toilet training

Toilet Training is a major milestone in a young child’s life (also parents!). When is the time right? It varies, of course. Typically between 2-4 years of age, but it can be later for children with special needs or chronic illnesses. Girls usually train ealier than boys. First children typically later than their younger siblings (parents – you get better with experience).

What signs suggest your child may be ready? When (s)he:

  • Walks well and can sit for short periods.
  • Is more independent in completing tasks.
  • Shows interest in others using the bathroom.
  • Has dry diapers for 2+ hours.
  • Has predictable BMs or announces when they are occuring.
  • Shows displeasure with wet, soiled diapers.
  • Can pull pants up and down.
  • Can stoop and recover.
  • Will follow simple commands, like “give the ball to me.”

Note that it is not necessary for all of the above to be present in order to proceed.

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eczema

A question was raised about eczema; feeling winter’s dry chill this week makes it a good time to discuss this topic.  Eczema(atopic dermatitis)is a chronic skin condition that causes redness, scale, crusting and sometimes blistering(particularly in African Americans).  We often refer to the problem as the “itch-scratch cycle” and ” the itch that rashes” because of the phenomenon of itching LEADING to irritated, dry, flaky skin.  Eczema can involve almost any area of the body.  In babies it often starts on the forehead and cheeks and spreads to trunk and limbs, children commonly have it on inside of elbows and knees and teens on face, neck, and back.  Its course is variable–in some children it gets better with age, in others it can worsen.

Eczema is mainly caused by allergies and is part of the ” atopic triad”–eczema, hay fever, and asthma; effected individuals frequently have a family history of these problems.  It effects 10% of all American children.  9 of 10 cases start before age 5, 65% in the first year of life.  Girl:boy ratio is 2:1.  Many factors may lead to flare ups: allergies to foods, pollen, dust mites, or animals; weather extremes (sudden changes in temperature, humidity); excessive sweating or excessive bathing; skin irritants (cleansers, harsh soaps, perfumed topical products); harsher fabrics(wools and nylons);and even stress.

Eczema has no cure but there are many effective management strategies.  Keep skin clean and nails cut short.  Keep your house clean to avoid dust mites and other indoor pollutants.  Hypoallergenic pillows may be of benefit.  Avoid offending foods if that effects your child.  Use unscented soaps and skin products, have your child wear loose fitting cotton clothing, and it can often be helpful to wash new clothes prior to first wearing.  Liberal use of moisturizing creams (the thicker the better)after bathing can help.  It may be better with certain effected children to avoid sports where intense sweating is expected or participants wear heavy uniforms or equipment.  Rinse skin after swimming.

There are several classes of medicines that are used if the above gives inadequate relief: topical steroids,TCI’s, topical tar preparations, prescription emollients, and oral antihistamines like diphenydramine (benadryl)–better at night as it causes drowsiness.  If your child’s skin does not improve, shows signs of infection(redness, crusting, oozing) or she develops fever or uncontrollable itching you should call me and make an appointment.

Thanks so much for following.  As always, I invite comments or questions.

Fever

Let’s step back and talk about the basic but very important subject of fever.  As days shorten and temperatures cool, we’ll frequently be facing winter illnesses with fever.  It is the most common symptom prompting visits to the doctor, as well as a frequent cause of late night distress for children, parents (and pediatricians!).

So, what’s going on?  The hypothalamus of the brain is the body’s thermostat, maintaining basal body temperature at 97.6-100.2 F(36.2-37.8 C).  At night, our body’s diurnal variation dictates that our temperature is higher later than early in the day.  Rectal temperatures above 100.2 F are fever.  All human beings are normally in that range ( No person “runs low” normally).  When presented with an infection–viral or bacterial–white blood cells release pyrogens that raise the hypothalamic set point and the body temperature rises.

Why does this happen?  At higher temperatures most microbes reproduce and spread less effectively.  Also, white blood cells become more active and move toward and attack the infection better.  Of course, there are adverse effects as well.  Much of the discomfort associated with typical infectious illnesses–muscle and headaches, fatigue–are due to fever.  Most fevers are not primarily dangerous, however.  The human body can function very adequately at high temperatures and for a surprisingly long time.  Above 106 F (41.1 C) cardiac function and nerve conduction can deteriorate, and enzyme systems can malfunction.  Below this there are few serious effects.  Except in susceptible individuals (eg, family history) higher temperatures rarely cause seizure.  They do not cause brain damage or sterility.

So what to do? Moderate the child’s activity as much as reasonable.  Don’t overheat or overcool their environment.  Dress them appropriately (light clothing and thin blankets).  Bathe or sponge the child with lukewarm water (never use alcohol).  Use acetaminophen every 4 hours (orally or rectally) or ibuprofen every 6 hours (orally).  Never treat a febrile child with aspirin as it can cause Reye Syndrome, a severe liver ailment.  Also, be careful with acetaminophen dosing, as too much of this drug can also cause liver damage.

When should one become concerned?  Fever above 104 F( 40 C) or for greater than 72 hours.  Fever later in the course of an illness.  Fever in a child under 2 months of age.  A febrile child who is too listless to drink regularly or who vomits frequently and hasn’t voided in 8-12 hours.  Fever associated with severe cough or pain.  You should call if your child meets any of these criteria.

Remember, things are rarely as serious in reality as they are in our minds (especially at night!).  However, I always remind parents that if they have serious doubts about any situation, it’s always best to call so we can try and work it out together.

Please post comments or questions for future posts, and, as always, thanks for reading.

overdiagnosis

I’d like to go off on an (important) tangent and comment on overdiagnosis in medicine. MISdiagnosis gets it wrong. With OVERdiagnosis, the doctor gets the answer right, but it’s beside the point—studies show the information provides no benefit (or fail to show any benefit) to the patient.–thus, a waste of time, effort, anxiety and money.   I read a review article (its technical, but if you’d like you can see it here) and will summarize some findings:

  • Gastroesophageal reflux in infants—medications do not seem to provide any benefit and there is evidence that it increases the risk of respiratory infections. The condition almost always resolves spontaneously by 12 months
  • Newborn jaundice—we test and hospitalize children for this condition far more frequently but there has been no change in death or brain damage rates from this condition since 1979
  • Bronchiolitis—despite far greater rates of hospital admission and treatment with oxygen since 1980 (with the use of pulse oximeters—the clip on your nail used to evaluate blood oxygen levels) no change in infant mortality rates in that time. No benefit to patents has been demonstrated from administering oxygen to treat transient, mildly low oxygen levels.
  • ADHD—in all grades the youngest children tend to have the highest incidence of being diagnosed with this condition
  • Obstructive sleep apnea—Tonsillectomy and adenoidectomy (T+A) treatment with this procedure has increased from 12-77% from 1970-2005. Studies have shown no benefit in executive function or attention in children after undergoing T+A.
  • Urinary tract infection—medical and surgical treatments for chronic UTI have shown no decrease in the rate of renal scarring or insufficiency; even severe problems seem to resolve spontaneously over time.

Among adults:

  • After age 70, 80% of men are found to have prostate cancer at autopsy. The mortality rate from this condition is 3%.
  • A Canadian study of over 90,000 women followed over 25 years found no change in mortality rates in women diagnosed by screening mammography compared to women who did not have that procedure.

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More on sleep

From teens who never seem to want to get up to little kids who never seem to want to go to sleep–what’s a parent to do?Getting young children to sleep is a common problem.  First–what is a “normal” amount of sleep?  Infants sleep 16-20 hours/day–generally 1-4 hours asleep followed by 1+ hours awake.  Between 2-9 months most children will settle into a schedule of 8-12 hours of sleep with 2-4 hours napping during daytime.  Toddlers stop napping usually by age 5, many sooner (note: parents lose the “need for toddlers to take a nap” even later!)  School age children need 10+ hours to sleep.  See previous post for teens.

Good sleep habits include:

  • Regular schedule–wake up and bedtime roughly the same time every day
  • Light snack only when closer to bedtime.  Avoid chocolate which contains caffeine
  • Child’s room should be quiet, dark(dim light or hall light is acceptable) and cool(not cold)
  • Quieter activity closer to bedtime. Avoid stimulating or rough house games/play
  • A fluffy toy or blanket is always helpful

For infants and toddlers who won’t go/stay asleep on their own:

  • Standard routine to get to bed.  Rituals of a few steps only(bath, snack, story, prayers, night-night)
  • Avoid “curtain calls”–one more this or that.  You can leave a drink in the room for the child to sip as desired, for example.
  • For persistent crying, you should return to the child’s room every 10 minutes or so to “touch base” and stay for only a minute +/-.   A brief hug is acceptable but do not pick your child up out of bed (I know–this can be HARD).  For how long?  In most instances, for toddlers after 9 mo old, as long as it takes–most children will eventually settle in and fall to sleep if their crying/demands are not met with positive reinforcement responses(I compare it to “feeding the stray cat”).
  • For children who reawaken during the night–repeat the process(check every 10 min, don’t pick the kid up, etc)

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