Knowing the symptoms, causes and treatments for Urinary Tract Infections in children, is the first step in preventing this serious infection from occurring. First, we need to understand what the urinary tract is so we can better understand the infection.

The Urinary Tract

The urinary tract is made up of the kidneys, ureters, bladder, and the urethra. The urinary tract makes and stores urine. Urine is produced in the kidneys and then runs down two tubes known as the ureters. The bladder, a thin muscular bag, stores the urine until it is ready to exit the body. When it is time for the urine to exit the body, a muscle relaxes and urine is expelled through the body, through the urethra. The urethra opening is located above the vaginal opening for girls and at the end of the penis for boys.

Urinary Tract Infections

Normal urine has no bacteria. However, if bacteria does enter the urine this can lead to Urinary Tract Infections in children, two of the ways that germs can enter the urine are:

• The skin that surrounds the rectum and genitals.
• The blood stream from other parts of the body.

Bacteria can cause infections in one or all parts of the Urinary Tract, such as the following:

• Kidneys (called pyelonephritis)
• Bladder (called cystitis)
• Urethra (called urethritis)

Urinary Tract Infections in children are common and by 11 years old about 3% of girls and 1% of boys will have had one. Babies born too soon or infants that have something blocking the flow of urine are more likely to experience a UTI sooner in life. While it is more common for girls to contract UTIs than boys, boys can get UTIs as well. Boys who are uncircumcised have more UTIs than those who have been circumcised. Children who have a high fever, have a 1 in 20 chance of a UTI, even if they do not show any other symptoms.

Symptoms of Urinary Tract Infections in Children

Symptoms of UTIs may include the following:

• Pain or burning, during urination
• Needing to urinate more often or frequent bedwetting of a child who knows to use the toilet
• Urgent need to urinate
• Fever
• Refusing to eat, vomiting
• Side or back pain
• Abdominal pain
• Foul-smelling urine
• Bloody or cloudy urine
• Poor growth in an infant
• Unexplained and persistent irritability in an infant

Urinary Tract Infection Diagnosis

If your child is experiencing any of the above symptoms caused by a UTI, your pediatrician at The Pediatric Center will do any of the following procedures for Urinary Tract Infections in children:

• Ask about your family’s medical history, especially the history pertaining to Urinary Tract infections.
• Ask your child about their symptoms.
• Examine your child.
• Ask what foods your child has been eating and drinking.
• Get a urine sample, this is to test is check to see if your child’s urine contains bacteria or any other abnormalities.

How Urine is Collected

When it comes to Urinary Tract Infections in children, the urine must be tested and analyzed to determine whether there is a bacterial infection in the urinary tract. Older children will be asked to leave a urine sample in a container. Urine can be collected three different ways:

• Catheter – The preferred method to collect urine is by using a catheter. A catheter is a small tube that goes through the urethra into the bladder. The urine flows through this tube and is expelled into a special container
• Needle Aspiration – another method to obtain urine is to insert a needle into the bladder and extract the urine.
• Plastic Bag – for Urinary Tract infections in children that are too young to use the toilet, the doctor may place a plastic bag over the child’s genitals to get a good urine sample. Bacteria on the skin can contaminate the sample and give a false result, that’s why this method is only used to screen for an infection. If an infection does seem to be present within the urine, the doctor will collect the urine by using one of the first two methods mentioned earlier, to determine if bacteria is present in the urine.

Treatment for Urinary Tract Infections in Children

Since UTIs are caused by bacteria, antibiotics are used to treat this type of infection. The antibiotics will usually need to be taken for 7 to 14 days, depending on what your doctor at The Pediatric Center prescribes. Antibiotics can be administered orally with a liquid or pills. If your child is not able to hold food down, antibiotics may need to be given by injection. Even if your child feels better, you need to make sure that they take the entire prescribed medication to get rid of the infection. Urinary Tract Infections in children need to be treated to:

• Prevent the spread of the infection outside of the urinary tract.
• Reduce the chances of kidney damage.
• Get rid of the infection.

Follow up at The Pediatric Center

Urinary Tract Infections in children that occur when they are very young, are no cause for alarm, but they do require follow up appointments at The Pediatric Center. Your doctor will want to see your child for an ultrasound to see if the kidneys and bladder are acting normal. Remember early diagnosis and treatment for Urinary Tract infections in children is important because if left untreated, this can lead to long term medical issues in the future. If a child has had a UTI in the past, they are more likely to get one again. Call The Pediatric Center at (208) 523-3060 to talk to your doctor if you suspect your child has developed a Urinary Tract Infection.

Featured Image By Bobjgalindo – Own work, https://commons.wikimedia.org/w/index.php?curid=5652287

Strep Throat causes swelling and inflammation in the back of the throat and the tonsils, sore throat is a common sign of Strep Throat in children and young adults. If not treated promptly, this disease can lead to other potential serious problems.

At the Pediatric Center, we want to make sure you and your children are well informed about Strep Throat in children, so that you can avoid any major health issues.

It is estimated that between the ages of 5 and 15 at least 15%-40% of the cases of sore throats in children are actually caused by this Streptococcus bacteria. The symptoms of this disease can vary based on the age of the child when they get Strep Throat.

Viral Infections VS. Strep Throat

It is important to note that viral infections are different from the bacterial infection of Strep Throat. Being able to distinguish between the two is important, as Strep Throat can be treated with antibiotics. Symptoms of Strep Throat in children usually happen within the incubation period, which can be 1-4 days after they get infected. Some of the symptoms you will need to look for are different based on the age of your child. If you are still not sure after going over this list of symptoms, contact your pediatrician at The Pediatric Center for more information.

Symptoms

• Infants – When an infant contracts Strep Throat, their symptoms might include a slight fever and possibly thickened or even bloody nasal discharge.
• Toddlers (ages one to three) – Strep Throat in children, ages one to three, varies slightly from infants with Strep Throat. Children may also experience bloody and thickened nasal discharge, but they may also suffer from a sore throat and complain about an upset stomach as well. These symptoms will usually leave a toddler feeling quite cranky and with no appetite.
• Children over three years of age – When children over the age of three contract Strep Throat, their symptoms can be more severe.Usually they will suffer from a high fever above 102 degrees fahrenheit (38.9 degrees Celsius). Their throats will be extremely sore, with swollen tonsils and glands, making eating and drinking uncomfortable.

When to Call The Pediatric Center

If your child has a sore throat that will not go away, even if it is not accompanied by any of these above symptoms, such as a stomachache, fever, or loss of appetite, it is important that you get a hold of your pediatrician right away. If your child seems to be extremely ill and is experiencing any of the symptoms of Strep Throat in children, that phone call should be all the more urgent. If your child is experiencing drooling due to the inability to swallow or shortness of breath, this could be sign of more serious problems and you need to contact your child’s pediatrician as soon as possible.

At The Pediatric Center

When you do bring your child in, our doctors will provide a thorough and gentle examination of the throat, glands and tonsils. The doctor will also perform a throat culture to determine the nature of the infection and to decide whether it is a bacterial or viral infection. For this test, the pediatrician will take a cotton swab and touch it to the back of the throat and tonsils, he or she will then take this sample and smear it into a special dish that helps the bacteria to grow if they are indeed present. Within a 24 hour period after this test is done, the doctor will be able to see if there is bacteria present.

Most pediatric centers will do a rapid test first that only takes a matter of minutes to determine whether or not the infection is viral or bacterial. If this rapid test comes back negative, your doctor may do a culture test to confirm whether or not Strep Throat is the case. If both the culture and rapid test come back negative, this will mean that the symptoms are most likely caused by a virus and not a bacteria. If this is the case, there will be no reason to prescribe antibiotics (which are for bacterial infections) to the child.

Treatment

Treatment for strep throat is relatively simple, but if not caught early enough Strep Throat in children can lead to very serious issues such as; kidney problems, abscesses in the tonsils and can lead to rheumatic fever. If your child does have Strep Throat, your pediatrician will prescribe a couple different options for treatment:

• Antibiotics – Antibiotics are the best option, even in severe cases, as their sole purpose is to directly attack the bacterial infection.
• Tonsillectomy – if your child has bad sore throat issues in the past, a tonsillectomy can be prescribed to prevent further infections. This procedure is only prescribed for very serious cases and even after the operation infections can still persist.

Prevention

Many throat infections are contagious and can be easily be passed around. It is easy to prevent your child from getting these infections if you are able to keep them away from people who show signs of infections. However, most people are already contagious before they start showing symptoms of their illness. Avoiding holding hands or sharing drinks with people who show signs of a sore throat can help.

Call The Pediatric Center

At the Pediatric Center, we want to give you and your child the best information and diagnosis, you can get. If you are noticing any of the sore throat symptoms in your child, don’t hesitate to call your doctor at The Pediatric Center today. Contact us today at our Idaho Falls location at (208) 523-3060 or our Rigby location (208) 745-8927, to set up your appointment.

Sleep Apnea in children is a common problem that affects about 2% of children with many more still undiagnosed. At the Pediatric Center in Idaho Falls our physicians are there to help you with any concerns you may have concerning your child’s health. If you believe your child does have Sleep Apnea, you will want to schedule an appointment today to see one of our specialists. If left untreated, Sleep Apnea can lead to serious issues with a child’s development, growth and behavior as well as heart problems in the future.

Sleep Apnea Symptoms in Children

If you notice any of the following symptoms be sure to let your pediatrician at The Pediatric Center know as soon as possible.

• Frequent Snoring
• Gasping, having long pauses, or even stopping breathing during the night
• Sleep is not sound and may have irregular sleeping positions
• Mouth breathing.
• Behavior Problems
• Difficulty pay attention in school
• Sleepiness during the day
• Bedwetting

At the Pediatric Center in Idaho Falls our physicians want to provide you and your children with the best care. If your child has any of the symptoms listed above, our specialists may want to do a sleep study on your child to determine the cause of their Sleep Apnea. This sleep study is called polysomnogram. This study is done overnight at medical centers as well as hospitals. The polysomnogram will determine if your child does have sleep apnea. During this study the doctors will monitor your child’s breathing, oxygenation, and brain activity. Sensors will be attached to your child while they are asleep to get the best results.

What Causes Sleep Apnea in Children?

When we think of adults with Sleep Apnea we usually tend to think of an overweight, middle-aged person, although weight can be an issue for Sleep Apnea in children, it is not always the case in children.

Some causes of Sleep Apnea in children are:

• Enlarged tonsils and adenoids (Hypertrophy)
• Children born with medical conditions, such as Down Syndrome, Cerebral Palsy, or craniofacial abnormalities
• Overweight or obese children

Tonsils are the round, red masses on either side of your child’s throat. Tonsils help to fight infections that may enter the body. Adenoids can only be seen with an x-ray and are located in the space between the nose and throat. Children with Sleep Apnea usually have larger than normal tonsils and adenoids. Large tonsils can block the airways which will make it difficult for the child to breath as well as cause excessive and loud snoring. Some children with large tonsils do not have sleep apnea. A sleep study can help to determine whether or not your child suffers from sleep apnea.

Low muscle tone in the throat and mouth area can cause children with Down Syndrome to have some obstructive sleep apnea. Also, narrowed passages in the mouth and upper airway, poor air coordination movements, and an enlarged tongue can cause sleep apnea for children with medical conditions.

Overweight children have a higher risk of sleep apnea. When a person gains weight in the neck and throat area this increases the risk of poor respiratory functions. Usually an overweight child will have enlarged tonsils and adenoids due to increased fatty tissues in that area. It is very important to get an overweight child tested for sleep apnea. When overweight children get only 4-6 hours of sleep they have a higher risk to get diabetes since the processing sugar declines if they are not given the proper amount of sleep.

How To Treat Sleep Apnea in Children

At the Pediatric Center we want to help your better to sleep better at night. The most common way to treat Sleep Apnea in Children is to have the tonsils and adenoids removed. This will open up the airways to allow a better flow of oxygen and promote a better night’s sleep. A tonsillectomy and adenoidectomy is a fairly regular surgery and since your doctor can reach both the tonsils and adenoids by simply having your child open their mouth, there is no reason for incisions outside of the skin.

Since Sleep Apnea causes shallow breaths or pauses in breathing another effective treatment is CPAP or continuous positive airway pressure. This treatment requires the child to wear a mask while they sleep. The mild pressure from CPAP keeps the air passages from getting blocked or collapsing. CPAP treatment requires a machine with three parts including a mask, a machine with a motor that blows air, and a tube that connects the machine to the mask. This is an effective treatment for children that are not candidates for a tonsillectomy and an adenoidectomy or patients that have already received one and show now improvements in their sleep.

In overweight children they may need to lose the weight before their sleep apnea improves. In the meantime, until the weight is gone a CPAP is a good idea until their condition improves. As
always children may need additional treatment if they are overweight or have another serious condition.

Come see us at the Pediatric Center

If you suspect your child does have sleep apnea the first thing to do is call your doctor at The Pediatric Center, they specialize in Sleep Apnea in Children and will be able to help. If you can bring a record of your child’s sleep, fatigue levels throughout the day, and any other symptoms that you notice or think could be attributed to sleep apnea. Call us at (208) 523-3060 to schedule an appointment today.

What is Scabies in Children

The scabies rash, caused by microscopic mites that burrow into the skin’s upper layers, is an extremely itchy and contagious skin infection. Scabies is an infection that can be passed not only in children, but people of all ages.

What are the Symptoms of Scabies

There are many different skin rashes caused by thousands of culprits, from allergies to infections, there are signs that help to differentiate scabies from of rashes.

After the mites responsible for scabies have entered the skin it usually takes about 2 to 4 weeks for the rash to appear. The rash itself is the body’s reaction to the proteins, eggs and other excretions from the mites in the skin. The rash can be extremely itchy with the irritation increasing at night. Another sign that the rash is from a scabies infection can be the presence of thin, threadlike gray or white lines on the skin from the burrowing mites. These lines resemble irregular pencil marks.

Scabies in children younger than 2 years old the rash is most commonly found on the palms, soles of the feet, head and neck. Older children usually develop the rash in between the fingers or in the folds and creases at the wrists, elbows, waistline, thighs, buttocks and genitals.

Scabies has an incubation period of usually 4 to 6 weeks, however, if scabies has previously infected your child, symptoms can occur much quicker. Symptoms can occurs as quickly as 1 to 4 days after being exposed to the mites again.

What Caregivers Can Do for Scabies in Children

Scabies is extremely itchy and irritating, however scratching will only increase the chances of the skin developing a secondary bacterial infection. You can help your child by helping them not to scratch and keeping their fingernails trimmed during a scabies infection.

When to Call Your Child’s Doctor

If you notice or your child complains of an itch rash, contact your child’s doctor. The doctor will need to examine the rash to make a diagnoses and recommend treatment for the scabies infection.

Diagnosing Scabies

Your child’s pediatrician can often diagnose a scabies infection by examining the rash and asking about the intensity of the rash’s itchiness. Scabies can be difficult to identify due to the fact that children are usually unable to resist scratching this highly irritating rash, cause scratch marks and crusting.

If your pediatrician decides they need to confirm the diagnoses they may take a gentle scraping from the rash or a burrow. The sample will be examined under a microscope to identify the scabies mites or its eggs.

Treatment for Scabies in Children

Children with a scabies rash will need to be cared for with one of several lotion or cream options. These lotions and creams include:

• Permethrin 5% cream
• Crotamiton 10% lotion or cream
• Lindane lotion (safe only for children over 2 years of age)

For most cases, pediatricians choose a permethrin 5% cream. The cream needs to be applied over the entire body from the neck all the way down to the toes. For infants and young children it will also need to be applied to the head and scalp as the mites can infect these parts of the body in small children.

Although other creams and lotions can be used, such as crotamiton 10%, permethrin is most commonly used for treating scabies in children. Talk to your pediatrician about how often the cream or lotion should be reapplied. Often treatment should be reapplied about a week after the initial treatment.

Scabies is a very persistent rash. Even after being effectively treated, the itching associated with scabies can last for several weeks and even months. Although this continued irritation is frustrating for both parents and children, it does not mean that your child still has the scabies infection. To help relieve the itching, talk to your child’s doctor about an oral antihistamine or a topical corticosteroid. Keep your child’s fingernail trimmed and encourage them not to itch to avoid further infection.

Prognosis

Although scabies is very contagious, produces extreme itchiness and discomfort, the condition is mild and highly treatable. Once your child has completed their treatment for scabies they can return to school or childcare.

What Parents Can Do to Help Prevent Scabies

The mites that cause a scabies infestation are easily spread from person to person through close contact, especially skin to skin. If a family member has scabies, talk to your healthcare provider about whether other family members should be tested or treated for scabies.

To help prevent a second infestation clean all clothes and linens using hot, soapy water and dry with high heat. For items that your child has come into contact with that cannot be washed, try to “starve the mites” by sealing objects in a plastic bag out of the way for a couple weeks. The mites will die after a few days without food.

The Pediatric Center is Here For You

If you think your child may have scabies do not hesitate to call your child’s pediatrician to have your child check out. Remember these key points about identifying scabies:

• Location of rash
• Increased itch at night
• Threadlike gray or white lines

Keep in mind that scabies, although irritating and very itchy and uncomfortable, it is highly treatable. If you want to learn more or have further concerns about scabies in children or treatment options for you child, give us a call at The Pediatric Center. We are here to help you best help your child.

Featured image: By Steschke – Own work, https://commons.wikimedia.org/w/index.php?curid=37900

Ringworm can be localized to a particular area of the body or it can be found all over the body. It usually affects the scalp, feet, groin, arms, legs, and other places.

Ringworm is usually itchy and can become painful if the sufferer scratches the affected area enough that sores develop. If left untreated, ringworm can spread to more areas of the body and it can also be spread to others. Ringworm is very common among young children and those whom share a home with pet cats.

How do you catch ringworm?

Ringworm is very contagious. It can be spread by simple contact with the fungus that resides on people or animals or with a surface where the active fungus happens to be. The fungus that causes ringworm thrives in wet environments such as public showers, pools, and dressing rooms and coming into contact with the fungus if you have minor skin abrasions or injuries multiplies your risk of becoming infected with ringworm.

Those who go barefoot often are at a higher risk of getting ringworm as well as those who share hairbrushes or wear unwashed clothing. House cats also readily carry the fungus and can easily transfer the fungus to those who handle them.

So how do you know if your child has ringworm?

Ringworm infection usually results in the following conditions:

• Raised, red, scaly, itchy patches of skin
• These patches may have oozing blisters
• A characteristic “ring” of dry raised red skin encircles the scaly, dry patch

Ringworm that affects fingernails may result in discolored and cracked nails while infections on the scalp may result in bald or thinning patches on the head.

How does my pediatrician diagnose ringworm in children?

The ringworm fungus will glow under a blacklight.  Your pediatrician may use a blacklight in a darkened room to inspect the infected areas on your child’s body. If glowing patches appear, your pediatrician may order additional tests to identify if indeed it is a fungal infection. Sometimes a biopsy or a skin cell sample may be collected and examined under a microscope.

A diagnosis is usually pretty accurate, especially if the infected areas on the skin are pronounced.

So my kid has been diagnosed with ringworm. Now what?

Once ringworm has be diagnosed, your pediatrician may prescribe medication designed to treat the infection based on the severity of the affected area. Typically, a skin cream or lotion is prescribed that is specially formulated to kill the fungus and soothe the infected area and decrease itchiness. There are multiple types of this lotion available so if one doesn’t work, another can be prescribed. The most common medication prescribed for ringworm is Ketoconazole. This treatment is applied to the affected area multiple times per day for up to 4 weeks at a time, or until the infection is gone.

In addition to medication, your pediatrician will also recommend lifestyle changes that are meant to reduce the exposure to common methods of infection. Also, behavior changes may be recommended to include:

• Avoiding tight or restrictive clothing that prevents the affected areas from drying out or excessively rubs the infection.
• Regularly washing bedding and clothing your child sleeps in and wears.
• Washing and drying your skin on a regular basis.
• Consider limiting contact with pets or avoiding them altogether.

How long does a ringworm infection last?

Left untreated, ringworm can last for years. With medical treatment, ringworm usually clears up anywhere from 2 to 4 weeks. Ringworm infections that persist may require an oral antifungal medication to be prescribed. Most children respond well to treatment.

What do I do if I suspect my child has ringworm?

Call your pediatrician if over-the-counter medications fail to reduce and eliminate the infection. The office visit to diagnose a ringworm infection involves a quick check of the infected areas and is non-invasive. The Pediatric Center in Idaho Falls is a great place to bring your children for a ringworm checkup. Our pediatricians are very experienced in diagnosing and treating ringworm infection and are available to answer any questions you may have.

Image Credit: By James Heilman, MD – Own work, https://commons.wikimedia.org/w/index.php?curid=19051050

Between 1940 and 1945, around one million cases of whooping cough were reported. However, after the vaccine was introduced later in the same decade, the number of pertussis in children was drastically reduced.

Pertussis in children causes:

• shortness of breath
• vomiting
• drooling
• tearing up
• bluing around the mouth

Children under the age of one can develop severe and potentially life threatening breathing problems if the illness is not treated quickly. A child exhibiting symptoms related to whooping cough should be taken to the pediatric center for proper treatment.

How to identify Pertussis in Children

It’s important to know the symptoms of pertussis in children because it initially shares symptoms with the common cold. The first stage can last from one to two weeks and consists of a runny nose, sneezing, a low-grade fever, and a mild cough. The second stage lasts up to 10 weeks and coughing severity increases to its’ namesake. Watch for a cough that continues to worsen and listen for the “whoop” sound as you child inhales deeply and quickly between coughs. Your child might have a hard time breathing normally and become exhausted. A compromised immune system at this stage of infection increases your child’s risk of incurring a host of other conditions including pneumonia, ear infections, weight loss (resulting from lack of appetite), and dehydration. Even seizures may results from lack of oxygen to the brain during a coughing fit. Recovery often begins two to four weeks after the initial coughing fits, marked by increasing ease of respiration and a reduction in coughing. The cough may not go away entirely for many months and can easily return with another respiratory infection.

When should I take my child to the Pediatric Center?

Because the symptoms of pertussis in children starts as just a common cold, it’s important to watch for these signs that it may be more such as:

• Child is under one year old and has not be fully immunized
• You find out that your child has been exposed to someone that may have a chronic cough or whooping cough.
• Child’s cough has become more severe and causes lips and fingertips to turn blue.
• Child’s cough has become more frequent and they have a hard time catching their breath after a coughing fit.
• Child is exhausted after coughing fit, vomits after coughing, and has little or no appetite.
  Pertussis in children under the age of six months is usually treated in a hospital since pneumonia can develop in one in four of those children. When receiving care, your child may be kept in isolation so as not to infect other patients or their family. Thick respiratory secretions may need to be suctioned from your child’s lungs and oxygen can be given to help your child breathe better. If you child more a year old, they can usually be treated at home after a visit to the Pediatric Center.

Treatment at the Pediatric Center

When you arrive at the center, your doctor or caregiver will perform a physical examination and will likely take a swab of the back of the throat through your nose to perform a laboratory test. They may also request a blood sample. If the results come back positive, pertussis in children is treated with a course of antibiotics that lasts two weeks. This method is most effective if a positive diagnosis is made when coughing is weak. Antibiotics are helpful at minimizing the spread of whooping cough, but they won’t stop the coughing so you’ll need to use other forms of care to reduce the discomfort of coughing. The following treatments will help to minimize coughing discomfort and promote healing.

• Put a cool-mist vaporizer in the room with the child to help soothe the irritated lungs and breathing passages.
• The cool-mist vaporizer will also help loosen the buildup of secretions that are coating the respiratory tract and make coughing more productive.
• Keep your home clean or irritants that can start a coughing fit such as smoke, dust, or fumes.
• Encourage your child to drink plenty of fluids. This can include water, juice, soups, and fruits. Keeping hydrated will lessen the chance of coughing from having a dry throat.

How do I prevent whooping cough?

When your baby is two months old, your physician at the Pediatric Center should start the DTaP regime of vaccinations. DTaP stands for Diphtheria, Tetanus, and whooping cough (Pertussis), for which the vaccination is formulated to protect against. Your child will receive immunizations shot at two months, four months and six months. They will also need a booster shot between 12 – 18 months, and then again at 4 – 5 years. DTaP may be administered as a booster to adults and pregnant women, as well as to children 7 – 10 of age who were not immunized completely with all previous DTaP shots. A booster is needed every 10 years thereafter. After your child receives the vaccine with a shot in the upper thigh muscles, they may experience low-grade fever, swelling, redness, and tenderness at the injection spot. They may also experience exhaustion and body aches, but all side effects should go away in a day or two. If the vaccination is administered on the recommended time schedule, the efficacy of the vaccine for your child is nearly 100%. Over time, however, the effectiveness of the vaccine declines. Seven in ten children are fully protected five years after they receive their last dose of DTaP but by then, they are older and are less likely to be hospitalized. You can help prevent exposure to whooping cough by making sure that those who spend time with your child are up to date on their vaccines.