A Potty Training Strategy

Potty training can be a very exciting or a very frustrating time for both parents and children. Making potty training stress-free is an exercise of patience for a parent, but does make the process easier in the long run. There are many options for potty training your child, but the real secret is consistency and perseverance. That being said, I do have a favorite method that stresses positive reinforcement with relatively quick results.

Step #1: Introduce the potty early (12-14 months). Let your curious toddler explore the bathroom, watch you or other siblings use the potty and get them a small potty to experiment with. Every time your toddler shows interest in the potty, give positive feedback with smiling, clapping, hugs/kisses (whatever makes you look silly and gets your child excited)!

Step #2: Start encouraging your toddler to sit on the potty without a diaper on. I do this before or after bath time, when they are already comfortable being naked. If they are resistant, then wait longer and try again. When they do sit on the potty or actually pee, increase the positive reaction to a full on party! Continue this step until they make the connection between the potty and peeing/pooping. Your child is physically ready to move on to Step #3 when they can go 2-3 hours with a dry diaper and they know (and can tell you) when their diaper is soiled.

Step #3: When you and your child are ready - meaning you have a few days at home, your child has made the pee/poop/potty connection, and is physically ready - you can start the real potty training process. Prepare to stay at home for 2-3 days and take away the diapers. You can keep your child naked or in "big boy/girl underwear" during the day. I suggest staying in a room with floors that are easy to clean during this time and only giving drinks with meals and snacks. Put your child on the potty every 1-2 hours and 10-20 minutes after eating or drinking. If they do go pee or poop on the potty, do the same as before and have a huge party or reward them with something they like, IMMEDIATELY. The first day, they will most likely have several "accidents". When they do, calmly clean it up and take them to the potty. You will notice less "accidents" as the days go on and on the 3rd-4th day, most people can attempt outings without diapers. They do make plastic covers for carseats, which I suggest investing in!

Most children are not ready for naptime/nighttime potty training when they start daytime potty training. It is normal for some children to have nighttime accidents until late childhood. Make sure to explain to your child that diapers and/or pull ups are only for sleeping and underwear is for the daytime. I do suggest putting a waterproof mattress cover on their bed at this time, because some are ready and willing to try nighttime training out. You will know they are ready when they wake up dry most mornings. Make sure not to sabotage their efforts by giving drinks before bed! 

If potty training is not going well and either you or your child is frustrated, buy another box of diapers and try again in 1-2 months. Do not pressure your child during this time and go back to positive reinforcement for exploring the potty. Make sure to save the real parties for the fantastic moments that they do go pee or poop on the potty!

Heather Joyce, MD

Sports Physicals

Its that time of year again.  It's time to fill in the checkmarks on those many questions and take your child to get a physical so that he or she can participate in sports the upcoming year.  You're thinking, "why do I have to schlep my kid to the doctor every year for this?"

There has been a lot of collaboration among sports medicine pediatricians over the last several years to make sports physicals worth your time and effort.  The questions we asked have changed and the focus on the physical has also changed so that we can save lives.  Sure, we can pick up and treat any joint pain or problems during a sports physical, but the true purpose of doing them year in and year out is so that sports related deaths can be avoided.

One of the most common causes of non-traumatic sports related deaths (vs traumatic deaths due to things like collisions) in youth sports is cardiac - meaning that there are a handful of congenital heart problems that can lead to sudden death while being physically active.  You hear about these every year on Sportscenter ... for example, it's the basketball player that suddenly collapses after shooting a lay-up.  It's scary stuff.

So, questions on your child's sports physical form are directly related to figuring out if he or she may have a cardiac problem.  We pay careful attention to any family history of heart-related death at a young age, or symptoms like dizziness, chest pain, or palpitations (funny heart rhythm) with exercise.  It's important that you don't run through the questions on the form marking "no," but to carefully review them with your child.

If we suspect that your child has a heart condition based on family history or symptoms experienced during exercise, he or she would then likely undergo a series of tests and consultation with a pediatric cardiologist to make sure that it is ok to participate in sports.

Sports physicals are also a great environment to talk about how to avoid another common cause of catastrophe on the sports field, which is heat related deaths.  And some of the questions on the sports physical form in your state may examine your child's vulnerability to heat illness asking about things such as prior issues with heat illness.  There has also been a lot of dialogue between sports physicians and state high school athletic associations about measures to avoid heat related death.  For example, during high school football season, there is a limit on two-a-day practices, and practice times may be limited depending on the ambient temperature.

Again, sports physicals are also a good time to review aches and pains that may be occurring during athletic activity, but make sure not to speed through the questionnaire and review it carefully with your child.  It could definitely save his or her life!

Rachel Brewer, MD

Hip Pain

Hip pain can be a tricky thing in kids.  Sometimes it's hard for them to actually point to their hip and say "this hurts," so they may point to their groin, thigh, or even knee, even though the problem arises from the hip.

One of the most common cause of hip pain in kids is synovitis (otherwise known as transient synovitis), which may come in combination with a viral illness and/or fever.  The pain comes from inflammation inside the hip joint.  This problem is not caused by a fall or trauma.  These kids are usually less than 10 years of age, and complain of hip pain, difficulty walking, and they also tend to walk with a limp.  The condition is self-limiting, meaning that it goes away on it's own.

Even though synovitis is self-limiting, it is necessary for kids with this problem to be evaluated to make sure that they don't have more serious hip problems that can be detrimental long term.  This means that they need an x-ray of their hip and pelvis.  Again, x-rays in kids with synovitis are normal, but they help make sure that other treatment is not needed.  Treatment is non-weightbearing (rest) and medicines like tylenol or ibuprofen until the pain resolves.

Some hip problems in kids affect their bones and may need surgery.  In older kids (around adolescence), the growth plate in the ball of the hips joint can actually slip and cause long term damage if surgery is not done immediately.  This problem is called slipped femoral capital epiphysis (or SCFE).   In young children (usually before school age) there is a condition called Perthes disease where blood flow to the hip is compromised and the ball of the hip joint is affected.

Hip pain can of course also occur with falls or trauma.  But sometimes kids aren't the best historians and you may not witness the fall, so it could be difficult to determine if a fall or injury is causing their pain or limp.

So .... if your child limps, regardless of his or her age, make sure that they are evaluated by a pediatrician or orthopedic doctor.  If not, they could sustain long term damage and arthritis in their hip!

Rachel Brewer, MD

Hand, Foot, and Mouth Disease

Just so we are clear, I am not talking about foot and mouth or hoof and mouth disease in farm animals, but a mild virus in children that causes fever, mouth sores, and rash. Hand, foot, and mouth disease is caused by a virus that likes warm weather, so it is most common spring through fall in my neck of the woods (Middle America), but can occur any time of year in tropical locations. The illness is very common in young children because it is spread by direct contact with saliva and stool - think lots of drooling, diaper changing and hands in the mouth. It starts with fever and is followed by sore throat, drooling, and rash. The rash is characterized by red, raised bumps or blisters on the hands and feet. In my opinion, it should be called hand, foot, mouth and bottom disease, because I see diaper rash as a symptoms just as commonly as the rash on the hands and feet. Your child may also get fatigue, fussiness, runny nose, vomiting and diarrhea. Often, little children refuse to eat and drink. The illness typically lasts 7-10 days, with fever for 2-3 days. The most important part of hand, foot, and mouth disease for a parent, is keeping your child from getting dehydrated. Below are my tips for keeping your child comfortable and hydrated during this common illness:

• Ibuprofen or acetaminophen - give an appropriate dose for your child's weight as needed for fever and pain (including feeding refusal). If your child will not swallow medicine by mouth, there is a rectal form of acetaminophen that works well. 
• Offer fluids at all times - this includes breastmilk, formula, milk, Pedialyte, Gatorade, water, popsicles, ice cubes, ice cream (basically anything they will drink!) 
• Avoid spicy and acidic foods/drinks 
• Offer soft, easy to swallow foods 

Home remedies:

• Salt water rinses for older children - 1/2 teaspoon of salt mixed with 1 cup of warm water, swish and spit as needed for pain 
• Magic mouth wash - Maalox (Aluminum Hydroxide and Magnesium Hydroxide) and Benadryl (diphenhydramine) mixed together 1:1 and dropped in or placed in the mouth with a Q-tip. The best way to make this is to mix 5 ml of Maalox with 5 ml of Benadryl. Use 1 ml on the sores every 6 hours. 
• Gly-Oxide is another over the counter product that works well to clean and coat the ulcers  

I do not recommend mouth numbing gels (like Orajel) during this illness, because of the large amount required to numb all of the sores and the short lived relief. There are rare, but serious side effects from using too much of this medication. Unfortunately, there is no antibiotic or medication to shorten the length of the illness. Seek medical care if your child is refusing to drink, has decreased urination or wet diapers, dry mouth or you are concerned about dehydration.  

Heather Joyce, MD