In the wake a baby is dead and her mom has been charged with her murder. In addition, the baby’s dad has been charged with aggravated battery and cruelty to a child for diluting their baby’s breast milk with water, then refusing to take the child for medical care.

By the time they did take her to the hospital, she was already dead.

Unfortunately, this is not uncommon. I remember a similar case from years ago in which a child’s family was desperate for money and thought they could use extra water to make their formula last longer. In a study from Clinical Pediatrics, up to 25 percent of families considered “food-insecure” admitted to using various methods to make their formula last longer.

The problem is that extra water is not safe for babies. It causes the sodium level in their blood to drop. Low sodium will lead to brain swelling which can cause poor feeding, lethargy, seizure and eventually death.

Giving free water to babies is not just an issue of formula stretching. Families commonly ask during the summer months if their babies need extra water due to the heat. The answer is NO!

Some reasons babies don’t need water:

• Breast milk and formula is mostly water (80-90 percent). Babies don’t get thirsty. Their diet is primarily liquid.
• Water does not have nutrition or electrolytes babies need. If a baby is going to be drinking something, why not make it be something that can help them grow?

Babies can safely start to drink some water after six months but they still don’t need a lot. They can get one to three ounces during their meals if parents want to introduce and practice with a sippy cup.

1. The Centers for Disease Control and Prevention (CDC) is closely monitoring the current outbreak caused by a novel (new) coronavirus first identified in Wuhan, Hubei Province, China.
2. Coronaviruses are a highly contagious type of respiratory virus that will sometimes cause outbreaks in regional areas (if you remember SARS, think along those terms).
3. Human coronaviruses are common throughout the world. The CDC states there are seven different coronaviruses that scientists know of, that can make infect people and make them sick.
4. A current strain of the coronavirus caused hundreds of cases in China. Symptoms typically are runny nose, cough, sore throat and fever.
5. Because the virus replicates and causes high levels of infection in the lungs, it can spread rapidly to a large number of people.
6. Because it’s so new, there’s no specific treatment for coronavirus, but exposed individuals should be monitored for upper respiratory symptoms and worsening breathing problems.
7. For now, most of us in the U.S. are at low risk for coronavirus, but care should be exercised for anyone traveling to or from the impacted areas of China.

We will continue to monitor the CDC and other health organizations. If there’s something new to report, we will be sure to let you know.

*Image Credit: NIAID

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.

I've been interested in essential oils for a while now, beginning with a Facebook post where I sought out questions that might come up regarding essential oils and their use in children. Well, after much consideration, study and investigation, I think it’s time to release some of those results.

Whether you agree with my conclusions or not, I think you’ll find the information helpful and interesting…so here goes!

The slippery assumptions of oil supporters

We all have pre-conceived ideas about things. We can’t help ourselves. We were brought up in a particular culture or educated in a certain way or have friends that believe certain things. One of my primary goals as a person is to constantly challenge what to believe to see if there are holes in my thinking or understanding of things that are not logical.

I’m going to go ahead and put some of my pre-conceived notions and assumptions out there so that we can all be on the same page:

1.I have a strong trust in science, the scientific method and organized medicine. I can’t blindly follow any of those things, but I’m going to rely on them most of the time to make decisions for myself, my children and my patients. If the science proves that something works, I’m willing to use it or at least allow it to be used by my families.

2.I am very skeptical of anecdotal stories and advice. I often have to say, “I can’t contradict what you are saying, but it goes against what I know about this condition.”

3.I am generally very nervous about new treatments or new uses for old treatments. I often say, “I don’t want to be the first to try something nor the last. Somewhere in between is where I feel comfortable.” I want to weight risk vs benefit for everything.

4.I believe that the overwhelming percentage of parents (99.9999 percent) want the best for their child and would never intentionally harm their children in any way.

Because of these assumptions, I may evaluate oils in a different way than most people who use them do. I get that. But my patients who use them will tell you that when we talk about them, I am not judgmental (at least, I try not to be) and I am willing to listen to how they are using them as long as they will listen in return when I provide suggestions or push-back. (Most of them pretend to listen, at least, ha!)

I thought as we move through all the evidence about oils I have discovered, it would be helpful to challenge some statements made by my oily friends that imply false assumptions about me:

1.“I just don’t want to give them medicine for every little thing.”

That’s awesome, me neither. When patients leave my practice, it’s most commonly because I don’t give them a medicine or test that they want. The four most common examples are medicine for colds (cough and congestion), reflux, colic or antibiotics. If medications are not indicated for those conditions, I’m not going to be writing for them. If the decision is on the fence or unclear, I’ll engage the parents to help make a decision. The three little kids running around my house rarely get any medicine, especially for those symptoms for which I see oils being used. They rarely get medicine for fever or runny nose, never for cough and certainly never because their behavior is bad that day. Most of you probably don’t use oils for this-but some of you do…I’ve seen it. I’m not trying to single out a child with special needs or developmental problems, I’m more referencing a kid/parent who just aren’t quite getting along that day. In many of these cases, the use of oils is not in place of a medication, it is often additional to what I would do.

2.“You are a medical doctor so I’m sure you don’t like alternative medicine.”

Not exactly but this one is closer to true. Traditional medicine, to me, means tried, tested and proven. Alternative medicine might be old, might be tried but in my mind the definition means that it is unproven. In fact, through my studies the last few weeks, I have come across a couple of ideas that I am considering incorporating into my practice. But, at that point, if I begin to recommend it based on review of the scientific literature, is it alternative? Or, if the oils work like some claim they do, then eventually won’t we all be using them? Are they still alternative? This assumption is partially true but only because I want to be clear with my patients on what we absolutely know about oils, not what some have claimed.

3.Patients don’t tell me about their oils because they are scared of my reaction or assume I don’t want to know.

Incredibly wrong. I have to know what medication your child is on, period. If there is information about drug interactions or negative outcomes as a result of any medication use, I need to know who’s taking it so I can get in touch with people who are using them. We do the same thing for vaccines and everything else we use in the office so that if there is a recall or another issues, we can get the word out to our patients and tell them what to be on the lookout for.

Now we can move on to some research…

The Research on Essential Oils in Kids

These are the oils for which I found some research. I’m sure I left some off but I thought these were a representative list from a Facebook question I saw come across my timeline and would give us enough information to start the discussion.

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

I started by looking myself and then had our staff librarian follow up with a PubMed search. Because I knew that would not be enough for some, I also reviewed the following websites at the suggestion of the followers of my Facebook page (The Doc Smitty): aromaticscience.com, Dr. Robert Pappas Essential Oil University and airase.com (cost me $75). I also used the NIH Center for Complimentery and Integrative Health, the MedLine Encyclopedia & Natural Medicines Comprehensive Database and the Sloan Kettering Integrative Medicine Database.

First, I’ll summarize what we found from the more traditional medical research on each oil (PubMed, NIH Complimentary and Integrative Health, MedLine and Sloan Kettering):

Lavender

• One study shows use of lavender associated with decreased use of acetaminophen after children had their tonsils out but did not show decrease in pain intensity or nighttime awakenings. (48 patients)
• Several adult studies showing calming effect of lavender.
• Another very small study showed that lavender use in babies had a calming effect.
• These and other published research involve small sample sizes (less then 50 subjects) and often the study design is lacking or flawed in other ways.

Tea tree oil

• Some fair quality studies that included children showed some possible benefit for lice, acne and warts.
• A small study in adults showed possible improvement in toenail fungus.
• Many reports of side effects from accidental overdose are pretty common with tea tree oil (confusion, drowsiness and possibly coma). Just a reminder (just like other medicines, I’m not singling out oils) that we should keep these oils out of the reach of children. I have seen people make comments like, “These are natural so you can’t possible overdose on them.” This is simply not true.

Chamomile

• A review of the use of alternative methods for treating colic (including chamomile) was published in Pediatrics in 2011. The conclusion of the reviewers was that a further look into the issue was warranted.
• Colic studies are difficult because defining what is colic is difficult, if we can agree, deciding what constitutes improvement is even harder as most “cases” resolve on their own without treatment.

Peppermint Oil

• Some studies (some including children) have shown benefit for use in irritable bowel syndrome and recurrent abdominal pain.
• Other possible uses have been studied in adults (including headache), which has shown some promise but no definitive answers have been found at this point.

Eucalyptus

• Studies have shown that use of eucalyptus and lemon can work as an insect repellant although there have been case reports of toxicity from widespread application on the skin.
• There are multiple reports of severe toxicity after excess ingestion in children.
• Some studies have shown benefit for treating head lice.

We tried to research some other oils (thieves and frankincense) but found any evidence for their use in children to be lacking or unavailable.

Of note, you’ll see that there is no evidence for the use of these oils for some of the common uses I see them touted as being beneficial for: fever, cough, congestion, allergies, teething symptoms and (the one that makes me the most frustrated-see above) behavior problems.

Other Sources

At the suggestion of readers I also reviewed the literature from aromaticscience.com and discovered one article for which I had not previously found and only discovered 11 studies when searching for children.

I also reviewed Dr. Robert Pappas’ website but could not find further information about studies in children.

The gist of most of these websites is to list tons of articles of test tube and animal models with adult studies mixed in but they have very little to no information on children.

An example of this is the Facebook page of Scott Johnson who is “one of the world’s leading experts on evidence-based, therapeutic use of essential oils and natural products.” I looked back over 6 months of his postings on Facebook. There are roughly 2-3 posts per day. I found four posts related to children: one about probiotic use for colic, one about mother/baby skin-to-skin contact, one promoting increased physical activity in kids, and one about exercise during pregnancy promoting brain growth in children. None that truly show evidence of the efficacy or safety of the use of essential oils in kids.

Finally, I signed up for a website so that I could review a study that got a lot of buzz last year in the essential oil community. It was looking at the use of oils in autism spectrum disorder (ASD). You can read more about ASD in my post here. There are many issues with the study that limit its ability to be used as proof of effectiveness: the sample size is small (12) and there is no control group (even a group that used a different concoction of oils would be helpful). It’s not that this type of study should not prompt further thinking into the issue, it’s just that the number of children and parents who started using oils for autism based on it is inappropriate. For more traditional investigations into the use of medications for autism, this would be one of the most preliminary studies and would need to be followed up by significant further studies to test for effectiveness and safety of the regimen that was recommended. Why do I care so much? Because my parents of children with developmental concerns are desperate for something that might help. I’m desperate to have something more to offer them, but I am very protective of them when it comes to those who might take advantage of them.

Summary of Research

There’s just not much out there. What is out there is small studies or case reports and other poor study designs. This effectively turns their current use by consumers into the study of essential oils. The problems is that, with no oversight, no one is systematically watching for effectiveness or safety so we may not know until much later.

Effectiveness/General Use

Do they really work or is it a mind over matter thing?

I think that there are probably some uses for oils that will be studied and proven to work. I think these will be pretty rare and only a small fraction of the claims that are currently made.

So, is it mind of matter (placebo)? Here are some of the most common uses I see for oils in kids:

Teething - It’s not even clear what symptoms teething causes …fussiness, fever, runny nose, etc have all come into question. But, if you give an oil and a symptom goes away, does that mean the oil fixed it? Not likely.

Fever - Fevers come and go during the day with illness, even without medication.

Cough/congestion - The regimens I see where children have oils placed frequently basically make it impossible to know if they do anything for these symptoms. Cough/congestion will be worse at certain times of day and better at others treatment or no.

How close are we to having actual research on the use of oils?

I still think we are quite some time away. Those that are currently doing research are often biased, are not doing high-quality studies and are using small sample sizes.

Marketing

Why are they sold through multi-level marketing (MLM)?

It’s a fast way to get a product out there and make a lot of money. Since I’ve been on social media, I’ve seen several of these types of MLM ideas crop up. The difference with these is I have some specific knowledge about the conditions they are being used for and specific concerns about how their use could harm a population of people that I care very much about. I know very little about bags and good smelling wax that can be melted with a light-bulb so I haven’t gotten involved until now.

In many ways, it protects the big company because they are not the ones out there making claims about the oils and what they can do. That falls to their independent distributors. If someone were to have a bad outcome because of their use of essential oils, who is responsible? If I prescribe a medicine that someone is allergic to, that responsibility falls squarely on my shoulders, not the makers of amoxicillin. If I prescribe the wrong medicine for a kids asthma and something bad happens, that responsibility falls to me.

Are they an increasingly popular trend or just something I was not aware of?

I’m not sure but it certainly does feel like they are gaining in popularity. Social media makes it seem that way at least.

Do you believe the claim that certain brands of oils are superior to others?

I’m sure there are differences but since we don’t even know what they do for the most part, it’s hard to answer this question.

Philosophy/Opinion

Regarding writing about essential oils: Are you mad, man?

Yes, in fact, I think I must be.

What’s the number one reason you see parents using oils instead of medicine?

In general, people are becoming less trusting of experts and organized institutions. Medicine and doctors are no different. The gap between what a doctor knows and what patients know shrinks every day. People can find out information about their conditions and know basically the treatment options that exist. People are looking to live more natural lives and most who use them feel that oils fit within that idea. When you combine these two issues, right or wrong, essential oils seem to step in the gap.

What is a good way to communicate with your doctor about your use of essential oils (for specific conditions and generally)?

I think it’s important to be honest with you doctor about your use of essential oils. As new information is uncovered it would be important for your doctor to be able to show you new research etc, especially if something shows a particular oil to be unsafe. They can only do this if they know about your use of them. Also, as doctors are prescribing medications, we need to know anything you might be on that could cause a drug interaction.

What is your take on the potential political barriers to the study of essential oils given that they are not backed by super profitable pharmaceutical companies?

Young Living is a very profitable company. They are big and profitable and will only continue to be more profitable. There is no reason that they could not start testing their own products or set up independent testing.

After your research as a pediatrician, would you use them on your children?

People will read all of this information or even do further research and come to different conclusions from me but here are two reasons I won’t:

1. I do not treat my kids with unnecessary medications. Since they are recommended for symptoms and given with the hopes of reliving those symptoms, I consider these oils to be medication.

2. I believe that, due to the lack of good studies, the use of them in children should be considered experimental at this point.

Summary

• The use of essential oils seems to be growing.
• The evidence for their use in children is slim.
• Talk with your doctor about the products you are using so that they can be aware of potential safety issues and medication interactions. 

Previous articles on this topic:

• New York Times Report: Are Essential Oils Safe For Kids?
• Essential oils and their use on children
• How safe are essential oils for children?

“My baby never spits up, but seems like they are fussy all the time."

I know this sounds like reflux, but the truth is spitting up can be normal. Even if it’s with every feed, even if it seems really bad.

Maybe you just have a happy spitter.

I call babies who spit up a lot but still gain weight and who aren't fussy with feeds “happy spitters.” They present more of a laundry problem (their clothes, your clothes, sheets, burp cloths, couch cushions…) than a medical problem.

The passage of milk and stomach contents into a baby’s esophagus is a normal process and can even result in VERY frequent, VERY large amount of spitting up and still be normal. It happens because the muscle that sits on top of the stomach is relaxing off and on all day long. If the pressure inside the stomach is higher than the resistance provided by that muscle, the baby can spit up.

But when is it a problem?

I consider reflux a problem if one of two things are happening:

1. The baby seems fussy after feeds or they are fussy when they spit up.
2. The baby is having significant spit up and is not growing well.

Fussiness after feeds is particularly concerning for reflux if the baby is arching their back or starting to refuse their feeds once they start. 

Because pressure is a big player in the spit-up/reflux process, there are some simple things you can do:

1. Make sure you are not overfeeding the baby. Babies who are overfed and spit up can seem hungry after, but that only makes the problem worse.
2. Avoid laying the baby down immediately after feeds when possible. Keeping a baby upright 20 minutes after feeds can help the milk to move further down and be less likely to come back up.

So when do we need to consider medication for reflux?

When the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, despite limiting overfeeding and keeping the baby upright, we consider treatment with an acid reduction medication.

One common medication is a group of acid reducers known as H2-blockers, the most common example is ranitidine. Another group of acid reducers are known as PPIs, such as lansoprazole.

It’s important to keep in mind that the medications don’t do anything to keep the milk down, so it’s likely that the baby will continue to spit up hopefully without being fussy and gaining weight (and another good reason not to treat a “happy spitter”).

RSV has arrived at Cook Children's.

Last week, 178 kids tested positive for RSV, compared to only two who tested positive for Influenza A.

RSV is a virus. It’s short for respiratory syncytial virus. It causes a disease in young children (especially those less than 2 years) called bronchiolitis. The RSV season usually begins around mid-August and runs through March.

Bronchiolitis is a disease of the lower respiratory tract which causes children to wheeze. They are wheezy because their small airways have swelling and junk (mucous and cells from the lining of the airway) in them.

The smaller airways are similar to the area where a child with asthma has issues (which is why they wheeze). The difference is that children with asthma have a squeezing down of the walls of the airway (which is what a breathing treatment reverses). This is why breathing treatments in children with bronchiolitis usually don’t work.

Bronchiolitis is not just caused by RSV. There is a long list of viruses that can cause the same symptoms:

• RSV
• Rhinovirus (usually a cause of the common cold)
• Parainfluenza
• Human metapneumovirus
• Influenza (Flu)
• Coronavirus
• Human bocavirus
• Human polyomavirus

Here are some answers to the most common questions I hear from parents:

What are the symptoms of bronchiolitis?

Typically the child starts with runny nose and cough. This will progressively worsen over a few days and possibly develop into difficulty breathing and difficulty with eating. The symptoms typically last a total of about 5-7 days with the worst day being the day in the middle. It is not uncommon for the cough and runny nose from bronchiolitis to last 2-3 weeks.

How do we treat bronchiolitis?

In most children, treatment is done at home and consists of sucking snot (click here for more advice on this) and counting wet diapers. This isn’t very fancy but, unfortunately, until someone invents TamiRSV we don’t have anything more specific. As far as wet diapers go…I am looking for a wet diaper about every 6 hours.

Who goes to the hospital?

Getting admitted for bronchiolitis is usually based on: dehydration, severe difficulty breathing or low oxygen levels.

Children who can’t eat because they are breathing fast and are puking because of all the mucous draining into their belly are at risk for dehydration. Unfortunately, the only way to fix this is to put them in the hospital for intravenous (IV) fluids until they are able to drink better.

A child who is having severe difficulty breathing also needs to be observed in the hospital. Unfortunately, babies with severe bronchiolitis can get tired from all the heavy breathing they are doing and this can progress to needing ICU care. It is best to have those babies who are breathing that hard in the hospital so that they can be monitored closely by people who know what they are looking for…

Babies with bronchiolitis often need extra help keeping their oxygen level up by getting extra oxygen. We monitor these babies closely and I put them on oxygen for severe difficulty breathing or if their oxygen level is less than 90 percent.

Summary

1. Bronchiolitis stinks, it makes kids sick and I don’t have much to offer.
2. Whether it’s RSV or not often doesn’t matter.
3. Watch for difficulty breathing and decreased wet diapers.

For more information on bronchiolitis and RSV, read this post from one of our hospitalists.

According to the National Conference of State Legislatures, Texas is among 18 states that allow families to opt out of vaccines for personal or moral beliefs. The Morning News reports that Plano, Fort Worth, Austin and Houston all ranked among the 15 U.S. metro areas with the most such conscientious exemptions for kindergartners. Each had more than 400 kindergartners exempted from vaccines.

Fifteen years ago, about 2,300 students opted out of at least one vaccine. Today, that number has grown to 56,737 kindergarten through 12th grade students.

This has many doctors, including myself, worried about more measles outbreaks in Texas.

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

News about vaccine preventable diseases is important for us to share, but it brings up many strong opinions.

Here’s how the debate usually goes:

“Please vaccinate your children.”

“If your child is vaccinated and vaccines are such a good thing, why do you care if my child gets vaccinated?”

Most people don’t have a good answer for it so it tends to be a good trump card.

So why do I care?

There are two reasons.

1. I care about your child. I firmly believe that vaccination is the right thing to do. I vaccinate my children on time and on purpose. I would not want any child to receive less care than I would provide my own children.

2. Vaccines sometimes do not provide complete protection. Most provide protection in the 90-percent plus area (some nearly 100, some lower). Because of this, even a vaccinated child can contract the disease. I will go into this in more detail below, but the more children who are vaccinated for a disease the less likely it is that any child will contract that disease. This occurs through a process known as community, or herd, immunity.

Many people will stop reading right here because they have already decided or have read somewhere that herd immunity is not a real thing. Here are some of the arguments against herd immunity I come across from time to time:

• It’s not based on a science, but on epidemiology. Epidemiology is the study of the way diseases spread. It is a very complicated field, involves tons of statistics and research and IS science. To say that it is not science is a false comparison.
• We still have outbreaks even in areas where there are high vaccination rates. This is most definitely true, but does not prove that herd immunity is not real.

How does it work?

Since it's most timely, let’s use measles as an example. First, you need to know some things about measles…

Measles has an attack rate of a susceptible individual at 75 percent. This means that 75 percent of people exposed to measles who are not protected will contract the disease. I’ll use 70 percent to keep my numbers round and err on the side of people who would disagree with me.

Measles vaccination has a 95-100 percent protection rate. Again, I will use 95 percent so that I am not cherry picking the best results to prove my point.

There are two scenarios below. The first scenario has a case of measles in a classroom where everyone else is vaccinated. The second scenario is a case of measles in a class with one child who is not vaccinated.

Scenario No.1:

Scenario No. 2:

In scenario No. 1, all the children are vaccinated which means they have a 5 percent chance of catching measles. If that child goes to another class or event where all children are vaccinated, each of those children have much less than a 5 percent chance because the child doesn’t likely have the disease and they only have a 5 percent chance of catching the disease even if he did.

In scenario No. 2, one child in the classroom is unvaccinated. He thus has a 75 percent chance of catching the disease. He’s going to go to other locations with other children, even if those children are all vaccinated, we have potentially opened up a whole second circle of exposed children. Not to mention that the children in the first class have now potentially been exposed twice.

So, in scenario No. 2:

• If I gave you a choice, would you want your child in group A or B?

• Does it matter if your child is vaccinated or not?

• What if you also have a baby in your house who cannot be vaccinated?

• What if you child is in class B, but has a disease for which they cannot receive the MMR vaccine?

The answer is no, none of these things matter. Logically, we should all want our child in room A because it decreases the odds of our child being exposed. Is it 100 percent? No, but it doesn’t matter. Are you more likely to be angry about a measles outbreak if your child cannot be vaccinated? Yes, and I understand that.

For one last thought, consider this … a  study in Pediatrics described geographic clusters of people who choose not to vaccinate at all or to under-vaccinate their children. I suspect that is true across our area as well, but I also suspect that there is clustering according to other factors as well: socioeconomic status, church/religious affiliation, etc. Populations where there are multiple families who choose not to vaccinate would be particularly susceptible in an outbreak situation. Let’s pray we don’t get there.

This is herd immunity and why the question, “If your child is vaccinated and they are such a good thing, why do you care if my child gets vaccinated?” doesn’t end the conversation.

Did you know the American Academy of Pediatrics (AAP) actually has an official stance encouraging pediatricians to talk with their families about the importance of daily, out-loud reading to your children (Literacy Promotion: An Essential Component of Pediatric Primary Care Practice).

Sometimes, when the AAP releases statements like this, that seem like common sense, I have to resist the urge to roll my eyes and tell myself, “Ok, thanks for stating the obvious.”

This one, while perhaps common sense, is very important. 

Why?

Despite the fact that I think most parents would agree with the importance of reading to your children, studies show that only about half of children are read to aloud every day. In addition, reading to children sets the stage for their speech development which helps them do better in school. So what are the reasons for not reading to your child?

1. I don’t have time.

We aren’t asking that you read “War and Peace” every night with your 6 month old. I’m hoping for about 5-10 minutes of reading (1-2 short books). Ultimately, if you don’t have that much time then just read for the amount of time that you can, any amount is better than none. Our kids really like to read during meal times as well, it tends to keep them eating and moving and keep their fighting about food to a minimum. If you routinely watch TV during meals, it’s a much better alternative.

2. If they don’t understand, it doesn’t matter.

Reading to your children even before they are speaking is an important part of teaching them language. Babies learn the sounds of language long before they know any words. The number of words a child hears before they start kindergarten is a strong predictor of how well they will do in school. This is why it’s not only important to read to them, you should also spend time talking with them all throughout the day.

3. It’s so boring.

This one I can really sympathize with. There are nights where I feel like I deserve an Oscar for my dramatic performances … but there are also nights where I drone on in monotone and doze off between pages. It’s important to really engage your children as best you can, based upon their age. Have them help you count objects, letters or words on the page. If it’s a book you’ve read 1,000 times, read the wrong word and let them correct you (“Ohhhh … daaaadd, you’re so silly!”). You can be selfish here. Do whatever it takes to make it interesting for you, it will make it easier for you to do it and it’s likely that your child will enjoy it more as well.

4. They don’t even seem to enjoy it.

Let’s face it … sometimes they don’t even seem like they care. Your 12 month old is crying because he or she is tired but doesn’t want to go to bed. My youngest would rather chew on a book than have you read it. My oldest child would often rather be reading his own book than listening to me. But, I press on. Reading is not only beneficial for the language development, but studies show that it helps to develop more nurturing parent-child relationships. Perhaps more importantly, is what it does for me. After a hard day at work, getting home to referee the boys fight for 2 hours, it’s nice to have some one-on-one time with each child to remember that I still like them.

5. No one ever told me it was important.

Well, you can’t use this one anymore can you? Just in case you missed the message, it’s important.

Start by making a plan to read to your child every day for the next month.

Get a calendar out and mark off the days. 

I promise it will benefit your child for years to come.

Resources For Families

• AAP Tips for Families for Early Reading and Literacy
• Is Your Child Ready to Read?
• 5 Ways Parents Can Improve Their Child's Vocabulary
• The Unique Challenges of Raising a Highly Gifted Child

The Dallas Morning News reports that person from another state who had mumps traveled to Dallas for the National Cheerleaders Association All-Star National Championship, which took place Feb. 23-25 at the Kay Bailey Hutchison Convention Center. 

At this point no Texas residents have developed mumps in connection with the case, but people are urged to watch for symptoms. 

This is another reminder about the value of vaccination in preventing what can be serious illness. Mumps cases decreased 99 percent after the introduction of a successful strategy for vaccination.

Here's a quick look at mumps cases over the years according to the CDC:

*Case count is preliminary and subject to change

** Cases as of Jan. 27, 2018 Case count is preliminary and subject to change

Mercury (Thimerosal)

Thimerosal is a preservative that was used in vaccines starting from the 1940s. The preservative contains a small amount of mercury and chronic mercury toxicity has been shown to be related to psychiatric problems and other medical issues. Because of this, it was brought up as a concern around 1999 because the overall number of vaccinations was increasing that perhaps over time the exposure to mercury could be a cause of autism.

Studies started quickly to determine if this could be the case, but in the meantime, the vaccine companies, at the request of the American Academy of Pediatrics (AAP) and the Food and Drug Administration (FDA), began to take Thimerosal out of their vaccines. Thus, by 2001, Thimerosal (and mercury) were removed from vaccines except for one exception (see below). Fortunately, in 2004, further studies released by Institute of Medicine determined that mercury was not a cause of autism.

Currently, the only vaccines that contain mercury that I offer in my clinic are seasonal flu vaccines when they are given in a mutli-dose vial. I try to order as much “preservative free” flu vaccine as I can so that this is not even a concern for my patients. However, because studies have shown that mercury is not a cause of concern, I do not worry that receiving their flu vaccine from a multi-dose vial would harm my patients.

MMR Vaccine

Autism is generally diagnosed around 15-18 months, right after the time when children receive their measles, mumps and rubella (MMR) vaccinations. I believe that is because of this relationship in time that MMR was ever thought to be associated with autism.

The original paper that reportedly found a relationship between MMR and autism by Andrew Wakefield was published in The Lancet. The research has now been completely discredited after multiple other scientists were unable reproduce the results and significant problems with the methods he used for conducting his research. In addition, further information has come out regarding Dr. Wakefield’s conflicts of interest and his motivation for publishing the paper. Over time, ten of the twelve authors involved in the writing of the paper retracted their support of its conclusion.

Finally, after many years, The Lancet published the following statement, “We wish to make it clear that in this paper no causal link was established between (the) vaccine and autism, as the data were insufficient. However the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper.”

Despite this overwhelming criticism of his paper, the damage done by Dr. Wakefield and The Lancet still persists today. Parents continue to ask about and remain fearful of MMR and a possible (although incorrect) link to autism. His belief caused parents to fear the use of MMR vaccine and unfortunately, this often extends to all vaccinations.

“Too Much, Too Soon”

Are children getting too many shots too soon?

Will receiving all the scheduled shots, so many more than we got as kids, overload their immune systems?

This is a conversation I often have with parents of newborns. And despite the fact that I’m pro-vaccine, I am not afraid to have discussions with parents who have fears and simply want what is best for their child.

Because of that, I follow the evidence closely and love to see new studies that look at different angles of the vaccine discussion.

That’s why I was I excited to see a recent study in the Journal of the American Medical Association (JAMA) that analyzed children with infections not covered by vaccines to determine how many vaccines they had received and if that was a potential reason why they got the infection.

The research looked at around 200 children with diseases and compared them to 750 other children. Those who contracted the diseases had a total vaccine exposure of 240.6 antigens while those in the control (without the disease) group had 242.9.

So, it doesn’t appear that vaccine load on the immune system is a contributing factors towards children contracting other diseases.

This study is another perspective and further evidence that lends support to the idea that vaccines are one of the most successful, safest advancements in the history of medicine.

Maybe you thought it was no big deal. Maybe you heard something about it that made you worry.

Here are 4 facts about sugar bugs that you should know:

1.Prominent veins are common in the newborn, infancy and childhood period. They can occur on the face, hands/feet, trunk and extremities (basically all over). If you look closely enough in all babies, you’ll find some veins that are more noticeable than others.

2.One suggested link with sugar bugs has been an association with mutations in a gene known as MTHFR. MTHFR mutations are common, approximately 50 percent of the population carries some type of mutation. The significance of MTHFR mutations is still unclear but no studies link the presence of sugar bugs to these mutations. You can read more about MTHFR mutations and there significance here: A Pediatrician Goes In-depth into MTHFR.

3.While it has been speculated by practitioners of traditional Chinese medicine that sugar bugs might suggest a syndrome (known as Kanmushi) where children show a voracious appetite and severe sensitivity to sugar, I find no evidence that support this is a true connection.

4.Proponents of Kanmushi suggest that you limit your child’s sugar intake, provide a structured environment and opportunities for physical activity. Obviously, these are great ideas for all children.

So, should you be worried about your child’s sugar bug?

It’s always possible that further information could surface, but given current theories and information, I would say that any connection to a more serious issue is unfounded and not a concern.

Learn more about Kanmushi by clicking here.

But, here goes …

Our intestines are full of bacteria that help us to break down food products and whose function has an effect on immunity and possibly allergies. These bacteria can be called “probiotic” organisms.

1.What are probiotic/prebiotic supplements?

Probiotic bacteria can be given as a supplement which can be mixed in with foods, beverages or given as a supplement (similar to a vitamin).

Prebiotics are substances which, when ingested, help to increase the number of probiotic bacteria in the colon. Prebiotics are typically small chains of sugars that humans cannot digest or use. They can be ingested in beverages or nutritional supplements and are even added to some formulas.

2.Are they safe?

Studies suggest that the use of probiotics is safe in healthy infants and children. However, some patients might be at risk:

Children who have abnormal immune systems such as ill preterm babies or children with implanted catheters (or other medical devices) should consult with their doctor because infections have occurred as a result of giving probiotics in these groups. Studies have also shown that adding prebiotics to infant formula is safe.

3.What conditions do they work for?

Infectious diarrhea (stomach bugs)

Some evidence suggests taking probiotics might prevent cases of infectious diarrhea, particularly in day care centers, but the effect is very small. It would take about seven kids taking the probiotic daily to prevent just one case of diarrhea, thus I don’t recommend use of probiotics to prevent diarrhea.

Once diarrhea has started, there’s pretty good evidence that starting probiotics may decrease the time of a child having diarrhea by as much as 40 hours. So it would seem good to provide probiotics at the first sign of infectious diarrhea. The effect was greatest with a probiotic known as Lactobacillus rhamosus GG (LGG).

Antibiotic associated diarrhea

Diarrhea is a common side effect with children who are taking antibiotics. Studies have shown that taking may decrease the child’s risk of developing diarrhea. Once again, the effect is small as it takes seven kids taking the probiotic to prevent one episode of antibiotic associated diarrhea. However, because it only requires the child to take the probiotic during the course of the antibiotic, this seems like a reasonable approach. Treating antibiotic associated diarrhea once it has already started does not appear to be helpful.

4.What conditions might they work for?

Eczema and allergies

Studies have been mixed on the use of probiotics for both prevention of and treatment for allergic diseases (including eczema). One of the major problems is that these diseases often are difficult to study because they are difficult to define and assessment for improvement is often subjective.

Colic

Some early data suggested that probiotics might be helpful for infants with colic. This is also very difficult to study as definitions for colic are wide and varied. It’s hard to even know if colic is a real, definable illness or just a baby that cries a lot. Further information and studies would be necessary in order to fully recommend probiotic use.

5.What’s next?

As we learn more about the normal bacteria that live in our intestines and how variation of the amount and type might contribute to disease, I’m hopeful that we’ll continue to see conditions for which probiotics are safe and effective.

1.Technology

2.Newborns

So, you might not be surprised to hear that a new tool for evaluating jaundice using a smartphone definitely activated my nerd alert.

Jaundice is a high level of bilirubin in the blood. Yellow skin is a reliable sign, but diagnosis is made with a blood test to measure the bilirubin level.

BiliCam is a smartphone enabled app which helps to measure a baby’s level of jaundice (bilirubin) by taking a picture alongside a calibration card which is then uploaded and analyzed.

The good news is that those measurements were found to be close to those drawn from the blood and, most importantly, were accurate in measuring infants with bilirubin levels over 17 (which is near the level at which treatment would be necessary). Currently, children who are on the border requiring phototherapy might require frequent visits to the doctor for blood draws to assess their jaundice levels. A non-painful option that could be done by the parent at home would be amazing.

BiliCam is just one of a number of rapidly expanding uses of technology in parenting a newborn. Starting with BiliCam, here are 4 technological advances in newborn care and my review:

1.BiliCam

I love the idea and I really think it could be useful. But I found a couple of problems right now. I can’t figure out how to implement it in practice. As far as I can tell, it's not commercially available at this time. Another problem is that it requires parents to have a card. I suppose I could keep them at my office for those babies who I’m sending home that I know will need a screen but, otherwise, if they need to be screened, they’ll have to come and pick up a card (which kind of defeats the purpose).

Overall Rating: B-

2.Respiratory and other vital sign enabled-monitors

We’ve written about these before, but I feel like a new one comes out every month. Every time I publish this story, there are people who comment about how much they loved theirs. But there are also people who echo my concern that they caused tremendous anxiety. Because of this and because there is no proof that they prevent bad things from happening to your child…

Overall Rating: C-

3.Baby tracking apps

Do we really need to know every time your baby poops, pees or feeds? Probably not. But I have found them to be helpful when babies are having trouble gaining weight. I’ve also seen parents use them to help their baby find a more predictable feeding schedule. With very little risk and the benefit of giving my accountant parents something to do…

Overall Rating: B+

4.Your smartphone camera

While you may not find this particularly groundbreaking, I have found it to be one of the best technologies for newborns. Whether it’s taking a picture to track head shape changes or birthmarks or if it’s for connecting with me for a live telemedicine visit that allows parents to stay home with their newborn, a lot of information can be gathered based on the quality of photos that can be taken.

Overall Rating: A

What are some other technologies you used during the newborn period? What other technology would you like to hear more about in the near future?

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

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

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

1)The Manipulator/Negotiator

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

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

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

2)The Screamer/Crier

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

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

3)The Creeper/Sneaker

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

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

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

About the author

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

Just in time for the holidays a reader wrote in with this question:

“My friend...was told by her grandson’s pediatrician that her grandchildren who are vaccinated should never be around any unvaccinated children. Well, the parents of her other grandchildren do not want to vaccinate their small children…As a result there are no more family gathering with all grandchildren. They have to spend holidays on separate days. My question is: Why would the pediatrician say this? If the children who are vaccinated and the children are not showing symptoms what’s the problem?”

This is definitely a sad and tricky situation and one that we should use extreme care when discussing.

One thing I will say is that no matter what one’s choice about vaccinating is, parents believe they are making the choice in the best interest of their child. Of course, I have strong opinions about how important it is, but this discussion is not for the faint of heart.

There are probably some doctors that would tell you it’s no big deal and you shouldn’t worry about it (I would disagree with them). There are other doctors that would say you should never have your child around children who are unvaccinated regardless of your child’s health (I recognize this is not reasonable in many situations).

Here are the questions to consider:

1. How old is the child? The younger the child, the more vulnerable they will be to infection. They cannot receive protection for chicken pox or measles before 1 year. Older children who are fully vaccinated have a significant amount of protection and they likely encounter an unvaccinated child at school every day.
2. Who isn’t vaccinated? This question is about family members which makes transmission of infectious diseases more likely than if you just walked by someone on the street and were not interacting with for longer periods of time.
3. Can you have an open conversation with those involved? The discussion is clearly more complicated than simple medical advice as it broaches on several tricky areas including family dynamics and vaccination.

The easy (get out of having to make a committed answer) is that there is no one answer to the question. The family should talk with their doctor about their specific concerns and make a decision with their counsel.

Should I stop the blog post there? Not so fast.

Instead, I want to give you a framework for having that discussion with your doctor.

What diseases should I be worried about?

I believe that all vaccines are important, period. But there are 3 diseases that jump to the top of my list when considering this issue:

1. Flu

Flu season is predictable in that it comes every single year at roughly the same time. It is unpredictable in that we never know how widespread it will be and how severe the cases will be when it does come around. Flu is particularly dangerous in babies and they cannot be vaccinated until they are 6 months old. Remember that the flu vaccine isn’t perfect, so I’m not saying that everything’s cool if we all have flu vaccines but it would seem logical to get as much protection surrounding the baby as possible.

2. Pertussis

Pertussis, or whooping cough, is still common and is a very serious disease for anyone who gets it. In children, teenagers and adults it tends to cause a very rough and painful cough that lasts for weeks to months. I know of adults who have had broken ribs because the coughing is so hard. The real danger for pertussis comes in small babies (less than 3-4 months). These babies commonly have spells of coughing that cause them to stop breathing; leading to ICU stays for intubation and unfortunately, death. Babies are vaccinated against pertussis at 2, 4 and 6 months which increases the number of children who are protected with each shot but they go on to get another vaccine at 4 and 11 years as well. So, when are they fully protected? It’s impossible to say. In addition, vaccines are not perfect so even vaccinated infants who are exposed could develop pertussis. Pertussis still occurs commonly in the United States and is generally carried by older children and adults who are coughing but do not know that they have pertussis. Just like flu, having the vaccine does not prevent disease 100% and I still feel that we need to do something better with the pertussis vaccine but again, it would seem logical to increase protection as much as possible.

3. Measles

Measles is another disease that still occurs in the United States. In 2014, there was a record number of 667 confirmed measles cases reported to the Center for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases (NCIRD). That’s the highest number of cases since measles elimination was documented in the U.S. in 2000. Measles can cause pneumonia and have a higher risk of hospitalization in children under 5. Children receive their first measles vaccine at 1 year of age, but they have no protection from measles until then.

What criteria should I use for being around others?

1. If your baby is under 6 months, use extreme caution. Many babies do not have full protection until after the 6 months shots. In addition, they cannot receive a flu vaccine until 6 months.
2. If your baby is under 1 year, I would also use caution. Your baby cannot be vaccinated against measles or chicken pox until 1 year.
3. After your child is vaccinated at 4 years, they have much of the protection that they need to protect themselves against the vaccine preventable diseases.
4. Babies or children who may not have a normal immune system-such as those with chronic illness or who were born premature deserve extra caution.
5. Anyone with symptoms of illness, especially fever, cough, congestion or rash, should not be around your baby or child regardless of your contacts’ vaccination status.

Can you get a definitive answer about when your baby can be around unvaccinated children? No, but you at least have some information to make an informed decision.

After you’ve discussed your plan with your pediatrician how do you handle the conversation with friends and family?

Here are some thoughts about some things you might say:

1. Our baby/child doesn’t have protection against many very dangerous diseases and we do not feel comfortable having her around people who could spread them to her.
2. Our baby/child has already been through so much, we can’t risk putting her through another medical problem. Especially something that we could have avoided.​
3. The doctor was emphatic that we cannot be out around anyone (especially someone who is not vaccinated or you could leave that out) until __________. (I’m fine with a family placing the “blame” completely on me.)

Sometimes I have to be reminded by Mrs. Smitty to put down the iPhone or the tablet and spend some family time. After all, this is the new era of fathers being more involved than ever before.

The  American Academy of Pediatrics (AAP) highlights the significant amount of research that has been done on the 'New Fatherhood' and the important role that dads play in their child’s development, mental health and many other areas of well-being.

And the benefit of fathers is not just restricted to the biological dad.

Fatherhood can be defined generally as “the male or males identified as most involved in caregiving and committed to the well-being of the child, regardless of living situation, marital status, or biological relation.” This means that biological, foster, adoptive, step-, grand- or any other father matters.

The report highlights the many benefits that fathers provide for their children throughout the child’s years of development.

Before Birth

Even before the baby is born, father’s help to set the foundation for their children’s health. If fathers are involved during pregnancy, moms are 1.5 times more likely to get early prenatal care. If mom smokes, they are more likely to stop smoking if dad is involved with the pregnancy.

Newborn and Infant Period

Supportive fathers play a huge role in the success of breastfeeding and a “competitive” father can undermine it. Fathers play with infants differently than mothers. Their play tends to be more “stimulating, vigorous and arousing.” These interactions may encourage more exploration and independence in children.

Early Childhood

Fathers speak to children differently than mothers. They tend to use words that are new which might stretch a child to learn new and different words. If dads are involved with their children during infancy, those kids are less likely to have mental health symptoms when they get older.

Adolescence

When a father is involved, adolescents are less likely to have depressive symptoms (both genders) and be less likely to be involved in risk-taking behaviors (especially in boys). Daughters benefit from father involvement by being less likely to have “early puberty, decreased early sexual experiences, and decreased teen pregnancy.”

Summary

While they may not always do things the same as mothers, the role of the father and the benefits they provide need to be acknowledged. Perpetuating old stereotypes about fatherhood undermines the importance in the development of their children. Highlighting the value of fatherhood should encourage fathers that their involvement matters in many ways.

That’s how I remembered this:

Blood, frogs, lice, flies, disease, boils, hail, locusts, darkness, death.

You might ask, why was I learning the order of the plagues? Obviously, for a bible quiz game we used to play in Sunday school. Because I’m ultra-competitive, even when it comes to Sunday school.

The recent weather in North Texas has many questioning if we are witnessing plagues or if the Apocalypse is upon us.

Fortunately, it looks like the worst of the drenching rain (and hopefully the flooding as well) are behind us. As the waters recede, the rising threat will be mosquitoes and mosquito borne illness.

What’s the big deal with standing water?

Standing water is the breeding ground for mosquitoes. There are four stages of life for mosquitoes. The adult flying stage is the only one that does not rely upon water for survival. The eggs, larva and pupal stages must live in standing water.

Any standing water - water in a bird bath, pond or standing water from improper drainage can be a place for mosquitoes to breed.

Why do mosquitoes bite?

Female mosquitoes bite because they need a source of protein before they can produce eggs. Otherwise, like males, they can feed on nectar or sap.

When females bite, their long mouthpart breaks through the skin and gets into the small blood vessels just underneath. They also inject a small amount of saliva into the wound to make entry easier and to keep the blood from clotting.

What harm do bites cause our children?

Local reaction - While not technically an allergy, some kids will have a large local reaction with swelling and redness at the site of mosquito bites. These can be itchy and cause distraction in school or lack of sleep when severe.

Local infection – It’s not uncommon to see local infection in kids who have scratched mosquito bites, leaving a gap in skin, which can lead to infection. If the swelling worsens after the first few days or if there is significant warmth from the site of the bites, you should see your pediatrician to see if antibiotics are necessary.

General infection - Because mosquitoes can carry diseases, bites from mosquitoes can transmit infection that can affect the entire body. Mosquito borne illnesses cause over one million deaths world wide, most commonly from malaria. Two other diseases that we have seen in Texas associated with mosquitos are West Nile Virus and Chikungunya.

Given the amount of rain and the season, mosquitoes will be inevitable this summer season. Read more here about the many different ways you can reduce your child’s risk of discomfort and serious illness: How to fight (and) win against mosquitoes.

Leaving it on the list would have drawn the ire of the overwhelming majority of the scientific community who believe that vaccines are safe and one of the most effective medical ideas ever. If he decided to pull it, he faced the backlash of a loud, but passionate few who sympathize with Andrew Wakefield and his ideas regarding vaccines and autism.

De Niro pulled the film from its single screening at Tribeca.

It went on to be shown in limited screenings, starting in New York. The turnout wasn’t great and the discussion about the film faded almost as fast as it started.

I thought it was over. I was wrong.

Autism is an issue that breeds passionate responses. Robert De Niro, who has a child with autism, is clearly personally affected by them. Many others are personally affected and passionate. Reporting a study that shows no link between autism and vaccines is difficult to do with passion. Science and truth are not always emotionally compelling but passion and emotions do not prove anything.

This morning, on the Today show, De Niro was asked about his decision to pull the movie. He had a lot of things to say … below are some quotes I pulled from De Niro and my response:

“I think the move is something that people should see … there’s something to that movie.”

If a movie came out that said cigarettes are safe and don’t cause cancer, in fact they are good for you, would we insist that everyone should see it? No, and those who did would only do so to see the absurdity of the claims. I will see the movie when I can and I’ll have a better feel for the content. But the bottom line is, Wakefield has worn his credibility thin over the years and doesn’t deserve the benefit of the doubt. His study has been discredited due to his falsifying evidence and unethical means of collecting data.

“To shut it down, there’s no reason to. If you’re scientists, let’s see. Let’s hear. Everybody doesn’t seem to want to hear much about it. It’s shut down. You guys are the ones who should be doing the investigating. Do the investigating.”

“There is a link. The obvious one is thimerosal which is mercury-based preservative. I don’t know, I’m not a scientist but I know because I’ve seen so much reaction about it. Let’s just find out the truth.”

Scientists want truth also. Scientists have done the research. Scientists continue to do research.

Multiple studies looking at vaccines have shown that they are safe. Continuing to research these same topics steals time and resources of our most intelligent scientists who might actually get to more answers about autism. We desperately need help in our understanding of the real cause, how to get an early diagnosis and best treatments for autism. We don’t need another study that disproves the link between MMR and autism.

“There’s something there that people aren’t addressing. And for me to get so upset, here today, here on the Today Show with you guys means that there’s something there.”

Finally, “I am not anti-vaccine. I want safe vaccines.”

I can partially agree with this statement. I am not anti-vaccine either. The difference is that I believe we have already found safe ones.

A new study in Nature Medicine started the process of trying to answer this exact question

You might be thinking, “What the?” But there is some logic to this:

1. Babies born via C-section have been shown to have slightly higher risk of some diseases (obesity, allergies and asthma for example).
2. We are beginning to understand how the makeup of bacteria in our intestines affects many different diseases.
3. Babies born via C-section are not exposed to the normal bacteria that line the birth canal

The question then would need to be asked: Can you reverse this process by exposing babies to the vaginal flora after they were born via C-section? This small pilot study of four babies seems to suggest that you can.

The process: Within in the first two minutes after birth, take a piece of gauze, which has been placed in the vagina. Swab the babies mouth, forehead and the rest of their body. Test these babies to see what bacteria are present in their bodies.

The answer: Those C-section babies who were swabbed with vaginal secretion showed that the bacteria they carried more closely resembled babies who were delivered vaginally.

This was a small study, which needs to be repeated on a larger scale and there are still many questions to answered:

• Does changing the bacteria that a baby carries actually help to prevent diseases?
• How do we make sure this procedure is safe? How do we screen moms to make sure there is no added risk to the baby?
• What is the best means of transferring the bacteria? Is there a better way that what was done in this study?

The role that the bacteria we carry play in our health is gaining interest. I’m sure that we will continue to see studies like this and many others in this area. Stay tuned.

While that was an easy question to answer, I do get more difficult questions about young children with hyperactivity.

In order to start this conversation, it is important to remember the core ADHD symptoms: inattention, impulsivity and hyperactivity.

Based on appropriate diagnostic criteria, you cannot diagnose ADHD until age 4. It is also difficult to diagnose children until they are in school because the diagnosis requires that symptoms be present in more than one environment.

As with any type of behavioral problem, the degrees of severity present a wide spectrum of the various symptoms of ADHD.

Inattention-Some children can focus for hours at a time but some jump from one activity to the next very quickly, seeming to never really focus on one thing for a significant amount of time.

Impulsivity-Some children are very cautious and don’t do anything dangerous, while others jump from my exam table across the room to the chairs on the other side.

Hyperactivity-Some children can sit still for long periods of time, while others are constantly fidgeting and restless.

So, how does this look in a 3-4 year old child?

All 3 and 4 year olds show signs of inattention. There are a select few children in this age group who can maintain focus for extended periods of time. Because of this, it’s hard to get too excited about concerns about a 3 year old’s attention span.

I have definitely seen varying levels of impulsivity in this age group. Those that are highly impulsive, in my experience, often go on to meet criteria for ADHD as they get older. Remember, however, that talking back and aggression are not necessarily impulsivity.

The most common symptom that parents interpret as ADHD is hyperactivity. There is definitely a difference between the general restlessness of a typical 3 year old and a child that truly becomes ADHD in the future.

Children at this age are often described by parents who report, “Their motor is just always running” or “They just go non-stop from the moment they wake up.” Because I see so many children of this age group every day, I also have some subjective sense of what is normal or abnormal for the age group and this can help my assessment over time. However, I never make snap judgments because any child can act like they have ADHD on a particular day.

So, what if you are concerned that your young child may be showing some signs of hyperactivity? A great place to start is here: ADHD Behavioral Treatment-8 Tips.

Here are some basic things to remember:

1. Try to stay patient.

Because so many of these young children will outgrow these symptoms, it is important to stay patient with them.

2. Try to stay calm.

Anxiety only makes hyperactivity worse. Yelling at a kid to sit down and shut up will most likely just make your problems worse.

3. Try to stay consistent.

Children with hyperactivity do their best with structure and clearly defined boundaries. If these children don’t know what to expect from minute to minute, they cannot adjust as easily as most kids. If they are not disciplined consistently, they do not know where the boundaries lie. With any behavior problem, I ask my families to pick out what 1 or maybe 2 behaviors that they want to extinguish and be consistent in the their punishment for those. It is not feasible to fix all of your child’s problems at once.

Also remember to praise them when they do the proper behavior. If a child is only getting negative reinforcement, they will often choose that over positive reinforcement.

I have to start with an apology.

It’s not that I didn’t care, or wasn’t concerned.

I asked about feedings and dirty diapers. I asked about sleep positioning. I asked about your plans for vaccination. I educated on how to take a temperature and what a fever is, whom you should call when you are concerned.

I know a lot about your baby from our little time together.

But, I often forgot to ask about you.

Sometimes, if you looked particularly tearful, concerned … I don’t know, maybe distraught, I asked how you were doing. You might have said “fine” and I probably left it that.

Recent news reports reminded me that I should be doing better.

Depression affects about 30 percent of women between 18 and 44 years of age. I don’t want to get bogged down with more stats, but about 15 percent of women in their reproductive years take antidepressants. Most experts agree that untreated depression carries much more risk to babies than medications for depression. Studies have shown mixed results with most indicating that they are safe and others indicating a slight increase in risk for birth defects.

A special US Preventative Service Task Force report stated that all adults should be screened for depression but placed particular emphasis on the importance of screening pregnant and new moms. They conclude that screening should be implemented “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”

If new moms should be screened for depression, who is going to do it if I don’t? Many don’t go back to their obstetricians until six weeks. What doctor are they seeing in the mean time? Who is going to screen them for postpartum depression? It has to be me.

Many pediatricians do this very well. They have built a system in place and screening has been part of their process for years.

Those of us who didn’t have many reasons…

Other priorities took over.

Checkup times are too short.

We’re not sure what we would do when we identified someone with postpartum depression.

But none of those are good excuses.

Because of this, I promise to work to develop a system that works.

I have to.

For you and for your baby.

I will report back with more soon.

Sincerely,

PS. Symptoms of postpartum depression can include:

• Increased irritability
• Loss of patience
• Quick mood changes
• Excessive energy or extreme fatigue
• A sense of feeling hopeless or overwhelmed

If you are someone you know is suffering from these symptoms, please ask for help from someone. Start with a friend or a doctor but do not suffer in silence. There are resources available.

Currently, I am the lone survivor of the war on Smith-Summertime-Flu-Like-Illness-2015.

You name the symptom and someone in my family has had it: fever, cough, runny nose, congestion, headache, sore throat, vomiting ... I could go on.

All of these symptoms are annoying. Running to grab the “puke bowl” when your 4 year old is “frowing up” is not my idea of a fun nor peaceful Wednesday evening. Trying to discern if his “headache” is really a headache, or fever or the early stages of some terrible bout with meningitis is not good for this pediatrician’s soul (nor his wife’s after she read this. It’s not meningitis, babe, I promise).

But the most annoying of all these symptoms for me is cough. When I have a cough, I generally try my best to keep it in for as long as I can, and let it go just before I feel like I’m going to drown in post-nasal drip. When my 6 year old has a cough, I’m pretty sure he feels like it is his duty to release that cough every five seconds. I think he does this just to remind me that he’s not feeling well and I haven’t given him anything to help.

Why don’t I give my kids cough medicines?

I don’t give cough medicine to my kids because they don’t work.

They really don’t.

Really.

The hard thing about this fact is that they were a staple of pediatric care for decades. Cough and cold medicines were first approved for use in children in 1976. There were no studies done to determine if they worked or what the appropriate dosing should be. I think the process back then went something like this:

“Why not give half the adult dose for children 5-12 and a quarter for the adult dose for children age 2-5?”

“Sounds good to me, let’s do this.” (Or maybe “Right on!” or “Groovy!” I don’t know, it was the 1970s.)

Since 1976 there have been several studies looking at the use of cough and cold medicines. The most recent review of the 25 best studies done stated this as a conclusion: “There is no good evidence for or against the effectiveness of OTC (over the counter) medicines for acute cough.”

I don’t give cough medicine to my kids because they can cause problems.

Side effects, even serious, even fatal ones, can occur as a result of giving kids (especially those under 6) cough medicines.

If you want to read some scary stories read these case reports from Pediatrics:

1. 3 year old ends up in ICU after becoming lethargic, having a slow heart rate, fast breathing and high blood pressure. Diagnosed with toxicity from Dimetapp (in this one we don’t know how much mom gave-could have been too much).

2. 3 year old being treated for pneumonia develops a fast heart rate, so fast that it start to interfere with the heart’s ability to work right. Parents were thinking they were giving Tylenol but ends up they were giving Tylenol Cold (acetaminophen, chlorpheniramine and dextromethorphan).

3. 9 month old boy is discharged from the ER with a diagnosis of pneumonia, doing well. Returns 12 hours later after being found cold, blue and not breathing. Unfortunately he dies after he is unable to be resuscitated. Toxicology on autopsy finds acetaminophen, pseudoephedrine, chlorpheniramine and dextromethorphan in the blood and heart tissue.

It is estimated that about 7.000 children are treated nationwide for toxicity related to cough and cold medicines and 64 percent of those are children under 6 years of age.

Everything in medicine is about weighing whether something works and if it could be harmful.

Cough medicines do not work and could cause harm, so my kids will pass.

P.S.

So will my patients because I don’t prescribe them either.

New research published this week in the Journal of Clinical Psychiatry may challenge that stereotype or at least require us to broaden what we think ADHD “looks like.”

The research looked at the overall rate of ADHD comparing surveys of parents completed in 2003 and 2011. It might not surprise you to learn that the overall diagnosis of ADHD increased during that time. But you may not have heard that increases were found across all racial/ethnic groups, with the largest increase in Hispanics (83 percent). Perhaps another surprise was the fact that the increase in girls was greater than the increase in boys (55 vs. 40 percent).

Symptoms of ADHD can include difficulty paying attention, hyperactivity and impulsivity. Diagnosis is based upon a conversation you can have with your pediatrician or a psychologist and usually involves a screening questionnaire to be completed by a parent and teacher. Treatment starts with behavioral and parenting strategies to help children cope with symptoms but can require medication when these are not successful.

The study showing this increasing number of children diagnosed with ADHD certainly grabbed my attention. As someone who generally does not like medication for kids, I worry that this means the number of children on medications for ADHD is also increasing. As with all medications (and more than most), treatments for ADHD do not come without risk.

I do have some theories as to why the number of children diagnosed is increasing:

Theory No. 1 - Parents and teachers are more aware of the signs of ADHD.

Many hyperactive and impulsive children were previously labeled as trouble-makers and ended up spending lots of time in detention and in school suspension. Many inattentive children slowly started to have more trouble as classes got harder and parents and teachers eventually gave up on them as someone who just “wasn’t made for school.” Now we are realizing that those hyperactive/impulsive kids can’t simply “just sit still” and that those kids who were previously doing well shouldn’t be failing just because they can’t listen to lectures or get their paperwork turned in on time.

This particularly accounts for the increased rates of diagnosis in children of Hispanic and African-American descent. Previously, the stigma associated with all mental health conditions (including ADHD) prevented parents from seeking help. Also, because many girls are inattentive, rather than hyperactive and always in trouble, they could also go undiagnosed.

Theory No. 2 - Physicians are increasingly giving in to parent demand to “fix” their child.

This is by far my least favorite, but I just believe it is something we should at least consider. In a world where the expectation is that a pill can cure just about anything right now, parents increasingly want something today that will resolve their child’s behavior problems. Long term treatment plans that involve behavioral techniques and maybe even counseling aren’t as popular for all parents. However, we should fight against this as the diagnosis of ADHD and decision to start treatment should not be based on demand from a parent.

Theory No. 3 – The expectations and demands on children are changing.

Children are learning to read and do more intense math earlier and earlier. Homework was virtually non-existent when I was growing up until second or third grade. This is not necessarily the schools or teachers fault so don’t call up and gripe at your child’s teacher. Many of the requirements for what they teach and when they teach it come from above them. The simple fact is that, in trying to keep up with the success of other countries, we have decided to accelerate curriculum and to challenge students. It’s not always a bad thing, but it can be if you have a hard time sitting still for long periods or can’t keep yourself organized.

Theory No. 4 - New medications with less side effects have made parents more likely to seek treatment.

No one wants to see their child “turn into a zombie.” It’s still the number one concern I hear when starting treatment for ADHD. Fortunately, with newer medications, the side effects are much less severe and much less common. Loss of appetite and difficulty falling asleep are now the most common side effects I see, even those are not that frequent.

Keep in mind, each of these things are theories based on my experience. We will need to continue investigating why we are seeing this increase in the rate of ADHD. We all need to be observing our children for signs and symptoms, particularly if they are struggling with school but parents and teachers need to be careful not to attribute all school struggles to ADHD.

For more information, read: 

It could be that amoxicillin prescription that your child took last week.

Antibiotics have been one of the greatest advances in medicine. People used to die frequently from diseases that we now view as simple because antibiotics are readily available. However, the ease of use of antibiotics, combined with what seems to be a low risk associated with them has created a huge and growing problem.

I believe that the biggest reasons why antibiotics are overprescribed deal with several myths surrounding antibiotic use:

Myth No. 1: Parents always want antibiotics.

This myth is one that physicians frequently believe. You would like to think that it doesn’t influence their behavior but it does. A study from 1999 showed that physicians prescribed antibiotics for viral infections 62 percent of the time when they believed that parents wanted them and only 7 percent of the time when they didn’t. Hopefully we’ve gotten better and this gap is closing but still, WOW. The interesting thing about this study is that the physicians often thought that parents wanted antibiotics when, in fact, they did not.

So, this one falls on us. We need to ask more questions about what parents goals are and we need to educate rather than prescribe when antibiotics are not what is best.

Parents if you want to help your doctor understand when you would prefer not to use antibiotics, read this post: Does my child really need an antibiotic?

Myth No. 2: All infections will get better with antibiotics.

Some infections in kids require antibiotics for improvement. Strep throat, urinary tract infections and skin infections will need antibiotics to treat and prevent worsening of the symptoms.

Ear infections don’t always need antibiotics. In older children with less severe disease, a period of waiting can allow the infection to go away without treatment.

Many infections in children are caused by viruses. Flu, colds, sore throats that aren’t strep and many other infections in children simply need a little time and TLC. Mary Suzanne Whitworth, M.D., medical director of Cook Children’s Infectious Diseases adds, “Most viral upper respiratory tract infections start with clear runny nose, maybe fever, and maybe a cough. After a few days the nose drainage is green and then after a few more days it goes away on its own. Antibiotics are not needed for these viral illnesses. The child might have bacterial sinusitis and need antibiotics if the green runny nose lasts for over 7 to 10 or if symptoms worsen after a few days.”

Myth No. 3: There’s no harm in giving antibiotics.

While you might not have ever seen side effects or dangerous reactions to antibiotics, I see them almost every day. Children can have severe, even life threatening, allergic reactions (even if they have taken that antibiotic before and been fine). Because these are rare, they are not a reason to avoid antibiotics when necessary but they are a reason to use caution when antibiotics are not the right treatment in the first place.

Antibiotics can also cause other side effects, most commonly diarrhea. This diarrhea can last weeks and can be quite severe. If the diarrhea is severe (especially if blood or mucous is present) your doctor might have to consider testing for C. difficile which is a potentially serious infection that can be the result of antibiotic use.

Finally, we are beginning to see an increase in the number of infections caused by bacteria that do not respond to the antibiotics we have traditionally used for them. This requires us to use stronger antibiotics which can often cause more side effects. You can see why people are concerned if we continue along the same path but fast-forward 25 or 50 years. What types of bacteria would emerge? This is why we must use extreme caution.

Dr. Whitworth adds, “Antibiotics are important and often life-saving. But each time they are used there needs to be a conscious decision made about exactly why they are indicated, what the best choice is for patient compliance, and what the risks and benefits are. They should not be used just because they are expected or requested.”

Parents and doctors all play a role in decreasing the unnecessary use of antibiotics. Open conversation about the child’s condition, the parents’ expectations and the possible risks and benefits of antibiotics treatment are all important parts of each decision regarding antibiotics.

I hear statements like these:

1. “She must’ve been about 103 because she felt really hot.”

Touching a child to determine if you should check their temperature is valid, but skin temperature can vary based on what the child has been doing. If they feel hot after playing hard, being outside or waking up, give them a few minutes to cool off because you get too concerned.

2. “He had a 99 which is a fever for her because he usually runs around 97.”

Everyone’s temperature varies throughout the day, but we have to have a real cut-off for fever. You’ll see definitions vary but that cut off for me is 100.5 in children less than 3 months and 101.5 in children older than 3 months. (Remember that any child under 3 months that has a fever warrants a call in to your doctor right away.)

3. “He had a low-grade fever of 100.”

See above…it’s either fever or it’s not.

4. “I was worried because I know that fevers above 104 can cause brain damage.”

Temperatures that the body is generated because a child is sick are internally driven. The fever will stop rising at some point. Children are at risk for complications if their temperature rises because they are in a hot car or other external factors, but not because they are sick.”

5. “I knew something must be seriously wrong because his fever was so high.”

I think of fever like an on/off switch. A child has fever or they don’t. If they have a fever I need to look for the source, but the height of the fever does not indicate that something more dangerous is going on.

6. “I didn’t give him any medicine, because I wanted you to see how high the fever is.”

Nooooo ... If your child has fever and is uncomfortable, don’t leave them miserable until you come in to see me. I trust you if you say your child has a fever. If you’re worried I won’t trust you, take a picture of the thermometer.

7. “He was doing fine, then he had a fever of 102 and when I woke him up to give him some medicine, I couldn’t get him back to sleep.”

Another nooooooo ... never wake a sleeping baby to treat their fever. Never interrupt a playing baby to treat their fever. Treat fever based on the child’s comfort or to help them drink if they won’t. Otherwise, it’s fine to let the child have a fever.

I know it’s hard when your child is running fever. You feel worried and helpless.

Hopefully, dispelling some of these myths will help you treat your child with confidence.

* Read Dr. Smith's previous blog: "My child has a fever."

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

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

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

Do amber teething necklaces work? If so, how?

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

They tend to center around three main concepts:

• Magnetism, energy or natural flow of energy

• Thyroid gland stimulation to control drooling

• Succinic acid released causing anti-inflammatory and pain relieving

Magnetism, energy or natural flow of energy

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

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

Thyroid gland stimulation to control drooling (or other symptoms)

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

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

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

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

Succinic acid release causing anti-inflammatory and pain relieving

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

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

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

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

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

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

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

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

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

Me: So, how do you know this works?

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

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

Is it a choking hazard?

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

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

So, why do amber teething necklaces “work?”

It’s really based on three points…

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

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

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

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

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

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

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

Along with this goal of each child’s attendance, we have to balance the goal of keeping others safe from infectious diseases. Our contagious students need to stay home when they are sick to keep the rest of their classmates safe. (This is why I don’t really care for perfect attendance bike raffles. I prefer responsible attendance.)

Balancing these tensions is often hard for the parent, the school and the pediatrician because we often don’t know exactly when a child is no longer contagious. This is why I got so geeky excited last week to see a new study released in the Pediatric Infectious Disease Journal about the contagiousness of strep throat.

The study looked at 111 children with strep throat over two days.

Day 1: Children who tested positive for strep were given their first dose of amoxicillin before 5 p.m. (They also had cultures taken which allow to see if bacteria will grow from a swab of their throats.)

Day 2: Children were retested and cultured for strep in the morning to determine if they still carried the bacteria in their throats.

Here is what they found:

• 101 children tested negative for strep on the morning of day 2.
• 7 children had significantly decreased growth of bacteria from their throat cultures.
• 2 children continued to have high loads of bacteria.

The author’s conclusion: “all children treated with amoxicillin for streptococcal pharyngitis (strep throat) by 5 p.m. can, if afebrile (fever free) and improved, may be permitted to return to attend school on day 2.”

I’m pretty sure you’re not as excited as I am, but THIS IS HUGE!

Based on current guidelines, children must be treated for 24 hours before being allowed to return to school. If we treated according to the results of this study, it would allow for the child to be back in school and for the parent to be back at work a whole day earlier.

I feel like there is a lot of work to be done in this area and this type of study, along with other models of health care delivery, are good examples of the work that will be necessary.

Because I value education and our school districts so much, I want to be constantly thinking about ways we can do this better. As a general pediatrician, I can really boil down the goals of my job to these:

1.Keep kids growing and healthy.

2.Keep kids developing and learning.

Early in your baby’s life, this looks like frequent checkups for preventing illness, monitoring growth (and talking about diet) and teaching ways that parents can help their child with development. (Read: Everyone should homeschool.)

As your child gets older and starts school, my role changes a little bit. I don’t ask my elementary age patients about fractions or my high school students about “The Great Gatsby.” Instead, I might ask, “How is school going?” “Any problems I need to know about?” “Any way I can help?”

On a practical level, this means offering school aged children after school appointments when possible. It means getting sick kids in the same day so that we can start treatment and get them back in their desks as soon as possible.

In the future, this may mean totally different modes of delivering health care and working with the school and school nurses in order to decrease missed class time.

But I’m getting ahead of my geeky self again. I’ll save that discussion for later.

Asthma is a big problem across the country with about 25 percent of children age 9 diagnosed. Children ages 6-9 are three times more likely to have asthma than others in the state of Texas.

Fortunately, most of those cases are mild and require only rare treatments with albuterol inhalers. However, some of those cases can be severe and can result in significant issues for families.

The social complications of asthma are costly:

1. Missed school for doctor visits, emergency room and hospital stays.
2. Missed work for families.
3. Decreased activity level resulting in other poor health outcomes.

There are times where these complications might be unavoidable. But these should be very, very rare cases.

I don’t believe that any general pediatrician should use physical activity restriction as a means to manage a child’s asthma.

Why? Most cases of asthma can be managed by the pediatrician and involve the following treatments:

Avoid Triggers

Allergies - If the child has allergies, make sure that he or she is on adequate treatment using a step approach to include antihistamines up to nasal steroid sprays.

Viral infections -Train your children to wash their hands frequently especially during winter months. Get your child a flu shot every year.

Stop smoking - If you are smoking, you do not get to tell your child that they cannot participate in sports. It’s hard to quit smoking, but it’s harder to be a child who wants to do an activity but can’t because their parent’s smoking makes their asthma too severe.

Develop a Treatment Plan

Treatment plans for asthma are called “asthma action plans.” Children with have asthma need one.

Treatment for asthma generally starts with albuterol on an as needed basis. This might be the case in a child who has rare symptoms or who only wheezes once or twice a year when they get a bad cold.

Treatment for asthma should include some type of daily medication for control if either of the following is present:

• Symptoms more than twice a week or a limitation in activities due to asthma
• Symptoms at night more than twice a month (waking up coughing or with difficulty breathing).

Refer to a pulmonologist

If you and your general pediatrician cannot seem to get a handle on your child’s asthma, request a referral to a pulmonologist or allergist before telling your child that he or she cannot participate in physical activity.

Here are a few guidelines based on current asthma severity that might help when you are managing asthma and physical activity:

• Children with well-controlled asthma who are symptom free should not be restricted in any way. They don’t get to run less or skip out if they are feeling well.

• Children who are having mild symptoms (cough from an upper respiratory infection) may need to be modified but sometimes do not need to be completely sedentary. (They can walk around the gym if everyone else is running.)

• Children with moderate to severe symptoms should be receiving medical care by the school nurse or their pediatrician. Asthma can be serious, even deadly so don’t wait to call if you are concerned.

Children with asthma can and should participate in physical activity. I do not believe that they should be restricted based on the recommendation of a general pediatrician alone.

Everything should be done to allow them to play first: avoiding triggers, treating aggressively, even to seeing a pulmonologist.

For more information about what is being done in our area to help prevent and treat asthma, check out the report from The Center for Children’s Health’s Asthma Think Tank-Childhood Asthma: A Guide to Action.

Advocating for breastfeeding is a big part of a pediatrician’s job in the first few months of life. We state the benefits of breastfeeding. We encourage families who are struggling and provide help with troubleshooting issues. We point them towards lactation consultants and other resources that can help when things are not going well.

But, is there a point where “breast is not best?”

Does all the conversation about breastfeeding pressure moms to seek out breast milk from other sources when they choose not to breastfeed or when breastfeeding does not work for them?

The answer is: Yes.

Breast milk donation can be used to provide much needed breast milk to premature babies. Many of these babies would otherwise not receive breast milk. This provides an amazing service to a vulnerable population. I strongly encourage moms who are interested and have extra breast milk to look into donating their milk to one of these organizations.

There are other means of exchanging breast milk that I am not as excited about. Families can buy and sell breast milk online via websites that link buyers and sellers (often called “communities” or “societies”).

But, is this method of obtaining breast milk safe?

A recent study showed that out of 102 samples of breast milk bought online, 10 of those samples contained more than 10 percent cow’s milk. This shows that at least some sellers are mixing cow’s milk with their breast milk, most likely to increase volume and income from their breast milk sale.

Why is this dangerous?

It is dangerous because previous studies have shown that 20 percent of online breast milk buyers are buying milk because of a medical condition in their child - many of those are listed as formula intolerance. Introduction of cow’s milk into the breast milk increases the odds that these children could have a reaction or problem with the purchased milk especially if they have a true allergy to cow’s milk.

While this risk is not insignificant, I feel the danger is much greater. I believe that the real danger lies more in the motivation of the sellers. If they are willing to actively deceive buyers by adding cow’s milk, what else are they willing to lie about in order to find a buyer for their milk? Anyone ever thought of why we do not pay blood donors or allow for payment for organ donation? The motivations matter.

Here are some other potential issues with breast milk sold online that you should be aware of:

1. Storage and bacterial contamination

Safe storage of breast milk is not as simple as just throwing it into the freezer. Transportation of sold milk also creates another potential source for unsafe storage. The same group of researchers showed in a previous study that 74 percent of the milk they bought online contained enough bacteria to question their safety for infants.

2. Medications/drugs/alcohol

Many of the sellers’ listings make a point to say that the milk is free of substances or that the donor did not engage in risky behavior. In fact, sellers who made such claims (in addition to claims for clean handling and infectious disease screening) were 6 times more likely to sell their milk than those who did not make those claims. Does this encourage honesty?

3. Infectious diseases

You would hope that donors would be honest about their infectious disease history because many diseases can be transmitted via breast milk. Also, there are some transmitted diseases that the donor may not be aware of at the time they pumped the milk.

Of course, I advocate for breastfeeding for moms who can. But, let’s be real. Formulas have come a long way since the days where it was practically evaporated milk. So, let’s be realistic about the lengths we will go to in order to provide our child breast milk.

How do you know when it is something else or when it could be more dangerous?

A report last week from the CDC described a cluster of infections caused by shigella, a bacteria that can cause severe diarrhea.

Shigella is common, causing an estimated 500,000 cases of diarrhea in the United States annually. But this group of infections is unique because it has been found to be resistant to the most common type of antibiotic used in adults used for shigella. Most cases have been located on the East and West coast and many have been associated with travel outside the United States.

Fortunately, there were no cases of this more severe form of shigella reported in Texas so I feel that we are pretty low risk at this point. I did want to take a second to tell you about warning signs that might alert you that diarrhea might be more than a stomach bug.

Here are some symptoms that might alert you that should trigger a call to your doctor:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that last more than one week.
6. Let your doctor know if your child has traveled recently.

What are Salmonella and Shigella?

Two of the most common bacterial causes of infection are salmonella and shigella. They are both fairly frequent causes of severe diarrhea in children.

They can both be transmitted by contaminated food or water but can also be spread from person to person. Salmonella is more frequently caused by transmission from contaminated food, but also can be contracted from infected reptiles. Shigella is more frequently acquired from other children and is much more contagious than salmonella.

(Just to give you an idea, stool of a child infected with shigella contains 100,000,000 bacteria per gram of stool. Ingesting just 200 bacterial cells is enough to cause infection. Because of this, outbreaks of Shigella are common in child-care settings.)

The most common symptoms with both infections are diarrhea, abdominal pain and fever. With shigella, fever is often higher and children are more likely to have blood or mucous in their stools.

For either infection, your doctor can run stool studies to confirm the diagnosis. This may not be necessary if there are known cases that the child has been exposed to.

Both infections will typically go away on their own in seven days or less. Most healthy children do not require antibiotics. I do not routinely recommend anti-diarrheal medications in children because they can prolong symptoms with some infections.

If you suspect your child has one of these infections, consult with your doctor and keep them out of day care until we are sure they will not put other children are risk.

ADHD stands for attention deficit hyperactivity disorder.

There are three core symptoms of ADHD:

1. Inattention

2. Impulsivity

3. Hyperactivity

Inattention

Inattention can present itself in many ways. Some of the most common complaints that I hear about are daydreaming, forgetting assignments and inability to complete a short list of chores at home.

Often children who mostly have inattention do not become recognized until they are older because they are not the ones causing all kinds of problems in the kindergarten classroom. They will skirt by making OK grades and not getting in trouble until they get a little older and the requirements to sit still and complete assignments on their own increase.

Impulsivity

Do you know that split second where you think about telling someone off but you stop yourself? Or you think about driving 100 mph because you’re running late but don’t because you realize it will be dangerous? That split second is another thing that children with ADHD are lacking. They push right through that pause and act before thinking about the consequences of their action.

The best summary for this problem is that they lack the ability to determine if the upcoming action is: safe or appropriate for time and place.

Hyperactivity

The hyperactive symptoms are the ones that most people (even strangers) will notice about children with ADHD. They are not even necessarily bad kids, it’s simply that they have a significant struggle with staying seated, staying still when seated and not talking out of turn. These symptoms are usually noticed by 4 years of age and progressively worsen until about 7 years.

Learn more about hyperactivity and ADHD here.

ADHD subtypes

There are three major types of ADHD and they are characterized by which of the core symptoms your child demonstrates: mostly inattentive, mostly hyperactive-impulsive and combined.

Diagnosis

The diagnosis of ADHD can be made by multiple practitioners: pediatricians, psychologist, psychiatrists and some counselors are trained to diagnose ADHD. I prefer to make my own diagnosis in my clinic unless the case is particularly challenging or there is something complex about the presentation.

There are many different modalities that can be used to diagnose ADHD but it is mostly made by parental history, teacher’s reports and screening scales. I prefer to use the Vanderbilt scale but there are many other scales out there that can be used.

Diagnostic criteria

Diagnostic criteria for ADHD start at age 4 so younger children are generally not diagnosed with ADHD. This is due in part to the complexity of trying to decide what is normal and what is hyperactive or inattentive for a child younger than 3.

The following criteria are used:

1. Be present in more than one environment (home and school) - this is important because children who have issues only at home or only at school are usually having more of a problem with the structure at one place than actually having a tendency towards ADHD

2.  Be present for more than 6 months

3. Be present before age 7 - this is becoming more of a problem as adolescents and adults are becoming more aware of the problem but demonstrating that there were symptoms prior to age 7 can be difficult

4. The symptoms must impair function-see below

5.  Be excessive for the developmental level of the child - An active 2 year old is not hyperactive but normal.

Does it impair function?

My main point when I am discussing a child’s ADHD with the family is focused upon this aspect of the diagnosis and treatment. For most children, impairment of function means that they are not progressing through school appropriately, are in trouble at school regularly for hyperactive or impulsive behaviors or have difficulty performing regular function at the house because of their ADHD.

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer

If you want to start, visit Cook Children's guide to choosing a pediatrician. Then, go check out your doctor on healthgrades.com or vitals.com or any of the other rating sites you can find. What you’ll likely find is a sampling of a small handful of raters. These sites are a sample size and can be heavily skewed by one great (if you like your pediatrician, let people know) or one terrible one. 

So, where else can you go for advice?

Friends

Ask your friends who have kids what doctors they use. This especially works well if you have friends that are similar in belief systems, medical philosophy and personality. If they like their doctor and you’re similar to them, chances are you’ll like them too. Good old fashioned word of mouth (it’s actually more commonly via Facebook or what I like to call “word of mouse") is still probably the best way to learn about the doctors in your area.

Practice websites

Practice websites are helpful in determining the practical aspects of the practice you are considering. Look at office hours and availability of care after hours via phone, etc. If having a doctor that is up to date with latest medical knowledge and technology is important to you, make sure that their website looks professional and is updated. This is also a place where you can find a little bit about the doctor’s personality (from their bio) and see their picture but these often become pretty predictable. Everyone likes to spend time with their family and has a few particular interests in pediatrics like obesity or development. They also went to medical school and residency somewhere (in case you were wondering).

Ranking websites

There are several of these out there. Some of the most popular ones are healthgrades.com and vitals.com. I like vitals.com because it allows people to leave narrative comments and not just rate with stars. Some of those comments can really give some insight into what the doctor is like. These website are not without fault-because the number of reviewers is often small, they can be skewed heavily by someone who has a negative experience (this is a good reason to go over and rate your doctor that you like).

So, how do you know if your doctor is the best?

The right question is this: How do you know if your doctor is the best for you?

I think this comes down to two basic questions:

1. Can you ask your doctor any questions without fear of judgment or feeling silly?

2. Do you trust the doctor’s answers to your questions?

If you can answer a resound YES to both of these questions, then you are in the right place. If not, you should probably be looking elsewhere.

a) Nails on a chalk board.

b) 6 a.m. alarm clocks.

c) Your child’s teeth grinding.

Sorry that there’s no “all of the above.”

Around 25 percent of kids grind their teeth at some point. It most often occurs at night but can occur during the day (usually they are not conscious that they are doing it.) The most common ages are from 7-10 years and most grow out of it without any problems arising.

We don’t really know the cause of teeth grinding although it has been linked to stress and one study showed it to be more common in kids who talk in their sleep or wet the bed.

Most children do not have complications related to grinding their teeth. Some complications that have been reported are: jaw pain, headaches (more common in adults) and damage to teeth.

Treatment for teeth grinding can be very frustrating as there are no quick fixes. Since stress can be a related factor, try to have open dialogue with your children about factors that could be causing them stress. Mouth guards are not frequently used in children because they are not likely to help and making one to fit is difficult because children grow so quickly.

If the teeth grinding continues, talk with your pediatrician or dentist to see if there are new treatments available.

We have been trained to assume that chest pain is caused by the heart and an emergency, which is right in adults. But, one of the basic principles of pediatrics is that children are not “just little adults.”

Chest pain is a perfect example.

What are some common causes of chest pain in children?

1. Muscular or rib pain - This is the most common cause of chest pain in children. Pain can be caused by a bruise, muscle strain or after repetitive coughing.

2. Lungs - Asthma and pneumonia are two common lung causes of chest pain.

3. Stomach - Reflux can cause chest pain (think “heartburn”).

4. Psychological - Stress, anxiety and panic attacks frequently show up as chest pain.

If most chest pain in children is not an emergency, when does it become one?

1. The pain is severe, especially if it has the classic findings of heart pain (crushing pain, under the breastbone, moving to the left arm or up the jaw).

2. The pain is associated with difficulty breathing.

3. The pain has is associated with other symptoms (fever, nausea/vomiting for example).

What are some other findings that suggest the heart is the cause of chest pain?

1. The pain is associated with exercise or limits the child’s ability to exercise.

2. The child has lightheadedness, dizziness or faints with exercise.

3. There is a family history of heart problems or sudden death, especially if early in life.

If your child has any chest pain, a visit to your doctor is important so that they can ask you questions and perform an exam on your child to determine the cause and right treatment.

A recent study done in the adult oncology world and published in JAMA, found that doctors had a perception that patients were demanding extra treatment and testing. Review of the patient encounters showed that doctors perceived demands that did not actually occur. Many of the requests that did occur were medically appropriate.

In pediatrics, the most common issue where this comes to a head is the desire to give children antibiotics. It can also play out in other areas as well. Another common one that comes to mind is request for further testing for diagnosis.

Fortunately, in my experience, parents are becoming more informed about what situations require antibiotics and which illnesses will pass with a little time and TLC.

The problem is that many doctors have gotten into the unfortunate habit of wanting to provide what the parents are requesting without actually asking the parent what they expect. Doctors may perceive that parents want antibiotics or further testing when, in fact, they simply want reassurance that waiting is OK. This becomes a particular problem in urgent care or retail clinics where patient satisfaction plays a bigger role in getting patients to come back and see you.

So, how can you prevent this from happening to you?

Here are five casual statements that you might use the next time you visit the doctor to help them understand your expectations:

1. I’m pretty sure I’m just over concerned. I just wanted you to check things out so I can be sure.

2. I don’t really like to give my kids medicine but I wanted your opinion about what we should do next.

3. I’m totally OK with waiting, if that’s what you think is best.

4. What would you do if it were your child?

5. Are there other things we can try first or other options?

Your doctor should not feel threatened by these statements. If antibiotics are the only right choice, they should be able to explain the reasons why that is.

With each injury, parents commonly find themselves asking each other, “Do you think it’s broken?”

Broken bones are one of the most common types of injuries in children that need treatment.

They most commonly occur in the arms.

They can be the result of direct contact with something but are also common with falls where the child tries to catch themselves with their hands.

A common quote, “Well, he could move it so I know it wasn’t broken.”

If only it were that easy.

Here are some signs that your child might have a broken bone (we’ll start with the obvious and move to the less obvious):

• The bone is sticking out of the skin.
• The extremity is crooked.
• There is severe swelling or pain (if leg injury, is not able to put weight on it).
• The pain is not severe but does not steadily improve over a few days.

If you find yourself unsure or you have questions, give your Cook Children’s pediatrician a call. They can do an exam to determine if an x-ray is necessary and get your child the treatment they need.

So, you have a new baby. That means your automatic, "I worry about poop" button is switched into active mode. It seems that you can't have a new baby and not worry about their stool. Suddenly, it's the main topic of conversation at the dinner table, in bed before you go to sleep at night -- anywhere, anytime is the appropriate time to discuss pooping habits. (Just remember, your child might be discussing your pooping habits and diaper changes around a dinner table in the future.)

So, what is normal poop?

We generally state that babies should be having wet and dirty diapers about six to eight times per day in the first week. However, there can be a lot of variability in this. Babies can poop every time they feed or just once a week and still be normal. You should worry if the baby is having hard stools or has a lot of swelling of their belly.

Normal stool color and consistency also varies. The color can be all over the place.

Also, straining and turning red and pushing with all their strength is normal. They're learning what muscles to push with to get the stool out. Imagine if you didn't know and were just guessing how to poop. It wouldn't go so well.

There are many varieties of normal stool but if you are concerned about your newborn’s poop, call your pediatrician.

Newborn U

Having a new baby in the house is an exciting, and generally, very happy time. It can also be a time of worry and fear. Learn more at Dr. Smith's Newborn University.

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

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

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

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

Over-the-counter (OTC) Meds

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

Duct Tape

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

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

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

About the author

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

I resolved to quit doing them years ago. Which means I quit systematically breaking them years ago as well.

This doesn’t mean that I don’t work to improve myself; I just try to do it every day and not just on New Year’s Day. Bad habits are easy to form and hard to break. This is no different for parenting.

Here are some things I am working on:

Be purposeful

I have chosen two character traits I want my children to have: grit and integrity. I want my kids to try hard to overcome obstacles and I want to be honest, whole people, even when no one else is watching.

The best way to accomplish this is not to sit down when they are 12 and have a sit-down conversation that magically imparts them. The best way is to take every opportunity now to teach them in a developmentally appropriate way. I don’t swoop in to rescue them when they are having trouble with a puzzle and I make a point to call out (in a loving way-at least most of the time) the little white lies that toddlers and young children often tell.

Be patient

My mind runs 1000 miles a minute. I get from point A to point B really quickly. Why can’t my toddlers do that as well? I also don’t like to waste time doing anything…walking up or down the stairs with a 2 year old is the epitome of “wasted” time. “Daddy come? Daddy scoot?”

I have to remind myself that my goal for ultimate efficiency can harm my kids. If I quickly take the task from them, I am taking away an opportunity for them to learn or try something new. If I end up getting angry with them for this, I’ve doubly harmed them. Why would they ever want to try something new?

Be present

This is my biggest one. I have never been the dad who is gone all the time. I am fortunate that I don’t love golf and my job does not require frequent travel, so I’m home a lot. But just because I am home doesn’t mean I’m present.

The draw of Twitter, sporting events on TV and JackThreads is just as strong (and perhaps more dangerous) than golf ever could be. It doesn’t take long for the kids to notice that you’re not paying attention and their efforts to garner that attention will escalate until they get it.

Find a place for your phone that is not disruptive, turn off notifications for non-essential apps, whatever it takes, just be present.

We can all be better parents in one way or another.

I plan to work on being purposeful, patient and present.

What can you do to be a better parent today?

Oh, and if you do want to find something useful to do with your phone, while you are hanging out with your kids ...

About the author

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

This week presented an excellent opportunity for me to return the favor.

Our family chose to cancel our usual family Christmas. Not because the kids were bad and we’re not rewarding them. Not because we were frustrated with how commercialized it has become and are taking a stand. 

Actually, the rest of our extended family all got together and opened presents on the Sunday before Christmas as usual. We just didn’t go this year.

So, why didn’t we participate?

Flu.

Since I have been a practicing pediatrician, I have somehow avoided bringing the flu home. Whether it was luck or blessing or whatever you want to call it, we have been spared, until this year. My two boys have the flu.

So why didn’t we go?

Believe me, skipping the excitement and fun of watching our kids with their cousins is heartbreaking. This is the first year that all of our kids seem to know something is different about this time of year and Christmas at my grandmothers is always one of the highlights.

But, taking a risk with the rest of our family is not worth it and it should not be for you either. If your child is sick, find some other way to celebrate that doesn’t put others at risk. 

Think about those people who are most at risk from complications of the flu: children under 5 years (especially under 2, all the new babies out there), adults over 65 years (grandma and grandpa), pregnant women (your cousin’s first baby) and people with chronic medical conditions. These are just the types of people who it’s hard to stay away from at Christmastime.

We will make the best of today and pray that we are all better come Christmas Day. You should do the same.

About the author

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

Flu Myth #1

The flu shot can give you the flu.

Nope. Not true.

http://www.usatoday.com/story/news/health/2013/01/14/can-flu-vaccine-cause-the-flu/1833793/

Flu Myth #2

The only time I got the flu was the year I got the flu shot.

This may be true, but it’s completely coincidental. There’s no mechanism where the shot would make you more susceptible to getting the flu.

Flu Myth #3

The flu is annoying, but harmless.

This is true for many children, but we should watch for dehydration and difficulty breathing. Kids with asthma and other chronic medical conditions should be monitored closely.

Flu Myth #4

I had the “stomach flu.”

If you had vomiting and diarrhea only, you probably had another virus. Flu symptoms are fever, cough, congestion and body aches but rarely stomach problems.

Flu Myth #5

Because the flu shot is only covering 2 strains, you should skip it.

Getting coverage for 2 strains is better than 0.

http://www.checkupnewsroom.com/does-my-child-still-need-a-flu-shot/

Flu Myth #6

Over the counter cough and cold medicines help kids with the flu.

Cough and cold medicines do not work very well for anyone and can be harmful in kids. Just skip them. Run a humidifier and if over one year, give them some honey at bedtime.

Flu Myth #7

If you suspect your child has the flu, they need to see the doctor right away.

If they are drinking OK and staying hydrated, home care can be appropriate. Certainly call your doctor before going to the emergency room unless they have symptoms other than fever, cough and congestion.

http://www.checkupnewsroom.com/more-flu-longer-waits-in-the-ed/

Flu Myth #8

Every child who has the flu needs Tamiflu.

If your child is healthy (no asthma), the benefits of Tamiflu are minimal if anything, it is expensive and there are possible side effects. Consider these factors when and have a conversation with your doctor.

About the author

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

Get to know Justin Smith, M.D.

Justin Smith, M.D., is a pediatrician in Trophy Club  and the Medical Advisor for Digital Health for Cook Children's in Fort Worth, Texas. Dr. Smith is an experienced keynote speaker for a variety of topics including pediatric/parenting topics, healthcare social media and physician leadership. If you are interested in having Dr. Smith present to your conference or meeting, please contact him at thedocsmitty@cookchildrens.org.

He has an active community on both Facebook and Twitter as @TheDocSmitty and writes weekly for Cook Children's checkupnewsroom.com. He believes that strategic use of social media and technology by pediatricians to connect with families can deepen their relationship and provide a new level of convenience for both of their busy lifestyles. Dr. Smith’s innovative pediatric clinic, a pediatric clinic “designed by you,” open now. Click to learn more. To make an appointment, call 817-347-8100.

Breaking news concerning the weirdest week in celebrity-infectious disease history:

Peyton Manning helped lead the Broncos to victory despite suffering from a flu-like illness.

Sidney Crosby and multiple other National Hockey League stars have been diagnosed with mumps.

Angelina Jolie missed press events for the release of Unbroken, a movie which she directed, because she was diagnosed with chicken pox.

Maybe it is not breaking news. In fact, I’m pretty confident that they will all recover without any issues. Most people with any of these three diseases do.

We so rarely see mumps and chicken pox that we often forget how people used to suffer severe consequences from these diseases.

Here’s a quick reminder of some of the problems people can have as a result of these infections:

Flu

We have talked a lot about flu and flu vaccination in the past few weeks. Most children with the flu will have fever, cough, congestion and body aches,but will recover without incident in three to five days.

What do we need to watch for?

The most common problems with flu are dehydration and wheezing or difficulty breathing (especially in children with asthma).

A couple of more rare complications:

Pneumonia - Children can have viral pneumonia or a “secondary” bacterial pneumonia after the flu. (Secondary means that it comes after and as a result of having the flu. Think of it like the flu made the lungs weaker and more likely to get a different kind of infection.)

Nervous system involvement - These are rare but can involve confusion (caused by encephalitis-which is inflammation of the lining of the brain) and weakness (Guillain-Barré syndrome).

Mumps

Most children with mumps have low grade fever, fatigue, headache and muscle soreness. These symptoms are followed quickly by the most characteristic sign of mumps which is swelling of a gland in the cheek, called the parotid gland. The infection is typically more severe in adults than children.

What do we need to watch for?

Orchitis - This is a mumps infection involving the testicles. It is the most common complication in adolescent and adult males and can lead to sterility. A similar infection can occur in girls in the ovaries but is less common.

Nervous system involvement-Infected persons can have meningitis which causes fever, headache and neck pain. In addition, prior to vaccination mumps was one of the most common causes of deafness in children.

Chicken Pox

Because most of us had chicken pox and only suffered fever and the characteristic red, itchy rash, it is sometimes difficult to understand why we are vaccinating against the virus. Fortunately, that is the case for most children who contract the disease.

What do we need to watch for?

Skin infections - Because staph skin infections are so common now (and often resistant to some antibiotics), I am glad that we have a vaccine to prevent chicken pox. Any open sore, especially one that children are scratching is prone to infection.

Best advice is to stay away from athletes and celebrities this holiday season.

Ultimately, just remember that these diseases can be serious even though these celebrities should be just fine.

The official name for this behavior is pica.

Every child does it to some degree so don’t assume that there’s something wrong with your child just because they like an occasional mud pie. Who doesn't, right?

Pica is most common in children 2-3 years.

Some things to think about (but usually aren’t the cause):

• Lack of nutrients (iron or zinc)
• Developmental problems (autism)
• Normality- Usually this is it!

Why we worry about it:

• Choking risk
• Lead poisoning - Paint (especially in old houses)
• Blocked intestine - Hair or cloth
• Tooth injury - Hard things (rocks)
• Grossness (That’s why parents worry about it, not me so much.)
• Poisoning - Remember 1-800-222-1222 for poison control

What you can do:

1. Tell your child what is OK to eat!

I must say 1,000 times per day to my 4 year old (yep, we all deal with the same problems, even pediatricians): “Food and drink are the only things that go in your mouth.”

2. Lock away dangerous items and things your child “craves.”

3. Offer your child a well-balanced diet

4.  Don’t stress, but monitor as closely as you can especially in those areas where you know you child is likely to start “snacking.”

About the author

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

I just got back from a vacation at an indoor water park; otherwise known as The Land of Five More Minutes. I could not walk around without hearing some child be told how much more time they had before they had to leave.

It’s no secret that children, especially young children, have a hard time with transitions.

One great way to ease these difficult times is to set them up with a defined period before their current activity is going to stop. Another is to set clear expectations for what is going to come next and your expectations for their behavior and attitude at the time of the transition.

The conversation might go like this: “We have five more minutes, then we are going to change clothes and go eat lunch, all with a happy attitude.”

I’m pretty sure grandparents think we’re crazy for walking around at the mercy of the timers on our phones all the time but it really can work well.

Here are some ways to fail at using your timer:

1. Bargain - Five more minutes turns into one more and one more until everyone is hangry (hungry and angry) and the whole point of the timer is defeated. Besides, think about the culture you are setting up for your child. Your word and your boundaries mean nothing because they know with enough fussing they will get their way.

2. Choose the wrong time - Thirty seconds isn’t enough. Ten minutes is too long. Somewhere in-between is just right.

3. Be inconsistent - If you only do a timer once a week, it is not going to work. Your children need to know what it looks like, how it works and know that you are going to stick with it no matter what.

You may feel like a timer is the most ridiculous thing you could ever imagine (especially if you don’t have kids, because I was a perfect parent before I had kids too). If you think it is silly, that’s fine, it’s just a suggestion.

If you are doing it all wrong, make those changes.

If your kid screams every time they are asked to stop an activity, give it a try, what can it hurt?

About the author

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

Some good news this week about smoking rates: Gallup reported that smoking rates tied an all-time low with only 20% of adults reporting having smoked a cigarette in the last week.

Quitting smoking is one of the hardest things to do. I have seen motivated patients put them away, but come back to them when stress or cravings became too much. Your doctor (you know, the one for adults) can talk to you about all the health benefits for you and I recommend a conversation with them. However, I think one of the best motivators for quitting is your child’s health. Here are a few of the problems that secondhand smoke can cause for your child’s:

1. Increased risk for prematurity (smoking by pregnant moms)
2. Sudden Infant Death Syndrome (SIDS)
3. Increased upper respiratory infections
4. Worse asthma-wheezing is more common and more severe
5. Ear infections

As you can see the effects of secondhand smoke exposure have a wide variety, some more severe than others. Unfortunately, strategies like smoking outside and changing shirts are not as effective as quitting altogether.

Believe me, I am willing to do anything I can to help your child with asthma breathe easier. I will use all the medicines and treatments at my disposal and ultimately put them in the hospital for more help if needed. However, the best thing you can do to help is to quit smoking.

About the author

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

I won’t be thankful that I can’t sleep in due to my 3-year-old alarm clock.

I will be thankful for extended breakfast with that 3 year old and big smiles for the blueberry bagel.

I won’t be thankful for traveling in a car with 3 children (under 5) who won’t sleep by my plans.

I will be thankful that when we get there they will be with family that loves them (and for the human hurdle):

I won’t be thankful for battles over eating new and different foods.

I will be thankful for three healthy children whose business and spunkiness brighten every day.

How can you survive this week?

• Be flexible.
• Allow a little extra screen time.
• Don’t stress if they don’t eat all their food.
• Remember that a few days off their nap schedule won’t ruin their chances at Harvard.
• What are you thankful for this week?

Parenting presents many challenges and sometimes it takes a little extra effort to remember those things that we can be thankful for.

Start with some simple things…

• Health - If you child is healthy, start with that. If your child is sick this holiday season, we pray for quick healing.
• Time - Extra time sometimes means extra conflict. Your kids don’t want perfection, they want you present, so just be present.
• Fun - With added stress due to family visits, it’s easy to lose the fun for your kids. Plan an activity for them, play a game or start in impromptu dance party.

About the author

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

Oh, there she is, over there checking out Facebook.

Are you nervous every time her kid climbs up the ladder he might fall down and injure himself?

She’s still playing Candy Crush. Ok, let me rescue her kid from the top of the slide.

There’s new evidence to suggest that there may be some truth to your concern.

A recent study from Yale Economics professor Craig Paulson showed that, from 2005-2012, unintentional injuries in children aged 0-5 increased. He was able to correlate the increase in injuries with the expansion of 3G cellular networks across the country. Many of these injuries occurred during times of parental supervision (not day care or with other caregivers). There was no similar increase in injuries of children aged 6-10.

This trend is the opposite of the overwhelming decrease in unintentional childhood injuries since the 1970s.

While there could be other explanations of this trend, clearly distracted parenting is becoming more of a problem in today’s world.

Here are some things to think about:

1. You will underestimate how long you will be looking at your screen. Even if you look away for one task, that task will take longer than you think and you are likely to get sidetracked by something else.
2. Injuries in children often take mere seconds to develop. There may be no build up from independent play to dangerous predicament in the time it takes to read and respond to a text.

In any situation, you should be aware of how much time you are spending with your smartphone.