When a child refuses to poop

Posted September 18, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Michelle wrote in: “We trained my 3 year old son approximately 3 months ago, and it’s been great. He’s been having virtually no accidents. The problem is that he’s terrified of making ‘dirty’ on the toilet. He does it in his pamper at night when he’s sleeping. He’s very verbal about it, and tells me that he’s scared to let the dirty come out. It’s really difficult to deal with because there are days when he holds it in all day, and misbehaves all day because he’s in pain. All of my friends tell me to give him laxatives to make him go, but my pediatrician recommended against it because he said he doesn’t want to mess with his muscles, and he’ll get over it eventually. I trust my pediatrician completely, but I wanted to hear your thoughts.”

Here are three parenting truisms: you can’t make kids eat, you can’t make kids sleep, and you can’t make kids poop. So issues around eating, sleeping, and the potty are often the biggest parenting challenges, a least for younger children. Parents wish they had a way to “fix” these issues, or “make” their child do what they know their child needs to do. It can be frustrating, but raising children doesn’t always work like that. Children really do have ultimate control over their own eating, sleeping, and pooping. Why do children sometimes hold their stool? Sigmund Freud felt that stool holding was part of the anal psychosexual stage, and that a children who rebelled against potty training would develop anal-retentive personalities. He also thought that boys in particular had a fear of castration, and that stool looked like a little penis, so boys didn’t want to even symbolically lose their little penises into a toilet. Fascinating stuff, Freud—though it’s worth remembering that his specific analytic theories were just about 100% wrong, even though he deserves credit for figuring out that experiences and subconscious thought affected our outward behavior. In other words, I doubt Michelle’s son is holding his stool because he’s afraid his penis is falling off, but I do believe that his fear could be related to other experiences he’s having a difficult time articulating.

Freud’s theories aside, I think the most common reasons for kids to hold their stool are more ordinary: (1) they like being in control; and (2) stools sometimes hurt. Whatever the initial cause, stool holding inevitably leads to larger, more-painful stools, which makes the child try even harder to hold the stool. I’ve called this the “constipation death spiral.” Fixing stool holding means interrupting the cycle of holding leading to pain leading to more holding.

One thing you can try that will not work: talking. I’m not saying you shouldn’t talk about this with your child, but honestly, once your child learns it hurts to poop, you’re not going to be able to talk him out of it. Sure, you’d love to crawl into his little brain and say “Relax, honey. If you let the poop out it will feel better and you’ll be OK.” Good luck with that. Instead, try all of these methods, all at the same time:

Don’t make passing stool any more uncomfortable than it already is. Don’t try to force it, and don’t punish any behavior that’s involved with stool. Don’t belittle the child or insult him. Avoid saying things like “don’t act like a baby” or “you’re making me mad.” Don’t show even with body language that you’re disappointed or upset, even after a stool accident—all of that just feels negative to the child, and will reinforce a holding habit.

Please, please don’t rely on enemas or suppositories. Maybe once every ten years I’ve suggested one of these, and I’ve usually regretted it afterwards. Almost all constipation and holding, no matter how bad, can be managed without sticking things into your child’s bottom. Believe me, once you start wresting with things down there, it will only get worse.

Make stools more comfortable by using an oral, daily stool softener. You can get exact doses and instructions from your pediatrician. The key here is to use a consistent daily dose to keep stools soft and painless, and to not stop using the stool softener until all memories of the painful stools have disappeared. This usually requires months of therapy. That may sound discouraging, but it’s much better than going on and off medications for years. The main medication you’ll use will be a softening agent only, though sometimes we have to add a laxative to get the bowel squeezing. Again, rely on your own child’s pediatrician for specific advice here.

Michelle mentioned a concern that medications might change the muscles of the bowel. While it’s true that with long term use some laxatives (including Exlax and Senokot) can cause changes in muscle functioning, the stool softeners (like Miralax) are not addictive in any way, and don’t permanently change anything. They just make stool softer. In fact, by relieving the pressure of a big retained mass of stool, softeners allow the muscle wall of the colon to return to normal. No one should be afraid of using these sorts of agents to help their child.

Encourage healthy eating, though don’t harp on it or make it a big deal. More fruits and vegetables, and drinking more water, can help. More dairy can make things worse. But, again, don’t harp on diet or punish your child because of food issues. That will lead to even bigger problems. You will not solve a holding habit by changing diet alone.

Set aside a “potty time” every day for Junior to go sit on the pot, to wait to see what happens. A good time for this is right after dinner. Don’t let Junior just sit there a few seconds and have a little tiny BM—encourage him to sit a long time, read a story, or play with your phone (I think some Samsung phones are water resistant!) Do whatever keeps him happy. This should not come across as a punishment. The idea here is to stop relying on whether Junior says he does or doesn’t have to “go”—just tell him it’s time to go, once a day. And don’t rush.

One final idea: add some fun with something called “The Poopy Party”. (Works best for boys over age 3)

By the way, as with many of my posts, all of this applies to ordinary, healthy, neurologically typical children. If your child has GI problems or developmental challenges, other approaches might be more appropriate. Please talk with the doctors who know your child best.

With time and patience, stool holding will stop. The approach needs to be gentle, non-judgmental, and consistent—and even with that, it takes time to develop new habits. Good luck, Michelle, and let us know how it goes!

Homemade infant formula is not a good idea

Posted September 15, 2014 by Dr. Roy
Categories: Guilt Free Parenting, Nutrition, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Miranda wrote in with a topic suggestion—she wanted to know about homemade infant formula. She had noticed a lot of people suggesting it. What’s the deal?

Speaking about nutrition and human babies, it makes sense to start with this: human breast milk, from mom, is the best food for babies. But even that is an over-simplification. It turns out that in the modern world, human breast milk is often deficient in vitamin D, and maybe iron, too. I know I’m going to get some heat over this, but it’s true: even human breast milk isn’t “perfect.” It’s close, but if we’re going to be honest, even straight-up mom’s milk isn’t “ideal” for babies.

So what’s the best alternative? The contestants: human breast milk, which we’ll just call “human milk.” Commercial infant formula, which we’ll call “science milk.” This is the stuff that’s been studied for years, and is lab-designed to give babies the exact nutrition they need to thrive. Then there’s home-mixed infant formula, which we’ll call “homemade milk”, usually prepared based on an internet recipe.  What kind of “grade” should we give our three competitors, based on an objective assessment of their composition?

The number one “ingredient”, so to speak, is water. Clean, pure, safe water. Human milk, fresh from the breast, is free of harmful contaminants and infectious germs. Science milk is made under sterile conditions, and the liquid versions are pasteurized—as long as they’re stored correctly, there’s essentially no risk of infections spreading. Homemade milk? Who knows. I doubt anyone at home is sterilizing all of their surfaces to the extent done in a commercial lab. And some of the homemade milk recipes call for unpasteurized, “raw” milk—which can be loaded with animal colon bacteria as has been linked to all sorts of colorful infections. Winners: human milk and science milk (tie); loser: homemade milk.

Then there’s protein. There’s too much protein of the wrong kind in most mammal milks (including cow and goat), so science milk relies on modified mammal milk or soy to get the right amounts of the right kind of proteins. The wrong proteins can cause intestinal and kidney damage. One homemade milk recipe I found used blenderized livers as a protein source, which is even more dangerous. Human milk, protein-wise, is perfect. Winner: human milk, with science milk a close second. Loser: homemade milk.

The carbohydrate in all mammal’s milks is mostly lactose. Goats, humans, cows—our milk is all lactose-based. Science formulas sometimes substitute other carbs, largely to take advantage of the fear of lactose intolerance (which doesn’t occur in human newborns.) There’s no known downside to this, though it’s kind of silly. Winner: tie! Lipids (fats) are pretty much the same across the board, or near-enough so.

Sodium: ordinary milk from other mammals (goats and cows and presumably kangaroos, though I honestly don’t know about them) has far, far too much sodium. To properly reduce this, homemade formulas have to dilute that out somehow. Winners: human and science formulas.

Other micronutrients: there are a lot of these, of course—iodine and vitamin C and vitamin D and iron. And these really are important. Iron deficiency in infancy can contribute to permanent cognitive problems. You really do want to make sure that Junior is getting all of these vitamins and minerals in the exact proportions needed. The micronutrient content of human milk has been extensively studied, and science formula does a great job in either copying that, or even improving on that (re: iron and vitamin D.) Winner, science formula, by a nose; human milk is a very close second. Homemade formula are based on dozens or maybe hundreds of recipes, and no one has systematically figured out which if any actually deliver the micronutrients that are needed.

 Here’s a funny, true story from my residency: an 8 month old baby was admitted to the pediatric intensive care unit, near death. (Wait, it gets funnier.) He was very, very anemic—I remember noticing when drawing blood from his nearly lifeless body that the blood itself was kind of watery and runny. He also had neurologic problems and his vital organs had shut down. It turns out that his father was traveling hours a day, back and forth, to a farm to pick up fresh goat’s milk to feed him (because his parents had heard that goat’s milk was healthy!) Since goat’s milk is entirely deficient in one of the B vitamins (folate), the child’s blood marrow pretty much shut down. And there were a whole bunch of other health consequences related to other nutrient deficiencies and protein overload. After a few weeks in the ICU the baby survived. Isn’t that a funny story? No, of course it isn’t. It isn’t funny at all.

Ease of use and preparation: human milk wins, here, of course—though it has to be said, not always. Some women really do have a hard time nursing. It’s not always the easiest choice. Fortunately, we have another reasonably easy alternative: science milk. Mix the powder with water in the right proportion, and you’ve got pretty much exactly what your baby needs. The worst choice, here, would be homemade milk: it’s complicated and fiddly, has a lot of ingredients to get wrong, and it still may not even provide the nutrition your baby needs.

Homemade infant formula is a terrible idea. There is no way for parents to make something as pure and complete as either human milk or commercial infant formula (science milk.) There’s no evidence whatsoever that it even might be safer or better in any tangible way. This is one case where homemade is not the way to go. If you’re not breastfeeding, you should use commercial infant formula. Do not trust your baby’s health on your chemistry skills and recipes from the internet.

Protect your kids from the “new” respiratory virus

Posted September 10, 2014 by Dr. Roy
Categories: In the news, Medical problems

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Facebook and other social media sites are all a-twitter (ha!) about a “new” respiratory virus, sweeping the country and sickening thousands of kids. There is something new, or new-ish, out there, and it looks like the infection can get pretty bad. But now is not the time for panic. We’ll get through this, like we get through other spikes in viral infections. With some common-sense steps, your kids will be OK.

As reported officially by the CDC this week, in the last month hospitals in Illinois and Missouri reported an increase in emergency department visits and hospitalizations for respiratory symptoms. Since then, reports of similar illness are coming in from many other states, scattered across the country. Most (but not all) of the cases with more severe illness had pre-existing lung disease (like asthma).

The illness seems to be mostly affecting children. Most cases begin with ordinary, cold-like symptoms—and it’s likely that most cases actually never develop into anything more than that. The reported cases, so far, may well be a “tip of the iceberg” effect, where only the sickest children get tested and identified. These are the kids who develop trouble breathing and low oxygen levels, and often need intensive care. It’s quite likely that most children with this infection quickly recover after a cough, sniffles, and runny nose. Of the cases reported so far, only about 1 in 4 or 5 runs a fever. Probably, most children and adults who have this infection don’t seek medical care, and very few of them (so far) are even being tested for the likely viral cause.

Most of the reported cases are testing positive for a specific virus, called enterovirus D68. That virus was first identified in California and 1962, and until now had rarely been a reported cause of illness. The enterovirus group, as a whole, contains a lot of other viruses that cause a whole bunch of different symptoms—fevers, respiratory illnesses, GI problems, heart disease, rashes, and neurologic problems. Pediatricians and others who take care of kids are used to seeing tons of enterovirus, which usually strikes in the summer, most typically as hand-foot-and-mouth disease, or as a fever. So we’re used to these kinds of viruses, even though this specific one is a newly-recognized member of the family. We’re not 100% sure, yet, exactly how D68 is transmitted, but other enteroviruses spread though respiratory drops and in stool, and can remain infectious for a long time on contaminated surfaces.

As with many viral infections, prevention is the best strategy. Common sense things can really help: keep your kids home when they’re sick, and don’t send your kids off to play with sick children. Encourage your kids to wash their hands and use hand sanitizer frequently. Get a good night’s sleep and moderate exercise. Keep your child up-to-date on vaccines—though there is no specific vaccine for this enterovirus*, bacterial and viral coinfections with influenza and pneumonia can be prevented. If your child has asthma (or any other respiratory problems), make sure that you’re keeping up with all prescribed treatments, so things are less likely to spiral out of control when an infection strikes.

If your child does get sick with cough, look out for these symptoms:

  • Having trouble breathing. You may see individual ribs poking out with each breath, or the depression at the bottom of the neck sinking in, or bobbing up and down. Children with trouble breathing usually breathe fast, and sometimes breathe noisily.
  • Having trouble speaking. If you can’t get good breaths in, you can’t typically complete sentences and talk normally.
  • Seeming listless, with low energy. Children with serious respiratory compromise may not be getting enough oxygen to their brains. They can seem “foggy” or “out of it.”
  • Drinking poorly. Younger children and babies may have a hard time eating and (especially) drinking when they’re really ill.
  • Looking blue or pale.

If you’re seeing those kinds of symptoms, take your child to the doctor right away, or head to the emergency department. Even if things don’t seem quite that bad, if you’re worried, don’t hesitate to call for help.

Most children who are getting enterovirus D68 infection will do just fine. Some of you have probably already had children with this, and didn’t even know it. Every year, we see spikes of infections like this, caused by a variety of viruses like RSV, metapneumovirus, or influenza. Though there is no specific therapy for most of these, we’re pretty good at recognizing who needs extra help, and we can provide good supportive care when it’s needed. It sounds scary when you see news of a new, bad infection—but in truth, this isn’t very different from other infections we’re used to dealing with. We need to stay vigilant and keep our eyes on whatever’s out there making our children sick, but there’s no reason to get too worked up over this latest challenge.

*Fun trivia challenge: we routinely vaccinate against one other enterovirus, one that historically caused infections in the summertime. Guess!

This was adapted from a post I wrote for my practice website.

Dr. Bob Sears says skipping vaccines is not good for public health

Posted September 9, 2014 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

This weekend, The Los Angeles Times reported on California pediatrician Dr. Bob Sears’ role as a favorite among vaccine-fearing parents. What he tells them is absolute nonsense that he has freely admitted he made up in a Reddit interview. Now he’s let a little more honesty shine through. He told the reporter:

“I do think the disease danger is low enough where I think you can safely raise an unvaccinated child in today’s society,” he said. “It may not be good for the public health. But … for your individual child, I think it is a safe enough choice.”

I had wondered: is it possible that a board-certified pediatrician, one from a family of influential and well-known children’s health experts including Dr. William “Attachment Parenting” Sears and Dr. Jim “The Doctors” Sears, could really believe the idiocy in his own book? Now we know. Dr. Bob Sears says screw public health, screw everyone else’s children, screw your neighbors and their families. It’s fine if you skip your child’s vaccines, because for your child the risk isn’t great. That may not be good for the public, Bob says, for all of those other idiots out there—we know if people start skipping vaccines the disease will surge back. But for your snowflake, well, it’s OK. You can even picture him winking when he says it.

This is just despicable. Mendacious, vile… I’m running out of adjectives, here. Dr. Bob thinks his own special pals, his patients, the suckers who buy his books, they don’t need their vaccines—they can just hide in the herd, as long as the rest of us get our kids vaccinated. His white, affluent, Orange County kids can’t be bothered with needles. Sure, it’s no good for public health, but public health isn’t something his parents need to think about.

Dr. Bob freely regurgitates long-disproved anti-vaccine canards throughout his laughably mis-named The Vaccine Book: Making the Right Decision for Your Child. The book has sold well. He’s telling people exactly what they think they want to hear, blaming all sorts of ills on vaccines, fueling fear and anxiety and a mistrust of every legitimate health authority on the planet. They’re all wrong, he says, the CDC and the IOM and every county health officer and every single country’s health ministries and all of the pediatricians, family medicine docs, infectious disease specialists, and everyone else who’s invested their careers in protecting the public health. We don’t need no stinkin’ evidence.

He’s making oodles of money off of your fear, while freely admitting that what he’s doing is no good for the public health. Don’t forget: the public is you, your children, your family. We’re all in this together, sharing our planet and sharing these infections. You can help keep your children and communities safe by making sure your kids are vaccinated. Or you can join the “me first, screw you” brigade led by Dr. Bob.

Back to school means back to backpack back pain

Posted September 8, 2014 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2014 Roy Benaroch, MD

(Yes, I know, I need an editor to help me write better headlines for these stories. Send in your application to our human resources department.)

From researchers in Spain, a simple, brief study confirms what you would have guessed: kids’ huge backpacks are hurting their backs.

A team collected data from about 1400 students in lovely Galicia, Spain (where I have decided I want to go on vacation, despite the hordes of back-injured children. I won’t tell them I’m a doc.) Those carrying the heaviest backpacks had a 50% increased incidence of back pain. The risk was higher among girls.

There are a lot of pressures on kids these days. You’d think a huge backpack wouldn’t have to be one of them. There are some things parents might be able to do to mitigate this problem:

  • See if you can access textbooks online—and if so, encourage your child to just leave his books at school rather than lugging them back and forth.
  • If you can’t get online access, consider getting a second set of books to keep at home. You can probably buy them used on Ebay or Amazon, or maybe convince the school to give you a second set with a doctor’s note documenting back problems.
  • If allowed, try a rolling backpack. Many schools discourage these because they gum up the overcrowded hallways.
  • Use a backpack that fits right, with the straps tight enough to hold the weight high on the back. A high-quality backpack has wide, padded straps and is designed to keep the weight close to the body, not hanging down the back.
  • Discourage the slouchy, single-shoulder carry. A backpack with a significant amount of weight is best carried on straps across both shoulders—or even better yet, with a belt across the lower belly that supports some weight on the hips.

Perfect iced coffee

Posted September 6, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Put one cup of freshly ground coffee in a French Press. Don’t use a really fine grind, it’ll make a muddy mess—ordinary drip medium grind is fine. You want a good shiny bright coffee, like an Italian Blend, or something from Mexico or South America. Fill with cool water to the top, and leave it at room temperature for a day.

Press down the grounds, and pour the supernatant (sorry, geek word. The liquid off the top) through a coffee filter. You can just use your drip coffee maker—load up a filter and pour though. What drips into the carafe will be super-concentrated, cold brew supercoffee.

I like to mix in some simple syrup as a sweetener. Remember sugar won’t mix well into anything cold, so you have to add it ahead of  time. Mix 1:1 water and sugar and heat it up until melted in the microwave or on the stove. About ½ cup water + ½ cup sugar works for me. Once it’s all melted, add to the supercoffee. Store it in a mason jar in the fridge.

To make your drink: mix about ¼ cup supercoffee + ¾ cups cold water (much stronger than that and you’ll end up hovering) over ice, and add a little squonk of heavy cream (much better than half and half, trust me on this. Don’t even think of using plain milk.)

Enjoy.

Breastfeeding and post-partum depression: A possible cure, a possible cause

Posted September 3, 2014 by Dr. Roy
Categories: In the news, Nutrition

Tags: , , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.


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