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Newsymail from 2011. 

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2011 newsymails


Jan3, 2011

Hyland’s Teething Tablets was called off the market.  I never have recommended it and most teething pain is mild and can be managed with Acetaminophen or Ibuprofen.  (And teething does not cause fever.)  The Teething Tablets contained varing amounts of a toxic chemical called belladonna.  It has been used for centuries as a poison or medication called Deadly Nightshade.   Belladonna alkaloids have anticholinergic effects such as fast heart rate, increased body temperature, dry skin and dry mouth, skin flushing, constipation, decreased urination, agitation, disorientation, hallucinations, and dilated pupils.  Drowsiness may also be seen in infants.  It probably quieted the infants through this mechanism.  Like many homeopathic herbs, these tablets were never evaluated by the FDA, and had no proven benefit.  The FDA now has issued an advisory warning for consumers to stop using and discard them. 

See: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm230762.htm?source=govdelivery

Roger Knapp MD

As an aside, the statistics for 2009 birth rates were finally announced and the declined 3% in America.   It is probably lower in 2010.  I think it was the economy.  “Lets wait until we can better afford a child?”   I guess it is the reverse of the blackout of electricity years ago in NY. 
Happy New Year.

 Jan 15, 2011

It is interesting that the first president of America who was born in a hospital was Jimmy Carter.  Around the turn of the century most people were born at home.  Things have certainly changed … for the better.

 A recent study showed for the 5-year period 2000-2004 there were 1,237,129 in-hospital certified nurse midwife attended births; 17,389 in-hospital 'other' midwife attended births; 13,529 home certified nurse midwife attended births; 42,375 home 'other' midwife attended births; and 25,319 birthing center certified nurse midwife attended births.

 The neonatal mortality rate per 1000 live births for each of these categories was,

Hospital/birthing center:    0.5, 0.4, and 0.6.

Home births:………………1.0, and 1.8

Twice as many for home births.

 Other neonatal outcomes of interest in this analysis that showed significant increases in risk for home births included the need for mechanical ventilation for >30 min among women delivered by 'other' midwives, OR=1.63 (1.38, 1.94) (almost twice as many); and the risk for neonatal seizures, OR=3.15 (2.25, 4.41) (twice as many). For home deliveries attended by both CNMs and 'other' midwives the risk for 5 min Apgar scores <4 was significantly increased compared with in-hospital deliveries by CNMs, (respectively OR=7.83 and 3.39) ( 7 to 3 times as many ).

 I know the problems of medical care in the hospital, but it is still better there than at home.

 Roger Knapp MD


 Also.. a study comparing pregnant women taking fish oil or DHA supplements with controls who did not take them,  did not show a difference in postpartum depression or intelligence in the children.  However there were half as many preterm deliveries so keep taking the DHA.

Jan 18, 2011



 This is an infection around the nail bed of the finger or toe will cause redness and frequently an abscess beside the nail.  See picture below.  (Old fashion name for this a “run around”.  The infection runs around the nail. Ha.)  This infection is caused by trauma to the skin beside the nail and bacteria getting under and inside the skin.  It usually is staph (generally not the bad kind called MRSA.)  Treating it topically will not help.   You can try soaks and also drain the puss if a white or yellowish looking area occurs as seen on this picture.  Long ago we used to cut or poke the skin to drain it but it is easier to push the cuticle back with a finger nail file or other nail instrument.  Then squeeze the pus out between the skin and nail.  Usually we also treat with antibiotics.  If you drain it and it is not better in a few days, then call your doctor for antibiotics.  If it is the big toe, you also may need to treat it for an ingrown nail also. Podiatrists are great at treating ingrown nails.

 Roger Knapp MD


 Jan 22, 2011

Parents come in commenting that this is their child's third illness this year.  It seams that we occasionally have a bad year.  Even our appliances in our homes do not break down one a year.   In one year the air conditioner, the disposal, and the washing machine goes out.  Then nothing else breaks for 3 years.  So machines do not break down one a year and humans do not either.  In one year they will have two ear aches, impetigo, and a viral fever.  Then they do not get ill for 3 years.  As long as they become normal between these illnesses, then there is nothing wrong deep inside, they are just having a bad year. 

 Giving frequent antibiotics does not weaken the immune system.  But children with weak immune systems died in the 1800s.  In fact 10% died the first year and the average life span of the human was approx. 35 years old.  Now we have antibiotics and these kids are growing older and their immune systems mature enough to get them survive (and they are having more children with weak immune systems.  We interrupted survival of the fittest.).  So it turns out that the weak immune system forced us to give more antibiotics,  not the other way around. 

Parents frequently come in saying that there is strep throats or whooping cough in the school.  That is nice to know but we watch out for every child who comes in to have strep, whooping cough, meningitis, or any disease.  We check every child for almost everything.  So knowing they have been exposed to it does not help as much as you would think.  Just because there is strep in the school does not mean your child has strep and not meningitis.  Similarly when the parent says "there is scoliosis in the family".  This does not help since we check every child for scoliosis.  Because there is not a family history of scoliosis does not mean we will not check the child for it.  So good doctors are looking at every patient for every thing. 

 There are rare exceptions where some inherited problems are deadly and need to be screened early.  We now screen every newborn for Cystic Fibrosis.

 There is a lot of flu and strep out there... One patient said the waiting time at Cook's emergency room was 7 hours.  And the other day they notified us that 30 patients were waiting in the ER for a bed in the hospital to open up.   Hopefully the flu and strep will be over soon.  Vit C does not prevent or treat illnesses.  Use good hand precautions and take your Multivitamins with zinc. 

 Roger Knapp MD 


 Jan 24, 2011

ABC News reports today:

Lack of Sleep Linked to Childhood Obesity

Children Who Sleep the Least at Increased Risk for Obesity, Study Finds

"There is growing evidence for a link between sleep duration and childhood obesity. What is new … is that perhaps even more important than sleep duration is the effect of day to day variability of sleep wake timing on weight regulation."


 I have talked recently about studies that show a correlation but not cause and effect.   Frequently it may be the reverse and the other factor caused the original problem.  For example a study came out showing prolong use of infant walkers delayed their development.  The actual situation is that the children who had delayed development had to use the walkers longer because they did not walk until very late. 

 So here is another problem of believing some doctors that have an agenda to prove one thing when all they have shown is a correlation.   It is not a cause and effect.  The news media also loves to dramatize the studies.  Another study was done by a group of doctors from Ohio who showed a correlation between obesity in kids and the lack of routines in the house.   Their conclusions were:

 Preschool-aged children exposed to the 3 household routines of regularly eating the evening meal as a family, obtaining adequate nighttime sleep, and having limited screen-viewing time had an ~40% lower prevalence of obesity than those exposed to none of these routines.

 So the problem are the parents who are not in control of the house routines and rules and do not make their children adhere to their rules.   The children are “running the house”.   Parents are afraid to limit the kid’s desires.  Children will want what is not good for them for 20+ years.  They will want too much candy,  too much TV, and stay out till 3 in the morning as teenagers.  So parents who do not enforce house routines do not limit their child’s eating.  Making your children sleep more is not the problem.  It is the routines.

 Don’t be afraid to be consistent and firm.  Your kids will actually feel safer and more loved when the parent is in control. 

 Roger Knapp MD


 p.s.  The dog whisperer on TV says they same thing about pets.   Funny J

 Feb 2, 2011

 There is a change in the vaccine schedule for Menatra that is for Meningococcal Meningitis.  Kids mostly get this in their teens and early twenties.  We gave it for 15 years to seniors before college since that is the peak age for it.  But there were some cases in high school that we were missing.  So the vaccine was moved down to 12 yr old and now required for 7th grade.  Studies however showed the immunity did not last through college and some of them were still getting sick or dieing.  Now a recommendation came out to rebooster a second dose of vaccine in their senior year of high school.  I strongly support this recommendation since this is a very deadly disease. If you have a child already in college and they were given this vaccine at 12, see the college doctor for a booster.

 Roger Knapp MD



We are closed Wed morning (Feb 2nd ) and if we open Wed afternoon it will be posted at my web site.  I  will also post there if we end up closed Thursday or Friday.  We may be able to handle some medical problems over the phone.  A nurse will be screening calls that come in during this winter storm.  We will reschedule you if you had a well exam scheduled during these days.  Sorry for the inconvenience.

 Feb 27, 2011

Seems like every parent gets a humidifier.  Most of us use them with colds but there are a few that run them all the time.  Careful you don’t increase molds by running them all the time.  That is why most allergists do not recommend them.  We do not recommend putting Vicks or other smelly stuff in them.  Most of the time the humidifiers do not help.  Sometimes the moister precipitates in the nose and makes more mucous.  They really help Croup which is the seal bark cough.  The moisture does not go far past the vocal cords so these do not help lower chest problems.  Be sure to use distilled water in them.  A rare complication is severe lung damage from “mineral dust” which is the high concentration of minerals. I didn’t even know that could happen.  Gee!

 I have parents coming in with their ill child informing me  of “what is going around in the school”.  Most of the time we know what is going around because we see them in our office.  “There are 4 cases of strep in her room.”  That is nice to know but we check and look for all diseases that cause fever.  To assume the child’s fever is strep and miss pneumonia or meningitis would be bad.  So we should check all children for all things.  The same with knowing there is scoliosis in the family.  We check every child for this.  The exception is when the child was exposed to a very rare illness that we never see here (like Ebola) or a rare inherited disease that nobody ever hears about and is one in every million children.  But otherwise knowing about common things does not help us decide what is wrong with the child. 

 Roger Knapp MD


 Also a new version of the recommended vaccine schedule is out and the main difference is a second Meningococcal vaccine Menatra at 18yr old before college.  They get one at 12 yr and now a second one their senior year.

 March 22

The American Academy of Pediatrics and the National Highway Traffic Safety Administration now recommend keeping infants in car seats facing backwards until 2 years old.  It is because there are far less injuries and deaths if facing backwards.  Facing forwards their head is violently whipped forward and can break their necks.  They do not mind their legs being bent.  They fuss because they cannot see you.  Put a large mirror there so you can see them and they can see the front.

Dr. Roger Knapp


Infants and toddlers—rear-facing

The AAP recommends that all infants should ride rear-facing starting with their first ride home from the hospital. All infants and toddlers should ride in a Rear-Facing Car Safety Seat until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer.

Types of rear-facing car safety seats

There are 3 types of rear-facing car safety seats: infant-only seats, convertible seats, and 3-in-1 seats. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat or 3-in-1 seat.

Types of Car Safety Seats at a Glance

 Age Group

Type of Seat

General Guidelines


Infant seats and rear-facing convertible seats

All infants and toddlers should ride in a Rear-Facing Car Safety Seat until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer.


Convertible seats and forward-facing seats
with harnesses

All children 2 years or older, or those younger than 2 years who have outgrown the rear-facing weight or height limit for their car safety seat, should use a Forward-Facing Car Safety Seat with a harness for as long as possible, up to the highest weight or height allowed by their car safety seat’s manufacturer.

 School-aged children

Booster seats

All children whose weight or height is above the forward-facing limit for their car safety seat should use a Belt-Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age.

 Older children

Seat belts

When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection.


All children younger than 13 years should be restrained in the Rear Seats of vehicles for optimal protection.


All car seats should be replaced if they are involved in a crash with the child riding in them. The plastic shell and the harness absorb the impact of a crash only once, and cannot be guaranteed a second time. Most insurance companies pay for a new seat as part of repairing the vehicle. Parents must be advised to contact their insurance agents and explore that possibility.


Also a study came out looking at the blood oxygen of newborns who where strapped into car seats and other devices.

METHODS: A consecutive series of 200 newborns was recruited on the second day of life. Each subject was studied while placed in the hospital crib (30 minutes), car bed (60 minutes), and car seat (60 minutes). Physiologic data, including oxygen saturation, frequency, and type of apnea, hypopnea, and bradycardia were obtained and analyzed in a blinded manner.

RESULTS: The mean oxygen saturation level was significantly different among all of the positions (97.9% for the hospital crib, 96.3% for the car bed, and 95.7% for the car seat; P < .001). The mean minimal oxygen saturation level was lower while in both safety devices (83.7% for the car bed and 83.6% for the car seat) compared with in the hospital crib (87.4%) (P < .001). The mean total time spent with an oxygen saturation level of <95% was significantly higher (P = .003) in both safety devices (car seat: 23.9%; car bed: 17.2%) when compared with the hospital crib (6.5%). A second study of 50 subjects in which each infant was placed in each position for 120 minutes yielded similar results.

That means that Ľ of their time they had low oxygen.  See my web site about a back support to keep their oxygen more normal.

March 25

It's that time of year with sun and mosquitoes.  Just a reminder to use sunscreen and repellants.  Sunscreen is OK down to 2 months but watch out for irritation rashes.  I like the spray since it dries out quick and you can spray your hand and wipe it on the face of infants.  We already have seen sunburns on the face of infants.  You can burn in the shade from reflected sunlight.  (It is not wind burn like grandma said.)  Use the SPF of 20 or more. 

Use the repellants starting at 6 months old.  The deet in Off has been well studied but the other products have not.  Mosquitoes carry bad diseases and we see cases of encephalitis every summer.  There is also a bad viral disease called Dengue Fever that is in S. America and Mexico but headed North toward us.  If you are going to the park or camping, put long pants and even long sleeve shirts on them.

Some sites I think are good:
Recepies: http://www.cookstr.com/
Keep kids safe: http://www.youtube.com/watch?v=N2vARzvWxwY
School Work Help: http://www.khanacademy.org/

Roger  Knapp MD

 March 29, 2011

We are seeing many cases of a chest cold with most having fever with it.   It is not the flu but I do not know what virus.  You cough for 2 weeks and if you have fever it is during the first 3-4 days.  We can check the child over during the first part of it but we can’t cure viruses.  Keep them at home and treat the symptoms.  Bring them in if there is fever or ear pain after the fourth day.   I was booked solid Monday and could not see all my patients it was that busy.  Strep throat does not have a cough with it.  You generally don’t just get pneumonia from the outset.  See previous Newsymail about chest x-rays being read incorrectly.  So watch for fever around 7 days into it.

Dr. Roger Knapp MD

p.s.  How long has it been since you went out as a couple without the kids.  Every few weeks leave the kids with grandma and go out on a “date”.  Do the fun things you did when you were younger.  Go bowling or play cards with friends down the street.  It does not have to be expensive.  Laugh and enjoy each other.  That is good for the marriage and therefore good for the kids.  If all you do is eat and sleep together, there is a high probability of a divorce.   Also treat your spouse with respect.  Instead of criticizing in an ugly way, try asking nicely.  If your spouse is asking you to do something over and over, then try hard to do it.  Just as you want them to do what you want done. (except snoring, we can’t help that!)

 March 30

Crib Safety

See: http://www.cpsc.gov/info/cribs/index.html


March 4, 2011

The New Crib Standards

Since CPSC approved a new crib rule, your questions have been flowing into us. While most questions have revolved around the drop side, it’s important for you to know that the new standard affects far more than the drop side. The new rules require crib’s mattress support, slats 2 3/8 inch gap, one finger gap beside mattress,  and hardware are now required to be more durable and no drop side rails.   There are not requirements for height of the side rails.  They figure if the child can climb out, the height won't stop them. 

The new rules, which apply to full-size and non full-size cribs, prohibit the manufacture or sale of traditional drop-side rail cribs, strengthen crib slats and mattress supports, slats with 2 3/8 inch gaps, one finger gap beside mattress and rail, improve the quality of hardware and require more rigorous testing. The details of the rule are available on CPSC’s website at www.cpsc.gov/businfo/frnotices/fr11/cribfinal.pdf .

Beginning on June 28, 2011, all cribs sold in the United States must meet the new federal requirements. After that date, it will be illegal to manufacture, sell, garage sale, contract to sell or resell, lease, sublet, offer, provide for use, or otherwise place in the stream of commerce a crib that does not comply with the CPSC’s new standards for full-size and non-full-size cribs. This includes manufacturers, retail stores, Internet retailers, resale shops, auction sites, garage sales, and consumers.

As a consumer, what can I do if I have a drop-side crib?  Some drop-side crib manufacturers have immobilizers that fit their cribs. Drop-side crib immobilizers are devices that are used to secure drop sides to prevent dangerous situations in which the drop-side either partially or fully separates from the crib. As part of a recall, CPSC staff works with companies to provide fixes, or remedies, for products. For drop-side cribs, that remedy has been immobilizers.  These immobilizers were evaluated and approved by CPSC staff for use with these particular drop-side cribs.  If your drop-side crib has not been recalled, you can call the manufacturer and ask if they are making an immobilizer for your crib. (list of manufacturers is at my web site or at the CPSC Site.) Remember, though, that those particular immobilizers have not been tested or evaluated by CPSC staff for use with your specific crib.

Note that a drop side crib, even with an immobilizer installed, will not meet the new CPSC crib standards.

Dr. Knapp

p.s.  Most parents move them out of the crib to a youth bed around 2 yr old.  But the age range is 18 months to 3yr.  When the toddler starts climbing over, move them out.  You can use a youth bed or you can put the crib mattress on the floor, have Dad get wood and nail a box around it, sand and paint it, stick pictures on it.  Cheaper.  I like hand made.  Also it is not child abuse to contain them in their room.   Get a gate or lock the wood door.  If the house catches fire, the smoke will not get to their room and they will be saved.  We have had 2-3 year olds light the stove, go out the front door, and come in on parent's bedroom activities.  So do not be afraid to contain them in there.   

April 6

There were two cases of Measles this week in Tarrant County.  They were adults who were not fully immunized.   There are usually around 60 cases in America each year.   There were 11 cases in America this last few weeks. The case in Houston was an 11 month old infant who has not had a MMR yet.  Minnesota had 15 cases and most were in a Somalia neighborhood who do not immunize.  The rate of vaccinated children in America is 90%.  Texas has 84-86%.  That area in Minnesota only had 30% vaccinated.  There needs to be 90% or more to prevent outbreaks.  Some kids will not make proper immunity after one MMR so the county in Minnesota where the outbreak is located is recommending the second MMR earlier than 4 yrs. old. 

Most cases here in Texas and other states are acquired from foreigners who came here sick.  Most people who are immunized should not worry.  Children below 1 year are susceptible and if there are more cases we will give the single Measles vaccine to those over 6 months.  We will let you know if these steps are needed here. 

The last big outbreak occured in 1989 when 500 kids were hospitalized and 3 died.

It starts out as a cold and then higher fever and by day 3-4 there is a rash all over with continued fever.  It is contagious 5 days before the rash!  It is viral and no treatment.

Dr. Knapp


p.s. Remember how to do first aid for injuries?  The weather is nicer and we are starting to see more booboos.  See: http://www.rogerknapp.com/medical/injuries.htm

April 10

Allergic reactions are common.  The most frequent is the child having hives or urticaria.  Hives are large whelps where viral rashes are small dots below pencil eraser size.  Typically the hives are caused by three things:  Medications, foods, and infections.  Of these three, the most common are infections.  Many people who become ill with fever and take an antibiotic and then develop hives are not allergic to the medication, but are allergic to the germ that caused the infection.  75% of adults who say they are allergic to a medication are not. 

For example a child will started running fever and the parent just wants to watch it at home.  Then after a few days the child breaks out in hives and that scares the parent and they bring him in to see me.   Had I seen him the first day of the fever and gave antibiotics, then when he broke out in hives a few days later everyone would say “He’s allergic to the medication.” 

If the child does break out in hives during the course of a medication, I recommend stopping the medication, switch to another one but keep the original medication.  Then a few weeks later give a day or two of the medication and if they break out in hives a second time, then call and have his medical record labeled allergic.  If he does not break out, then it was the infection that caused the hives. It is safe to rechallenge them with the medication if the orginal allergic reaction was just hives and not a more severe reaction. If the hives last for more than 2-3 days, then very likely it is not the medication which is out of your system quickly.  Also when they first break out in hives, stop all very allergic foods like dairy, nuts, peanut butter, shell fish.  If the hives go away, then one at a time rechallenge the child with the medication, and the foods that were eliminated. 

If the hives last more than a week, then remove other foods by eliminating food groups.  Stop all vegatables for a week and if it continues, then put them back in the diet and eliminate all fruits, then all meats.  If the hives stop during one of these food group eliminations, then put them back in the diet one at a time.  If you put them all back in the diet and the hives do not recur, then it was nothing in the diet and the hives just happen to stop during those days. 

Roger Knapp MD

p.s. Remember, if someone injures your body, like a spranged ankle, wrap it with tape for 24 hours.  Wrap it immedicately before it swells.  Not with an ace bandage…. Use athletic tape or duct tape.  And ice is OK if you want to put it on your boo boo later but the first thing coming off the field is compression.  

April 20

Bullying is not cool.  It is not only cruel but also now days can get you in a law suit.  Here are some web sites that help kids understand and help cope.




  Also for families in this North Texas area near Bedford, Southlake, and Colleyville, a very good psychologist Susan Gifford is having group social skills sessions this summer.  They learn to explore social challenges and how to modify their thoughts and behaviors.  It equips them to reduce meltdowns and fear while increasing their repertoire of social skills.   These sessions last most of the summer.

See: http://www.drgifford.com/superkids/

April 28

It seems that people who leave ratings on the internet are mostly those
who had a negative experience.  We need to leave more ratings for
products and professionals when we have good comments. 

Here are some sites that rate MDs and your comments about your
doctors can help give a better picture of them to others who may
be looking around for a new doctor.

1.  www.ratemds.com/

2.  www.healthgrades.com/

 3.  www.vitals.com/

 4.  www.doctorscorecard.com/

There are others also. Thanks...

Dr. Knapp

May 4


Kids become picky eaters between 1 and 2 yr. old. They are really picky between 2 and 6 yr. and somewhat picky after that. In all age groups some will be pickier than others. They start to not want their vegetables and want more junk. They only gain 3-4 lbs. per year after 2 yr. old so they only need one meal a day, and nibble at the other meals. That is only 1 lb. every 3-4 months …. I can gain 1 lb. in 3-4 minutes! So they can easily get by with very little food.

You can work this picky eater problem in three different ways.

1. You could outwait them. If you start off with meat and vegetables (proper foods) and they refuse it, put it in the refrigerator and pull it out again the next morning, and again at noon. After going a few days hungry then they will eat anything. The kids stranded in the Super Dome in New Orleans during Katrina ate anything off the floor. They get hungry they will eat the dog food.(probably try that anyway.) So you could outwait them and after going hungry for a day or so they will eat anything. The problem is that they need very little food so they outwait you. I have done this with a few of my grandkids when staying with us.

2. You can disguise the food. Grind up the proper foods and put the ground up stuff into the macaroni and cheese, spaghetti sauce, or in the peanut butter. There is carrot cake and zucchini bread. Seinfeld’s wife wrote a book about this called “Deceptively Delicious”. Put the proper foods into whatever they are eating. If your kid likes sour things like pickles, then put the raw vegetables into the pickle jar. Buy dehydrated peas that have BBQ powder on them. Dip the vegetables into Ranch dressing or cheese wiz. Get creative. Most kid’s taste buds are not geared for the flavor of vegetables.

3. And the last way is to let them eat whatever they want, give them multivitamins, and 12 oz of milk ….. and they will grow up fine. (Give the vitamins to all the kids.)

The problem is that you let them eat what they want one day and the next you are fussing at them to eat the proper foods. YOU are not being consistent. Pick which one of these three methods and BE CONSISTENT! (I prefer a combination of the first and second method. Disguise and flavor up the proper foods and then outwait them.)

Other things to think about:

1. Eat healthy balanced meals yourself and set the example. Control how much junk food is in the house and how much everyone eats.

2. Do not force them to eat. If they eat so much proper food, then they get a proportional amount of desert. But to make them finish their plate to get the cookie is forcing them to eat too much and leads to obesity. “Feel guilty about leaving food on the plate.” “Love that stuffed engorged stomach.” Those are bad habits we fight. Leftovers are the same whether they are on our plate or in a pot on the stove. Leaving food on the plate is not being wasteful; cooking too much food is being wasteful. Most families cook too much food so no one will go hungry. So you will have leftovers every meal. Whether they are on my plate or on the stove, I would like to mail it to Haite or Japan, but I can’t. Being wasteful is cooking too much food. Just keep the desert in proportion to how much proper food they eat.

3. Offer healthy choices. Sometimes let them pick what the family will have for that meal if it is within reason.

4. Avoid going back to the kitchen and prepare something different for the child.

5. If the child is not hungry at that time, and we all are hungry at different times, put the dinner in the refrigerator and when they are hungry later, pull it out and warm it up again for them.

It is important to have a sit down family meal. There are less drugs and pregnancy in the teens and less divorces in the parents. Turn off the TV and phones and visit. If the child is not hungry, then sit and visit while we eat.

May 11

Many parents are talked into saving their baby’s cord blood for their baby.  There might be a need for it in case their baby has cancer or some disease that would need a bone marrow transplant.  The problem is that many bone marrow failure, anemia, and cancers are from a defect in the DNA.  The doctors do not really want to use the same DNA blood.  They are very good at getting DNA matched cord blood from some other baby and use it for the bone marrow transplant.  The American Academy of Pediatrics does not recommend saving your baby’s cord blood for your baby.  It is expensive and will hardly ever be used. 

But you can donate your baby’s cord blood for free to the national cord blood bank to help other babies.  And many other parents give their baby’s cord blood for you to use if the need should arise.  Here is the web site that you can read up and get contact information to donate it.


Dr. Knapp

May 12

Children’s social security number are being stolen and Identity Theft with their name.  But the parent does not know it until the child becomes an adult and tries to buy a car or house.

See:   http://miami.cbslocal.com/2011/05/05/i-team-child-identity-theft-surges/

 You don’t need Life Lock or other companies.  Just contact the three credit agencies and lock up your credit with a one time small fee.  Lock up your children’s and your credit so no one can scam you even if they get your SSN.


 Don’t get a credit report.  Just Freeze your credit.  It is easy to unfreeze it for a few weeks if you do need to apply for a loan.

 Roger Knapp MD



Acetaminophen (Tylenol)will not come in concentrated drops for infants in the next few months.  The only liquid will be the children’s liquid with 160mg / tsp.  It will still be the same dose as our chart in our clinic or at my web site.  It will come along with a syringe to give more accurate dosage.



Poison Ivy is around every summer.  If you are allergic to it then it will cause a blistery itchy rash a few days later.  If you get around it and come in right away, take a sudsy bath and put the clothes in the washer, then you will not break out much.  If you do get a rash, it is not contagious.  We thought it spread but we could not intentionally spread it.  What happened is that one area broke out in 1 day, another in 3days, and another in 5 days.  We thought we were spreading it but didn’t.  Or you get out in more of it.  There are 10 plants out there that can give you the allergic rash but Poison Ivy is the most common.   Treat the rash with hydrocortisone.  If worse then get a Rx for stronger Steroid creams.  If all over and on the face, then call to get oral steroids.  Attached are pictures of the rash and the plant.

 Roger Knapp MD



June 2

Outbreak Notice E. coli 0104:H4 infections in Germany

CDC Released: June 02, 2011

Current Situation

German health authorities have reported an outbreak of a severe illness called hemolytic-uremic syndrome (HUS) in Germany since May 2, 2011. In this outbreak, HUS is being caused by an infection with a Shiga toxin-producing Escherichia coli (STEC) bacteria. Many people have been hospitalized, several requiring intensive care, and some people have died. New cases are still being reported. The organism causing the outbreak has been identified as E. coli O104:H4, producing Shiga toxin. This strain of E. coli causes an illness similar to infection with E. coli O157:H7 here in America.

Most infections have been reported in people in northern Germany (mainly Bremen, Hamburg, Lower Saxony, and Schleswig-Holstein) or in people who have recently traveled to these areas. Cases in travelers to northern Germany have been reported in Denmark, the Netherlands, Spain, Sweden, and the United Kingdom.

They suspect that the source is contaminated food, possibly raw vegetables.

Advice for US Travelers to Germany

German health authorities recommend that people in Germany, especially in the northern part of the country avoid eating raw tomatoes, fresh cucumbers, and leafy salads, until further notice. Also raw meats.  How about any raw food.  If you have traveled to Germany and have bloody diarrhea and stomach cramps or symptoms of HUS, go to a doctor right away and tell him or her about your recent travel.

STEC infections can cause different gastrointestinal symptoms, but often include severe stomach cramps, diarrhea (often bloody), and vomiting. If there is fever, it is generally not very high (less than 101˚F [38.3˚C]). HUS is a disorder that usually occurs when an infection in the digestive system (such as STEC) produces toxic substances that destroy red blood cells and cause kidney injury.  Signs of HUS typically start 5–7 days after the start of diarrhea, and diarrhea or bloody stools may no longer be present when HUS develops.

Dr. Knapp’s comments:

You may have heard on the news about this germ.  Do not be overly concerned with the news media hype.  This is a new strain of the E coli O157 that we have had here for years.  This new germ has a little more toxin in it but the one here is deadly also.  In Germany about 1000 people have become ill,  477 have developed HUS, and 17 have died.  Those numbers may increase.  To put this in perspective, the US had 1,420 cases in 1994, 3,840 in 2000, 2,621 in 2005, and 4,600 cases reported in 2009.  Around 250 cases are reported (many more that are not reported) in Texas every year.  It is here and you need to be careful to clean all lettuce and vegetables, cook meats, and be careful of surfaces and utensils that come in contact with the raw meats and vegetables before cooking.  

Roger Knapp MD

p.s.  We are already seeing swimmer’s ear.  There is advice at my web site on how to prevent it.

 Sept 20

Lets look at healthy fruit juice that we all give our children.

Recommended intake for Children 1-6 yr take 4-6oz a day of juice.

 Motts Fruit Juice       (10oz=74 cal)

6.75 oz

13gm fructose sugar

50 cal

 Martinelli’s Apple Juice     (10oz=175cal)


31gm fructose

140 cal.

 Welches 100% Grape Juice   (10oz=175cal)


36 gm fructose

140 cal.

 Tropicana 100% Orange Juice  (10oz=216cal)


30gm fructose

130 cal

 Cranberry 100% juice no sugar added   (10oz=145cal)


31gm fructose

116 cal

 Coke    (10oz=116cal)

12 oz

39gm fructose sugar from fruit!

140 cal

 Martinelli’s and Musselman’s juice is from the USA and not from China.

No Arsenic or mercury that we know about.

So when you are giving most juices to your kids it is similar to giving them a coke (they are all fructose) or even more.   For comparison of 10 oz: 

Motts juice  ……………………………74cal

Coke   …………………………………..116cal

Cranberry 100% juice …………..145cal

Welch’s 100% Grape ………….175cal

Tropicana 100% Orange juice  216cal.

 When you go crazy when someone gives your child a sip of coke,

Remember you are giving a lot more “coke” in the form of

“healthy” natural juice.   Same stuff!

 The vitamins in these juices are for 2000 cal adult diet.

Divide then in half to figure the vitamins for 1000 cal todler’s diet.

 You might look at fruit rollups.  Similar to gummy candy???

 Go ahead and give your children juice but keep it down to 4-6 oz a day.

 Dr. Knapp

Sept 25

2011 October 1 issue of Clinical Infectious Diseases will present this information and recommendations.

The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened an expert panel to review the management of Community acquired Pneumonia (CAP). The PubMed database was reviewed through May 2010. The expert panel included clinicians and investigators who represented community pediatrics, public health, critical care, emergency medicine, hospitalist medicine, infectious diseases, pulmonology, and surgery.   The first-ever guidelines on the diagnosis and treatment of CAP in infants and children, from PIDS and IDSA, emphasize the importance of immunizations  (Prevnar), including a yearly influenza vaccine, to protect children from life-threatening pneumonia.  A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the print October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence.

Recommendations for Diagnosis  "Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children,"  Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting. "In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states.  The guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized.

Amoxicillin Sufficient for First-Line Therapy In addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful.  According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia. 

"With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates.  "Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children,"   "Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes.”

It is interesting that they do not recommend x-rays.  When you take an x-ray the cloudy area that one sees is called pneumonia but in fact is just “congestion”.  It is mucous.  The mucous can be sterile as in allergies and asthma, it can be viral with a chest cold, or bacterial as with bronchitis or pneumonia.  The x-ray does not tell you which but is reported “pneumonia”.  Then the doctor faced with a x-ray report of pneumonia has to treat it as if it is bacterial pneumonia so that he does not “miss” pneumonia and get sued if the patient later comes in the secondary bacterial pneumonia after the chest cold.  We have discussed in previous articles about the chest viral cold with fever and cough at the beginning is usually viral and a recurrence of fever and lethargy after the fifth day is secondary bacterial infection.  That is when we need to see the patient.  But many people are treated for pneumonia who have a viral chest cold or allergy.  Everyone who is coughing and goes into the walk-in emergency clinics gets a chest x-ray and many get treated for their “pneumonia”.  I don’t take a lot of x-rays for this reason.  It does not affect your medical decision that much.

 While we are talking about false diagnosis with tests, let’s talk about strep tests.  10% of strep cultures and rapid tests are negative when there actually is strep throat.  And 5% of the population carries strep around in their throat all year.  They are carriers. So you can have a strep throat and a negative test and not get treated.  Then you can have a viral/allergy sore throat and positive test and get treated for a strep that has been in there all year and had nothing to do with the sore throat.  That is why your friend says their child had a strep throat and did not even run fever.  Or the doctor started antibiotics for “strep throat” and the patient was not well in a few days so they changed antibiotics.  There are no strep resistant to Amoxicillin.  When they changed antibiotics then the viral sore throat finally went away and it seems like it was from the changing of the antibiotic.

 Also think of Urinary tract infections.  Most girls below 5 yrs. old who have burning do not have an infection but just irritation.  There is what is called asymptomatic bactiuria.  There are bacteria in many females bladder and it is in there all year.  It does not harm them and does not need to be treated.  But the child gets irritation from a bubble bath and the culture comes out “positive”.  Those may have been bacteria that were in there all month.  They still get treated to be on the safe side. (no bubbles and use Dove soap in the bath.)

 What I am saying is that it is not exact and gets confusing as to what is real or not.  A lot of clinical judgment, experience, and common sense goes a long way. 

 Roger Knapp MD

Oct 11

There have been some recent cases of tuberculosis in the news.  Students in Ellis county and suspected case in Denton county.  TB is so rare in the US that they stopped giving routine skin tests to everyone in 1987.  If a person with TB disease of the lung who is ill with coughing can spread it to others.  You have to be in contact with that person 40 hours a week or more.  You won’t catch it walking  through a store.  If a person gets the bacteria in their lung it is generally dormant for many years.  Your skin test becomes positive after 8 weeks but you do not have lung disease and are not contagious.  The germ can become active and cause lung disease years later.  Diseases such as HIV and diabetes can increase your chance of catching TB or having lung disease.  Smoking increases the chances also.  Most cases in the US are imported from other countries where there is a lot of TB disease.  These countries are Latin America, Caribbean, Africa, Asia, Eastern Europe, and Russia. We in the health care field are still required to have yearly TB tests.  If these students who were exposed to TB have a positive test, they will take medication for months to kill the germ.  They are not contagious themselves.  Since the test takes 8 weeks to become positive, they really should retest them in 2 months.  There is no reason for panic here and health officials just need to identify cases and treat them.  Don’t be afraid of every one you hear coughing.  It is still very rare. 

 Roger Knapp MD

November 2

A common question is “do we need to put PE tubes in the infant’s ears” because of the ear infections this year. Line up 10 different ENTs, Pediatricians, or parents and you will get many different answers.  Age of the infant, time of the year, how frequent, and other factors go into the decision.  Here are some facts that you might think about.

1.    There are studies showing the ear infections and fluid decreases the hearing to some degree.   Just as many studies show this slows down the speech of the child and just as many show it does not affect the speech.  A few studies came out that showed it was the quality of the daycare that affected the speech and not the infections.  There are many more ear infections among infants in daycare than those at home or with grandma.  http://www.sciencedirect.com/science/article/pii/S0885200605000396

2.    A recent study showed infants who underwent anesthesia for any surgery had a higher number with learning disabilities …. Controls 21%, one anesthesia 23%, and more than one 36%.  http://news.nurse.com/article/20111009/NATIONAL02/110170016/-1/frontpage There were more learning disabilities in the children if the mother had general anesthesia for C-section rather than if the mother had an epidural. 

3.    The scar in the ear drum from the tubes can decrease the hearing later on just as much as the fluid and infections.  The hearing is better while the tube is in the ear drum.

4.    Most tubes fall out in 1 year.  There are a very few that come out in a few months and some go for years and have to be removed.  Some babies will continue to have ear or sinus infections despite the tubes.   And by the way, surgery on the tonsils and adenoids will not help these ear infections. 

I tend to be on the conservative side of things but I still occasionally recommend tubes.

Roger Knapp MD  www.rogerknapp.com

I am not worried about the miniscule amount of formaldehyde in the Johnson’s baby shampoo that was on the news.  You put far more chemicals into your baby using the diaper wipes.  Read the list of those chemicals.

 Nov 8, 2011

 A study came out showing a correlation between using Facebook and use of alcohol, tobacco and marijuana.  Half of 12 yr. olds use Facebook and 20% of 10 yr. olds.  It is 70% by late teens.  Of those adolescents who frequented the social network sites, 26% used alcohol, 10% used tobacco, and 13% used marijuana.   Among those who did not use these sites 9% used alcohol, 2% tobacco, and 7% marijuana.  This is not necessarily a cause and effect but a correlation.  It may be influencing some but I think it is a reflection of good strict parents who are involved with their kids and monitor what they are doing.  Would you let your child hang out with neighbor kids who are alcoholics and drug users?  Then why would you let them hang out on the internet with them and have their words influencing your kids.  Multiple studies have also shown that kids that watch TV shows like “Gossip Girl”, “16 and Pregnant” or “Skins” that contain smoking, sex and drinking are more likely to do those things.  Again it may be parents lack of monitoring.  There also was a study that just came out showing that outlawing soft drinks in schools did not decrease the number of those drinks consumed by adolescents during the whole week.   They made up for it after school and at home.   Again parenting!   Not to put all the blame on parents but we are a major factor in their outcome.  It is important that they get out and have friends but moderation is a good thing in all things.  Have more family time and activities.  And decrease our use of Facebook and texting.

 Roger Knapp MD

 December 6

The FDA has been testing for arsenic contamination in juice products for several years as part of FDA programs that look for harmful substances in food, and have not found evidence that juice is unsafe for consumers young or old.  FDA monitoring has found that total arsenic levels in apple juice are typically low.

 Earlier this year The Dr. Oz Show publicized results of private tests showing arsenic levels higher than the FDA level of concern (23 parts per billion) in a number of popular brands of apple juice. FDA officials publicly rebutted those claims.  Arsenic and apple juice have become a recurring theme in food safety politics. Consumer groups point out that most U.S. apple juice is imported from China and other countries, and they fear some of it may be tainted with arsenic and other heavy metals.  The FDA has increased its monitoring of imported juices. In one recent sampling, all 74 samples collected had originated in China. But only one of those samples tested slightly above 23 ppb of total arsenic, and 95 percent tested below 10 ppb total arsenic.  The FDA tested juice from the same Nestle/Gerber lot that the TV program had shown to contain 36 ppb total arsenic, but the FDA tests showed arsenic levels ranging from 2 to 6 ppb.  I think there are exaggerations and lies on both sides for political gains.  These levels show the TOTAL arsenic and does not mention the amount of inorganic form.  See: http://news.consumerreports.org/Consumer%20Reports%20Arsenic%20Test%20Results%20January%202012.pdf  for levels reported.

 There is an important difference between organic and inorganic arsenic. Organic arsenic is considered part of the natural environment, present in small amounts in drinking water and foods and essentially harmless, while inorganic arsenic is the poison made famous by mystery writer Agatha Christie.   Most studies report the total amount.

 I agree with the FDA.  The apple juice sold across the U.S. is safe to drink, with naturally occurring arsenic levels well below the agency's "level of concern." It needs to set new guidelines on an appropriate level for inorganic arsenic.  The rare juice that might have a high level will be 1% of the juice a child will drink and not enough to harm them since the arsenic ingested will average out in the safe range.  There are other reasons not to drink too much juice….  less eating health foods and obesity.  Like everything else… moderation!

 Since we are talking about arsenic, did you know it is in treated wood for playgrounds.  They stopped using it in 2004 but playgrounds built before that have arsenic in the surface of the wood.  So don’t let your kids lick or bite we wood of old playgrounds or they will get more arsenic than the apple juice.  And do not burn treated wood because if you breath the smoke, you will get very high levels of arsenic. 

 Roger Knapp MD

 December 12

Hives or Urticaria

 This is typically an allergic reaction to something that is inside your body.  Topical substances almost never cause hives but instead causes rashes.  Hives are large circular rashes that are larger than pencil eraser size.  If the child has tiny red spots smaller than eraser size and usually 2-3 mm size, then that is a viral rash and not allergic hives.   Some infants with Roseola who have fever and then a few days later get tiny spots on their chest and back get labeled allergic to an antibiotic that was given by their doctor.  The doctor gave an antibiotic for a possible ear infection when the problem was a viral fever.  Then the infant gets labeled allergic when the whole thing was just a common viral illness that every child gets in the first 2 years. 

 There are many causes of hives.  The three most common causes that come to the pediatrician office are listed below.  The others like stress and pollens are seen by the allergist since they persist for long times and more difficult to figure out. 


1.     Foods.  A person can become allergic to something at any time and it is common to become allergic to eggs or some food/medication at any time.  So you can eat strawberries your whole life and then when 20 yrs old you start having hives from them.  Usually the parent figures this out when the child breaks out multiple times after they give a certain food.  The usual foods are Nuts like almonds, peanut/peanut butter (the peanut is not a nut but a legume from the ground),  seafood, strawberries, and eggs.   But a person can be allergic to anything so it could be their breakfast cereal or anything.  The first thing parents think of are the new foods but it more likely will be the old things that the child has eaten since 6 months old.

2.     Medications.  The same applies to meds …. It may be an antibiotic that the child has taken many times and to which they are now allergic.  So it can be after 1 or 9 days of taking the medication.  When stopping the medication the hives should go away in 2 days and if the hives go away a week later then probably not the medication causing it.

3.     Infections.  Did you know 75% of adults who say they are allergic to a medication are not.  25% are but 75% were mislabeled allergic.  For example I will see a child who had been running fever for a few days at home and the parent was just watching it.  Then the child breaks out in hives all over from the infection and that scares the parent and they bring them in.  Had I seen them in the office during the first day of the fever and given penicillin and broke out in hives a few days later from the infection, then we might have blamed it on the antibiotic.  The more common infection causing it is strep but any germ can do it. 


So when the child comes in with hives with or without fever and/or cough-cold, I generally stop the allergenic foods and medications, give Benadryl, and give it a week to go away.  If they go away, then the parent restarts one at a time the foods and meds that were stopped.  If the hives continue 10 days or more then go see the allergist for tests. 

 If the child was on an antibiotic for an infection, the medication is stopped, a different antibiotic is given.  The parent is asked to save the first medication and in a few weeks when nothing else is going on , then give 2 more days of  that antibiotic and watch for hives.   Studies show this is safe if the allergic reaction was only hives.  If they break out a second time, then call and we label them allergic to the medication.  Some parents are anxious about giving it again and they want to park outside of an ER or the doctor’s office and give the medication.  Some parents prefer going to the allergist and having them skin tested and that is OK if that is what they are comfortable doing.  I almost never hear from the parents about the child being allergic.

 If they are allergic to peanut butter, nuts or eggs, then we give epipen for the parents or grandparents or school to have on hand in case of allergic reactions.

 Roger Knapp MD


 p.s.: Poison ivy is a topical allergic reaction.  The lesions on the skin are NOT contagious.  You cannot spread it around your body or to other people.  We used to think that but doctors tried to experimentally spread it but could not.  It happened that one area broke out in 1 day, another in 3 days and another in 5 days.  We thought it was spreading around from the first lesion. Or the person just got out in more of it.  But the areas are not contagious.  Put hydrocortisone cream on it and if worse, come in for stronger steroid treatments.

 December 31

Many nutritional supplements sold over the counter contain small amounts of substances that can give an athlete’s test for “doping” with steroids a positive test.  Several successful athletes reputation and income have been damaged from using supplements that contain these small amounts of steroids or steroid precursors.


See: http://antidoping.nl/nzvt/thenetherlandssecuritysystemnutritionalsupplements or just Google supplements containing doping substances. 


Also sold are the actual precursors to anabolic steroids in high concentration.  Here is an excerpt from testimony from Terry Madden:


Over the last year, we conducted more than 7,000 tests for steroids and other prohibited doping substances.  I am here today to speak to you about the increasing number of products sold over-the-counter in the United States that contain anabolic steroid precursors. These products, marketed and sold as dietary supplements, contain substances, such as androstenedione and norandrostenedione. These substances are one chemical step away from anabolic steroids. Once ingested these products are converted within the body into anabolic steroids.


The perils of anabolic steroid use are well known.. In the body, androstenedione metabolizes into the anabolic steroid, testosterone, and other steroids. The documented side effects of steroids and steroid precursors among these East German athletes, particularly women athletes, are severe and include effects on the liver and reproductive system, susceptibility to cancers, and permanent masculinization of women. Other side effects include growth arrest in adolescents, and shrinking of testicles and impotence in men.


Today, American consumers can walk into their corner nutrition store and buy products containing androstenedione. After professional athletes acknowledged that they used androstenedione, sales of these supplements in the United States dramatically increased. This phenomenal demand, particularly among teenagers, led to the mass marketing of other steroid precursors like 19-norandrostenedione, which metabolizes in the body into the steroid nandrolone, another controlled substance. Now the nutrition store shelves, and the internet, are flooded with products containing these steroid precursors. Further, the manufacturers of these substances attempt to take advantage of DSHEA by touting these substances as "natural," and implying in their advertising that "natural" equals safe.


Under the current regulatory scheme, a manufacturer is not required to test its steroid precursor product for either side effects or purity prior to putting it on the shelf. This is of particular concern when adolescents are considered. Instead, the burden rests on the government agencies to prove that a particular product is harmful. However, by the time action is taken against a specific product, an unscrupulous manufacturer could simply make a minor chemical change and reintroduce the product.


The marketers of these products glorify the muscle-building qualities of these substances and do everything possible to reinforce the association between these products and controlled anabolic steroids. These products are marketed under names that reinforce their connection to anabolic steroids, including "Cycloroid," "Masterbolan," "Anabol-X," "Paradrol," and "Animal Stak." These products are advertised as equal to or better than the "real steroids" and promise the user huge gains in muscle mass. The advertising also stresses that these products are "legal" in order to raise the implication that they must be safe.


In a society where high school athletes can sign multi-million dollar endorsement contracts, we cannot expect teenagers to ignore advertisements claiming that these products are "safe alternatives" to steroids and will make them "ripped," "huge," improve their athletic performance and give them the body of their dreams.

See: http://drugcaucus.senate.gov/steroids04madden.html


Most supplements over the counter have no quality control.  I stay away from them.


Roger Knapp MD   www.rogerknapp.com


Have a happy and safe New Year. 

By the way, more DWI auto accidents occur on Super Bowl Weekend rather than New Years.