Know your babies' limits and plan ahead when making a trip outside so you can keep them well this winter.

Bundle Up

Before infants head outdoors, make sure they are wearing fresh diapers and are insulated against the cold and wet. 

"A good rule of thumb is to dress newborns in as many layers as you're wearing," said Diane Arnaout, M.D., FAAP, a Cook Children's pediatrician in Willow Park. "That includes covering their heads, hands and feet. Those areas can lose a lot of heat and be harder to keep warm."

As a mom of young children, Dr. Arnaout has first-hand experience in facing area winters with a newborn. She recomends using socks to keep tiny hands and feet warm, knit hats for infant heads and sunglasses to keep the bright winter sun out of little eyes.

Pay Attention

It's important to regularly check on newborns while you're together outdoors. Babies tend to fuss when they're uncomfortable, so if they are crying or restless while you're out and about, it may be time to move outside. 

To see if infants are getting too cold, check their ears, nose, hands and feet regularly. If your own nose or ears are cold or your lips and becoming chapped, odds and it's too cold outside for babies.

Blue skin, shivering and a cool chest and stomach are signs that children may be dangerously cold. If you see these signs, take action immediately to get kids out the cold. Seek immediate medical attention if you're not able to warm the body.

About the source

Dr. Diane Arnaout joined the Cook Children's Willow Park practice in 2011. Dr. Arnaout was born and raised in the Dallas-Fort Worth area. She served as a leader on the medical education committees during her internship and residency in pediatrics at the University of Texas Health Science Center in the Texas Medical Center at Houston, Texas.

I'm gonna get my sweet little buddy Carson here to help me.

For starters:

1. No, it's not that cattle disease with a similar name. Heehee. 
2. Yes, it's super contagious. 
3. Nope - no reason to freak out. We see it all the time. You probably had it when you were a kid.
4. Go get some popsicles. I'm gonna prescribe them.

Hand Foot and Mouth Disease (HFM from here on out) is caused by a virus. What does that mean? Come on - I know you're sick of hearing me say it - that means no antibiotics needed! Woo hoo! This is a virus which your strong kiddo can clear on his own!

Most of the time this happens in kids under 5. They catch it from day care or school classmates. Usually they catch it by getting oral secretions or fecal secretions in their mouth or airway from a buddy. I'll let your imagination run wild on the methods kids go through to experience this fun transfer of germs. It's really contagious.

People with HFM are most contagious during the first week of their illness. However, they may be contagious for weeks after symptoms go away. Some people, especially adults, may not develop any symptoms, but they can still spread the viruses to others.

This is a common SUMMER virus! But can happen any time of year.

Soon after catching it (like 3-5 days), kids start with a fever and a new rash. The fever is usually low (under 101) but can be high at times. Sometimes they have a runny nose, or other cold symptoms.

The rash is unique. They're red spots with/without thick bubbles of fluid.

Usually, they're on or in the mouth, and on the palms of the hands and soles of the feet. Hence the name. However, I joke with parents that it should be called "Hand-Foot-Mouth-Butt-Arms-Legs" because you can see the spots in other places, too.

HFM is commonly mistaken for other things. Often, parents worry about chicken pox. Remember - chicken pox is itchy and tender. HFM is not. People also mistake these for bug bites - again, not itchy like bug bites are.

The mouth sores hurt. They're typically the main complication I see with HFM - they hurt so much kids don't want to eat or drink. The eating I don't mind -but it's important that they drink. Load up on popsicles. All my "sugar rules" go out the door when a kiddo has HFM. Sometimes if it's really bad we will prescribe a mouthwash for pain.

Something else you should know - more than one strain of virus causes this bad boy. So kids can get it more than once. And if an older child/adult catches it? It can be more troublesome/painful than in a younger person.

It'll go away on its own. This can typically take 7-10 days. The fevers usually last just a couple of those days. Kids typically are just fine. It's actually adults that can experience the worst of it!

Hope this helps!

Hugs,

Dr. Diane

Swimmer’s ears are infections in the canals of the ears that make the ear very painful to touch and movement of the ear. It is typically caused from water sitting in the canal too long, resulting in swelling and drainage in the canal from the bacterial overgrowth.It is not typically accompanied by fevers and cold... symptoms.

Because it is outside of the ear drum we can use prescription drops to treat it. Motrin works well for the pain and heating pads if needed.

You can prevent them by using the over the counter ear drying drops after swimming. I have included a photo of what they look like. You can also make you own with equal part rubbing alcohol and white vinegar and place 5-10 drops in each ear.

Inner ear infections typically follow prolonged periods of nasal congestion from allergies or a cold. The nasal swelling causes fluid to back up behind the ear drum. It is not usually painful on the outside of the ear and can cause fevers. We have to use oral antibiotics to treat them, because the drops can’t penetrate behind the ear drums where the infection is.

You can keep swimming with an inner ear infection, we recommended waiting to swim until pain is resolved with a swimmer’s ear.

As always, call us with any questions and enjoy the warm weather and swimming season!!

-Sperry, NP

Let me be real for a second – it’s been a pain in the you-know-what. We’re updating, changing, training, stressing. I may or may not have purchased more wine this month than usual.

Why are we doing this?

Because it’s better. It’s faster, more efficient, more organized, and SAFER than our old systems.

We are doing it because it will lead to better overall care for your child.

I’m actually really excited about it. As a pediatrician, my days revolve around a computer. Many of you may notice I always bring a computer into the room with me. I show you how your kiddo has grown. I take notes to remember important things you tell me. I look up what happened in the hospital when you went to the Cook Children’s ER. I read that consult note from when your child saw the ENT.

The way I do those things will be changing.

Things will be new and glitchy at first – just like any big change is -- but overall, the improvements in your child’s care will be awesome.

But… what does all of this mean for you and your children?

It means that, for a little while, you might experience a bit of a longer wait in the pediatrician’s waiting room, or urgent care, or ER as we learn to use the system.

You might experience slightly longer hold times on our phones while my staff is figuring out how best to schedule your kiddo’s appointment.

Our front desk people have to get used to the changes in booking appointments, changing charts, and updating your insurance information. Don’t worry, it’ll speed up with time.

Our nurses might need a little extra time to type in what medications your child is on, their medical history, and your concerns. Again – this’ll improve quickly.

It means that I, as your PCP, will be able to know every single thing that happened to your child in the hospital (as opposed to a tiny summary that doesn’t give me much information). Every single vital sign, oxygen reading, X-ray, lab result, consult note – I’ll have access to all of it! I may fumble around for the first few days when I try to show you things on my computer. Feel free to giggle at me.

It means that your child’s specialists and I will be able to communicate more effectively.

It means that YOU will have a new portal system called MyChart.

This thing is awesome!

• You’ll be able to look up your child’s vaccine records and print them, see summaries of all of our visits together, and ask me (and my staff) direct emailed questions!
• You can look up test results, see lab work, and find out when your next appointment is!
• Go to www.cookchildrens.org/mychart for more information - You can sign up now!
• It means that we will be SAFER – more safety checks on prescriptions, and constant updates to how we calculate and order things.
• It means it will be less of a hassle for us to get your child’s medical records from many hospitals around the country.

Bear with us, friends, as we embark on this new journey. I promise, it makes a difference in your child’s care.

And feel free to bring us some sympathy chocolate at the office on March 1st…. ;-)

I get the question all the time at my office in Forest Park - "When can my baby safely have a blanket/pillow/lovey/stuffed animal in the crib with her?" I'll try to answer that here.

Don't we pediatricians seem silly sometimes? We're always lecturing you about what not to do. DO NOT put your baby on their stomach to sleep. DO NOT put anything in your child's crib. DO NOT sleep with your baby in your bed! DO NOT use those darn crib bumpers!

We seem mean, right? And strict. And out-of-touch with surviving the sleep deprivation involved in raising a small person.

I'm here to tell you that the reason we tell you these things is because we don't want your baby to die. Dramatic, I know. And I'm not trying to fear-monger. Hear me out.

A recent study by the American Academy of Pediatrics found that over half of American sleep environments for babies under 1 do not follow recent "safe sleep" recommendations. That's so scary to me.

Babies have died by suffocating under stuffed animals, blankets, and bumpers in bed. I know it seems silly, but it's happened. Open up your web search engine and do a quick search. I've personally done CPR on a 4-month-old infant who had gotten their little head trapped between a bumper and a crib rail. I will never forget the look on the mother's face of another child, a newborn who suffocated on a pillow in the crib. These memories haunt us, folks. These babies' deaths were preventable.

The reason these tragedies happen, and the reason we harp on "safe sleep environments" is because before age one, babies still have not developed the muscle strength and coordination to deal with crib items the way an older child or adult can. And their brains are still not old enough or developed enough to wake them up to change a dangerous situation, like their face being mashed into a soft mattress, or a blanket covering their head. They are not coordinated enough or strong enough to unwrap a tangled loose sheet, or unwedge their head from a loose bumper.

I don't think you should put anything in the crib with your baby, other than a wearable/zip-up blanket and a pacifier, until they are 12 months old.

After that, have at it. My 3 year old sleeps with no less than 15 animals/blankeys in his bed at night. My 18 month old has a small blanket and a lovey she adores and needs right now to soothe herself to sleep. The incidence of crib deaths drops drastically after age 1 - typically if a toddler dies suddenly in bed, it is due to a medical issue (though there are very rare exceptions out there).

Before age 1, put a wearable blanket on your baby. They're in all the baby stores and online, are washable, and they're affordable. They should have arm holes and a hole for the head, and should zip up. They come in linen, fleece, you name it. They keep kids warm enough in the winter.

Pacifiers are OK in the crib anytime. In fact, studies in recent years have shown a paci used at night drastically reduces the chance for SIDS death.

Loveys are a tough one. I consider a "lovey" to be one of those small pieces of cloth with a little soft animal head attached. I think they're safe to introduce around 12 months - when a child's core muscles are nice and strong and they're easily able to roll, prop up to sitting, and self-soothe. Some of them are bigger than others. I'd be worried if one was long enough to wrap fully around a child's head or neck.

You could do a little experiment to see if your baby is ready for a lovey. After they fall asleep, take the lovey and put in on their face, then observe. Do they breathe easily? Do they eventually swat it to the side? If the answer is yes, it's ok to keep it around!

I am a big believer in healthy baby sleep practices and children learning to self-soothe when they are ready. I hope this helps guide you in what can safely go in the crib!

Hugs,

Dr. Diane

DEET gets a pretty bad rap. In a day and age where people are pushing for the more "natural" approaches to prevention and medical care, DEET seems to be the least natural thing out there, right?

You know what is natural? West Nile virus. Zika virus. Chikungunya virus. Powassan virus. Ugh. All nasty viruses which are passed from human to human thanks to mosquitoes.

Citronella hasn't been proven to last very long and has to be at high concentrations to have any effect. So it has to be used really frequently to make up for its lack in efficacy.

Wristbands have been proven time and again in studies not to work, regardless of ingredients.

Lemon eucalyptus oil actually can help - but studies have shown that it's about half as effective as DEET and hasn't been tested for safety in kids under 3.

"Various botanical oils other than those discussed previously, including sandalwood, geranium, soybean, and others, have been used alone or in combination for repelling mosquitoes and ticks. The majority of studies of these alternative plant-based repellents show that the protection they offer is far inferior to DEET" - straight from a peer-reviewed medical article (UpToDate). I had high hopes for my marigold and lavender plants but I don't think they will work (Insert your own frown emoticon here).

So what do I put on my kids? DEET. Because no other compound (natural or synthetic or otherwise) has been proven to be as effective at keeping away mosquitoes, ticks, fleas, and chiggers.

DEET comes in different percentages - 10 percent to 70 percent. Stick with the 10-30 percent range. Ten percent will get you about two hours. Twenty-four percent gets you about five hours of protection. If your children are older, you can use higher concentrations if you'll be outside longer than five hours. The higher the concentration, the longer the effect will last.

DEET can be used on kids as young as 2 months. I know, I know - the thought of putting a synthetic compound on a sweet baby makes me cringe too. But honestly - it's OK for a few hours at a time. Scary things like neurotoxicity have actually only occurred in giant, massive doses after prolonged exposure, and even then it's super rare. Fewer than 20 cases of this happening have been recorded WORLDWIDE since the beginning of time.

If you have aerosolized spray, do what I do - spray it on your hands, then rub it on their arms, legs, neck, ankles, torso. Don't spray it on them directly , and try to avoid inhalation. Don't put it on their hands (because if they're anything like my kids, their hands are in their mouths nonstop). Avoid the eyes. Give them a bath when you're done with outside time.

DEET really is the best way to keep the bites away. And with such a wet "winter" that we had this year - it sounds like we will all need some.

Hugs,

Dr. Diane

We doctors call them "aphthous ulcers" because we cannot use names in medicine that are easily pronounceable. Come on.

Green, glossy leaves that grow in clusters of three characterize these common plants. The leaves contain a type of oil that, when spread to the rest of the body by scratching or contact with contaminated clothing or pets, causes irritating symptoms for many children.

“A rash can appear hours to days following contact, eventually developing into red bumps or blisters that often rupture and ooze,” said Jenica Rose-Stine, D.O., pediatrician at Cook Children’s in Willow Park. “For moderate cases, soak the area in cool water or have your child take a cool shower and apply over-the-counter, 1 percent hydrocortisone cream. Contact the pediatrician if your child is especially uncomfortable, if the rash is severe or if blisters appear on a sensitive area, such as the face or genital area.”

When it comes to avoiding poison ivy and poison oak, education is the key to prevention. Show your children pictures of the plants so they can learn to recognize them and steer clear. Dress them in long pants, long-sleeved shirts and closed-toe shoes if they plan to play in the woods. If they come into contact with the plants, have your children bathe and change their clothes and shoes right away. They may grumble about having to take a break from activity, but a few minutes in the shower beats weeks of discomfort.

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.

That's one of the most common questions I get while doing my AMAs on our Willow Park Pediatrics Facebook page. 

The answer I give, most of the time, is - nothing.

Here's a few points about vitamins. Short and simple.

1. If your kiddo eats a well-rounded, healthy diet, they don't need a daily vitamin. This means meats, milk, veggies, fruits, and whole grains daily.
2. If your kiddo has a "bad day" - a.k.a. a chicken-nugget, mac-and-cheese kinda day, offer a simple chewable children's multivitamin that day.
3. Limit your child's milk intake to 20-24 ounces or less per day. While we love the calcium and Vitamin D in milk, it hinders the absorption of other vitamins, like iron, and fills kids up so they don't eat the other foods they are supposed to eat.
4. Large doses of certain vitamins can actually be harmful. Be careful of natural websites/naturopaths who claim "megadoses" of vitamins can cure ailments. Be especially careful with kids, as there is lacking research about this and some bad side effects can happen.
5. If your child is a vegan or a vegetarian, or allergic to milk, they need a daily vitamin. Talk to your pediatrician about this.
6. Certain medical conditions require vitamin supplementation. Think food allergies, GI tract disorders like celiac and Crohn's, and endocrinologic (hormone) problems. Talk to your doc.
7. Vitamins can have SIDE EFFECTS! Yes! Vitamins! For example, B vitamins are associated with night terrors and nightmares. Other vitamins can cause nausea, dizziness, vomiting, headaches. They're similar to medications, folks - yet not as strictly regulated by the FDA - and you have to be careful with them.

Cook Children's published a good article about vitamins a few years ago. Check it out!

Hugs,

Dr. Diane

About the Author

At Willow Park, we are getting tons of calls for it if a child has been exposed, a parent has been exposed, a neighbor has it, your dog sniffed someone's bum who had the flu two weeks ago, etc.... 

Ask most physicians about Tamiflu and we'll tell you...."Meh." Tamiflu is helpful, but is not vital to getting over the flu.

1. It is not a "cure" for the flu. It allows for recovery one day faster than if you did not take anything.
2. It is expensive.
3. It does not come without side effects (especially tummy side effects) - sometimes worse than the symptoms of the flu!
4. It works best only if started within 48 hours of symptoms appearing.

Tamiflu is important to use and prophylax in children who have underlying medical issues - think asthma, diabetes, immune system deficiency. It is also indicated for use in children under age 5 if the child has the flu, or has a close contact with the flu.

It is NOT needed for healthy older children who are not symptomatic.

The best way to not catch the flu/get a milder version of the flu is to get the flu vaccine yearly! 

Hugs, 

Dr. Diane

About the Author

Dr. Diane Arnaout joined the Cook Children's Willow Park practice in 2011. Dr. Arnaout was born and raised in the Dallas-Fort Worth area. She served as a leader on the medical education committees during her internship and residency in pediatrics at the University of Texas Health Science Center in the Texas Medical Center at Houston, Texas.

My son Jack marched up to me this morning and announced, "Mama, there's a raisin in my nose!"

And that sucker was pushed in real deep. 

I didn't have any of my fancy extraction tools at home to get it out, so I'm gonna let you in on a little secret I learned about in residency: the "Mother's Kiss." Google it. It's great for getting out small things wedged up your kid's nose.

You close the "open" nostril and blow into your child's mouth. The pressure pops the object right out. It needs to be the "force of a sneeze"... whatever that means.

It worked beautifully for me today. I actually changed it up a bit and closed his mouth while I blew into his "open" nostril (I know...the things we do for our children). I was able to blow it out just enough to reach in and grab it.

Hope this helps you in your time of crisis 

Hugs,Dr. Diane

I should call this: "The Eustachian Tube - Dictator of Ear Happiness." More later on that.

Few things I want to put out there first:

1) There are two kinds of ear infections: middle ear infections (otitis media - the type you get tubes for) and otitis externa (outer ear infection, no tubes for this)

2) "Water in the ear" from a bath or pool typically does NOT cause middle ear infections! It CAN cause something called "otitis externa," or, "swimmer's ear," which is an ear canal/skin infection that may require ear drops to improve. I'm not going to talk about that kind of ear infection today. From here on out when I say "ear infection," I mean the middle-ear kind.

3) Ear infections are incredibly common. Do NOT freak out if your child gets one. Five out of six kids will have at least one by their third birthday (and most will have more than one).

4) A "red ear" does not mean a child has an ear infection.

5) A "baby messing with an ear" does not necessarily mean they have an ear infection.

6) A fever with your child's cold does not necessarily mean an ear infection is happening. The only way to know if your child has an ear infection is to have the ear drum examined by a medical provider.

Why do ear infections happen? Well....snot. And inflammation. Snot and inflammation from colds. Snot and inflammation from allergies. Snot and inflammation from just walking into the door of daycare or that play date.

The inflammation blocks a vital little guy called a eustachian tube. Look at the picture to the left. Find the eustachian tubes. See how they're a little exit canal for the inner part of the ear? They drain the ear. An infant's eustachian tube is smaller than an adults', and more horizontal. That causes problems. It just doesn't drain well.

It swells up, gets blocked off, and the snot in the middle ear has nowhere to go. Once the cold or allergies are better, it de-swells, opens up, and voila!, ear infection is gone. All the junk drains out. The baby's eustachian tube is different than an older kid's, or adult's. This fact along with the fact that babies and toddlers are snot machines and always putting things in their mouths - that's why they get more ear infections. We hope they "outgrow" this eustachian tube problem (and hands in mouth problem) by age 2-3.

It can take 3 weeks to 3 months for the fluid to drain out of the ear. And your kiddo may have an ear infection and you'd never know about it, and that's ok - because they usually get better on their own! Most ear infections are VIRAL! That means the fluid just has a virus in it, and it will all go away on its own thanks to our great immune systems.

When I look into a child's ear, I examine the ear drum to know if they have an infection or not. When there is no infection, an ear drum is translucent, kind of like a shower door. When it is infected, it is red, bulging out, and full of what looks like pus. Sometimes this is just viral fluid. But sometimes, while that eustachian tube is all swollen and blocked off, the liquid stuck in the inner ear gets bacteria in it. We can tell the difference by looking in there. And that is why some children need an antibiotic for some ear infections. To kill the bacteria while we wait for the eustachian tubes to un-swell.

So...who needs "tubes?"

There are a few things that cause kids to get lots of ear infections:

1. Being in a child care setting (lots of kids...lots of snot).

2. Secondhand tobacco smoke exposure (as if you needed another reason to quit).

3. Taking a bottle to bed (when the child lays down and drinks, the milk actually puddles in the area where the eustachian tube meets the nose/throat and causes swelling and bacteria to hang out back there - this habit also causes cavities - no bottles in bed, folks!!)

Some kids have really tiny eustachian tubes that stay really swollen all the time. If they're around other kids a lot, like day care, they get tons of colds each year, and that's normal. However their little eustachian tubes mostly stay swollen shut, sometimes for months at a time. And we see them in our office 1-2 times a month for repeated ear infections.

I guess a "rule" I follow is that if a child gets 5-6 bacterial ear infections in a year, or more than 3 months of constant fluid in the ear, I will send them to the Ear-Nose-Throat doctor to get tympanostomy tubes (or just "tubes", as most people know them) put in. This brilliant procedure creates a little "canal" for the fluid to escape from the inside of the ear. They fall out in about a year, when we hope they've "outgrown" the problem.

Sometimes, I send a kid to ENT if I've put them on 3 or more rounds of antibiotics and they're still having fevers and still in pain and I just can't get that dang fluid to go away. Who wants a kid on antibiotics for that long!? Another reason to see the ENT is if the fluid is making it hard for a child to hear. When a small child can't hear, they can't learn to speak. I've seen kiddos get ear tubes and within 1 week they are talking up a storm! It's amazing.

However, surgeries and anesthesia comes with risks. If you're worried your child has had too many ear infections, talk to us. We will let you know if we think it's time to see the ENT.

Wow...this was long. I hope it helped you learn something about one of the most common ailments we see in the office!

You try to talk some sense into him, but it’s almost as if you aren’t there. He’s babbling gibberish.

His heart rate is up – probably not as high as yours. Why is he acting this way? Is something wrong? Is he even awake? You attempt to talk to him, wake him up, anything - but he’s not paying attention. You lead him back to his bedroom and lay him back in bed. The next morning, he’s happy, playful ... and doesn’t remember a thing.

So what happened? A night terror happened.

I hear about these all the time at my office in Willow Park. It’s pretty common. But just because it’s common doesn’t mean it isn’t super scary to see in person.

Look up “child night terror” videos on YouTube and you’ll see what I’m talking about. The babbling, sitting up in bed, screaming, sweating, crying, wandering the halls. Sleep walking and talking is very common. It’s very easy to feel helpless as a parent in this situation. They can last up to 30 minutes!

We’re not totally sure why they get them – it’s probably the over-arousal of the brain’s “panic center” after the first 2-3 hours of deep sleep – but it’s usually genetic. Eighty percent of kids who have night terrors have a parent who had them, too.

I usually find kids who are going through major growth spurts have them more frequently – maybe there is a link between brain growth and night terrors?

They’re more common in boys, but happen in girls too. They’re most often happening between ages 4 and 12, but I’ve seen them in younger kids too.

They’re different from nightmares. Nightmares tend to happen at different times in the night, in different stages of REM sleep. Kids remember nightmares – they have visual images they can recall – but they have no memory of night terrors.

If your child gets night terrors, please try not to worry (easier said than done, I know). It’s always fine to talk to us about them and we will mostly reassure you that they will get better, and your child will outgrow them.

If your child has a night terror, know that they likely don’t even know you’re there in the room. You have to patiently wait it out.

Move anything on the floor that might get in his way so he doesn’t get injured. Put yourself between the child and anything that could potentially hurt him (a tall dresser, for example).

Ways that you can reduce how often they’re happening is to assess your kiddo’s stress level. Sometimes these happen more often when a child is under stressors like a parents’ divorce, or starting a new school, or new sport. Talk about these stressors during the day.

Establish a good bedtime routine. Bath, teeth brushing, and a book is always a favorite at our house. Try to avoid screens for an hour before bedtime.

This was a common sound heard on the inpatient floor this past year as I worked as a hospitalist. Young babies coughing until they couldn’t catch their breath followed by our respiratory monitors alarming for low oxygen saturations and low heart rate. Unfortunately, it was so common I could diagnose the problem from the hallway. If you watch the news often you’ve probably guessed the diagnosis.

Pertussis. Also commonly referred to as whooping cough or, ”the 100 day cough”.

Tarrant County has seen many cases of whooping cough in the past several years:

• 2013 - 700 cases
• 2014 - 467 cases
• 2015 - 308 cases

Recently there was a case in the news media about an infant death from pertussis; unfortunately this happens to between 0.5-1 percent of children under a year who contract this illness.

Pertussis is primarily a respiratory infection caused by the bacteria Bordetella pertussis. It is very contagious! It is a tricky diagnosis to make because the initial 1-2 weeks of infection seem like a cold. Patients have a clear runny nose, sore throat, watery eyes with mild cough and may not even run a fever. These symptoms are usually treated symptomatically at home. When they fail to resolve and become more severe with the characteristic coughing spells they come to medical attention.

To diagnose pertussis a nasal/throat swab (similar to a flu test) has to be obtained. Unfortunately, the diagnosis usually isn’t made until this second phase of illness and treating with antibiotics at this point doesn’t do much to alter the course of the infection. The cough is frequently followed by a “whooping sound” as the patient struggles to catch their breath. Infants don’t tend to make this sound as often as older children. It is common to vomit after these long coughing episodes and this phase of illness lasts for at least a month. A month!

In younger babies (less than 4 months) it is common for them to cough until they are blue and to stop breathing (apnea) and to not be able to maintain adequate hydration or weight gain. Young infants with pertussis frequently require hospitalization. While working as a hospitalist, it was not uncommon for a baby to be in the hospital for a few weeks while we gave them intravenous fluids to keep them hydrated, fed them through a nasal feeding tube and supported them during coughing fits.

Unfortunately, this infection can be fatal and frequently babies do require mechanical ventilation (breathing machine) in the intensive care unit. Less commonly, the infection can cause brain swelling (encephalopathy) and cause seizures.

Pertussis is spread through respiratory droplets. Babies, who are at highest risk of severe complications and too young for vaccination, usually catch the infection from an adult who is undiagnosed. Patients are contagious for a long time, up to several weeks. Often, it is an older family member with a cough for several weeks duration. It is devastating to families when they realize they were unknowingly the source of the infection that has caused the baby to be hospitalized.

All pregnant women are now encouraged to receive a pertussis vaccine in the third trimester of their pregnancy along with the other adults that will be living in the home. Having this “cocoon” of protection helps protect vulnerable infants until they are old enough to receive the immunization themselves.

Tetanus is a nervous system disorder that causes severe muscle spasms. It is caused when a spore that is in the soil, known as Clostridium tetani, gets into damaged skin. It will not grow in healthy tissues, which is why things such as splinters and other puncture wounds, burns, and certain fractures put the body at risk for it. Once inside the body it produces a toxin that irreversibly attaches to the spinal cord and brain stem, and after a few days the symptoms begin.

I can’t imagine many diseases that would make me feel more helpless than if I watched my child in the grips of tetanus. It starts with restlessness, sweating, and rapid heartbeat. Later it progresses to the inability to open the mouth due to muscle spasms (lock jaw). They have episodes of intense and painful contraction of muscles and intense muscle spasms that can be triggered by stimuli such as physical touch, light, or sound. It would be so terrible to try to comfort my child and triggering an episode of them arching their back, clenching their hands, straightening their legs, and holding their breath. The worst part is that there is no change in their awareness, they know it is happening, and they know that it hurts.

The muscles surrounding the throat and lungs can even stiffen to the point that they may need help breathing as well. They are usually monitored in the intensive care unit due to this, and also for the need to control pain.

An intensive care doctor told us the story of a young unvaccinated child with tetanus: “She was walking outside with her parents in a large field, and cut her foot on something. Soon after, she started having muscle spasms in her calves. They got more and more intense, so her parents brought her to the hospital.” The child ended up needing intensive treatment, including numerous rounds of painful treatment injections. The parents finally realized how important vaccination was when she was transferred to the ICU because there was concern she would need assistance with her breathing.

How long can the symptoms last? A long time. The toxin attaches to the nerve and requires the new nerve growth until symptoms resolve, usually around 4-6 weeks. The main treatment is trying to control the pain, and ensuring they continue to breathe.

The bad news is that we can’t eliminate the element in the soil that causes tetanus, and we certainly can’t protect our children from open wounds.

But we CAN give them a vaccination that can prevent this terrible disorder!

Related stories:

• The Flu Can Kill
• It's only the flu that killed her
• Chicken pox: Why We Vaccinate

About the author

Sperry Binnicker is a nurse practitioner at Willow Park. Sperry joined Cook Children's in 2009 in the Pediatric Intensive Care Unit (PICU). In that role, she earned the Daisy Award, an award given to a nurse that is nominated and selected by the parents of patients for excellence in patient care. She continued her education while working full time and received her master’s degree from the University of Texas at Arlington in May of 2015.She is a Board Certified Pediatric Nurse Practitioner and a member of the National Association of Pediatric Nurse Practitioners. Learn more about the Willow Park staff here.

I want to go over some general information about the varicella virus and discuss complications that can arise. Chickenpox is highly contagious. When one individual in a household had it, there is a 90 percent infection rate for those in the same household who have not previously had it or been immunized. It is spread through droplets (think body secretions – runny nose, sneezing, coughing) and direct contact of lesions on skin when in the ruptured vesicular stage. This virus has a really long incubation period, which means there is a long period between the time you are exposed and the time you develop symptoms. The average time is 14 to 16 days! Just when you think you are out of the woods, you can develop symptoms!

Varicella generally starts with 1 to 2 days of fever, fatigue, sore throat, and loss of appetite, followed by a rash. The rash starts as tiny red bumps to the face, spreading to the torso and then extremities. There are three stages of a chickenpox rash: maculopapules, vesicles, and crusts. The maculopapular rash appears as tiny red bumps from pinpoint to pea sized. Vesicles are typically pea sized and are fluid filled (blister like) on an red skin base. One description I like is “dew on a rose pedal” appearance. After several days the vesicles will rupture and leave crusts. The crusts usually resolve in 1 to 2 weeks and can leave areas of lighter colored skin that will eventually disappear. As I mentioned before, it will usually start on the face and move down to the torso and then extremities. There will be several “crops” of new papules, which allows there to be rashes in different stages of healing. Start to finish, chickenpox can last anywhere from 7-14 days. I missed 10 days of school when I had it! You are contagious 48 hours prior to rash appearance (usually when fever starts) until all lesions have crusted over.

But if chickenpox is so mild, why do we bother with vaccinating? Varicella can have severe complications that can cause as little as discomfort or as much as death. The most common complication is secondary bacterial infections. Here is a list of a few:

1. Soft tissue or skin infections: It’s hard not to scratch when you’re itchy, especially if you’re a child! This can lead to secondary skin infections. The common culprit is strep, a common bacteria that lives on your skin. There are even cases of flesh eating bacteria post chickenpox!

2. Encephalitis: Before vaccinations, this neurological issue accounted for 20 percent of hospitalizations and 50 percent of the deaths related to varicella. Encephalitis is swelling of the brain that can happen after or with a virus. It causes delirium, stroke like symptoms, and seizures.

3. Pneumonia: This is a common complications with lots of viral illnesses, and possibly one of the most feared. The mortality rate with varicella pneumonia is estimated between 10-30 percent. Typically you develop high fever, after initial fever has resolved, and cough.4. Hepatitis: This is a liver condition that can occur in our patients who contract chickenpox and already have a low immune system. Kiddos with cancer or who have had organ transplants are at highest risk.

In my prior work in the ED, I have unfortunately witnessed all of these complications with the exception of hepatitis. Complications can affect any age, regardless of current health. I have seen some previously healthy children develop encephalitis and have permanent neurological and seizure disorders after!

With the development of the varicella vaccine in 1995, chickenpox cases decreased 90 percent! The American Academy of Pediatrics and the Centers for Disease Control recommend two doses of the varicella vaccine at 12 months and 4 years.

As always, if you have questions, please call the office. I am happy to discuss things with you. Our goal is to keep your kiddos happy and healthy while avoiding potentially fatal outcomes from preventable diseases!

Tara, NP

About the author

Tara Haraldson is a nurse practitioner at Cook Children's Willow Park office. To make an appointment for back-to-school vaccines, contact your Cook Children's pediatrician. To find a pediatrician near you, click the following link. 

I’m going to teach you about a rash that we see weekly in our office at Forest Park – often many times a day.

It freaks parents out, looks weird, and (always surprising to me)….none of the parents I speak with daily have ever heard of it.

Let’s learn about – molluscum contagiosum!

Ugh, molluscum. People stress so much about these little guys. And honestly – they’re usually no big deal and are totally harmless.

Molluscum contagiosum is the name of a rash that looks like fleshy little bumps. They’re caused by a virus and they can be found anywhere on the body.

They’re round, shiny, vary in size, and look like a cuter, cleaner version of warts. They can be white, pink, or flesh-colored. They often have a little “pit” or dot in the middle of them. They also sometimes have cheesy white stuff in them – this isn’t pus. Try not to pop them – this can lead to infection and scarring.

They spread from person to person very easily. They are passed by skin-to-skin touching, sharing towels or clothes, or using wrestling or gymnastic mats. They are also a common STD. I find that water is a common transmission source – baths, pools, hot tubs.

In my experience, they typically last 6 months to 2 years. The CDC mentions they can last as long as 4 years, but I’ve never seen that.

I always tell folks, if they can, to just leave them alone and let the body get rid of them. There is less scarring that way. Molluscum usually look a little inflamed right before they go away, because the body is finally paying attention to the virus and fighting them off.

Like I mentioned before – molluscum are usually harmless. They can, however, cause kids and parents to worry about their appearance, get irritated by clothing, and can get infected by scratching.

There are different ways to go about getting rid of them. Treatment is designed to irritate the spots. This is to encourage the body's immune system to recognize the virus and destroy the infected cells.

Just like with warts, we can freeze them in the office, or apply a blistering compound (“beetle juice”) to hopefully cause enough irritation to make them go away. Sometimes if they’re really bad, I’ll send kids to the dermatologist where they can inject yeast antigen into the lesions to make the body pay attention and get rid of them! Isn’t that crazy cool? This works sometimes for warts as well.

Other ways to approach getting rid of them involve creams we can prescribe. There are even oral medications that sometimes help (although I haven’t had the best of luck with these). You can also try a compound called Zymaderm. I’ve had some patients have luck with tea tree oil. And I’m a big fan of apple cider vinegar for both warts and these guys.

Bottom line is – they’re pretty benign, they typically are just annoying, and I promise you they will go away eventually. If you’re really worried about it, come on in and we will walk you through some treatment options.

Hugs,

Dr. Diane

Skin cancer is a serious problem in the United States. Did you know this information from the Skin Cancer Foundation?

• One in five American will develop skin cancer in the course of a lifetime.
• Over the past three decades, more people have had skin cancer than all other cancers combined.
• About 5.5 million Americans nonmelanoma skin cancer each year.
• Melanoma accounts for up 3 percent of all pediatric cancers.

Children who are overexposed and under protected are at greater risk for developing skin cancer as they age.

“The majority of skin cancer is preventable,” said Jenica Rose-Stine, D.O., a pediatrician at Cook Children’s Willow Park office. “Protecting your child from the sun at an early age is key.”

A new study in JAMA Dermatology found that 40 percent of the most popular sunscreens sold on Amazon didn’t provide proper protection. The American Academy of Dermatology looks for these three requirements:

• A sunscreen should have a Sun Protection Factor of at least 30.
• Protect skin against both UVA and UVB rays.
• Resistant to water, including sweat.

Dr. Rose-Stine recommends:

• Using sunscreen labeled “broad spectrum,” which protects against both UVA and UVB rays. Choose a sunscreen that has a Sun Protection Factor (SPF) of at least 30, preferably 50, and apply enough of the sunscreen to cover all exposed areas including the ears, back of the neck, hands, feet, lips and top of the head for children with fine hair. Reapply at least every two hours or after swimming or participating in activities that produce sweat.
• Liquid sunscreens that are “physical blockers.” They physically deflect or block the sun’s rays. Look for the words “zinc oxide” or “titanium dioxide” listed first in the ingredients (Blue Lizzard is a good brand.)
• Purchasing sunglasses for children that block 100 percent of UVA and UVB rays, as sun exposure can increase the risk of intraocular melanoma developing in the eyes – particularly those that are light-colored.
• Avoiding the sun during its peak summer hours between 10 a.m. and 4 p.m.
• Have your child wear a swim shirt to minimize sun exposure to chest, shoulders, and back.

Recent studies suggested that many children are now deficient in vitamin D, a vitamin necessary for healthy bone growth and development. Children only need 15 minutes of sun exposure a day to absorb their daily dose of vitamin D.

“Children should get vitamin D from a diet rich in eggs and fortified foods, such as milk, cereal, orange juice and yogurt,” Dr. Rose-Stine said. “Sun exposure triggers the skin to produce vitamin D, but parents shouldn’t rely solely on sun exposure because of the associated risks.”

Click to read the JAMA study.

About the author

Jenica Rose-Stine, DO is a pediatrician at Cook Children's Willow Park pediatrics - 136 El Chico Trail, Ste. 102 Willow Park, Texas 76087. Dr. Rose Stine is enthusiastic about several areas of pediatrics including development, safety and prevention, and nutrition and she thoroughly enjoys her interactions with first-time parents and their newborns.

To conncet with Cook Children's Willow Park pediatrics, please follow them on facebook https://www.facebook.com/ccwillowpark

She is a sweet and happy baby who loves to babble ("mamama"... be still my heart!), pick up small toys and explore them slowly, play peek-a-boo, pick up her tiny foods with two fingers, point, laugh, and clap.

Things she cannot do? Crawl with her belly off the floor. Pull up to stand, or really put much weight on her legs at all. Shift from sitting to crawling to sitting again. Cruise along the furniture while holding onto it. She has delays in what we call “gross motor development” – the development of the “big movements.”

I see patients all the time at our Willow Park office that have gross motor delays, so I know not to worry. Lots of things can contribute to this. Sometimes it's just genetics. Sometimes it’s the baby's weight-to-height ratio. I notice that leaner, smaller kids tend to develop these movements faster, and bigger, longer kids sometimes need more time to build the strength to try these things. As you can see from the pictures, Abby has not missed any meals. There are exceptions to every rule of course, but I think this plays a role.

The baby’s temperament can also lead to delays. Some kids want to go go go...and some are completely fine with sitting still and working with what is in a close vicinity. Abby certainly fits into this latter scenario.

Of course there are numerous medical conditions that can cause motor delays. Always make sure, if your child has delays, to ask your pediatrician for a good neurological exam to check things like muscle tone.

Unfortunately, I believe what has played a big role in Abby’s delay is the amount of time she has spent in her favorite jumpers.

Baby jumpers, bouncers, exersaucers, and activity centers (they’re all basically the same thing) are stationary devices that allow a child to “stand” and bounce prior to developing those skills naturally. Kids love them because they’re fun and stimulating – most have toys and games attached – and they get to see more of the room and things going on around them, along with getting a chance to bounce up and down easily. Parents love them, because, let’s face it – they’re a quick and safe option for a break.

Baby walkers are similar – except they are on wheels so babies can bounce/pull themselves around the house. I have never owned one of these because they come with safety risks – children can fall down stairs, tip over, touch a hot stove, get pushed by siblings, pinch fingers, and slam into walls in these devices, and as fun as they seem, they’re not a good idea.

Around 4-5 months we started putting Abby in a jumper and she was thrilled! Finally she could be propped up and see everyone! She could control her body enough to bounce, and loved it. We were happy too, because we were constantly chasing her 2-year-old brother around, and it was nice to have a safe place to plop her down while that happened. Admittedly, it became a habit. When we’d read books, Abby would be propped up to be able to see the pictures. When we’d sing songs and play music with her big brother…Abby would get to howl and jump along in the bouncer. When we had to deal with the 2-year-old tantrums (and boy are those frequent)…in she went. Emptying groceries? Bouncer. Going to bathroom? Bouncer. Cooking dinner? Boom. Folding laundry? Ker-splat. She was probably in them a total of an hour to an hour and a half a day.

Looking back, she was in the bouncer way too much. Learn from my mistake, friends. Yes, pediatricians make mistakes.

Other doctors may think these things are harmless, but I respectfully disagree. Especially since I suspect my own child has likely been affected. Physical therapists have been warning parents for years about the problems with bouncers. And the more I’ve researched it, the more I’ve realized that too much time in these things can be detrimental to a child’s development.

I spoke with Gail Abaray, a pediatric physical therapist in Weatherford, who told me, "Bouncers don't allow infants to explore and move. They are limited in what they can do, and are stationary. And that pull to explore is so important. When they cruise the furniture, they learn about lateral movement, and how to turn their legs and feet. In a stationary bouncer, all of that coordination can't happen."

Look at the picture of Abby in her favorite bouncer. See how she’s on her tiptoes? This is typical and leads to the majority of the strength being recruited from her calves and thighs. What is not getting a workout is her hip, gluteal, pelvic and core muscles – and these are the ones that help children crawl and eventually walk.

Their hips are spread unnaturally wide by a piece of stiff fabric. They often lock their knees, especially the younger babies.

Babies cannot see their feet or the ground in these devices either – and thus cannot coordinate their body well in them.

Their upper bodies are also thrust forward – taking all the pressure/weight off their gluteal and hip muscles. The very muscles they need to strengthen.

The same things happen in walkers – babies are pulling themselves along while most of their weight is supported, and this works out and coordinates all the wrong muscles. They also can’t see the ground or their feet. “Walkers” are a true oxymoron here – they lead to delays in walking naturally.

So what do I recommend to parents now? Well…go buy a bouncer! They’re great! But – use them in moderation. Don’t put one in every room, like I did – it’ll only lead you to use them more. Use it only for very short periods of time – maybe 15 minutes here and there, once or twice a day – 20 or 30 minutes a day, max! Physical therapist Gail agrees: "I always tell parents not to feel guilty for using them. I did! But moderation is key!"

And avoid walkers in general. I am not convinced they’re safe or worth the money.

Don't feel guilty if you've put your baby in a bouncer - we all need breaks. And it's hard to deny they're so happy in them! But remember the big picture - kids need to learn to explore their environment on their own. It's vital to their development!

As for miss Abby-pants? Well, we got rid of all the bouncers and for the past month have set strict tummy time rules – she must work for toys on the floor for nearly the entire day, and must practice standing several times a day. She yells at me about it all day, but boy has this tough love helped. She has already shown vast improvements. She is now able to stand supporting herself on a piece of furniture, can quickly army crawl (using her arms mostly), and is starting to lift that big belly off the floor! We are also enlisting the help of a local pediatric physical therapist to help with some exercises and strategies. Slowly but surely, she’ll get there!

Hugs,

Dr. Diane

Constipation is the cause of alllllll the things. Just joking.

No, but really – it’s one of the most common things I see in my office at Willow Park, and it causes strange problems sometimes. Parents often don't believe me when I tell them it's constipation causing the problem. 

What is constipation? It doesn't necessarily mean your child isn't stooling daily. A kiddo can be constipated and poop many times a day. Constipation means hard, dry stools. They’re often painful to push out. And yes, most kids with constipation will go a few days between stools.

I really feel that constipation has become more prevalent over the years because of how our kids' diets have changed. In general, kids are eating less fresh fruits and veggies and depending more on packaged goods for snacks and meals. 

There are lots of medical causes for constipation as well. Did you know that hard poops can cause:

1. Stomach pain
2. Withholding of stool
3. Vomiting
4. Refusal to eat
5. New urinary accidents
6. Wetting the bed
7. Diarrhea
8. Poop accidents 
9. Blood in stools, blood in diaper
10. Fever (yes it can cause fever! mostly lowgrade)

Here's the deal - and let's get down and dirty about it. The things your kids eat affect the quality of their poop. If they eat and drink things that don't have much fiber (think cheese, yogurt, pastas, cookies, white bread, bananas, milk, goldfish crackers), their stools will be harder. 

Also, did you know our bodies absorb water out of our stools if we need it? So if your kiddo isn't drinking enough water, his body will just take it out of the poop, and it will become hard. 

The poop gathers at the “end of the tube” in a child’s body – the rectum and descending colon – and stretches everything out a lot. See the pic. This chronic distension leads to problems with the “valves” inside the rectum. Sometimes, this leads to leaking – soft stools can leak out without the child being able to control it. 

These big bulky stools can also push on neighboring organs, like the bladder, and even push urine out sometimes. And children with chronic constipation tend to develop poor control of their pelvic muscles and can lose control over their bladder, leading to leaking. One study showed that after being treated for constipation, 89% of 250 kids had complete resolution of their daytime wetting problems.

When the stools become hard, they hurt to push out. So kids don’t want to poop. So they hold it in. And the body slowly takes water out of it. And the stools get harder. And more difficult and painful to push out. Thus starts the painful cycle. 

Kids can get constipated anytime, but I find it’s most common 1) when babies start solid foods, 2) when kids start potty training, and 3) when kids start school.

So how do you fix the problem? Well, that depends on the severity of the problem and the age of the kiddo. But some general rules:

1. WATER. LOTS OF IT. Children and teens should drink at least 6 to 8 cups of water a day. 
2. Fresh fruits and veggies! I encourage kids to eat green veggies, prunes and other fruits (but not bananas), bran, whole grain bread. Sometimes those puree pouches with the kale, spinach, and broccoli are a good start for the picky kids.
3. Certain fruit juices – ok, we pediatricians are NOT big fans of juice. But I’ll make an exception in this case – go with prune, or pear.
4. Fiber supplements – flax seeds are great. Fiber gummies and cookies are good, too.
5. Behavioral and schedule changes – encourage a routine for “potty time”. 20-30 min after meals, have your kiddo sit on the toilet for 5 minutes. Encourage your child to listen to his body and stop playing when he feels the urge to “go” (and not hold it in). 
6. Do not punish your child, or get mad, if he has an accident (urine or stool) – remember, this isn’t under his control!
7. Avoid those foods I mentioned before for a few days – bananas, cheese, crackers, milk (if over age 1), breads, pastas.

If there is anything I can’t express enough to parents – it’s BE PATIENT! It takes many months for the intestines to stretch out and constipation to form in toddlers and children, and it takes many months (sometimes even years) to treat it. Sometimes we use safe laxatives or glycerin suppositories to help during the really rough patches – call or come visit us to talk more about that if you think its necessary. 

Hugs,Dr. Poop (er, Diane)

One way to narrow this down is asking, "What part of your head is hurting?" and "What does it feel like?" (Note! These are some very general guidelines and don't apply to all headaches. Most headache causes however can be found in one of these categories.)

Migraines are typically a one-sided severe, throbbing and intense pain occasionally accompanied by nausea/vomiting and sensitivity to light. Migraines have a genetic component though so we typically want to know about family history of headaches. They can be triggered by things such as: stress, hormones, dehydration, hunger, and lack of sleep.

What about neck/back of the head pain? Think about what is causing those muscles to pull and strain and cause you pain. Heavy backpacks are a BIG offender. Also, body positioning is huge. For example, staring down at the phone/iPad all day? (AKA every teenager). How about arms not on a level surface when studying? What happens is their shoulders are pulled up all day while they study, creating unnecessary tension and/or pain in the neck and shoulders. Oh, and don't forget heavy ponytails too!

Front of the head/forehead pain: Pain here can be caused by eye strain, so let's start by checking their vision. This type of pain can also be caused by allergies/sinus infections, especially if tender to the touch.

General causes of headaches: The number one reason I see headaches is dietary. Not drinking enough water and not having good protein for breakfast or before exercise is a large factor. This can also make them dizzy and feel faint.

Sleep!! I don't care what or how much you change in your life, if you don't sleep enough you are going to get headaches (I have tried to work around this rule- ya just can't). Most children need 9-11 hours of sleep, depending on their exact age.

Some red flags are: severe headache especially with fever or neck pain, headache that is progressively worsening and not responding to usual treatments, waking up in the middle of the night with a headache, early morning headache especially with vomiting, or any with neurological symptoms (not walking right, personality changes, weakness, decreased vision, etc).

Now, not every headache fits exactly into these categories. This is just a general outline to give you some things to take note of before the visit. I have also included a headache journal that, if you filled out before your visit, your provider would do a happy dance for you!!

We are always happy to talk about your headaches and want to do that. I want this to help make your visit and discussions with us more productive! It will be if we have already been taking note of these common types and offenders.

- Sperry, NP

About the author

Sperry Binnicker is a nurse practitioner at Willow Park. Sperry joined Cook Children's in 2009 in the Pediatric Intensive Care Unit (PICU). In that role, she earned the Daisy Award, an award given to a nurse that is nominated and selected by the parents of patients for excellence in patient care. She continued her education while working full time and received her master’s degree from the University of Texas at Arlington in May of 2015.She is a Board Certified Pediatric Nurse Practitioner and a member of the National Association of Pediatric Nurse Practitioners. Learn more about the Willow Park staff here.

Then, I was blessed to have a beautiful son...

….who decided that I needed to be re-taught a few things about children.

And by a few things, I mean everything.

Don’t get me wrong – you don’t have to be a parent to be an excellent doctor. I still dish out the same advice. The books and studies are spot-on and I’m going to give it to you straight. Breastfeeding does provide the best nutrition for babies. But I understand the pain you’re going through to meet that goal. And I understand the frustration of having a child who just won’t latch on. And I understand now why you look at me, with a crazy twitch in your eye, when I tell you to try an extra pumping session a day to build up your supply, mama. I hated that thing, too. Can anyone say “dairy cow”? And guess what – formula isn’t poisonous. I wasn’t physically able to meet my full breastfeeding goals with my kid – there’s no judgement here if you grab that can. And it’s okay if it makes your relationship with your child happier, healthier and more fulfilling.

Our car seat remains rear-facing at 18 months. It’s been proven to be five times safer than forward-facing. I’m sorry for my lecture during your little one’s checkup. And oh yes, I too want to rip my hair out when I can’t reach over far enough to give my kid that 400^th toy to keep them quiet on the trip to grandma’s.

“Crying it out” was a tough one for me. Pre-child, it was so easy to coach parents - encourage them to drop the constant rocking, the running into the nursery at all hours of the night, the fear of allowing their child to cry in order to learn put themselves to sleep. Then I went through it with my son. Let’s just say I give the same advice now (it really does work) …and recommend a glass of wine for every 15 minutes of crying. I probably cried more than my kid did. Motherhood helped me give this advice with a much softer tone. I get it, mom and dad. And I feel your pain (and exhaustion).

Pacifiers – I missed that thing so much. So, so much. Oh man I missed that thing when it had to go. I think I needed one myself when the time came to get rid of it.

As for the well-rounded, healthy meals I recommend offering your child throughout the day – I now understand why there are food shortages in some parts of the world. It’s because all that food is currently on the floor of my kitchen. Where my son threw it. I get it. And I’m here to help you find tricks to make things better. Tried and tested in my own home.

In all seriousness, motherhood has been the most exhausting, challenging, humbling thing I’ve ever experienced. But I can say without a doubt that it’s made me a better doctor for your child. Because helping you get through those everyday challenges is a huge part of what being a pediatrician is all about.

I recently polled some physician mom colleagues to get their take on how motherhood changed them:

• “I am that much more in awe of the composure, patience, faith, resolve my patients' families have, especially considering how chronically sick the kids are that I see, and how too not-infrequently, limited the treatments are. I see my son in every patient. Everything is different. Every heartache is my heartache. Each illness, each story seems to hit home that much harder. I am so so appreciative.”
• “I am much more empathetic and practical in some advice. I think that I am much more emotionally available post having kids and can understand a variety of stresses parents who go through NICU may encounter.”
• “You come to understand that "by the book" is not always what is possible in real life!”
• “I feel like when the kids have a tougher diagnosis - cancer- it hits closer to home and I hold my kids a bit tighter. Likewise, little pearls and tricks that I used help make it more of a village caring mentality for the family which has been lost over the last 30-40 years.”
• “My medical advice is not too different, but I understand the unspoken worry so much better now. So I try to address the emotional stuff first in ways that would not have occurred to me pre-kids. Now I'll directly say things like "you are a good mother even if you need to use formula," or "this lymphadenitis/rectal bleeding/etc is NOT cancer," or "they are not dangerous, but constant viral illnesses all winter TOTALLY SUCK.” I think it has made me a much better pediatrician.”
• “One of my favorite attendings in peds residency told me, as I was a mess after coming back from maternity leave with my first, that a little part of your heart will always be on the outside, dangling like a vulnerable little wisp in the wind that is parenting- and that little wisp makes you so much stronger and so much softer- all for the good....it's so true.”

Happy Mother’s Day, everyone!

When my son Jack was born via C-section, everyone had something nice to say about his beautiful round head. “It’s so perfect! Not like the poor little cone-headed babies!” Little did they know that his pretty little spherical skull would soon resemble a pancake on one side.

Does your baby’s head have a flat spot? A flat region?  A flat continent?  Do not fear!  It’s likely normal skull flattening (the fancy medical term is positional plagiocephaly), it’s totally normal, and only rarely do baby craniums need any “fixing.”

Let’s talk about infant skulls – like many baby body parts, they aren’t small versions of the adult skull. They are unique and functional. They are made of bone plates that are loosely held together, and they can move and shift. This special ability helps the baby with an easy exit through the birth canal, and allows the brain to rapidly grow during the first year of life.

However, after that exit, there are lots of external forces that can flatten the infant skull. Often, it’s due to your pediatrician’s golden rule of putting her on her back to sleep. In 1992 we launched this campaign to reduce the rate of SIDS, or Sudden Infant Death Syndrome. What came next was a beautiful drop in the number of babies dying in their sleep, and the unfortunate side effect was the rise of plagiocephaly. 

So your baby is a few months old now, you’ve been putting her on her back to sleep like your pediatrician recommended, and now she’s got a big ole flat spot on the back of her head. What can you do to make it better?

• Give her plenty of supervised tummy time while she’s awake. Find new toys or objects to stimulate her everyday. A mirror is very entertaining! Prop her up on a pillow to give her a little height (And her heavy head a soft landing pad). I find the breastfeeding pillows have the perfect curve for it. 
• Hold your baby while she’s awake to relieve pressure from carriers, swings and infant seats.
• Alternating things in the room to encourage laying on the other side of the head. I found that putting a bright light-up toy, or a mirror, or even myself on a certain side would encourage Jack to look that direction and relieve the pressure on the flat spot. This also works during naps/sleep time – if your baby likes looking out the slats of the crib, flip her head/feet orientation in the crib so that she has to turn her head a different direction.
• There are many commercial items that claim to “round out baby’s head,” with new things coming out everyday. Research these products carefully and bring it up with your pediatrician before making the purchase, to assure they are safe.

When is a funny-shaped head a true medical problem?  If you have concerns about your baby's head shape, always feel free to talk with your pediatrician about it. Pediatricians typically evaluate the shape of an infant's head during the physical exam at the many checkups they gets during her first year. Usually positioning changes (like the ones listed above) can fix a flat head over time, but sometimes a helmet can be used in severe cases to help it along. In rare cases, we advise that a specialist be seen, like a physical therapist or a neurosurgeon.

Rare instances include:

• The flattening has led to facial changes, like a protruding portion of the forehead, and/or one ear that sits asymmetrically to the other.
• A misshapen head that is due to the skull's bone sutures closing too early (called craniosynostosis - your pediatrician is trained to notice signs of this)
• If you notice that your baby has problems with or may even be unable to turn her head to one side, leading to skull flattening, it may be due to a tight neck muscle - a condition called torticollis.

So my point – and I do have one - is that I’ve seen many funny-shaped heads in my office (and witnessed the evolution of a pretty darn cute one at home), and the vast majority fix themselves over time. Always talk with your pediatrician if you’re worried. That’s what we’re here for!

And as for Baby Jack, he did lots of tummy time to help get rid of those flat spots!

When I came home from the hospital with my new bundle of joy last fall, the first two weeks were filled with the tasks of survival – learning to feed my son, making sure he was growing appropriately, entertaining family and friends who wanted to meet him, catching a snooze here and there, and establishing a routine. After those two weeks ended and I had barely left my house, my next plan of action was: Operation Mama Sanity! I needed to get out!

Everyday in my office I have parents who ask me when they can take their newborn babies out and about, and get into the swing of life with their new child. My answer is always the same: now! But … with a few rules.

From day one it is absolutely fine to get out into the fresh air and go for a walk in the park, or in your neighborhood, if the weather permits.Try not to go out on extremely hot or extremely cold days, and as a rule of thumb, dress your little one in as many layers as you are wearing. Make sure the baby is not exposed to direct sunlight. Most strollers these days come with a nice shade for this purpose, or you can use an umbrella.

If you’d like to go out where there are a lot of people, like a busy restaurant, grocery store, or mall, I always tell parents to try to keep their infant’s seat completely covered by a light blanket.This serves a few purposes. First, a baby’s immune system before age 6-8 weeks is still immature. If someone at the next table sneezes or coughs, its best to have this protective canopy over them so viruses and bacteria are less able to come in contact with her. Also, it keeps the baby hidden as a deterrent to well-intentioned patrons from touching your sweet little one. As nice as that is, it’s best if people don’t touch your baby during those careful first weeks. 

If it’s holiday season and you and your new baby are expected at the family get-together, don’t fret. Just politely ask that everyone wash their hands before they hold her. If you’re too shy to ask them yourself – do what I tell my patients to do – blame me! Say, “My pediatrician says everyone has to wash their hands before holding her!”  This way no one can get their feathers ruffled. Carrying a small bottle of hand sanitizer and offering it to everyone is also a great and easy way to get germy hands cleaned. If someone appears to be sick and you don’t want that person to hold your baby at all, don’t. It’s Ok. You can blame that on your pediatrician too.

Don’t be afraid to go out with your new baby – she and YOU need it! Getting fresh air, exercise and social interaction in those first few months is vital to parents, and happy parents make happy babies. 

Hope my two cents help you muster the courage to venture out! And remember, many pediatricians have slightly differing opinions about these things, so it’s best to speak with yours if you have questions.

About the author:

Dr. Diane Arnaout joined the Cook Children's Willow Park practice in 2011. Dr. Arnaout was born and raised in the Dallas-Fort Worth area. She served as a leader on the medical education committees during her internship and residency in pediatrics at the University of Texas Health Science Center in the Texas Medical Center at Houston, Texas.

We know that children who are overweight or obese often continue their unhealthy habits into adulthood which may predispose them to heart disease, diabetes, and many other health problems. The HCCPC adopted “5-2-1-0 Let’s Go!” as their program to address this problem in Parker County. The evidence-based program encourages healthy nutrition and fitness in schools, after-school settings, and at home. Emphasis is placed on regular exercise and incorporating healthy foods into everyday life. HCCPC has been working with community and educational leaders to step foot into elementary schools to implement the program.  Here is how it works:

5-2-1-0 Every Day! 

5 or more fruits and vegetables 

2 hours or less recreational screen time    

1 hour or more of physical activity                     

 sugary drinks, more water and low-fat milk