Hard to believe it’s been 26 years, though I remember the excitement of taking my own kids to  the first one:  in a few weeks, on Sunday, the 25th of August, our city's outstanding arts organizations will offer the annual Houston Theater District Open House. This is a  free, fun-filled, family day of learning more about Houston’s many major performing arts organizations.  Hours are from noon until  5:00 (well, the symphony concert starts at 4:00)  This is probably the only such event in the country, and is offers youngsters the opportunity to explore performing arts  venues with which most kids and even some adults  are completely unfamiliar.  This is really a unique opportunity for kids to explore different seating levels, stages, the whole terrain of concert halls like Jones Hall, the Wortham Theater, and the Hobby Center, and the Alley Theatre, all of which required extensive renovation after the Harvey flooding.

But there is much more than just seeing big music spaces. Adults and children alike can  enjoy activities and live performances by several  of the Theater District’s groups including: musical theater shows, behind-the-scenes backstage tours, interactive "musical instrument petting zoo," meet-and-greets with costumed performers, complimentary trolley rides between venues, food trucks, and a free Houston Symphony concert at Jones Hall at 4 PM. Parking is no problem, as there is the huge underground parking facility as well as nearby garages and surface lots.

The annual event presents a preview of Houston’s vibrant arts season, and there is special pricing for many of our arts organizations' seasons.  Yes, it’s quite hot outside, but very cool inside all the venues.  Children of all ages will really get a lot from this rare opportunity.  Details of the schedule of the day’s performances, as they are finalized can be found at http://theaterdisctrictopenhouse.com

Parents will often comment that their children "always" seem to develop an illness or injure themselves and need medical attention  after pediatric office hours, weekends, or holidays.  While the reality is certainly not always or even usually, it is often enough.  Because of this situation as well as  the high incidence of families with both parents working, the number of facilities offering acute care for kids has significantly increased in recent years, and they represent a wide range of quality of care,  In general, it is usually best to start with a phone call to your pediatrician, as the conversation will help families determine whether seeking medical attention after hours is even necessary, what "red flags" to be watching for, and what care suggestions can be made just from a phone call.  If that midnight or Thanksgiving Day visit does seem to be warranted, guidance can also be given regarding the level of facility most appropriate.  It is important to realize that facilities that satisfy the criteria for emergency rooms are likely to suprise families with much higher co-pays and other charges depending on the insurance coverage.

A helpful and  practical guide to selecting an urgent care center vs. emergency room has been provided by Texas Children's Hospital which operates both types of facilities.  Below is a personally modified version of this publication:


  • allergic reaction (unless serious, such as anaphylactic)                 
  • asthma (unless child in distress)                                                      
  • ear pain                                                                                            
  • fever in infants older than 8-12 weeks (depending on temp)          
  • flu                                                                                                     
  • minor burn                                                                                                                                                                                                                                                                                                                             
  • minor injury from fall or sport
  • pink eye
  • rash
  • simple laceration
  • skin infection
  • sore throat
  • sprain and strain
  • suspected urinary tract infection
  • vomiting and diarrhea (unless baby or child appears quite ill


  • broken bones (serious or with deformity)
  • bleeding that won't stop
  • extensive or complicated cut or laceration
  • procedure requiring a CT scan or sedation
  • seizure without a previous diagnosis of epilepsy
  • serious burn
  • snake bite
  • spinal injury
  • sudden change in mental state
  • sudden shortness of breath or difficulty breating
  • voimiting or coughing up blood

The guidelines conclude with the appropriate disclaimer that this only a guide for general information, and is not intended to be a substite for professional medical advice, diagnosis or treatment.  Also, if there is uncertainty regarding urgent care vs. ER, it is best to go to the closest emergency room or phone 9-1-1.

Two closing considerations.  Other things being equal, a pediatric urgent care is preferable to a general one for small children, and stand-alone urgent care centers are likely going to provide more a higher level of  care than a pharmacy situated one.  Finally,  if the illness is something that can wait until the office opens,  there are distinct advantages to that: the history and exam are probably going to be more thorough, and the doctor has access to records and real familiarity with the patient and family, and the notes of this visit automatically become a part of that patient record.

Occasionally diseases that are actually pretty rare attract enough attention though media (and social media), that they are perceived to be far more prevalent and threatening than they actually are. Current prime example:  AFM, an acronym for acute flaccid myelitis, a serious condition similar to polio in its clinical picture. It affects the nervous system, specifically the spinal cord, causing weakness and paralysis in arms and legs, and, like polio, affects mostly young children.  The CDC began keeping track of this illness only since there was a prominent jump in cases in 2014, and the reason for its recent media attention was a recent spike in the number of cases from August to October  of this year.  There were similar sudden increase in cases in 2014 and 2016, also in the summer and early fall, almost all in children, bring the total to about 120  for 2018, and a few more than 400 since 2014.

The illness generally starts with fever and mild respiratory or GI symptoms, followed by the development of the neuromuscular signs of arm/leg weakness and sometimes pain.  The clinical picture may also include weakness of eye/eyelid activity, speech, swallowing, and even respiratory failure.  Diagnosis is based on  history and  exam,  as well as blood and spinal fluid studies and MRI findings in the brain and spinal cord.  There is no specific treatment available, though a number of therapeutic measures have been tried though not in controlled studies.   The recovery pattern is highly variable, with some patients recovering rather quickly, but others having to deal with lengthy periods of paralysis.

The most prominent question about AFM remains without a solid answer:  what is the cause of this affliction?  Since polio was caused by infection with a particular virus, it might have seemed that this was too.  However, this has not been nearly so straightforward .  Several viruses, including other members of the enterovirus family that includes poliovirus, have been detected in AFM patients, so have several other viruses including coxackie, West Nile and other viral agents, but causal relationship has not been established.   Sometimes no virus is found. It is not even clear if the cause is direct viral infection, or if a virus causes an immune or inflammatory response in the nervous system.  Clearly, a substantial degree of mystery remains here, but also a lot of ongoing research.

And how should parents view all this?  Most importantly, realize how uncommon  AFM is despite the extensive media attention, fewer than 100 cases a year in the whole country.  Next, follow common precautions the CDC recommends  including good handwashing, reasonable avoidance of individuals with viral infection, and seasonal mosquito repellent use.  Finally a word about immunization.  With so much anxiety and attention from a rare disease for which there is no vaccine available, how ironic and unfortunate it is that so many parents fear and even avoid immunization for more likely illnesses with clearly recognized and essentially preventable infections, and  potentially severe, even lethal outcome.  Just doesn’t make sense. 

A footnote.  With memories of polio reawakening with the appearance of AFM, it is worth recalling the history of polio in the country, and of an environment when a particular vaccine was desperately sought and awaited, and accepted by parents with the enthusiasm it deserved.  You can appreciate this in a fine video production from the American Experience series,  at https://www.amazon.com/My-Lai/dp/B004AUMAAY/ref=sr_1_1?s=instant-video&ie=UTF8&qid=1543207048&sr=1-1&keywords=american+experience+documentaries.  Not sure this is free without Amazon Prime, but it’s worth watching.


Vaccine for the 2018-2019 flu season is now arriving in physicians’ offices and other facilities that offer vaccine administration, and on September 3rd the AAP announced its policy statement on this year’s flu vaccine recommendations. We wanted to share the basic information to better educate parents about this important annual recommended immunization.

  • Flu vaccine should be considered as essential for even healthy children, starting at six months, as serious complications can occur in even healthy children.  It should be given when avaiable (now), but especially by late October.
  • For the 2018-2019 flu season, the injectable form of flu vaccine is recommended as the primary choice. Although the nasal spray will be available, it is has been less effective in recent seasons and is expected to again be so this year.
  • This year's quadravalent vaccine will contain components against different strains of A and B, as well as one B strain which was in last year's product.
  • The number of doses depends on the child's age and vaccine history. Children up to eight years should receive two doses (separated by a month)   if this is the first time being vaccinated. Only a single dose is necessary for kids nine and up, or for children up to eight years who have received at least two doses of vaccine before, even if not in the same season.
  • All children with egg allergy can receive influenza vaccine without any addition precautions beyond those recommended for any vaccine.  Egg allergy is not a contraindication for flue vaccine, nor does it require special consideration.
  • Aniviral medications are often beneficial in the treatment and control in influenza, but are not a substitute for flu vaccination.
  • Annual vaccination is the best way to prevent the flu. The vaccine works well, but its effectiveness varies from year to year, depending on how closely the particular flu virus in a community match the strains included in the vaccine. The CDC tracks vaccine effectiveness year to year, to better protect communities the following year.
  • The most common side effects from the flu shot are pain and tenderness at the sit of injection. fever is also seen within 24 hours after administration in about 10 to 35% of kids younger than 2, much less often in older children and adults.
  • Children can not get the flu from the shot. However, because the vaccines are made from killed or weakened viruses, mild systemic symptoms such as nausea, malaise, headace, muscle ahces, and chills can occur.

Our practice, and I am sure all others, welcome questions from parents in an efforts to maximize the number of families we can immunize.  It is worth adding that vaccinating your children does not only protect them.  By reducing the likelihood of coming down with influenza themselves, this also might prevent spread to babies too young to get the vaccine themselves (and who are at higher risk for  more serious illness), and elderly people in whom the vaccine might not work as well.




One of the most important goals of pediatric checkups, especially in the first two or three years, is monitoring  child development.  Recognition of the attainment of developmental milestones at the proper age is vital both for recognizing delays that might prompt a search for a specific diagnostic reason, and for initiating  early intervention that can make a huge difference in long-term optimal accomplishment and success.  Over the years, pediatricians and their staff have gone from making broad observational developmental assessment, to carefully carrying out  increasingly detailed screening and surveillance, with various tools providing  earlier, more sensitive recognition of delay.

Not surprisingly, the internet is offering increasing assistance, and now a new phone app from the CDC (Centers for Disease Control) is bringing a valuable new—and free—tool for parents and pediatric professionals, “Learn theSigns, Act Early.”  Available for download from GooglePlay and the AppStore from  cdc.gov/ActEarly, this multi-faceted site offers milestone checklists featuring  interactive milestone guidelines  for children aged 2 months to 5 years. There are photos and videos to help parents understand and evaluate their children’s attainment of these. Parents can score "yes," "not yet," or "not sure" to each milestone. There are also tabs for “When to Act Early,” recommended “Tips and Activities,” and a Milestone Summary page, as well as free materials such as books and charts.

This excellent resource can be really valuable to parents, and will enable them to assemble developmental data to bring to their children’s checkups, making their pediatricians’ own assessment more detailed and accurate.


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