Toilet training can be a prolonged and frustrating experience for both parents and children.
Most children potty-train by 3 years of age, with an average training time of 6-7 months. Daytime continence (urinating in the toilet) with dry pull-ups or underwear precedes night-time continence. Most of the developmental skills necessary for toilet training success begin at about 2 years of age. Certain physiologic signs should be present before successful training: voluntary bladder control (usually starts at 12-18 months), awareness of urge to go (15-24 months) and ability to maintain dryness for more than a 2 hr period (usually 25-30 months). Children should be able to follow commands and communicate that their diaper is wet/dirty. Children with developmental delays may need extra time/attention especially if communication skills are an issue. Children also need the motor skills necessary to get to the bathroom, remove their clothing and sit on a potty chair or the toilet. In the early stages, a child will also need to understand what the potty is for; imitating or watching adults or older siblings go the the bathroom is useful. Some children continue to need pull-ups at night until 5-6 years of age, so being completely dry at night is not necessary to begin the toilet-training process.
Toilet training may begin when children start to show readiness and interest, either by imitating adults or by attempting to remove soiled or dirty diapers. This may begin anywhere between 18-24 months; however, some 2 year old children are not showing readiness signs, and shouldn't be pushed. Buying a potty chair and talking about the potty can occur, and children can "practice" by sitting on the chair fully clothed, then with pants off and only wearing a diaper, etc. when the parents are using the bathroom. This imitation of parent activity can be a positive and enjoyable experience for kids. As children develop urge, it is important to notice this and associate urge with voluntary release of urine or stool. Constipation is a frequent issue with children, especially at toilet training age, and can definitely interfere with the toilet-training process. Family pressure and stress, a change in environment, new baby in the family, or a change in family dynamics may retard the process.
Tips:
1. Focus on ownership of the process - recognize what skills your child has and what they can do. Start with small steps and work up as children show success. For example, take off dirty diapers in the bathroom, have the child help with clean up/new diaper. Once this is established, you can work up to potty-sitting (with or without a diaper) if the child is not resistant.
2. Eliminate stress - talk about the potty, make it a positive experience and don't push; if a child shows regression (was previously interested, now is not) - back off, put them back in diapers or pull-ups and try again in a few weeks. You can still have them come in the bathroom with you or talk about peeing/pooping, even if they won't participate.
3. Schedule potty time - regular times that your child can sit on the potty with or without actually going; the gastrocolic reflex leads most people to go 30 min. after a meal. Sitting time should be about 10 min.
4. Reward systems work - star charts, M and Ms, stickers, etc. Have the chart in the bathroom and reward kids for sitting on the potty - even if they do not actually go. Heap praise on your child when he does go in the potty. Talk about how proud you are of them learning to go potty.
5. Stay positive, and be flexible - adjust tactics if needed, and don't get discouraged for children who regress or take longer
6. Address constipation and stool withholdiing if this interferes with the process. For many children, constipation needs to resolve before they can truly have good urinary continence. Address constipation issues with your child's medical provider.
7. Seek out books that are age-appropriate that discuss children learning to go potty. Point to the pictures, and talk about what is going on. This will reinforce the normalcy of the process, and repetition will breed comfort with the activity of sitting on the toilet.
Wednesday, December 12, 2012
Monday, August 27, 2012
Hand, Foot and Mouth Disease - update
We are starting to see more local cases of Hand, Foot and Mouth disease, a viral illness usually caused by a virus called Coxsackie. Typically, summer and fall are the seasons in which we tend to see more Hand, Foot and Mouth disease. Several years ago, a more severe form of Coxsackie started showing up in various locations around the U.S, and this new variant was identified as "Coxsackie A6".
In the past, Coxsackie A6 patients with Hand, Foot and Mouth disease tended to be sicker and younger (63% less than 2 years old), with some children needing to be hospitalized. The classic rash of Hand, Foot and Mouth tends to be pink or red vesicles on the sides of fingers, hands, toes and feet. The hands are involved more often than the feet. Some children will have small red dots and vesicles on the back of their throat lateral to the tonsils or on the back of the palate.
The current cases we are seeing also have vesicles on the buttocks, lower legs and the perioral (around the mouth) area. These lesions around the mouth may be mistakenly diagnosed as impetigo (a bacterial skin infection).
Hand, Foot and Mouth disease is most common in children under the age of 5; in rare cases, older kids and adults can get it (I have seen parents and older school age children with cases in the last month). Most often, the disease is caused by coxsackie viruses, though a virus called enterovirus 71 can also cause a similar illness. In Asia, enterovirus 71 has caused a cluster of severe neurologic symptoms and encephalitis. Thankfully, what we see here in the U.S. is usually limited to rash and fever - sometimes the fever can be quite high.
Hand, Foot and Mouth disease has a short incubation period - usually about 4-6 days, and will resolve spontaneously in about a week. The virus is transmitted through contact with infected saliva, respiratory secretions, the skin vesicles themselves, or contact with stool of someone who has the infection.
You can prevent the spread of Hand, Foot and Mouth disease by:
covering coughs, washing hands often (especially after changing diapers), disinfecting dirty surfaces, and avoiding close contact such as kissing and sharing eating utensils with infected persons.
In the past, Coxsackie A6 patients with Hand, Foot and Mouth disease tended to be sicker and younger (63% less than 2 years old), with some children needing to be hospitalized. The classic rash of Hand, Foot and Mouth tends to be pink or red vesicles on the sides of fingers, hands, toes and feet. The hands are involved more often than the feet. Some children will have small red dots and vesicles on the back of their throat lateral to the tonsils or on the back of the palate.
The current cases we are seeing also have vesicles on the buttocks, lower legs and the perioral (around the mouth) area. These lesions around the mouth may be mistakenly diagnosed as impetigo (a bacterial skin infection).
Hand, Foot and Mouth disease is most common in children under the age of 5; in rare cases, older kids and adults can get it (I have seen parents and older school age children with cases in the last month). Most often, the disease is caused by coxsackie viruses, though a virus called enterovirus 71 can also cause a similar illness. In Asia, enterovirus 71 has caused a cluster of severe neurologic symptoms and encephalitis. Thankfully, what we see here in the U.S. is usually limited to rash and fever - sometimes the fever can be quite high.
Hand, Foot and Mouth disease has a short incubation period - usually about 4-6 days, and will resolve spontaneously in about a week. The virus is transmitted through contact with infected saliva, respiratory secretions, the skin vesicles themselves, or contact with stool of someone who has the infection.
You can prevent the spread of Hand, Foot and Mouth disease by:
covering coughs, washing hands often (especially after changing diapers), disinfecting dirty surfaces, and avoiding close contact such as kissing and sharing eating utensils with infected persons.
Wednesday, July 25, 2012
Handling Childhood Emergencies - part 2
When to call 911: Conditions that require immediate attention
Child is unconscious or is choking/turning blue or struggling to breathe
A seizure that lasts longer than 5 minutes, or any seizure if your child has never had one before
Fall from a height of 10 feet or more, or if you child cannot move or talk following an injury. In this case, it is important not to move your child - wait for an ambulance to arrive.
Injury to an arm or leg with: bone protruding through the skin, limb is awkwardly bent or child cannot move the injured extremity.
Burns that are blistered, severely swollen or appear white or charred; any electrical burn
Uncontrolled bleeding from a wound; animal bite from a potentially rabid animal or bite accompanied by difficulty breathing
Fever with a stiff neck (possible meningitis)
Unexplained rash accompanied by shortness of breath or chest tightness
Severe vomiting or diarrhea and dehydration -- signs may include no urine output for several hours, no tears when crying, skin or lips look purple
When to call your pediatrician or doctor's office:
Child has mild asthma symptoms (shortness of breath or wheezing)
Seizure that lasts less than five minutes, if the child has had previous seizures
Fall from a relatively short distance - off playground equipment or down a short flight of stairs; child is conscious and can move/walk
Swelling, tenderness and pain at the site of an injury, but child can still move injured part
Burns with slight swelling or redness
Cuts that are more superficial, but not bleeding profusely; cat or dog bites with minor bleeding and no other symptoms
Unexplained rash without other symptoms
Vomiting and diarrhea without obvious signs of dehydration
Child is unconscious or is choking/turning blue or struggling to breathe
A seizure that lasts longer than 5 minutes, or any seizure if your child has never had one before
Fall from a height of 10 feet or more, or if you child cannot move or talk following an injury. In this case, it is important not to move your child - wait for an ambulance to arrive.
Injury to an arm or leg with: bone protruding through the skin, limb is awkwardly bent or child cannot move the injured extremity.
Burns that are blistered, severely swollen or appear white or charred; any electrical burn
Uncontrolled bleeding from a wound; animal bite from a potentially rabid animal or bite accompanied by difficulty breathing
Fever with a stiff neck (possible meningitis)
Unexplained rash accompanied by shortness of breath or chest tightness
Severe vomiting or diarrhea and dehydration -- signs may include no urine output for several hours, no tears when crying, skin or lips look purple
When to call your pediatrician or doctor's office:
Child has mild asthma symptoms (shortness of breath or wheezing)
Seizure that lasts less than five minutes, if the child has had previous seizures
Fall from a relatively short distance - off playground equipment or down a short flight of stairs; child is conscious and can move/walk
Swelling, tenderness and pain at the site of an injury, but child can still move injured part
Burns with slight swelling or redness
Cuts that are more superficial, but not bleeding profusely; cat or dog bites with minor bleeding and no other symptoms
Unexplained rash without other symptoms
Vomiting and diarrhea without obvious signs of dehydration
Handling Childhood Emergencies - part 1
Many parents feel ill-equipped to handle household injuries and emergencies. With some preparation and training, you can start to feel equipped and ready for some common emergencies that may happen in your household.
When emergencies happen, parents have to be ready to make quick decisions: whether to call 911 for emergency aid/ambulance, whether to take their child by car to an emergency room, or call their child's regular doctor for advise. If a child is not in a life-or-death situation, their physician's office should be able to see them sooner than an overwhelmed and busy emergency room. It is important to know, however, what the pediatrician's office can handle -- asthma flare-ups, injuries, etc. Most physicians are equipped to see you on a same day basis if the office is open, and give medications (like breathing treatments or steroids) and order X-rays if needed. Some doctors' offices do not do stitches, so if your child has a laceration that may need to be repaired, an urgent care center or emergency room is more appropriate. Find out the closest emergency room and urgent care center to your home, and which hospitals or after hours clinics your physician prefers. Once you know where to go, write down the directions and keep them easily accessible in your house.
When visiting an ER or urgent care center, be prepared to answer the following:
Proof of insurance coverage if any, regular doctors' name, address, phone number
Time of your child's last meal (in case anaesthesia is needed)
List of your child's medical conditions (if any), regular medications taken, and date of last tetanus shot
Consent form for someone else (grandparent, babysitter) to seek emergency care for your child; it should read "I hereby grant [name] permission to seek emergency medical help in the event that my child [name] is injured or otherwise in need of medical care. I will assume financial responsibility for treatment rendered during this time". This can be handwritten. Place a phone number (such as a cell number) where you can be reached if needed.
Emergency room physicians also like to remind parents to bring any medicine or cleaning substance that children have swallowed to the ER with them. In a panic, most parents forget this and then cannot recall exactly what their children have ingested.
It is wise to keep these written instructions together near the kitchen refrigerator or phone in case you need to grab them quickly.
A list of emergency numbers should also be posted by a central telephone, including: pediatrician's phone number, phone number for the local ER or after hours clinic, phone number for poison control.
The local poison control center can be invaluable in the case of an accidental ingestion, and can direct you in home treatment vs. the necessity for an emergency evaluation. Give poison control any specific information that you can - oftentimes, it is necessary to estimate how much a child has ingested, especially with medications.
When emergencies happen, parents have to be ready to make quick decisions: whether to call 911 for emergency aid/ambulance, whether to take their child by car to an emergency room, or call their child's regular doctor for advise. If a child is not in a life-or-death situation, their physician's office should be able to see them sooner than an overwhelmed and busy emergency room. It is important to know, however, what the pediatrician's office can handle -- asthma flare-ups, injuries, etc. Most physicians are equipped to see you on a same day basis if the office is open, and give medications (like breathing treatments or steroids) and order X-rays if needed. Some doctors' offices do not do stitches, so if your child has a laceration that may need to be repaired, an urgent care center or emergency room is more appropriate. Find out the closest emergency room and urgent care center to your home, and which hospitals or after hours clinics your physician prefers. Once you know where to go, write down the directions and keep them easily accessible in your house.
When visiting an ER or urgent care center, be prepared to answer the following:
Proof of insurance coverage if any, regular doctors' name, address, phone number
Time of your child's last meal (in case anaesthesia is needed)
List of your child's medical conditions (if any), regular medications taken, and date of last tetanus shot
Consent form for someone else (grandparent, babysitter) to seek emergency care for your child; it should read "I hereby grant [name] permission to seek emergency medical help in the event that my child [name] is injured or otherwise in need of medical care. I will assume financial responsibility for treatment rendered during this time". This can be handwritten. Place a phone number (such as a cell number) where you can be reached if needed.
Emergency room physicians also like to remind parents to bring any medicine or cleaning substance that children have swallowed to the ER with them. In a panic, most parents forget this and then cannot recall exactly what their children have ingested.
It is wise to keep these written instructions together near the kitchen refrigerator or phone in case you need to grab them quickly.
A list of emergency numbers should also be posted by a central telephone, including: pediatrician's phone number, phone number for the local ER or after hours clinic, phone number for poison control.
The local poison control center can be invaluable in the case of an accidental ingestion, and can direct you in home treatment vs. the necessity for an emergency evaluation. Give poison control any specific information that you can - oftentimes, it is necessary to estimate how much a child has ingested, especially with medications.
Wednesday, July 11, 2012
Vaccine Studies: Examine the Evidence
I usually don't cut and paste or forward too many medical spam articles, but this is a great synopsis of the articles that have addressed concerns regarding immunizations (specifically MMR) and autism. The consensus of multiple medical studies is that there is NO link between vaccines and autism.
Most physicians believe that vaccines have been associated or thought causal in the lay press solely because of timing -- many childhood vaccines are given in the 6-12 months prior to the development of classic signs and symptoms of autism.
If parents remain overly concerned about autism, they can choose to delay some vaccines (such as MMR or Varicella) until their children are 18-24 months old, the age at which symptoms of autism usually become apparent.
HealthyChildren.org - Vaccine Studies: Examine the Evidence
Most physicians believe that vaccines have been associated or thought causal in the lay press solely because of timing -- many childhood vaccines are given in the 6-12 months prior to the development of classic signs and symptoms of autism.
If parents remain overly concerned about autism, they can choose to delay some vaccines (such as MMR or Varicella) until their children are 18-24 months old, the age at which symptoms of autism usually become apparent.
HealthyChildren.org - Vaccine Studies: Examine the Evidence
Friday, July 6, 2012
Help! My baby/toddler won't stay asleep!
This is a common topic that we address with parents -- probably because sleep issues are common AND distressing to parents, who are sometimes at a loss when it comes to solving the issues surrounding sleep and nighttime for young children.
Waking during the night is normal at 3-6 months old, and 30% of babies are "signalers" who cry and expect a parental response to their crying. By 8-9 months old, 60-70% of infants can self-soothe when they wake at night, giving them the ability to put themselves back to sleep. 20-30% of toddlers are night wakers. When problems are not addressed at this age (and self-soothing behaviors taught), sleep problems will continue for many children -- into early elementary school.
The goal when approaching any sleep issues is to help your infant/todder or child be able to fall asleep on their own without "props" or excessive parental strategies. All children need a bedtime routine, and this can be started and maintained from a young age. It is important to be consistent at bedtime - doing the same things every night, putting children to bed at the same time every night. We often refer to the "bedtime routine" and this is family specific - it may include a bath, bottle or feeding for young infants, cuddling, story time or soft music. It is very important to put your child to bed while sleepy BUT not completely asleep. I repeat: sleepy but NOT asleep. This is important. Do not let your baby or child fall asleep somewhere else and move them. Learning to fall asleep on their own is the most important skill your child needs to acquire.
Dr. Charles Zeanah, a professor of Pediatrics and Psychiatry at Tulane University, recently spoke at a pediatric meeting and outlined his approach which he called a "hardball strategy": Leave your child in the bed at bedtime. If they continue to cry, go in the room after 5 minutes, soothe the child by using words or gentle touch, but do not get them out of the bed. Leave again -- and repeat at 5 minute intervals if the child keeps crying. As your child adapts, these intervals can gradually be lengthened -- 10 min., then 15 min, etc. In my practice, this "crying it out" strategy takes 5-7 days to work. As a parent, you have to be "all in" and invested in this strategy and follow it to the letter for it to work. It is also very important that both parents (or caregivers) be consistent in the approach.
A more gentle strategy is to respond to the crying but to sit next to the child's bed soothing them - but again, not getting them out of the bed. You can sit next to the bed until your child falls asleep. The next night, sit farther away and gradually move farther away each night -- letting your child see you is important in alleviating some fear. I know personally that this strategy works - especially for toddlers who can either get out of the bed (and love to come to their parent's bed - if they can get away with it) or who continue to call out/cry/cajole for parents to come back in the room. My husband and I tried this approach when my daughter was 2 years old and bedtime avoidant. I tried to be as boring as possible in the 5-10 minutes I stayed in her room - I didn't engage with her, and spent the time lying on the floor reading. Eventually, she gave up needing us in her room in order to fall asleep.
Remember -- your goal is to help your child fall asleep without you :)
Waking during the night is normal at 3-6 months old, and 30% of babies are "signalers" who cry and expect a parental response to their crying. By 8-9 months old, 60-70% of infants can self-soothe when they wake at night, giving them the ability to put themselves back to sleep. 20-30% of toddlers are night wakers. When problems are not addressed at this age (and self-soothing behaviors taught), sleep problems will continue for many children -- into early elementary school.
The goal when approaching any sleep issues is to help your infant/todder or child be able to fall asleep on their own without "props" or excessive parental strategies. All children need a bedtime routine, and this can be started and maintained from a young age. It is important to be consistent at bedtime - doing the same things every night, putting children to bed at the same time every night. We often refer to the "bedtime routine" and this is family specific - it may include a bath, bottle or feeding for young infants, cuddling, story time or soft music. It is very important to put your child to bed while sleepy BUT not completely asleep. I repeat: sleepy but NOT asleep. This is important. Do not let your baby or child fall asleep somewhere else and move them. Learning to fall asleep on their own is the most important skill your child needs to acquire.
Dr. Charles Zeanah, a professor of Pediatrics and Psychiatry at Tulane University, recently spoke at a pediatric meeting and outlined his approach which he called a "hardball strategy": Leave your child in the bed at bedtime. If they continue to cry, go in the room after 5 minutes, soothe the child by using words or gentle touch, but do not get them out of the bed. Leave again -- and repeat at 5 minute intervals if the child keeps crying. As your child adapts, these intervals can gradually be lengthened -- 10 min., then 15 min, etc. In my practice, this "crying it out" strategy takes 5-7 days to work. As a parent, you have to be "all in" and invested in this strategy and follow it to the letter for it to work. It is also very important that both parents (or caregivers) be consistent in the approach.
A more gentle strategy is to respond to the crying but to sit next to the child's bed soothing them - but again, not getting them out of the bed. You can sit next to the bed until your child falls asleep. The next night, sit farther away and gradually move farther away each night -- letting your child see you is important in alleviating some fear. I know personally that this strategy works - especially for toddlers who can either get out of the bed (and love to come to their parent's bed - if they can get away with it) or who continue to call out/cry/cajole for parents to come back in the room. My husband and I tried this approach when my daughter was 2 years old and bedtime avoidant. I tried to be as boring as possible in the 5-10 minutes I stayed in her room - I didn't engage with her, and spent the time lying on the floor reading. Eventually, she gave up needing us in her room in order to fall asleep.
Remember -- your goal is to help your child fall asleep without you :)
Tuesday, June 12, 2012
RIsks of CT scans in Children
I just recently read two articles on the risks of radiation exposure through CT scans in children - one on-line via Fox News, and one in the local Washington Post newspaper.
A 20 year study was recently published combining data from the US, Canada and Great Britain. The results show that exposure in childhood to the radiation equivalent of 2-3 Head CT scans can triple the risk of developing brain cancer later in life, and a child exposed to 5-10 CT scans is three times as likely to develop leukemia than a child who had no scans done.
Children are more sensitive to radiation than adults due to growing bones and tissues, as well as their relatively lower body weights.
This is sobering information that doctors have been alerted to for awhile -- I have been to several conferences at which childhood radiation exposure was discussed, from X rays to CT scans. A CT scan gives great definition, and is useful in looking for bleeds (in the case of head trauma) and solid tumors. Many emergency rooms use CT scans as part of an evaluation of abdominal pain, when the diagnosis of appendicitis is entertained, but not clear cut. Yes, doctors do sometimes practice defensive medicine, but no one wants to miss the appendicitis, the brain tumor or a devestating bleed from a case of head trauma in an otherwise healthy child.
There are alternatives: ultrasound exams do not expose one to radiation, and an MRI (Magnetic Resonance imaging) exam may give great definition of some structures without radiation. An MRI is typically more expensive, may be denied by your insurance company, and requires your child to remain motionless for a more prolonged period of time.
Many experts have weighed in on either side. Per Dr. Raymond Sze at Children's Hospital in Washington DC, "If the benefit to the child is greater than the theoretical risk, then (the CT scan) is appropriate".
A campaign called Image Gently is designed to alleviate concerns of providers and parents, and reduce radiation exposure through greater education. In addition to recommending that scans only be performed when medical benefits are clear, it also recommends limited scanning -- only the area of the body absolutely necessary. Image Gently also recommends evaluation of other imaging modalities like ultrasound and MRI. Donald Frush, chairman of the American College of Radiology's pediatric radiology commission, has said "People need to ask: Is it necessary? Can you do another test, such as an MRI? Can you wait a couple of days?"
Doctors suggest parents discuss CTs with the ordering provider and act as advocates for the children by asking if facilities take steps to reduce radiation exposure in children.
As a parent, I do understand the concerns of exposing one's child to radiation unnecessarily. At the same time, I am a doctor, and need to weigh the risks and benefits with my parents whenever I am ordering studies of any kind.
A 20 year study was recently published combining data from the US, Canada and Great Britain. The results show that exposure in childhood to the radiation equivalent of 2-3 Head CT scans can triple the risk of developing brain cancer later in life, and a child exposed to 5-10 CT scans is three times as likely to develop leukemia than a child who had no scans done.
Children are more sensitive to radiation than adults due to growing bones and tissues, as well as their relatively lower body weights.
This is sobering information that doctors have been alerted to for awhile -- I have been to several conferences at which childhood radiation exposure was discussed, from X rays to CT scans. A CT scan gives great definition, and is useful in looking for bleeds (in the case of head trauma) and solid tumors. Many emergency rooms use CT scans as part of an evaluation of abdominal pain, when the diagnosis of appendicitis is entertained, but not clear cut. Yes, doctors do sometimes practice defensive medicine, but no one wants to miss the appendicitis, the brain tumor or a devestating bleed from a case of head trauma in an otherwise healthy child.
There are alternatives: ultrasound exams do not expose one to radiation, and an MRI (Magnetic Resonance imaging) exam may give great definition of some structures without radiation. An MRI is typically more expensive, may be denied by your insurance company, and requires your child to remain motionless for a more prolonged period of time.
Many experts have weighed in on either side. Per Dr. Raymond Sze at Children's Hospital in Washington DC, "If the benefit to the child is greater than the theoretical risk, then (the CT scan) is appropriate".
A campaign called Image Gently is designed to alleviate concerns of providers and parents, and reduce radiation exposure through greater education. In addition to recommending that scans only be performed when medical benefits are clear, it also recommends limited scanning -- only the area of the body absolutely necessary. Image Gently also recommends evaluation of other imaging modalities like ultrasound and MRI. Donald Frush, chairman of the American College of Radiology's pediatric radiology commission, has said "People need to ask: Is it necessary? Can you do another test, such as an MRI? Can you wait a couple of days?"
Doctors suggest parents discuss CTs with the ordering provider and act as advocates for the children by asking if facilities take steps to reduce radiation exposure in children.
As a parent, I do understand the concerns of exposing one's child to radiation unnecessarily. At the same time, I am a doctor, and need to weigh the risks and benefits with my parents whenever I am ordering studies of any kind.
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