The recall in February from Abbott Nutrition has placed extra pressure on the supply chain and some stores are limiting the amount a customer can purchase.

Bianka Soria-Olmos, D.O., of Cook Children's Pediatrics Haslet and Alice Phillips, M.D., of Cook Children's Pediatrics Cityview answer top questions for parents and caregivers.

RELATED: Do's and Don'ts of the Formula Shortage (checkupnewsroom.com)

Parents may be wondering if they should get their children vaccinated. Vaccines are the best way to prevent serious illness in people of all ages, including children. 

Based on available data, our health care providers and pediatricians at Cook Children’s strongly recommend that parents get children vaccinated as soon as they are eligible.

“It is important to keep our children safe now and in the future," said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. "This is one way to safely protect your children AND protect people who they might expose from catching SARS-CoV-2."

We asked Dr. Whitworth to answer some of the big questions and shed a little light on the subject.

Why should my child get the COVID vaccine? 

Children are at risk to get sick from COVID-19 disease, requiring hospitalization, and in rare cases, dying from the infection.  More commonly they will get a mild infection and recover quickly. But while they are contagious they can spread this to others such as vulnerable grandparents.

How do we know it’s safe for children 5 and under?  

The children who participated in the vaccine research had no serious adverse events and we know that the FDA is extremely cautious and will review the data quite carefully before approving this.

Should parents get their children vaccinated, even if their child recently had COVID?  

Yes. Those who have been infected with this virus can get infected again. This second infection may be the same, milder, or more severe – and they are able to transmit SARS-CoV-2 to those who are more vulnerable.

What about if I live in an area with a low number of cases?  

SARS-CoV-2 will not be eradicated.  We will have this infection with us for years to come, just like influenza.  Low numbers now are something to enjoy, but we will all be exposed at some point in the future. 

What should parents do if they have more questions?

Talk to your pediatrician. They have your child’s medical history and are the best source of information for this topic. They have the latest information available and want to help you make an informed decision. 

If your child is eligible for the COVID-19 vaccine, please contact your local pediatrician's office to schedule an appointment.

RELATED: BioNTech Asks the Food and Drug Administration to Authorize COVID-19 Vaccine for Children Under 5

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

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

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

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

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

What is “asthma control”?

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

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

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

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

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

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

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

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

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

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

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

Are nebulizers safe during the pandemic?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For more information about COVID-19: cdc.gov

References

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

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

For more than six years, Cook Children’s online newsroom has provided the latest in pediatric health news to more than 16 million people in 230 different countries.

But during all that time, the team behind the scenes felt they had more to accomplish. At the top of their list was creating an online Spanish language presence. This month, they reached their goal with the publication of Checkup Newsroom En Español.

This new newsroom is in Spanish, with content written and approved by Cook Children’s pediatricians and health care providers.

“We know the importance of sharing up-to-date and evidence-based information with our patients and their families,” said Bianka Soria-Olmos, D.O., a Cook Children’s pediatrician and primary contributor to the webpage. “Checkup Newsroom is hugely important for getting out timely and relevant health information. With our community being so diverse, we realize making this information available in Spanish is necessary.”

The addition of the Spanish-language newsroom builds on Cook Children’s ‘Promise’ to improve the health of every child through the prevention and treatment of illness, disease and injury.

The COVID-19 pandemic has highlighted the need for credible health information in the Hispanic community. According to Tarrant County Public Health, 27% of COVID-19 cases are among Hispanics, making it the most affected group by race and ethnicity. Further, Texas’ Hispanic population has grown by more than 2 million since 2010 and the state's demographer predicts that Hispanics will be the state's largest population group by mid-2021.

“We are so happy that Cook Children’s is making so many efforts to be inclusive,” said Vicki Kelley, Family-Centered Care Program Manager, who oversees the Hispanic Family Advisory Council at Cook Children’s. “All parents want to do what’s best for their children. Having an online presence such as Checkup Newsroom gives parents a great resource to find helpful and accurate information for their kids.”

“The publication of our Spanish newsroom is a great next step in our diversity and inclusion efforts at Cook Children’s,” Wini King said. “We’ve talked about making this happen for many years, but were limited in time and resources. The timing just felt right, and with the COVID-19 pandemic, we know this information is needed now more than ever.”

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

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

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

Most people develop some redness and itching after a mosquito bite. Unfortunately, some children will have what’s known as a large local reaction, or “Skeeter syndrome.” This happens due to an allergy to mosquito saliva. These patients develop redness and swelling within hours of a mosquito bite. The swelling can be very large (like an entire arm or leg) and typically worsens over 1-2 days. In the worse reactions there can be bruising and even blistering!

It’s not always easy even for your doctor to tell the difference between “Skeeter syndrome” and a skin infection. One of the big differences is the timeline. Skin infections usually happen several days after a bite or an injury, but “Skeeter syndrome” usually starts within a few hours of a bite. Most often children with a large local reaction will complain about intense itching. Only in the more severe cases are pain and fever seen with allergy. It’s not common, but some even develop severe allergic reactions to mosquito bites that lead to difficulty breathing.

Large local reactions are best treated with oral antihistamines (Benadryl or Zyrtec) and topical over-the-counter steroid cream (hydrocortisone 1 percent). Fingernails need to be trimmed very short, because scratching causes local skin damage that can become infected. Cold compresses several times a day help alleviate some of the discomfort. In patients who have a history of this type of reaction, I recommend daily antihistamines such as Zyrtec during the time of the year when bites are difficult to avoid. This doesn’t totally prevent the reaction, but can help keep the swelling from being as extreme. I don’t recommend topical antihistamines (Benadryl cream) because some people develop a contact allergy that actually worsens the problem

So, when should you come to the doctor? 

Any child with significant eyelid swelling or swelling that is limiting activity or skin blistering deserves an office visit because they require further evaluation and sometimes even need oral steroids or more potent prescription topical steroids. Red/swollen/hot areas of skin that are associated with pain or fever should also be examined to rule out a bacterial infection.

Tick bites don’t usually cause itching like mosquitos, but are more of a concern due to infections they can transmit. Ticks are predicted to be more prevalent this summer due to the winter being relatively warm. Ticks can transmit several infections with Lyme being one that is often discussed.

If you find a tick on your child it should be removed with tweezers by grasping the tick as close to the skin as possible and pulling straight up. Different types of ticks spread different infections. For example, infected deer ticks can spread Lyme after being attached for 36 hours or longer. Certain areas of the country have a much higher rate of local tick infection than others. Texas is not a part of that area, but cases of Lyme do occur every year.

It is best if children bathe after coming in from playing outside to wash off ticks prior to attachment. It’s a good idea to look in hidden areas such as behind the ears and on the scalp. Remove ticks if you find them and watch for a rash. Certainly, a rash that looks like a bull’s eye or a target (erythema migrans) is concerning for Lyme infection and needs to be seen for further testing.

Insect bite avoidance is important (and hard)! The large local reactions are definitely very uncomfortable, but infections transmitted by mosquitos such as West Nile or Lyme from ticks are potentially very dangerous. Using DEET containing insect repellant and wearing long sleeves during peak mosquito times are helpful.

As always, see your pediatrician if you are worried about a bite or rash and we are happy to help.

Related:

• The deets on DEET from a pediatrician
• Protecting Your Child From Ticks

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

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

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

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

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

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

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

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

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

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

For more on this topic:

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

There is currently no vaccine available for COVID-19. Studies are currently underway, but they are in the very early stages and there is no clear timeline for when it will be available.

Treatment for COVID-19 in children is mostly supportive. Making sure that they are drinking well and not having trouble breathing are the two major things you can do to help your child. Novel treatments such as antivirals and other medications are being studied, but it is not clear when those will be available for treatment-especially in children.

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

High Fever

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

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

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

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

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

Stomach Hurts

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

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

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

My Head Hurts

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

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

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

Related Topics:

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

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

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

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

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

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

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

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

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

• Strep throat
• Whooping cough
• Urinary tract infection

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

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

• Ear infections
• Sinus infections
• Bronchitis

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

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

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

• Common cold
• Viral sore throat

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

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

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

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

The licensed psychologists at Cook Children's have seen this issue throughout their careers. It’s a symptom of a feeding disorder she describes as “pocketing.”

Alaina Everitt. a licensed psychologist, said the issue of pocketing usually begins when children are young. The children may experience something painful, such as reflux or a sore in their mouth, and they find it difficult to eat.

The children then may begin a process of holding, spitting out or refusing food altogether.

Children who pocket food should be checked out by an occupational and speech therapist, even if they have had no other type of therapies or been diagnosed with any medical conditions, according to Everitt. She said those specialists can make sure there are no other problems, such as difficulty moving food around in their mouth with their tongue or if the tongue is weak. These children can usually be cured with basic therapy exercises to overcome these obstacles.

If it’s a sensory issue, more extensive therapy may be needed. Children with sensory difficulties, autistic children for instance, may need a lot of food for them to even feel it in their mouth.

“These kids will over stuff and pile food in their mouth and get the ‘chipmunk cheeks,’” Everitt said. “These children tend to like crunchy or spicy foods because they may have trouble tasting or feeling other foods because of sensory issues.”

Lots of toddlers will hold their food and that tends to be developmentally appropriate. If a child gets closer to age 5 then parents may have cause for concern.

As children get older, they become more skilled at pocketing food. The kids may keep their food in their cheeks until they discard it or the parents can’t get their children to swallow.

“It becomes a meal-time battle,” Everitt said.

Cook Children’s helps parents with a team approach to treating children with a feeding disorder. A pediatrician would help guide the child’s care. A dietitian may help the child find foods they can swallow. Speech and occupational therapists lead the actual therapy portion to teach swallowing and resolve sensory issues. Everitt comes in to help with any emotional or behavioral issues, such as anxiety or parent-child power struggles.

“Therapists have little tricks they teach parents; how to do the right type of massage or how to get in their child’s mouth with a vibrating tool as it helps them from a sensory perspective,” Everitt said. “These things can help children swallow easier. You also have to make sure they don’t have a swallowing problem at this phase and the speech therapist will help with that. If the kid has choked before or has trouble swallowing, why would they try to swallow? Even when that issue gets treated the kids are still scared and that’s when they come to me.”

I am reminded of a very festive party I had for my kid a year or two ago. I served cupcakes with blue frosting. What followed was a week of worried messages from friends. “Something’s wrong with his poop”. “I don’t know if he ate anything different recently, it’s so bright green!” Ha. I brought that one on myself.

So what colors of poop make a pediatrician worry? Well, mostly – black, white and red. I’ll explain. Let’s dive into the different colors. So to speak. 

GREEN – super common with food dyes that are green and blue (like…. blue cupcakes). Also very common when breastfeeding infants drink a lot of foremilk (rather than a mix of foremilk and hindmilk), or kids drink formula. Taking antibiotics. Eating grass. Eating a lot of dark leafy green veggies like kale and spinach. Having a tummy bug (gastroenteritis, which causes vomiting and diarrhea sometimes).

BLUE – mostly food dyes. Blueberries.

ANY SHADE OF BROWN – Normal. Yes, tan is okay. Light brown. Greenish brown. All fine.

RED – Sometimes cause for concern. Could mean bleeding in the lower half of the intestinal tract. Could be Cow Milk Protein Intolerance. However, I’ve seen red stools with certain foods like beets and cranberries, too. The antibiotic Cefdinir (and other meds) can make stools red or orange. Your doctor can test a red stool to see if it’s actually blood or something different.

ORANGE – usually normal with foods like carrots and sweet potatoes. Medications like Cefdinir can cause orange stools too.

BLACK – Sometimes worrisome, sometimes not. Newborn babies have dark black tarry stools at birth and for a few days following. Pepto Bismol, licorice, and iron supplements can cause black stools. Can be due to blood from higher part of intestinal tract. If persistent and your kiddo isn’t taking meds, would see your doc.

YELLOW – totally normal in breastfed babies. Can sometimes happen with diarrheal illnesses in kids.

WHITE/PALE – I think this is okay if it’s an isolated 1 day event. I see it sometimes with diarrhea illnesses. However if it persists past 1 or 2 poops, time to talk to your doctor about possible liver disease.

This list is in reference to kids only. Adults have different-colored poops for similar, but not always the same, reasons.

Call your doc if you feel like your kiddo’s stools are any of the concerning colors above.

"What happens if my child eats all of my adult vitamins?"

We received this question recently. Let's discuss.

Just like any adult medication, vitamins should be locked away so that kids can't get to them. Vitamins are particularly risky because, while they may seem harmless, ingestion of multiple vitamins can be dangerous. In addition, vitamins are colorful and often made in forms that kids love to eat (chewables and gummies).

Vitamin toxicity can occur if a child is taking a few extra vitamins per day or if a child ingests a large amount of vitamins in one sitting.

The most dangerous vitamins ingested by kids are the fat soluble vitamins (A, D, E and K) and iron. Other vitamins and minerals can cause problems as well, but many are passed in the child’s urine without concern.

If you suspect your child has ingested a large amount of any vitamin, call Poison Control at 1-800-222-1222.

They can help you asses the amount that the child ingested and what the risk is.

Most commonly your child will have some stomach upset with or without vomiting. Severe toxicity can occur with Vitamin A and iron, which can lead to multiple problems and ultimately lead to death.

Hope this helps. Just remember to keep all medications locked away and out of reach of your kids. 

Doc Smitty

But choosing the best place to go for your child's care  can be a difficult one for some parents. After all, Cook Children's offers several options within its system, ranging from primary care, urgent care, the neighborhood clinics and the emergency department.

So how do you know where to go? To begin with, visit the handy infographic to the right or click here.

"Every patient who comes into our Emergency Department is important to us. However, some patients may be able to receive the care they need from their primary care physician, a neighborhood clinic or an urgent care center," said Corwin Warmink, M.D., medical director of Cook Children's Emergency Department. "The best thing a parent can do is know what constitutes an emergency, so they know where to go when that time comes."

When it comes to choosing where to go, Kara Starnes, D.O. medical director of Urgent Care at Cook Children's, advises parents to think about the severity of the issue.

For instance, your child's Cook Children's pediatrician can see a number of ailments, including allergies, the flu, migraines, pink eye, sprains and vomiting.

During times when your pediatrician's office is not available, the Urgent Care Centers at Cook Children's can handle the same ailments, along with most fractures (broken bones) and cuts. Fractures with severe deformities or open fractures should not come to the Urgent Care but instead should go to the Emergency Department (ED). The ED has more equipment to handle the most severe cases, and the child can be admitted quickly to the medical center for continuing care.

If your child has multiple injuries, neck injuries or head injuries with loss of consciousness and/or vomiting, they should go to the ER. These kids typically need the ER because the UCC is not as equipped in imaging and other sophisticated tests available at the medical center.

"Possible surgery, such as appendicitis, is tough for parents to determine because most of the time, abdominal pain is caused by something simple like constipation," Dr. Starnes said. "But severe abdominal pain, testicular pain or swelling, bleeding when vomiting or severe bleeding with bowel movements are reasons to go to the ER."

You should visit the ED with your child in case of a medical problem that could cause death or permanent injury if not treated right away.

Daniel Guzman, M.D., a Cook Children's Emergency Department physician, adds “when in doubt of the severity, always visit the higher level of care such as the Emergency Department” and if immediate attention is required call 911.

And of course, we are right in the middle of flu season. Last week (Jan. 5 to Jan. 11, 2020), 837 kids were tested for the flu. Of those kids, 141 tested positive for Influenza A, 187 for Influenza B and another 102 for RSV. 

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

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

Kids are gross.

Germs and kids are doubly gross.

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

We all hate this part of winter.

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

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

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

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

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

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

Stay well,

Doc Smitty

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

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

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

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

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

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

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

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

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

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

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

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

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

Consider the source

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

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

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

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

Dig deep

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

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

Look for red flags

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

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

Read the fine print

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

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

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

For more information

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

Cook Children's approved health resources for you:

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

"Heavy metals in baby foods leading to lower IQs"

You might have seen these headlines in the past few weeks as a result of the report, "What's in my baby's food?" from the Healthy Babies, Bright Futures initiative.

The report looked at a variety of foods for four different heavy metals: arsenic, lead, cadmium, and mercury. Each of these heavy metals can be linked to developmental delays and loss of IQ points over time.

But, the tricky part is that these metals are present in many different substances, foods, even the dirt that your child eats on the playground. So, it's not just the fact that the metals are there but how much and how often they are ingested that matter.

And despite what you read in the headlines, it's not possible to avoid these exposures by switching to organic or by changing to baby-led weaning or homemade purees. Because these heavy metals are present in our soil, they are taken up by plants as they grow. Even the report goes on to say, "Organic standards do not address these contaminants, and foods beyond the baby food aisle are equally affected." So, moving away from jarred baby food doesn't eliminate the risk of your baby having exposure.

While we'd love to eliminate any risk and should continue to do so, is there a real risk to your baby?

The report spends significant time discussing lead exposure and it's a risk to babies. Interestingly, many pediatric offices (including mine) run a screening lead level at age 1 and 2 but we do not see a significant number of children who test at a detectable level and even fewer who fall above the level of 5 at which a child is considered at risk for problems. We do not routinely screen for the levels of the other chemicals but, likely, those would not be present in a significant number of babies either.

The headlines and articles have spent significant time discussing the 11 million IQ points that have been lost due to exposure of heavy metals, but what does that mean to YOUR baby. Probably not much. First of all, those lost IQ points are based on the known IQ loss from excessive exposure and many other assumptions to calculate the total loss. And, while it's not clear from the reports, the assumption is those IQ points were a cumulative loss over all children from 0-24 months which when averaged out over all those children work out to a fraction of a point per child which would mean nothing to an individual baby.

So, what should we do?

Of course, the baby food and agricultural industry should continue to work to provide a sustainable source of healthy nutrition for all of us (including our babies). Subtle changes, like searching for soils that have less heavy metal exposure for root vegetables (like carrots and sweet potatoes which absorb more heavy metals from the soil) might be beneficial. The food processing industry should continue to make as many gains as possible in decreasing the steps that might lead to an increase in heavy metals in our foods.

Here are some tips for parents that you can make to minimize your child's exposure:

1. Remember that switching to organic or providing homemade purees will not reduce risk. So, if you wouldn't otherwise, there's no need to make that change now.
2. Avoid higher risk foods, especially those that contain no other nutritional benefits. Rice cereal, teething biscuits, puff snacks (rice-based) and apple juice are some of the riskiest foods and have little to no benefit.
3. Provide a variety of foods regularly. Sweet potatoes and carrots can be an important part of your baby's diet but should be given in with a mix of a variety of other foods.

When parents report a croupy cough, it means different things. Some parents call bad/deep/dry/wet/rattly coughs croupy.

When I think of “croupy cough,” I mean “barky” like a dog or a seal. We are seeing quite a bit of croup this winter so I thought a quick update might be in order.

Age (When will my kid stop barking?)

The disease typically occurs between 6-36 months (can be as young as 3 mo but usually not older than 6 years).

Season (What time of year does my kid bark?)

Infections typically occur in the fall to mid-winter.

Time (When will my kid bark?)

Most ER admissions for croup occur between 10 p.m. - 4 a.m.. Unfortunately, things really can get worse at night.

Pathology (What makes my kid bark?)

Initially, the virus infects the nose and throat and then spreads downward causing swelling in the area just below the vocal cords. When looking with a camera at this area, there is a lot of swelling and redness (inflammation). The vocal cords themselves can also become swollen, causing them not to close as well. This is what can cause children to have a hoarse quality to their voices when they speak. The speed of the air as it travels through this area coupled with the swelling and inflammation causes the noisy breathing and barky cough.

Recurrence (Why does my kid get croup over and over again?)

Research has shown that some children are more prone to croup than others. I think that this has something to do with shape of the area around their vocal cords, consequently putting them more at risk for difficulty breathing and barky cough with any viral infection.

Treatments (What do I do for my little seal?)

All the treatments listed are intended to reduce the swelling in the vocal cords and below, helping your child to be more comfortable.

1. Warm steam – We used to put kids in croup tents where we pumped a humidifier in to get the humidity way up. To achieve the same affect, you can turn on the shower in the bathroom and just sit with the child. You can also run a humidifier in the child’s room.
2. Cold steam – Open the freezer door and put the child’s face in front of the steam the freezer emits.
3. Steroids – Giving the child steroids by mouth (or a shot in severe cases).
4. Racemic epinephrine – This is a specific breathing treatment that currently can only be given in the office or hospital.

Two take home tips:

1. The next time your child is barky, feel free to come in and tell us that your child is “croupy.” However, if your child isn’t sounding like a little seal, it’s helpful to try to find a different word to describe the sound of his or her cough, as there are many different causes for the different sounds of a cough.

2. If I start to explain this process to you in the office, stop me and say, “I got this. I read your blog about it.” Nothing would make me happier.

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

And here are 5 other common causes of chest pain:

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

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

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

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

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

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

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

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

The 3 Ts of firearm safety and children

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

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

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

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

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

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

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

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

Even as the summer was winding down, every member of the Emergency Department knew a fatal drowning could still happen at any moment. Tragically, that moment came over the weekend when two sisters were found unresponsive in a Haltom City apartment swimming pool. News agencies report the girls were taken to Cook Children’s where they both died.

“Drownings occur year-round and there is no ‘drowning season,’ especially in Texas,” said Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s. “You can’t get comfortable and complacent with children and water, no matter the time of year.”

Before this weekend’s pool drownings, three children had died from drowning at Cook Children’s in 2019 – two separate incidents in bathtubs in March and one child in open water in May.

Even in the month of September, the warm Texas weather means kids are getting in the pool. From 2014 to 2018, there have been a total of  16 drownings (13 in a pool and 3 in open water) during the month of September, with two being fatal.

“I worry that with the end of the summer and kids being back in school that people will relax a bit,” said Dana Walraven, community health outreach manager for Cook Children’s. “But we can’t let our guard down even for a little bit. The temperatures are still warm and there’s plenty of time left for kids to be in the water. All the same rules apply to keep our kids safe.”

As a pediatrician, I have been lucky to practice medicine in the post-vaccine era. Although I have watched kids struggle with whooping cough, meningitis, mumps and pneumonia, I am happy to say I have never seen many of the vaccine-preventable diseases. I rely upon my education and training to know about the diseases and recognize them should the need arise.

I do frequently wonder, ‘What was life like for families and children before vaccines were introduced?’ How did people manage the illnesses and anxiety that came with the disease?

For a firsthand answer, I only had to talk to the person sitting at my dining room table during a typical weekend family dinner – my mom.

It was the summer of 1949. While other children were skipping rocks and riding their bikes, my mom was lying in a hospital bed as one of many children struck down by polio.

The illness began as a fever with trouble swallowing and weakness in her left leg. The doctors quickly admitted her to the hospital for quarantine and treatment. Her most vivid memory of the time has to be of the spinal tap used to aid in her diagnosis. At the time, there were no child life specialists to comfort her. She was told to hold still and if she moved the test might kill her.

After 3 months in the hospital with only her mother allowed to stay, her symptoms seemed to be worsening. Her kind physician came into the room one day to visit and cheer up the family. His kindness unfortunately, resulted in him contracting the disease and being confined to a wheelchair for the remainder of his days. After all, back then doctors did not even realize the value of handwashing.

I asked my mom what people thought about polio in the pre-vaccine era. “Everybody was scared to death of catching it! They did not know how they got it but knew it was prevalent in the summer months. They tried to avoid the sun and swimming holes since those seemed to be related.”

We now understand the transmission of polio much better. Polio comes from a virus that is highly contagious. It is spread person to person through sneezing, coughing or contact with human feces. Before the successful introduction of the polio vaccine in the 1950s, the disease resulted in the paralysis of 15,000 people per year. Since 1979, no cases of polio have originated within the United States but cases can be brought in by travelers with the disease.

My mom was one of the lucky ones. Just as a conversation with her medical team was turning to placing her in an iron lung to support her breathing she began to recover. The impact of the illness, however, continues to this day with residual weakness in her legs that makes walking for her a constant challenge.

I asked her what she thought about vaccines as a mom and a grandmother. She responded, “I experienced polio and its effect on my life. I want all my kids and grandkids protected so they don’t have to go through what I did.”

Vaccine-preventable diseases such as polio and the re-emerging measles and mumps are not historically that far away from us. We cannot forget the tremendous impact these diseases have had on the lives of so many before the introduction of vaccines.

If you want to learn more, you can check out the CDC website on polio. 

Better yet, just look across the table on a sunny Saturday afternoon and if you are fortunate to do so, ask the folks who lived it. Their stories and experiences are powerful.

More Information On This Topic

• 'I'm Worried Too.' Pediatricians Concered As Texas' Nonmedical Vaccine Exemption Rates Hit All Time-High
• 5 Questions We Get Asked About Vaccines Answered
• Vaccines for Your Children: 9 Facts Parents Need To Know
• Vaccines and Immunizations
• Information for Parents

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.

This may not be one of the questions you expect to hear from a pediatrician during a well-child visit, but it’s always on the checklist for Vanessa Charette, M.D., a Cook Children’s pediatrician in Fort Worth.

Dr. Charette asks this question for a few reasons. For one, she’s genuinely interested and she’s even gotten some great recommendations of books to read to her children.

“I also ask because I want your child to know that adults around them think reading is important and I am hoping this small question may help them grow up with a love for reading,” Dr. Charette said.

It’s never too early to begin reading to your child.

Ear and brain structures for listening begin working between 25-39 weeks of gestation. At about 28-30 weeks, connections between the brain and the ear start happening.

“For the auditory brain to develop, babies need to listen to language, music and all different kind of sounds,” wrote Becky Clem, an education coordinator for Rehab Services and a speech-language pathologist and listening-spoken language specialist. “Reading aloud is a great way to help children learn to listen and talk. Reading aloud to that growing baby in utero is a jump start to listening, talking and future reading. Reading aloud to children of all ages has huge benefits.”

Clem said the first three years of a child’s life is the most important time for learning. Reading aloud to children boosts their vocabulary, listening and talking skills.

Research on reading aloud to children tells us that it:

• Is the single most important thing to help a child get ready to read and learn.
• Helps a child learn more, unique words. Children who know more words do better when starting kindergarten.
• Helps a child’s brain develop. Language development is vitally important from birth to 3 years.
• Helps a child love to read.
• Helps a child learn.
• Helps parents bond with their child.
• Sets an example for children that reading is important and fun.

Of course, your toddler won’t sit still, but Dr. Charette says parents shouldn’t worry about reading the entire story to them. “Look at the pictures, point things out on the pages, have them find things on the pages,” She said. “The Richard Scarry books are great for this and we read them over and over when my kids were this age.”

For the school-age child that maybe doesn't love reading yet: Dr. Charette suggests getting them books on topics they love. Does your child love Legos? Then Lego® books it is. Do they love animals? Then try National Geographic kids’ animal fact books. They have lots of pictures and fun, short reading sections. Is your kid funny? Then try a joke book. But Dr. Charette warns as only a mom can: "This leads to the most ridiculous knock-knock jokes being read aloud to you.”

“For your older school-age or teen child: Be a two-person book club,” Dr. Charette added. “I have done this a few times as my children became older and they loved it when I read a book at the same time they were reading it. It allows them to talk to me about the story. They were so excited to share with another person what is happening with the characters and what may happen next.”

Clem understands that families lead busy lives in today’s world, but she offers these tips for reading aloud into your day and week:

Some ideas for fitting reading aloud into your day and week:

• Visit your local library. Get a free library card for you and your child. Check out books weekly. It’s FREE!
• Visit read aloud storytime at the library.
• Read aloud at breakfast time.
• Keep books in the car to read while waiting at appointments.
• Make bedtime book reading a family tradition.
• Have a family storytime every week.
• Keep waterproof books in the bathtub for a quick read during bath time.
• Read together as a family every day.
• Have older siblings read aloud to younger siblings.

For more on this topic, read Becky Clem's blog, "Raising Bookworms."

It was also during this time that measles showed up in Texas and when I received my second MMR.

My sister had been in San Antonio with my mother for two months receiving care at a Bone Marrow Transplant center. While she had no memory of her twenty-third birthday, I saw pictures of the nurses and doctors surrounding her with a cake.

Later when she returned home, she commented on this nice shirt she had found in her suitcase as she had not seen it previously. I did not have the heart to tell her that it had been a gift from me for her birthday, she just had been so ill she did not remember.

As the number of measles cases in Texas were climbing, her doctors became fairly insistent that I receive a second MMR. They really didn’t want me to be around her without being protected.

Some may feel that wasn’t their decision to make. However, those doctors were not only scientifically correct but they cared deeply for my family. They knew me well enough to know that if I gave anything to my sister that would have hurt her, I likely would have never recovered from that guilt.

While measles can harm anyone, it likely would have been a death sentence for my sister. Initially, my mother was concerned about any possibility of me developing measles after the vaccine and giving it to my sister. The doctors reassured her and said the only way to protect her was to protect me. My mom had to make so many difficult decisions that year. Sometimes she did what the physicians recommended and sometimes not. Her goal everyday was to advocate and protect her daughter. So I was vaccinated based on the new two dose MMR policy.

Then I was able to be with my sister. I was with her when they told her that cancer returned. I was there to watch my platelets infuse into her weak body. I was there on the morning she died. Holding her hand. It would have been too risky during the measles outbreak for me to be around her that summer if I had not received that vaccine. While I grieve the loss of her beautiful mind and spirit still after almost 30 years, I realize that experience inspired me to enter medicine and advocate for children.

It is so unfortunate that the discussion around vaccination has become so volatile. Like my mom, parents are just trying to make the best and safest decisions for their children. They have to navigate a much more complex world of information available to them. At my clinic, we spend a good amount of time discussing questions and concerns regarding vaccines. While I try to work with families and guide them, in the final discussion, vaccinating children is the healthiest choice for them. Not just for their own disease prevention but for all of those who cannot receive certain vaccines through age or medical condition.

Honestly, I was a bit nervous writing this realizing potential backlash from those not agreeing with vaccinations. Yet as I was looking through my closet the other day, I saw that shirt I gave my sister. It made me smile remembering her wearing it and it reminded me of how all of us had to be brave in different ways that year. In her memory, I will continue to try and be brave.

Vaccinate. It saves lives.

"There are a lot of patients who need specialized care or even higher levels of care and it’s really important that in this rapidly growing community that we have that available to these families," said Dr. Hogan, pediatricitian at Cook Children's Pediatrics Prosper Trail.

Dr. Hogan is one of 24 Cook Children's pediatricians currently treating patients in this region of North Texas. She says patients like hers need a place to access specialized and emergency pediatric care without having to drive 30 minutes to an hour away from home.

"A lot families have hardships and are not able to drive that far, or take off work all the time to go to these visits, and having this inpatient hospital and specialized care right her will make it easier for all the families," Dr. Hogan explained.

Construction of Cook Children's Medical Center North is in the initial phases with plans to have a full service hospital completed in 2022. The new hospital will be located on a 23-acre site in Prosper at Windsong Parkway and Highway 380. Having started in October of last year, phase one is already underway with plans to open a primary and urgent care clinic in the fall. An outpatient surgery center and specialty clinic with imaging and lab services will open in 2020.

"I'm really excited about the hospital opening up and being able to refer my patients to specialists, right here in Prosper, and being able to send my patients to get the specialized care that they need, having higher levels of care right across town," said Dr. Hogan. "I think that is going to be really wonderful for the families here."

Currently, Cook Children’s operates eight primary care offices in and around the Town of Prosper. The expansion near Windsong Ranch marks the first time in Cook Children's 101 year history that a full-service hospital has been built outside of Fort Worth.

"Just like the Town of Prosper is family, a close knit community, so is Cook Children’s," said Dr. Hogan. "We are all here wanting your children to be healthy and do better in life and be able to get the care they need to grow up to be happy and healthy adults."

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

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

The slippery assumptions of oil supporters

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now we can move on to some research…

The Research on Essential Oils in Kids

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

Lavender

Tea tree

Chamomile

Peppermint

Eucalyptus

Where did I look?

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

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

Lavender

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

Tea tree oil

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

Chamomile

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

Peppermint Oil

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

Eucalyptus

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

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

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

Other Sources

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

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

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

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

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

Summary of Research

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

Children initially begin to walk between the ages of 12 and 15 months. In the early stages of walking, you may notice your child “waddling” with their feet wide and their arms out like an airplane. Once a child has become more comfortable with walking, you may notice them becoming “brave” and attempting to walk fast or even run. As a child goes through these stages of development, you may find your him or her falling several times during the day.

It’s normal for children to fall frequently as they are learning to walk. In the early stages of walking/running, a child is learning to plan movements, find their balance and explore new-found independence.

As children gain more control of their body, you will find they begin to walk with a narrower base and their arms are at their side. A child will walk/run with decreased hesitance and you should notice less falls. This will occur within the first 2-3 years of learning to walk.

When should you be concerned about your child’s falling? There are many different reasons why children lose their balance throughout the day.

• Pay attention to when your child is falling and ask yourself a few simple questions:

• Did the type of shoe he or she is wearing change? Often times children have difficulty finding their foot placement with new shoes, especially ones that are heavy (such as a boot) or non-supportive (such as a sandal or slip-on shoe.

• Are they only falling when reaching a curb or changing surfaces? Sometimes vision can play a big role in a child’s ability to maintain balance with walking and running. If you suspect a visual deficit, you should contact an eye care specialist.

• Does your child only fall when playing with peers their age? Children have to think constantly about their next move when walking/running during play. You may find that they will trip or fall when attempting to keep up with peers their age. This could be the cause of decreased coordination, meaning they are having a difficult time organizing movements during play, causing them to fall.

• Try to pay attention to how your child is falling, sometimes a child may have a difficult time clearing their toes when walking/running and will fall. This would be good to mention to your pediatrician for possible referral to a physical therapist.

If your child is falling more than 10 times per day and doesn’t fit into the above categories, it may be beneficial to talk to your pediatrician about a physical therapy evaluation to assess your child’s needs.

About the author

Morgan Hubbard, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield. If you would like to schedule an appointment or speak to our staff, please call 682-885-4063.

My question to you is...what in the world am I talking about? Our children’s vocabulary is very important, and if we use words such as “this” and “that,” we lose out on opportunities to teach our kids new words. I took a course recently that said that children between the ages of 4 and 5 demonstrate the most significant growth in vocabularies.

A child the age of 4 has a vocabulary of about 1,200 words, but a child the age of 5 has a vocabulary of 5,000 words. That is a HUGE growth in words.

Your child's vocabulary is so important. Think of each skill your child develops as building blocks. Starting from infancy, your child begins by cooing, which turns into babbling that then turns into words and eventually sentences. Research shows that children with higher vocabulary results in better decoding abilities. All that to say that their reading skills will benefit from having better vocabulary.

So what can I do to help my child?

1.Be specific when talking to your children. If I changed the story above to something more like this, it would all make sense…..

The other day I went on vacation. We went to South Padre Island. I enjoyed it because we went parasailing and fishing. My son caught a fish but his line got tangled with someone else’s. We couldn’t stop laughing, but eventually we helped him untangle the line and get it on the boat.

Now isn’t that so much better.

2. Try teaching your child new words or even different variations of the same word. For example: “The elephant is big” can turn into “The elephant is gigantic.” or even “The elephant is enormous.”

3. Use the same word in many different ways. Think about the word “run." The dog ran fast. I ran next to him, but I could not run as fast. My brother tried to run, but he fell down. After I ran, I was really tired. Running is fun.

4 .Make learning new words fun. Instead of doing flash cards (snooze), find something that is interesting to your child and think of words based on the activity. If your child likes playing with farm animals, think of several words you could teach your child involving farm animals. As you play, introduce those words you wrote down.

5. Read books to your child. Books offer so many new and wonderful opportunities for learning words. You don’t have to necessarily read all the words, just talk about the pictures. Try thinking of words you can use multiple times throughout the book.

Vocabulary development is critical for children. It helps with building sentences and it’s important for reading as well. Markus Zusak put it well when he said, “The words. Why did they have to exist? Without them, there wouldn’t be any of this."

Pediatric Palliative Care (PPC) has been a board certified subspecialty in pediatrics sponsored by the American Board of Pediatrics since 2008. PPC has been a specialty service at Cook Children’s Medical Center (CCMC) since 2007. Palliative care is widely misunderstood by many medical professionals, as well as the general public. While many believe that palliative care is synonymous with end of life care or hospice care, this is not entirely true. Palliative Care is a specialty service that helps care for any child and their family living with serious and potentially life limiting complex chronic conditions. Hospice care is along the continuum of palliative care. All hospice is palliative care, but not all palliative care is hospice. The PC team is grateful to become involved as early as diagnosis and at any time along the disease trajectory including in the midst of therapy with curative intent. The role of the palliative care team is to help with symptom management (caused by disease or treatment), medical decision making and to support families through the uncertainty of serious illness.

The PPC team at CCMC is comprised of physicians, nurse practitioners, nurses, social workers and chaplains. The team collaborates with child life specialists and other supportive services available at the medical center. The PPC team works alongside the child’s medical team to alleviate the suffering of the child and family. We address not only physical suffering (pain, shortness of breath), also psychological (anxiety, depression), social (isolation, financial stress) and spiritual suffering of the child and their family.

We have worked with hundreds of children with serious, complex chronic diseases and assist with anticipatory guidance and medical decision making along the disease trajectory. For example, the family of a child with swallow dysfunction associated with neurologic impairment may be faced with a decision of whether or not to pursue gastrostomy tube placement when aspiration continues despite other means of prevention. The PC team helps to facilitate informed decision making along the disease trajectory in hopes of preventing the need to make critical decisions in times of crisis.

If you have a patient that you feel might benefit from Palliative Care services, you may speak directly to our nurse coordinator, nurse practitioners or physicians to ask questions or make a referral. We can see patients in both the inpatient setting and in our outpatient clinic. PPC does not admit children to the hospital and we do not primarily manage the patients. We work with the primary care providers and the child’s other specialists to ensure that the child is receiving care that is consistent with the family’s goals of care and that we are looking at the whole picture and not just individual systems.

I spend a good portion of my day asking my daughter to give my son a little space; sister loves hard!

Recently, my son was playing in the kitchen (right next to me) when my daughter suddenly came in, sat behind him and looked like she was doing the Heimlich on him. As I was telling her to back away slowly, I noticed he was trying to put something in his mouth and wasn’t able to due to her pestering... and then I wanted to throw up. It was a button battery. A tiny battery that he could have swallowed without difficulty, and without me ever knowing it.

Last year, more than 470 children visited the Cook Children's Emergency Department after swallowing a "foreign body." Most objects that children ingest can be passed without much concern, but a battery is not one of those things. A battery lodged in the esophagus is a medical emergency. Essentially it can erode the lining of the esophagus. They are very dangerous and can be deadly without treatment.

As a previous pediatric ICU nurse and currently a primary care nurse practitioner at the Willow Park office, I knew this. I warn others of this danger. So how did it almost happen 2 feet from me?

I suddenly remembered my daughter was wearing a headband that lit up the day before, and she accidentally pulled the back off spilling the batteries. I thought I had picked up all the batteries, but one was hiding under the kitchen mat.

After thanking my daughter for her brother obsession, I went on a mission to locate all the button batteries in the house.

Keeping these babies safe is a hard job, for ALL of us! Doing a quick scan of the house to make sure no batteries they could easily swallow are in their reach is a good step towards safety.

-Sperry, NP

For more on this topic, read:

• Number of Kids Seen in ER for Swallowing Small Objects Doubles Over Past Two Decades
• Button Battery Injury Prevention Safe Kids
• Choosing Safe Baby Products
• Is Your Home Safe for Baby?
• Is This an Emergency?

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.

Over the course of a week, there were three different auto pedestrian injuries, where a child was hit by a car and ended up in Cook Children’s Pediatric Intensive Care Unit.

Once the school year ends, Sharon Evans, Trauma Injury Prevention coordinator, calls this time of year “the 100 deadly days of summer” because kids are so much at risk. They are spending more time on their own or with friends and often times without adult supervision.

"Kids are out because they are playing with their friends, going to the ice cream truck or riding their bike. In other words, it’s just kids being kids. But that’s also when children are getting hurt," Evans said. “We are asking parents to make sure their child knows how to cross the street, mainly that they wait until the driver actually motions to them to cross the road. Just because you think the driver is looking at you doesn’t actually mean they ‘see’ you.' These days everyone is so busy or distracted, even while behind the wheel, you can’t take anything for granted."

Studies show children don’t have the cognitive ability to safely cross the street until they are 10 years old.

So even though they can ride a bike and do multiplication tables doesn’t mean they can safely cross the street, Evans said. While they may ride or walk on the sidewalks, you still have the danger of cars backing out and/or turning into driveways. During the summer, Evans said the medical staff at Cook Children’s sees an increase in backovers. 

“With our larger cars and SUVs, you often can’t see the child and that’s where the backovers happen as you are leaving,” she said. “Of course this disaster is even worse because the injury is usually caused by a parent or family member.”

Evans asks parents to be extra aware that kids are out during this time of year and to be on the lookout for them. She adds distracted driving plays into this too.

“Drivers need to be extra aware that kids are out and about,” Evans said. “It’s up to us, as the adults, to be on the lookout for them. Of course, distracted driving plays into this too. We also need to make sure we are all driving the speed limit or below the limit in neighborhoods, around parks or just anywhere kids may be outside and playing. Really it’s up to all of us to be careful and watch out for kids."

The first death occurred in Providence Village on Thursday, June 24, 2019. CBS11 reports the 4-year-old boy was found outside a home just before 5 p.m. when temperatures were in the mid-90s.

The second tragedy occurred on Sunday, June 23, when an 18-month-old was left inside a car for five hours outside of a restaurant in Galveston. 

The deaths were the first two of the year in Texas and the thirteenth pediatric vehicular heatstroke deaths nationwide.

The peaking 100 degree temperatures are dangerous, especially for children, whose body temperatures rise three to five times faster than adults. There have already been 11 pediatric hyperthermia (heat stroke) deaths this year in the United States from children being left alone in cars.

Although there have not yet been any recorded in Texas, this state typically leads in hot car related deaths. Since 2010 there have been 60 juvenile deaths in Texas from children being left alone in a hot car.

Most cases of child heat stroke deaths in cars are accidental. There was a change in mom or dad’s routine, and the child was unintentionally left in the back seat. Like drowning, it is quick and it can happen to anyone.

“We do get a very small amount of people who leave the child in the car intentionally, but the majority is when you just totally forget,” Cook Children’s Injury Prevention Coordinator Sharon Evans said. “There is no socio-economic, no educational or cultural factors. It can be anyone.”

Evans and her team have partnered with Safe Kids Worldwide to develop a Texas Hyperthermia Board to educate Texans about how and why this can be preventable. The task force has changed legislation in 2016 to require birthing hospitals to educate new parents about hyperthermia and car seat checks.

“The biggest problem with injury prevention is everyone thinks it won’t happen to them,” Evans said. “We hear lots of people saying, ‘Oh, that’s just a horrible parent. How could they forget?’ Today’s world is so technologically driven, and people give more time than ever to their cellphones. If you can forget your phone somewhere, you can forget your child in the backseat.”

Outdoor temperatures don’t have to be sweltering for heat stroke to occur. The first vehicle-related heat stroke death this year occurred in April with 79 degree weather. The temperature in a car can rise nearly 19 degrees in ten minutes. Heat stroke can occur when a body temperature rises above 104 degrees and body organs begin to shut down near 107 degrees.

There have been many instances where people walk through the grocery store parking lot, see a child alone in the car and do not act for fear of prosecution if they damage the car. Texas released Texas House Bill 478 (HB 478) in 2017 to protect Good Samaritans and potentially save children from heat stroke.

HB 478 allows citizens to rescue a vulnerable child under the age of seven if there is no reasonable method for the child to exit the vehicle without assistance and if the Good Samaritan has reasonable belief that entry into the car is necessary to avoid imminent harm to the child. HB 478 also requires law enforcement must be notified and the citizen must not use more force than necessary to enter the vehicle.

Child car-related heat strokes are preventable, but can happen to anyone. It’s important to take measures in educating adults and children about the dangers of a closed car door. The effects could ultimately last a lifetime.

“It doesn’t matter how good of a parent you are. It’s just a tragic accident,” Evans said. “Being vigilant could save a life.”

In his veto statement, Gov. Abbott called the bill “an unnecessary invasion of parental rights and an unfortunate example of over-criminalization.”

Texas law already requires children younger than 8 years old or shorter than 57 inches to be secured in a car seat and that the car seat be installed according to the manufacturer's instructions. The current law does not specifically mention car safety guidelines for children under 2 years old.

Following the veto, Chris Turner, D-Grand Prairie, who authored the bill said to The Dallas Morning News: “The governor’s veto sends the irresponsible message that it doesn’t matter if a child under age 2 is rear-facing. It does matter, because it is proven to save young lives.”

In much of the medical community, the talk among experts has shifted away from the age of the children to simply keeping them safely in a rear-facing car seat as long as possible. In 2018, the American Academy Of Pediatrics updated its recommendations on car seats for children. The AAP recommends children remain in a rear-facing car safety seat until they reach the highest weight or height allowed.

Benjamin Hoffman, M.D., FAA, the lead author of the policy statement and chair of the AAP Council on Injury, Violence and Poison Prevention, said newer car seats allow children to remain rear-facing until they weigh 40 pounds or more, meaning most kids can remain rear-facing past their second birthday.

“It’s best to keep your child rear-facing as long as possible. This is still the safest way for children to ride,” Dr. Hoffman said. “Car seats are awesome at protecting children in a crash, and they are the reason deaths and injuries to children in motor vehicle crashes have decreased. But that also means we just don’t have a large enough set of data to determine with certainty at what age it is safest to turn children to be forward-facing. If you have a choice, keeping your child rear-facing as long as possible is the best way to keep safe.”

Nationally, car crashes remain a leading cause of death for children. The American Academy of Pediatrics states that over the last 10 years, 4 children under 14 died each day.

Last year at Cook Children’s, 37 kids, who were 2 years of age and under, were involved in motor vehicle crashes, including five deaths (the most in at least five years). According to Cook Children's Trauma team, there have been 205 children in that age range invovled in wrecks and 12 deaths since 2014.

Spinal cord injury is a major concern for children who have transitioned from rear-facing to forward-facing or booster seat too soon. Melodie Davis, director of the Pediatric ICU, Transitional Care Unit and Rehabilitation Care Unit at Cook Children’s, said a young child’s head is so heavy as a toddler that it whips and causes damage.

“Properly used car seats protect children from injury and death,” Davis said. “Infants and toddlers are at risk for head, neck, and spine injuries during car crashes because their heads are large and heavy compared to their bodies. When placed rear-facing, the car seat can better support these high-risk areas because the seat is able to absorb the force of the crash. Unfortunately, we see significant neck injuries with cord damage in incorrectly used car seats. Another common injury includes traumatic brain injuries because of the force of the crash. Following proper car seat use guidelines can significantly decrease injuries and death in children.”

Using the right car safety seat or booster seat lowers the risk of death or serious injury by more than 70 percent, according to the AAP. Parents are suggested to check the instruction manual and the labels on a car safety seat to find the manufacturer’s weight and height limits. When a child is approaching the limit, it’s time to think about transitioning to the next stage.

“We hope that by helping parents and caregivers use the right car safety seat for each and every ride that we can better protect kids, and prevent tragedies,” said Dr. Hoffman.

Smith, a Dallas native, wrote about the unthinkable news on his Twitter and Instagram account. It was later confirmed by the singer’s representatives that his son had died due to a drowning accident at home.

“Amber and I made the decision to say our last goodbyes and donate his organs so that other children will be given a second chance at life,” Smith wrote.

The news came on the same day that the U.S. Consumer Product Safety Commission released their report that shows:

• A 10% increase in fatal child drownings over the past two years.
• Almost three-fourths of the drownings (74%) involved children younger than 5.
• An average of 363 pool-or-spa related fatal child drownings were reported per year for 2014 through 2016, involving children younger than 15. The highest number of drownings occured in 2016 with 389 reported fatalities.
• On average, an estimated, 6,600 pool-or-spa related, non-fatal drowning injuries were treated at a hospital emergency department treated each year for 2016 through 2018.

The data identified June as the month with the highest fatality incident rate and that residential locations made up most (72%) of reported fatal drowning incidents. In June 2018 at Cook Children’s, 16 children were treated for drownings, with three being fatal.

"Our data shows us who is drowning and when and where these fatal drownings are happening – children, in the summer, at residential locations," said Acting Chairman Ann Marie Buerkle. "This report underscores the need for all families to stay vigilant and practice water safety anytime they are in or around the water."

None of the statistics surprised Corwin Warmink, M.D., medical director of Emergency Services at Cook Children's.

“This is not anything new. We live in Texas and we see this all the time. There are lots of pools and lakes here. It’s just water and children don’t mix without adult supervision and children wearing their lifejackets all times around the water,” Dr. Warmink said. “For us in the Emergency Department, it’s just sad because this is something that’s totally preventable.”

The safety commission’s recommendations to keep children safer in and around the water mirror the suggestions from Cook Children’s experts, including:

• Install a four-sided fence with a self-closing, self-latching gate around all pools and spas.
• Designate a Water Watcher to supervise children at all times around the water. This person should not be reading, texting, using a smart phone or be otherwise distracted. Water Watcher tags are available at Cook Children' to any person or group who will use them or would like to distribute them. To receive a Water Watcher Tag, email safe.kids@cookchildrens.org. 
• Learn how to swim and teach your child how to swim.
• Learn how to perform CPR on children and adults.
• Keep children away from pool drains, pipes and other openings to avoid entrapments.
• Ensure any pool and spa you use has drain covers that comply with federal safety standards and if you do not know, ask your pool service provider about safe drain covers.

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.

Miraculously, the child was safe. The Mankato Department of Public Safety said in a press release that the 2-year-old girl was not injured.

While the incident continues to be investigated for charges of child endangerment by the authorities, three things are known:

1. Car seats are remarkably durable and safe.

2. Parents should make sure their child’s car seats are securely and properly fastened into the car.

3. Make sure the car door is shut and locked.

"National Highway Traffic Safety Administration statistics show that three out of five car seats are not properly installed,” said Dana Walraven, Community Health Outreach Manager at Cook Children’s. “It appears this little girl was properly harnessed into the car seat and that’s why she’s alive and well. However, another crucial step was not taken, making sure the car seat was securely fastened to the back seat of the car.”

Texas law states that “all children younger than 8 years old, unless taller than 4’9”, are required to be in the appropriate child safety seat system, including properly secured in the car, wherever they ride in a passenger vehicle. The safety seat MUST be installed according to the manufacturer’s instructions.”

The Texas Department of Public Safety states on its website that best safety practice is: “if the child is not yet 4’9”, they are better protected if they continue to use the appropriate child safety seat system until they can fit properly in the adult safety belt.”

“We talk a lot about the safety of a child in a car seat, but what happened in Minnesota is a reminder for all parents that there are two important steps: First, install the car seat in the back seat of the car and two, harness the child into the car seat,” Walraven said.

The best way to make sure your child is secure is to have a certified child passenger safety technician teach you how to install the car seat, and how to fit the child in the seat. Cook Children’s offers free car seat checkups to ensure your seat is properly installed. Call 682-885-2634 for more information.

More Information:

• Vehicle/Car Safety
• Choosing The Right Car Seat
• Ultimate Car Seat Guide
• Car seat safety (Newborn to 2 years old)

About one minute outside was all it took for 1-year-old Harrison Bakke to be bitten by a baby rattlesnake. It happened just three feet from the door of his home in Abilene, Texas on Tuesday, June 26, 2018. He’s currently being treated at Cook Children’s.

This is the fourth patient treated for a snake bite at Cook Children’s this week and the fifth this month. According to the Cook Children’s Trauma registry, a total of 14 kids have been seen at the medical center for snake bites this year. Since 2010, 167 children have been treated for a snake bite.

Erin Bakke, Harrison’s mom, said she had just walked out of the room when her 3-year-old daughter opened the back door and both children stepped outside to play. Within no time, Erin heard Harrison crying. She ran outside and saw her son’s right hand bleeding.

She also saw the snake. Erin pulled both children inside and called 911. The fire department arrived to kill the snake and an ambulance took the little boy to an area hospital where he was administered the inititial doses of antivenom.

Harrison was then flown to Cook Children’s. He has received a total of 24 doses of CroFab at the time of this article's publication and is currently receiving two vials of CroFab (antivenom) every six hours. Surgery was also performed on his hand to make two small incisions to allow blood and fluid to drain from Harrison’s hand and reduce the swelling.

“A whirlwind would be the best phrase that for me would describe everything that’s happened,” Erin said. “We spent the first two hours at Abilene Regional Medical Center and it felt like we were there for 15 minutes. Everything was so chaotic, but at the same time everybody has done their job to keep our son healthy. I’m so thankful for everyone who has taken care of Harrison and the quick response.”

Erin and her husband, Michael, both run and walk in the neighborhood and have never seen a snake in the area. She said they live in a suburban area of Abilene and there’s not a lot of construction. Erin said she can’t believe this has all happened so fast because she only took her eyes off her children for such a short time before they made their way outside.

Texas Parks and Wildlife offers these tips for discouraging snakes from coming into the yard:

• Removing their shelter is one of the most effective ways of discouraging them.
• Eliminating rock piles, brush piles, and areas of tall grass will cause snakes to seek a more suitable habitat.
• Store lumber, wood piles and other debris around the home at least 18 inches off the ground.
• Controlling insect and rodent populations in the area will also help to discourage snakes by eliminating their food supply. Snakes will sometimes enter houses, barns and other buildings because they are attracted by the presence of rodents and insects as well as by the cool, damp, dark shelter provided by these buildings.
• To keep snakes out of houses or other buildings, you must seal off all entry points. Snakes usually enter a building at or below ground level.
• For this reason, all openings around water pipes, electrical outlets, doors and windows should be sealed. Any holes in masonry foundations around the home should also be sealed off with mortar.
• Hardware cloth or sheet metal can also be used to seal holes in wooden buildings or siding.
• As the weather heats up and kids are out of school, the opportunity for kids encountering snakes increases.

Mark Shelton, M.D., an Infectious Disease doctor at Cook Children’s and an Eagle Scout with the Boy Scouts of America, says it’s important to teach respect for snakes.

"If you ignore a snake, more than likely, the snake will avoid you,” Dr. Shelton said. “But kids being kids, that’s sometimes easier said than done. Talk to your children about staying away from the snake. Don’t try to pick it up or kill it. Teach your child not to touch it or walk near it. Children should stand still when they spot a snake, then turn around slowly and walk away. Usually, the snake will crawl away into the bushes.”

Sharon Evans, Trauma/Injury Prevention Outreach Coordinator at Cook Children’s, says it’s not just live snakes that pose a threat either.

"We’ve seen bites that occurred after a snake was killed. Often the parents or kids want to get a closer look at the ‘dead’ snake and the head still had the reflex to bite,” Evans said.

As the warm weather approaches, this is a good opportunity for parents to talk to their children about snake safety.

Here are nine tips to start the conversation with your child:

1. Don't touch a snake.
2. Don't try to kill a snake.
3. Ignore the snake if you see it.
4. Wear closed-toe shoes in wooded areas.
5. Don't put fingers under rocks or crawl under houses or other structures.
6. Don't canoe or boat under limbs on rivers, streams or lakes.
7. Avoid edges of lakes, streams and rivers where vegetation is high.
8. Instruct your children to notify you if they see a snake.
9. If bitten by a snake, seek medical help immediately. DO NOT open the wound or try to suck out the venom.

1. I’d be Terrified the Day my First Child was Born. Guess what? Reading tons of books about the health of children makes you no less prone to the paralyzing fear that arrives when that new cute little elephant-in-the-room appears. I wish they came with an instruction manual instead of a placenta.
2. Breastfeeding Ain't Easy. I had a lot of difficulties breastfeeding one of my children. He had horrible reflux, a poor latch, and a stubborn disposition. I thought, "hey – breastfeeding shouldn’t be that bad, right? You just put the baby on the boob and they figure out the rest!" Nope. It’s no wonder there are some wonderful people out there who dedicate their whole career to helping women breastfeed. And guess what? I had to use some formula to get my kid through his first year. And that’s OK.
3. Children Sometimes (All the time) Don’t Go By the Book. First teeth don’t always appear when the books say they do. Weird rashes never look like the pictures online. My daughter had lots of motor delays, way past when the books said she should….and she’s fine now. It takes the experience of a good pediatrician to let you know when to worry, since all kids are so different. We gain experience via treating thousands of patients with time. I had to take off my pediatrician hat and only wear my mama hat when it came to my kids. And had a great pediatrician reassure me that everything would be OK.
4. Fevers Make Me Worry, Too. My son once woke up with a 105.6F temperature when he was a toddler. Of course I was supposed to be seeing patients in the office 20 minutes later. That was one of the most difficult mornings of my life. I had to choose who to care for – my son, or my patients? I took some deep breaths and tried to talk myself through what I tell my patient’s parents. Warm bath, dose of ibuprofen, lots of snuggles (with Daddy). He was fine. But it reinforced why I’ll never judge a parent who is worried even about the tiniest of temperature elevations. 
5. Living with a Toddler is Like Living with an Irrational, Angry Drunk Person. I’d read all the books about effective behavior management. Learned techniques for distraction, offering choices, creating reward charts. But when your three year old is flailing on the floor, mopping the tile with his Oscar-worthy tearfest all because I offered the blue plate instead of the red one…one questions how many bottles of wine to buy for the week.
6. Explaining Simple Things Can Become Very Difficult. “Why is that man in a wheely-chair, Mommy?” “Why did Harper’s dog die? Where did he go?” “How do planes work?” “How come kids go to different churches?” Being a board-certified pediatrician doesn’t mean that I don’t struggle with how to explain things to my kids. I want to be fair and accurate and informative…and somehow word it in a way that my little people understand it. It’s hard, I know. And I can’t promise I do it any better than you. But like you, I’m trying my best!
7. The Online Mothering Community Can Be Both Supportive and Judgmental. It really does take a village to raise a child. And I really hadn’t dabbled in the online world of mothering until I became one. What are the best breast pumps available? Where are the best parks in town? Which restaurants are most kid-friendly? I loved all the readily available advice I found online, but with that help also came the judgmental comments, the guilt, and the unintentional comparing of myself to others. I quickly put a stop to the latter in my mind – and now understand how to better reach my patient moms, who struggle with this dichotomy of feelings social media can conjure.
8. Becoming a Mom Doesn’t Mean I Have to Change Who I Am and What I Love. I was fiercely independent and very driven before I had kids. This hasn’t changed since my two little turkeys came into the world. It did however change how much time I’d have to practice my hobbies and be the best doctor I could possibly be. My lifestyle had to change a bit, but I’ve found that staying true to what you need to be happy – whether it's picking up a camera, a book, getting some time at the gym – makes you a better mom. Do it, and don’t feel guilty about some time to yourself.

I share these pieces of vulnerability and advice with you so that you know you’re not alone. Being a great mom means many things, and know that even childhood experts have their daily struggles. I’m still learning every day. And I always tell my patient’s moms: my two best teachers are my kids. At the end of the day, no matter how many arguments and challenges have ensued, if your kids know they’re loved, you’ve reached beautiful success.

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

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

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

1)The Manipulator/Negotiator

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

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

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

2)The Screamer/Crier

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

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

3)The Creeper/Sneaker

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

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

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

About the author

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

How do we know that parent-talk builds children’s brains? A study by Betty Hart and Todd Risley, “The Early Catastrophe: The 30 Million Word Gap by Age 3” showed that by age 3, children from lower socioeconomic backgrounds heard 30 million fewer words than children from prosperous backgrounds. This disparity of 30,000,000 words heard had effects on children’s IQ and test scores by the time they were in third grade. Why is this important? All children have the right to full access for learning; to grow their brain; to learn to talk, read and write. What parents and caregivers do and say has a profound impact on a child’s development.

Dr. Dana Suskind, a pediatric cochlear implant surgeon at the University of Chicago recently released her book Thirty Million Words: Building a Child’s Brain. At the center of her program are the “Three T’s.”

• Tune In
  • What does your baby/toddler like to do? Let’s say your little one is super interested in those pots and pans in your cabinet but you would rather baby play with the ball. Think about helping baby explore those pots and pans: making noise, pretending to stir, wearing the pan as a hat, etc. Make it all about baby’s interests.
• Talk More
  • What are you saying to your baby? For example, “Come over here and get this” could have many meanings. A richer language example could be “Walk to sister and get the ball!” By using ‘walk, sister, and ball’ baby hears specific words instead of more non-specific words (‘here’ and ‘this’). By using specific, rich language, baby’s vocabulary increases. We learn to talk based on what we hear. I often encourage parents to ‘be a thesaurus’ – constantly increasing the complexity and richness of their language.
  • Another tip is to teach verbs, verbs, and more verbs. Verbs carry far more meaning in communicating than nouns. For example, the word ‘drink’ will result in more action from parent than ‘milk’. Baby says ‘drink’ parent says, “Oh you want a drink? I have milk, juice, water, ____”. If baby says, ‘milk,’ parent says, “Here’s some milk.” ‘Drink’ can be paired with many other words as children start stringing words together: drink more, drink please, drink milk, drink all gone, drink spill, drink hot, etc.
• Taking Turns
  • From the moment parents meet their new baby, communication begins. Babies coo, giggle, scream, cry, and babble to communicate. Parents then respond with sounds, words, and actions. These early interactions are the beginnings of conversation. As very young children start using words, listen to what they have to say. The more you talk back and forth with them, the more words they learn. The more words they learn, the better readers they will be.

Talking to our babies and toddlers is something we can all do to help babies’ brains.

What can we do as parents and professionals to close that Thirty Million Word gap for all children? How can you use Dr. Suskind’s “Three T’s” strategies to grow your child’s vocabulary?

She is obviously looking for some sort of action on my part other than my smiling and nodding affirmatively. Since she’s my number one girl, I’ve learned the idiosyncrasies of her developing speech and know exactly how to handle this request. But to the layperson (or even Daddy or Grammy), I’m fairly certain I would need to come to the rescue with my toddler translator skills.

Mamas, I know you’ve been there. Your 3 year old launches into a monologue you find equal parts incomprehensible and adorable. Adorable, that is, until the tantrums and frantic attempts to understand and obey her demands kick in. In my practice, I have observed some masterful decoding mamas and some skillfully adaptive little ones navigating the waters of communication breakdown. Let’s talk a little bit about speech sound development and when to fret.

Articulation is the movement of the tongue, lips, soft palate and jaw to make speech sounds. It’s also the driving force behind your toddler’s incomprehensible speech. As parents, we are so excited when our little bundles of joy begin talking, but oftentimes, that excitement is quickly replaced with frustration when we realize we can’t understand a lick of what they’re saying.

An articulation disorder occurs when a child has difficulty forming speech sounds, most likely due to a structural or motor-based deficit. Most children tend to have some difficulty with certain speech sounds. Because creating sounds is challenging, he may substitute easy sounds for tough ones (think dumb for thumb), delete sounds (ha for hat), or distort problematic sounds (this is most often noted when children have a “slushy” quality). An articulation disorder occurs if these substitutions continue past the expected age.

Are all sounds created equal? In short, no. Children master sounds gradually. Most children can pronounce all of the speech sounds of English correctly by age 8. While each child’s speech sound acquisition is different, the following are age ranges in which most children master certain sounds:

• Introducing the “early birds”: Most wee ones will use m, n, y, b, w, d, p and h correctly between 18-30 months. That may explain why mama, dada and ball are frequently reported as first words.
• Not to be outdone, the middle of the road sounds includes: t, ng, k, g, f, v, ch and j. You may hear your little one utter these sound appropriately as early as 2 or as late as 6 years of age.
• Finally, the late bloomers include: sh, zh, r, s, z and th. This final pack of sounds contains the frequent offenders when it comes to articulation disorders. They are challenging for children to master and can wreak serious havoc on the clarity of their speech. We expect children to master these sounds between the ages of 3-8. (Based on Shriberg, 1993)

As children get older and learn new speech sounds, they gradually become easier to understand by a wider variety of listeners. Developing clear speech is a journey for our littles, albeit a frustrating one at times. And like all journeys, no two are equal. Some children are clear as a bell by their second birthday while others need a bit more time. As parents, we typically understand our babes before the rest of the world and therefore, are awarded the esteemed role of toddler translator. In many situations, one parent has a better handle on their child’s speech sound system than the other. But, as a general rule of thumb (or rule of “fum” if you happen to be a toddler):

• By 2 years of age children can be understood by familiar adults most of the time.

• By 3 years of age children can be understood by unfamiliar adults most of the time.

• By 4 years of age children can be understood by unfamiliar adults almost all of the time.

• By 5 years of age children can be understood by unfamiliar adults all of the time.

(Based on Flipsen Jr, 2006)

Although a continuum exists when it comes to speech sound development, there are a few red flags to be mindful of when chatting with your child.

It may be time to check in with your pediatrician regarding an evaluation with a speech language pathologist if your child:

• Uses only vowel sounds and a few consonants or shows limited babbling at 18 months.
• Seems to have a “slushy” (think mouth full of marbles) quality to his speech.
• Is difficult to understand and has a history of frequent ear infections.
• Leaves off the beginning or ending sounds of words (hatàha).
• Leaves off entire syllables of words (pa for purple).
• Is not understood by people outside his immediate family by age 3.
• Seems to be frustrated by his difficulty with speech or appears hesitant to interact or respond to peers or adults.

So what can you do to help him along?

Above all, it is important to always show your child you value WHAT he is saying regardless of HOW he is saying it. Always reinforce his attempts at striking up conversation with you! When you hear one of those adorable substitutions, help him to learn by repeating it correctly (If he says “tar” you can say “yes! A car!”) and moving on with the flow of conversation. Play face to face with him so he can watch the way your mouth moves to make sounds. Emphasize beginning and ending sounds in your own speech so he can hear them and begin to realize they are part of the word, too. If all else fails, ask him to SHOW you what he needs. And take comfort in the knowledge that this process is a gradual one.

Oh, and my daughter? She wanted to watch Frozen on the big T.V. and relax a little bit. Obviously.

1. Shriberg, L.D. (1993). Four new speech and prosody-voice measures for genetics research and other studies in developmental phonological disorders. Journal of Speech and Hearing Research, (36), 105-140.

2. Flipsen, P., Jr (2006). Measuring the speech intelligibility of conversational speech in children. Clinical Linguistics and Phonetics, (20) 4, 303-312.

3. http://www.asha.org/public/speech/disorders/SpeechSoundDisorders/

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

Ball sports and games have many benefits for kids besides being a lot of fun. Playing ball helps kids develop skills:

Increased coordination with both hands

How?

o Stand in one place and dribble a basketball.

o Run while dribbling a ball.

o Playing/bumping a volleyball.

Increased hand eye coordination

How?

o Playing catch.

o Batting practice.

o Playing mini golf.

o Playing a racquet sport like tennis or ping pong.

Improved balance

How?

o Kicking a ball while standing in place.

o Kicking a ball while running.

o Jumping and reaching to catch a throw.

There are great ball options for kids of all ages and abilities. 

For kids 3 and under

Once babies can sit on their own, they can begin to roll a medium sized ball. As they grow, they will begin to use two hands to attempt to catch by pulling a ball closet to their body. Kicking is something that we should start to see with toddlers. At first your little one will walk into a ball to move it forward. As your child matures they will begin to lift one leg to kick. This requires balance and is a good challenge for toddlers and preschoolers. As their balance improves they will be able to the kick the ball harder and farther and in a straight line.

For grade school kids

At this age, kids are ready to be challenged with balls of different shapes and sizes like soccer balls, footballs, baseballs and tennis balls. These balls can be thrown and caught, but also can be used in more complex ways as part of a game. A great way to get this age group active is to create a game that they can play with friends.

For the preteen and teenagers

If your child is not yet involved in a team sport, it is important to continue to encourage them to be active with their friends, including games that include ball skills.

Sports are beneficial whether played on formal teams or as part of pick-up game with friends. Sports not only challenge your child physically, but encourage them to work on things like taking turns and being a good sport. Activities like soccer, baseball, and basketball require children to coordinate their own movements with the movements of other children in order to be successful. Teamwork and compromise are great skills for all kids to work on and will benefit them in many areas of their life.

So whether it is on their own, with siblings and friends, or as part of a team, encourage your kids to be active this summer and get involved with ball games. Remember that all kids should be getting at least one hour of physical activity a day and they will need lots of water when playing outside in the Texas summers. 

About the author

Kate Mcgee, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

Dr. Aaron spent her morning on Thursday, July 24, doing interviews with newspaper, radio and three local TV stations.

“I’ve never been one to reach out to the media or certainly get in front of the camera,” Dr. Aaron said. “I’ve had those times where I’ve been asked to be on camera and needed to do that. This is the first time where I’ve ever picked up the phone and called our team and said, ‘Guys, we need to do something. We need to reach out because three in one week … that’s just too many.’”

The mother of a 2-year-old son, the swimming deaths hit way too close for Dr. Aaron. All three children who died were between the ages of 2 to 4 years old. The teams at Cook Children’s involved in the three drowning events met with Cameron Brown, a member of Cook Children’s Pastoral Care and a firefighter, who is specially trained to lead caregivers through a critical incident stress debriefing. To put it simply, they were heart broken.

“This is what we do. This is our profession, but it impacts us,” Dr. Aaron said. “We’ve had great sorrow. That is minimal to what we sense must be happening with these families and close friends. It’s unusual for us to have three cases in one week ... and we still have many weeks of summer left.”

What makes the deaths even more tragic is the fact that most drownings are preventable. Dana Walraven, Cook Children’s Community Health Outreach manager and Safe Kids Tarrant County coordinator, also spent the day with media to discuss drowning prevention steps. Texas has the highest incidence of swimming pool- and spa-related childhood drownings in the United States. All three children who died were pool related incidents.

Drowning is the leading cause of unintentional deaths for children 1 to 4 years of age. The common myth of children splashing, waving their arms around and yelling is simply not true.

“In many drowning situations, an adult was just a few feet away from the pool and didn’t realize anything was wrong because he or she didn’t hear any sounds of distress, such as splashing or yelling,” Walraven said. “Drowning is a silent event that can occur in the time it takes to send a text message. Should supervision fail for any reason, having multiple layers in place helps protect your child.”

Walraven offers these drowning prevention basics:

• Have your children take swim lessons.
• Have the entire family taking swim and safety lessons.
• Learn CPR.
• Provide 100 percent supervision without distractions.
• Use pool and child alarms to alert you if your child gets in the water without you.
• Isolate your pool from the rest of your backyards with a permanent, four-sided fence with self-latching gates to prevent kids from accessing the pool area without adult supervision.

“We realize that it could happen to anyone,” Dr. Aaron said. “It happens very, very quickly. We’re not being judgmental. We feel so strongly about this and knowing how it impacts us we wanted to reach out and raise awareness to the community.”

For more information:

• Drowning prevention
• Water safety
• Vento family story
• Cookchildrens.org/safety
• Backyard and Pool: Household Safety Checklist
• Household Safety: Preventing Drowning

One of the biggest stories centers around the suspension of Luis Suarez for biting an Italian defender.  It’s not the first time he has done it either.

I usually tell families that their kids will outgrow this problem, but I guess if you’re a world-class soccer player, that’s not always true.

What do we do when our child is the biter?

First off, this happens ALL THE TIME…

Your child is not the first child who has bitten and won’t be the last so let’s be calm.

There’s really just a few things you can and need to do in these situations …

When the bite has already happened

Separate biter and the bitten child.  This helps the “victim” feel safer and diffuses whatever frustration caused the biting in the first place.

Try to talk it out.  Often you are dealing with a pre-verbal child, but it is still important to try and talk about the situation that led up to the biting.  Usually the child who bit is just as scared as the child who was bitten.  You are typically dealing with young toddlers with limited verbal skills, but talking with them about their frustration/anger that led up to the biting can help them understand that there is a better way to express these emotions.

Preventing the Problem

The ultimate goal in helping with biting is to prevent the situation that leads to biting in the first place.  The key to this is: distraction, distraction and distraction.  Keep the frequent biters from their trigger situations or be prepared to intervene quickly before the frustration levels begin to rise.

Or, Just Bite Them Back

Of course, everyone has had a family member or someone tell them that this is the best way to get a biter to stop and while it may have worked for them in the past, I feel that this strategy is simply modeling the behavior you are trying to extinguish.  Toddlers learn best through seeing their parents’ actions and having your parent bite you only makes you think that is appropriate behavior.

About the author

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