We always get plenty of phone calls

Here are some common scenarios for which we have parents call our office:

Vomiting with diarrhea—could be a viral gastroenteritis, commonly called the “stomach flu”. It’s usually not dangerous, but very uncomfortable. Very young children are most at risk for dehydration. But, because most children are very resilient, significant dehydration won’t occur if the child is able to take sips of liquids frequently during the illness and the illness is short, typically a day or 2.

Vomiting with fever—many conditions can cause this from early symptoms of a cold or the flu to some gastroenteritis or strep throat.

Vomiting with bloody diarrhea—could be due to serious intestinal infections and the child should be seen as soon as possible.

Vomiting with change in mental status (confusion, disorientation, excessive sleepiness)—could be due to a head injury, a poisoning, etc. A child with this presentation should be seen immediately.

Vomiting with a headache—may be due to a migraine, an infection such as the flu or strep, but if these symptoms occur after a head injury, this could signal a serious problem due to the injury. In this case, go to the emergency room.

Over -the-counter products are not typically recommended for young children.

If a clinician determines that the condition isn’t serious, then recommendations for home treatment will be given.

We would love to be able to “turn it off” so your child feels better, but most of these conditions are only treated with supportive care and TLC—care that parents can provide at home.

Often we see children in the office to assess for dehydration. Signs to watch for include:

• Dry cracked lips and a dry mouth
• Decreased urine output and very dark urine
• Drowsiness or irritability
• Cold or dry skin
• Low energy levels, appears weak or limp
• No tears when crying
• Eyes sunken or a baby’s soft spot (fontanelle) sunken in

Commercially available solutions such as Pedialyte, Gastrolyte or Enfalyte will contain the properly balanced amounts of water, sugars, and salts to promote absorption of the fluid. Oral rehydration is the best option for mild to moderate dehydration. Give your child 5-10 milliliters (1-2 teaspoons) of one the previously mentioned drinks every 5 minutes, slowly increasing the amount as your child tolerates. If you breastfeed your child, continue to do so.

If your child refuses to take an oral rehydration solution, try giving fluids you know your child likes, such as milk or water mixed with juice. But if your child has severe diarrhea, milk and juice may make it worse. So encourage the oral rehydration as best you can.

If you think your child is severely dehydrated, go to the Emergency Department immediately.

When these are the main complaints on my patient schedule, I know it’s probably norovirus time. 

The Centers for Disease Control and Prevention (CDC) estimates that each year norovirus causes 19 to 21 million illnesses, 56,000 to 71,000 hospitalizations and 570 to 800 deaths. Anyone can get infected with norovirus and you can get it more than once. It is estimated that a person will get norovirus about 5 times during their lifetime. Many people usually get sick with norovirus in cooler months, especially from November to April.

Here are 5 facts you need to know about norovirus:

1. Norovirus can cause SEVERE vomiting and diarrhea. Treating children with fluids and monitoring for dehydration is critical.

2. Norovirus is HIGHLY contagious by contact with another person with the virus, eating food that is contaminated or touching contaminated surfaces and putting your fingers in your mouth. Symptoms usually develop 1-2 days after you have been exposed.

3. Prevent infection by washing foods very well, washing your hands with soap and water frequently and disinfecting contaminated surfaces.

4. Norovirus “season” typically runs from November to April but it appears there are several cases popping up over the last month across the country and in North Texas.

5. Monitor for the following signs of dehydration including: dry mouth or lips, decreased activity level or decreased urine.

If you have had a child (or you have had) with norovirus, here is a cleaning plan to help “decontaminate” your house:

1. Wash your hands with soap and water frequently.

2. Wear gloves for everything (diaper changes, cleaning and handling clothes esp…).

3. Clean all toys and surfaces with a bleach solution (5-10 tablespoons in 1 gallon of water).

4. Wash laundry on the hottest, longest cycle available and machine dry.

Hopefully with these tips you can prevent norovirus from entering your home or at least stop the spread. If you have further questions, contact your Cook Children’s pediatrician.

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.

This is often said when someone is hit in the head during a sporting event. But this type of injury should never be taken lightly. A concussion can occur when a person has a trauma such as a blow to the head or the head being shaken. In fact, concussions can happen whether the person is actually “knocked out” (loses consciousness) or not.

Concussions are a common issue among school aged children and teenagers, especially if they are active in sports. In the United States alone, more than 300,000 concussions occur per year as a result of sports. An athlete who plays a contact sport, such as football, wrestling, basketball or soccer, is estimated to have a 19 percent chance of suffering a concussion in a single season. Other activities such as gymnastics, cheer, skateboarding, bicycling, or even jumping on the trampoline also come with an increased risk of concussion.

Can my child still get a concussion if he or she is wearing a helmet?

Yes. Although helmets do protect your child from a fracture of the skull or an injury that causes bleeding to the brain, they do not necessarily prevent concussions. It is possible to sustain a concussion while wearing a helmet because the helmet protects the bones of the head, but cannot stop the brain from making contact with the inside of the skull.

But what exactly is a concussion?

A concussion is a type of brain injury that interferes with the way the brain functions. It can cause symptoms such as:

• Headaches
• Nausea and vomiting
• Vision changes
• Irritability
• Difficulty concentrating
• Memory problems
• Balance issues
• Sleep disturbances

The majority of concussions (80-90 percent) resolve within 7-10 days, but may take longer for children and adolescents. Sometimes, the symptoms of a concussion will linger or worsen. If symptoms become persistent, your child may require further treatment to help symptoms resolve so they are able to return to attending school and participating in normal activities. Even a child with a “mild” concussion should be evaluated by a physician. A doctor will be able to decide if any tests are needed to check for more serious injuries. He or she will also check your child’s symptoms to find out the severity of the concussion, and determine whether referrals to other healthcare providers, such as a physical therapist, are required.

As a parent, what do I need to know to help my child get back on the playing field after a concussion?

Patience is key when it comes to safely returning to sport following a concussion. Every young athlete is eager to get back to sports or activities as soon as possible. It is up to the parents to make sure that this process is not rushed and happens in a safe way. More and more research studies are proving that the effects of concussions can compound and have long-term effects if another concussion occurs before adequate time for recovery is allowed. If an athlete or child returns too soon, he or she may be susceptible to negative effects of post-concussion syndrome such as depression, memory loss, fatigue, chronic headaches or pain. Parents should be diligent with following up with healthcare providers to get appropriate treatment prior to returning to sports.

How can a physical therapist help an athlete return to sport after a concussion?

Physical therapists will assess the need for treatment of any musculoskeletal injuries that occurred at the time of concussion. If your child has pain in the muscles or joints of the neck or spine as a result of injury, a physical therapist can help decrease this pain with hands on techniques or exercises. An injury to the brain can affect the brain’s ability to tolerate physical activity, movement, and balance. Sometimes these symptoms interfere not only with an athlete returning to his or her sport, but also with every day activities such as attending school, reading a book, or playing video games. A physical therapist will also assess the athlete’s tolerance for activity, function of the vestibular system (a part of the inner ear), and balance.

A physical therapist has the ability to monitor a patient’s symptoms while safely progressing from light aerobic activity, to sport-specific drills and eventually to non-contact drills. This allows the athlete to return to full practice and eventually to his or her sport. The vestibular system is a part of the inner ear that sends signals to the brain regarding a person’s movements and position in space. Additionally, the vestibular system is closely associated with an athlete’s ability to maintain balance. Balance can be affected when a child suffers a concussion, and can require rehabilitation from a physical therapist. Physical therapists can use specific exercises designed to strengthen the vestibular system and improve balance to prepare your child to safely return to sport or activity.

So what’s the bottom line when it comes to concussions?

1.Head injuries, or “getting your bell rung”, should not be taken lightly.

2.Helmets protect the skull, but do not always prevent concussions.

3.It is important that a physician evaluate your child after an injury to the head.

4.Parents and athletes must be patient in order to safely return to activities in order to allow concussions to fully heal.

5. Physical therapists can treat patients who have had a concussion to help with musculoskeletal or vestibular system issues, tolerance for physical activity, and balance training to help safely return to sport.

For more information:

• What every parent needs to know about concussions
• Concussion management and update
• Football injury prevention
• ​Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• ​SPORTS resources
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries

About the author

Jessie L. Diebold, PT, DPT, OCS, is a SPORTS physical therapist at Cook Children’s. Cook Children’s SPORTS Rehab is a leader in the community in sports injury. Additional information and helpful tips can be found on the Cook Children’s SPORTS Rehab website. Cook Children’s SPORTS Rehab is a leader in the community in sports injury prevention.

The DSHS has received reports of 205 cases of Cyclosporiasis in Texas. No cases have been reported at Cook Children's. In Cook Children's six-county service region, the following numbers have been reported:

The U.S. Food and Drug Administration's alert says cilantro from the Mexican state of Puebla may be the cause for the recent outbreaks.

Symptoms usually begin 2 to 14 days after ingestion of contaminated food or water.Mary Suzanne Whitworth, M.D.,medical director of Infectious Diseases at Cook Children’s, advises parents to contact their Cook Children’s pediatrician if they have a diarrhea-like illness lasting more than a few days or diarrhea accompanied by severe weight loss or fatigue. Those are symptoms of Cyclospora.

Symptoms include severe diarrhea that can last a week to months, and if not treated, the person may relapse. Additional symptoms may include fatigue, severe weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and low grade fever. If your child is experiencing these symptoms, do not wait. Contact your Cook Children’s pediatrician. If your child is diagnosed with Cyclospora, an antibiotic can be prescribed.

However, most cases of diarrhea or an upset stomach do not need treatment with an antibiotic. Usually, diarrhea is caused by viruses, so time, rest and diet will take care of the problem.

“Past outbreaks of Cyclospora in the U.S. have been caused from imported, fresh produce,” Dr. Whitworth said. “The best way to prevent Cyclospora in your household is to wash your fruits and vegetables as thoroughly as possible. Let fruits and vegetables soak for a few minutes in clean water in the sink, and then drain and spray them off with clean water before eating them. Thorough washing of fresh produce is highly recommended, but it may not remove the risk of someone in your family getting Cylospora entirely. If your child has these symptoms, it’s best to see a pediatrician and get treated as quickly as possible.”

Cyclospora is generally not transmitted directly from person-to-person, however children with diarrhea should always avoid swimming in pools to avoid the spread of infection.

The Centers for Disease Control and Prevention has more information about Cyclospora.

When should you call your pediatrician about diarrhea? Watch this video from Justin Smith, M.D., for more information.

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

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

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

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

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

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

What are Salmonella and Shigella?

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

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

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

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

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

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

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

Fever, headaches, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite.

Over the next few months, many children will have these symptoms and many parents will, and should, call their Cook Children’s pediatrician because of how their child’s feeling.

Unfortunately, many parents will assume the worst … Ebola. But the chances of that being a reality are extremely low. While knowing it’s not likely to be Ebola may be a relief, it’s important to remember that Ebola is not the only dangerous virus on the horizon for our children. The symptoms listed above are much more likely to be the flu.

Investigation of 25 outbreaks of Ebola over 38 years has shown that only direct contact with a person with Ebola would cause someone to become infected. Right now, there’s no approved vaccine to limit the epidemic in West Africa.

On the other hand, influenza can be deadly. The 2013-2014 flu season led to 108 pediatric deaths in this country. The flu is spread readily through the air by small droplets which can be infectious to someone near a person who is coughing and sneezing and is much more easily acquired and easily prevented through vaccination.

Please make sure to get your children the flu vaccine and parents should get them too! ASAP. Both injection and nasal mist vaccines are effective.

I must get this question three to four times a day in the office and it's one of those things that keeps you up all night wondering what you should do. The answer, "There is no fever you should go to the ER for..."

That doesn't mean that children with fever don't sometimes need to go to the ER, but the height of the fever is not an indication that a late night drive and time in the ER wait is the right thing to do.

We always want to take the fever into the context of the following questions:

1) What are the other symptoms that the child is having?

• Runny nose, cough? Probably not.
• Abdominal pain? Depends on severity an location.
• Vomiting? Not if can keep some liquids down and still peeing.

2) What is the child's behavior like? Lethargic or active. Is the child laying around all day, not even really wanting to wake up to drink or do they perk up and act like they feel better at times (especially when their fever is down). If they are lethargic, bring them in.

3) Is the child drinking and peeing?  If so, then we will almost always recommend a call to the office over an ER trip.

Common fever myths:

"The child's brain will be fried if the temperature is over 105." Ummm. No. Temperatures that the body is generating on their own as a response to illness will not cause brain damage or any of the other things that your grandmother/neighbor/best friend said they would. We commonly have children with 105-106 temps walk in and out of our office smiling cause they got their stickers for being a good boy/girl.

"If the fever gets above 103 they will have a febrile seizure." Wrong again. In fact, most febrile seizures occur when the temperature is between 102 and 103. We don't know exactly why this is but it is thought that it is related to the rate that the temperature rises and not the absolute number that the temp gets to.

"The baby felt warm so she had a fever" or "The baby was really hot so the temperature must've been about 104." Sorry to the back of grandma's hand, but judging the temperature especially trying to put a number on it by touching a child's head is incredibly unreliable. I would prefer an axillary or temporal thermometer, or in the babies less than 3 months, I'll commonly ask for a rectal temp.

"He had a low grade temp of 99" or "99 is hot for him because he usually runs 96." “Low grade temp” should really be taken out of our vocabulary. They have done studies where they took children's temperatures several times a day and have found that any temp <100.5 in a child less then 3 months and <101 in an older child should not be considered fever. These are normal temperatures that can occur during the course of the day for any child who is healthy and has no reason to be running fever.

So, what temps should I call for?

• Any temp over 100 in a baby less than 3 months.
• Any temp in a child who is not drinking well and with decreased urine.
• Anything else that has you concerned.

The ultimate point is that we should not be afraid of fever. Fever is just another symptom in a long list of possible symptoms a child can have when they are sick. It means that we need to think about what is going on and watch the child close but resist the urge to panic!

About the author

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