The Doc Smitty’s New Home

27 Oct

I just realized that I had never officially posted on my old blog in order to alert people that my blog has moved!

Come over and check it out on it’s new home:

The Flipped Check-Up

17 Apr


When we moved to Irving and I decided to join a practice in Lewisville, I realized I wanted to know more about the schools in the area and get a feel for the culture of the teachers that would be teaching my patients and kids.  I searched online and found great and encouraging information about Carrollton-Farmers Branch, Irving and Lewisville school districts.  I also looked up several teachers and administrators.

While I expected to get good information, I never expected to learn a concept that I hope to incorporate into my medical practice, but that is exactly what happened.  I followed an educator on Twitter (@LaurenBibby) who is the Technology Integration Specialist for Lewisville ISD (@LewisvilleISD) and she has since “introduced” me to a concept known as the flipped classroom (even though she doesn’t know it yet).

Wikipedia describes flipped learning as “a form of blended learning in which students learn new content online by watching video lectures, usually at home, and what used to be homework (assigned problems) is now done in class with teachers offering more personalized guidance and interaction with students, instead of lecturing.”

So, students watch lectures at home in the afternoon then come to school the next day to do homework and other projects during class time.  This gives the teacher time and opportunity to address what the student doesn’t understand from the lectures rather than have students turn to their parents for their Calculus homework (when dad had trouble passing Algebra).

So, how does this apply to me and my practice?

I’d like to have more patients to do “flipped check-ups.”

In the flipped classroom, student listen to lectures at home and come prepared to do work and application related to the material.  In a flipped check-up, parents would read and learn about the upcoming checkup (check out this page on my blog: Check-Ups for an example), develop specific questions and then allow me to get into deeper, higher-level education when they come in for their check-up.

Yes, contrary to the stereotype, you did just hear a doctor advocate that his patients do on-line research prior to their visit (but I want it to be good information).  In fact, it’s the reason I started my blog in the first place.  I wanted my patients to be able to access my advice (in effect, access me) when I wasn’t there beside them to answer their questions.  I wanted them to have a place to go that had accurate recommendations that fit with my philosophy (so, why not have them actually be my recommendations, right?).

Here’s an example of how it could go:

Family has 4 months check-up scheduled.

They review the 4 Month Check-Up Blog Post.

Family comes in for a 4 month check-up.

They say, “We read your blog 4 month check-up blog post and are ready to start solids and he seems to be developmentally ok but we did have some more questions about helping him sleep through the night.”

This allows me to touch on the other areas for clarity and completeness but spend the majority of the rest of the visit discussing in depth about sleeping and some options for sleep training (or not, depending on the family’s preference).

When the child is older we could cover the topics located in my Masters in Parenting Series to cover some topics of development more deeply.

So, this leads me to some questions for you…

1)     Is this something you’d be interested in?

2)     If you wanted to do it, how could I make it easier for you?

Some Essential Questions to Ponder

11 Apr



I know just by seeing the picture above I’ve peaked a significant amount of interest…

I get asked a lot about essential oils.  I answer very little. Why?

The answer is simply that we don’t know much about how or if they work.  Except for anecdotal stories about how they have helped certain people in certain situations, no one has done a large studies to truly evaluate their effectiveness or safety.

The main explanation for why they are used is that people (parents) are simply looking for something that’s an alternative to using what I’m going to call from now on “conventional” medicines.

Going forward, I’m not going to rely much on my knowledge as a doctor, I’m just going to be using common sense and asking a series of questions that I hope will get you all thinking.

What is medicine?


This is the definition: any substance or substances used in treating disease or illness.

Doctors prescribe conventional medicines that enter the body from many different avenues.  I have patients that take Zyrtec (cetirizine) by mouth, inhale albuterol, sniff steroid nasal sprays.  There are conventional medicines that are delivered topically but they aren’t as commonly used (especially in kids).  The most common example was the Daytrana patch for ADHD but I haven’t seen it used in years (I’ve never prescribed it.) because topical medications can have unpredictable rates of absorption which makes determining how much medication actually gets into the system difficult to estimate.  I only really use topical creams for things that need to be treated topically (rashes).

I see friends recommending essential oils on all my social media accounts for many different ailments and it’s not always clear to me what they are recommending-topical application, diffusion or ingestion.  But, if medicine is “any substance or substances used in treating disease or illness” and medicine can be inhaled, applied topically or ingested, then why aren’t essential oils considered just another type of medicine?

What does it mean that they are more natural?

Another discussion that is centered around essential oils is that they are more natural.  I get this concern.  In a world where everything is processed (down to a lot of our food), why wouldn’t you want something that is more natural for your family?  However, just because something is natural, doesn’t mean it’s a good thing…

Let’s take formaldehyde.  Parents cite this preservative as a reason they don’t want to use conventional medicine. I’m not particularly concerned about formaldehyde because it is a by-product of metabolism inside our own bodies.  It is formed during metabolic processes and can then be converted into CO2 and exhaled or urinated out.  Keep in mind that it is a known carcinogen when the dose gets to high but we know (from history) that it requires a very high level of exposure to get to the point where it causes cancer.  Ultimately, the concern I have with formaldehyde is this…it is commonly used as a reason by families who don’t vaccinate even thought it’s made in the body (Is there anything more natural than that?).

A more simple argument against using essential oils based on the reason that they are more natural is this: “Oh, it’s more natural? Well, so is marijuana.”-@mrsdocsmitty.

Do doctors prescribe medicine for every little thing?

I commonly hear this: Doctors just want to prescribe a drug for everything.  I want something different for my family.

The whole thing that motivated me to write this post was a posting I saw on a social media account last week: It is a picture of a line of essential oils across a bathroom counter (about 10 bottles-not sure if they were all used this morning or not) and part of the caption below: “He uses oils for allergies, eczema, acid reflux and stress.”  I’m not attacking this person at all and I’m not actually sure who it belongs to (so don’t take it personally).  But, does trading a “conventional” medicine for an essential oil make any difference?  Are essential oils becoming the new “take one for everything”?

I personally have occasional struggles with allergies, acid reflux and stress but I might take medicine allergies or reflux every few months. I do modify my diet, sleep habits and exercise to help with reflux and stress.  Therefore, taking essential oils would not be an alternative to taking a medicine for me at all because I’d rather take nothing.  I think people assume that because I’m a doctor, my wife and I shove medicine down ours and our kids throats for just about any and every symptom imaginable. This is simply not true.  Our kids occasionally get cetirizine for allergies (on average less than once a month), acetaminophen or ibuprofen (on average less than once a month) and my asthmatic gets inhalers (1-2 days per year).  They take antibiotics only when absolutely necessary. Other than that, our kids take vitamins every day.

So, be wary of using the reasoning that doctors use medicine for everything.  Some may, but this doctor doesn’t and I don’t consider it any different to be using an essential oil for every little thing.

Do doctors stand to benefit when they prescribe a medication?

Fortunately and unfortunately, I don’t practice medicine in a time where I can get flown to Hawaii for a long vacation with my family for prescribing a certain medication.  I’m very glad I didn’t because working in that environment would have been very difficult.  When I first started practice, drug reps could bring lunch and some pens but even these two practices have stopped.  At this point, I have no incentive to prescribe a medication except the desire to see my patient improve.  In fact, soon I will be incentivized to not write for medications as insurance plans become more focused on cutting expenses by decreasing their cost of prescription drugs (I will be encouraged to use cheaper alternative when available but nothing is cheaper than not writing for anything.).  So, the argument that doctors are pushing drugs in an effort to profit is simply not true for most doctors.  There are doctors who are paid consultants and speakers for drug companies, but most are not.

Now, think for a second about your Young Living or doTERRA rep. How do they stand to benefit when they recommend a treatment for you?

Finally, for my distributors and reps out there: Are you practicing medicine without a license?

This is the definition of practicing medicine without a license from Michigan (I’m sorry I couldn’t find the one from Texas for my Texas people):

An individual who practices or holds himself out as practicing a health profession subject to regulation without a license or registration or under a suspended, revoked, lapsed, void, or fraudulently obtained license or registration, or outside the provisions of a limited license or registration, or who uses as his own the license or registration of another person, is guilty of a felony. For the purpose of the offense of practicing medicine without a license, the “practice of medicine” means the diagnosis, treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint, or other physical or mental condition, by attendance, advice, device, diagnostic test, or other means, or offering, undertaking, attempting to do, or holding oneself out as able to do, any of these acts. (emphasis mine)

The last part is the interesting part: the practice of medicine means the diagnosis, treatment, prevention, cure or relieving of human disease…by attendance, advice…or holding oneself out as able to do, any of these acts.  You’ll have to read it closely for yourself to see what you think.  Think about what would happen is something did go wrong with one of the oils you recommended or sold. Would your company back you?  Maybe you should ask them and see what they say.  Many people feel that the reason that the most profitable essential oils companies are structured as direct marketing is because the company can hide behind their individual representatives’ claims.

Now that I’ve kicked the ant pile, I will now sit back and see what happens.  People who know me personally know that I am one of the most open-minded pediatricians they know about calmly weighing evidence on either side of a discussion or debate.  I try very hard not to bring my preconceived ideas into consideration when I make a decision.  I have extensively studied essential oils personally and am confident that, at this time, I cannot recommend them for my patients until further studies come out regarding efficacy and safety in children.  I just pray now that you will consider my questions in the same way I have considered yours over the years.  Regarding comments on this post, based on the way I have structured this blog to provide relevant and scientifically accurate information, I cannot allow the comments to become a marketing ploy for essential oils.  If you want to debate some of the logic or concepts that I have presented or cite real scientific evidence, that is fine, but I will not allow comments that tout anecdotal evidence of how essential oils have helped you or your family.

Head Lice-My Head Will Itch All Day Just From Writing this Post

27 Mar


Pic from A.D.A.M.

Since I went after school attendance policies on the blog, I thought it was time to discuss another school attendance issue.

It’s that dreaded phone call that no parent wants…or that dreaded sign on the door/letter in the backpack that gets everyone wondering…who’s the one in the class that should be pointed out and mocked: “Unclean, unclean!”?

“You’re child has lice and they need to be picked up and treated before they come back.”

“This letter is to inform you that an individual in our childcare center/school has head lice.”

A recent article on got me thinking about my experiences treating head lice in the clinic and my exposure to lice policies in schools.

Top 7 Myths About Head Lice

  1. Head lice are a problem of people with poor hygiene-Simply not true, anyone can get them…even your child-Mom who washes their kids hair twice a day.
  2. Head lice can carry other diseases and spread them person to person-Body lice can but head lice do not.
  3. Head lice are very contagious-Head lice can’t jump or crawl so it actually takes pretty extensive contact to spread them from person to person.
  4. Head lice are easy to diagnose-The little guys move away from light and do it pretty quickly.  If you see a bunch
  5. There is a test for diagnosing lice-You just have to find one alive on the scalp.
  6. Head lice can be spread to and from the family pet-Good news, Rufus doesn’t have to go to the pound.3
  7. Everything the school nurse or parent or grandparent calls head lice needs to be treated as head lice-I often can’t find anything but dandruff in kids that have been in and out of school for months with head lice.

So, what do you do when your child has lice?

Treat them and don’t freak out…

The most common, easiest and cheapest treatment is over-the-counter permethrin.


  1. Wash hair with non-conditioning shampoo.
  2. Apply product to damp hair.
  3. Leave on 10 minutes and then rinse off (in a sink to prevent exposure to other skin).
  4. Repeat process in 7-10 days.Image

Combing nits out of the hair is not necessary but you can if you want because they gross you out.  You can buy one of the cheap-fine tooth combs when you get your shampoo or you can buy the MagiComb (I guess the equivalent of the battery powered snot sucker and not available right now, sorry.)  Wow!  This one is even better…an electronic bug zapping comb, the RobiComb Electric Lice Zapping Comb (I do not actually endorse this product so please don’t waste your money).

Other Tips:

  • Check everyone in the house for lice or nits and treat anyone who is affected.
  • Change pillowcases and sheets (risk or transmission is fairly low (4%) but why not?
  • Vacuum floors, couches and other fabrics.

Shout Out and Advice for my School Nurses:

The AAP is very clear on what school policy about lice treatment should be.

  1. Children should not be sent home on the day of diagnosis (They have probably already had it for months and a few more hours won’t hurt-They should go back to class and avoid head eskimo kissing other children).
  2. Children should be allowed to return to school, even if nits are present.  In the AAP policy it states, “No child should be allowed to miss valuable school time because of head lice.”
  3. You can be the voice of calm when everyone else (parents, teachers and administrators) is freaking out.  Remind everyone involved that it’s not an indictment of poor parenting for a child to have lice.

So, keep calm and try not to itch your scalp the rest of the day after seeing this…



Sneezing-Help in a Flash

24 Mar

Image    Image    Image

It’s so annoying walking outside on a sunny day and being attacked by a fit of sneezing or when your 2 yo is watching Thomas the Train and has a complete meltdown “I got BLESS YOU all over my Kindle.”

Why do children sneeze?

  1. To clear irritants out of the nose (stimulation of hairs in nose)
  2. Allergies (as a result of histamine)
  3. Sunlight (a genetic reflex in ~20% of people)
  4. Just because (sneezing in newborns is common for no apparent reason)

People commonly list sneezing as a concern for their children during visits.  Unfortunately, it’s not a very helpful symptom in getting to the bottom of what is going on.  Sneezing by itself is not an illness and when there is an underlying cause you can usually tell by all the other things that are going on…

If you want to treat sneezing each of the causes does have a cure:

  1. Help the child learn to blow their nose
  2. Give your child an antihistamine (we use Zyrtec or Claritin)
  3. Never go outside
  4. Don’t have a baby

Making Wise Choices about Your Child’s Medical Care

21 Mar

Choose Wisely


The American Academy of Pediatrics (AAP) works together with the American Board of Internal Medicine (ABIM) to produce a list of medical procedures and treatments that are commonly used or have a potential to cause harm but may be unnecessary.  Their goal is to encourage “physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.”  The ABIM has worked with many other specialty groups (you can see more about them here if you are interested) but I’m not because adult aren’t as cool as kids…

First of all, let me start by saying that if you read these you need to know that they are all serious and important issues.  They weren’t added to the list just because.  Your pediatrician probably has a good reason for any test they are ordering so any of them could be justified but these are some that are particularly overused and possibly without good reason.

Secondly, if your pediatrician suggests one of these tests or treatments, you should be completely comfortable asking them for their reasoning.  If you don’t feel comfortable, maybe you should consider if you are sitting in the right office.  In my opinion, truth is truth and I’m certainly not threatened by a question so bring it on!  If I can’t give a logical answer to what I’m doing, then maybe I need to reconsider as well…

Now, on to the recommendations:


#1-Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).  This is particularly important to me.  Don’t push for antibiotics. Don’t settle for a doctor that recommends antibiotics as a quick fix for everything, period.  If you want to wait a few more days before you start antibiotics, ask your doctor if that would be appropriate.  One way to help them understand is to start your visit off by saying this, “I’m sure everything is OK but I just wanted to come and make sure.  If there’s nothing to be done, I’m totally ok with that.”  You can phrase this any way you want just communicate that you’d like to be conservative with antibiotic use for your child.


#2-Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.  Studies are clear that they don’t work in children under 4 (maybe even under 6, maybe never).  They certainly cause side effects (when given in appropriate doses and with accidental overdose).  So, why are we still using them in this age group?  Not sure.  I spend significant amounts of time educating (and re-educating false information) regarding #1 and #2.


#3-CT scans are not necessary in the immediate evaluation of minor head injuries.  50% of children with even minor head injury presenting to the ER get CT scans.  I’m not sure if this is due to parent insistence, physician nervousness or what but it is clear that many of these are unnecessary.  Especially beware of a CT scan that is ordered before the physician has seen you…unfortunately this is all too common.  Think of all the negative effects of the CT scan-radiation exposure, incidental (normal) findings that require further testing and cause anxiety.  Not to mention cost.


#4-Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.  This is hard for many parents to understand but febrile seizures are not generally the result of a problem with your child’s brain.  Febrile seizures occur most commonly in children age 6 mo-6 yrs.  They are generally brief (a minute or 2 or less) and involve a generalized (all over body) shaking.  If any of these things are not true then imaging might be necessary.  If not, everyone should focus on finding the cause of the fever.


#5-CT scans are not necessary in the routine evaluation of abdominal pain.  There are other ways to look at the abdomen.  Even in children with appendicitis (one of the most common indications) we are using ultrasound more and more to evaluate.  If your doctor is ordering a CT scan first for any abdominal problem, it’s ok to ask if an ultrasound would give you the same information.

Image#6-This is one for the neonatology folks.


#7-Don’t perform screening panels for food allergies without previous consideration of medical history.  it is not uncommon for a child to have a very strong, obvious reaction to a food but test negative.  It is also common for a child to have no problem eating a food but have a very positive reaction on the testing.  So, just be aware that allergy testing is not the end all, miracle that some people think it is (patients, physicians and the reps who sell the test).


#8-Avoid using acid blockers and motility agents such as metoclopramide (Reglan) for reflux that is effortless, painless and not affecting growth.  Do not use medication in the so-called “happy-spitter.”  I have been saying since I started in pediatrics that I only treat reflux in babies that seem to be in pain after feeds or that aren’t growing.  One of my very first blog posts was: My Baby Spits Up…A lot-Reflux.  It sounds like the ABIM and the AAP read my post…medicines don’t fix the spitting up part of reflux.  They just make the spit up less acidic.  They go on to discuss that the use of imaging for reflux is not necessary.  There’s no need to get a swallow study an UGI or an ultrasound.  Finally, it’s not on the recommendation but let me just put out there that going to a chiropractor for reflux makes no sense whatsoever.  (This might should be a blog post all by itself.)


#9-Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteruria.  Basically, if you child is not showing symptoms of a urinary tract infection (pain with urination, frequent urination, etc) they don’t probably don’t need antibiotics even if their urine shows some signs of having bacteria in it.


#10-Infant home apnea monitors should not be routinely used to prevent SIDS.  Again, one of my earliest posts was about this topic: SIDS-Risk Factors and Prevention.  Monitors have never been shown to reduce the incidence of SIDS.  They cause parent anxiety due to false alarms, etc.  They can be useful in premature and other babies that have had periods where they have stopped breathing in the hospital and some other related conditions but are not recommended for routine use.  I believe that commercially available monitors with heart/respiratory monitors are an inappropriate attempt to play on parents fears.

In summary, help your doctor choose wisely for you!  Don’t pressure them into testing or treatment where it may not be warranted.  Ask questions if you don’t understand their reasoning.

You can read the full post from ABIM and the AAP here: Choose Wisely

Constipation is Hard Stuff (But This Is How I Treat It)

19 Mar


(Warning, this blog contains a significant amount of junior high-level potty humor and puns.)

I’ve said it before and I’ll never stop believing it.  Something happens when you become a parent that automatically determines that you will stress about your child’s poop.  You can say you won’t (I said I wouldn’t but I still did) but it’s a given.  I have written about abnormal poop before and there are more details about it at Red, White and Hard-What is Abnormal Poop? (

So, specifically, what is constipation?

Simply…hard stools.  (Click to tweet.)

I’m not concerned if the stools are 10 times a day or once per week.  I also don’t worry if your baby/child is turning red, grunting or spouting obscenities at you (except for the disrespect component).  Imagine if you suddenly forgot how to push poop out…think of all the weird grunting noises and facial expressions you would make while you tried to figure it out.

There are also some children that will have runny stools and even diarrhea that will be related to constipation. As the stool hardens and a ball forms in the lower intestines, the only stool that can get around is leaky and runny.  These children often leak stool into their underwear (and not even be aware) because they have lost the sensation of needing to stool.

What causes constipation?

Think of it this way (it’s a simple description and an “amazing” mental image):

As stool moves down the colon, it is in a race against time to get out before it gets dry and hard.  Some people have better systems for drying the stool than others and some people hold on to their poop longer than others.  This balance is what makes some people more likely to have constipation than others.  It commonly runs (or doesn’t run, depending on how you look at it) in families.

The following diet factors can contribute to constipation:

  • Large amount of dairy intake
  • Low fruit and vegetable intake
  • Lots of greasy/fatty foods

Another contributing factor is stool withholding.  This most commonly occurs around potty training.  If a toddler can’t control anything else in their life, they will control when they drop a load or not. (Click to tweet.)

How do I treat constipation?

(These strategies may differ significantly from doctor to doctor so be sure and ask your pediatrician how they would like you to handle constipation.)


In children less than 4 months I recommend adding 1 tsp of Karo syrup to one bottle per day.  If they continue to have hard stools or go longer than 1 week without stool, half of a glycerin suppository can be used to get things moving.  (There are doctors who do not recommend Karo syrup so check with your doctor before using.)


In children older than 4 months but less than 1 year, I recommend giving 2-4 ounces of pear or prune juice per day.  If the child is on solid foods, you can also give prunes or pears.  If this doesn’t work, contact us and we can talk you through other possible solutions.


In children older than 1 year, you can always try prune or pears (or juice) as well.  However, I have had the best success with using a gentle stool softener like Miralax.

Start with 1/2 cap per day mixed with 8 ounces of fluid.  The cool thing about Miralax is that you can change the dose based on what your child needs.  If their stool is runny on it, you can drop the dose down.   If you aren’t seeing stool, you can bump the dose up to 1 cap per day.

If you child is not resolving after having 1 cap of Miralax per day for 1 week, then contact us.

You must give the Miralax every day for about 2 weeks in order to let the intestines heal and shrink back down to normal.  If you stop the medicine early, I find that the problem tends to recur and you find yourself back in the same position.


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