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Potty Training

Potty Training

Daily Dose

How to Treat Stool Holding

Stool holding part 2: how to treat this common ailment.On Friday, we discussed stool holding and encopresis: what it is and why kids have trouble going to the bathroom.   Now it’s time to discuss treatment.

The medicinal component of treatment begins with  cleaning out the rectum. This is typically done by using enemas (Fleets) to get rid of the large amount of old stool that has distended the rectum.  Mineral oil given orally may also help the stool to be evacuated (it is tasteless but a child can see the oil, so get a soft drink or juice and put a top on it and mix in the mineral oil and serve with a straw), you can also mix into oatmeal. I typically use an enema to start and then keep up daily mineral oil for awhile until the stools are routinely soft and not painful.  Enemas are not well liked by anyone.  A daily laxative is also important. Milk of Magnesia and Miralax are my favorites.  The dose may be titrated but you want to ensure that your child is having a stool every day. The laxatives are not habit forming, but are serving a purpose to help the colon begin to work correctly again. Once your child is having regular bowel movements without pain, or avoidance you can slowly wean the laxative too, but do this over several months. Dietary therapy is also important to help soften stools and decrease the transit time of stool in the colon. Healthy eating habits which incorporate high fiber foods are helpful. The formula for fiber intake is the child’s age in years + 6 = number of grams of fiber /day. You would be surprised at fiber content of foods and they are all listed on the food packages. Benefiber is also a good source of fiber and can be used daily.  I like  to use Metamucil cookies too and if necessary put a little icing on top.  Adding more fluid to a child’s diet is equally important , and a “prune juice cocktail” made with prune juice and seven up or ginger ale is a great way to get in some more fluid with additional laxative benefit. (you taste it not bad at all!) Lastly, behavior modification.  Begin by establishing a regular toileting schedule. This is typically after each meal (to take advantage of the gastro-colic reflex which occurs after eating and causes intestines to contract) and at bedtime.  I sometimes use a timer as a game to try and have the child “beat the clock” in pushing out their poop, and then they receive a “prize” (Dollar store is adequate, does not need to be expensive etc.). A child needs lots of positive reinforcement with charts, stickers to show their progress and even larger reward (maybe trip to bookstore, or ice cream store etc) for a week of good work. Remember, this is not an overnight resolution but typically takes weeks to months of work, so be creative as to positive reinforcement. If your child does not stool every day, try using a suppository and increasing the laxative.  They can also practice doing the Valsava maneuver (where you hold your breath and bear down to have a bowel movement) which will also help them push out the stool which should be soft. If your child is in school you need to discuss these strategies with the teacher so that the child has adequate bathroom time when needed. By working on all 3 areas encopresis can be treated and successfully cured while saving the child embarrassment and anxiety that often comes with it. No one wants to have “poopy pants” they just need the tools to fix the problem. For very difficult cases you may need to ask your pediatrician about using a behaviorally trained pediatric psychologist for assistance. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Potty Questions Keep Coming

1.15 to read

Potty training always gets lots of questions and one of the most common is having a child who will "tinkle" in the potty but is not yet "pooping". When potty training all three of my boys, they all pooped later than they tinkled. I know some people disagree, but I certainly think I hear of more people who have to work a little harder and longer to get to pooping on the potty. It may be due to a toddler's fear of letting their poop go, or the difference in sensation with stooling or any number of issues that toddlers are working through as they are potty trained.

Whatever the reason for children who arenot wanting to poop, you have to continue to be patient and praise their success on the potty with urination. Continue to discuss poop within the family, and let your child see you going to the bathroom. Talk about how animals, birds, fish and people all poop and they don't do it in a diaper or underpants but in the potty. During all of this conversation (and while you are frustrated), make sure that your child is not holding stool and becoming uncomfortable, which only adds to anxiety and fear and further withholding poop. You might want to try putting your child on a prune juice cocktail, milk of magnesia, or Miralax to soften the stool and ensure that they are having a soft stool every couple of days. A toddler will often hold their stool until bedtime when they are in their diaper and will then poop or may ask for a diaper to poop during the day. This is not uncommon and usually does not last terribly long. If they want to poop in their diaper I would have them sit on the potty with a diaper and poop and then put them back in their training pants. I also praise and rewardthem for sitting on the potty to poop, even if it is in a diaper, and use a sticker chart or M&Ms or both. Hopefully, over time they will realize that sitting on the potty to poop is perfectly normal and will give up the diaper. You can even cut a hole in the diaper to let the stool come out into the potty so that they may see that it is not painful, scary or difficult. Always remember to praise and not punish and to be patient and consistent with your messages about poop. Rewards seem to go a long way, and albeit small, they often work wonders. It may take several months of persistence to conquer the poop issue, so remain calm. If they continue to have problems have a further conversation with your doctor about the possibility of stool holding and encopresis. That's your daily dose, we'll chat again soon.

Daily Dose

The Scoop On Poop

It seems that I get a lot of questions and concerns from parents about their child’s stools (poops). Who would have thought that once we become parents we would be so interested in poop!!

But from the time a baby comes home from the hospital, so begins lengthy discussions about pooping. In the newborn period stools are actually very important. A baby begins pooping shortly after birth and will have those dark, sticky meconium stools. It is important that these stools are passed and this gives both parent and pediatrician the sense that the GI tract is working properly. Soon after a baby begins eating, either breast milk or formula, the stools will quickly “transition” from meconium to lighter more normal appearing poop. Again, the baby’s stools reassure everyone that the baby is getting enough to eat and digesting the milk. For a breast feeding mother, seeing the stools should also be a gauge of breast milk production, as a baby can’t make poop without milk. It is normal for a breast fed baby to poop with almost every feeding. But be assured poop does change as the baby gets older. Once your infant seems to be eating and stooling normally, and gaining weight, it is really not necessary to keep a chart of each wet diaper and stool, as you will soon grown tired of charting, and by then it probably really doesn’t matter. Babies, just like adults, do have different stools. Some babies go more often than others, and there is not a rule as to number of stools your baby needs to have. It is not unusual for a baby to skip a day of pooping, and make it up several times the next day. If your baby is eating well, seems comfortable etc, not to worry about a day (or even two) without poop! Once a baby is out of the newborn period stools may also change in color and consistency. We get many calls about poop color, from yellow, to green, to brown to khaki, poop does come in all colors. Just wait until your baby starts eating baby foods as once again poops will change dramatically depending on what your child is eating. They also tend to stink a lot more than when an infant is only drinking milk. No wonder we parents go from worrying about how many times a baby poops, to discussions about how to get your child potty trained. The fascination with poop seems to diminish as your baby/child gets older and I laugh when our nurses ask parents of toddlers about stool history. As a mother, I could not have told you if my toddler pooped every day or not, I was more concerned that they had a bedtime routine and ate their vegetables (we all have our issues). Rule of thumb for poop is that a stool should be any color except bloody or stark white. If your child has a bloody or chalk white stool, save the diaper to show the doctor. Most stools that a baby/child has should be somewhat mushy, and not uncomfortable to pass. Again, every one will have an occasional harder, firmer stool. But you should not have a child who is always passing hard stools with difficulty. Many times it is easy enough to manipulate stools by changing diet and giving more vegetables, prunes, etc. I guess the best advice is not to perseverate about poop, and just know that this too shall pass. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

When Is The Best Time To Potty Train?

1.30 to read

Every parent wants to know, when is my child ready to potty train? A study that was recently published in an issue of The Journal of Pediatric Urology is one of the first to show that timing of potty training children seems to be more important than the technique.

I found this quite interesting as the lead author, Dr. Joseph Barone stated, this is the first study “that gives parents an idea of when it’s a good time to toilet-train”. The best time to potty train has typically been thought to be somewhere between the second and third birthday, but that is a wide range.

This study suggests that age 27-32 months is the appropriate time to move a child out of diapers. In the study, children who were toilet trained after 32 months were more likely to have urge incontinence, and problems with daytime wetting and bedwetting when they were between the ages of 4 and 12 years.

This data was gathered from a retrospective study of children who were being seen by pediatric urologists for problems with urge incontinence (daytime wetting episodes) and their answers to a questionnaire on when they started potty training and what method they used, was compared with children who did not have urge incontinence. The results showed that the mean age for children with the wetting problems to have been trained was 31.7 months while those children who did not have problems were toilet trained at 28.7 months.

Potty training continues to be at the top of the question list for parents with toddlers. I still believe and this study tends to support that children who are potty trained younger seem to have “less issues” than those that are older. That is not meant to say that your child will be potty trained by 28.7 months, but in most cases if you begin discussing the potty and following a child’s cues and follow through with reinforcement and consistency that the majority of toddlers may be potty trained by age 2 ½ (which would be 30 months).

In my experience as both a mother and pediatrician, those toddlers who are put in pull ups and never asked about going to the potty or are not taken to the potty seem to be the ones that I see at 3 year old check ups still wearing their pull-ups. By this time if you ask them if they want to go potty they all say, “NO”. I believe this is termed “the child directed approach” which seems analogous to me as saying “what time do you want to go to bed?”

In most cases, if a toddler is introduced to the toilet, goes with their parent to “sit or practice or watch Mommy and Daddy potty” during the early 2’s, and given some incentive to perform, whether that be a sticker or M & M or both, they will become interested in the potty and then they will become ready to potty train. I guess this is a combination of both the parent directed and child directed approach.

Once you see your child is interested you have to “go for it” and put them in good ‘ole cotton training pants and go to the bathroom frequently. You can’t ask if they want to go, again it is a statement, “time to go potty” and most will be trained by the “magical” 27-32 months of age.

To me potty training is somewhat like a space shuttle launch. “The window is not that wide” and you have to potty train during that magical window or the launch window may not come around again for a long time!

That's your daily dose. We'll chat again soon.

Your Toddler

Potty Training

If you ask 10 parents how they potty trained their child, you will most likely get 10 different answers. “Potty training isn’t one diaper fits all and it doesn’t work in one day,” says pediatrician Dr. Sue Hubbard, co-host of The Kid’s Doctor radio show. “When your child is ready, there are signs they are ready.” Those signs, she says, include showing interest in the potty and going to the potty several times successfully. “Start at 18 months and buy a potty, put it in the bathroom and let the child touch it, sit on it, play with it, carry it around the house, whatever, to be involved in the bathroom.”

By age two, a child may use the potty on occasion and then, Dr. Sue says, you can put them in training pants, not “pull-ups.” “Pull-ups are diapers with legs. The child does not understand the difference. They don’t get wet, they don’t have that sense of feeling dirty,” she emphasizes. It can take anywhere from three to six months for your child to become potty trained. During that time it is important for parents to praise and reward their children for their efforts, but do not punish them if they have a relapse or accident. “Parents need to recognize there is a commitment parents must make in order to make this successful,” says Dallas-based child neuropsychologist Dr. Kristy Hagar. Dr. Hubbard concurs saying “Parents need to use declarative statements like ‘It’s time to go potty Susie’ not ‘Do you need to go?’” Both Dr. Hubbard and Dr. Hagar offer some final pieces of advice for parents: Realize that every child is different and if you are in the middle of potty training, don’t give up.

Daily Dose

Why Kids Hold Their Stool

Dr. Sue explains a very common bathroom issue and why it occurs.Poop and stool habits account for numerous discussions among parents, especially for those with newborn children or parents who are in the throes of potty training.  It's true, no topic is off limits when it comes to raising healthy, resilient kids!

A problem that is more common than many know (or not willing to admit to) affects children  who do not want to poop, in other words, stool holding. Stool holding is called encopresis and is often seen in children with a history of chronic constipation or who have had stool avoidance issues. Chronic constipation and encopresis may be related to a child having had pain with going to the bathroom. The normal response to the need to poop is to go the bathroom.  Seems very simple right?  While everyone may occasionally have a difficult or painful bowel movement, some children who have pain with pooping recall that it hurt “so, why would I continue to poop and have it hurt?”  In this case when a child feels the urge to poop they also feel they need to hold the poop in. The urge to poop is due to the fact that stool has entered and stretched the rectal vault, which in turn sends impulses to the brain that “I need to poop.” If this feeling is repressed (by a child who doesn’t want to poop), the pressure may lessen for awhile but stool continues to fill the rectum, which gets more stretch and even further distended with stool. As this scenario occurs multiple times a day, the stool becomes a larger mass filling the distended rectum, which can no longer be totally “held in”.  When the child inadvertently relaxes the rectal sphincter, the softer fecal material will escape from the rectum and causes an “accident” and soiling of a child’s underwear. Many times a child is totally unaware that soiling has even occurred, but this is only “the tip of the iceberg” as there is still a huge amount of stool that is being held in the rectum. This held-in stool is usually hard, and dry and painful to pass. The treatment of encopresis is multidisciplinary, with a combination of medicinal intervention, dietary changes and behavior modification. This must involve both parents and child and it may take as long as 4 – 12 months to adequately treat and resolve the issue. Explaining the mechanics of stooling to both parent and child is important. It is also important that both parent and child understand that encopresis is NOT a behavioral problem nor is it “all in a child’s mind”. It occurs because the colon is not working as it should. Unfortunately, there is not a “quick fix” for encopresis and patience is important. More on treating encopresis on Monday.

Daily Dose

When Is The Best Time To Potty Train?

Every parent wants to know, when is my child ready to potty train?A study that was recently published  in an issue of the Journal of Pediatric Urology is one of the first to show that timing of potty training children seems to be more important than the technique.

I found this quite interesting as the lead author, Dr. Joseph Barone stated, this is the first study “that gives parents an idea of when it’s a good time to toilet-train”.  The best time to potty train has typically been thought to be somewhere between the second and third birthday, but that is a wide range. This study suggests that age 27-32 months is the appropriate time to move a child out of diapers. In the study, children who were toilet trained after 32 months  were more likely to have urge incontinence, and problems with daytime wetting and bedwetting when they were between the ages of 4 and 12 years. This data was gathered from a retrospective study of children who were being seen by pediatric urologists for problems with urge incontinence (daytime wetting episodes) and their answers to a questionnaire on when they started potty training and what method they used, was compared with children who did not have urge incontinence.  The results showed that the mean age for  children with the wetting problems to have been trained was 31.7 months while those children who did not have problems were toilet trained at 28.7 months. Potty training continues to be at the top of the question list for parents with toddlers. I still believe and this study tends to support that children who are potty trained younger seem to have “less issues” than those that are older. That is not meant to say that your child will be potty trained by 28.7 months, but in most cases if you begin discussing the potty and following a child’s cues and follow through with reinforcement and consistency that the majority of toddlers may be potty trained by age 2 ½  (which would be 30 months). In my experience as both a mother and pediatrician, those toddlers who are put in pull ups and never asked about going to the potty or are not taken to the potty seem to be the ones that I see at 3 year old check ups still wearing their pull-ups. By this time if you ask them if they want to go potty they all say, “NO”.  I believe this is termed “the child directed approach” which seems analogous to me as saying “what time do you want to go to bed?” In most cases, if a toddler is introduced to the toilet, goes with their parent to “sit or practice or watch Mommy and Daddy potty” during the early 2’s, and given some incentive to perform, whether that be a sticker or M & M or both,  they will become interested in the potty and then they will become ready to potty train. I guess this is a combination of both the parent directed and child directed approach. Once you see your child is interested you have to “go for it” and put them in good ‘ole cotton training pants and go to the bathroom frequently. You can’t ask if they want to go, again it is a statement, “time to go potty” and most will be trained by the “magical” 27-32 months of age. To me potty training is somewhat like a space shuttle launch. “The window is not that wide” and you have to potty train during that magical window or the launch window may not come around again for a long time! That's your daily dose. We'll chat again soon.

Daily Dose

Focusing on a Baby's Stool

A recent email inquiry posed a frequently asked question: "How often does my your-baby need to poop?" It is still strange to me that we focus so much on poop when we have newborns. I can still remember the days, years ago, when my husband would come home from work and ask, "Has the your-baby pooped today?" We kept poop and pee charts for a few weeks and these charts were reviewed and discussed like people analyze the stock market these days. Finally, after several weeks of this, I had an epiphany, as both a mother and pediatrician.

The your-baby seemed to be just fine and probably didn't care if we micro-managed his poop schedule. I guess that might have been one of the origins of helicopter parenting. Now, it is true that in the immediate newborn period, we as pediatricians are interested in knowing if the your-baby is "urinating and stooling" or in other words, pooping and peeing as this is a good gauge of the your-baby's formula or breast milk intake. You have to have food and liquids to make poop and pee, so knowing that the your-baby is having a lot of wet diapers and that the stools change from the sticky myconium to soft yellow stools is important. But once a your-baby is eating well and is already gaining weight, the issue of stool frequency is quite variable. Breast fed infants typically stool more frequently than formula fed infants, and in fact may stool with each breastfeeding. Parents will swear that the your-baby has diarrhea, but later on in the course of parenting get the chance to figure out "real" diarrhea. Once you see that, you know the different. At the same time, some babies will only stool every day or every two to three days, but thrive and are happy. Again, if the stool is soft, not uncomfortable, and your-baby is content, just leave the issue of stooling alone. If your child is having hard, rabbit pellet stools, seems uncomfortable, and is having infrequent stools on a regular basis, talk to your doctor about options for helping constipation. Remember, this is one of the times that we must remember, the your-baby is a person too, and we all have different bathroom habits, and not everyone at work wants to hear about them. Maybe leave the stool charts at home. That's your daily dose, we'll chat again tomorrow.

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