Archive: TCH Ask the Expert Series

The Junior League of Houston’s Premier Community Partner, Texas Children’s Hospital, is a world-renowned institution with experts in every pediatric specialty. Each quarter, a Texas Children’s Hospital physician answers questions about current medical issues.

Archive

December 2015: Infertility: Dispelling Common Myths and Misconceptions
October 2015: The Mata Twins: Inside the Groundbreaking 26-Hour Surgery of Conjoined Twins Knatlye and Adeline Mata
April 2015: Ovarian Cancer: It Whispers, So Listen
January 2015: Treating Your Child’s Scratches and Cuts
October 2014: Clean Eating

August 2014: Headaches in Children

May 2014: Children’s Sleep Habits

January 2014: Flu Symptoms: When to Bring Your Child into the Emergency Center
September 2013: Healthy Exercising: Suitable Physical Activities for Pregnant Women
June 2013: Q&A About Dehydration


Infertility: Dispelling Common Myths and Misconceptions

December 2015

According to The Centers for Disease Control and Prevention, an estimated 7.3 million people are affected by infertility in the United States. That is roughly 12 percent of the reproductive-age population. There are a lot of myths floating around about infertility, many of them not based in fact. Dr. Paul W. Zarutskie, a reproductive endocrinologist at Texas Children’s Hospital, helps to dispel some common infertility myths.

If am having regular periods, shouldn’t I be able to get pregnant?
This is most commonly heard by women in their late 30s to 40 years old. The issue is that advanced maternal age (35 years of age and older) increases the likelihood that an egg released is not chromosomally normal and thus not successfully implanting, despite the woman having normal periods.

My husband had children in a prior marriage, so is it more likely that I am the “problem”?
Time can change things for men that might affect sperm form and function, including lifestyle changes, potential environmental exposure in a new job and changes in medical conditions as they get older.

If I quit my stressful job and relax, will I be able to get pregnant?
Extremely high levels of stress can affect fertility by altering the brain hormones that regulate egg formation and ovulation; however, the stress levels would have to be high enough to see significant changes in the menstrual cycle. The kind of stress that might do this would be an extreme exercise program, a crash diet with dramatic weight loss, anorexia or an eating disorder, or stresses that require medications to decrease anxiety or to aid in treating insomnia.

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The Mata Twins: Inside the Groundbreaking 26-Hour Surgery of Conjoined Twins Knatalye and Adeline Mata

October 2015

Delivered in April 2014 at Texas Children’s Hospital, twin girls Knatalye and Adeline Mata came into the world sharing more than the close bond of sisterhood. The Mata girls were born as conjoined twins, sharing a chest wall, lungs, the lining of their hearts, diaphragm, liver, intestines, colon and pelvis. Driven by the hope of giving Knatayle and Adeline separate lives, Texas Children’s Hospital assembled a medical team from 13 different specialties to perform a separation surgery. The intensive and highly complex procedure took over 26 hours and required a team of 26 clinicians including 12 surgeons, six anesthesiologists and eight surgical nurses. It required the cooperation of surgeons and caregivers in general pediatric and cardiovascular surgery, as well as urology, transplant, gynecology, orthopedic, and plastic surgery units. The surgery was a success, making this the first successful surgical separation of conjoined twins with this particular configuration. Audra Rushing, the operating room coordinator for this case, talks about the process and outcome of such a high-stakes operation.

When did Elysse and Eric Mata first come to Texas Children’s Hospital?
The Matas, who are from Lubbock, first came to Texas Children’s when Elysse was 27 weeks pregnant. Their physician had discovered in a routine ultrasound that the babies were conjoined, and immediately referred them to Texas Children’s Hospital. Dr. Darrell Cass, a pediatric surgeon and co-director of Texas Children’s Fetal Center, saw that while their odds of survival were not good, both girls each had a heart and brain that was fully functional. Elysse was placed on bedrest at Texas Children’s and over the next month, the family underwent extensive prenatal imaging, multidisciplinary consultations and a development of plans to achieve a safe delivery and postnatal care. Knatalye and Adeline were born via Caesarean-section at 31 weeks gestation, weighing three pounds, seven ounces each.

How did the nurses and surgical team prepare for such an arduous and complicated surgery?

Knatayle and Adeline lived at Texas Children’s Level IV Neonatal Intensive Care Unit from their birth in April 2014 until their separation surgery in February 2015. During that time, Texas Children’s created a 3D model of the twins to help the surgeons prepare for the separation. The entire team participated in a full simulation of the surgery in Texas Children’s simulation center. In December 2014, Texas Children’s surgeons performed a five-hour surgery to place custom-made tissue expanders into their chest and abdomen area. The tissue expanders helped to stretch the babies’ skin in preparation for the surgery.

In your opinion, what was the most important moment in the surgical process?

I feel the most important moment in the surgical process was the amazing team work that made it all flow so well. The entire procedure was full of milestones, but the communication and seamless integration of the services made the procedure a true success.

How are the twins today?

The twins are doing beautifully today. Knatayle was released from Texas Children’s in May, and Adeline followed her in June. Today, the Matas have returned to their home in Lubbock with their daughters and six-year-old son Azariah.

What does the future hold for the health of the Mata twins?

The future for the girls is limitless. They are both healthy, and of course will need some cosmetic procedures, but they will both have very full lives.

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Ovarian Cancer: It Whispers, So Listen

April 2015

Thousands of women are diagnosed with a gynecological cancer every year. Dr. Celestine Tung, a gynecologic oncologist at Texas Children’s Hospital, shares important advice about the silent killer — ovarian cancer.

Why is ovarian cancer called the “silent killer”?

Ovarian cancer is the fifth leading cause of cancer-related deaths among women. The disease was historically referred to as a “silent killer” because it was thought that symptoms were not evident until the disease was in an advanced stage. The fact is, however, that symptoms often do exist in the early stages of ovarian cancer. A woman’s strongest defense against this disease is merely to listen to her body and be attuned to changes.

What are the symptoms of ovarian cancer?

The symptoms of ovarian cancer are not specific to the disease and are often similar to other more common conditions. Symptoms include bloating, pelvic or abdominal change, loss of appetite, vomiting or changes in bowel habits. We all have bloating and a poor appetite at times, but if symptoms are persistent and out of the ordinary, it’s a key indication that there may be a deeper issue.

Are there any tests available to detect ovarian cancer?

At this time, there are not any recommended screening tests for ovarian cancer that we can use as an early detection tool. I’m often asked by patients why I can’t just give them an ultrasound. So far, no studies have shown that an ultrasound is beneficial in the diagnosis of this deadly disease.

What should I do if I have a family history of ovarian cancer?

For women who have a strong family history of ovarian cancer, genetic testing to check for gene mutations may be recommended. A woman’s risk of developing breast and/or ovarian cancer is greatly increased if she inherits a mutation in the BRCA1 gene or the BRCA2 gene. You may recall hearing about the BRCA gene in the news several months ago after actress Angelina Jolie announced that she had the gene mutation and opted to have a preventive double mastectomy to minimize her risks for breast cancer.

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Treating Your Child’s Scratches and Cuts: From the Medicine Cabinet to the Emergency Center

January 2015

Children love exploring and playing … a set-up for fun, excitement, joy … and unintentional injuries! Skin wounds such as scrapes and cuts will occur in all children, and knowing how to care for these types of injuries is very important. Luckily, many skin injuries can be cared for at home and do not require immediate treatment in an emergency center. Dr. Katherine Leaming-Van Zandt, Pediatric Emergency Medicine Specialist at Texas Children’s Hospital, gives us a closer look at the different types of skin injuries and what kind of care you should seek:

Which skin injuries can I treat at home?

Scrapes, scratches and abrasions are surface wounds that do not cut through the skin. Unless the wounds are persistently bleeding, dirty (with retained foreign body) or caused by an animal/human bite or electrical injury, most of these skin injuries can be cared for at home.

When should I seek professional care for my child’s skin injury?

Cuts, gashes and lacerations are typically deep, jagged and/or gaping, with visible fatty tissue. Typically, these types of wounds need stitches, and medical care should be sought (either at an urgent care or emergency center).

What should I do if the cut is bleeding?

Apply direct pressure to the wound for 10 minutes or until the bleeding has stopped. Then, gently wash the wound with soap and running water and remove as much dirt from the cut as possible. Once the skin is dried, apply an antibiotic ointment to help moisturize the skin and reduce the risk of infection.

Which ointment is best?

Most over-the-counter antibiotic ointments contain one or more antibiotics such as neomycin, polymyxin and bacitracin. The combination of these three antibiotics is often referred to as a triple-antibiotic ointment. Although the active ingredients are the exact same, many store-brand preparations are less expensive than the brand-named products.

What do I do in the meantime if the wound requires stitches or further medical evaluation?

Cover the open wound and continue to hold direct pressure for persistently bleeding injuries.

Should I take my child to an urgent care center?

Does your child remain relatively calm with cleansing and first aid? If your child does not appear overly anxious or scared, he/she may tolerate the laceration repair with topical and oral pain medications and distraction techniques. In this case, an urgent care center may be a safe choice.

Or should I take my child to a pediatric emergency center?

If you think your child may need sedation, you should take him/her to a pediatric emergency center. If your child is very young and/or extremely anxious and scared or if the wound is extensive, he or she may need sedation medications to facilitate a successful repair. Avoid letting your child eat or drink while heading to the emergency center, because most children need to have an empty stomach to safely undergo sedation.

Will your child potentially need a pediatric sub-specialty surgeon, such as a pediatric plastic surgeon or pediatric orthopedic surgeon? If your child has an extensive laceration that is very large or deep, may involve underlying nerves, blood vessels, tendons, bones or joints, or was caused by an animal/human bite and is located on the face, hands or feet, you should take him/her to a pediatric emergency center.

When is it serious enough for 911?

If your child’s wound is significantly bleeding and is not stopping with direct pressure, has occurred to the face, neck or chest and is causing your child to have difficulty breathing, or is associated with a bone deformity or amputation, call 911 and have your child taken to the closest emergency center.

What should I expect afterwards? Scars? Infection?

The goals of wound management, particularly suture repair, are to avoid wound infections, stop bleeding and provide an aesthetically pleasing scar. All sutured wounds, regardless of whether an emergency medicine physician or plastic surgeon repairs the laceration, will leave a scar. The extent of the scar will depend on a variety of factors, such as the child’s genetic ability for skin healing (i.e., risk for keloid formation) and the size and severity of the laceration. Applying sunscreen to the area once the skin has healed and the sutures are removed may help aid in the cosmetic appearance of the scar. Additionally, unless the wound was caused by an animal/human bite, associated with an underlying broken bone or cartilage, tendon or joint injury, or exposed to excessive wound contamination, most healthy children do not require an oral antibiotic to prevent an infection.

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Clean Eating: What Does It Mean? 
October 2014

It seems we can’t go one day without hearing someone talk about “clean eating.” Whether we hear a story on the news, from a friend or colleague, or by clicking a link on social media, talk of “clean eating” is everywhere! Kristi King, Senior Clinical Dietician at Texas Children’s Hospital, tells us that phrase is actually one of her biggest pet peeves. Here are her thoughts:

Is “clean eating” a new, revolutionary trend?
No, not at all. The term “clean eating” has been around since the 1960s and has come to mean various things.
What are the different ways people practice “clean eating”?
Practice 1: consuming mostly plant-based foods, unprocessed whole grains, and lean meats, but no red meat
Practice 2: avoiding gluten, dairy or meat products
Practice 3: consuming only foods with less than 10 grams of sugar, less than 200 mg of sodium, and foods found in their natural state (raw)
Practice 4: participating in “clean eating” detoxes, which include extremely low calorie intakes and juicing Note – since our bodies naturally detox, there is no need to put them through this.

Still confused with why you can’t master “clean eating”?

“Clean eating” not only lacks an actual definition, it implies that those who don’t follow common “clean eating” practices are “eating dirty” or making poor choices. Everyone has a definition of what healthy is, and these definitions are not all the same. Many “clean eating” practices found on the Internet require extensive time in the kitchen, which may not be possible for today’s busy lifestyles.

Can “clean eating” be bad?

Applying labels like “clean” versus “dirty” or “good” versus “bad” can lead people to become obsessed with trying to “do it right.” The unhealthy focus on eating right and fixation on food quality and purity to the point where eating becomes extremely restrictive is called orthorexia. This practice can be detrimental to overall health. These behaviors are considered very alarming, particularly among tweens and teenagers.

Can “clean eating” be good?
Am I happy that “clean eaters” are making an effort to eat healthier? Absolutely! Half of our plate (or lunch box) should consist of fruits and vegetables. A diet high in plant-based foods has been associated with lower blood pressure, lower cholesterol and lower body weights. The fiber they provide also helps keep us full and our digestive systems healthy. Whole grains, even those with gluten, are also important, because they provide fiber and other great nutrients that our bodies need.

Low-fat dairy is a great source of protein, as well as calcium and vitamin D, which are essential in keeping our bones strong. Lean meats such as fish or chicken as well as beans, nuts and seeds provide the protein our muscles need. And guess what? Our bodies actually need fat – healthy fats like canola oil and olive oil, which provide the essential fatty acids needed for brain development in children, among other things. We also need some saturated fats in moderation.

What’s my proposal?
Turn the hashtag #cleaneating into #healthyliving. Meaning, focus on incorporating a variety of ALL food groups into our diets in moderate portions, living an active lifestyle – aiming for 60 minutes of physical activity daily (yes, kids too) – and doing what is best for us individually and for our family. Living a healthy lifestyle can be an adventure for the whole family. Parents can exercise with their kids and involve them in preparing food in the kitchen. A registered dietitian can answer questions and help get families on track to a #healthyliving lifestyle.

Happy #healthyliving!

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My Child Has Headaches: What Should I Do?
August 2014

Did you know that 20 percent of adults who develop headaches in their lifetime will begin having them before 10 years of age? Headaches are a common problem in children, which is why it’s important to know when to treat them at home and when it’s time to seek help from a physician. Dr. Michelle Holick, a pediatric neurologist at Texas Children’s Hospital, answers some of the most common questions about headaches.

What are headaches and how do they affect kids?
There are many types of headaches and causes, but most commonly we see children with migraines and tension headaches. These types of headaches are caused by several parts of the brain, including blood vessels and pain centers. During a migraine, messages from these areas are sent, releasing chemicals that inflame and irritate the nerves and vessels. This can make even normal sensations, such as lights or noise, intense and painful for your child.

Are my child’s headaches serious enough to seek the help of their pediatrician?
Children may feel better if they can “sleep off” their headache, but occasionally headaches can be more serious, causing children to miss activities and even school. If headaches become debilitating and interfere with everyday life, seek help.

Can headaches be treated at home?
Headaches are often easily treated at home, with sleep and/or over-the-counter medication. When headaches continue despite these interventions, are frequent, or if there is question regarding the cause of the headache, pediatricians will usually refer your child to a neurologist.

When should I seek the help of a neurologist?
It’s important to look for warning signs, such as headaches that change over time or increase in frequency. Additionally, certain symptoms raise concern. Visual changes, loss of vision, weakness or loss of sensation, headache on awakening with or without vomiting, confusion or difficulty thinking signal a concern for secondary headaches (a headache caused by an underlying medical problem). Note that migraines can involve these symptoms, but other secondary causes should be considered as well. If any of these symptoms are present, parents should let their child’s pediatrician know.

What should I expect after reaching out to a neurologist?
The neurologist will likely recommend you keep a diary of your child’s headaches (e.g. frequency and triggers). They will advise having your child avoid any known headache triggers and suggest treatments for the headaches. Treatment may include preventative medication and/or medicine to stop the headaches once they begin. Your child may also be referred to physical therapy, psychology or another specialty if there are other concerns. Imaging, such as an MRI of the brain, is conducted when there is concern that the headache may be due to an underlying structural issue. Other tests may also be considered and a thorough medical history and neurologic examination is necessary in making an accurate diagnosis.

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Children’s Sleep Habits
May 2014

Dr. Marni Axelrad, a child psychologist at Texas Children’s Hospital, shares important advice about a topic to which all parents can relate — children’s sleep habits.

At what age is it typical for children to experience problems with sleep?
All parents will run across sleep dilemmas with their child at some point. If it doesn’t happen at 5 months old, it will happen at 5 years old, but it will happen! To say sleep is important would be a major understatement – sleep is necessary to function, to live. The good news is that for the vast majority of people, healthy sleep is just a habit or two away.

What if an infant is having trouble sleeping?
If the baby is less than 9 months old, consult a pediatrician if there are sleep difficulties.

How early can babies be sleep-trained?
Most babies can be sleep-trained before they are 9 months old.

How much sleep does a child really need?
There is individual variation here, but on average:

  • 1 to 2-year-olds need 11 – 12.5 hours of sleep per night
  • 3 to 5-year-olds need 10.5 – 11.5 hours
  • 6 to 7-year-olds need about 10.5 hours
  • 7 to 13-year-olds need about 10 hours
  • Even 18-year-olds need about 9 hours of sleep each night

Why does it seem impossible for children to get the recommended amount of sleep?
The reason it seems impossible usually is not because the child would not benefit from that much sleep but because by the time parents arrive home from work, the family eats dinner, homework is done, maybe the child has sports practice – it is already too late for bedtime. Life happens, and we would not tell anyone to put a child to bed without feeding them (most of the time) or visiting with them, but routines need to be structured in a way that get children the amount of sleep they will thrive on most of the time.

What can be done to maximize the amount of sleep a child gets?
If the child will sleep an hour later on a weekend, see if the child can get on a soccer team on Fridays or if 6 p.m. gymnastics is going to throw the whole family off, give that feedback to the coach. Parents would be amazed how quickly class times can change, even by 30 minutes, if enough parents give the same feedback.

When should a child give up her nap time?
Although most 4-year-olds are no longer napping, some still are and the amount of time a child needs to sleep is spread over a 24-hour period. For this reason, a 4-year-old may go to sleep earlier than a 2-year-old. If a 4-year-old still naps, understand that when they are in school this will no longer happen, and bedtime will need to be adjusted.

What should be done when a child does not seem tired at bedtime?
If a child seems hyper at bedtime, and bedtime is based on the recommended average number of hours of sleep, chances are the child is overtired. Try to put them to bed 30 minutes earlier the next night, or try to catch them just before the witching hour and start bedtime then. It is counterintuitive that children become hyper when they are overtired, but it often happens. Also, kids will do anything to resist bedtime – they want to stay up and spend more time with their parents.

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Flu Symptoms: When to Bring Your Child into the Emergency Center

January 2014

The United States is in the midst of a severe flu season, with a significant jump in flu-related emergency center visits and hospital admissions over the past several weeks.

It’s important for parents to understand when they should or should not bring a child into an emergency center with flu-like symptoms, explains Dr. Katherine Leaming, Pediatric Emergency Medicine Specialist at Texas Children’s Hospital.

The flu can have a range of symptoms and effects, from mild to severe. Most healthy people – including children – can recover from the flu without problems and do not need to go to the emergency center or be hospitalized.

Symptoms of the flu can include:

  • high fever,
  • headache,
  • tiredness,
  • cough,
  • sore throat,
  • runny or stuffy nose,
  • body aches,
  • diarrhea, and
  • vomiting.

A child with mild flu-like symptoms usually can be cared for at home with fever-reducing medication (such as Tylenol or if the child is over six months old, Ibuprofen), clear fluids and bed rest. If diagnosed early enough, some children may benefit from Tamiflu®, a medication which can be prescribed by a pediatrician. To ensure that a child fully recovers from the flu, he/she should stay home for at least 24 hours after the fever is gone.

If the child has worsening or severe flu-like symptoms or is at high risk of flu complications (children with chronic illnesses such as asthma, heart disease, diabetes, sickle cell disease, cancer and/or children who are younger than 2 years old), call the child’s physician or primary care provider for advice on treatment.

Seek immediate medical attention if the child exhibits any of the emergency warning signs listed below:

  • severe headache or neck stiffness;
  • fast breathing or trouble breathing;
  • bluish skin color;
  • not drinking enough fluids;
  • not waking up or not interacting; or
  • being so irritable that the child does not want to be held.

In adults, emergency warning signs that need urgent medical attention include:

  • difficulty breathing or shortness of breath;
  • pain or pressure in the chest or abdomen;
  • sudden dizziness;
  • confusion; or
  • severe or persistent vomiting.

Remember – although most flu-like illnesses can be treated at home, if  there is elevated concern about the child’s illness or the child exhibits any of the emergency warning signs,  seek immediate medical care!

As always, vaccination is the best way to prevent the flu in people of all ages, and it is not too late to get vaccinated.

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Healthy Exercising: Suitable Physical Activities for Pregnant Women

September 2013

There is no question that exercise is good for the body. Many women worry that exercising during pregnancy will do more harm than good. What steps should be taken to continue regular exercise during pregnancy? Dr. Codi Wiener, an OB/GYN at the Women’s Specialists of Houston at Texas Children’s Pavilion for Women, says, “If women follow certain guidelines, exercising during pregnancy may be more than safe – it may be extremely beneficial.” Read more of Dr. Wiener’s advice below:

What are the benefits of regular exercise during pregnancy?

Regular exercise during pregnancy can have a positive impact on physical and emotional well-being. Physical activity may help to reduce constipation and swelling, and has the potential to prevent gestational diabetes. Exercise during pregnancy life can also lead to an improvement in mood. Furthermore, women who exercise while they are pregnant are generally able to lose their pregnancy weight at a faster rate after delivery. Physical activity also prepares women for the big day because being in labor is like running a marathon – the more endurance a woman has, the easier it will be!

What are the current exercise recommendations for pregnant women?

The American College of Obstetrics and Gynecology suggests exercising for at least 30 minutes a day. Non-exercisers should focus on walking and swimming. If a woman is an active runner before pregnancy, she may continue to go on normal runs as long as this is approved by her obstetrician. When lifting weights, women who are pregnant should use lighter weights and do more reps, and remember to avoid holding their breath. These exercise guidelines have been the subject of studies that looked at the effects on the fetus and mother immediately after exercise, during labor and even later in the child’s growth. As a result, these guidelines are backed by sound medical research.

What precautions should women take while exercising during pregnancy?

Physical activity during pregnancy is only safe if done correctly. This means that pregnant women should avoid all contact sports and any jumping or jarring movements. After the first trimester, pregnant women keep away from exercises that require lying on the back for more than a few minutes at a time. Most importantly, pregnant women must ensure to stay properly hydrated and consume an adequate amount of calories.

What are some signs that women should stop exercising while pregnant?

If there is any vaginal bleeding, leakage of fluid, contractions, chest pain or decreased fetal movement, pregnant women should immediately stop regular exercises and contact their obstetrician.

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Q&A About Dehydration
June 2013

With hot summer weather on the horizon, one of the most important ways parents can keep their young, athletic children safe is by making sure they are adequately hydrated. Roberta Anding, Director of Sports Nutrition at Texas Children’s Hospital has plenty of advice to make sure active kids are getting the hydration they need.

Why it is important for a child to stay properly hydrated?

During exercise, water and electrolytes are lost in sweat. If the loss is not replenished, this could lead to a decrease in performance and potential life-threatening, heat-related injuries. Younger athletes are more at risk for dehydration.


What are the signs of dehydration?

Muscle cramps, nausea, dizziness, weakness and the inability to concentrate are all signs of dehydration.

Athletic performance is at its best when fluid balance is achieved. Optimal hydration should replace sweat loss. The Institute of Medicine recommends that sodium, potassium and carbohydrates be included in replacement beverages. An adequate amount of sodium may help prevent cramping, and carbohydrates provide extra energy. Cramping for nutritional reasons is almost always due to a loss of fluid and sodium. Note that the amount of electrolytes in a sports drink is less than the amount in sweat.


What are three easy ways to assess hydration in my child?

  1. Sweat Rate: To determine sweat rate, weigh your child in typical active wear. After your child has played for about an hour, change them into  dry clothes, wipe off all sweat and weigh your child again. The difference in body weight is your child’s sweat rate assuming your child did not drink or eat during the activity. For every pound lost, replace with 16 oz of fluids within 24 hours.
  2. Specific Gravity: Testing the specific gravity of your child’s urine will also help to assess hydration. Test strips are available at most drugstores along with directions on use. Urine specific gravity should be within the range of 1.010 to 1.020.
  3. Urine Color: Assessing urine color during exercise is another way to monitor hydration. The lighter the color, the healthier the hydration.


How much fluid and electrolytes are needed for exercise?

The amount of fluid and electrolytes needed for exercise depends on many different factors which affect sweat loss including age, gender, clothing, weather, medications, intensity and duration of exercise, recent heat exposure  and fitness level.

When beginning activity  it is important for athletes to be well-hydrated. At least 4 hours before physical activity begins, your child should drink a half cup of fluid for every 40 pounds of body weight. Hydrating during intense activity is very important, but amounts will differ based on an individual’s sweating and duration and intensity of exercise. Hydration should occur during every break. Once completing physical activity, it is essential to replace what was lost. By adding extra sodium into the diet in the recovery phase, thirst is increased and fluid is recovered. Fruits and vegetables are hidden sources of fluid.

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