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Newsymail archive of 2014



The news is scaring you about the flu.   Again they like to make it horrible to get viewers.  They have startling news of snow storm in new England area….. Wow!.  It happens every year.  We have flu and rare flu deaths every year.  It happens.  Tragic but it is life.  This year we are having an average number of cases.  Some years it is less and some years more.  For example, look at West Nile disease.  We had in Texas in 2012 approximately 1800 cases and this year 170. You did not hear much in the news about West Nile this last summer.   The flu hit the elderly worse last year but this year it is the middle age adults.  It varies year to year depending on what age is susceptible to what every strain is going around.  Take the normal precautions,  get the vaccine every year, and pray you are not that rare tragic case.  See my web site for the numbers, graphs, and recommendations on who should be tested or treated.

 I saw a patient with high fever and headache and nausea like all the kids with the flu.  Mom wanted him tested for the flu because it is “going around at the school”.  I saw the patient and he had strep throat and I gave him antibiotics.  Mom asked to test him for flu and it came back negative.  The point I am making is the doctor has to be careful not to get tunnel vision.  When a disease is in the family  or school, the doctor just thinks of that disease and not the full list of possible diseases.  There may be strep in one child but the other might have meningitis, ear infection, pneumonia, flu or some other disease.  Doctors should look for almost every cause of the symptoms.  Just like the mom who comes into the office and tells me there is Scoliosis in the family.  Nice to know but we check every child for Scoliosis, heart disease, diabetes, etc.  So knowing it is in the family only helps in rare inherited diseases.

The goal of news media now days is to scare you to get viewers or to sway your vote.


I hate to keep mentioning it but the news is still trying to scare you about the increasing cases and deaths of flu.  It is actually decreasing.


“DALLAS (CBSDFW.COM) Jan20, 2014- The flu continues to be deadly across the DFW area, and now local health officials are concerned that the height of the epidemic has yet to hit North Texas. The virus is already to blame for 48 area deaths, with 35 of those being in Dallas County.  January is normally the peak of flu season. But the Dallas County Health and Human Services Department is now thinking that DFW could not reach the peak until the end of February.”

WHAT?  See the graphs at my web site… the cases are decreasing.


 The Flu in Dallas County is Killing About As Many People As It Usually Does. Twenty-one deaths (17 in Dallas County) seems like a lot, but it's about on par with previous flu seasons, which annually claim around 25,000 lives nationwide. The difference this go-round -- and the reason you're seeing so many death-tallying news reports -- is that this is the first year Dallas County has tracked adult flu deaths.

 Right!   This is a typical year and sadly some will die…  every year from flu, cancer and car wrecks.


Dallas county flu cases report.  It is on the decline.

 You will also see people wearing masks in photographs to keep them from catching the flu.  It will absolutely not help.  People who already have the flu might wear masks to keep the germs from going out into the air when they cough, but it will not prevent you from catching the flu. 




Falls injures millions of people every year.   Falls are the number one cause of death in the home.  Children have to fall from a fair distance to cause damage.  When the toddler pulls up on the couch and falls down it is not far enough to cause harm.  They have to fall 3-4 feet or higher to cause internal damage….. about the height of the grocery cart handle.  There are children injured from falls from grocery carts every 22 minutes, 24,000 at year, bad enough to go to the ER.  Most of the children are under 5 years old.  See a 19-year-old worker at an Alaska Home Depot catch a falling infant from a cart:


Be vigilant and keep them buckled in the carts. 


Medical studies are hard to evaluate and results are manipulated to show improvement
when there really is very little difference.

Here is a study showing less allergy symptoms from a certain therapy. 
They reported 40% less with their medication but when you really look at the
decrease, it is only 12% difference in allergy symptoms. 
They reported 40% less by comparing it to the amount of
allergy symptoms compared to the starting baseline amount of symptoms.
They will even use that to report a statisticly significant improvement.
Most people would not notice a big difference in their allergies and
would not want to pay $200 for that medication.
Oh that's right, you only pay $15 copay!!! It still costs us all since we
pay higher health insurance or higher taxes for Medicaid. 
People will think it is a great medication since the news reports the 40%.
Even the doctor who does not look at the actual numbers will be
influenced to prescribe it by the report or by the drug salesman.
(or saleswoman.... since he won't be thinking about the medication.) 

I had to order the full medical study that had the actual data.  
If you only read the abstract, you may not be able to tell what is
really significant or not.

Remember when searching medical information, stay with main sites
like WebMD or other oficial sites.  Or use Google Scholar search:

Dr. Roger Knapp MD

p.s.  The olympics are starting soon.  Shaun White should be awesome
on the snowboard.  He was born with severe heart defect called
Tetralogy of Fallot and had two heart surgeries the first year.  Amazing huh?


Where you deliver is more important than who delivers them.  91 % are delivered in hospitals by MDs, 8% by midwives in hospitals, and 1 % outside the hospital.

For every 10,000 deliveries, Neonatal mortality (does not include brain damaged) are:

3  … midwives in hospital

6  … midwives in birthing centers

13 … midwives at home

18 …  others at home


 Mortality numbers for America are misleading since it includes premes that are not going to make it, and genetic mistakes that are not viable.  America reports all things and many countries do not report certain problems.   Kind of like the video of the 5 rings at the 2014 Sochi Olympic opening ceremony… what Russia saw on TV was different than reality. 

 Roger Knapp MD

 Get postage stamps with your kid’s picture on it!


 Also… getting wax out of ears can be frustrating.   I remove wax every day.  Those of us in the medical profession have a lot of problems since our stethoscope keeps the wax down in and not come out.  Kids will put their fingers into their ears and push it in.   Or the parents use a Q tip… of course not you all!  You can use a Bobby pin with the smooth loop end and hook the wax at the entrance of the canal and pull it toward you.   You can irrigate the wax out with warm water (do not use cold) by putting some Debrox or hydrogen peroxide in the ear canal and 20 min later wash it out with a bulb syringe (the one they gave you for the babies nose… it is actually for the ear) or large syringe or even a turkey basting syringe.  Fill it full with warm water and put the tip at the entrance of the canal and squirt forcefully down the canal.  It is not painful but feels weird and you hear a roaring sound.  Keep the tip at the entrance and not down the canal.  Good luck!


At last there was an article talking about what I have been preaching for years. ….

Feeding Preschool Children

 “The academy recommends that child-care providers eat with children in order to act as models of healthy eating. In addition, children should not be pressured to take another bite or finish a serving before they're offered another food or activity.

 If a child doesn't want to eat, child-care providers shouldn't urge them to eat out of concern that the youngster may get hungry before the next meal.

 If a child doesn't eat at one meal, he'll compensate for it over a 24-hour period. Making kids eat when they're not hungry is probably the worst thing you can do.”

 The parent’s job is to provide a proper diet, it is the child’s job is to eat enough to grow, and if the child does not eat enough, then it is the doctor’s job to find out what is wrong!   It is NOT the parent’s job to make them eat.  That will not fix what is wrong anyway.  Don’t let the child hold out for junk food and you give them anything they are willing to eat.   Then they are picking their diet.  Leave it up to them and they would eat candy all day, watch TV all day and not go to school.  See “picky eater” at my web site. 

 Or you can make the healthy food taste better.  Seinfeld’s wife wrote a book called Deceptively Delicious and it help can help.  Just get creative and find a way to make the proper foods taste better.  You and I doctor every food and drink.  We put something on our meat, salad, and even a lemon in our water.  It is OK to put flavors in the milk. 

 Here is one study where they added flavor to the vegetable and eventually the kids ate it plain.

Flavor-pairing may teach kids to like vegetables

 Your children are trapped in your restaurant.  If you do not like a certain vegetable, you don’t cook it.  No one is making you eat the food you hate.  Making your kids try “one more spoon full” is not going to make them like it.  It is OK to have them try a new food.  So if you know they hate that certain food you are having that day, give them raw carrot or broccoli and dip into ranch dressing or cheese.  You don’t have to be a short order cook but give them something they like.  Get creative.  Give them pickled raw vegetables if they like sour stuff or dehydrated peas with BBQ powder on them.  Try different ways.

 Difference between broccoli and buggers… your kids eat their buggers… what does that say about their taste in food.

 Roger Knapp MD

 Also …. I don’t recommend cough cold meds that have expectorants in them.  Very popular is the brand Mucinex with Guaifenesin in it.  It tastes really bad, and there are studies showing that placebo or a drinking plenty of fluids did the same.  If you think it helps you then use it but be sure on the amount you are takeing because there have been deaths from over dosing it.


A frequent question is when is my child not contagious and can go back to daycare or school.  The standard answer is 24 without fever.   Since most fevers are more frequent in the evening and night, then if they can go all night after 5 PM without fever and feels good in the morning, then they go back.  But most viruses are shed for a week.   And you are most contagious the 12 hours before symptoms.  So most others in their class room have already been exposed and it is really too late.  We quarantined Chicken Pox for a hundred years and we still had Chicken Pox.  By the time we noticed they were ill, too late.  They already spread the disease.  So after the third day or 24 hours after the fever is gone is a good rule.  Since they usually have more fever in the night and less in the morning, just because they do not have fever in the morning does not mean it is over.   That is why they say 24 hours no fever since the fever may be back again that night.  Some illnesses like throat infections are not as contagious through the air and as long as they don’t share drinks, it is not that spreadable.  Flu and coughing illnesses are spread more rapidly and all illnesses are spread through the hands. 

 Roger Knapp MD

 p.s.  You can order temporary tattoos with your name and phone number to put on your smaller kid’s arm when you are on vacation.  See: http://www.tottoos.org/  Just in case they get misplaced.  Silly since I know you keep up with them but things happen.



You may have heard of the dramatic rescue of the baby that stopped breathing In the traffic jam and a

woman gave CPR to resuscitate it.


  If I have talked with you in the newborn nursery, term healthy babies do not choke on liquids.  It is later

 they choke on meat or toy. But it is important to keep their head from falling forward in the car seat,

 swing or carrier.   The head should stay in line with the body.  See my web site  on car seats:


Premes like the one in the news article are especially prone to trouble because of their small body and

large head.   Even term babies can sometimes have trouble and especially if they are carried in a sling

like this one:

 The have been recalled because of deaths in them.

 Premes are supposed to be tested for low oxygen while in a car seat in the hospital before discharge.

We should test all babies but it is uncommon in term infants.  It is simple to put a receiving blanket

behind the baby’s back to allow the head to stay in line with the body during the first 6 months. 

 Roger Knapp MD



Study came out that white noise machines made for babies that were played at loudest setting could damage a baby's hearing.

Well no duh.  Any parent with common sense would not play an extremely loud thing by their baby.  Use your parent
intuition and keep them soft.  Same with too much sun or too much of anything. 

Roger Knapp MD

p.s.   I decided to start a Facebook page with some of thse email topics and other comments about pediatric news.

Link is at my web site.


Now this was an interesting article.  You can become allergic to red meat (OMG NO!) after being bit by a lone star tick. Mostly Southeastern America. Forget Lyme disease…. I can’t live without my red meat.   It is an allergy to what is called an alpha-gal allergy.  See article Meat Allergy.  A tick has to be on you for more than 24 hours to give you Lyme disease…. Not sure how long it takes to get this alpha-gal allergy.  Did you know there is a tick paralysis?   Sudden onset of rapidly progressing paralysis and if you remove the tick it all goes away.  Weird huh?

 Roger Knapp MD

 If you are going to Disney World, Disney World Magic Guide is a good app.  Also the best show is the Hoop-de-do Review.   Fabulous show and meal for the whole family but go to the early show if you have young ones.  Reservations go quick so make them far in advance.  They now have new “tickets” called magic bands that are around your wrist.  It works pretty well.  You can make fast passes months ahead of time for rides and still get regular fast passes in the park when there.  Best to go when school in session for grade school ages when it is cooler and low attendance.  Chart of attendance.


Weather should be getting warmer and we will have more outside activities and injuries.   Remember we talked in the past about wrapping injuries in tape before ice.  Teeth are a common injury in children.  If knocked out completely, push a permanent tooth back into the socket in the correct direction.   Only handle the tooth by the crown and not be the root.  If you cannot  re-implant the tooth back into the socket, save the tooth in Saliva in the corner of your cheek and gum.  Or in milk in a bag and put on ice.  If filthy, rinse briefly with water but only for seconds.  Water for a long time is harmful.  There are also tooth transport media that a can be purchased.   It is preferred to have the tooth implanted inside 2 hours so go now!  DO NOT SAVE OR RE-IMPLANT BABY (DECIDUOUS) TEETH.  It is worse to put them back in.   Re-implant permanent teeth only.


 Roger Knapp MD

p.s.  Teething tablets have been called off the market.   Never did recommend them.  BAD!

 p.ss. This week is time to put pre-emergents on your lawn to prevent weeds next Fall.


We do see a lot of fevers in the spring during April, May, & June. There are several viruses that cause it. Have you heard of Spring Fever? The kids would run fever and be tired in the spring and not want to do their school work and through the years it was transferred to “I don’t care about school in the spring” but it started from the fevers in the spring. Just like Hay Fever. Hay does n...ot cause fever but the viral fever in the spring when the hay grew and they blamed the fevers on the hay growing. Then through the years that term was transferred to allergies in the spring and we say we have hay fever. These terms started from the fevers we see in the spring. The children will run fever for 2-3 days and act normal. No other symptoms but fever. If they are over 2 and act normal, no sore or red throat, and no other symptoms, then give it a few days.

 Roger Knapp MD

 Also there is a large decrease in births from 15-19 yr old girls.... nearly 30%.   Still too many though: around 3% of girls.  It also varies with race.  See CDC:




A recent study found a correlation between how much parents monitor the television and video game habits of their children and their children’s performance in school, their relationships with peers, their weight and their behavior.   Other studies have shown an effect on smoking and younger age of sexual activity.  Pediatricians recommend only around 2 hours of screen time.    The problem is the parent setting the example.  We parents need to watch TV, i-pad and texting less also.  We clean up our language when our children are 2 yr old.   We start to look into the mirror and wonder what example we are setting for our children.  Our children are good for us because they make us behave better.   When parents start to restrict their children’s screen time, they will go through “withdrawal” like a drug addict and throw fits but they will eventually act better.   The study shows a correlation between better kids and how much the parent is involved with their lives and activities.  I think the TV-video games do affect them but the true situation is the parent being a good parent.  Play more board games and less screen time.



It is interesting the things sold for adults or children’s symptoms can be just as good as grandma’s advice.  Grandma would put sweet oil into the ears for ear pain.  I recommend warm olive oil.  They sell over the counter and prescription pain drops for ears…. They put numbing medicine in the oil.  It cannot make contact with the ear drum because it is in oil and controlled studies showed they work about as well as plain olive oil.  The homeopathic drops like Otikon Otic Solution (Healthy-On Ltd, Petach-Tikva, Israel), a naturopathic herbal extract (containing Allium sativum, Verbascum thapsus, Calendula flores, and Hypericum perforatum in olive oil) worked the same as plain olive oil in medical studies.  (Don’t believe everything you read on the net….. use Google Scholar search that I have told you about many times.)

 I do not recommend expectorants (Guaifenesin) that are in many cough meds (like Mucinex) because it tastes terrible and studies showed drinking some water did just as good a job at loosening mucous.  Expectorants increase mucous in order to loosen it…. Why would you want more mucous!!!  So the old grandma advice to drink plenty of fluids and take pain medicine was not so bad for a cold.  Medical studies even showed that chicken soup helped kids get over colds a little quicker… strange!.  Sometimes simple old fasion stuff works as well as expensive stuff people want to sell you in stores or on the net.  Research information in true medical studies … not just “salesmen” on the internet.  I even had a vacumme salesperson try to sell an expensive vacume cleaner because it killed the germs in my carpet and there would be less illnesses in our grandkids. Most germs are from hands, school, and shopping carts.    See Google "Scholar" search for true information. :  http://www.google.com/intl/en/about/products/

 Dr.  Knapp MD



A study came out and reported in the news concerning 1 in 20 diagnoses were wrong.  The doctor did not do research on his own.  He looked at two previous researches on lung cancer and colon cancer only.  They looked at cancer that was diagnosed and found that 5% of the patients had seen the doctor for cough, stomach ache or other symptoms and were not diagnosed on the first visit.  Doctors cannot run xrays and scans on everyone who comes in with cough or stomach pains.  We have watch dogs looking at how many tests we run and disciplining overutilization and cost over-run.  This study did not look at the thousands of other illnesses that are diagnosed every day.  But the news loves to scare and dramatize things.  I do have parents worried when their child complains about leg pains (growing pains), stomach aches, headaches and other complaints.  Their body hurts just like our body hurts every day.  Watch for progression.  For example, a child complaints about stomach aches most days…. Especially during grade school years.  But if they start having diarrhea, weight loss, and even blood in their stools, then there is concern.  We would not want to do a colonoscopy with anesthesia for every stomach ache.  Se we watch for the severity of symptoms, is there worsening symptoms, and our experience with the timing, age, and location of symptoms.   Our system is not perfect and involves human judgment and sometimes errors….But it is as good as it gets.  Just use common sense when a doctor tells you something, don’t be afraid to ask questions, return to see your doctor or get a second opinion if symptoms are not getting better as they should.


Probiotics have been debated for decades.  Half of the medical studies show they help various medical conditions and help your digestion and immune system.   But half the studies show they do not help.  It does not hurt to try them since they will not harm you.   Many products are not good since the healthy bacteria are killed by processing and by your stomach acids.  If the product says it has a billion units before manufacturing… then they do not promise how many life probiotics you are actually getting.  So most tablets and many capsules do not have may viable probiotic bacteria in them.  The products should promise how many their product supplies to your body.  The better products are refrigerated to keep them alive.  Also it might be a good idea to mix them in milk or yogurt to help them pass through the stomach acids safely. 

 Here is a good brand I recommend.  Kids Raw Probiotics by Garden of Life. 
It is good for infants 3 months and older.

The Sunflower Shop has them as well as many health food stores.

 Dr. Roger Knapp MD

Also a study was reported recently how starting high dose antidepressants can double the incidence of suicide in depressed Teenagers. That starting low dose and working up on the dose did not increase it.  Other recent studies showed no increase in suicide with antidepressants in teens.  Treating them is better than leaving them depressed and the benefits definitely outweigh the risks. Always be vigilant in your care of depressed teens. 



The MERS virus and illness has been in the news lately.   With two imported cases from Saudi Arabia.  These are people who contacted the germ there and came here ill.  Neither one has died.  It is a virus similar to the SARS virus back in 2003 that was apparently eliminated.  They do not know where the virus is from or how it is acquired.  Another human can catch it from a sick person with a lot of saliva or body fluid exchange.  So health workers and family members are at risk.  People in the town, or building, or even ER waiting room are not at risk.  Just like West Nile, many cases are probably mild and never diagnosed.  So the 25 % death rate is only based on the very ill who are hospitalized.  It most likely is far less than that % since many are not diagnosed.  It is a bad virus and the CDC needs to find out how people catch it.  They know it is in camels and bats in Saudi Arabia but not sure how it gets to humans.  Hopefully they will figure it out and isolate it.

See : http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML


Summer is here and swimming a lot is a way to stay cool.   Most kids do not get swimmer’s ear Some are prone to getting it.  You can tell it is swimmer’s ear because moving the outer ear will cause pain.  It is more often in the older kids who spend a lot of time below water.  Also it is more common in Lakes and ocean than swimming pools.  The ENT doctors found out it was not as much the wetness as the water turned the ear canal from normal acid state to an alkaline state.  So to prevent swimmer’s ear you need to put a solution of ½ alcohol and ½ vinegar after they swim.  You can also put olive oil in their ear before they swim.  When treating swimmer’s ear, put a few drops of hydrogen peroxide in the canal and let it bubble.  Then put the medicated drops in.  This will kill some germs and flush pus out of the canal. 

 By the way, we stopped recommending hydrogen peroxide on cuts and wounds.  It kills bacteria but also kills the cells that are trying to heal the injury.  Use soap and water to clean and then put antibiotic creams on it.

 Roger Knapp MD


 p.s. There is not much difference between SPF ratings of sunscreen.  The SPF is a measure of time it would take to sunburn if you were not wearing any as opposed to the time it would take to burn with sunscreen.  It is logical for someone to think a 30 is twice as good as a 15 sunscreen.  NOT!  A SPF of 15 blocks 94% of rays, a 30 blocks 97%, and a 45 blocks 98% of the rays.  I recommend at least a 20 SPF since most people do not put a think enough layer on their skin.  Also use a product that blocks both UVA and UVB.  And wear swim shirts!


With the advent of stronger neodymium-iron-boron magnets and their inclusion as part of children’s toys, jewelry, and desk toys, there has been an increased in the number of cases of children swallowing magnets resulting in serious morbidity and in rare cases, mortality. In 2010, shortly after smaller, more powerful magnets, often sold in multiples, were introduced to the marketplace.  Multiple magnets pose the unique danger of being able to attract each other through different loops of bowel, arresting their movement, and potentially causing mural pressure necrosis and perforation. Cases have been recorded that required the surgical removal of magnets because of intraabdominal sepsis or suspected imminent bowel perforation.  Parents should be careful of any loose magnets and be aware they do pose a hazard.


Exercise!   OH NO!  Yes we need to do more.   Me too.

In 1998 of the whole ADULT population, 14% were getting enough aerobic and muscle strengthening exercise and that increased to 20% by 2012.  Still not very high.  That is all sexes, races and economic groups together.  Males in 2012 the number was 24% and female 17%.  The economic groups were 11% in the lowest quarter and 30% in the highest quarter of income groups. 

 In the adults who had the recommended aerobic exercise (without muscle strengthening), the numbers in 1998 were 40% and it increased to 50% in 2012.  Again it was higher in males and in the higher income brackets.  The elderly were doing fairly well.  It was 60% in the 20yr olds and 28% in the 75 yr olds.  Not bad. 

  National Physical Activity Plan Alliance (NPAPA), a non-profit organization released their 2014 U.S. Report Card on Physical Activity for Children and Youth.  The Physical Activity Guidelines recommend that children between the ages of 6 and 15 get at least 60 minutes of moderate to vigorous physical activity five days of the week. However, the report found that overall, only around 25 percent are meeting this recommendation.  When looking at certain age groups, it seemed that younger kids were better.  It revealed that 42% of children between the ages of 6 and 11 met this requirement, while only 8% of children between the ages of 12 and 15 met the recommendation.

 So we adults need to set the example for our children.  Kids are good for us because we start looking in the mirror and asking what example are we setting for our children.

 I'd rather see a sermon than hear one any day;
I'd rather one should walk with me than merely tell the way.
The eye's a better pupil and more willing than the ear,
Fine counsel is confusing, but example's always clear;
And the best of all preachers are the men who live their creeds,
For to see good put in action is what everybody needs.
I soon can learn to do it if you'll let me see it done;
I can watch your hands in action, but your tongue too fast may run.
And the lecture you deliver may be very wise and true,
But I'd rather get my lessons by observing what you do;
For I might misunderstand you and the high advice you give,
But there's no misunderstanding how you act and how you live.

By Edgar Guest

 Roger Knapp MD


I have talked about West Nile and how it is more common than reported.  Also very mild in children… read my article at my web site. Same with MERS illness in Saudi Arabia.  Many mild cases go undiagnosed.  And in my article on West Nile I mention Dengue Fever from viruses that are moving up from South and Central America.  Now the news is mentioning a similar but not as deadly virus from mosquitoes called Chikungunya.  Chikungunya was first described during an outbreak in southern Tanzania in 1952. The name ‘chikungunya’ derives from a word in the Kimakonde language, meaning "to become contorted" and describes the stooped appearance of sufferers with joint pain. It causes fever, severe joint pain, muscle pain, headache, nausea, fatigue and rash, It has been rapidly spreading in the Caribbean with 135,000 new cases in 6 months.  Now it has been detected in the U.S. The Providence Journal reports that Rhode Island public health officials have confirmed the first two cases of chikungunya in travelers who had recently been to the Dominican Republic. They returned on May 27 and 29, and other possible cases are being investigated.  There have not been new cases of people who acquired it here in America... yet.


See: World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC)


Most patients recover fully, but in some cases joint pain may persist for several months or even years. Just one more illness to not be concerned about but try to not have mosquito bites.


Roger Knapp MD


p.s.  A bionic pancreas designed to take over blood sugar control in people with type 1 diabetes got patients to near normal levels and prevented dangerous drops better than standard therapy in two demanding five-day trials. Adults having the device roamed the Boston area eating and exercising. They fared best with the bionic pancreas that checked their blood every five minutes and administered insulin and another hormone as needed. The pancreas was tested in 20 adults and 32 adolescents.  All had better blood sugar control with the device than with their normal care.  I would rather have stem cells make us another matched pancreas instead of a machine that has to be refilled and batteries recharged.


With states starting to legalize marijuana, it is appropriate to mention studies showing that teenagers’ rapidly developing brains put them at high risk of harm from marijuana use.


Scientists at the National Institute on Drug Abuse (NIDA), note that active brain development during adolescence leaves the brain especially vulnerable to exposure to environmental chemicals such as tetrahydrocannabinol, the active ingredient in marijuana. This may help explain why teenagers are particularly prone to suffer adverse effects from regular and early use of marijuana. The effects include greater potential for addiction than adults; impaired critical thinking and memory that persists for days after use; poor school performance; increased risk of dropping out; and lower achievement later in life.


As compared to adults, teenagers who use marijuana are 2 to 4 times more likely to develop symptoms of dependence within 2 years of starting the drug.


A long-term study in 2012 showed that regular marijuana use in early adolescence led to neuropsychologic decline, including lowered IQ and cognitive impairment. The effects persisted into adulthood and quitting the drug didn’t fully reverse them. Adults who smoked marijuana regularly as teenagers have fewer neural connections in important areas of the brain that involve functions such as learning and memory, executive functions (including control of inhibitions), and processing of habits and routines.

 Dr. Roger Knapp MD


p.s. Did you hear about the trap-jaw ants coming up from Central America and now along the Gulf Coast?  They can flip 3-4 inches using their jaws.  Google their images or YouTube videos… amazing.  The fire ant still hurts more.  Ants and spiders leave a small blister where the mosquito is just a red round bump.  So is a chigger.  Chiggers bite around the socks, groin, and arm pits.  Mosquitos bite exposed areas.  Use insect repellants past 6 months old.


Medications can cause methemaglobinemia. Methemaglobinemia is a change in the hemoglobin molecule of the red blood cell causing it to not deliver oxygen to the body.    Signs and symptoms of methemoglobinemia (methemoglobin >1%) include shortness of breath, cyanosis, mental status changes (~50%), headache, fatigue, exercise intolerance, dizziness and loss of consciousness.  Severe methemoglobinemia >50% patients have irregular heartbeats, seizures, coma and death (>70%).

 Medications that can cause this are: antibiotics (trimethoprim, sulfonamides and dapsone), local anesthetics (especially articaine and prilocaine), and others such as aniline dyes, metoclopramide, chlorates and bromates. Ingestion of compounds containing nitrates such as bismuth nitrate can also cause methemoglobinemia.  Benzocaine applied to the gums or throat (as commonly used in baby teething gels).



 So use teething gels sparingly and infrequently like once or twice a day.   I do not recommend teething tablets.  Just use Tylenol and if the infant is in a lot of pain, it may not be the teeth causing all the crying.

 See: Warnings from FDA on Teething Tablets.


Every summer I see advertisements about swimming lessons for infants less than one year old.  There was an episode on NBC Friday night News on ISR for infants and teach them to float on their backs and “swim” over to the edge.  They interviewed the instructor of one of these programs working 10 minutes a day for 2-3 weeks at $80 a week.  Then the instructor said “this does not replace constant adult supervision of the child”.  The classes stress this does not drown proof your child and no study has shown that claim.  The American Academy of Pediatrics does not recommend this and neither do I.  Complications are swallowing too much water and convulsions, chlorine damage to the lung causing asthma, parents become less vigil about watching the infants around pools, the infant is less afraid of water, and infections from dirty diapers by cryptosporidium.  And if you are going to be closely and constantly watching the baby, why risk it since it is our responsibility to make sure our kids do not drown.  I do recommend swim lessons for 3-4 yrs and older.   Studies do show they decrease the number of drownings. 

 Roger Knapp MD

 Also watch out for babies getting low body temperature (hypothermia).  That is why their lessons are only 10 minutes and they are usually in a warmer pool.  Plus sunscreen is safe at 4-6 months old and even better to use swim shirts.  


Ebola cases in Africa have increased from 82 to 1200 since Feb 2014.  It has been hypothesized that the first patient becomes infected through contact with an infected animal. Humans transmit it to others by direct contact with the blood or secretions of an infected person, or exposure to objects (such as needles) that have been contaminated with infected secretions and not sterilized properly.  It spreads through families and friends by coming in close contact with infectious secretions when caring for ill persons or activities that exchange body fluids.  Exposure can occur in health care settings where hospital staff are not wearing appropriate protective equipment, such as masks, gowns, and gloves.  Proper cleaning and disposal of instruments, such as needles and syringes, must be sterilized before being used again or the transmission will continue and amplify into an outbreak.  In Africa, the difficulties in containing the outbreak include the multiple locations across country borders, inadequate equipment given to medical personnel, funeral practices, and public reluctance to follow preventive practices, including "freeing" suspected Ebola patients from isolation, and suspicion that the disease is caused by witchcraft, or that doctors are killing patients.  Just like most illnesses, there are many cases of mild or subclinical illnesses that go unreported, especially in Africa where medical care is not readily available.  The death rate has been estimated at 55-75% but I bet it is more like 20% or less.  It is still a bad disease and we pray it does not make it to America where we have not had one case yet. 

 Roger Knapp MD

I played golf in Arizona and here is a picture of a cactus near the T box with golf ball holes all in it. 

Also here is a Dad that put his toddler in his car seat and strapped it into the wheel chair to move him around in the airport.  Good idea.



Breast development can occur at any age.  Infants between 1-6 weeks old can develop breasts from the mother’s hormones in the breast milk.  This can occur in males as well as females.  The can actually produce milk (old term it was called witch’s milk)  and they can get breast infections…. Watch for redness of the breast. 

 The females can grow breasts starting 9-12 months old.  It is called Premature Thelarche and most will go away with time.   Sometimes it occurs after 2 yrs. old and they may not go away.  There are no other signs of puberty such as pubic hair or accelerated growth. 

 Girls can go through premature puberty in childhood (7yr old or younger) but is rare.  Most will start developing at 9 with rare girls at 8 yrs. old. 

 Then men can get breasts as they get older and can get breast cancer.

 Certain “natural” products can cause breast development in young boys. Several studies have shown Lavender and tea tree essential oils have been shown to cause gynecomastia in boys.  Many people are using essential oils these days and it is only a different way to put drugs and products into our body.  Either you swallow it, put them on your skin, or use suppositories, it is still in your blood and body.  Be careful what we put into our system.  Parents get concerned about mercury in vaccines and then turn around and put stuff into their kids when they have no idea what is in them. 


Skin products can also contain lead and mercury:


 Roger Knapp MD

 Why do you not want to let Elsa from Frozen hold your balloon?

She might  “Let it go…. Let it go “


Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is an excessive thickening of the heart muscle in the ventricular septum between the two ventricles of the heart.  This is genetic with half inherited from family and half just happens sporadically. It occurs 1 in every 500 persons and in both sexes and all races.  Most will have no symptoms but some can have problems.  It can cause chest pain, shortness of breath especially with exercise, and rarely sudden death.  We screen teenagers with a sports ECG around 12-14 yrs old trying to detect it.  Our physical only picks up 10% but the ECG can pick up 80-90% of them.  Cooks does the ECG for $25 which is a great bargain.  Some high schools are actually starting to require the test for athletes.

 See: http://www.nlm.nih.gov/medlineplus/ency/article/000192.htm

and: http://www.cincinnatichildrens.org/service/c/cardiomyopathy/types/hypertrophic-cardiomyopathy

  Here is a video on this heart condition.


 Dr. Roger Knapp MD


"Our research has shown that permanent damage to the tooth enamel will occur within the first 30 seconds of high acidity coming into contact with the teeth. This is an important finding and it suggests that such drinks high acidity levels in soft drinks, fruit juice and sports beverages pose a threat to youngsters' teeth are best avoided," study corresponding author Dr. Sarbin Ranjitkar, of the Craniofacial Biology Research Group at the University of Adelaide in Australia, said in a university news release.  "If high acidity drinks are consumed, it is not simply a matter of having a child clean their teeth an hour or 30 minutes later and hoping they'll be OK -- the damage is already done," he added.  The findings were recently published in the Journal of Dentistry.


Triclosan was in the news recently with concerns about it affecting the endocrine system of our body. The research is borderline and controversial with some suggesting it does and some suggesting it does not.  I am not convinced either way but using toothpaste without it will not greatly change the effectiveness of the toothpaste.  It was mostly the Colgate brands that contained it.

 The pH and source and availability of nutrients are the critical factors in the development of dental caries. Bacteria digest carbohydrates and produce acid that causes demineralization of the tooth enamel.  The demineralization phases are followed by periods of alkalinization, which help restore the integrity of the enamel. Dental caries occurs when the acidification phases outweigh alkalization phases.  The more frequent sugar and even food is put into the mouth, the more likely cavities occur.  We do not recommend parents put the infant to bed with bottles, sippy cups or breasts with the milk pooling around their mouth.  Frequent juice or food in the older children during the day will cause cavities… it is the frequency all day long.

 Some research is looking into finding bacteria that produce more alkaline substances rather than acidic ones thereby decreasing dental caries.

 So brush teeth frequently with toothpaste approved by the American  Dental Association (“ADA approved” is on the package).  After 2 yrs. old, a toothpaste that has flouride, bacteria killing properties, and an alkaline pH is preferred.  Arm and Hammer and Aquafresh toothpaste might be a better choice but there are others.    

 Gum Crayola for kids        no fluoride   pH<5

Oragel for kids                    no fluoride   <5

Colgate for kids                   fluoride         <5

Crest for kids                                   fluoride         <5

Toms for kids                                   fluoride         <5

Aquafresh for kids             fluoride         8

Arm&Hammer                                fluoride         8         


At 1-2 years old use non fluoride toothpaste since they swallow it and gives them too much fluoride.  The difference between adult and kids toothpaste is flavor and cute packaging. So 3 and older could use either one.

 What time of the day should you go to the dentist?   At tooth-hurty. Lol

 Roger Knapp MD


This is about the severe respiratory illness Enterovirus 68.  The most common sense article I have found on the internet is this one.


 Enteroviruses are a group of viruses that include the polioviruses (viruses that cause polio) along with other types of viruses called coxsackieviruses and echoviruses. Rhinoviruses (viruses that cause the common cold) are the most common viruses infecting humans. The second most common viruses infecting humans are the non-polio enteroviruses (all the members of this virus group excluding the polio-causing viruses).

 While the polioviruses have been eliminated in the Western Hemisphere, there are 62 different non-polio enteroviruses that are known to cause disease in humans. Anyone can be infected by non-polio enteroviruses, which are believed to cause 10-15 million illnesses per year in the U.S. alone. Infants, children, and adolescents are more likely than adults to develop an illness from enteroviral infection since they are less likely to have immunity to these viruses from previous exposures.

 Enteroviruses are associated with various clinical symptoms, including mild respiratory illness, febrile rash illness, and neurologic illness, such as aseptic meningitis and encephalitis. Enteroviruses can also cause flu-like symptoms, rash, or in rare cases, inflammation of the heart or brain. Serious complications are more common in infants, those with major health problems, and those with weakened immune systems. The condition known as hand foot and mouth disease is also caused by some of the non-polio enteroviruses.

 EV-D68, however, primarily causes respiratory illness, although the full spectrum of disease remains unclear because it is identified at only a few limited number of laboratories in the United States.  So EV-D68 is not frequently identified.

 Enterovirus infections, including EV-D68, are not reportable.  Since the original isolation of EV-D68 in California in 1962, it has been reported rarely in the United States.  There were reports received during 2009–2013 with clusters of respiratory illness during 2009–2010.

Most people infected with an enterovirus will not become ill and will have no symptoms of the infection. Others will develop a respiratory illness similar to the common cold. Because infections with non-polio enteroviruses are most common during the summer and fall and are diagnosed as a "summer cold".  

 I have mentioned that many cases of severe diseases are mild and never get diagnosed or reported.  See my articles on West Nile and Ebola.  In 1920 we had polio.  Did you know 90% of polio infections cause no symptoms at all.  Paralysis occured in only one in 1000 cases in children and adults one in 75 cases.  So there are many cases of Enterovirus 68 that are not diagnosed.  Then when some cases are diagnosed, the doctors hear about it and start running tests for it. 

 This current strain has caused children in at least 11 states to experience sudden difficulty in breathing.  From Aug. 18 to Wednesday afternoon, Children's Hospital Colorado had treated more than 1,750 children for severe respiratory illness in its emergency locations.  Of these, 156 were admitted to the hospital.  72% of the severe cases had asthma. 

 There have always been cases of respiratory disease outbreaks.  Remember last year the news went crazy about the Middle East Respiratory Syndrome MERS http://www.cdc.gov/coronavirus/mers/ until Ebola came along.  There was a case of MERS this year in May here in America. And before that there was SARS – Severe acute respiratory syndrome http://www.cdc.gov/sars/. They were coronaviruses.  We normally average yearly 100 children deaths from flu in America but we had 282 in 2009 with the new strain H1N1.  There were 1700 cases of West Nile in Texas in 2012 but last year there were 180.   There is a large increase in many illnesses because of a new strain that no one has immunity to or there are a lot of people that are not immune to the disease in the community.  That is why we have outbreaks of Measles when many kids do not get vaccinated. 

 There are a large number of cases this year of EV68 because there are a lot of children who have not yet had this illness and those with health issues are hit hardest.  That is why we recommend flu vaccines for children but especially for those with asthma and other debilitating diseases.  That is why more children are getting this Enterovirus disease since older teens and adults are immune to it from years ago.

 Watch for a cold and cough that causes the child to have severe difficulty breathing. There is no cure except giving oxygen and supportive care.

 It is spread in the same ways as the winter flu and for precautions against it,  use similar techniques … like hand washing. Most illness are contagious right before symptoms start so using good precautions every day is wise.

 It is a bad chest cold and pray our kids do not get it or at least have a mild case.  It is heart breaking when a child is ill and horrible when they die.  We can’t prevent all illness and death.  All we can do is use the normal illness precautions and pray.

 Enterovirus 68




Croup.   It is a chest cold this time of year.  The children have a cough that makes a honk seal-bark sound. It hurts the trachea windpipe below the vocal cords when they cough and hurts the throat somewhat when they swallow.  Strep throat hardly ever has a cough with it.  This is a viral chest cold and will usually have low fever and achiness with it.   Older kids may not have a croup sound to the cough, but they will have pain on coughing and hoarseness to the voice.  Some children will have trouble breathing with what is called stridor causing noisy hoarse breathing and frequently retractions of the chest.  It is helped by humidity &/or cold air.  That is why many children who are in respiratory distress when brought into the ER have greatly improved with the moist cold night air.  Parents can run a cool mist humidifier in their room, put them in the restroom and steam it up, sit outside with them, or even put their head in the refrigerator to breath the cold air.  If they continue to have difficulty breathing, you can take them into the ER for a certain breathing treatment that is different than the one for asthma  and wheezing.   If less than 3 years old, bring them into the doctor’s office and get some steroids.  That opens up their airways so they do not have to go into the ER or even in the hospital with respiratory distress.  The most common complication is an ear infection in smaller infants. 

 Roger Knapp MD


The head of the World Health Organization talked about Ebola:

 Yes, Ebola is a scary infectious disease. But the first thing you should know is that it's not very contagious -- the virus isn't spread through the air via coughs or sneezes like the common cold. It's spread through frequent contact with bodily fluids and can be spread only by someone who is showing symptoms.

So if they're not feeling sick ...

Many viruses can hide in the body and spread from person to person without causing any symptoms in the people it infects. Ebola isn't like that.

"Ebola doesn't spread before someone gets sick," Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said Tuesday. "Ebola does not spread ... from someone who doesn't have fever and other symptoms."

Symptoms generally occur abruptly eight to 10 days after infection, though that period can range from two to 21 days.

As people with the Ebola virus become sicker, they become more infectious, experts say. The virus can also spread through bodily fluids after the patient dies.

And by 'bodily fluids,' you mean?

Blood, sweat, feces, vomit, semen and spit. Basically any kind of fluid that comes from the body. People in West Africa are avoiding hugs and handshakes because the virus can be spread through the sweat on someone's hand.

 So we are trusting someone who says it can’t be spread by cough or sneeze.  But it can be spread by spit and sweat.  I kind of thought those were similar saliva contamination.  I am still not convinced that it is not contagious until there is fever.  HIV is contagious 5 years before symptoms.  I cannot find any reported medical studies that prove the time patients are contagious.  Who knows! 

 I still think we do not know how many people in Africa get Ebola and not die.  Probably there in Africa it is high but with modern therapy it probably is less.  Mortality in Africa outbreaks have ranged from 37% to 80%.  It still is a bad infection and we don’t want it here.  I pray that none of the people exposed here come down with it.

 I wonder how many healthcare workers, who are over cautious and still getting infections, are acquiring it from foods.  Their food handling sanitation is probably terrible. 

 Do not be overly concerned about this disease at this time.

 Roger Knapp MD


Well we finally had our first case of Ebola acquired in America.  You heard of the nurse that came down with it.  She went to the hospital with symptoms and after 1 ½ hours was admitted to isolation.   Spreading the virus for a time.  Why did she not call from home and say she was exposed and ill and to come get her.  They then could have put her is a suit at home and transported her safely to ICU and Isolation.  I wonder how long the first index case man who went to the ER, was sent home, then went back to the ER, and was finally suspected of having Ebola.  How long was he exposing  hospital workers until he was put into isolation.  This nurse either did not follow isolation techniques carefully or (as I think) was exposed to it before they put him into isolation.  Hopefully with our better therapy she will be OK.  And they are now starting human trials of a vaccine and it will be in high gear to rush to market through the FDA.

 Roger Knapp MD

 Careful this Halloween.  Use electric lights in your pumpkins.  We hand out glow sticks or necklaces.  The kids love them, they get too much candy, and it is very safe walking down dark sidewalks.


    School is in full swing and I am already getting calls about school difficulty.  The most common problem is not paying attention.   Many kids are mild and we tell parents to bear with it.  The more severe kids may end up getting stimulant medication like Ritalin.  That medicine is just like strong coffee.  Most of us adults drink coffee every day to be more alert or attentive.  Ritalin is not bad… just strong “coffee”.  Adderall is stronger and is a type of Amphetamine.  Then there is Nicotine!  Many teens and adults self-medicate themselves by smoking and that is going to kill you.   Studies showed less smoking and less car wrecks in teens whose ADD was treated.  There is a debate over holding the “immature” boy behind in Kg to help this.  But the attention span will not improve for 5-8 years and if you hold them back, then instead of trying to get the 17-18 year old, who is not crazy about school, to finish high school, now you have a 19 year old you are trying to keep in school.  It is hard to decide and one answer does not fit all.

    Then there are slow readers who are behind to some degree and even labeled dyslexic or autistic (more to get special help than the fact that they really have those diagnoses).  Many kids and especially boys do not read well until 9 years old.  Boys are late developing in every stage of growth.  Even we adult men are more immature! Lol J In our present day school system it seems that they want everyone to be perfect in everything.  They spend a huge amount of time, money, and effort working on their weaknesses and a lot less on their strengths…. when those are the areas that we will choose our life’s work.  Stressing the kids so much about their weaknesses harms their self-esteem.  That is why I am not sure I favor “no pass no play”.  I understand what it is trying to do but you are preventing them from learning a skill that can make them more money than I make.  So in this day and age, Michael Angelo would not be able to go to art class because he was not a good reader.  Or famous musicians could not go to band because they were not good in math.  Albert Einstein was a terrible reader and failed his college admission exam.  But he was good in math and physics.   We need to work on our weaknesses but focus more on the areas of our strengths.  

 Roger Knapp MD

 also injuries are occurring in sport and play.  Read my article at the web site on “injuries” and put tape on injuries and not ice.


New car seat recommendations have come out and a list of good and bad brands are listed.
See: http://www.iihs.org/iihs/ratings/child-boosters
There are diagrams where seat belts should hold the child are also at the site.

Also see my web site car seat advice: http://www.rogerknapp.com/medical/restraint.htm


Flu cases are starting already but we will not have a major outbreak until 2015.

Brief comments on the flu… full explanation at my web site:

The test for flu misses around half the cases and is not very good and should not be relied on to decide to treat a child or not.

The medication Tamiflu should be given to high risk patients (see Web site for list) and not everyone in town.

Giving everyone in the family Tamiflu to prevent it is not a good idea.

Many kids throw up the Tamiflu.

Watch for fever after the fifth day of illness and then you need antibiotics for bacterial infection.

The flu vaccine only prevents the flu 50-60 % so you still can catch the flu but it lowers your chances.

Hope you all stay well.

Roger Knapp MD

 Dr. Knapp’s web site on the flu:


 CDC flu site:


 p.s. You may have heard about small children being hospitalized from energy drinks.  Keep them away from children below 12 years old.


With all our cell phones it is becoming a national habit or addiction.  Now we have "text neck".  Pain in our necks and upper back
being bent over looking at the phone.  See: Text Neck article.  It is sad when you see people out with friends or family
but they are not together.  Their minds and hearts are with someone else that is not there.   How rude. 
See this family having "fun"?

So lets turn off everyone's phone all day this Thanksgiving and enjoy each other.

Roger Knapp MD

See cute video "Tiney Hamster Thanksgiving"

Speeking of sore backs.  Number one cause of teens sore backs is jumping on a trampoline.
We see many injuries on them.  I don't recommend them at all I would not let my child go to
birthday parties at Trampoline park.


It is Christmas time and shopping for your children.  We want to get them some fun items but always think of safety.  The most common injuries in kids over 7 is the foot powered scooter with small wheels.  Wear a helmet!  For younger children it is choking and any item that can fit through a toilet paper roll can be dangerous.  Also I have mentioned in the past about button batteries that when swallowed can cause deadly results. I have also mentioned in the past about trampolines that are the more common cause of back pain in teens. 

See: Danger of popular toys

 Roger Knapp MD

 Also there is a new recommendation from the CDC saying the benefits of circumcision outweighs the  risks. 

See: CDC recommendations of circumcision

AAP advice on circumcision


You probably heard that the flu was going to be worse this year since the flu virus had a genetic shift.  What that means is that there will be more cases… not more severe disease.  In the best years the vaccine will prevent the flu 66% but in not so good years it works 30-40%... probably this year.  The infectious disease specialists guess back in May which strain will be coming the following winter.  Tough!  The CDC and I recommend treating with Tamiflu only the high risk population (see my web site or the CDC site) but some recommend treating everyone.  It is expensive, many kids throw it up, half the studies show it does not prevent pneumonias, and it only shortens the illness by 12-24 hours.  That is why you have to start the medication the first 24-48 hours of the illness.  There is fever the first three days, less the fourth day, and any fever after the fifth day is bacterial complications and needs antibiotics.  We are starting to see a lot of cases especially for this time of year so I do think we will have a large outbreak this year.

 Roger Knapp MD

 Also a study came out proving the HPV vaccine did not increase risky sexual behavior.  I would want the HPV vaccine if I was a teenager and recommend it.  See my web site for information.


Mistletoe at Christmas is fun and always a gag to “kiss under the mistletoe”.  In ancient times it was supposed to possess mystical powers which bring good luck to the household and wards off evil spirits. It was also used as a sign of love and friendship in Norse mythology and that's where the custom of kissing under Mistletoe comes from.  When the first Christians came to Western Europe, some tried to ban the use of Mistletoe as a decoration in Churches, but many still continued to use it! York Minster Church in the UK used to hold a special Mistletoe Service in the winter, where wrong doers in the city of York could come and be pardoned.  The custom of kissing under Mistletoe comes from England. The original custom was that a berry was picked from the sprig of Mistletoe before the person could be kissed and when all the berries had gone, there could be no more kissing!  Awe Shucks! 

Mistletoe has a reputation of being poisonous and can kill you.  A study looked at all the cases of ingestion from emergency rooms and no one died.  It will make you sick and cause vomiting, diarrhea, and weakness.  The risk is with larger amounts ingested and smaller size bodies like children and pets.  Have fun with mistletoe but keep it away from kids and pets.  It is the basketball-size dark green clumps of vegetation you see in barren trees this time of year so you can find your own if you can reach it.

Roger Knapp MD

 Here is a cute Christmas video “Box of Rocks”



I like to tell parents to brain wash their kids into their moral standards.  You can’t wait until 14 yrs. old because it goes in one ear and out the other.  So between 5 and 10 years old tell you kids how you feel about all the bad stuff that goes around you.  If you see a person driving recklessly in and out of traffic, then say “I don’t like people who drink alcohol and drive.  Isn’t that bad.  Isn’t that terrible.”  You do not say “don’t you do that”.   Just say how you do not like that behavior.  So when you see bad behavior in life or videos, tell them what you think about it.  You tend to want them to not see it but it’s too late…  they probably already saw it.   So turn it around into a lesson of what not to do.  Even if it is relatives!

 Also do not tell your children what you did as a youth.  It kind of gives them permission to do it also.  Swear you were a virgin when you married.  And if they find out otherwise later on, then tell them you wanted to set a higher standard for them.   And tell relatives not to tell your children all the bad things you did as a youth.  Uncles love to tell on your bad behaviors to your kids.  Not good.

 Roger Knapp MD