help keep everyone organized especially if you are keeping track of multiple assignments and deadlines for more than one child.
• Find a space in your home that is free of distractions and noise and designate this area as the area for learning. Avoid choosing rooms or areas that have easy access to toys or distractions such as TVs. Make sure the area is well lit and has access to electrical outlets for access to charging devices if necessary.
• Identify activities that will allow your child to remain socially engaged with peers or family virtually and if in person ensure you know the proper precautions that should still be taken.
• Stay informed: The information coming from school districts is immense. Make sure you are reading any communications that your school is putting out. Consider attending any virtual meetings which are discussing the preparations the school has made for the start of school year. Keep up with the constant changes that occur as new guidelines are made for school districts to consider.

Consider the following and ask questions regarding the following to ensure you are well prepared:

• Will your student be expected to be logged in at certain times of the day for live video instruction? Will the access to recorded lessons?
• How will attendance be taken each day?
• Will the school offer any sort of physical activity opportunities? If not remember it’s important to come up with your own to include in your kid’s daily routine.
• If your student participates in the school’s meal program, does your school plan to make meals available while students are learning online, if so how will you be able to access these?
• If your child has an IEP (Individual Education Program) or 504 Plan or receives other support services (PT,OT, Speech) from your school, how will your school provide these during the virtual at-home learning period?
• If you anticipate any technological barriers (we all experience these at some point), does your school offer support such as allowing students to borrow a laptop? Will they help with internet connectivity if this is an issue? Make sure you know how to access the school’s IT department for questions or issues.

Remember there has already been a lot of stress with handling the many unknowns and issues the COVID pandemic has brought, it is important for children and adults to take breaks when necessary, get plenty of sleep, exercise and eat well and stay socially connected during this time.

Related Content:

• Returning to School During the COVID-19 Pandemic: In-person learning
• Regreso a la escuela durante la pandemia de COVID: Planificación para el aprendizaje en persona
• Regreso a la escuela durante la pandemia de COVID-19: Planificación para el aprendizaje virtual

Did you know that schools consider French fries and ketchup as vegetable servings in their cafeteria served lunches?! In just a few minutes in the evenings, you can prepare a more nutritious lunch for your kiddos.

You can prepare these meals even if you’re not sending your child off to school yet. Go ahead and get in the routine of lunch prep at night, and they can eat their “school lunch” during the noon break from virtual school. In fact, prepping lunch and snacks will limit the constant grazing we might have gotten into the bad habit of over the lockdown and summer.

 Here are my healthy takes on kid-friendly favorites.

Kids Meal Prep Ideas for school lunches:

1.“Pizza Lunchables”: 1 or 2 Wheat English muffin halves, with side of low salt pizza sauce (make your own real quick with low or no salt tomato sauce seasoned with pepper and oregano), shredded mozzarella, and turkey pepperonis. Side Veggie: sliced bell peppers. Side Fruit: fresh mandarin orange

2.“Lunchables”: Handful (approx. 12) of wheat or veggie crackers, 3 slices of low salt, no preservative deli turkey or ham cut in quarters, 3 slices of low fat cheese cut in quarters. Side Veggie: celery sticks with hummus or ranch dip. Side Fruit: No sugar added fruit cup

3.Roll Ups: Corn or wheat tortilla with sliced cheese or spreadable cheese (such as laughing cow) and low salt no preservative deli meat. Can add spinach and/or smashed avocado as well. Slice in 6 equal pieces to have cute pinwheels. Side Veggie: carrots and dip. Side Fruit: grapes

4.Egg muffins:

Recipe: 1 cup Bisquick

• 1 lb cooked turkey sausage or ground turkey
• 4 eggs, beaten
• 1 cup shredded cheddar cheese
• *Optional: 1 cup chopped veggies such as peppers and mushrooms
• Mix all ingredients and split between 12 servings in a muffin tin. Bake at 350 degrees for 20mins
•  Side Veggie: cucumber slices and cherry tomatoes. Side Fruit: berries

5. Pasta salad: Cooked whole wheat or veggie pasta with chopped grilled chicken and vegetables such as tomatoes, zucchini, and spinach. Add a little dressing to the pasta salad such as pesto or Italian dressing. Side Fruit: apple slices.

6. Quesadillas: Corn or wheat tortillas with bean & cheese or chicken & cheese. Side Veggie: broccoli and dip. Side Fruit: mango or peach slices

7.”Chicken Nuggets”:

• Recipe: Cut 1 lb chicken breasts into strips or large chunks.
• Coat in flour mixture: 1 cup or more whole wheat or oat flour mixed with ¼ cup ground flax seeds, ½ tsp salt & pepper, 1 tsp garlic powder, and 1 tsp paprika. Now dredge coated chicken in beaten eggs, and then again coat with flour mixture.
• Bake or air fry until cooked through. (Double recipe to make for dinner, then to have leftovers for next day’s lunches.)
• Side Veggie: veggie chips or sticks. Side Fruit: fruit & veggie squeeze pouch

8. Meatballs:

• Recipe: 1 lb ground beef or turkey
• ½ can pureed pumpkin
• 2 slices wheat bread, torn apart in small pieces
• ¼ cup flax seeds
• 1 egg
• ½ tsp each salt & pepper
• 1 tsp garlic powder
• 2 tbsp low sugar ketchup
• Mix all ingredient until well combined. Make 1-2 inch balls and place on greased sheet pan. Bake 15-20mins at 350 degrees until cooked through. Can serve with ketchup or bbq sauce. (Double recipe to make for dinner, then have leftovers for lunch next day.)
• Side Veggie: Cauliflower and hummus or ranch. Side Fruit: pineapple
• Extra additions to above lunch ideas, 1 per day: small individual cookie packs, all natural fruit twists (actual fruit instead of packs of fruit snacks), granola bar, fruit & nut bar such as LaraBar, ¼ cup trail mix, ½ cup honey wheat pretzels.
• No juice, soda or sports drinks; instead have water or 2% milk.

I hope you enjoy! 

Your child has ADHD, and you’ve gone through testing, 504 plans, in school accommodations, trialing of different medications and dosages. Now what?

ADHD is a difficult condition to treat because treatment has to be tailored to each child. Standard stimulant medications such as Adderall and non-stimulant medications such as guanfacine (Intuniv) do a good job, but what else can you as the parent do to optimize your child’s ADHD treatment?

Behavior therapy by a licensed psychiatrist or psychologist can be very helpful, and they often will have an option for parent training too. Parent training focuses on age and developmentally appropriate behavior expectations, and giving clear commands/ rules rather than a general “behave” or “be good.” Behavior therapy can also be offered to your child one-on-one or in small groups, but is more effective when the parents are involved in sessions.

Children, especially those with ADHD, live in the moment. I recommend a reward chart calendar with stickers given for good behavior and accomplished chores, a daily visible reminder and source of accountability. At the end of the week, review the chart together and only give the small reward (i.e. a Sno-Cone) for a complete week of good behavior. If your child had several days at school of poor behavior notes, no prize should be given that week. Praise good behaviors when they occur, “You’re playing so nice with your brother right now” or “I am proud of you for sharing your toys”, that way your child hears and acknowledges what behaviors you want them to continue.

You also need to appropriately discipline your child. Again, age and developmental ability is key. No 6 year old boy, ADHD or not, can be expected to sit still for eight hours in a row. Children need plenty of physical activity and brain breaks. Find what discipline works for your child. For some, time outs and calm down techniques do the trick, others need electronics or favorite toys taken away for the day.

Regarding discipline: you will NOT irrevocably damage your child by disciplining them. They can be told NO and turn out just fine. They can be punished by time outs or however you deem is necessary and still be fine. The American Academy of Pediatrics offers good advice on the best ways to discipline a child.

Raising children is HARD. Raising a child with ADHD can be harder. When a child misbehaves, respond calmly and clearly. Hold your hands tightly behind your back, bend down to the child, speak in a low and authoritative tone, and let them know that behavior is unacceptable. Then turn away, no attention is given to a poor behavior. I have so much respect for the parent of the screaming child on the floor of Walmart who will not give in to their child’s demand, compared to the parent or grandparent who silences the child by giving the desired treat. What does a child learn from that? Answer: throw a big enough fit and I’ll get whatever I want. This is NOT what we want, the child cannot be the one in control!

After they are settled down from the tantrum, now is the time for a conversation on what wrong they did, their feelings in that moment, and let them brainstorm on how to not duplicate the bad behavior. Now time for the punishment- i.e. put away the toy out of reach but NOT out of sight if the poor behavior was throwing that toy at their brother, or saying I’m sorry and being grounded from an upcoming activity for sass-mouthing mom. Again, point out times the child is acting well so they don’t feel like the only time they’re getting feedback is for naughty behaviors.

Other tips for parents: Create a routine and try to stick to it daily. Limit choices so they still can assert some independence, but not be overstimulated (i.e. choose this outfit or that one, or between two vegetables at dinner). Limit distractions during homework time, but know that some children concentrate better with white noise (i.e. classical music) or when they are moving (i.e. under desk cycle). Be clear, specific and brief when giving directions. Help your child get organized and put their backpack, shoes, etc in the same place every day. Create opportunities for positive feedback, whether from sports, art, or music, find something where they feel good about themselves and watch their self-confidence grow!

In the classroom, busy bodies with hyperactivity need special non-distracting accommodations to better their attention and to not be disruptive. I recommend a balance ball chair, or under desk cycle to allow for muscle movement without constantly jumping out of one’s chair. Give your child’s hands something to touch (not those fidget spinners!). I suggest taping both sides of Velcro strips under the desk to allow for the tactile stimulation that these kiddos crave.

There is evidence that the brains of children with ADHD are deficient in certain kinds of omega-3 fats. I like the Smarty Pants brand of kid’s vitamins that contain omega 3 along with a complete multi-vitamin.

Also, caffeine can HELP your child to FOCUS and be more CALM. I know. This seems counterintuitive! But think of how a stimulant medication works: the same way caffeine does, it balances what brain chemical is low and instead of the brain over-reacting and creating too high of levels causing hyperactivity, the brain can “relax”. I don’t like the thought of children drinking sodas on a daily basis, but allowing a mini can of caffeinated beverage at breakfast for a struggling ADHD child can be of big benefit, just make sure they brush their teeth very well afterward.

Continuing the topic of food/ drinks and ADHD, some children are highly sensitive to processed foods and/or food dyes. Red dye 40, among other artificial dyes, is known to worsen behavior issues. As we should anyway, eat more whole fruits and vegetables, lean proteins and whole grains. Limit or eliminate highly processed, sugary, and dyed junk foods and snacks. This includes breakfast cereals: Lucky Charms, Fruit Loops, Cap’n Crunch and Apple Jacks are full of food coloring. Cheerios (plain and many of their varieties), Trix, Cocoa Puffs, Reese’s Puffs, and Golden Grahams are free of artificial coloring and have no high fructose corn syrup. Start looking at the ingredient list of any packaged item you buy, from cake mix to jello, to ketchup and popsicles- try to find a “natural”, “no artificial dyes or ingredients” version.

There is so much that goes into optimal management of your child’s ADHD. Talk with your Pediatrician about where to start. Talk to them again when you’re stuck in a rut and need to know what else can be done.

Sleep, it’s important, right?!

Has your kid's new COVID-19 schedule got them going to bed after midnight and sleeping until noon?

Well it’s time NOW to start getting back into a normal sleep schedule for school, even if they are learning online.

So how much sleep does your child need? This is a good estimate, but teenagers can require up to 12 hours of sleep while they’re going through a growth spurt.

How much sleep does my child need?

• 3-6 year olds need 10-12 hours of sleep
• 7-12 year olds need 10-11 hours of sleep
• 13-18 year olds need 8-9 hours of sleep

If your child has a midnight or (gasp!) even later bedtime right now, start working on adjusting their bedtime slowly over the next few weeks. I propose the following schedule:

• Aug 1: 11:30 p.m.
• Aug 2: 11:15 p.m.
• Aug 3: 11 p.m.
• Aug 4: 10:45 p.m.
• Aug 5: 10:30 p.m.
• Aug 6: 10:15 p.m.
• Aug 7: 10 p.m.
• Aug 8: 9:45 p.m.
• Aug 9: 9:30 p.m.
• Aug 10: 9:15 p.m.
• Aug 11: 9:15 p.m.
• Aug 12: 9 p.m.*

*Early elementary children will likely need a 7 p.m. or 8 p.m. bedtime, adjust the 15-minute pattern above as needed.

Keep in mind that bedtime means lights out, no screen time. Charge your child’s phone in your room, you’d be shocked to find out the long text message conversations happening at 2 a.m.! No TV in the bedroom either. If your child is having trouble with the adjustment in bedtime, it is perfectly fine to give melatonin about 20-30 minutes before bedtime. One or 3 milligrams is appropriate for elementary age, up to 5 milligrams for teenagers. Don’t allow caffeine after noon either.

Best of luck transitioning to school this year! We’re all going to have to work nicely together to get through this, but we can and we will!

Is it necessary to get a sports physical this year?

After all, are we even going to have sports this year? Plus, in the age of COVID, you may feel hesitant to bring your child to a pediatrician’s office right now.

I understand your concern about going to a doctor’s office, but I promise it’s never been a better time to be seen! We have increased our cleaning protocol, which was already great, in the office and we want you to rest assure we have a clean and safe environment for you and your child.

So to answer your question in short, YES. Let’s take a look at why a sports physical is so important.

Not only is a yearly sports physical required by the school district to be cleared for sports, going to your pediatrician for a yearly well check-up is vital to the health of your child. At a wellness visit, we review growth and development, catch up on vaccines, address any concerns from the child or parent, as well as perform a complete physical exam. We also assess vision, hearing and order any labs or imaging deemed necessary.

It is far better to obtain your child’s sports physical from board-certified pediatricians, such as a Cook Children’s physician, who perform a complete well child checklist. Specific to the sports physical component, we take a heart history of the patient and family and check from head to toe for any joint or muscle issues. So even if your child’s sport gets postponed or canceled because of our current pandemic, this is a great way to evaluate the health of your young athlete.

In 2019, over 495,000 boys and 330,000 girls participated in high school athletics in Texas. Participating in sports is a great way for your child to remain physically active. Healthy bodies fight off infections such as COVID-19 better. We recommend at least one hour of strenuous physical activity daily (this means the heart is pumping hard, and you’re breaking a sweat!).

During the sports physical/ well check, we are making sure the heart is capable to handle this elevated level of activity. One specific condition we evaluate for during a sports physical is a potentially fatal heart condition called HOCM (hypertrophic obstructive cardiomyopathy) that has been found to occur in 1 out of every 500 adults, and can cause sudden cardiac death in young athletes. Your pediatrician will evaluate if your child has an increased risk of HOCM, and we can refer him or her to a Cook Children’s cardiologist for timely assessment. If you’ve ever heard Cook Children’s referred to as a system, this is where it comes in handy. Your pediatrician actually works with the cardiologist to provide history and get your child seen quickly.

Heart ailments and many other diseases can be evaluated at your sports physical. Please call your pediatrician today and schedule your child’s sports physical. School starts in less than three weeks!

Citations:

Raj MA, Bansal P, Goyal A. Hypertrophic Obstructive Cardiomyopathy. [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430820/

Number of participants in high school athletic programs in Texas 2009-2019

Published by Christina Gough, Aug 30, 2019

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

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

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

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

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

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

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

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

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

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

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

Recently, I wrote a post titled, “Is Going Back to School or Online Learning Best for Your Child?” A Pediatrician Shares what Parents Should Consider?”

Following that initial article, we received a lot of questions from you all. I wanted to take this opportunity to answer them all at once.

Let’s get started.

For families with multiple school-age children, is it counter-productive to send some children and keep the others home? I think one of my kids can thrive with online schooling, but it would be much harder for the other two (due to dyslexia, age, socialization needs, etc.).

Not necessarily. While the child at school could contract the virus and bring it home, the fewer children and contacts, the less likely the family is to be exposed. I can easily see a family weighing the risks versus benefits and making different decisions for each child.

When looking at a child as a whole and not just at the physical, can you talk about what repercussions we could be looking at from keeping kids home from school. As a nurse, one of our core principles is looking at the entire patient and not just the patient's body. I think we should have a discussion about the mental health, emotional health, educational health, and even social health repercussions of keeping kids home. This won't be the often very successful home schooling that people do.

Yes, I think it is very important for families to consider both the medical risk of COVID on children and household contacts in the context of how being home from school would affect their child educationally, socially and emotionally. It should definitely be a whole child conversation.

Is it worth sending kiddos with special health needs to public school this year? We had hoped to send our youngest who has cystic fibrosis back to public school for his high school years starting this year.

And ...

Hi Dr. Smith, My soon to be 1st grader is on methotrexate for Crohn’s disease. How worried should I be about sending him to in person school? I’m worried the medication will make it harder for him to recover from Covid. Thank you for your insight!

This decision will be different for every child and every family depending upon the needs and risks for an individual child. These decisions would be best made with the pediatrician or specialist who knows the child's history the best.

If our kids go back to school, are we basically giving up seeing grandparents and anyone high risk? We’ve been very careful all summer in order to be able to spend time with my mom.

This is probably one of the worst parts about this decision for families. Based on the best information available currently, once our kids go back to school, I think we will have to use extreme caution with grandparents and other at risk contacts. Hopefully we will learn more over time what it looks like to protect grandparents and maintain connection.

My oldest is entering kinder, and it just seems/feels like such a big year for him. He loves school, and excels, but is also shy and sensitive to new things and transitions. We also have a grandparent that we see often who has cancer, so sending him would mean that we couldn’t see family. We are leaning towards homeschooling for the year, but don’t want him to miss out on such a big and important year. Is kinder a good year to homeschool or would it be more important to send him for the socialization and such?

Transitional years seem like the one that most families are struggling with. Kindergarten, 6th grade, 9th grade...as well as the obvious 12th grade. Unfortunately, I don't think that there is a straightforward answer but I am trying to remind families that everyone is facing the same decision and your child wouldn't be the only one who stays home...all that to say, there will be several kids starting first grade the next year who also home schooled.

For me it’s, if we as a family decide to send him back to school, how do we protect the rest of the family from germs he may bring home? Is it even possible? And at 13 is social interaction crucial for his mental state (he’s kind of a home-body anyways)?

I think I would be extra cautious about hand washing, perhaps even showering and changing clothes once they get home. Is it possible to keep them completely sterile? Probably not but it might make me feel better to make sure I was doing everything I could. Is social interaction crucial? It definitely depends on the kid. But it might not be as simple as thinking introverts don't need to go but extroverts do-perhaps it's our introverts who have the most to learn from being in a social environment. It's hard to say.

One of my two children has already tested positive. My youngest has not. Is it safe to send the one who has tested Positive back to school? Is there such a thing as immunity?

This is something I truly don't know if we have the answer to. Can a child who has had it get it again? Can they still bring it home even if they are immune? I don’t know the final answer to these questions.

What about the nonverbal language skills kids will lose by not being able to see their teachers and peers facial expressions behind a mask.

I think it’s safe to say that even being at school will not be normal and there will be some downsides and missed opportunities for learning. Even things as simple as not having lunch in the larger community and skipping recess (if a school chooses to do those things) will be something we need to consider.

Guilt. Am I a bad parent if I send my kids because I think they need in school learning? The spring at home was minimally successful and I do not think we have the capacity to do the teaching from home. How do I NOT feel like a bad parent?

I think this one will affect everyone. Trying to make the right decision with limited information and two options directly in front of you is a huge challenge. Dealing with the downfall when things go wrong or there are challenges down the road will inevitably lead this towards you wondering if you made the best decisions.

It’s the Bachelor phenomenon-how can an individual get to the end with two competitors and choose one-completely forgetting that the first was an option and not wondering if they made the right call? It’s probably why it seems to fail more than work out. (Except Sean and Catherine and a few others…)

And it’s not just the decision to send them that will have parents feeling guilty…parents choosing to keep kids home will have similar struggles.

How do you help with the guilt:

1. Remember that you’re not in this alone. Everyone else is having to make the same decisions.
2. Remember that kids are resilient. If they have a parent who loves them and is agonizing over this choice. They are likely to be ok in the long run.
3. Remember that no choice is forever. It feels like you’re making a decision that could have effects on your child for the rest of their life, but we will have options over time. None of them may be great options but we can make changes as we go and modify based on how it’s going.

What should performing arts classes do for safety? Is it safe for a bunch of teenagers to be singing, playing instruments, performing plays and musicals together in one room? 

Yes, I believe that most school will have to forego performing arts classes for the near future due to the risk that these activities could increase the risk of spreading droplets and disease.

How do we keep 2600 high school students from passing this like wildfire when we can’t easily keep them in 1 or 2 classrooms all day? Are teenagers being affected symptomatically similar to “kids” or more like “adults”?

I think secondary schools are going to present the biggest challenge to keeping infections at bay due to their mobility throughout the school day. We may see schools make decisions to keep kids cohorted for core classes and limiting electives or presenting electives in an alternative way. It does appear that adolescents appear to be presenting with more symptomatic disease-which may help monitoring infections and spread easier than in kids who are asymptomatic.

If one child in a classroom is positive will the entire class need to quarantine/virtual school for a 14 day time period?

It does not appear that the class will be shut down if a classmate tests positive for COVID. According to the TEA and local health departments, notification will be provided to families should a person on campus test positive but it is not clear how much information will be provided.

What are the thoughts on preschool. If we have the option is keeping them home worth the reduced risk of Covid despite it keeping the children from other children and a classroom? Will our preschoolers be behind come Kinder?

Keep in mind that many children start their first formal schooling experience with kindergarten and do well. Parents may still make a decision to send their child to preschool but I don’t think it should be out of fear for their education.

My heart breaks for my kindergartener who will start his public school experience looking SO different than his older sister. How much should I allow a 5 year old to endure. What are the “new rules” that are too much to expect (an active) 5 year old to adhere to?

I think they should be prepared that things will be a little different than their preschool years. Masks, recess, PE, lunch-everything will look a little bit different. Reassure them that all of the changes are to help them be safe. But also keep in mind that they probably don’t know what Kindergarten is supposed to look like. So, what does that mean? There’s no point in having significant discussions with them about what they are missing out on. Focus on the positives. The way we frame these discussions with our kids is going to mean a lot to them. Are masks going to be required? Don’t say it’s stupid but we’re going to do it anyway, just say, it’s part of life. Recess with just your class? Think of how much more room you’ll have on the playground. You’ll get so many more turns!

What happens when our 4 yo inevitably picks up another cold of virus at school with the same symptoms. Will we need to get her tested for Covid every time to rule it out? I also have a 6 month old so worried about him getting it from her. Just can’t wrap my head around how this will work when she does get sick with something.

This is going to be one of the biggest challenges of the fall. Because the list of COVID symptoms are so broad, we’re going to have to learn quickly what symptoms require testing and what can be monitored. Early on, I expect we’ll be doing a lot of tests out of precaution until we get better guidance. We’ll all be doing the best we can to minimize unnecessary visits but also to keep everyone as safe as possible.

I’m choosing to start my son out at home this year. How do I approach the decision with him? What is appropriate for elementary aged kids to know about why I made the decision and how do I make sure to address the missing of friends?

I think informing them of your thought process to the level of their development is an important part of how you transition them towards thinking about doing school at home. Finding ways for them to connect with peers will be something that you need to focus on-through technology or finding ways for them to participate in extracurricular activities that are following COVID guidelines are two thoughts that come to min.

Is it ok for a 3rd grader to wear a mask for 8 hours a day at school?

Yes! It will be a learning curve for sure but kids in schools all over the world have adjusted to wearing masks both now and in flu seasons throughout the years. Start practicing now. Explain to them the importance at their level. It’s just like covering your cough, washing your hands and not picking your boogers. Just another thing that we have to teach them in order to keep the environment safe for themselves and their classmates.

Should I have my child tested for antibodies to COVID if I think they had it earlier in the year? If they have antibodies will this help protect them when they go back to school? One of my children has special needs and gets sick very easily. I am fearful for him to go back to school but also fearful that lack of socialization for him will be detrimental.

Unfortunately, the accuracy of antibody testing has not been consistently good-some studies have shown that have shown false positive and negatives at a rate of 50%. In addition, we are not sure what antibodies actually confer immunity.

“What’s school going to look like in the fall?” “Should I send my child or keep them at home?”

These are the questions that every parent is probably already asking as school districts roll out their plans for re-opening school in the context of continued COVID-19 cases in our communities. Many schools may present the option for all in person, all online or some blended method. And parents will have to consider what works best for their children.

There have been many stressful decisions in regards to COVID, but this might be the most anxiety inducing one for parents so far. School districts realize how stressful this is for parents and are taking steps to protect their students and your kids.

 “We understand that some of our families are anxious about the new school year so we are implementing strict new cleaning protocols for every campus. That means that schools will be cleaned multiple times during the daytime hours rather than in the evening as has been the practice for many years,” said FWISD Superintendent Kent P. Scribner. “We are also making a significant investment in both Personal Protective Equipment--for both adults and children—as well as cleaning supplies for campuses and other FWISD facilities. The good health and safety of our students and employees remains our top priority.”

The Texas Education Agency released these guidelines for school reopening on July 7, 2020:

• Daily on campus learning will be available to all parents who choose that option for their children
• Parents may be asked to commit to remote instruction for a full grading period but will not have to commit until 2 weeks ahead
• Health and safety procedures should be in place for student and teacher safety

In normal times, making a decision about what your child will do for school in the middle of July would seem way too late, but this year it feels way too early.

Each parent will have to make their own decision but here are some things that it would help to consider:

Childcare and Other Resources

First and foremost, it’s important to consider that children attending school is an important part of allowing parents to work and function in society. Parent’s jobs help secure food, shelter and in many cases provide health care insurance that allow children to receive care when needed. Not all parents can work from home, stay productive and keep a job. In addition, many of our children receive their most nutritious and guaranteed meal during the school year through their school lunch. Schools provide many resources to our communities and children beyond education.

Medical

Healthy children, for the most part, are considered to be safe in the school environment. Children have been more or less spared from severe illness but, as with most illnesses, children with chronic medical conditions are at higher risk for severe illness. Parents of children with medical conditions may learn toward keeping their child in the online environment in order to protect them from exposure. In addition to the child, considerations must be made for other household members and extended family members with whom the child might have contact. If the child will have contact with family members who have weakened immune systems, they could bring the virus home despite not having significant symptoms.

School

Examining the policies and procedures of the school will be another important decision point for families. Is the school district taking the recommendations for safety seriously and attempting to implement them consistently? With kids involved, there will be a learning curve but districts should be considering policies in regards to social distancing, mask use and movement throughout schools at a minimum. The evidence suggests that most schools are taking the threat of COVID very seriously but each parent should make that assessment for themselves.

Educational

April and May taught us a lot about how capable our students were of learning in an online environment. While the school districts will be significantly more prepared for teaching online, there are certain kids for whom it was obvious that the online environment was not going to be the right choice for them. Children who receive services and support at school might have a more difficult time adjusting to life at home without that extra help. For others, they struggle to learn online and in-person teaching might be a better fit. In addition to the child’s learning needs, families must consider their ability to support their learner with their existing responsibilities. Teachers and school staff can help, but students at home will often require some, if not significant, guidance from someone in the home. This is especially true for younger students and those with special learning needs.

Social and Emotional Needs

Some kids have thrived in regards to their mental health with the online learning environment. Many children with anxiety in regards to school or formalized testing had significant improvement in their symptoms as they transitioned to at-home learning. Other students and families needed the structure and activity of school in order to maintain a sense of normalcy. The lack of contact with friends, teachers and other school staff affected them in very negative ways. Another consideration should be the child’s level of concern about COVID-19. Children with significant anxiety regarding the virus could anxiety, depression and other severe health and mental health issues.

Decisions regarding going back to school in the fall are complex. Each parent should consider how the effects of being at school or at home would affect their children and consider that as part of their decision.

For more information on this topic, read the recommendations of more than 50 Cook Children’s pediatricians, led by Medical Director of Infection Prevention, who worked to create guidelines for returning back to school. The AAP released similar guidelines that support opening of schools for in person instruction.

It’s likely the plans for each school will continue to change throughout the rest of the summer. Parents should consider the best option for their children and be prepared for disruptions to occur based on local case numbers.

For more on this topic:

• Cook Children's Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 pandemic
• COVID-19 Planning Considerations: Guidance for School Re-entry (AAP)
• Young Athletes and COVID-19: 'When Can My Child Start Playing Sports Again?'
• TEA Issues Comprehensive Guidelines for a Safe Return to On-Campus Instruction for the 2020-21 School Year

As Texas enters Phase 3 of Governor Gregg Abbott’s plans reopen the state amid the COVID-19 pandemic, bars, restaurants, amusement parks and sports venues are working to welcome back patrons.

But for many parents, their biggest concern remains what to do during the upcoming school year.

Medical Director of Infection Prevention at Cook Children’s Marc Mazade, M.D, hears questions about how to reopen school again on a daily basis from his patient families as well as his own colleagues.

“Everyone kept asking me, ‘Are kids even going back to school?’ I don’t really know what the plan is. I certainly hope schools reopen in the fall, but we have some work to do,” Dr. Mazade said.

Seeing a need for more guidance, Dr. Mazade worked with more than 50 Cook Children’s physicians to create “Recommendations for the Practical, Fair and Safe Reopening of Public Schools K-12 in the State of Texas.”

The doctors involved work in a variety of primary care offices as well as specialty clinics including Infectious Diseases, Emergency Services, Cardiology, ENT, Neurosciences and more. Dr. Mazade expects this to be a long-term plan, with elements in it that allow for looser restrictions based on current Centers for Disease Control and Prevention (CDC) guidelines for community transmission. He sent these recommendations to the governor and hopes to provide it to schools for the upcoming year.

Dr. Mazade admits to being cautious as kids return to the classroom, but he also believes a common-sense, careful approach will allow children the best opportunity to remain safe.

Students from kindergartners to high school seniors tend to tolerate infection better than adults, especially elderly people. Cook Children’s prescreening of asymptomatic children preparing for a medical procedure identified around 1% of children of all ages shedding the virus locally at the time of this writing.

“In order to put children safely to sleep, we have been testing children who are preparing for surgery for COVID-19 infection," Dr. Mazade said. "As feared, some children who have no symptoms are testing positive for COVID-19. That shows us that children with no symptoms have COVID-19 in our community and infection can spread unknowingly from person to person. We are urging everyone to continue to take precautions to keep everyone safe.”

The physicians worked on the document with the health and safety of students, teachers and their families at the top of mind, but they also thought about a common-sense approach to help bring a return of normalcy to kids’ lives.

“We want children to wear masks, but we also understand that’s going to be difficult for little kids,” Dr. Mazade said. “They may not understand why they are wearing masks, and it may cause problems for them emotionally. In those cases, we are asking for teachers and other adults around these children to take the proper precaution to protect younger children.”

It’s important to everyone involved in creating this document that kids are able to be kids. For instance, under the guidelines, athletes will return to the playing field, but that may mean playing in front of only family where everyone can be properly spaced out for safety.

“As we begin to look at these issues that students may face, we begin to focus on more than the spread of the virus,” Dr. Mazade said. “One of the concerns that came up was making sure we were screening kids for new problems such as starvation and hunger. We don’t know who all are dealing with these issues right now. The kid next door may not get enough to eat any longer. We want to think about screening for depression, too. We added those things to the document because it’s important to be proactive because the stresses are new, different, and so widespread.”

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

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

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

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

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

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

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

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

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

Other resources on this topic:

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

At my house, the 4- and 6-year-old natives are growing restless. The backyard isn’t cutting it anymore, biking up and down the street is growing old, and running around in the sprinkler now holds as much joy as a root canal. The parks are calling our name.

But is it safe?

Let me let you in on a little secret – there’s so much we still don’t know about this virus.

And by “don’t know” I mean, there are no great, large, long-term studies about the virus out there. My guidance for you is, at best….educated guessing. So bear with me.

In my office, I’m constantly asked “well….what are YOU doing with YOUR family, Dr. Diane?”

Well, I’ve read a lot. And it seems like the conditions ripest for catching the virus are in enclosed spaces with a large number of unmasked people, within areas of poor ventilation.

So…playgrounds and parks seem low risk. With some planning.

What is my family doing?

1. We have a heart-to-heart each and every time we go. If a playground has more than 1-2 families presently playing, we will try again later, or try a different park. My kids no longer melt down if a park is too full; it’s part of the game plan to be as safe as possible. They know this is part of the deal.
2. Also – we talk about keeping distance from other families. The CDC recommends keeping 6 feet between households if possible. In most playgrounds this is feasible, if not too many folks are there. My kids have adapted to the idea of “well, the swings are full, so it’s see-saw time until that family is done using the swings!”
3. This may not be easy for little ones, like those under age 3, so it’s important to watch over your kids and gently guide their curiosity to other parts of the park if they seem to drift towards new friends.
4. The CDC says if you can’t keep 6 feet of distance between your family and another, to wear masks if over age 2. In the Texas heat, my kids just wouldn’t be able to deal with this. Also, I’m just not comfortable with crowded parks yet. So we leave the playground if lots of people arrive – and again, that’s part of the heart-to-heart talk we have before we go.
5. We pee before we go. Using public restrooms ups your risk. If you have to use them, wash hands thoroughly afterwards.
6. Some news sources are telling you to “wipe down surfaces before your kid plays on it." I feel like park time is so chaotic, this would be really difficult for me to do. Constant movement and large playground pieces make me feel like this is near impossible. Studies show that the virus can live anywhere from 5 hours to 3 days on metals, which is worrisome, but the virus degrades pretty quickly on hot surfaces (thank you Texas sun). I think if you have wipes and your child is super focused on a favorite piece of playground equipment, absolutely, wipe away. But I think handwashing at the end of your trip is more important.
7. I keep hand sanitizer in my car and we use it the moment we get in. We also wash our hands thoroughly once we get home for at least 20 seconds.

I know it’s sad to think of all this THINKING for something as simple as a trip to the playground. But it won’t be this way forever, you guys. Being careful like this buys us time, resources, education, medications, and possibly a vaccine soon. It’s not forever – but why not keep things as safe as possible in these uncertain times?

Get outside and enjoy this summer safely.

Dr. Diane

Related Stories:

• Cook Children’s Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 Pandemic
• Should My Chld Go To Summer Camp?
• When Can My Child Start Playing Sports Again?
• Should I Take My Child To Daycare?
• Helping Families Manage COVID-19 Stress

Normally, it's time for kids to pack their bags, kiss their parents goodbye, get on a bus, and head to Camp John Marc. Last year, 1,081 kids, 175 employees and 231 volunteers went through some form of this ritual.

But as we all know, nothing is normal right now.

The circumstances related to the COVID-19 pandemic meant the cancelation of all summer camps. Well kind of, because while kids won't be going away this summer, they can experience camp from the comforts of their homes.

For several years now, a volunteer program called Happy Camper brought the camp experience year round to the medical center. This summer, Cook Children's will bring a new program called "Happy Camper at Home" to kids who would have attended a diagnosis-specific camp.

Katie Campbell, Child Life manager at Cook Children's, said a lot of kids count on camp for their socialization during the summer. Cook Children's Camp for Kids allows patients to learn about their diagnosis and be encouraged by others who share their same challenges.

"A lot of the kids who have chronic illnesses, at school they may be the only person in their class with diabetes, or they may not know anyone else at school with asthma," Campbell said. "They get a chance in the summer to go camping for a week with kids who are just like them. It doesn't feel as isolating or different. That's something campers will miss this summer is having that opportunity to be with people that share the same challenges and seeing their medical team in a different location. It's different to see their doctor in their regular clothes when you come to the clinic vs. shorts and T-shirt or in their trunks swimming at the pool with you."

So while kids wouldn't be able to attend, the experience to be a part of camp life was too important to cancel entirely. With a lower census than usual because of COVID-19, Child Life specialists focused on creating a different camp environment from home.

"Once we decided to shift gears and do something different, we started meeting weekly, and then everyone got creative and hit the ground running," Campbell said. "Our hope is for kids to opt-in virtually. They will get to come by the medical center in mid-June and pick up their 'swag boxes' with a bunch of branded camp stuff as they would usually get. They will get things like a T-shirt, a flashlight, water bottles, a deck of cards, those kinds of things. But then we also started to think about what activities we could offer the campers."

A YouTube page with content created by Cook Children's Child Life Zone staff will be available for the campers to watch. Just like any other summer, the campers will receive a mix of fun and education through watching YouTube. The YouTube channel will be available to all kids, even for those who aren't a part of the camps.

The channel will offer cooking, crafts, games and scavenger hunts. The medical teams related to a child's specific condition will provide short diagnosis education videos. Plus, kids can watch the Laughter League, Cook Children's clown program, perform comedy and circus skills, origami lessons and more.

More confined to the campers themselves, a private Instagram account will be available during the summer, which will be the home of a live talent show, dog visits, crafts and more.

"The hope is to build a little bit of a community within Instagram," Campbell said.

Campbell has been at Cook Children's for 21 years, and this is the first time that her summer won't center around attending or planning a camp. She said she would miss going, but this summer will offer some unique positive aspects that generally wouldn't take place.

"One cool thing about doing camps virtually is for the first time we'll be able to include kids with cystic fibrosis in our camping program," Campbell said. "Those kids can't go away to camp because of isolation restrictions around having CF. They can't be together in a community setting. So it will be neat because those kids will be able to engage in camp programming when they haven't formally had camps they could attend in the past."

Another interesting aspect of virtual is that other family members will get a taste of what camp is all about during the summer. Other than Camp Sanguinity, siblings of patients aren't allowed to go to camps.

"I think it will be fun to see what conversations kids will have with their parents and siblings about what happens at camp," Campell said. "My hope is it fills in some of the blanks for families of why camp is so important. Maybe, parents get a chance to watch over their kids' shoulders or the brothers and sisters share in some of the activities. I hope it brings the spirit of camps into everybody's house, and other people in the families benefit from it."

So, when can we get back to sports?

Like most else things related to COVID-19, it depends.

There are definitely different levels of risk, depending on the child’s sport.

• Low risk - Home training
• Moderate risk - Small group training
• Higher risk - Team training in low contact sports
• Highest risk - Team training with high contact

Even with these categories, deciding where your child’s sport fits might not always be clear. Cheer can easily be done as a small group but stunts require higher levels of contact. Baseball players can be spread out but baseballs are shared between players.

So, when should you start to get your child more active?

Now. If and when it can be done safely.

Here’s how to keep your child safe:

1. Encourage your child to practice general and sport specific activities daily at home. Conditioning will be an issue as we get back going so the more activity they have now the better.
2. Use small group training exercises where possible. Does the whole team need to practice three times per week or can shorter episodes with small groups be arranged?
3. Ensure that your coach and facility are maximizing social distancing and disinfecting procedures. Practices should be modified to minimize interaction. Waiting should be done in a social distanced manner.
4. General infection control measures should be stressed: wear masks when appropriate, cover cough and sneezes, find other celebrations than high fives and players/coaches should stay home if ill.
5. Travel should be limited as much as possible. Keeping practices and games local helps to minimize spread between communities.

Is it OK to get your kids back to their sports? Yes, but do so with caution and care.

For more detailed information on this topic, visit the CDC.

If your daughter is anything like mine, seeing an article with this title will likely send her slinking to her room, cheeks flushed. Kinda like when my dog disappears the moment he catches onto the fact that a visit to the vet is in the works.

But the question of when to take your daughter to a gynecologist is an important one, and, like other discussions of puberty or the birds and the bees, the same teens who might redden and squirm will likely be very thankful (inside) that you asked.

The answer to this question will vary from pediatrician to pediatrician. But my short answer as to when to take her to the gynecologist is as follows:

1. If she has a breast/gynecologic issue your pediatrician feels would benefit from a gynecologist’s input
2. Possibly if she is thinking of becoming or has become sexually active, although talk to your pediatrician first
3. When she is 21, at the absolute latest

Let’s break this down.

1. If she has a breast/gynecologic issue your pediatrician feels would benefit from a gynecologist’s input

We pediatricians — according to the American Academy of Pediatrics— should be seeing your child or teen yearly for well-child checks. At these visits we will discuss many topics including puberty, menstruation, sexuality and contraception. Checkups also involve a physical exam of the entire body, including a look at an adolescent’s breasts and a brief external look at her genitalia (not a full, dreaded pelvic exam, mind you, but still rather unpopular) in order to check on pubertal development and to screen for any other issues or abnormalities in these areas. Adolescent visits often frequently include some time when it is just the doctor and nurse talking with your teen (with you out of the room). This separate time allows teens to begin taking some ownership of their health visits, gives them a chance to bring up whatever more delicate concerns they might have, and to perform those more private parts of the exam.

If issues come up at these visits or at any point — issues such as heavy or irregular periods or somewhat slow, fast, or atypical growth or puberty— your pediatrician will help determine next steps. Sometimes, worries can be normal variations and might need simply to be watched and followed for a while. Asymmetric breast development (even in boys) and mildly irregular cycles for the preteen (particularly those new to having periods) often get better on their own. Other times, issues may veer further from the norm, and your pediatrician may feel it necessary to order lab tests and/or imaging. Depending on how the evaluation goes, your doctor may refer you to Cook Endocrinology and/or Gynecology.

2. Possibly if she is thinking of becoming or has become sexually active, although it’s still good to talk to your pediatrician first

As discussed above, as per the American Academy of Pediatrics, we pediatricians should be seeing your daughter for yearly well-care visits, incorporating an assessment of growth and puberty, a full exam, and anticipatory guidance. Similarly, the American College of Gynecologists and Obstetricians recommends a first visit to the gynecologist for girls between age 13 and 15, in order for the ob-gyn to do much the same thing. So there is some overlap in the services and roles which pediatricians and gynecologists can provide for a young teen. Following the letter of the law (that is, seeing both doctors) is always an option, as our colleagues in ob-gyn can be a wonderful part of the village helping to care for your child. Some of them have contraception education down to an informative yet entertaining art! That said, if your daughter is already having regular care through the pediatric office, and if she is also getting detailed education about sexuality and contraception choices at home, school, church, or through other groups, she may not need to see a gynecologist for that first introductory visit in addition. I leave that choice to you.

After laying the groundwork for future well-woman care, however, the next time to consider taking your teen to the gynecologist is if she is thinking of becoming sexually active or — less ideally—has taken that action already. If we have indeed moved from the theoretical “here’s what a person needs to know about birth control” to the actual “here’s what YOU need to know and start doing NOW with regard to birth control,” it is still a good idea to begin the discussion with your pediatrician. Pediatricians want to be kept in the loop and can provide information about the risks and responsibilities of sexual activity, options for birth control, and guidance for next steps.

There is variability between pediatricians as to whether or not they prescribe birth control pills (or COCs, combined oral contraceptive pills), though many do. Even still, most pediatric offices do not provide the full gamut of contraceptive options (such as hormone injection, IUD, or implants) available through a gynecologist. If other contraceptive options might be better suited to your particular adolescent, it would be a good idea to see a gynecologist.

3. When she is 21, at the absolute latest.

This AGE 21 bit is going to be for some girls and their parents the best news all day! In fact, let’s all do a little happy dance, as it is a fairly recent and welcome change (through the recommendations of ACOG, the American College of Obstetricians and Gynecologists), that a girl/woman’s first pap smear (for cervical cancer screening) does not have to be until age 21. What this means is that for a lot of girls (those who are without gynecologic symptoms, problems, or infections), the much despised first full pelvic exam (with stirrups and speculum— yeah that!) can be delayed to age 21. Hooray!

The recommendations used to be for earlier pelvic exams, pelvic exams at least within three years of sexual activity, and for pelvic exams prior to starting birth control, but things have changed. Internal pelvic exams are in most cases not needed before the initiation of pills or any other contraception with the exception of IUDs. So — big sigh of relief all around!

Of note, an important exception to the age 21 pap smear rule is that girls who have HIV or are immune-compromised need to start seeing a gynecologist regularly and getting pelvic exams when they become sexually active.

Well, that’s all, folks! Hope this gives some insight into when to take your child to the gynecologist. Now, come to think of it, when DOES the dog need his next vet visit, and where did he go?

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

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

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

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

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

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

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

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

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

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

For more on this topic:

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

As he completed the 26.2 miles, Joey’s physical therapists were the loudest and proudest cheerleaders in the Medical Center’s halls.

They are also the ones who helped create and implement the Exercise is Medicine initiative, which is aimed at increasing activity for oncology patients during their hospital stays. Miles in Motion, an incentivized walking program that’s a component of Exercise is Medicine, is used as a way to motivate patients to stay active, and is the program Joey, a pineoblastoma patient, took part in the last several months.

Unique to Cook Children’s, Exercise is Medicine ~ Miles in Motion is the brainchild of Lydia Robey, PT, DPT, a 10-year Cook Children’s employee and a graduate of Hardin-Simmons University. What began as an idea based on years of personal research about the importance of exercise for oncology patients, turned into a reality when Lydia and the PT staff teamed up with nurses, and other caregivers, to put ideas into action.

As part of the program, patients are able to win prizes as they complete certain distances (1-mile bracelet, 5-mile bracelet, 10-mile gift card).

Team Experience at its best

Lydia credits physical therapy's partnership with nursing, and creating a culture that embraces exercise in the oncology setting for their successes. “When we first started out, we never dreamed we would have a patient who would want to complete a marathon,” she said.

Empowered with Cook Children's 2020 system competency, which is the behavior of listening, Haleigh Schreck, PT, DPT, who has worked at Cook Children’s for four years and graduated from UNT Health Science Center, shared, “We all agree it’s hugely important to listen to our patients to make sure we are addressing their specific concerns and goals around exercise and other activities. We want to make sure we’re serving them the best way we can to meet their individual needs and not just following our agenda for what we think they need.”

“We want them to feel they are a part of the team,” she added. “We sincerely want them to enjoy their PT time as much as possible so they stay motivated and want to participate.”

The Miles in Motion program does just that, she insists, since it is not uncommon for bone marrow transplant and hematology/oncology patients to be in isolation or reverse isolation, and finding an outlet for exercise and interaction is vitally important.

Over the course of four admissions to the Bone Marrow Transplant unit on 5 Pavilion, each 2-3 weeks long, Joey was able to complete 26.2 miles, and he did so while being cheered on by his therapists, nurses, Child Life specialists and many others.

Joining Haleigh in caring for Joey, was Bryan Pyrc, PT, DPT, a Duke University graduate and Cook Children’s employee for the last four years. “We would ‘fight’ over who got to work with Joey because he’s just such a great kid,” Haleigh chuckled.

“It was such a privilege to work with Joey and his family,” Haleigh added. “They are truly the kindest and most positive people, who are so enjoyable and fun to be around. Joey truly taught us so much about what this program can really become. His hard work and accomplishments are the only reason we ever thought about a marathon even being a possible achievement through Miles in Motion. He has already been an example to other patients who have seen what he was able to do and they want to do the same.”

In fact, other patients are now riding a stationary bike to achieve their “miles,” and an additional patient has since completed his own marathon, and declares he was motivated by Joey’s story.

Haleigh adds: “It has been so inspiring to see how a positive attitude can really change your whole experience. We are all so proud of Joey, this program and what it’s become. It is just so cool to see all of this happening and to think of all the potential it has to really benefit so many patients.

“We have worked extremely hard and are thrilled that Exercise is Medicine is getting so much attention because it is going to be so awesome for our patients!”

And really… it already is totally awesome!

You can read Joey’s feature story here.

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

High Fever

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

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

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

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

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

Stomach Hurts

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

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

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

My Head Hurts

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

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

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

Related Topics:

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

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

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

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

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

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

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

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

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

• Strep throat
• Whooping cough
• Urinary tract infection

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

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

• Ear infections
• Sinus infections
• Bronchitis

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

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

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

• Common cold
• Viral sore throat

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

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

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

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

“I had my chest bone ripped open. It’s going to hurt,” Martin, 21 years old, said. “For a little while, I wasn’t sure if I had done the right thing. But looking back on it, I’d do it again. It may not have been the smartest choice, but it’s the one I made. It’s the one I’m living with, and I’m happy with it.”

The choice Martin made wasn’t based necessarily on health or even convenience. It was to continue to dive. Since he discovered diving at 6 years old, the sport became Martin’s passion. He won the UIL 6A State Diving Championship as a senior at Midland High, became the first full-time diver in school history at Texas – Permian Basin, and qualified for the NCAA Division II Championship in college. Now he wants to achieve one more thing – a national championship.

And all the while he’s competed at the highest level, he’s also been a heart patient at Cook Children’s. Martin has Shone’s Complex, a rare congenital heart condition that involves multiple valve problems. He received his first heart surgery at only 6 days old.

His doctors have balanced his love for his sport with what’s best for Martin’s health.

Last year, Martin received his latest surgery. Prior to the operation, doctors gave him two options. The smart choice for most people is a mechanical valve, meaning he may never need another surgery again. Once he has that surgery, Martin needs blood-thinning medication for the rest of his life. Running, walking or riding a stationary bike would be OK with that medication. Still, more extreme sports, including diving, could place Martin at a high risk of life-threatening bleeding.

Martin chose the second heart valve replacement option: a prosthetic, or tissue, valve. With the tissue valve, Martin will need another surgery someday, maybe even within the next years. Still, he won’t have to take blood thinners.

Most importantly, for him, at this point in his career, the prosthetic tissue valve allows Martin to continue to dive.

“My parents were in the room with me, and I didn’t even talk it over with them. I was like I know what I’m going to do. I’m signing up for a second (surgery),” Martin said. “So I went and got a prosthetic valve, a tissue valve. As soon as I decided that I said, ‘OK, this is my next to last surgery. Hopefully, I will never be getting another open heart surgery … after the next one.’”

Scott Pilgrim, M.D., a cardiologist and medical director of the Cook Children’s Adult Congenital Heart Disease program, began seeing Martin in 2018. Dr. Pilgrim said he wasn’t surprised by Martin’s decision to go with the tissue valve. Dr. Pilgrim knows that the choices they are making center around Martin’s desire to compete at the highest level.

“We’ve had very long conversations concerning Garret’s heart problem. We’ve had some interesting discussion points about what his long-term plans are with regards to diving,” Dr. Pilgrim said. “It’s my understanding that he’s quite good at what he does, and we didn’t want to remove him from what he loves. And so we are trying to make a decision that’s best for him medically, but also allow him to achieve the goals that he wants to go for in his life. I think that’s where we were in deciding to put in a bio-prosthetic valve or a tissue valve.”

As he arrives at Cook Children’s Mansfield Urgent Care and Pediatric Specialties clinic, Martin is the oldest patient on that particular day. With his scruffy beard and sweat pants, he looks like exactly what he is – a college student. Still, his age doesn’t make him feel any less at home at Cook Children’s.

“When I was a kid, this place made me feel safe, and as an adult, I know that this is the best place I could be for whatever I need,” Martin said. “I love it here. Now don’t get me wrong. I don’t want to stay, but if I have to be at a hospital, this is the only hospital I want to be at.”

Martin appreciates everything done for him at Cook Children’s. As he heads toward the end of his diving career, he has only a few goals left to accomplish. One of those is winning a national championship.

Then he can move on with a new life, making decisions based solely on his health. But don’t expect him to slow down. He’ll only be beginning the next chapter of his life, with a major in mechanical engineering.

“You don’t have to let anybody limit you. The only person that can tell you what you can and can’t do is you.” Martin said. “Granted, if you’ve got a condition, you need to be mindful of that. Make sure you take of yourself. But if you know you can do something, don’t let someone tell you, you can’t.”

That’s good advice that he’s seen first-hand from his medical team at Cook Children’s.

"Your child is here with a sore throat. I know they haven’t had a fever, but strep has been going around."

Whelp, there goes your day. Cancel all your meetings. Call your pediatrician's office. Get an appointment in a few hours. Get your child tested and see what happens next.

But for some families in North Texas, there might be a better way to get treated for illnesses.

Through a partnership with Cook Children's, students in Keller ISD join a growing list of other local school districts who can now see a pediatric provider via telemedicine as part of our School-Based Virtual Health program. All while staying at school.

Children with qualifying conditions such as earache, sore throat, pink eye and many others who present symptoms to their school nurse, connect with either a Cook Children's board certified pediatrician or a certified nurse practitioner via a secure video connection. The school nurse can use devices to show the provider the child's ears, throat, rashes, and other physical findings as well as allow the provider to listen via a digital stethoscope. Students also can be tested for both strep and flu while right there in the office.

The virtual visits are completely covered for children who are on Medicaid. For all other patients, the price of a visit is $65 for new patients and $50 for established patients.

Keller ISD and Cook Children's started a pilot program approximately three years ago in five schools. The success of the program led to the adoption of the program to the full district last fall. Funds from the Grainger Foundation allowed for the purchase of more equipment and marketing information to be distributed.

Enrollment at Keller ISD has increased significantly over time. Although registration can be completed on the day of the visit, there are now over 1,000 students pre-registered for visits. More than 150 appointments have been completed this school year. About half of those visits have allowed the student to stay at school. Staying in school means decreasing lost educational time, faster time to diagnosis and treatment as well as prevention of many parental headaches and frustrations.

Interested in more information about Cook Children's School-Based Virtual Health program?

Click here to find out more about the program and how your school might become involved. If you would like to donate to this program, click here and type in "telemedicine" when prompted.

Man…this is a tough one.

Remember when your child was a toddler, and you taught them to poop on the potty? It was all leading up to this moment. Everything we have taught them along the way was an effort to allow them to become more independent.

But, now that they are, why does it hurt so much?

This time can be painful and confusing, but it can be handled with grace on both sides.

Unfortunately, it’s not always easy.

Here are 8 mistakes that parents make when their child starts to pull away:

1. Holding on too tight. Not allowing your child to spread their wings can create resentment and frustration. Yes, they are your baby, but they don’t want to be treated like one. It’s OK to let them try new things and make mistakes. Be there to help them learn from them.

2. Not holding on tight enough. Even though they seem more independent and don’t seem to want you around, they are still immature and still need someone to protect them from the big mistakes. Monitoring their technology use and being aware of their friends are essential examples.

3. Taking this transition time personally. They might act as they hate you…they might even say that they hate you…but they probably don’t actually hate you. While you might get your feelings hurt from time to time, it’s important to remember that this transition is healthy and not a reflection on your parenting skills.

4. Making judgments too quickly. If your teen starts to tell you something about their life or feelings, they can see right through your judgy looks. Practice in the mirror…whatever it takes. Just listen without (apparent) judgment.

5. Giving up too quickly on family time and family plans. You’re going to get shot down over and over. It’s OK to make family dinners a requirement as often as you think it fits your family best. Also, make a point to involve your teen in planning family time. If they choose the activity, they are more likely to be a willing participant. You can also leverage that to say, “Remember when we all played Fortnite together? Now it’s your sister’s turn to plan.”

6. Trying to have serious and deep conversations all at once and face-to-face. These are awkward and unlikely to meet their desired goals. Talk about the issues in small chunks. Use the car ride or some physical activity time (playing catch).

7. Dominating conversations. Say anything that smells of “I-told-you-so” or involves a long drawn out lecture, and you’re actually doing more to push your child away.

8. Not recognizing warning signs that it’s more than just standard teenager stuff. Unfortunately, teens and pre-teens do get depressed, and significantly withdrawing can be a sign. Look for the following:

• Significant abrupt changes in interaction.
• Severe withdrawal (not coming out from arriving at home until school the next day).
• Moving away from activities that they used to enjoy.
• Loss or gain of appetite/sleep.

Growing up can be difficult. Don't forget that. We've all been there before. But normally, things will get better and they will come back to you soon enough.

Kids are gross.

Germs and kids are doubly gross.

As parents, we know this is true, especially during this time of year. The illness visits are piling up in my office and throughout the Cook Children's system. The days off school are starting. Missed workdays are causing stress.

We all hate this part of winter.

In my office, we're seeing lots of barky coughs from croup. We've also seen a ton of kids with sore throats from strep and viruses. Lots of fever from ear infections and flu season is just around the corner.

So what do you do? How do you survive the winter and keep your child healthy?

There's no magic vitamin. There's no magical food. There's no magical anything.

But here's something you can do: teach them not to be (as) gross.

1. Kids, stop licking and chewing stuff: Not the table, not your clothes, not your friends. There is nothing you can lick except your food, and really, you should chew it.
2. Kids, wash your hands. Several times a day. Wash them after you eat. Wash them after you go to the bathroom. Wash them just because you need to wash your hands. Get those germs off.
3. Kids, cough into the crook of your elbow. Don't cough on your classmates or your teacher (this isn't going to get you out of a test). Don't cough into your hands because then you will be spreading germs around the next time you touch someone or hand something to a classmate or sibling. 
4. Kids quit sucking your snot back up into your nose. You're driving us all crazy and making us all nauseous. It's disgusting. Really. And it's also bad for you. Get that crud out of your nose and out of your body.
5. Kids, stay home from school if you're sick. If you have a fever, it's not allergies, and no, you can't take Motrin on your way into school to make it through the day. (Ok, kids. This one was more for your parents.)

I'm sure there's more. What other lessons should we teach our kids so they won't be as gross this winter?

Stay well,

Doc Smitty

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

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

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

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

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

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

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

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

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

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

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

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

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

Consider the source

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

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

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

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

Dig deep

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

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

Look for red flags

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

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

Read the fine print

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

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

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

For more information

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

Cook Children's approved health resources for you:

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

The CDC found:

• That suicides increased by 56% during the 10-year span among people ages 10 to 24 years old.
• Suicide attempts among African-American teens increased by 73%.
• Suicide is the second-leading cause of death for teens from all demographics and the third-leading cause of death among black youths between the ages of 15 to 19 in 2017.
• In 2017, 2,200 teens between 15 to 19 years died by suicide.
• 1 in 5 high school students admitted to experiencing suicidal thoughts and 1 in 10 said they devised a plan to carry it out.
• The increase in the rate of suicides among 10- to 14-year old children have almost tripled between 2007 and 2017.

The CDC collected data from nearly 199,000 high school students by the CDC and Prevention’s Youth Risk Behavior Study.

Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s, realizes suicide in children and adolescents is a difficult topic for most parents. But she stresses it’s one that can’t be ignored.

“As a mental health professional, my worst fear is a child prematurely ending his or her own life,” Dr. Pyrc said. “As a mother, it is hard to comprehend the profound grief families must feel in the wake of a suicide.”

The American Academy of Pediatrics has updated its guidelines to recommend pediatricians routinely check for signs of depression in their young patients. The focus is to carefully screen patients ages 12 and over during annual checkups.

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” said Vanessa Charette, M.D., a pediatrician at Cook Children’s Magnolia office in Fort Worth. “Even if nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression.”

While researchers say they aren’t sure of the exact causes for the rising suicide rates, experts point to a rise in depression among adolescents, drug use, stress and access to firearms might all be contributing factors.

Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Cook Children’s Behavioral Health Clinic in Denton, is simply fed up. She’s seen too many kids come into her office depressed, frightened or even suicidal because they can’t get away from their bully or bullies.

“I think that bullying is worse than ever before because of cyberbullying,” Elliott said. “Kids can’t get a break.”

No child is bully-proof. Elliott offers parents the following talking points when speaking to their child about bullying:

• Even people who say they're your friends can bully you.
• You should confront your friends when they're being hurtful to you or others.
• Retaliating may feel good temporarily, but refusing to stoop to the bully's level will win you more popularity in the long run.
• When you hear a false rumor, just ignore it and be yourself.
• You're most likable when you respect yourself and others.
• Bullies usually have their own insecurities. Returning meanness with kindness is the best way to break down their defense.

Elliott advises parents to monitor their child’s computer and cell phone, and encourage them to spend less time on social media. If bullying expands onto social media, then parents should talk to their child’s teacher, coach or another school official.

“Parents should watch for any change in a mood like sadness, depression, hopelessness, irritability, anger, and hostility,” Elliott said. “You may see more tearfulness and changes in activity level. Watch for more withdrawal from friends and family, change in friends and loss of interest in activities once enjoyed.”

Elliott says warning signs of teen suicide include:

1. Alcohol/Drug Use
2. Preoccupied with death (writing, drawings)
3. Talking about feelings of hopelessness
4. Talking about being a burden to others
5. Telling loved one's goodbye
6. Decline in performance
7. Giving prized possessions away
8. Isolating and withdrawing
9. Acting highly anxious or agitated
10. Acting reckless and taking risks
11. Rages
12. Changes in sleeping and/or eating
13. Dramatic changes in personality and/or appearance

If you would like to schedule an appointment, refer a patient or speak to our staff, please call 682-885-3917. 

Sources for this Topic:

• Cook Children's Behavioral Health Center
• Youth Risk Behavior Surveillance System (CDC)
• Report: Suicide Attempts Among Black Teens Increased by 73 Percent (The Root)
• Suicide attmepts increasing among black children and teens, study finds
• Youth Suicide Rate Increased 56% In Decade, CDC Says
• Suicides and homicides on the rise in young people (NBC News)

1. The pain is "crushing" or pressing down.
2. There are other symptoms like passing out, nausea or skipping/racing heartbeats.
3. The pain is brought on by exercise.
4. There is a medical history that would worry you (examples are a history of heart disease, Kawasaki disease or Marfan syndrome).
5. There is a history of a murmur. 

And here are 5 other common causes of chest pain:

1. Muscular or chest wall pain. The pain comes back when you touch their ribs or chest.
2. Reflux. The pain is after meals or described as burning.
3. Anxiety. The pain is associated with stressful situations.
4. Lungs. The pain is associated with a deep breath or there is a history of asthma.
5. Who knows? It's fairly common that we can't figure out where it came from but this should only be said after everything else has been considered or checked for.

Dan Guzman, M.D., a Cook Children’s emergency physician, called the day gut-wrenching for the victims, their families, and the medical staff that took care of the kids, ranging from ages 3 to 14.

Gun awareness and gun safety is a passion for Dr. Guzman. He is the medical director of the Aim for Safety program at Cook Children’s, which promotes firearm safety for children. The program is a multi-step interactive experience that provides parental awareness and teaches children the steps they should take when they encounter a firearm.

“I think most people think this ‘won’t happen to us’ because we’ve taught our kids to never touch guns,” Dr. Guzman said. “But if you aren’t taking the proper precautions as the adult and parent, it’s probably only a matter of when, not if, your life may be affected by an unintentional discharge involving someone you know, and maybe even your child.”

Firearm-related fatalities are a top 3 cause of death among children in the United States.

Dr. Guzman said before the weekend, the medical center staff sees about one child per week. Already in 2019, three gunshot wounds treated at the medical center have been fatal.

“Unfortunately, the tragedy of children falling victim to unsecured firearms continues to happen daily,” Dr. Guzman said. “These preventable incidents and the pain and suffering they inflict can be reduced by properly securing your firearms.”

As part of the program, Dr. Guzman offers these safety tips to follow:

The 3 Ts of firearm safety and children

Talk – This includes your family, neighbors and friends. When your child visits other homes, ask the owners if there are guns in their homes and how they are stored. Dr. Guzman said this question is not to be insulting, but to keep your children safe from unsecured firearms.

Teach – Have a conversation with your kids about what to do if they see a gun:

• Stop
• Don’t touch the gun
• Run away
• Tell someone

Take – Dr. Guzman is asking gun owners to take action and store their firearms properly. And, to take personal responsibility for our children’s safety.

Dr. Guzman stressed that children are curious and impulsive which can be deadly when paired with a firearm. Storing a loaded firearm under the mattress, in a bedside table or a closet is placing your family at risk, Dr. Guzman added.

The most secure place for your firearm is in a safe with the ammunition stored separately. Unsecured firearms should always be in your possession. If you are unable to purchase a gun safe, then separating the ammunition from the firearm and using a cable or trigger lock will help reduce the risk of unintentional injury to your child.

“It’s important to assess and evaluate your home injury risk and find ways to reduce the hazards in your home whether it is related to firearms, water safety, poisonings or any other safety risks,” Dr. Guzman said. “Discussing with your children the importance of what to do when they encounter a firearm can help to reduce unintentional injury in your home.

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.