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Autism is a communication and socialization disorder. Pediatricians watch for  speech delay as a sign of autism. But even before your child is expected to start talking at around a year old, you can watch for communication milestones. Problems attaining these milestones may indicate autism or other disorders such as hearing loss, vision loss, isolated language delay, or other developmental delays:

By six weeks of age, your baby should smile IN RESPONSE TO YOUR SMILE. This is not the phantom smile that you see as your baby is falling asleep or that gets attributed to gas. Your baby should see you smile and smile back at your smile. Be aware that babies at this age will also smile at inanimate objects such as ceiling fans, and this is normal for young babies to do.

By two months of age, babies not only smile but also coo, meaning they produce vowel sounds such as “oooh” or “aaah” or “OH.” If your baby does not smile at you by their two month well-baby check up visit or does not coo, discuss this delay with your child’s doctor.

By four months of age, your baby should not only smile in response to you but also should be laughing or giggling OUT LOUD. Cooing also sounds more expressive (voice rises and falls or changes in pitch) as if your child is asking a question or exclaiming something.

Six-month-old babies make more noise, adding consonant sounds to say things like “Da” and “ma” or “ba.” They are even more expressive and seek out interactions with their parents. Parents should feel as if they are having “conversations” with their babies at this age: baby makes noise, parents mimic back the sound that their child just made, then baby mimics back the sound, like a back and forth conversation.

All nine-month-olds should know their name. Meaning, parents should be convinced that their baby looks over at them in response to their name being called. However, sometimes parents have so many nicknames for their baby that this milestone might be delayed a bit until parents are more consistent with always using the same name to address their child. Baby-babble at this age, while it may not include actual words yet, should sound very much like the language that they are exposed to primarily, with intonation (varying voice pitch) as well. Babies at this age should also do things to see “what happens.” For example, they drop food off their high chairs and watch it fall, they bang toys together, shake toys, taste them, etc.

Babies at this age look toward their parents in new situations to see if things are ok. When I examine a nine month old in my office, I watch as the baby seeks out his parent as if to say, “Is it okay that this woman I don’t know is touching me?” They follow as parents walk away from them, and they are delighted to be reunited. Peek-a-boo elicits loud laughter at this age (“You’re gone, you’re back, haha!”). Be aware that at this age babies do flap their arms when excited or bang their heads with their hands or against the side of the crib when tired or upset; these “autistic-like” behaviors are in fact common at this age.

By one year of age, children should be pointing at things that interest them. This very important social milestone shows that a child understands an abstract concept (I look beyond my finger to the object farther away) and also that the child is seeking social interaction (“Look at what I see/want, Mom!”). Many children will have at least one word that they use reliably at this age or will be able to answer questions such as “What does the dog say?” (child makes a dog sound). Even if they have no clear words, by their first birthday children should be vocalizing that they want something. Picture a child pointing to his cup that is on the kitchen counter and saying “AAH AAH!” and the parent correctly interpreting that her child wants his cup.

Kids at this age also will find something, hold it up to show a parent or even give it to the parent, then take it back. Again, this demonstrates that a child is seeking out social interactions, a desire that autistic children typically fail to demonstrate. It is also normal that at this age children have temper tantrums in response to seemingly small triggers such as being told “no.” Unlike in school-age children, difficulties with “anger management” are normal at age one year.

Pediatricians often use a questionnaire called the M-CHAT (Modified Checklist for Autism in Toddlers) as a screening tool . This test can be downloaded for free. In our office we administer the M-CHAT at the 18-month well child visit and again at the two-year well visit, but the test is valid down to 16 months and in kids as old as 30 months. Not every child who fails this test has autism, but the screening helps us to identify which child needs further evaluation.

At 15-18 months of age, children should show the beginnings of pretend play. For example, if you give your child a toy car, the toddler should pretend to drive the car on a road, make appropriate car noises, or maybe even narrate the action: “Up, up, up, down, down, rrrroooom!” Younger babies mouth the car, spin the wheels, hold it in different positions, or drag a car upside down, but by 18 months, they perceive a car is a car and make it act accordingly. Other examples of pretend play are when a toddler uses an empty spoon and pretends to feed his dad, or takes the T.V. remote and then holds it like a phone and says “hello?” You may also see him take a baby doll, tuck baby into bed, and cover her with a blanket.

Eye contact in American culture is a sign that the child is paying attention and engaged with another person. Lack of eye contact or lack of “checking in” with parents and other caregivers can be a sign of delayed social development.

Kids try periodically to get their parents to pay attention to what they are doing. Lack of enticing a parent into play or lack of interest in what parents or other children are up to by this age is a sign of delayed social development. Ask yourself, “Does my child bring me things? Does he show me things?”Also, although they may not share or take turns, a toddler should still be interested in other children.

Many two-year-olds like to line things up. They will line up cars, stuffed animals, shapes from a shape sorter, or books. The difference between a typically-developing two-year-old and one that might have autism is that the typically-developing child will not line things up the exact same way every time. It’s fine to hand your child car after car as he contently lines them up, but we worry about the toddler who has a tantrum if you switch the blue for the green car in the lineup.

Two-year-olds should speak in 2-3 word sentences or phrases that communicate their needs. Autism is a communication disorder, and since speech is the primary means to communicate, delayed speech may signal autism. Even children with hearing issues who are speech-delayed should still use vocal utterances and gestures or formal sign language to communicate.

Another marker for autism can be atypically terrible “terrible twos”. Having a sensory threshold above or below what you expect may be a sign of autism. While an over-tired toddler is prone to meltdowns and screaming, parents can often tell what triggered the meltdown. For example, my oldest, at this age, used to have a tantrum every time the butter melted on his still-warm waffle. Yes, it seemed a ridiculous reason to scream, but I could still follow his logic. Autistic children are prone to screaming rages beyond what seems reasonable or logical. Look also for the child who does not startle at loud noises, or withdraws from physical contact because it is overstimulating.

By three years, children make friends with children their own age. They are past the “mine” phase and enjoy playing, negotiating, competing, and sharing with other three-year-olds. Not every three year old has to be a social butterfly but he should have at least one “best buddy.”

Regression of skills at any age is a great concern. Parents should alert their child’s pediatrician if their child stops talking, stops communicating, or stops interacting normally with family or friends.

It’ s okay to compare. Comparing your child to other same-age children may alert you to delays. For example, I had parents of twins raise concerns because one twin developed communication skills at a different pace than the other twin.

Although you may wonder if your child has autism, there are other diagnoses to consider. For instance, children need all of their senses intact in order to communicate well. I had a patient who seemed quite delayed, and it turned out that his vision was terrible. He never complained about not seeing well because he didn’t know any other way of seeing. After my patient was fitted with strong glasses at the age of three, his development accelerated dramatically. The same occurs for children with hearing loss—you can’t learn to talk if you can’t hear the sounds that you need to mimic, and you can’t react properly to others if you can’t hear them.

If you or your pediatrician suspect your child has autism, early and intensive special instruction, even before a diagnosis is finalized, is important. Every state in the United States has Early Intervention services that are parent-prompted and free for kids. The sooner your child starts to works on alternate means of communication, the quicker the frustration in families dissipates and the more likely your child is to ultimately develop language and social skills. Do not be afraid of looking for a diagnosis. He will be the same child you love regardless of a diagnosis. The only difference is that he will receive the interventions he needs.

Julie Kardos, MD, and Naline Lai, MD

©2017 Two Peds in a Pod®

modified from the original  2010 and 2013 posts

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cold remedies

For kids over one year of age, the Honey Bear offers grrr-eat relief

So many children (and their parents) have colds now. Really yucky colds, often accompanied by fever. Take heart that it’s not quite flu season- the yearly flu epidemic has not yet fully hit the United States. Are you staring at the medicine display in the pharmacy, wondering which of the many cold medicines on the shelf will best help your ill child? How we wish we had a terrific medication recommendation for  treatment of a kid’s cold. Unfortunately, we do not. And antibiotics-as powerful as they can be at killing bacteria- do not cure colds, which are caused by viruses.

Watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects?

Don’t despair, even if you can’t kill a cold virus, there are plenty of things you can do to make your child feel better:

  • -If she has a sore throat, sore nose, headache, or body aches, consider giving acetaminophen or ibuprofen to treat the discomfort.
  • -Give honey for her cough and also to soothe her throat if she is over one year of age.
  • -Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a soothing, steamy shower, and teach her how to blow her nose.
  • -Break up that mucus by hydrating her well — give her a bit more than she normally drinks.
  • -For infants, help them blow their noses by using a bulb suction. However, be careful, over-zealous suctioning can lead to a torn-up nose and an overlying bacterial infection. Use a bulb suction only a few times a day.

The safety and effectiveness of cough and cold medicine has never been fully demonstrated in children.  In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of  children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.  

nasal bulb suction

The self billed “snot sucker” Nose Frida

So you can ignore the shelf of children’s cough and cold medicine. Instead,  buy saline nose drops or spray to help suffy noses, acetaminophen (Tylenol) or ibuprofen (Motrin, Advil), to treat discomfort, and fluids-  and yes, milk is ok during a cold– to prevent dehydration.

Fortunately, when your kids have a cold, unlike you, they can take as many naps as they want.

Naline Lai, MD and Julie Kardos, MD

© 2016, modified from 2015, Two Peds in a Pod®

updated from our  2011 post

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Photo by Lexi Logan

Photo by Lexi Logan

Parents ask us about fever more than any other topic, so here is what every parent needs to know:

Fever is a sign of illness. Your body makes a fever in effort to heat up and kill germs without harming your body.

Here is what fever is NOT:

· Fever is NOT an illness or disease.

· Fever does NOT cause brain damage.

· Fever does NOT cause your blood to boil.

· Unlike in the movies and popular media, fever is NOT a cause for hysteria or ice baths.

· Fever is NOT a sign of teething.

Here is what fever IS:

· In many medical books, fever is a body temperature equal to or higher than 100.4 degrees Farenheit.

· Many pediatricians,  consider 101 degrees Farenheit or higher as the definition of fever once your child is over 2 months of age.

· Fever is a great defense against disease, and thus is a SIGN, or symptom, of an illness.

To understand fever, you need to understand how the immune system works.

Your body encounters a germ, usually in the form of a virus or bacteria, that it perceives to be harmful. Your brain sends a message to your body to HEAT UP, that is, make a fever, to kill the germs. Your body will never let the fever get high enough to harm itself or to cause brain damage. Only if your child is experiencing Heat Stroke (locked in a hot car in July, for example), or if your child already a specific kind of brain damage or nervous system damage (rare) can your child get hot enough to cause death.

When your body has succeeded in fighting the germ, the fever will go away. A fever reducing agent such as acetaminophen (e.g. Tylenol) or ibuprofen (e.g. Motrin) will decrease temperature temporarily but fever WILL COME BACK if your body still needs to kill off more germs.

Symptoms of fever include: feeling very cold, feeling very hot, suffering from muscle aches, headaches, and/or shaking/shivering. Fever often suppresses appetite, but thirst should remain intact: drinking is very important with a fever.

Fever may be a sign of any illness. Your child may develop fever with cold viruses, the flu, stomach viruses, pneumonia, sinusitis, meningitis, appendicitis, measles, and countless other illnesses. The trick is knowing how to tell if your child is VERY ill or just having a simple illness with fever.

Here is how to tell if your child is VERY ill with fever vs not very ill:

Any temperature in your infant younger than 8 weeks old that is 100.4 (rectal temp) degrees or higher is a fever that needs immediate attention by a health care provider, even if your infant appears relatively well.

Any fever that is accompanied by moderate or severe pain, change in mental state (thinking), dehydration (not drinking enough, not urinating because of not drinking enough), increased work of breathing/shortness of breath, or new rash is a fever that NEEDS TO BE EVALUATED by your child’s doctor. In addition, a fever that lasts more than three to five days in a row, even if your child appears well, should prompt you to call your child’s health care provider. Recurring fevers should also be evaluated.

Should you treat fever? As we explained, fever is an important part of fighting germs. Therefore, we do NOT advocate treating fever UNLESS the side effects of the fever are causing harm. Reduce fever if it prevents your child from drinking or sleeping, or if body aches or headaches from fever are causing discomfort. If your child is drinking well, resting comfortably or playing, or sleeping soundly, then he is handling his fever just fine and does not need a fever reducing agent just for the sake of lowering the fever.

A note about febrile seizures (seizures with fever): Some unlucky children are prone to seizures with sudden temperature elevations. These are called febrile seizures. This tendency often runs in families and usually occurs between the ages of 6 months to 6 years. Febrile seizures last fewer than two minutes. They usually occur with the first temperature spike of an illness (before parents even realize a fever is present) and while scary to witness, do not cause brain damage. No study has shown that giving preventative fever reducer medicine decreases the risk of having a febrile seizure. As with any first time seizure, your child should be examined by a health care provider, even if you think your child had a simple febrile seizure.

Please see our “How sick is sick?” blog post for further information about how to tell when to call your child’s health care provider for illness.

Julie Kardos, MD and Naline Lai, MD

© 2016, updated from 2013 Two Peds in a Pod®

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waxy earsBabies are gooey. Spew tends to dribble out of every orifice and the ear is no exception.

Devin’s mother tipped her four month old baby’s head sideways in the office the other day and asked me what to do about the oily, yellow wax smeared around the opening of his ear canal. Despite the copious amount of wax on the outside, Devin’s ear canals were clear. “But the wax is simply disgusting,” said Devin’s mom, “Can I clean his ears? “

If you can get the wax with a wash cloth, it’s fair game. Otherwise, leave it alone. It doesn’t matter if you use a wash cloth or cotton swab.  The special shaped cotton swabs with the safety tips are unnecessary. Rest assured, you will not go too deeply into the ear canal if you only scrape off what is visible.

Now suppose your pediatrician does say the wax should be removed. Place an over-the-counter solution such as Debrox in the ears (children and adults can use the same formulation) – three to four drops one or two times a day (during sleep is easiest for babies and toddlers) for a few days. The solution softens wax.  For maintenance, mineral oil and olive oil are favorite remedies. Place one drop daily in ears. In the office some pediatricians can use a water irrigation system (like a water squirter in your ear) to wash out the wax. The worst side effect is that the child’s shirt sometimes gets wet. Irrigation is a very effective for removing wax  in a school-aged or teenaged child who complains of difficulty hearing.

Some say wax evolved to help keep bugs and other debris from reaching deep into our ear canals. Case in point: one of my least favorite memories during residency is of picking out pieces of a cockroach entrapped in a child’s earwax!

Keep in mind the amount of wax you see on the outside of the ear is not indicative of the actual amount inside the ear canal. Chances are, the wax is not hard and does not block the ear drum. Even if there is a large amount of wax, it is unlikely to greatly affect a baby’s hearing unless the wax is stuck against the ear drum. Equally normal is that some babies and children don’t seem to produce any ear wax. If you are concerned about your child’s ear wax or about her hearing, have your pediatrician take a peek with a light.

If you find you are constantly cleaning your kid’s waxy ears, take heart. At least there won’t be any roaches “bugging” them.

Naline Lai, MD and Julie Kardos, MD

©2011, 2016 Two Peds in a Pod®

PS: Medical vocabulary FYI: light used to look into ears= otoscope. Medical term for ear wax= cerumen.

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Nearly seven years ago, on the swimming pool bleachers at the local Y, I happened to sit next to Lexi Logan. Above the echoing din of kids splashing, I discovered that although she was trained as a painter, Lexi was interested in branching out into photography. Coincidentally, Dr Kardos and I were interested in branching medicine out into a new media called the internet and were dismayed at the lack of publicly available photos to accompany our blog posts. Lexi and I intersected in the right place at the right time. Since that chance meeting, Lexi has generosity shared dozens of photos with Two Peds in a Pod.

The woman in the photo below, between your Two Peds (Dr. Kardos with the curly hair, Dr. Lai with the straight hair), is our photographer extraordinaire, Lexi Logan. Her work, which you can check out at www.lexilogan.com,  speaks for itself.  Local peeps may want to contact her to take their own family photos.

This Thanksgiving we say thanks to all those parents we’ve ever sat next to on bleachers. All the kid-related information we have learned, from navigating chorus uniforms, bus stop times, best teachers, fun summer camps, and even starting up blogs, has been invaluable.

In particular- thank you, Lexi!

We wish all of our readers a very healthy and happy Thanksgiving,

Dr. Naline  Lai with Dr. Julie Kardos

©2016 Two Peds in a Pod®

two-peds-and-lexi

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13-1When I was in first and second grade, I took “special gym.”

I attended a public school in a small New Jersey town. The school building was about 100 years old, and the “special services” that my school offered were speech, reading help, and special gym.

I remember being THRILLED that I was selected to take special gym, because instead of just one day a week of bouncing balls and running races and turning somersaults during the school day, I got to go twice a week. I remember how upbeat and energetic the gym teacher was, and how much fun she made these exercises. I do not recall such words as “physical therapy” or “occupational therapy.” In fact, I did not realize the true point of the extra gym days until many years later, when I was in college and reminiscing about elementary school and caught myself mid-sentence:

“Well, when I was in first grade, I took special gym… hey… WAIT a MINUTE….!”

That’s when I realized that I had been flagged with a coordination challenge. Unbeknownst to me, in school I went to physical therapy weekly.

Now that first-quarter parent teacher conferences are over, you may be surprised that your child has been offered special services by the school. Teachers spend hours a day with our kids and are experts in the age group that they teach. Not all kids are good at learning all subjects and not all are equally sociable or equally physically adept. When teachers ask a parent’s permission to supply extra help, parents should not take this request as an affront or attack on their parenting. Rather, it is an opportunity to help kids  succeed.

I was never suspicious about my inclusion in special gym. No one made fun of me for being in the class, and in fact many were jealous. Kids in early grades may be aware that some of their classmates come and go during the day, but they do not distinguish between kids pulled out for a gifted program from kids pulled out for remedial education. As an adult, I appreciate that my teachers made me feel good about being included in the special gym club.

I have a magnet on my car now that says, simply, “13.1,” which is the number of miles that I ran to complete the Trenton Half-Marathon this past October. Special gym did not hold me back—it propelled me forward. I had no idea that my participation in special gym was emotionally charged for my mom until after I called my dad to tell him my race time (2 hours, 11.5 minutes). Only then did he tell me how crushed my mom had been about my inclusion in special gym. I am grateful that she hid that from me.

My message: Let your kids get extra help in school, allow them to be pulled out of a class they are failing and placed into an environment where they can learn and overcome challenges. Allow yourself to mourn the loss of the child you may have pictured. But know this: young children do not have enough life experience to independently think of themselves as failures in the early school years. They look to adults who are important to them for how to respond to challenges and frustration. Encourage them with the positive message that they will receive extra attention and extra time to work at reading or math or physical skills or speech skills. Who knows? They may become the kid who applies to medical school or runs a marathon (or a half-marathon) someday.

Julie Kardos, MD

©2016 Two Peds in a Pod®

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sore throat

Many times parents bring their children with sore throats to our office to “check if it’s strep.” Some are disappointed to find out that their child does NOT have strep. Moms and Dads lament, “But what can I do for him if he can’t have an antibiotic? At least strep is treatable.”

Take heart. Strep or no strep, there are many ways to soothe your child’s sore throat:

  • Give  pain medication such as acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin).  Do not withhold  pain medicine before you bring her in to see her pediatrician. Too many times we hear parents say, “We wanted you to see how much pain she is in.” No need for this! Pediatricians are all in favor of treating pain as quickly and effectively as possible. Pain medicine will not interfere with physical exam findings nor will it interfere with strep test results.
  • Give lots to drink. Some kids prefer very cold beverages, others like warm tea or milk. Avoid citrus juices since they sometimes sting sore throats.  Frozen Slurpies or milkshakes, on the other hand, feel great on sore throats. Tell your child that the first three sips of a very cold drink may hurt, but then the liquid will start to soothe the throat. Watch for signs of dehydration including dry lips and mouth, no tears on crying, urination less than every six hours, and lethargy.
  • Provide soft foods if your child is hungry. For example, noodles feel better than a hamburger on a sore throat. And ice-cream or sherbet therapy is effective as well.
  • Try honey (if your child is older than one year) – one to two teaspoons three times a day. Not only can it soothe a sore throat but also it might quiet the cough that often accompanies a sore throat virus. Give it alone or mix it into milk or tea.
  • Kids older than three years who don’t choke easily can suck on lozenges containing pectin or menthol for relief. Warning: kids sucking on lozenges may dupe themselves into thinking they are hydrating themselves. They still need to drink to stay hydrated.
  • Salt water gargles are an age-old remedy.  Mix 1 teaspoon of salt in 6 ounces of warm water and have your kid gargle three times a day.
  • Magic mouthwash: For those older than 2 years of age, mix 1/2 teaspoon of liquid diphenhydramine (brand name Benadryl 12.5mg/5ml) with 1/2 teaspoon of Maalox Advanced Regular Strength Liquid (ingredients: aluminum hydroxide, magnesium hydroxide 200 mg, and simethicone) and give a couple time a day to coat the back fo the throat prior to meals. The Maalox coats the throat and the benedryl acts as a weak topical anesthetic (pain reliever). Do not use the Maalox formulation which contains bismuth subsalicylate because bismuth subsalicylate is an aspirin derivative, and aspirin is linked to Reye’s syndrome.
  • For kids three years and older, try throat sprays containing phenol (brand name Baker’s P&S and Chloraseptic® Spray for Kids). Use as directed.

 

Strep throat typically does not cause a bad cough,  profuse runny nose, ulcers in the throat, or laryngitis. If your child has these other symptoms in addition to her sore throat, you can be fairly sure that she does NOT have strep. For a better understanding of strep throat see our posts: “Strep throat Part 1: what is it, who gets it and why do we care about it” and “Strep throat Part 2: diagnosis, treatment, and when to worry.”

The following are each a very important sign that a child with a sore throat needs to see a doctor for further evaluation:

1-can’t swallow (kids might even spit out their own saliva)

2-can’t open his mouth fully

3- hurts so much that the pain is not alleviated with the above measures in this post

4- presence of fever 101F or higher for more than 3-4 days

5-is accompanied by a new rash

Please also see our prior post on how to tell if you need to call your child’s doctor for illness.

 Julie Kardos, MD and Naline Lai, MD

©2016, 2015, 2012 Two Peds in a Pod®t

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swing

 

In this time of  United States “election stress,” we bring back guest bloggers psychologist Dr. Gage and pediatrician Dr. Penaflor’s post on how to build optimism in your children.

Recently, my daughter’s friend announced before a race, “I’m just not going to try my best.”

Why would a child give up before even starting?  Why such pessimism?

It turns out that her friend’s mother would say after every race, “You just didn’t meet your potential.  Did you at least beat Sarah (a fellow competitor)?”

This scenario illustrates how a parent who constantly gives negative responses can build pessimism in a child.

Why is optimism important?
An optimistic child is strong, enterprising, and resilient.  He or she does not wait passively for good things to happen to him or her. The optimist consciously plans, works hard to make things happen, and persists through challenges.

Research shows important benefits:
• A healthier heart and a greater ability to fight infections and survive disease
• Better response to stress
• Less likelihood to develop anxiety and depression
• More success in school, sports, social and recreational activities
• Greater accomplishments in life

How do I begin?
Does your child tend toward optimism or pessimism?  Is the glass half empty or half full?  Which would your child say, “It doesn’t matter… I won’t get it right anyway,” or “I did my best… I’ll get it next time”? Optimism is a learned skill that you can teach your child at home.
Here are some important tips.

Model positive behaviors and attitudes:

“This is tough, but I can do it!”

“I will find that lost pair of socks!”

Create an environment that fosters love and trust.
When children have a sense of security and trust at home, they view the world as a positive place to explore and try new things.

Encourage your child to view life in a positive way and to rise above negativity.
For example, one of our favorite techniques is “Rise up! Don’t dwell on it.” If someone did or said something hurtful to your child, teach your child to pause. Have her ask herself “How important is it? Will it matter in 5 minutes, 5 months, or in 5 years?” Think of the big picture.

Another is to approach mistakes calmly. Say “Oops!” and move on.

Validate your child’s feelings of disappointment or sadness, but teach your child that failures and mistakes are opportunities to learn and do something different and better.

After all, in life “Sometimes you win, sometimes you learn.”

 

Patricia Gage, PhD, NCSP and Gina Penaflor, MD, FAAP

©2016, 2014 Two Peds in a Pod®

Dr. Patricia Gage runs Brain Smart Academics, her own private practice as a school psychologist in Stuart, Florida, and has taken the lead in many charitable organizations that help promote children’s social/emotional wellness and women’s health.

Dr. Gina Penaflor, mother of a school-aged child, tween and teen, is a primary care pediatrician in South Florida with a background in emergency and hospital medicine.  She and Pat have combined their knowledge and experiences to create a Hang-In-There educational card series.  Their mission is to help busy moms and dads lead a more rewarding (and less stressful!) parenting experience.

To learn more, please visit their website at www.HangNthere.com or Facebook page, or e-mail them at busymoms@HangNthere.com.

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Just when you thought your child graduated from potty training ...there's more

Just when you thought your child graduated from potty training …there’s more

 

Believe it or not, this post is for parents of kids who are already potty trained.

Changes and transitions, such as the start of a new school year, can trigger regression in kids who have been potty trained for years. Now that your children have been back to school for a few weeks take the quiz:

-Does your child come home from school and make a mad dash for the bathroom before he even gets his shoes off or asks you for a snack?

-Does your child stop eating and complain of belly pain after two bites of dinner?

-Does your child’s poop routinely clog your toilet?

-Is your child’s underwear sometimes damp?

-Have you noticed skid marks (small streaks or smears of poop) on your child’s underwear?

If you answer “yes” to ANY of these questions, then read on.

Advanced Potty Training

The main problem many kids encounter is that once school starts, they have a lot of new distractions and can’t be bothered to pee or poop. First, the morning routine might be more rushed. In school, the teacher is teaching. Your kid is interacting with other kids. The school’s bathroom is foreign, and may even have an auto-flush toilet: scary for the newly-trained. And unlike your newly potty-trained toddler who often finds it thrilling to try out every public restroom he sees, kids in school may feel more self-conscious, and not as adventurous, about visiting new bathrooms.

School bathrooms can be smelly, loud, and even places where kids bully each other. Some kids develop an aversion to using the school bathroom. These kids hold their pee and poop all day long until they get home, then run into the house and make a mad dash for the bathroom.

A child’s internal debate

For a kid who becomes overstimulated at school or who develops an aversion to the school bathroom, his bladder and brain have a conversation that goes like this:

Bladder: I am full.

Brain: Hold it, I don’t want to use the bathroom right now.

Bladder: But I REALLY have to pee.

Brain: Tough luck, Bladder, just wait till we get home.

Bladder: But I have no more room for pee!

Brain: Deal with it, Bladder!

So, the bladder has two choices:

1-Bladder overflows, at least enough to relieve a bit of pressure. This causes damp underwear. (For other reasons click here to review our post on damp underwear.)

OR

2-Bladder distends to accommodate more urine and confuses the nerves that supply sensation to the bladder. Kids lose the ability to tell if they have to urinate, which leads to full bladder-emptying accidents, and can lead to urinary tract infections.

A similar discussion can occur between your kid’s brain and his rectum:

Rectum: I am full of poop, Brain. Take us to the bathroom.

Brain: In school? Are you kidding? I am enjoying this game the class is playing/I am embarrassed to poop in school/I am afraid of the school bathroom. HOLD IT!

Rectum: OK, but you’re not going to like how this comes out in the end.

The rectum also has two choices: release just a bit of stool so it doesn’t feel so full and uncomfortable – these are skid marks. OR it will just hold onto the stool, making it larger and harder all the while, so it becomes painful and scary to pass and ultimately clogs the toilet.

This cycle leads to more problems – over time, the distended rectum develops decreased sensation (sound familiar?) and ultimately the child loses the ability to feel when he has to poop. Large poop masses in distended intestines can lead to pain while eating (the kid who eats two bites of dinner, then stops because of belly pain). Poop can leak out without your child knowing because he is unaware of the sensation of the chronically-ignored-full-rectum. In addition, a full rectum will also press on the bladder changing the way the brain is sensing whether or not to void.

How can we parents prevent these problems?

Remind your child to use the bathroom upon waking up in the morning and again before leaving the house for school. Even if he says he does not have to go, tell him to “Just check- sit for 2 minutes.”

Ask your child if he uses the bathroom in school. Preschool and early elementary school teachers often have scheduled bathroom breaks, but then it’s entirely up to your child to remember to use the bathroom. Encourage him to stop in the bathroom around lunch time in school.

Once home from school, remind your child to use the bathroom or “just check” if he hasn’t already done so.

If you leave the house again for an after-school activity, insist that he “just check” again to decrease your chances of having to use another “foreign” toilet.

Incorporate a potty check into your child’s bedtime routine, even if he went relatively recently. Ideally the healthy bladder empties four to six times a day and the healthy bowel easily passes a stool  at least once a day or every other day.

Because boys usually stand to urinate, remind them to sit at least once or twice a day, even if they don’t feel the urge to poop. As a mom of three boys, trust me: they often surprise themselves.

Even middle school and high school kids can have these problems. Suggest to your older child who, for whatever reason, avoids school bathrooms, that she can stop by the school nurse’s office to use the bathroom. She could also get up in the middle of class, if needed, and use the bathroom when it is most likely to be empty of other students, unlike during change-of-class time.

School cafeteria food and snacks provided at sports or other after school activities are not always healthy and can contribute to making stools too hard, so make sure to provide healthy choices at home with plenty of fruits and vegetables. Teach your kids to avoid too many cookies and other high fat foods – these are constipating foods. Encourage water-drinking. Caffeine-containing drinks (ice tea, soda) cause excess urine production and thus more stress on the bladder that your child might already be forcing to “hold it” for too long.

As for the children who frequently run to the bathroom in the daytime, but only pee a tiny bit, beware of something called urinary frequency syndrome.

Final exam

1-Does your child use the bathroom regularly, without stress or pain?

2-Can your child “go with the flow” in school as well as home, without any toilet clogging?

3-At the end of the day, is your child’s underwear without urine or skid marks?

If you can answer YES to all of the above, then you and your child have passed advanced potty training!

Julie Kardos, MD and Naline Lai, MD

© 2016 Two Peds in a Pod®

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