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

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

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

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

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

1. Forehead strips

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

2. Wearable thermometers

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

3. Pacifier thermometers

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

4. Ear thermometers (tympanic)

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

5. Forehead thermometers (temporal)

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

6. Digital thermometers

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

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

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

7. Non-contact Infrared Thermometers

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

Bonus: Mom’s hand or lips

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

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

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

How to take a rectal temperature

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

How to take an oral temperature

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

But when the fussiness symptoms are severe and consistent with reflux or the baby is not gaining weight well, treatment with an acid reduction medication is considered.

One common medication is a group of acid reducers known as H2-blockers, with the most common example containing ranitidine.

Ranitidine is in the news right now because the FDA recently reported that they had found small amount of a potentially cancer causing chemical in brand name and generic Zantac (ranitidine) products.

CVS Pharmacy has stopped selling products which contain ranitidine (Zantac as well as its generic version of the heartburn medication) until further notice.

According to the FDA, Zantac has potential cancer-causing chemicals. But those are found in anything else we eat, breathe, sleep, live on.

For now, here’s what we do know:

1. There are likely many babies who have been placed on ranitidine unnecessarily for what is normal fussiness or normal spit up.
2. There are also likely many babies and children who have been started on Zantac but no longer need the medication and have been passively continued on it.

We don’t know the long-term effects, but this is your baby we are talking about. So, even if the risk is minimal it would be reasonable to consider your baby's case and have a conversation with your doctor about whether coming off the medication might be the right thing to do anyway.

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

And here are 5 other common causes of chest pain:

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

And only time will tell for sure, but some indicators lean toward a potentially severe influenza season.

Clinical experts in the U.S. watch the Southern Hemisphere of the world for signs of what might be in store for us in the north.

In Australia, where winter recently ended, the Department of Health reported the flu season arrived earlier than normal. Of special concern to the experts is the type of flu season seen in Australia – Influenza A (H3N2). H3N2 is a more dominant strain of the flu and causes more illnesses.

How effective the flu vaccine is depends on how well experts predict what strains of the flu will be circulating the globe that year.

“The vaccine strains are chosen about nine months before flu season, based on circulating strains from around the world by epidemiologists who are geniuses and do this for a living,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases.

Locally, the first case of flu (Flu B) was reported at Cook Children’s Medical Center two weeks ago. Last week, no one tested positive for either strain.

NBC News reports that one pediatric flu death has already been recorded in the U.S. – a 4 year old in California who had underlying health problems.

Jason Terk, M.D., a Cook Children’s pediatrician and a national expert on immunizations, adds his voice to other pediatricians and global health experts who say the flu vaccine remains the best way to prevent influenza.

“The great news about the vaccine is that even when it’s not always a perfect match for prevention, the flu vaccine can reduce the severity of the illness, even if you do catch the flu that season,” Dr. Terk said.

To make an appointment for your child’s flu shot, contact your Cook Children’s pediatrician. The vaccine is currently available in many offices and a second shipment will be delivered next week.

“It takes two weeks for the shot to become most effective. Because flu can hit as early as late October or early November, we recommend getting the flu shot as soon as possible and definitely before the end of October,” said Justin Smith, M.D., a Cook Children’s pediatrician.

More On This Topic:

• Flu Shot Appointments
• Influenza/Flu Information
• Let's Learn About ... The Flu
• How To Tell If It's Strep, Flu, Rotavirus Or Norovirus
• Comfort Menu to Ease Pain, Anxiety for Children Getting a Shot
• Is It a Cold or The Flu?
• Pediatricians Say Kids with Egg Allergies Should Now Get The Flu Shot

So what is difficulty breathing? How do you tell if your baby or child is having it?

In babies there are 3 main considerations to look for difficulty breathing:

1. The nose - When babies are having difficulty breathing, their nostrils will flare open and closed with each breath.
2. The area below the rib cage - Babies will begin to use their bellies to help them breathe when they are having trouble, this will look like sucking in and out of the area below the ribs.
3. Rapid breathing - Babies already breathe fast and they can breathe at a really unpredictable rates. But if you feel like the rate is faster over a sustained period, it could mean that they are having difficulty breathing.

In older children, there are some similar and some different ways you can assess difficulty breathing:

1. Watching - Just like babies, you can watch an older child under their ribs to see if they are breathing harder than normal.
2. Assessing activity - Are they able to go about their normal activities or are they getting short of breath?
3. Say the alphabet - Can they say the alphabet without breathing? How far can they get?

Obviously these aren't perfect assessments and children should be seen if you are worried. Any change in alertness or change in color (blue or duskiness) is an emergency.

My interest began with a report from the Tennesee poison center that said reports of toxic exposures to oils doubled from 2011 to 2015. Of those reported cases, four out of every five were in children.

As I began my research on essential oils, I asked what you guys wanted to know. I asked on Facebook what you all wanted to know and you guys had some great questions.

Most indicated that they “really wanted to hear my opinion.”

I will take the questions and try to divide them up by category as best as I can.

I feel like I owe it to you, and your children, to give my candid answers on the subject.

Safety

Q: What harm have you seen from patients choosing oils over modern medicine?

A: I’ve seen two examples of this. The first were parents using oils for their child’s eczema. They came to me after one month of attempts (including multiple different regimens) to treat with oils and the child ended up having a secondary staph infection of their eczema because the skin was open. In fairness, severe eczema happens and secondary skin infections happen, but most of my patients with eczema do not get that severe with the medications I typically recommend. The second patient was one who had an upper respiratory infection that led to croup (noisy, barky cough). The parents were trying oils at home for three days (again multiple different attempts to get the “right” oil) before they ended up in the emergency room and admitted for two days for difficulty breathing. The theme here has three components:

1.The oil itself did not hurt the child.

2.The ambiguity as to which oil should be used led to multiple different regimens and oils being tried.

3.The biggest problem with these two is the delay in receiving appropriate care.

Q: What is the best way to explain proper dilution to others?

A: Ummmm…I don’t know. Based on what I have seen regarding research this has not truly been studied, at least in children.

Q: Are there any that are harmful for use topically?

A: There are case reports of severe toxicity with topica application that uses eucalyptus and tea tree oil from those that I studied. These are mainly due to extensive application. Toxicity to any treatment is always related to dose. The more area you cover, the more likely it is to be toxic. There are also some reports of reactions with very small applications. The other concern I have (for which we don’t know the answer yet) is how does the toxicity change when these oils are being applied hourly (as I’ve seen recommended) or when multiple oils are being used at once.

Q: Can I use them in my child with asthma?

There are no studies that show effectiveness for asthma. Any inhaled substance with a small particle size that can get into the lungs could theoretically lead the airways to constrict which would actually cause more problem in children with asthma.

Q: What happens when oil are ingested (purposefully or accidental)?

Even most pro-oil websites don’t recommend ingestion of oils in children and to use extreme caution in adults. Because we do not have studies that evaluate the safety and appropriate dosing for ingestion by children, this is the one hard line I take with my patients who are using them. Please do not use them in this way.

Q: Have you seen allergic reactions?

The allergic reactions I have seen are mostly related to the skin. Application of anything topically can flare a child who has eczema or cause contact irritation of the skin.

Q: Are they really good for you or are you you doing more harm than good?

I don’t think we know the answer to this question on a global scale. If they do have all the anti-bacterial, anti-viral and all other properties, and will actually work for those uses (which are not proven in humans), would we go on to see essential oil-resistant-bacteria? I believe we would. Especially with the way they are currently being used. Basically applying whatever oil for whatever infection (I am basing this on the fact that anytime I see someone requesting help with which oil to use, they routinely get 5-10 suggestions). That is exactly the way resistance to antibiotics occurs - too many antibiotics for non-specific indications and next thing you know a certain antibiotics doesn’t work for certain infection any longer.

Q: Is it safe to use oils along with modern medicines?

We know that these oils can affect the liver and cause the liver to metabolize other medications faster or slower. This could lead to medications not being as effective or potentially be more toxic. Some information is being gathered in adults to try to figure this out but kids are not “little adults” and we’ll likely need research in children before we can answer this for sure.

More from Doc Smitty on this topic:

New York Times Report: Are Essential Oils Safe For Kids?

Essential oils and their use on children

Essential oils and children - more questions answered

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

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

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

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

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

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

What topics did we miss?

Related To This Topic:

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

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

What causes nosebleeds?

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

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

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

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

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

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

How do you stop a nosebleed?

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

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

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

When should you be concerned about nosebleeds?

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

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

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

How can I prevent nosebleeds?

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

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

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

But when it comes to newborns, forget everything I’ve always taught you about fever. If an infant has a fever, it is a sign something is wrong and a serious cause for concern

In older children, fever is almost never an emergency, the exact degree of the temperature doesn't really concern me and unless there are other reasons to do so, a workup isn't indicated.

In babies up to 3 months of age, the opposites are true.

Fever in a newborn is an emergency. When a newborn has a fever, parents should have a sense of urgency.

An accurate temperature really matters for newborns. You don't need to go around checking your baby for fever randomly. But if they feel warm, are not eating well or you're otherwise worried, we recommend taking a rectal temperature. Rectal temperature is important because it's the most accurate way to determine the temperature and the studies that tell us what to do with your baby are based on rectal temperatures.

Once you have an accurate temperature, I recommend that you call your doctor with any temperature over 100 degrees. Technically fever is anything over 100.4, but it's good to let us know so we can coach you on what you should be looking for. It also helps us decide what should prompt a visit to the emergency room if it rises overnight.

Fever is such an emergency in babies because they can be an early sign of serious, even life threatening infections and babies can't tell us if something hurts. Babies can have blood stream infections, meningitis or urinary tract infections with little other symptoms. They also can get all the other things that older kids get too like stomach bugs, flu and other viruses but we would rather be safe than sorry.

Because of these risks, babies with fever will typically receive some type of lab work to determine if infection is present. This can include blood work, urine test and possibly a spinal tap to rule out meningitis.

While it's scary and no one wants to think of your baby needing this work-up, the fear of missing one of these serious infections or leaving them untreated, even for a short period, is even scarier.

Most babies with fever will be started on antibiotics while we wait in results from the test. This prevents babies from getting worse while we wait for results to come back.

So, as you can see, fever in newborns is a LOT different.

But, the important thing to remember is to call your doctor if the fever is over 100 and we'll help you keep your baby safe from there.

Related Topics:

• My Child's Fever Isn't Going Away. Should I Be Worried?
• 7 Types of Thermometers and to what Degree You Should Trust Them
• My Child has a Fever. Should We Go to The ER?
• 5 Days of Fever. Now What Should I Do?
• When It Comes to Your Kids It's Never Just a Virus
• Let's Learn About Fevers
• 4 Reasons Why This Pediatrician Doesn't Alternate Tylenol and Motrin for His Kids

They can be very ugly. They can cause pain if they’re in a tough spot. They can last forever.

Because of this, I’ve seen families try just about anything and everything to treat them.

But what actually works?

Many warts will go away on their own over time. Studies have shown about 80% of warts are gone after four years … but sometimes we can’t wait that long, especially when it’s your child in pain.

Here’s a look at some of the alternative and conventional treatment options for treating warts, along with my thoughts on if they are worth your time:

1. Apple cider vinegar – There are limited studies that show mixed results for using apple cider vinegar. It can be very irritating to the skin for some children. It’s OK to try but I wouldn’t get my hopes up.
2. Salicylic acid – Yes, this is a cream typically used for acne, but salicylic acid has been shown in some studies to effectively treat warts. The skin irritation associated is common and expected, but it has a better chance of working than apple cider vinegar…so it might be worth it.
3. Tea tree oil – While tea tree oil has been studied (and actually works for a few pediatric skin issues), warts are not one of them.
4. Crushing aspirin or Vitamin C and applying – No on these as well. No evidence that they are effective and it sounds like a lot of work.
5. Aloe vera – While unlikely to cause any problems, aloe vera is not effective treatment.
6. Duct tape – One small study showed that covering a wart with duct tape led to resolution of the wart. Later studies were done which showed it didn’t work, but the researchers used clear tape instead of silver duct tape. So, right now we’re in a sticky situation (sorry) where we don’t know if it works or not. I would use the silver if I wanted to try it. It has been suggested to combine it with the salicylic acid treatment.
7. Freezing – The most standard treatment is freezing. Freezing works well, but might require retreatment after a few weeks if it doesn’t completely go away. Freezing can be difficult for warts on the feet or hands because the underlying nerves can be damaged.
8. Surgical removal – If all else fails, a physician can provide local anesthesia and remove the warts.

So there are lots of alternatives to try, but a conversation with your pediatrician is a great place to start. From there, you may be referred to our Dermatology team or to Pediatric Surgery. 

But for the most part, the best weapon against warts is patience.

Related To This Topic:

• Plantar Warts
• Molluscum Contagiosum: The Most Common Rash You Never Knew About
• 7 Skin Conditions Young Athletes Need To Know About
• 5 Common Medical Conditions That No One Shares On Instagram

Although she wouldn’t call herself “100% anti-vax” at the time, Amanda Carroll declined to give her first-born son his hepatitis B vaccine at birth.

With the next group of shots scheduled at his 2-month checkup, Amanda and her husband weren’t so sure what they would do next.

Amanda met with her pediatrician, Justin Smith, M.D., who was then in Abilene, and expressed her concerns. She talked about spacing out the vaccines or delaying them. She was concerned about the sheer number of pokes, the number of vaccines her baby would be given and wondered about a possible pharmaceutical company profit motive.

She figured she had two months to make a decision and began to read Dr. Robert Sears’ book that promoted a vaccine timetable contrary to the Center for Disease Control and Prevention’s schedule.

Amanda only made it halfway through the book.

At 3 weeks old, her son was rushed to a hospital in Abilene for emergency surgery. He needed a bowel resection after he was diagnosed with a strangulated inguinal hernia. After a code blue, the baby was flown to Cook Children’s by its Teddy Bear Transport team.

The little boy received two more operations at Cook Children’s, including another bowel resection from  pediatric surgeon Patrick Thomas, M.D. In all, the Carroll family’s son spent three weeks in the Pediatric Intensive Care Unit and two more weeks on the surgical floor.

During that time, Amanda and her husband developed a rapport with Dr. Thomas and felt comfortable expressing their concerns about vaccines.

“We talked to him about delaying or spreading out his vaccines,” Amanda remembers. “Dr. Thomas was so nice and he was very polite. He didn’t actually say these words. But in the nicest way possible he basically told us, ‘Really? I put so much work into saving your baby, you cannot do that. He needs to be vaccinated.’”

Because of his condition, the Carroll’s son had developed a blood infection and needed to see a doctor from Cook Children’s Infectious Diseases department. Dr. Thomas found out the physician would be Mark Shelton, M.D. Dr. Thomas told Dr. Shelton about the parents’ concerns.

“We spent an hour with Dr. Shelton. He was able to answer all of our questions in detail. I wish everybody who had the concerns we had about vaccines could have a similar experience,” Amanda said. “I wish they could sit down and talk to someone as knowledgeable about vaccines as Dr. Shelton.”

One memory that sticks with Amanda was when Dr. Shelton addressed Andrew Wakefield, the discredited British doctor and leading anti-vaccine activist. Much of today’s misinformation about vaccines began when Wakefield erroneously published a report linking vaccines to autism. That report has since been debunked.

Amanda recalls Dr. Shelton’s emotion at the mention of Wakefield’s name. He spoke passionately about the harm that Wakefield’s study had caused many children around the world.

Amanda is a sociologist and an educated person. Even after talking to Dr. Shelton, she still wanted to make the decision whether or not to vaccinate her son, using science as her guide.

“I looked at four or five other countries from around the world and found they had remarkably similar vaccine schedules in almost all of the western nations,” Amanda said. “When you looked at the CDC, the World Health Organization and other equivalent organizations, they all stressed vaccination.”

Then during her studying, another thought occurred to Amanda that chilled her to the bone. She had made the decision to not give her newborn boy the vaccine for hepatitis B. She realized after three surgeries and a blood transfusion there had been a chance, although small, that he could have gotten the disease because he was not vaccinated.

Once their son was discharged and recovered enough from his surgery, Amanda took her son to Dr. Smith for his full vaccine schedule.

She has continued to do so with her other two children, now 3 and 17 months old.

Amanda would be the first to describe her parenting choices as a “bit granola or hippie,” and she has several friends who are like-minded. But where she disagrees with some of her friends is about vaccines.

“I respect my friends’ opinions who are against vaccines or are vaccine-hesitant, although I disagree with them,” Amanda said. “I think they are absolutely trying to do what is best for their child, whether they are against vaccines or choose alternate schedules. My husband and I believe in the scientific research that says vaccines are safe. After our experience at Cook Children's, we felt comfortable going ahead with the schedule as is, and we have no regrets.”

For more information on this topic:

• Vaccines and Immunizations
• Common Questions About Immunizations
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know

They were doing great, breastfeeding or taking a bottle and eating some solids but now what?!??! You're expected to change everything. First off, remember that if you plan to continue to breastfeed (which is awesome if that’s your choice!), some of this won’t apply to you but some of it will.

With everything else going on, I’m here to tell you it doesn’t have to be that complicated.

Here are my 5 simple rules for transitioning to milk at 1 year of age (and only two low-stress choices for you to make):

1. Remember that there’s nothing magical about milk.

Cow’s milk is an easy source of calcium, calories, and protein but if they are eating those things then they actually don’t have to drink milk at all. Especially keep that in mind when you make the change if their milk intake falls off. It’s OK. I generally recommend 18-24 ounces per day. This should be enough to get your baby some extra calories, but not be so much that it can lead to constipation. Also remember that yogurt and cheese have similar nutritional content so they can be included in the total as well.

2. Transition to a cup before 15 months.

The closer to 1 year that you can transition to a cup, the better. Hopefully you’ve been offering some water at meal times with a cup for a while. Don’t buy any large quantities of a cup until you find out what your baby likes. Put the cup in front of them, they’ll eventually drink.

3. Decide on a milk. You have some choices.

Remembering rule  No. 1, it’s OK to give yourself some flexibility in the milk that you choose. I’m not worried about cow’s milk or dairy intake as a general rule. Depending on baby’s weight, I am Ok with either whole milk or 2% milk. Talk to your doctor about which might work for your child. There are a few milk alternatives that closely resemble cow’s milk in nutritional content (pea and soy milk are examples) but there are others that are basically water (almond milk). I don’t routinely recommend toddler formula unless medical indicated or recommended by your doctor.

4. Decide on a plan for your transition.

I’ve seen families make the change cold turkey the first day it was possible. I’ve seen families slowly transition by adding in milk alternating bottles with formula. I’ve also seen families mix some formula and some milk in individual cups. I haven’t seen any one particular strategy work better than another. I think most babies would do fine with a quick transition or cold turkey swap…but every baby is different.

5. Try not to stress too much about this.

There are plenty of things to worry about in parenting. Deciding what to give them to eat and drink shouldn’t add to your stress. Provide them plenty of fruits and vegetables. Decide on your milk choice and your method of transition and don’t stress the rest.

They will have good days and bad days (just like us).

But, I promise everything is going to be OK in the end.

To identify the hot spots, researchers from the University of Texas at Austin and Johns Hopkins University looked at each area’s volume of international travel from foreign countries with large measles outbreaks and the prevalence of nonmedical exemptions from childhood vaccinations.

The same researchers previously predicted outbreaks in Washington, Oregon and New York which are all experiencing an influx of measles cases.

“For measles, most experts believe that there will be one to two deaths per 1,000 cases, most likely infants. We are set to see over 1,000 cases in the U.S. in 2019. So, for the first time since the 1980s, we may expect infant deaths from measles in the U.S.,” said the study’s lead author, Sahotra Sarkar, a philosophy and integrative biology professor at UT Austin and an expert on public health, in UT news. “We have long known that vaccine avoidance is a critical public health issue in the U.S. and Europe. Our results show how travel from regions elsewhere compounds this risk.”

The Texas Department of Public Safety has confirmed 15 measles cases in Texas this year, including one in each: Tarrant, Dallas and Denton counties and two in Collin County. Comparatively, Texas had nine measles cases in 2018 and only one in 2017.

Already this year, more than 760 cases of measles have been confirmed in the United States, the highest number in decades.

Physicians at Cook Children’s call this news frustrating because measles is a disease once thought to be all but gone from the planet. Texas has one of the highest rates of unvaccinated children in the U.S., partly due to a 2003 state law allowing parents to opt out of getting their children immunized for reasons of conscience.

“It’s not a coincidence that as we have seen more people hesitant to receive the vaccine, we have seen the number of measles cases increase nationwide,” said Justin Smith, M.D., a pediatrician at Cook Children’s. “The numbers are very concerning.”

Measles is a highly contagious respiratory illness spread by contact with an infected person through coughing and sneezing. Measles is so contagious that if someone has it, 90 percent of the people around that person who are not immune will become infected.

The Centers for Disease Control and Prevention (CDC) recommends children who are older than 12 months get two doses of MMR vaccine, starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age. Teens and adults should also be up to date on their MMR vaccination.

Two doses of the MMR vaccine are about 97% effective at preventing measles; one dose is about 93% effective.

"Populations who choose to not follow the recommended vaccine schedule 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," said Jason Terk, M.D., a Cook Children's pediatrician.

Other Texas counties to make the Top 25 were Harris at No. 9 and Travis at No. 22.

To learn more about where you can receive vaccines in the Tarrant County area, visit the Immunization Collaboration of Tarrant County website.

For More on This Topic:

• 25 U.S. Counties Identified as Most at Risk for Measles Outbreaks
• Vaccines and Immunizations
• Immunization Collaboration of Tarrant County
• Common Questions About Immunizations
• Why Children Like Olivia Need You to Immunize
• From Vaccine Hesitant to Pro Vaccines. Why This Mom Changed Her Mind.
• Pediatricians Remember Experiences with Measles
• What The First Measles Case in Tarrant County Means for Your Child
• 'Vaccines Are Safe and Effective'
• When It Comes to Your Kids It's Never Just a Virus
• Measles Outbreaks Increase as Vaccination Rates Decrease
• Measles In the Classroom
• MMR/thimerosal/mercury: What you should know

Popular rocking sleepers have been in the news lately for all the wrong reasons. 

Last week, Kids2 recalled all of its rocking sleeping models after reports that say five children have died in its sleeper since they were introduced in March 2012. 

Approximately 700,000 products were sold at major retailers including Walmart and Target. The brand names of the sleepers included Disey Baby, Bright Starts and Ingenuity.

Earlier in the month, Fischer-Price chose to recall its Rock ‘n Play Sleeper after 32 infant deaths associated with the product. Fisher-Price chose to recall approximately 4.7 million of the units on April 12, following a report from the U.S. Consumer Product Safety Commission (CPSC).

Less than two weeks later, two class action lawsuits have been filed against Fischer-Price and its parent company Mattel.

While there were claims that the deaths were only associated with the unsafe use of the device, the CPSC stated the deaths occurred “after the infants rolled from their back to their stomach or side while unrestrained, or under other circumstances.”

“And our concern doesn't stop with only the Rock 'n Play or the Kids2 products,” said Justin Smith, M.D., medical advisor of Digital Health at Cook Children’s. “Other sleep aid devices such as hammocks, nests and wedges also can put babies at risk for both suffocation (where a baby turns into a soft surface and rebreathes their own breath) and positional asphyxiation (where a baby's airway is squeezed off by flexion at the neck).”

“It's clear that the safest position in which a baby should sleep is on their back, on their own in a boring, flat surface.”

So what do you do with a baby that never slept well anywhere else? We talked to Dr. Smith and Diane Arnaout, M.D., a Cook Children’s Pediatrician at Forest Park to get some ideas.

Dr. Smith: First of all, we want to say that we know the idea of making this transition away from a sleep device or the idea of having another baby without one (when your first baby only slept in one) is scary and overwhelming.

We hear you.

And, believe me, if we could recommend something magical that would help your baby sleep, we would tell you all about it. No one needs to sleep more than pediatricians, especially pediatricians who are parents.

Here are some tips that might help you survive with a baby who is a poor sleeper:

Give your baby their best chance to sleep by maximizing their environment.

Dr. Arnaout: Try to mimic the womb environment. What happened in the uterus? It was a dark, warm, noisy place. A baby is looking for that same type of environment outside of the womb.

Some adjustments that you can make that might help:

• Use a sleep sack that is snug but not tight (if you choose to swaddle make sure that you are stopping after two months)

• Turn on a sound machine to provide some white noise-this mimics the sounds of the blood vessels in mom's tummy.

• Allow your baby to use a pacifier once breastfeeding is established - not only does it help with sleep, it's also protective for SIDS.

• Help your baby go down to sleep drowsy but not asleep, this will help them make those transitions at night when they enter lighter sleep stages.

• Practice, practice, practice - use your sleep routine (or at least an abbreviated version) with every sleep, this helps your baby understand when it's time to go down.

Remember the bottom line is that babies should be sleeping alone in their own crib, staring on their back, with no blankets or pillows.

Dr. Arnaout: "I know this seems out of the blue and unrelated, but - It’s really important to make sure your baby is getting "full feeds". This doesn’t mean any particular number of ounces or minutes of nursing - this just means discouraging “snacking”. I tell parents daily that babies who snack all day are gonna snack all night. Babies who are encouraged to empty both breasts, or fill up on as many ounces as possible during a bottle feed, are able to go longer between feeds and are able to fast for longer periods at night."

We know that the transition out of the Rock N Play is going to be brutal. But you were going to have to make that transition at some point, this probably just accelerated the timeline (or kept you from having to make one at all). So, expect some rough nights and do your best to prepare.

Seek help when you need it. It's more than OK. It's necessary.

Dr. Smith: It's particularly hard to shoulder this burden of poor sleep when you feel like you're on an island. And I know there are parents out there who struggle to get help. But this is a situation where a tired baby, makes for a tired parent and a tired parent doesn't have the same patience to work with a fussy baby to help them through this transition.

I know that sometimes partners need to go to work the next day and feel like they can't work on shortened sleep. But, keep in mind, that staying home and parenting after no sleep is no walk in the park either. Find creative ways to share the burden. It's amazing what one good night of sleep will do to prepare you for a few difficult nights.

If both parents are working and your baby isn't sleeping well, seek out friends or family who might be willing to take a night or even just a few hours for you. Friends and family, when you hear that mom and dad are struggling to get sleep...don't ask what you can do to help, ask what night they want you to come over.

Dr. Arnaout: I think one of the hardest things for me to realize with my first baby was that we were gonna have good nights and bad nights, and one day…I’d sleep full nights again.

Dr. Smith: I think it’s important for parents to know that safe sleep is accessible for all babies. What doesn’t work one night may work the next, as the child grows and develops. And kids’ sleep is phasic - you’re gonna have weeks where they rock it, and nights when you’re totally questioning your life decisions.

Recognize your exhaustion as temporary! It will get better!

The more weight your baby puts on and the more self-calming mechanisms they develop as they grow will both help you climb out of the early infant months well-rested and feeling confident your child is safe while they sleep! And as always - if you need help - ask your pediatrician! We are honored to be a part of your “village” and have helped thousands of families during this trying time.

We know that this topic is one that inspires a lot of passion. No one wants to make a family feel guilty who has used the Rock n’ Play in the past or who are currently struggling with what to do. But, the reality is, that new information is almost always a good thing. And this information says that these devices are not safe. While we'd love to compromise, we can't advocate for using a device that causes infant death, especially when used as directed.

What about babies with reflux?

Dr. Arnaout: "One morning, I woke up to find that my first baby, who experienced pretty bad reflux, had barfed all over the place sometime in the night. It was everywhere - in his hair, his ears, and soaked into his sheet and sleep sack. I felt horribly guilty for not hearing it or being there to help - even though I was laying in bed right next to his bassinette. I was an exhausted mom, and looking back, I needed to forgive myself. I was worried that morning - what if he had choked? Aspirated? But then I remembered all the protective reflexes babies have to protect their lungs - namely, gagging and coughing - that gets it all out, and allows them to breathe again.

There is some thought that tucking a blanket or wedge under the mattress to elevate the baby might help, but lately, research has proven that elevation may not really help: "The supine sleep position does not increase the risk of choking and aspiration in infants, even those with gastroesophageal reflux, because infants have airway anatomy and mechanisms that protect against aspiration.”

What do you think about baby monitors?

Dr. Arnaout: I think monitors are both helpful and not helpful. The AAP says babies are most safe in the parents’ room in the first year, in their own sleep space (crib). But my kids were noisy little people - and I am a light sleeper who would jump up at every single noise. I’ve eventually used monitors with both of my kids when I moved them to their own room and depended on them to let me know when my baby wasn’t feeling well or was hungry. But I always turned the volume on low, and it only alerted me if the baby was yelling pretty loud. I did this because all babies make noises while they sleep: snort, sigh, cough. Refluxy kiddos are honky and loud sometimes when they sleep because the tummy acid juices and milk sometimes irritate the back of the nose as it goes up and down.

And, I’m pretty sure my freshly minted 10 year old will soon be asking about his own Twitter, Instagram or YouTube account soon. I realize this is a tricky situation. Especially since I’m the medical advisor for Digital Health at Cook Children’s and I’m active on social media.

Trust me I see the irony … or maybe the hypocrisy.

But Right now I’m planning to hold off AS.LONG.AS.I.CAN.

Why?

Because I’m a parent. I worry about my kids like everyone else and I want them to be safe and protected

I’m also a pediatrician and I talk to too many kids in my office who are dealing with the negative fall-out of social media. I also see way too many studies addressing how social media has caused harm.

Social media can lead to:

• A fear of missing out. I wasn’t cool in high school (this may shock you and if it doesn’t just stay quiet) but I really didn’t know what I was missing out on. Everyone partied on the weekend but didn’t say much to me about it on Monday. If there had been pictures and posts from the weekends, I would’ve understood how left out I probably was.
• Inappropriate expectations of appearance. We don’t look like the celebrities we follow on social media and we probably never will. Sometimes though it’s important to remember the celebrities don’t look like the celebrities when they are on social media either. They are photoshopped and edited many times. But still, our kids are left to compare themselves to people who taking professional photos or using editing software to make everything look perfect. It’s their job after all. Unfortunately, that doesn’t keep many of us from feeling jealous or feeling like we’ve fallen short when we don’t.
• Bullying. Anonymous or even semi-anonymous (or “behind the screen”) empowered bullying can cause isolation and fear. And it doesn’t stop when you go home from school like it did when I was a kid/teen.
• A lack of ability to process our feelings. The constant ding of dopamine we get from the amount of likes on our posts enables us to continue posting to get our fix rather than process and dive into our sadness.
• Oversharing and shame. Teenagers and preteens don’t understand the significance of oversharing and what can happen later when those details (or pictures) get shared to a wider audience.

So what should we do as parents?

Here’s what I recommend:

• Keep your child off social media as long as possible. I know. I hear it too with my three kids. But the longer you can keep them away from it, the more time you have to talk to your kids about this issue and let them mature to handle what will inevitably come their way.
• When they get on, you get copies of their passwords and connect with their accounts. You can have privacy when you are out from under my roof. Oh man, I’m starting to sound more and more like my dad. But until then, sorry kids, I’m doing everything in my power to protect you.
• You reserve the right to delete the account and take their phone at any time. I paid for it and I can take it away.

I hope this helps. Just know I’m dealing with it too and would love to hear your thoughts. Again for irony … on social media.

I hate that phrase and I know it never gives parents comfort when they hear it from doctors.

Doctors (I’ll admit I’ve said it too) usually say “it’s just a virus” to let parents know we don’t see anything that suggests a bacterial infection so your child doesn’t need antibiotics or other specific treatment. This is an infection caused by a virus and should go away over time. It’s meant to comfort mom and dad.

Then the appointment usually ends with “if things don’t get better to let me know.”

But it’s never JUST a virus when it’s your child, is it? As parents we know that viruses aren’t always simple and that kids can be VERY miserable and even get VERY sick.

RSV and flu still strike fear in the hearts of many parents. So much so that they’ll choose to have me test for them, even if I assure them it won’t change the treatment either way. But sometimes, the knowledge and the ability to put a name to it provides some level of comfort or the negative test gives them the ability to take a deep breath and relax (even though a no-name virus can be as scary as a named one).

We should take viruses seriously, after all they’ve been the cause of many of the most serious conditions the medical community has ever faced. Like I said earlier, once you catch a virus there’s not a whole lot doctors can do. We have to wait it out, try to treat the symptoms as we can and simply let things run its course.

That’s why the advancements that have been made in vaccines have been so essential. They were created to prevent the viruses before your child caught them or to lessen their severity if they did.

We don’t often think that these very serious conditions are viruses, but fortunately we have a vaccine for them:

• Polio which for many children might cause no symptoms at all or a mild upper respiratory illness, can also lead to devastating, permanent paralysis.

• Measles which for many children cause a syndrome with fever, rash and upper respiratory symptoms, can also cause pneumonia, death and a severe neurologic disease called SSPE which develops 5-10 years after the infection.

• Mumps which for many children caused fever, muscle aches and headache, can also cause infertility in males, meningitis and hearing loss.

• Hepatitis B which many believe to be a disease of adults (because it can be sexually transmitted and needle-borne) actually caused many infections in babies who contracted it from their mothers. Hepatitis B was less likely to be cleared by children which led to a 40 percent chance of liver cirrhosis and liver cancer.

Fortunately, for these viruses along with the flu, chicken pox and Hepatitis A, we can now protect kids with vaccines. We can protect them, not only from the suffering associated with the illness but also the devastating complications that can arise as a result of them.

How would it have felt to live in a time when these viruses were common?

Think about how you feel when you read stories about the polio-like illness that has been spreading across the country or how you feel when you hear that there are cases of measles in your community. Then imagine that you know someone or at least know someone who knows someone who has suffered from one of these disease personally.

Terrifying.

Imagine a doctor telling a family it’s “just a virus” in this environment. It wouldn’t fly.

I promise I’ll try to avoid saying “just a virus” but I’m thankful that it’s easier for me to get away with it today … thanks to vaccines.

Here are a few of my thoughts that will hopefully make you feel better. And who knows? This actually could turn out to be good thing for all of us (myself included) on what it means to be a good parent.

1. I don’t think it’s real. Despite all the drama and buzz. I can’t find anything that proves this is really happening. It appears to be a hoax  and this isn’t the first time this same story has circulated.

2. It’s motivating parents to reconsider their child’s media consumption. MoMo challenge or not, unsupervised browsing of user-generated video content is a terrible idea (even if that platform is labeled “kids"). Watch what your kids are watching with them. Censor. Protect. That’s what we we’re supposed to do. But we’ve gotten lazy because it’s easier to let the algorithm decide than to actually sit and watch and guide.

3. You get to have a hard conversation with your kids. If you decide to take an app off their device for their protection, you can explain that their safety trumps any momentary joy they might get from watching videos on a screen. You care too much about them to put them at risk.

4. You get to ask your child deep questions so that you might learn about their deepest fears. Because even if this thing isn’t real, some kids are really scared by what they’ve seen and heard. Simple questions like, “Have you seen anything in your device this week that scared you?” “Have your friends been talking about anything that gets you worried?” “How can I help?”

5. Because even if this turns out to be a hoax (which it seems to be), the fact that kids are scared and talking about it is heartbreaking. The fact that someone thought spreading this would be funny at the expense of our kids feeling safe is infuriating. You don’t have to validate the fears to ask about them but you should ask.

Don’t let your kid live in fear without knowing you’re looking out for them.

Here are a few articles about the Momo Challenge you might find helpful:

• Parents, please stop freaking out over the Momo Challenge
• Momo Is Not Trying to Kill Children
• The 'Momo challenge' isnt' a viral danger to children online. But it sure is viral.
• What Is The Momo Challenge?

Whatever you call it, parents have lots of questions about pacifier use.

Let’s look at some of the most common:

1. When is it OK to start a pacifier?

A pacifier can be a life-saver for the baby that doesn’t need to feed at the moment, but desperately wants to suck.

The classic teaching for breastfeeding moms is to wait 3 to 4 weeks for breastfeeding to be established prior to introducing a pacifier. But, I think the most important thing is to make sure you feel confident in your baby’s latch and nursing before introducing a pacifier (or bottle for that matter). If your baby can latch, it’s OK to give him or her a pacifier. This will help your baby’s need to suck and your need to sleep and get a break from the constant nursing.

So day 1, probably not, but you don’t necessarily have to wait 3-4 weeks if you have a baby who is latching and nursing well.

2. When should we stop using a pacifier?

Prolonged pacifier use can primarily lead to two problems: Interference with speech development and dental issues. To prevent these problems from occurring, I recommend changing your strategy for pacifier use to nap and sleep times only after one year of age and starting to wean completely by 18 months with a goal of having them gone entirely by age 2.

3. Do pacifiers actually work to calm a baby?

Yes. Babies have a desire and drive to suck and it’s not always limited to feedings. Some babies never really take to it but for others, it can be a life-saver. Be careful not to jump to the pacifier for every fuss, learn your baby’s other needs and check for those before using the pacifier. But using the pacifier for everyone to get some sleep is perfectly fine when all of your baby’s other needs have been taken care of.

4. Do pacifiers prevent SIDS?

Way below some of the other more significant risk factors for infant death like sleeping on the back, no smoking in the house and other significant findings, pacifier use may be protective for SIDS. Is it a direct and absolute reason to use one? Probably not. But it doesn’t hurt and may actually help.

5. What kind of pacifier is best?

Babies will like all different kinds of pacifiers so don’t buy a whole bunch of one type until you know your baby’s preference. Pacifiers that are single piece may be preferable because they are unlikely to break and turn into a choking hazard. At the very least, pay attention to multiple part pacifiers to make sure they are in good shape. Pacifiers that are easily cleaned and simple seem to make the most sense.

6. Should I put something on the pacifier?

No. The practice of putting sugar or honey on pacifiers is unnecessary and potentially harmful. They can both accelerate the damage to teeth and honey has been known to cause a severe infection known as botulism in infants.

7. When should I replace or change pacifiers?

Pacifiers that are damaged or have been chewed should be thrown away. Small pieces can dislodge and become a choking hazard. In addition, throw away a pacifier when a child can put the whole thing in his or her mouth.

8. Should I use a pacifier-attached lovie?

This might be the most controversial (or at least unwelcome) advice in this whole post but using a lovie attached to pacifier particularly at sleep times could be just as dangerous as having a large blanket or pillow in bed with the child and shouldn’t be used.

9. How should I clean my baby’s pacifier?

Use warm water to rinse a baby’s pacifier. Some are dishwasher safe. Soap can be used intermittently and some can be placed in boiling water. Can you clean them with your mouth? Yes and there have been studies that show it might decrease your child’s risk of allergies but can also spread germs.

I hope this helps. What other questions do you have about pacifiers? Respond in the comments and we’ll get back with you.

And yes folks, that means Q-tips. Look at what our medical director of Emergency Services has to say:

“Q-tips and cotton-tip swabs cause numerous ER injuries we see at Cook Children’s,” Corwin Warmink, M.D., medical director of Emergency Services said. “I know people hear this all the time, but children should not be putting cotton-tip swabs in their ears. They can cause damage and sometimes the damage can be severe.”

Natalie Roberge, M.D., an Ear, Nose and Throat specialist at Cook Children’s, says problems from placing cotton-tip swabs in the ear can include:

1. Pushing the wax further into the ear canal causing impaction.
2. Laceration/bleeding of the ear canal.
3. Increased risk of otitis externa from the trauma. It's called swimmer's ear, but really any trauma to the ear canal can lead to otitis externa.
4. Perforation of the ear drum. Some will not heal and require surgery. Rarely the middle ear ossicles will also be damaged.

So how do you get earwax out of your child's ear? 

Well maybe you don't.

Earwax is a normal, protective coating to the ear. Some kids make more than others.It doesn't need to be removed except in extreme circumstances and should not be removed by parents.

If you can see some earwax on the outside, it's OK to clean it off but there's never a need to place something in the ear canal to remove it.

Even if I see a lot of earwax during a checkup, I don't clean it out unless there is a concern for infection, a problem with hearing or there is discomfort from the wax.When it is time to remove it, we have a few options:

1. Drops to break down the wax. These can be bought over the counter but should not be used in patients that have a history of tubes or who might have an ear drum rupture.
2. Ear flushing - In the office, we can use a flushing of fluids to remove the wax from the ear.
3. Ear curettage - The most common and my preferred method is to use an ear currette to pull the wax out of the ear. This is done with extreme care because the child must be older or held properly to make sure they are safe.

I get asked a lot about earwax from parents. I hope this advice helps. 

Related to this topic:

• What's Earwax?
• Let's Learn Something: Ear Infections and Tubes
• 7 Ear Infection Myths Every Parent Should Know
• Another Ear Ache. Is It Time To See An ENT?

But, does your child have a cold or allergies?

After all, the mountain cedar pollen count is the highest it's been all season in North Texas and is in the "very high" category for the first time since January 2017. 

We're also in the middle of the cold and flu season. 

Determining the difference between colds and allergies can be very difficult, but knowing which it is can be helpful for treatment, expectations for how long it should last and for determining if your child is contagious.

Colds are caused by viral infections which are spread from person to person. They can occur year round but are going to be more common in winter months. Symptoms usually last 3 days to 2 weeks but remember that kids can get several colds per year so it’s possible for them to be sick for long periods if they catch a few colds back to back.

Allergies are caused by an overreaction of the immune system to allergens. Dust, pollen or molds can all be potential triggers. Allergies can occur year-round depending on what your child is sensitive to. Usually fall and spring are busy allergy seasons but pollen counts were moderate to high many days in December.

So, how can you tell the difference?

Symptoms with a cold usually build up over a few days but allergic symptoms can start quickly after the child is exposed to the substance they are allergic to.

Here are some of the symptoms that can be present and whether they are more likely a cold or allergies:

This time of year, if your child has cold symptoms but also have significant body aches or high fever, you should also consider if they might have flu (because they probably do).

Treatment for colds is treating the symptoms. Nasal saline and suction for babies. Honey for kids over 1. Make sure they are drinking plenty of fluids and getting rest.

Treatment for allergies should usually start with a long acting antihistamine like Zyrtec or Claritin. If that doesn’t seem to be helping, talk with your doctor.

Here are 12 day-ngers of Christmas:

1. Fireplace - Lighting a fire is one of my favorite winter time activities but it can be very dangerous for kids. Young children should always be supervised when around the fire and you should have them inspected regularly to prevent potential problems.
2. Candles – If you’re anything like my wife, the first thing you want to do when you get home is light a candle. The smells can really put you in the Christmas spirit but little hands love to explore flames and hot wax can be just as dangerous.
3. Small decorations – Small decorations (manger scenes or small tree ornaments) can be a significant choking hazard this time of year. Because they are often colorful and shiny, they can be spotted from across the house and crawling babies will find them.
4. Glass decorations – Little feet and crawling knees get glass in them frequently this time of year. A solid barrier around the tree and keeping fragile ornaments up high can help.
5. Stocking holders – Heavy stocking hangers can be a risk for kids as they reach up to pull down on the stocking and the heavy holder can cause skull fractures and bruises. Use lighter hooks, tape or otherwise secure the holders in some other way. It could even knock out your child’s two front teeth.
6. Tree allergies – Kids can be allergic to trees and this is the only time of year where we bring in a gigantic live allergen into our homes. If you are an allergic type family, think about an artificial tree; especially if your kid always end up miserable around Christmas-time.
7. Christmas tree water – Yes, kids will drink water anywhere they find it. The Christmas tree base is the perfect height for a crawling baby to lap it right up. Find kid safe tree nutrients or make sure that they are kept away from the base.
8. Holly/mistletoe berries – The old time fear of poinsettias may be true if your child ingests several flowers which can lead to abdominal cramping but the real risk is holly berries. Ingestion can cause severe stomach cramps and diarrhea from even just a berry or two.
9. Unstable tree base – Make sure that your tree is properly installed and the base is broad enough to prevent tip over if a child decides to do some indoor tree climbing practice or is rockin' around it.
10. Ladders – The process of decorating can be just as enjoyable as the decorations themselves. But ladder falls are common …your child doesn’t need to see you toppling over so be careful amateurs. Also be sure and put them away after each use so that little kids don’t decide that they can “help” later.
11. Electrical outlets – This time of year new things need to be plugged in and unplugged but don’t forget about your plug covers and electrical safety. Keep the cover nearby and replace it each time you unplug that tree or other decoration.
12. Hot drinks – Decorating and celebrating Christmas means more hot chocolate and apple cider but wandering little hands are eager to see what’s in that colorful mug…

This time of year can be amazing as a family…but stay alert.

When your baby is in a new house or environment be extra vigilant.

Take precautions as you deck the halls to prepare for safety at home.

Have a Merry Christmas!

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.

Texas Health and Human Services has sent out an urgent message warning parents about the risks of giving honey to children 12 months old and younger.

"Infants (children less than 12 months of age) should not be given honey, or pacifiers containing honey or other food products, because of the risk of contracting infant botulism. Consumption of honey is widely recognized as a risk factor for infant botulism by healthcare and public health professionals" THHS wrote in its health alert.

Babies exposed to honey can contract botulism which can present as constipation leading to the inability to suck, weakness (loss of head control) and ultimately difficulty breathing.

Kids under 1 should not have honey, honey containing foods or baby products containing honey.

Botulism cases are usually rare, with about  8 cases per year in Texas but there have been four reported cases in the state since August. All four of those cases were linked to honey containing pacifiers. Botulism can be fatal and should be considered a medical emergency.

Normally, honey is a great option for cough in kids, but it should NEVER be used under 1 year of age.

Symptoms in infants often include:

• Constipation
• Lethargy
• Generalized weaknesses (the “floppy” baby syndrome”)
• Poor feeding
• Poor head control
• Poor gag and sucking reflex

In the meantime, here are some things you can do to help.

Suction, suction, suction. Your old friend the bulb suction (aka nasal aspirator or booger-sucker) is the best thing you have against congestion. Many times people tell me they don’t get anything out when they use it but that is usually because they aren’t doing it right. Depress the bulb, push the tip in the nose until you have a seal on the nostril and then release. Repeat for each side. There are other devices that you can use to accomplish the same goal. I’ve seen a mom place her mouth directly over the nose and suck (yeah, wow) and there’s also the battery operated device. The other one that I have a handful of families using is the Nose Frida. This device allows you to suck mucous out of baby’s nose with a tube that has a filter in it. Seems kinda weird to me but my families who use it swear by it.

My two main recommendations about suction are that you should stop whenever you are no longer getting anything and that you shouldn’t suction thousands of times a day. If you continue to suction without production, you are only causing swelling in the nasal passage and making the problem worse. If the child is happy and noisy, there is no reason to suction them. Reserve your suction times to before meals and at bedtime. If they are just noisy, it is bothering you more than it is bothering them.

Nasal saline drops-putting some nasal saline drops in the nose can be very helpful with that hard to reach congestion in the back of the nose and when the congestion seems to be thickening such that it cannot be extracted with suction. Just place a few drops to each side of the nose and then pull with suction to get a little more snot out.

Humidity-keeping the nose nice and moist actually helps to smooth the air flow as it goes from the nose to the trachea and into the lungs. This helps the babies breathing stay comfortable. I get asked all the time about whether it should be warm or cool mist and I frankly don’t care. If you have child have bad congestion/coughing, getting the bathroom with the shower going can be helpful as well.

So, these are my helpful tips for congestion.

Any one else have anything that they have used out there? Any one used the Nose Frida?

I tell you that not to freak you out, but to let you know how common it is. Most cases are typically mild. When we see sever disease, it's often in immunocompromised patients and those cases are uncommon.

What's important to remember is the children who died in New Jersey were all medically fragile and had weakened immune systems.

I know this kind of news can be scary, so I thought I would take some time to answer a few questions you may have.

What is adenovirus?

For most children, adenovirus causes mild symptoms. Sore throat, pink eye, fever and common cold symptoms are the most frequent. The symptoms are typically similar to but much less severe than influenza and can also be mistaken for strep throat. Like most viruses, the initial symptoms go away on their own in a few days but upper respiratory symptoms such as cough and congestion can last up to two weeks.

There are multiple different types of adenovirus, some cause more severe disease than others. They are all spread by close personal contact and by droplets spread by coughing and sneezing. In addition, adenovirus is pretty resilient and can live on surfaces. It can also continue to be spread by people with weakened immune systems, even after the symptoms have resolved.

Should you be worried?

Because adenovirus is usually a mild illness, most parents don't have to worry about the virus. The situation in New Jersey is a tragic combination of factors that led to this terrible outcome. Multiple children who are medically fragile living in close quarters. In addition the type of adenovirus which affected the children is known to be one that causes more serious disease.

So, what if my child is medically fragile?

If your child lives or will spend time in a group rehabilitation home investigate their cleaning practices. There is little evidence to suggest that this rehabilitation center has made significant mistakes that caused the outbreak, but you can never be too careful.

Otherwise, keep you child away from illness as much as possible. If they are sick with upper respiratory symptoms, monitor them closely for sign of difficulty breathing and seek help quickly

For the rest of us, it's important to remember to keep our kids home when they are sick so that we do not put other children at risk.

We’re likely to share a cute video of our children blowing out their birthday candles or a picture of our kids in their baseball uniforms.

There are plenty of things that parents and kids go through that no one feels the need to post. Some of them are thought of as “gross” or “weird.”

But even celebrities aren’t immune to gross and weird. America’s cutest couple recently went through a battle with pinworms … it was so memorable that Kristen Bell felt the need to share it with everyone with a Netflix subscription when she went on the Joel McHale show and shared about her family’s experience with pinworms.

Here are 5 common medical conditions that no one (except maybe Kristen Bell) shares on Instagram:

Pinworms

Pinworms are an annoying cause of anal itching. Kids (usually elementary age) get them from touching and ingesting the eggs from foods on contaminated surfaces. You can usually diagnosis pinworms with the story alone but if you see a moving worm on the stool or toilet paper, you know what’s going on. Treatment is a medicine that you take twice, one immediately and one 2-3 weeks later depending on the type of medication.

For more information, read our full post on pinworms: 4 Things Every Parent Should Know about Pinworms

Molluscum

One of the most common skin problems that no one seems to know about is molluscum. Molluscum contagiosum is a viral rash that causes little flesh-colored bumps that can look like they have clear fluid inside. They are similar to warts in that they can spread from child to child and a child can spread them to other parts of their bodies. They tend to go away on their own but they can be frozen or removed if they are bothersome or are in tricky parts of the body. They are not concerning but one of the most annoying conditions we see in pediatrics.

For more information, read our full post on molluscum: The most common rash you never knew about

Scabies

Although less common than some of the other topics on the list, scabies is another condition that we see frequently but you’d never know it. Scabies is an infection with a parasite that causes itchy red rash all over but is most present in the spaces between the fingers and toes. The condition is not necessarily related to cleanliness, although this is a common misconception. Treatment is a topical cream that is applied neck to toes and repeated in a week.

For more information read this post about scabies (and cooties): Eww, cooties: The Doc Smitty on lice, scabies and yes, cooties

Lice

Oh, the dreaded email from the school, “There has been a case of lice in your child’s classroom.” Lice is sooooo common. Almost every child will have a case at some point during their school-age years. The diagnosis is made after the discovery of live lice or nits (which are eggs) on the scalp. The child will commonly be itching their scalp. The treatment is a shampoo that kills the nits or a treatment to remove the nits and prevent re-infestation.

Treatment for lice has become more complicated because of lice that are resistant to standard treatments. Here’s an article that explains what you need to know: 4 Ways to Fight Against Super Lice

Bedwetting

No one talks about this…but 15 percent of 5 year olds still wet the bed… 5 percent of 10 year olds…

Almost every bedwetter has another bedwetter that sits with them in class every day.

There are some subtle things you can do to help. But, most of all, children outgrow their bedwetting on their own time with bladder maturity and not often because parents find the magic fix. There are solutions that can be explored for sleep-overs and overnight camps.

There are some warning signs that might warrant further concern or investigation. Read more here: Bedwetting: When should you be concerned?

So what should you remember?

1. Get kids and do weird stuff (these and many others) that no one talks about.
2. It’s ok to keep it to yourself or share.
3. Even if you choose not to share, remember that you’re probably not alone.

So, are gluten free foods better for your child?

The answer is…

Complicated. It depends on your child.

Gluten is a protein found in wheat, rye and barley. The protein works as a “glue” to hold the foods together. It is often found in foods that might be unexpected or surprising.

Are gluten-free kid’s foods healthier for my child with celiac disease?

Yes. Definitely, absolutely yes.

Celiac disease is a genetic condition in which people have a severe auto-immune reaction to gluten that leads to damage of the small intestine. It can be difficult to diagnose because the symptoms are wide and varied but often include abdominal pain, bloating, diarrhea, stool changes and behavioral changes. Diagnosis can be tricky but involves lab testing and usually a visit with a gastroenterologist.

Avoidance of gluten is the primary treatment for children with celiac disease.

Are gluten-free kid’s foods healthier for my child with gluten intolerance (non-celiac)?

First of all, you have be very careful to determine if there is something to this. Because many of the proposed symptoms of gluten intolerance are vague and not specific (there are many doctors who question if it is a true condition). Whatever you believe, it can be easy to attribute normal child stuff to a sensitivity to foods.

Because of this, I highly recommend a long conversation with a pediatric, GI doctor or allergist before making the changes to your diet. Studies have shown that it is more difficult to obtain adequate calories and nutrition for kids on gluten free diets. Thus, it’s not without risk to decide to eliminate gluten from your child’s diet.

Are gluten-free kid’s foods healthier for my healthy child?

The answer to this is categorically no. In fact, they could be less healthy.

A recent study compared food for kids based on whether those foods were advertised as gluten free or not. The results might surprise you.

Gluten free supermarket foods were found to be nutritionally similar to regular child-targeted foods. One change was that 80 percent of gluten free kid foods had higher sugar content than non gluten free kid foods. Previous studies have shown that gluten free products have similar total calories but less protein and fiber.

Bottom line, if your child has a medical need, gluten free foods are important. Otherwise I’d save my money and skip them.

"I swear he looked worse when I called."

"She hasn't been this active in days."

"She felt so hot when we left the house."

I get it. I've always tried to understand when I hear parents say these kind of things and this week I was personally reminded how this happens.

After getting a worried text from my wife, I left a Cook Children's Physician Network board meeting and hurried home to rush my daughter off to urgent care. After a few minutes there and a trip to the bathroom...we were as good as new. Back to asking a million questions. Back to telling me to look at the screen to see the same scenes in the same movies we've been watching for years. Back to getting on the table, climbing off the table.

Has this happened to you? Most likely, yes.

But, we got our results back, everything checked out great and we were on our way.

Why does this happen? Maybe no one knows.

Here are my 5 suggested possibilities:

1. Time has passed. Kids can get rapidly better and rapidly worse. That's one of the amazing (and absolutely terrifying) things about working in pediatrics. Kids often get better within hours. So, it's possible they were just due for some improvement after you called for the appointment.

2. Your child's medicine has had time to kick in. Kids can look terrible when they have fever and can pretty much bounce right back to normal when it goes down. If their fever is down, they are going to look much, much better.

3. You're in the presence of trusted professionals. (all modesty aside) When you're really scared, it's nice to have anyone around. Having that someone be a pediatrician who's trained for years to handle just this situation might make them look "better."

4. Kids often look better in the daytime. If you were worried about your child at night but bring the child in the next morning, they often look much better. Viral illnesses often look worse at night. Also, when you are tired, you might be more prone to worry and less able to put your fears in context.

5. I have always joked with my parents that we have a magic spray in the waiting room that decreases fever, fussiness and otherwise just makes kids look better before they get back to the room. What I learned from posting about my experience with my daughter is that I'm not the only pediatrician who does so...some of them call it magic pixie dust, some magic spray but apparently we all have something that does the same thing.

Ironically, there were many other pediatricians who responded by saying that their kids often did the same thing. I wasn't alone.

So, the next time your child looks tragically ill at home and perfectly fine in the office, you can rest comfortable knowing that your doctor has probably experienced the same thing.

The CDC recommends people not eat this cereal and retailers not sell any Kellogg’s Honey Smacks cereal at this time because it might be contaminated with salmonella and could make people sick.

Justin Smith, M.D., a pediatrician at Cook Children’s Trophy Club office, said that salmonella is one of the most common bacterial causes of infections he sees in his office and it is a “fairly frequent cause” of severe diarrhea and abdominal pain in children.

Symptoms that might alert parents they should call a doctor include:

1. Severe vomiting with decreased urine frequency or other signs of dehydration.
2. Fever of more than 102.
3. Blood or mucous in the stool.
4. Severe belly pain.
5. Diarrhea that lasts more than one week.

“If you suspect your child has salmonella, your pediatrician can run stool studies to confirm the diagnosis,” Dr. Smith said. “This may not be necessary if there are known cases that the child has been exposed to. The infection will typically go away on its 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, Dr. Smith said parents should consult with their doctor and keep them out of daycare until the pediatrician is sure they will not put other children are risk.

The Kellogg Company recalled all Honey Smacks products that were on the market within the cereal’s one-year shelf-life on June 14, 2018. The CDC stated that even products with earlier dates could also potentially be contaminated.

In its press release, Kellogg Company states that none of their other products are impacted by the recall. “Kellogg launched an investigation with the third-party manufacturer who produces Honey Smacks immediately after being contacted by the Food & Drug Administration (FDA) and Centers for Disease Control (CDC) regarding reported illnesses,” Kellogg wrote in its release.

The CDC has this advice for consumers and retailers:

• Do not eat any Kellogg’s Honey Smacks cereal, regardless of package size or best-by date. Check your home for it and throw it away, or return it to the place of purchase for a refund. The Kellogg Company recalled the cereal on June 14, 2018.

• Retailers should not sell or serve Kellogg’s Honey Smacks cereal.

• Even if some of the cereal has been eaten and no one got sick, throw the rest of it away or return it for a refund.

• If you store cereal that looks like Kellogg’s Honey Smacks in a container without the packaging and don’t remember the brand or type, throw it away.

• Thoroughly wash the container with warm, soapy water before using it again, to remove harmful germs that could contaminate other food.

Illnesses due to the outbreak have been reported from March 3, 2018 to July 2, 2018. Ill people range in age from less than 1 year to 94. No deaths have been reported.

Chiggers.

Earlier this week, NBC5 reported chiggers in North Texas is the worst in 30 years.

So what does this mean for your kids?

The truth is mainly annoyance. Let’s take a look at what you should know about chiggers and dispel some of the myths you may have heard about these pesky little arachnids.

1. Chiggers burrow into your skin and need to be suffocated.

Chiggers attach very lightly to skin when they bite. They use piercing mouthparts to inject digestive enzymes into their host. This allows them to feed off the host’s skin cells. It’s the reaction to these enzymes that causes the itching and irritation.

2. Use nail polish to get rid of them.

Light brushing or a shower easily remove the chiggers, there’s no need to apply nail polish or another cream to suffocate the chiggers. Once your child has been bitten, treatment is aimed at treating the symptoms and can include oral antihistamines or calamine lotion.

3. Chiggers can transmit diseases like mosquitos and ticks.

Chiggers only barely pierce the skin and do not ingest or transmit blood-borne illnesses. They are super annoying but do not carry the risk of transmitting infections like mosquitoes and ticks. The most common infection after a chigger bite would be a local infection caused by itching.

4. Chiggers can cause multiple bites and can spread from person to person.

Once a chigger bites and detaches, it quickly dies. They can’t spread from person to person or even bite you multiple times along the way. When multiple kids get chigger bites, it’s likely because they were playing in the same area. Clusters of chigger bites usually occur around the waistband and sock line because that is the environment that they love-but the bites are caused by multiple chiggers.

Related Topics

• The deets on DEET from a pediatrician
• Protecting Your Child From Ticks
• Skeeter Syndrome: Is My Kid's Bug Bite Infected?
• How to fight (and win) against mosquitoes
• 4 Ways To Fight Against Super Lice

The FDA said the products were currently available, but that “supply levels may vary across wholesalers and pharmacies.”

"Based on the information provided by the manufacturer, the FDA anticipates the EpiPen shortage to be short-term," an FDA spokesperson said.

The advocacy group Food Allergy Research and Education (FARE) called on the FDA to act swiftly on the growing national shortage of epinephrine auto-injectors.

“Epinephrine is the first-line treatment for anaphylaxis, a serious and potentially life-threatening allergic reaction associated with severe food allergies,” the organization wrote in a press release. “Delayed use of epinephrine during an anaphylactic reaction can lead to death.”

FARE stated the shortage has been felt by patients in almost the entire country, and was not necessarily a “spot shortage.”

So what should you do if your child has an EpiPen need?

Justin Smith, M.D., a pediatrician at Cook Children’s recommends the following:

1. Check to see if your prescription is at or near expiring.
2. Check multiple pharmacies in your area as some may have it and some may not.
3. Check with your pediatrician for alternatives if you can’t find it.

But, does it help? Is it necessary?

I personally don’t think so…and here are 4 reasons why:

1. I don’t treat numbers, neither temperatures nor times.

When your child has fever, sometimes it’s not such a bad idea to let it be. If the child isn’t too uncomfortable and they are drinking well, it’s reasonable not to treat even if their temperature is high. If you’d like more information, read this great post from Dr. Paul Offit called, “The Case for Letting Fever Run It’s Course.” The bottom line is that treating fever may in fact cause the symptoms to last longer and the child to be contagious longer than just letting it run it’s course.

Bottom line: If treating the thermometer is not the best idea, should we be treating a child every three hours, around the clock, just in case? Maybe not.

2. It might keep the temperature lower, but it doesn’t make kids feel better.

There have been a few studies that suggest treating fever on a scheduled basis might keep the child’s temperature lower. So, it probably does work to do that. The interesting thing with those studies is that when you ask the parent how well they thought the fever was controlled, both groups reported that their fever control was adequate.

Bottom line: Even if the temperature was lower, the parents couldn’t tell the difference in how the child felt.

3. It increases the risk of extra doses.

When your child is sick, you are tired and stressed, things are complicated enough. The risk of extra doses is significantly higher when you are alternating medications. While the risk of an extra dose here and there probably isn’t high, if there is little to no benefit, I choose not to risk it.

Bottom line: If you are going to do alternating doses, write them down somewhere to keep track.

4. I’m lazy and it’s too much trouble for me.

This is not one of those issues that I’m willing pick a big fight with another doctor or patient over…but given the three points above combined with my desire to keep everything as simple as possible, I don’t personally alternate fever reducers for my kids and I don’t routinely recommend it for my patients.

On a recent interview with the Joel McHale Show, Kristen Bell described an episode in her family that highlights one common cause: pinworms.

If you haven’t seen the video, I highly recommend you watch it because, it’s actually pretty accurate; and, despite the fact that she uses a word near the end that’s a little too mature for Anna, she somehow manages to make having pinworms adorable in a way that only Kristen Bell can.

How do children get pinworms?

Kids usually get pinworms from eating foods or touching contaminated surfaces and then placing their hands in their mouths. The eggs are small enough to become airborne and swallowed.

So, like she says in the video, they are highly contagious.

How do you know if you or your child has pinworms?

Most infections with pinworms don’t cause symptoms (especially in adults) but the most common symptom is anal itching. Kids will sometimes itch so badly at night that they don’t sleep very well. Other sites of infection can occur and there can be enough worms to cause abdominal pain but these are both rare.

How do we diagnose pinworms?

Pinworms are formally diagnosed when the symptoms are present and the worm is seen - either around the anal area, on the outside of the stool or toilet paper. The worm are about ¼ inch long and thin like a piece of thread-but are often moving.

If you see the worms or the child has a known exposure to someone with pinworms and is showing symptoms, it’s reasonable to assume that they have them and proceed with treatment.

If you’re not sure, and you want a test to check, some recommend placing a piece of clear tape around the anal area first thing in the morning in an attempt to collect some eggs or worms-the Scotch tape test.

How do we treat pinworms?

The easiest, cheapest means of treating pinworms for kids over 2 years of age is pyrantel pamoate. It is available over the counter and is given in doses, one dose now and another dose in 2 weeks. If your child is under 2, consult your doctor.

Household members and caregivers of the child should also be treated. Avoid co-bathing during the 2 week period. Taking a daily shower and washing clothes in hot water can help prevent reinfection.

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.

You probably did, but hopefully that didn't prevent you from getting your child's flu vaccine.

New data from the CDC suggest that the vaccine was 50 percent effective for pediatric illness, which is actually a fair year. We’ve had better. We’ve had worse. But it's definitely way better than the 10-30 percent estimates that were being thrown around earlier this year.

In previous years, data have shown that nearly two-thirds of pediatric deaths have occurred in children who were not vaccinated. This data is even more significant as three-fourths of pediatric deaths have occurred in children who were not completely immunized (either no vaccines or only one vaccine in a baby who needs 2 for full protection).

Only 54 percent of children who died of flu had a condition that characterized them as high risk. This means that they were older, healthy kids who got the flu and died.

Is the flu shot perfect? No. Do I wish it were better? Yes.

But do any of these reasons for not getting one hold up?

"It doesn't sound like it's going to work very well this year anyway.""My kid's healthy, so I don't think they really need one.""We stay really careful to avoid others who are sick so we'll be good."

Nope. Nope. And, unless you live in a bunker from October to March: Nope!

It's actually still not too late. You can get protection from this year that will help and there is mounting evidence in adults that getting flu vaccines year over year may provide more protection than just for that season. We're still waiting on that evidence in kids, but logic says it could still apply.

Most pediatricians recommend breastfeeding as the primary source of fluid intake for up to one year of age (even longer is fine).

For those who choose not to or could not breastfeed, I recommend an iron-fortified formula until one year.

After one year, a healthy, normal developing children should be transitioned to a well-balanced diet.

Cow’s milk can be used as an easy source of calories, protein and calcium but there’s nothing magical about it. If your child doesn’t like it, or you choose not to, just make sure that they are getting a nice rounded diet.

So, what about toddler formulas and toddler drinks?

The formula companies would like you to believe that they are an essential part of a toddler’s diet. They have added components to make them more attractive including probiotics and DHA. They make the cans look similar to your infant formula, to make it feel like the transition is expected and necessary.

But, I think you can and should skip them, unless instructed by or prescribed by your pediatrician. Here are 3 reasons why:

Many of them have ingredients that I wouldn’t recommend for toddlers anyway: corn syrup and other caloric sweeteners for example.

We really don’t know much about what giving DHA to a toddler adds to his or development or intelligence. If you are worried about it, add some fish to your toddler’s diet.

Most kids get plenty of calories and nutrients from other food sources. They don’t need the added calories and the extra nutrients are unnecessary except for the pickiest, most restrictive eaters.

So, what is toddler formula?

Mostly hype and marketing.

What should you do about it?

Unless instructed by your pediatrician, save your money for college…and I mean it.

Here’s the calculation:

Assuming three 8 ounces cups of toddler formula per day, you will need about 70 cans of toddler formula from 12 to 24 months. Each can costs about $20. That’s a total of $1400 during that year. If you invested that $1400 over the next 16 years (until they reach college age) and averaged 10 percent growth, you’d have about $6,500 by the time they reach college age.

Are you panicked about the flu? How do you know if your kid is getting worse? What about all these kids getting really sick, even dying?

Here's what I've been saying all day, every day in my office this week.

1. Healthy kids who get sick from the flu get really bad because they get dehydrated. Push fluids. If they don't want to eat, that's OK. But they have to drink. Monitor urine output. Kids should pee about every 6 hours. If they aren't, they need to be checked out.

2. Healthy kids also get sick from the flu because of respiratory complications. Monitor for signs of difficulty breathing, especially fast breathing or signs that they are working hard to breathe. Look under their ribs, is it sucking in and out heavily? If so, they need to be checked out.

3. Look out for kids whose fever gets better and then comes back. Many times parents write off those symptoms as just a little left over from the flu but they could be a sign of a secondary infection. Ear infections, sinus infections and pneumonia often frequently follow the flu. Once the flu is over and the kid is getting back to normal, they shouldn't come back.

4. Kids with chronic medical conditions should be watched closely for worsening of their condition. Asthmatics should be watched closely for breathing. Diabetics should have their sugars watched, etc.

But I’ve been asked about some other treatment options. Do they work? Are they safe?

When it comes to “alternative” medications, I try to keep an open mind; but, I basically divide them into three categories:

1. Yep, go for it - Treatment options that have been studied and shown to be safe and effective in kids (or in adults but with reasonable belief it would also be safe and effective in kids).

2.  Meh, if you want, go ahead – Treatment options with mixed studies or no studies proving effectiveness but no studies or reason to believe that they would harm kids.

3. Nope, not a chance – Treatment options that have no studies and no logical pathway by which they could be effective and/or any reason to believe they could be harmful for kids.

Let’s look at a few alternatives:

Elderberry syrup/gummies/soup…

There are some VERY small studies (less than 50 patients) in adults that showed some improvement in flu systems for people already diagnosed with the flu but treated with elderberry within 48 hours of symptom onset.

I cannot find any studies addressing its use in kids or an appropriate dose. Also, despite its frequent use as a preventive option, I can’t find studies that support elderbery will decrease you or your child’s likelihood of getting the flu. I also haven't found a study that says it is safe to give over long periods of time.

So for me, it’s “Meh, if you want, go ahead.” I wouldn’t spend my money on it and I definitely wouldn’t give it over long periods of time for prevention, but I won’t give you a lecture if you are using it over short periods to treat flu-like symptoms.

Oscillococcinum

What is it? It’s a homeopathic medicine (meaning it’s a super diluted substance which supposedly maintains an imprint of the original chemical makeup) made initially from anas barbarae hepatis et cordis extractum 200C, which sounds impressive but is actually Muscovy duck liver. Keep in mind that the mixture is so dilute, it’s actually very unlikely that there is any duck liver present in the little tablets you put in your mouth. But, even if there was, just research how the guy came up with the reason for using duck liver and you’ll understand that there wasn’t much science or even logic that went into the idea in the first place. Large systematic reviews of the studies for use of oscillococcinum for both prevention and treatment of flu have shown no evidence that it works for either.

Fortunately because this is a homeopathic medication (and mostly sugar), there are no major side effects with its use. Because of that, I was tempted to put it into the “Meh” category. But because its use defies all science and logic, I just can’t, so it’s, “Nope, not a chance.”

Essential oils for treatment of symptoms/flu

We’ve covered this one…extensively. Our first post on it is called “Essential Oils and Their Use in Children.” Then you can read, “How safe are essential oils for children?” And finally, “Essential oils and children –more questions answered.” If you don’t have time or interest in reading those, here’s the TL;DR summary: If you use them within reason, and diffuse but don’t ingest, they are a “Meh, if you want, go ahead.”

But, you have to promise me you won’t go crazy and if things aren’t going as expected, or your child is getting worse rather than better, that you will seek help. Do you promise?

Neosporin in the nose to prevent flu

Neosporin is an antibiotic ointment. Flu is viral. There are no studies to support this. I don’t see how this could be helpful. So, “Nope.”

Sinus rinses

Besides the feeling like you got hit by a truck, one of the other most frustrating and annoying problems with the flu is the feeling of congestion so severe that it feels like you can’t breathe. Saline sinus rinses, either as a flush like a Neti-pot or spray and suction for babies, can be helpful to relieve this feeling. So, “Yep, go for it.”

Honey

The cough associated with flu can be deep and severe…but, as you probably know already, I don’t believe that any cough medicines (prescription or over-the-counter) work very well in kids and they can be harmful. So, my go to for cough for kids over one year of age? Honey. Yep, just honey. Yep, just give it with a spoon. Yep, as many times a day as you think your kids needs it. Seriously, just honey. (This might be a conversation I have daily to a parent with a look of complete and utter untrusting disbelief).

There are probably a million other alternative flu treatments out there but these are some of the common one that I get ask about.

What other alternatives have you seen?

As a pediatrician, I've never been in favor of these medications as a treatment for your child's stomach virus and diarrhea. Studies have shown that use of antidiarrheal medications may prolong the course of the illness. 

Stomach viruses are the most common cause of diarrhea. Diarrhea, after a stomach bug, can last a while, even up to 1 week. A close second is diarrhea associated with antibiotics which can last as long as the child is on antibiotics and even a few days later.

For most cases of diarrhea, you probably don’t need to see the doctor. Here are some things you can do at home to help:

1. Get back to a regular diet as soon as possible. Continuing the Gatorade or Pedialyte only makes it last longer.

2. Do not use antidiarrheal medicines (even Pepto-Bismol). They don’t work and can have severe side effects. 

3. Talk with your doctor about using probiotics. Some studies have shown that they might be helpful.

Here are some reasons it might be time to go ahead and give the doctor a call:

1. Stool with blood or mucous

2. High fever

3. Signs of dehydration (dry lips, not urinating for 6-8 hours)

4. Diarrhea that lasts more than 1 week

Diarrhea will never be fun because it can ruin your life for a few days. But, if your child’s diarrhea lasts more than a week, trot (sorry) on over to your friendly pediatrician. They might need to do some tests to help you figure out what is going on.

“Should I even bother getting the vaccine,” I get asked.

“Yes. You should definitely still get your child’s flu vaccine.”

Here’s why.

Is it going to be a bad flu season?

Widespread influenza activity is present in 46 states, including Texas. Hospitalizations for influenza associated illness are on the rise, with nearly 4,000 reported. Children under 5 (as well as adults over 65) appear to be at the highest risk for hospitalization.

As of December 29, there were 13 pediatric deaths associated with influenza in the U.S. And it wasn’t just little babies either, six of those deaths occurred in children over 5 years of age. Only two of those children were known to have high risk conditions, which means that many of the deaths occurred in healthy children. 

One of the major concerns, regarding the severity of the season, is that much of the circulating Influenza A virus is of the type H3N2. In previous years where H3N2 has been common, we have seen increased numbers of cases and more severe disease. Last week, more than 237 children tested positive for Flu A at Cook Children’s. Two weeks ago, 380 kids tested positive for Flu by our lab.

Is the flu vaccine coverage going to be terrible?

Scientists often use the previous flu season from Australia to predict what type of flu season and vaccine effectiveness we are going to have. You might have heard early reports that suggested that this year’s vaccine might only have 10 percent effectiveness. But, the important point to remember is that meager 10 percent only reflected activity against H3N2 and truly predicting which strain will be most common is tricky.

Another important factor to consider is that flu activity is regional. Influenza A activity nationwide is showing H3N2 activity at 7,012 out of 7,754 overall cases, or 90 percent. But, in region 6 (of which Texas is a part), H3N2 was present in 466 of 589 or 80 percent of Influenza A cases. Still not great, but there’s plenty of vaccine preventable flu out there.

So, will the vaccine coverage be terrible? Maybe, but we won’t know for sure until the end of the year and I believe there is evidence to suggest that it will be better than the 10 percent estimates we were reporting earlier in the year.

Should I still get my child’s flu vaccine?

Flu vaccine is an important part of protecting our children from this terrible disease.

Your child will almost certainly be exposed to the flu this year, and probably multiple times. Flu causes serious illness, even death. Even if the coverage was only 10 percent (and I think it will be better), I would still recommend it. Flu vaccine has been proven, even in bad years, to prevent flu-associated death in pediatric patients.

Flu vaccine cannot cause flu. It is an injectable, killed virus which cannot cause infection. Side effects might include soreness at the injection site, low grade fever and mild body aches.

You still have time. We expect flu activity to be increasing over the next few weeks, possibly even into mid to late February. Once you get the vaccine, it takes about two weeks before your protection is up and going.

So, call and get the vaccine today…for you and your children.

Last week, 1,118 patients were tested for the flu at Cook Children’s and 429 tested positive (380 for Flu A and another 49 for Flu B).

Get your flu shot (go ahead, it’s not too late), wash your hands, say a prayer…all the things you should do to prevent you and your family from getting the flu. The flu season is in full force and you’ll want to protect your family as much as possible.

Unfortunately, despite all your efforts… you still might get the flu.

So, now what?

Here are 6 tips for helping your child get through the flu:

1. Push fluids, fluids, fluids. Healthy kids with flu often get sick and worsen because they get dehydrated. Kids with the flu should have something to drink beside them constantly. Water, Gatorade and Pedialyte are all good options. Watch to see how much they are peeing. They should pee at least every six hours.

2. Treat your child with a fever reducer. Using acetaminophen or ibuprofen can help with not only fever, but also the headache and body aches that come with the flu. Remember the goal is not dropping the number of the temperature, but making your child feel better.

3. Allow your child to rest as much as possible. This is not a time for strict adherence to screen time guidelines. Resting and taking it easy is a big part of getting through the flu.

4. Use a humidifier or steamy bathroom. Steam can help to loosen up the congestion and help your child breathe, it can also help with their cough.

5. If your kids are over 1, given them honey to help coat their throat and prevent coughing.

6. Follow your child’s chronic condition. Children with asthma should be watched closely for signs of wheezing and difficulty breathing. Children with diabetes should have their sugars monitored closely. Children with chronic conditions are more likely to need Tamiflu so call your doctor at the first sign of symptoms if you suspect flu.

I hope you all have a healthy and happy 2018 but when you do have problems, call your Cook Children’s pediatrician. We’re always here to help!

I know Serena, babies are hard to read. As I read Serena Williams' tweets and the struggles she's going through with her baby my heart went out to her.

There were times in my own parenting journey where I wasn’t quite sure that everything I had been teaching my patients for years was actually the right thing. So, pediatricians aren’t immune to a little doubt when the going gets tough.

As Serena Williams discovered over the weekend, celebrities aren’t immune to this either. Apparently her 3 month old was having a REALLY fussy day. And, no doubt, those days are hard. You feel helpless. You’re sure that something is terribly wrong. You want to attribute it to something and you want to have something that will fix it. But…it doesn’t always work out that way.

https://twitter.com/serenawilliams/status/942435383027097600

I guess it didn’t get any better from there…

https://twitter.com/serenawilliams/status/942435460948922368

Of course, she got some suggestions.

Many of which have been shown to be useless (and might even be dangerous) such as: teething gels, homeopathic teething tabs and amber necklaces.

But, the best advice she received came from a friend of mine, a pediatrician from down in Austin, Dr. Ari Brown (@baby411):

https://twitter.com/baby411/status/942613460273238016

Because Dr. Brown is right, teething does get blamed for fever, diarrhea, fussiness, vomiting, diaper rash, sleep disturbance, poor eating, extra eating….I could keep going but instead here’s a post about 4 teething myths.

The reality is that babies most cut their first teeth after 6 months of age and they don’t show signs or symptoms of teething for 3-4 months. If they show any signs, it’s the day before and the day that the tooth erupts and even that is up for debate.

So, what could be the cause of your child’s “teething” symptoms? Here are 3 things to consider:

1. Viral illnesses-Because viruses can cause fever, rash, runny nose, diarrhea and a number of other symptoms for which teething is often blamed, they are a common cause of visits to my office for a concern of “teething.” Because viruses are self-limited (they go away on their own), they will resolve in 3-5 days which just further reinforces the idea in parent’s minds that the symptoms were due to teething.

2. Ear infections-It’s possible for children to have ear infections, even at early ages. Because fussiness and disrupted sleep are common symptoms of ear infection, they are often mistaken for teething. Especially if your child has fever and upper respiratory symptoms along with their fussiness, consider ear infection a possible cause.

3. Normal development-This is the least popular of my opinions on teething but I believe it is probably the most accurate. I think it is normal for babies to have periods of fussiness and sleep disruption. Just like we have bad days and just like we have nights where we don’t sleep as well, babies can too.

Because of that, here was my advice:

https://twitter.com/TheDocSmitty/status/942618451788615681

Just in time to travel for the Thanksgiving holidays, 23 kids tested positive for the flu (20 Influenza A, 3 Influenza B) last week (November 12-18). That’s the most patients we’ve seen since a really bad 2014. In comparison, we did not see a single case of the flu during the month of November in 2015 and 2016.

“We’re seeing flu consistently now, and I expect it to continue increasing,” said Morgan Pence, Ph.D., a clinical microbiologist at Cook Children’s.

So what can parents do to protect their kids from the flu? Here’s some advice:

1. Get the flu shot. The flu shot takes two weeks before it can protect you from the virus. So you won’t have time for it to work the time you get to the grandparents’ house, but promise me you will get your vaccine as soon as you can. Click here to read more about the flu shot.
2. Teach your kids to cover coughs. Remember to cough into the crook of your elbow and not into your hands. And throw away the tissues.
3. Wash your hands. Other than a vaccine, this is the most important thing you can do to protect yourself and your kids from the flu. Teach kids to use soap and wash their hands for at least 20 second or long enough to sing “Happy Birthday” or Adam Sandler’s “Thanksgiving Song” (just making sure you are paying attention).
4. Call ahead. You’ve waited (or in some cases dreaded) all year to see the relatives, but it might be worth a call to see how everyone’s feeling. If someone is sick, steer your child away from the person as much as possible. Maybe, make a joke (but be firm) about a quarantine room for the sick folks.
5. If your kids do get sick while you are out of town, keep them comfortable. Give them an antiviral medicine (Tamiflu) and make sure they have fever reducers – ibuprofen or acetaminophen.

Hope this helps. Everyone have a safe and healthy Thanksgiving.

Cord blood banking has grown increasingly popular among parents over the past decade. It involves collecting blood left in the baby’s umbilical cord and storing it for possible later use. The number of conditions for which stored cord blood continues to increase as further research is conducted.

According to the new, October 2017 policy statement on cord blood banking from the AAP, there are 800,000 cord blood units stored in public cord blood banks and 5,000,000 in private cord banks. As of 2013, there have been 30,000 stem cells transplants from donated cord blood used to treat cancers, hemoglobin disorders (like sickle cell disease) and severe disorders of the immune system.

Fortunately, the process for collecting stem cells is easy. After every baby’s birth, the umbilical cord is clamped and cut. For cord banking, a medical provider will then draw blood from the placental side of the umbilical cord (no needles anywhere near the baby). The blood is then shipped to a center where it is prepared and frozen for long term storage.

So, now for the $10 million question: Which is better, public or private cord banking?

First of all, it should be said that the science behind this is changing and changing quickly. It’s impossible to say what the science will be in 5, 10, 50 years. But, based on current knowledge, the American Academy of Pediatrics position reflected in their statement is that parents should opt for public cord banking.

Here are 4 reasons why public cord banking is preferable:

1. Oversight - Public cord banks are regulated in a much stricter way than private banks. Strict guidelines for collection, preparation and storage are important to maintaining cells in a usable state.

2. Usability - There are 30 times more cord blood cells used for clinical purposes from public banks than from private. Except for specific family diseases for which cord blood banking might be useful, it is much more likely that publicly banked cells will be used. Often the condition itself prevents usage of the cells inside the family. For instance, children with leukemia cannot receive their own banked cells because they already contain pre-malignant cells.

3. Cost - Donating cells to public banks is free. Private storage generally stars with a $1000-2000 placement fee along with yearly storage costs.

4. Benefit for others - Donating cells for use by others can have a huge benefit for society. Children who need stem cells for various conditions may begin to rely upon banked cord blood for those cells. Children of ethnic minorities especially need more possible donors for stem cells, including banked cord blood.

So, should you save cord blood?

Yes. But, for now, public banking appears to be the way to go.

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.

Yep, it’s possible and it’s probably true. It might make you anxious. But, it might not mean there is anything to worry about.

Most children with a cough that lasts one week or less have viral infections which do not require antibiotics.

But what about when the cough lasts longer?

In a recent study of nearly 900 children seen for upper respiratory infections (most commonly cough and congestion), 3 out of 4 children continued to have cough at one week. We already know that, early in life, children have an average of 10-12 respiratory infections per year. Combine that with this new data and it’s possible your child could have some amount of cough nearly half of the time and still not have a significant underlying condition.

So, how long until you should be concerned?

In this study, 1 out of 4 children with upper respiratory infection continued to have cough at 4 weeks. Those children were evaluated by a pediatric pulmonologist and, at that point, were much more likely to be diagnosed with a bacterial infection or an underlying lung disease (such as asthma).

So, should you wait four weeks? Not necessarily. Consider these features which might mean that a trip to the doctor for cough is warranted:

1. Does the child have a history of respiratory illness such as asthma?

2. Is the child showing any signs of difficulty breathing?

3. Is the child drinking OK or otherwise acting sick with symptoms such as: fever, decreased activity or other symptoms?

4. Is the cough worsening after the first week?

If the answer to any of these questions is “Yes,” give your pediatrician a call.

Not many kids look forward to the flu shot, but almost all of them realize that it wasn’t as bad as they thought.

Yes, it’s that time of year. Here are 6 questions we hear most often about the flu vaccine:

1. Who needs a flu shot?

We recommend the flu shot for anyone over 6 months of age. Kids under 5 have much higher risks of hospitalization, severe complications and even death. Pregnant moms have one of the highest complication rates.

2. Is it going to hurt? What about the mist?

Yes. It’s a SHOT. I never promise that shots aren’t going to hurt. I usually say, it’s going to hurt for a minute but it gets better soon. You might have some muscle soreness and achiness for a few days but it’s a lot better than having fever and body aches for 5 days. Unfortunately, we aren’t going to have the mist this year again. Previous years have shown that it wasn’t as effective so, pending new information, no one will be giving it out.

3. "What do you think, do you want to get one?"

When I offer the flu shot to parents, they commonly turn to their kid and ask this question of their children. Seriously, don’t do that. Of course your 4 year old isn’t going to volunteer for the flu shot. It’s a SHOT.

4. Is it going to work?

We don’t always know the answer to this question until much later in the flu season. When it’s too late to get your vaccine…so don’t wait to decide. My question is always: “Even if it’s only xyz% effective, isn’t that better than nothing?” Some years are better than others. Every year, despite the coverage rate, kids lives are saved because of the flu vaccine.

5. How bad is this season going to be?

We’ve heard reports that Australia has had a terrible season. Some experts say that might predict a bad season for us, but others say, it doesn’t matter and we can’t really predict. Bottom line is that it’s either going to be a bad year or it’s not, but we won’t know until much later.

6. When should I get my child’s flu shot?

Right now! Getting protected two weeks before the start of the season is important and we never know when it’s going to start.

Your Cook Children’s pediatrician has flu shots available and we recommend that you get them ASAP, before the start of the flu season. Call your pediatrician to schedule a flu shot today. 

In an interview with Billboard published October 8, she reveals that her time her away was a consequence of scary health scare, following the diagnosis and subsequent treatment for lupus.

Fortunately, Gomez is doing well. Her lupus is in remission and she is set to appear in an upcoming movie and her newest album, Revival, will be released October 9.

Here are 8 facts about lupus that will help you understand the disease and explain it to your children if they ask:

1. Lupus is a disease where your body’s immune system (which usually helps you fight off infections) starts to attack your own cells (it falls into a group of diseases call auto-immune diseases).
2. Symptoms of lupus vary from person to person but can include: fever, swollen/painful joints, facial rash, tiredness, body swelling, sun sensitivity and mouth ulcers.
3. Lupus is diagnosed through a combination of symptoms and lab testing. It is often difficult to make because it can look like many other disease s and there is not one specific test to confirm or deny the diagnosis.
4. Lupus is not a contagious illness. The exact cause is not known but is thought to be a combination of hormones, genetics and environment.
5. Lupus most commonly affects women 15-44 years of age but can affect younger children and boys as well.
6. When severe, lupus can cause anemia. It can also cause excessive blood clotting which can lead to strokes and other complications.
7. Pediatric specialists known as rheumatologists treat lupus in children.
8. Treatment of lupus includes use of medicines to treat inflammation, steroids, anti-malarial medications and occasionally stronger medicines, which are used to decrease the activity of the immune system.

For more information about lupus, you can read more from the Lupus Foundation of America at lupus.org.
 

*Photo from SelenaGomez.com.

My dad loved watching me play and my mom did as well. What she didn’t enjoy as much was throwing all of my sweaty, dirty clothes in the wash or sitting down on her furniture after a tennis match.

Let’s face it, young athletes are gross. And with all the sweat, grime and lack of showering or bathing come some pretty nasty infections, warts and viruses.

Here are 7 skin risks your young gym rat needs to be aware of as summer ends and the school sport seasons begin:

1. Staph skin infections

Staphylococcus aureus is a bacteria that can cause a variety of infections. The most common infection that spreads through gyms are skin infections such as cellulitis and abscesses. Symptoms of cellulitis include warmth, redness and pain at the site. When an abscess forms, it will appear as a hard ball that is painful and can be filled with fluid. Infections can become more severe if bacteria find their way into the bloodstream or the infection releases toxins that can cause dangerous, even life-threatening symptoms. Treatment includes antibiotics to treat the infection and, in the case of abscess, drainage of the abscess.

2. Folliculitis

Folliculitis is another bacterial skin infection with causes an itchy rash which appears like small pimples or red patches all over the skin. These infections occur as bacteria get in the hair follicle. It is sometimes called hot tub rash or hot tub folliculitis so athletes who are receiving hot tub therapy for injury may be more at risk. Folliculitis can often resolve without treatment but your doctor may prescribe a specific antibiotics cream like mupirocin or even antibiotics by mouth in severe cases.

3. Impetigo

Impetigo is a rash that appears as a red base with a crusted yellow scab (“honey-crusted”). They are mostly likely to occur in areas where there is a break in the skin or in areas where children have picked at scabs. Scratching the infection can cause it to spread to other areas. Some of the infections will respond to over the counter medications but these infections often require prescription antibiotic creams and oral medications.

4. Warts

Warts can occur on any part of the body but the one that can spread through close physical contact. I cannot find studies that prove it can happen, but anecdotal reports of plantar warts (on the bottom on the feet) have been reported to have been spread in gym showers. Plantars warts are on the bottom of the feet, are usually very thick and hard. They can resolve on their own but, when they do not, they can be very difficult to treat and often require surgical removal.

5. Ringworm

Ringworm is a fungal infection that is most commonly thought to be spread by animals but can be spread from person to person-especially on the scalp through shared hats, brushes and other items. On the body, the rash appears as a circular red ring, usually with normal skin in the middle. On the scalp they can have the circular appearance but often just looks flaky and dry, like cradle cap. Over the counter creams can often treat ringworm on the body. If the scalp is involved, the treatment involves anti-fungal medications by mouth, often for 4-6 weeks.

6. Athlete’s foot

Athlete’s foot is the same type of fungal infection as ringworm except that it affects the feet. The rash will most commonly be located between the toes, where there will be redness, itching and often cracking of the skin. Treatment for athlete’s foot is topical creams-most can be treated with over-the-counter options.

7. Herpes simplex

Herpes simplex (HSV-1) is the virus that causes cold sores. It can causes severe skin lesions and is a particular cause of concerns for wrestlers known as herpes gladiatorum. The rash often appears on the head, neck and shoulders and can be painful but is not always. Affected individuals can also have fever and swollen lymph nodes. Mild cases often do not require treatment but if the child has a severe or long-lasting case, has immune system problems or has frequent outbreaks, they may require treatment.

Now that you know what nasty things are out there, here are 7 ways to protect your child and their teammates:

1.Wear shower shoes - Many of the infections are spread by contact with the feet. While the flowing water of the shower might protect from some infections, walking to and from might even be more dangerous.

2.Wash your stuff - While this might be common sense, seeing a gym t-shirt that can practically stand on its own is not uncommon in a high school locker room. If your child’s coach does the wash, hopefully you’ll be good. If not, remember to double check.

3.Don’t share stuff - Clothes, hair ties, socks, hats, helmets…nothing. Just keep your germs to yourself.

4.Wipe stuff down regularly -Get your child in the habit of wiping down the weight bench, locker room bench, even their own equipment frequently.

5.Cover open wounds - If your child has an open wound, make sure that they are taking precautions to keep it covered. Because many of the infections love open wounds, you’re protecting both your child and their teammates.

6.Get stuff checked out early - Accurate diagnosis and early treatment is the best way to contain an outbreak. Trying to keep things on the down-low hurts everyone.

7.Don’t participate until fully cleared - Most of your kids will not be a professional athlete. If they are going to be, missing a few days of practice because they are contagious isn’t going to change that. Follow the advice of the trainer/doctor.

Regardless of what sport your young athletes play, I hope they have a great, safe and clean season.