Constipation 2018/Because the poop has to come out!

Constipation - The poop, the whole poop, and nothing but the poop One day your kids will be completely out of diapers. Believe it or not, the day will come when they no longer want you to wipe their butt after a poop (that age tends to vary greatly from child to child.) The years pass and while at some point you tend to lose track of your child's bowel movements, it is the rare parent that gets a completely free pass. If you are a patient of Noe Valley Pediatrics, I am betting that at some point before your child goes off to college, you are going to have a conversation with the advice nurse team about your child's BMs. It is quite common for kids to occasionally complain about tummy aches. In my experience, a full 90% of these are constipation related. Of course we never want to ignore other possibilities. Abdominal pain could be all sorts of other things that need attention. Tummy aches that come from constipation tend to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body. If we have a patient with a complaint of a tummy ache, we are going to want to know the frequency and consistency of the stools. Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can't get through. What they will pass is some very runny substance that is getting around the solid mass of impacted stool. Because of this, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing. When was the most recent poop? Was it normal size? Smaller than usual? How often are they pooping? Are they sitting for a long time trying to get it to come out? Are the stools coming out in little hard pieces? If your older child is feeling a little bit shy about it, consider having them take a picture. There is something called the Bristol Stool chart that can help with the description. Bristol Stool Chart Having a regular poop routine is helpful (particularly for boys who stand to pee). They should get into the habit of sitting on the toilet for 5 minutes at least 2 times per day, even if they don't think they have to go to the bathroom. Ideally this will be done after meals. Sitting on the toilet should be limited to 5 minutes and there should be no straining! (Maybe take the Harry Potter book out of the bathroom.) After 5 minutes, just get the kids up - if they have the urge again, then they can sit back down. Many children don't like to poop at school or camp. (Hey some adults have strongly prefer the privacy of their home bathroom as well.) If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the urge passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. They may pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be "yes". I like to do a little 'Nurse Judy poop math' (this can't possibly surprise any of my regular readers.) Figure out how large your child's average size stool might be. Let’s say it is the size of a hot dog. Assume your child doesn't have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache! It is time to sit and talk to your child about a very important rule. There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option. These kids need to be cleared out. All the prune juice into the world is not going to be able to blast through an impacted mass of stool. Thanks to Dr Wild for telling me about the following video! The Poo in You Parents can take a look and see if you think it might be a good teaching tool for your child. Massage and a warm bath are a good starting point. Some kids actually maybe able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation with an utterly miserable child who is holding onto their poop as though it is a treasure, you will be happy to see them poop anyway that you can make it happen. Some people find that adding a few teaspoonfuls of either baking soda or epsom salts to the warm bath water will can also help. If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. Another option (which I prefer) is a liquid glycerin called Pedialax. The directions on the box advises that these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in the small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes. Chronic constipation is not a quick fix. The first step is obviously to get rid of the poop, but then the muscles need some time to be retrained. Once you get some of the hard stool out, we can start to focus on making some adjustments to the diet. Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/ toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to avoid those until they are having softer stools. Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps (if you do this, make sure they are getting enough calcium.) Fruits and veggies are great. Smoothies might be useful if they won't eat them raw. Make sure they are drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to get you back on track. Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet. See if you can somehow hide some molasses and flaxseed oil in some oatmeal or baked goods. Kids will often eat something if they had a hand in baking it. Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion. Fiber is essential. The usual rule of thumb is that a child should be consuming their age + 5 in grams of fiber (For instance, a 10 year old needs 15 grams of fiber, a 15 year old needs 20 grams of fiber per day). This is up to a maximum of the adult dose of 25-30 grams per day. It is important to make sure that all this fiber is washed down with lots of water. Too much fiber and too little water will actually bulk up the stools and worsen constipation. If you are finding it a little tricky trying to get enough fiber into their diet, try offering FiberOne bars, fiber gummies, fiber powders (Metamucil, benefiber, citrucelle, etc) to get to their goals. Make sure your child is getting enough magnesium. Natural Calm (available at Whole Foods and natural food stores) is source that many folks like. An appropriate dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form. Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day. The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1 to 1-1/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps. This also comes as a gummy!!! Posture makes a difference! Go online and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “third world problem”. It turns out that our sitting position is not really helping our body with elimination. You might want to experiment with a little footstool in front of the toilet or potty that gets your child in a better position. You can try it too! If you have a young child, check out the book Itsy bitsy Yoga. Some of the stretching positions might help move things along. Itsy Bitsy Yoga Acupuncture is another option. Check outwww.theacupunctureden.com We have had some success sending folks for biofeedback. Alas this may or may not be covered by your insurance. If massage, position and good diet don’t seem to be doing the trick, talk to your doctor about getting your child on Miralax. Miralax is an over the counter fiber that is heavily used by pediatric GI specialists to deal with constipation. Miralax has recently had some articles about it that made some folks uncomfortable about it’s use. There are no studies about its safety for long term use and one of the biggest concern is the lack of testing in pediatrics. While that is true, official studies aside, it has been used for years and years without any known contraindications The specialists don’t seem to have concern about the safety. Miralax doesn't get absorbed into the system. What it does is pull the fluids into the intestine to make sure the stools are softer. We have some patients who are on it for an extended period of time with no ill effects. That being said, I never want anybody on medication that they don't need. If your child has been given a dosage for a course of Miralax, I am perfectly happy if you do a daily adjustment of the dose depending on that day's stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose. If you are pretty sure you child is not constipated and they have an abdominal pain that is more steady than intermittent, they need to be evaluated! Thanks so much to the wonderful UCSF GI specialist, Dr. Wild, for helping me update this post!

Potty training considerations

 

Potty training tidbits

If you look at parenting as a journey, consider that every single one of us has to pass through the ‘toilet training’ station. Some kids do it very easily, but they are the minority. There are tons of differing opinions on how best to tackle this. Regardless of which method appeals to you, the key is recognizing that kids all will present their own unique way of achieving the ‘big kid/no more diapers’ status. Watch your child's cues. If you start too soon, more often than not, you can expect several months of aggravation. My kids were no exception to this and I learned some valuable lessons along the way. My first daughter, Lauren, mastered most of the milestones on the early side. Seriously, she was singing show tunes at 18 months. She was interested in the potty and was mostly trained well before she was 2. But it wasn’t completely smooth sailing. She went through a period of horrible constipation.  Constipation is very common during this phase. I am defining constipation as when they have hard or pellet-like stools. I see this happen ALL the time. Toddlers are now physiologically able to hold their poop. If they hold it too long, it will be uncomfortable coming out; this will make them want to hold it even more. Even one painful poop is going to make them more reluctant to go. This is the proverbial vicious cycle. Keep track I don’t think it is necessary to track every pee and poop (sneeze, yawn, ounces of milk etc) when you have an infant. However, once you have a child who is on the brink of leaving diapers behind, it is very important to pay attention to their poops. This is especially critical if there are multiple caregivers. It is easy to lose track. Kids might skip several days before anyone notices. If they miss a few days and the stools are still mushy, that is just fine. However, more often than not, the infrequent stools are harder than we want them to be. I would suggest starting a shared document or using a tracking app such as Huckleberry. This is to make sure that whoever is on duty when the poops make an appearance, marks it down. Make note of the consistency as well. This would include daycare providers, grandparents and anyone who is part of the team. All the caregivers should not only help keep track, but it is really important that everyone is on the same page and giving consistent messages during this process.  Pay attention to diet Be proactive. Make sure they are getting lots of fluids and fiber. Make some healthy muffins with ingredients like oats, flax seeds and molasses. Kids tend to eat things that they have helped with. Or make smoothies with lots of veggies. Let them add things to the blender, be in charge of turning it on and have a special cup that they drink it out of. All the kids will manage to get out of diapers sooner or later.  If you wait until they seem ready, they can have success within a week. My younger daughter, Alana took her time with all of the milestones. Having Lauren do everything so quickly made it feel even slower. She was slow to walk, slow to talk and not in the least bit interested in getting rid of the diaper.  Be careful how you ask the questions! Me: " Hey Lani, don't you want to be a big girl? Do you want to wear these wonderful big girl undies?" Alana: " Nope. I like being a baby. I like my diapers." Hmmm, for some reason, that wasn't the response that I was expecting and I didn't have a follow up. Just when I was figuring that this 'big for her age' almost 3 year old would need to start wearing "depends" all of a sudden she was magically ready. She asked for underwear and barely had an accident after that. As with everything, Alana waited until she was good 'n ready before doing anything and then simply mastered it. (her first poop in the potty was 5/31/93 How can I possibly know this???? Check out the "keep a journal post!" ) For anyone who is worried, Alana is a local therapist who has given her blessings to me sharing this. Books, songs and Potties As soon as they show the slightest signs of being interested, I suggest getting a selection of the children's books and videos about potty training. Let them get familiar with the concept that some day, big kids pee and poop in the potty or toilet.  Regardless of which method you choose, books can be a fun part of the learning process. A simple search on Amazon will show you that there are tons of cute ones out there. My grandson, Elliot likes the Elmo book P is for Potty, and he also likes the song “Go Potty Go” by Daniel Tiger. My old friend and ex-boss Dr. Schwanke’s favorite is an old book called Toilet Learning, by Allison Mack. This one is especially good for boys. He likes that the title helps parents recognize that it is learning, not training.  Everyone poops is another classic So many options There are also all sorts of potty seats. Some have steps and fit over the toilet. Others play music. Talk to your child about the choices that exist. Which one would they like to try?  Lauren and Adam inherited an Elmo potty that makes noise and Elmo laughter, which they have quickly come to resent.  Monkey see. Monkey do Let them watch you do your business. Although most kids start out by sitting down, little boys and dads...go play the ‘sink the cheerio game’ (I don't really need to spell that one out, do I?) If they are in daycare, exposure to some little friends who have made the transition makes a difference. Elliot has a bunch of little friends that occasionally do some facetime from the potty to show off a successful pee or poop. If you have siblings, cousins or friends who are willing to demonstrate, kids can be motivated by watching their peers. It is okay if they master Pee before the ‘daunting poop’ You may opt to allow this to happen in stages. For some reason most kids are way more comfortable tackling the pee issue but are much more reluctant to poop out of the comfort of their diapers.  Go ahead and work on peeing in the potty first. Some parents have their kids wear undies but tell them when they need to poop and then put a diaper or pull-up on for that. Potty training is the second (hunger cues are the first) big developmental transition where our children learn to listen to their bodies. And as you well know, some are better at listening than others. Having them recognize that they need to pee or poop is such an important first step and a big win. Rewards may or may not be helpful Sometimes a simple star chart is all you need. Other parents have success offering limited use of the ipad or phone for potty sitting.  Some kids are motivated by the lure of ‘big kids’ undies. There are so many fun choices. Princess, dinosaur, super hero, let your little one decide what they would want to wear. Watch out for reward backfires. With Lauren we were offering some little M&M for each poop in the toilet. She proudly squeezed out a pea size piece of poop, pointed to the ‘no longer clean’ potty. She received her treat and a round of applause...."but wait Mom and Dad...look there's more!" Like a gumball machine, she had figured out how to dispense a small piece of poop at a time. After washing out the potty multiple times, we had to do a recalculation (much to her displeasure). And suddenly they are over 3 Aside from reading a few books, unless a deadline is forced on you, such as acceptance to a preschool that only accepts kids who are potty trained. I usually leave the more recalcitrant kids alone until they are 3-ish. Once that birthday is on the horizon, I think it is now time to take some action. There are popular methods available that some folks swear by. The premise is that disposable diapers are very absorbent and make it very comfortable for kids to hang out with a dirty one. Most kids are not inclined to just pee anywhere when the diaper is off. Drawing a firm line in the sand and just getting rid of the diapers is the fastest way to do this. Here are some of the more popular ones Oh Crap potty training guide This is probably the best known Three Day Potty Training This is the one that Lauren’s friend Arielle used with her son Makai and it worked really well. Potty training made simple. This one was created by Big Little Feelings These systems typically help you make a step by step plan. Most involve finding a several day stretch of being home with no diaper. Make sure that you pick a convenient time where you can carve out several days at home where you don't need to be anywhere and can focus a good bit of attention on this. Kids may cry for their diapers, but these method usually works pretty well. I share these because using a program or formal method is great for people who crave firm guidelines and handholding. The costs are variable. For everyone else, remember that generations of parents successfully potty trained their children without fancy apps or prescribed ‘methods’ . It is fine to just wing it!! Here is a consideration/incentive for your older kids. Take them to the store with you when you buy the diapers. (Amazon will survive). Use cash. Singles if you have them. (Remember what actual currency looks like?) Show them the money that you give to the store every time you buy some diapers. Then, look at some toys and see how much they cost. Plant the seed, so that when they are ready, instead of a box of diapers, you can perhaps use some of the money to buy that toy instead. Obviously this tactic works better when the kids are old enough to understand the concept. Recipe for success Give some nice positive attention for any attempt at sitting on the potty and making a real effort.  Ariell shared that the sustained and also specific enthusiastic praise was SO key to their success. Now Makai gives her a hip hip hooray every time she goes to the bathroom and she has never felt so celebrated for such a routine part of the day! Set a timer and have them sit on the potty or toilet for five minutes when they are working on a poop.  Just like squatty potties are great for adults, helping your child be in the right position can facilitate easier pooping. Give them a little place for their feet so that the knees are bent a little.  Make sure that they are wearing outfits that they can pull up and down easily so that when they do remember on their own they are not hampered by difficult buttons. Kids get involved in playing and often don't pay much attention to their body's cues. Get in the habit of taking them to the potty every hour or so. The adults who are watching them need to be consistent. Oops/accidents happen There should be no shame or punishment, but once they are three, they can have a little ‘skin in the game’ They need to help clean up and know where the dirty clothes get deposited. As you are cleaning it is fine to mention how nice it would be if the poop went right into the toilet. Have them be part of the problem solving team  Pay attention to your language “What can we do to keep your new undies dry” Consider having a ‘poop agreement’ so that everyone is clear on any rewards and /or consequences that have been discussed Leaving the diaper phase has its challenges Being out and about with a newly potty trained child is an adventure. You will quickly learn which friendly merchants have clean and accessible toilets that you can run in and use. You will learn to watch out for the telltale signals. The hand down at the crotch and the jiggling up and down usually mean you have a minute or less to find a bathroom.  An inner tube and a large kitchen garbage bag make for an excellent makeshift potty. I used to have those in my trunk and this came in handy on many occasions when my kids were little. Some toilets are scarier than others You actually never know what is going on inside their little heads. When my nephew was 5, he started having some accidents because he refused to pee in his upstairs toilet. I asked him what that was all about? He showed me that there was a towel rack that was crooked. His mom fixed it and he no longer had an issue with that bathroom. Sometimes it is indeed a simple fix I have had some little patients absolutely terrorized when a public toilet automatically flushed while they were still sitting on it. Perhaps you go first and show them how it works. Arielle did the very wise move of getting her guy comfortable with public bathrooms well before they started the toilet training process. They explored the automatic faucets, noisy hand dryers, different toilet flushes and it made him much more comfortable. In fact recently they went to a show and he wanted to spend more time in the bathroom flushing the toilet instead of seeing the show because he was so intrigued by the sounds. If the toilet happens to go rogue and flush while someone is still on it, make it funny. “Silly toilet, I wasn’t finished yet” Or you can use this brilliant ‘post it note’ hack If you put a post it note over the sensor, it should eliminate the toilet from flushing until you are ready!  I have other patients who are really struggling with their aversion to the toilets at school or daycare. It is worth meeting and problem solving with the staff to see if you can come up with a workable solution. Blink and they are 3 ½ Do not shame or yell at a child who isn't quite ready. If your child is over 3 ½ and you don't feel that you are making progress, it might be time to talk to the pediatrician to see if they can help you move forward. Night time is a whole different issue.  I suggest working on the toilet training during the day and using pull ups at night. Don’t even think about tackling night time peeing until your child is waking up dry or asking to get rid of the night time pull ups  Extra Pearls of Wisdom from some experts Julie King, parent educator and coauthor of How To Talk So LITTLE Kids Will Listen shares: I learned from my own child not to ask certain questions. "Do you have to use the toilet?" always got me a "No!" My toddler was probably thinking, "No, I don't have to go. I'm sure I can hold it for at least another ten seconds. I'll keep playing." (Ten seconds later, of course....) I know a mom who asks her little one to "check in with your bladder and your colon. Do you have any pee or poop in there?" Her daughter will stop and try to feel what's going on in her body.  You can also model for your potty learner by checking in with your own body, and reporting out, to help them make the connection. "My bladder is getting full. I better go empty it." When I wanted my little one to empty his bladder before we went out, it worked better for me to say, "Let's see if you can get three drops of pee in the potty." Turns out that once you open the spigot, the pee flows freely! I'm also in favor of being playful. When my daughter was learning to use the potty, she was resistant to "trying" on command. But she was delighted when I used the toilet, and then told her, "My pee wants to say hi to your pee!"  (If you come up with other playful ideas, please share them with me julie@julieking.org! We might as well have some fun while we're spending so much time thinking about pee and poop!) It's not unusual for kids to resist using the potty, especially when it means they have to interrupt their play. (Raise your hand if you have ever sat somewhere for a tad longer than you probably should have, so you could finish an email or a video ... and then had to race to the bathroom? My hand is raised.) Our kids have less experience -- and smaller bladders -- than we do, so the problem is not uncommon. It can help to sit down and problem solve with your child -- come up with a plan for reminders or potty breaks. We have a pretty hilarious example of using problem solving to address this issue with a child, which is on page 110 of our book How To Talk So Little Kids Will Listen. It's called Miss Liberty Pitches In, and it's a true story from my co-author Joanna's family.  And just a reminder that kids with sensory processing differences or developmental delays can take longer to figure out all the steps of potty learning. One of my kids didn't have a good sense of what was going on in his own body, and he didn't feel it when his pants were soaking wet. It took him longer than what is considered typical, but he did eventually figure it all out. If you think you might have one of these kids, it can help to adjust your expectations so you don't get frustrated and impatient with the process, which can affect their ability to make progress. I know, easier said than done! It may help to remember that, for most kids, it will happen.  Mona Singhal of Sparks wonder, and Oath’s behavioral specialist adds: What to Wear: This is always a hot topic. Some experts say wear nothing, go commando! I am not a fan of that. Firstly, that isn’t always the best option depending on where you live. Secondly, we are a society that does wear clothes (most of the time) so that is what we should be teaching our children.   My preference is to have your little ones in underwear and loose sweatpants. You want them to feel wet because that will make them want to change and eventually not want to wet themselves. If they are naked it may not be that bothersome to pee everywhere. Remember to be casual when they have accidents. “Let’s go clean up! You can always tell us when you have to use the bathroom. What color pants do you want now? Can you put your pants in the laundry please?” Drop in the reminder to tell you but don’t focus on it.   Thanks to Julie, Mona, Lauren and Arielle for their valuable time,wisdom and feedback.

 

Is your child getting enough iron? Are you? Many adults are anemic and don't realize it. Iron is essential for energy, growth and brain activity. If you have a baby younger than a year old, you can see how much brain activity is constantly going on. Watching them grow and learn is a marvel. It is useful to be aware of the Daily Iron Requirements: Infants/Children: 7-12 months: 11 mg 1-3 years: 7 mg 4-8 years:10 mg Females: 9-13 years: 8 mg 14-18 years: 15mg 19-50 years: 8 mg 51+ years: 8mg Males: 9-13 years: 8 mg 14-18 years: 11 mg 19-50 years: 8 mg 51+ years:8 mg It is important to note that by the time a baby is 7 months old, breast milk and/or formula alone are no longer adequate for your child’s complete nutrition needs. Dr Ted and I are firm believers that they need to be eating solids! Although there is no other time that the brain is developing quite as rapidly, it isn’t just babies who need iron. Symptoms of Anemia Anemic kids (and adults) can present with headaches, restless leg syndrome, low energy, and trouble focusing. They may look pale and have cold hands and feet. They may have a faster heart rate. Children who have low iron levels also tend to put non food items in their mouths more than other kids. If you have a child who loves to chew on ice, that can also be a signal that they are anemic.  There is also a strong connection between anemia and poor sleeping! I had a family in my old practice who called me about their little 2 year old being a terrible sleeper. Because insomnia can be connected to anemia, one of my first questions was about the iron intake. Both of the mamas were vegetarians. I suggested that these parents hold their noses and offer some meat to their little guy to see if he was interested. Several weeks later, they followed up with me. It turns out that this fellow loved his meat. He turned into a veritable vacuum cleaner, “Meat meat meat”. They started feeding him what he wanted. He ended up sleeping like a champ. It isn’t always such a quick fix, but it is worth keeping this in mind. I have been mystified over the years by the rather remarkable observation that kids tend to eat what they need. Some also actually recoil from things that they are allergic to. Make sure to offer iron rich foods, if they gobble them down, listen to their cues. Please don’t automatically make your kids be vegetarians just because you are. If it makes you feel better, make sure that any meat offered is organic, hormone free and ethically sourced. That is preferable for everyone.  An extra note about vegetarians..... Vegetarians might have to work a bit harder to make sure they are getting enough iron than the meat eaters. I myself am in the vegetarian camp, but made sure to let my children follow their own path. Additionally, you might note that there are entire countries that are vegetarian and raise their children vegetarian. Diets in those countries tend to offer three meals a day of tremendous amounts of bioavailable plant iron: lentils, beans, legumes, and nuts, all paired with Vitamin C (tomatoes, limes, lemons etc), a necessary co-transporter for plant iron to be effectively absorbed by the human intestine.  LAB INFO It is a standard part of routine care to get hemoglobin levels checked. This will give you a clue if there is an issue with iron. Depending on your child’s diet your doctor might recommend getting the screening done at either the 9 month, 12 month or 15 month exam. Of course you don’t need to wait until 9 months. If you have concerns about anemia at any age, give your doctor a call. Some doctors can do a quick little finger stick in their office that will give you instant results. Others might give you a lab slip for a CBC (complete blood count). Many will order the lead level to be done at the same time. If you live in an older house is or are aware of other potential lead risks, ask them to make sure to add that extra test. There are two components in the CBC that give us most of our information about your child's iron level. The hemoglobin is part of the red blood cell that carries oxygen. Your body needs iron in order to have a normal hemoglobin level. The normal hemoglobin level ranges between 11-16. This changes with age and sex. It is usually higher for men. The hematocrit is a measure of what percentage of the blood is the red blood cells. The normal range for a child 6 months to 2 years is 33-40%. These ranges can vary from lab to lab and I have seen lots of goofy lab results over the years that have terrified parents needlessly. If you ever get an extreme result of any sort the first action should be to repeat it. Iron is a fairly finicky mineral when it comes to absorption. Some foods may actually be high in iron but are also high in something called phytic acid which blocks absorption. For you anemic adults out there I hate to pass along that coffee and tea also are a problem when it comes to helping the iron do its job. Iron loves vitamin C, so squeezing an orange or lemon over iron rich food is a fun trick for helping the iron get absorbed.  On the other hand, iron doesn't absorb well with milk. Because of this, kids who drink more than 24 ounces of milk once they have hit the one year mark have a higher incidence of anemia. Interestingly breastmilk is not particularly high in iron, but the iron in the breast milk tends to be very well absorbed.  Iron rich foods can be divided into two groups: heme versus non-heme. Heme iron is much more easily absorbed. Animal sources like meat, poultry, eggs and fish contain heme iron. The dark meat chicken and turkey are higher in iron than the white meat. The egg yolk is a better source than the egg white. Non-heme iron can be found in dried fruits, beans, tofu, enriched cereal and dark green leafy veggies. Other good iron rich options are nuts, and seaweed snacks. Become a good label reader! As you can see from the above list, fortified baby cereals are an easy way to help get your iron requirements for the beginning eaters. Cooking in cast iron pans is actually a great way to get some extra iron into the diet. Supplements You will note from the iron requirements table at the top of this post, that the age ranges don’t start until 7 months. That is because babies are actually born with some iron storage from mom. Maternal iron stores drop down slowly in the first 3 months, reaching their lowest point by 3-4 months.   Assuming mom has taken her prenatal vitamins and is not terribly anemic herself, most doctors don’t worry about iron levels before 4 months But once a baby has reached four months, the American Academy of Pediatrics now recommends that if they are exclusively breastfed, they be given an iron supplement. Why the recommendation? Iron won’t be present in good amounts in mom’s milk, and won’t enter the body until babies get it from solids. Since we believe that solids between 4-6 months are all about exploration, the brief supplementation makes sense. You can skip it if you’re actually doing high-iron solids or supplementing with any formula.  Ideally, once they are getting regular meals of solid foods, you can offer enough food choices that you can get adequate iron from your diet and don’t need to fuss with giving iron.  However, if you have a very fussy eater and the lab shows that the iron level is low, you may need to continue the supplement. Be aware that some iron formulations can cause constipation. Some of the drops can cause tooth discoloration, so make sure you pay attention to tooth brushing.  Iron supplementation can also cause very dark, almost black stools. This is harmless. As long as your child has a nice soft tummy and is comfortable, the black stools can be ignored. If your baby if having troublesome constipation or abdominal pain, you can dose the iron every other day. This will trick the body into thinking there is a scarcity of iron, and increase the absorption through the intestine without the same side effects. Dr. Ted likes the Wellements brand organic iron for infants 4+ months. For toddlers, one of my favorite brands is Floradix. Read the label, but for most toddlers the dose is 1 teaspoon/day.  Floradix contains honey as one of the ingredients, so this is NOT an option for a baby under one year. A good brand for the grown ups out there is ferrochel. It is reasonably priced, available online, and seems to be well tolerated without causing constipation as much as other brands. When your child is old enough, some of the iron supplements options come in a tasty chewable or gummy form that are easy to take, but MUST be kept in a childproof area. Too much iron (if your little one gets a hold of them) can be very toxic. A little attention goes a long way! When your little one eats their iron rich foods, give them positive reinforcement, feel their muscles, and tell them that all that healthy food is helping them grow big and strong. Kids like to dip things…soft cooked meatballs that they can dip in humus or ketchup are a hit for some. You can also hide a lot of things in waffles or pancakes. Be creative. Perhaps buy a special cup that you can call the super hero cup and fill it with an iron rich smoothie. Have the kids add the ingredients to the blender and turn it on. They love eating and drinking things that they ‘helped’ with. Bonus recipe from Oath’s Dr Ted Iron-Rich Vegan Chocolate Milk Base: - 2 cups oat milk - 2 cups spinach (should look like obscene amount) - 1/2 cup frozen mango Blend until perfectly smooth and vibrant green Add 1-2 ounces/2-4 tablespoons pure cocoa powder Blend again after adding any of the below desired additions: Optional Additions: - handful of almonds for extra protein, fats, and iron - heaping tablespoon or two of peanut butter for extra protein, fats, and iron - half an avocado for extra fat (warning, will become very thick after blending) - two slices of ginger (I keep in the freezer and cut off about a tablespoon's worth for each smoothie) - spices: cinnamon, Cayenne pepper (makes it a Mexican chocolate flavor) Thank you to the worlds best models… Sawyer at the top playing the role of Henry VIII and EJ enjoying the hamburger.

Bed-wetting

Nocturnal enuresis, otherwise known as bed-wetting, is something that many patients and families have to deal with. More than half of the bed wetters are boys. To give you a sense of numbers and make you not feel so alone, 15% of 5 year olds still wet the bed; 5% of 10 year olds continue to have issues of staying dry at night. Most of the persistent older bed wetters will grow out of this by puberty without any intervention, but hopefully you don’t need to wait until your child is a teenager to get this resolved; that is the purpose of this post.

There is definitely a genetic tendency at work. Unless on-line dating has taken it to a new level, history of bed-wetting is typically not a subject that comes up on the first date, but now it is worth knowing if one of the parents had the same issue. For those of you washing the sheets every night for your twelve year old, please keep in mind that there is a reason that most camp forms ask about bed wetting. This is not an uncommon situation. The goodnight pull-ups come in such big sizes because there are plenty of older kids needing them

If a child had been dry at night and the bed-wetting is new, check in with the doctor to make sure there isn’t something else going on. This post is referring to patients who have never consistently been able to stay dry through the night.

This can be a really frustrating issue and there are many opinions about how to deal with it. Wetting the bed should not a punishable offense. Waking up wet and feeling loss of control is punishment enough. It is not okay to humiliate your child. Having your child begin to accept some responsibility however, is not a punishment.

The natural consequence for having a wet bed is to be part of the clean up team. Perhaps your child can be in charge of stripping the wet sheets off the bed. Let them be part of the solution rather than being the cause of the problem.

Until your child has shown that they can be dry at night, I would have them in special nighttime pull ups and make sure you have waterproof pads on the bed. Expecting dry sheets before your child has shown they are ready is just going to be aggravating for everyone.

There are some basic considerations and common sense approaches to start with.

The very first thing is to figure out if there could be any constipation issues. (click here for a link to my previous blog post)

Once the kids are out of diapers and off at daycare or school, many parents lose track of the kids bowel habits. Are they pooping daily? Do they have to sit for a while before the poop comes out. Does it come out in hard little pieces? Constipation is a huge factor and is your first step to eliminating bed-wetting issue. Often times, kids are found to be constipated even if they are pooping once or twice a day and the poops seem normal. According to Anne, the wise and wonderful nurse at the UCSF Continence Clinic, this may be because the kids don’t always take the time to get all of the poop out. When we end up sending patients to the continence clinic at UCSF to treat the enuresis, they start off by cleaning almost all of the kids out with a combo of Miralax and sometimes suppositories.

Other common sense steps include  having them better hydrate during the school day. Some kids are “camels” at school and don’t drink. Talk about what the fluid options are. Is there an accessible fountain? Do you send something to drink with their lunch?

Recommended fluid intake for children is measured by weight:

<2 year/<10 kg        30-35 ounces/day

2-5 years/<20 kg     40-50 ounces/day

6-12/<50 kg             50-60 ounces/day

Teens                      60-70 ounces

While we want to bump the fluids during the day, it is time to start  limiting fluids after dinner. Consider taking your child for a “dream pee” before the adults go to bed.

Often you can walk your sleepy child to the bathroom without having them fully wake up. If these "twilight trips' to the bathroom appear to be  disrupting their sleep cycle, see if you can adjust the timing.

If they are impossible to rouse enough to get to the bathroom without you practically carrying them, Dr. Schwanke would suggest that this is a big sign that they aren’t ready yet.

Let's give that bladder some exercise. The continence clinic does not generally recommend “kegels”  exercises for their patients, but once in awhile it is okay to have them practice starting and stopping the urine stream if they can. Another activity is to see if they can hold the pee for a couple of moments when they first realize that they need to go. Without good relaxation of the perineum, children are unable to empty their bladder completely. Try to teach your child to relax when they are peeing. One way to do this is to have them give a big sigh. Sighing is a normal relaxation trigger.

If none of the above actions has made a difference, it is up to you when you want to stage an intervention. I usually wait until your child has expressed readiness to tackle this. Dr Kaplan says that in her opinion, once the kids are old enough to read, they are old enough to be dry at night. She gives her patients a little talking to and tells them that they are in charge of telling that good brain of theirs that they need to not pee at night. She claims a degree of success!

Sometimes, once they are old enough for summer camp or sleepovers, kids are more invested in a cure. If they don’t care one way or the other, you can increase their role in the clean up, but until they are an active and motivated part of the team, I would wait a bit.

Once you are ready to intervene there are several options.

Some of my families have had long lasting success with the bed-wetting alarms. There are several on the market. Here is an email that was sent to me from a mom who wanted to share her experience"

"We purchased a Chummie bed-wetting alarm (along with an extra sensor so we'd have two of those) and I read a really helpful book called "7 Steps to Nighttime Dryness" (by Renee Mercer) which I read through quickly and highly recommend.  

Some takeaways from the book:

-- kids who wet their beds after age 6 likely will benefit from an intervention (like a bed-wetting alarm, which is the most effective intervention available) WHEN both the parents and the child are ready to take the time and effort to do so and are willing to have the disruption to their sleep (which can be tough on everyone).

-- When first starting use of the alarm, parents need to respond promptly when the alarm goes off to scaffold the learning process for their child -- i.e., they'll have to help the child wake up and get to the toilet to start developing and patterning that behavioral response.  Slowly, over a period of time (12 weeks total on average), the child's body will start to learn to wake up when their bladder is full and they'll be able to get themselves to the toilet... until eventually their bladder learns to hold urine until the morning.

-- The author recommends using a chart to track progress. This helps you see and feel a sense of progress, which is helpful to everyone involved.  For example, at first our son would pee heavily twice each night (those wake-ups every four hours reminded us of our prior sleep disruption patterns when we had a baby!)... then it became lighter pees since he started to stop himself mid-stream and would get the rest into the toilet with our help... and then he would pee once per night lightly, and so on until he was dry and slept through the night without disruption.

-- Once your child consistently has dry nights for 2 weeks straight, you wean them from the alarm for another 2 weeks by using it every other night.  This weaning leads to the most effective long-term results.

Before starting the alarm intervention, I had imagined in my head that perhaps our son's bladder got full while he was sleeping, his bladder communicated its fullness to his brain, but he didn't wake up to respond properly so he simply would pee while sleeping.  The alarm helps that transmission of info work properly.

Our experience:

Our son was highly motivated to stop wetting the bed, so we decided to try this alarm approach to see if it might help him.  At bedtime, our son put on his undies, taped the sensor to the outside of his undies as instructed (so the alarm goes off when the sensor starts to feel pee), and then he wore a pull-up outside of all that (so we didn't have to change his bedding a gazillion times).  Our son's first dry night happened 3 weeks into the alarm intervention (although we had forewarned him that it would take 12 weeks so his expectations were realistic).  At 3 weeks, for a few nights he was dry every other night, and then he was miraculously dry every single night from thereafter.  We continued with the alarm for another several weeks and did the weaning process and he has been dry ever since (we first used the alarm 3/26 so it's been 2 months. Woohoo!).  We are thrilled and surprised since he is such a deep sleeper and always has peed at night.  He was a quick-results case, which we were not expecting.  It feels like the alarm kind of magically connected a synapse that wasn't there before!

We used a weekly chart to track his progress.  We used tiny reward stickers both for cooperation (in the "good determination award" cell) and for "dry night" (the latter obviously doesn't happen for a while so it's nice to feel rewarded for at least trying.)"

There is no medication that cures enuresis, but there are some medications that can address the symptoms. The most commonly used is DDAVP. This is a prescription approved for children over 6. It comes as a  tablet. It used to be available as a nose spray but that has been discontinued due to side effects.

When the drugs are stopped, the bed-wetting usually returns unless the child has naturally outgrown the condition. It is nice to know that this possibility exists for use on an intermittent basis such as an overnight or summer camp.

Please note that even when you feel like you have successfully put this behind you, it is possible for mini relapses to occur with little illnesses or increased stress.

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