Daily Dose

How to Treat Stool Holding

Stool holding part 2: how to treat this common ailment.On Friday, we discussed stool holding and encopresis: what it is and why kids have trouble going to the bathroom.   Now it’s time to discuss treatment.

The medicinal component of treatment begins with  cleaning out the rectum. This is typically done by using enemas (Fleets) to get rid of the large amount of old stool that has distended the rectum.  Mineral oil given orally may also help the stool to be evacuated (it is tasteless but a child can see the oil, so get a soft drink or juice and put a top on it and mix in the mineral oil and serve with a straw), you can also mix into oatmeal. I typically use an enema to start and then keep up daily mineral oil for awhile until the stools are routinely soft and not painful.  Enemas are not well liked by anyone.  A daily laxative is also important. Milk of Magnesia and Miralax are my favorites.  The dose may be titrated but you want to ensure that your child is having a stool every day. The laxatives are not habit forming, but are serving a purpose to help the colon begin to work correctly again. Once your child is having regular bowel movements without pain, or avoidance you can slowly wean the laxative too, but do this over several months. Dietary therapy is also important to help soften stools and decrease the transit time of stool in the colon. Healthy eating habits which incorporate high fiber foods are helpful. The formula for fiber intake is the child’s age in years + 6 = number of grams of fiber /day. You would be surprised at fiber content of foods and they are all listed on the food packages. Benefiber is also a good source of fiber and can be used daily.  I like  to use Metamucil cookies too and if necessary put a little icing on top.  Adding more fluid to a child’s diet is equally important , and a “prune juice cocktail” made with prune juice and seven up or ginger ale is a great way to get in some more fluid with additional laxative benefit. (you taste it not bad at all!) Lastly, behavior modification.  Begin by establishing a regular toileting schedule. This is typically after each meal (to take advantage of the gastro-colic reflex which occurs after eating and causes intestines to contract) and at bedtime.  I sometimes use a timer as a game to try and have the child “beat the clock” in pushing out their poop, and then they receive a “prize” (Dollar store is adequate, does not need to be expensive etc.). A child needs lots of positive reinforcement with charts, stickers to show their progress and even larger reward (maybe trip to bookstore, or ice cream store etc) for a week of good work. Remember, this is not an overnight resolution but typically takes weeks to months of work, so be creative as to positive reinforcement. If your child does not stool every day, try using a suppository and increasing the laxative.  They can also practice doing the Valsava maneuver (where you hold your breath and bear down to have a bowel movement) which will also help them push out the stool which should be soft. If your child is in school you need to discuss these strategies with the teacher so that the child has adequate bathroom time when needed. By working on all 3 areas encopresis can be treated and successfully cured while saving the child embarrassment and anxiety that often comes with it. No one wants to have “poopy pants” they just need the tools to fix the problem. For very difficult cases you may need to ask your pediatrician about using a behaviorally trained pediatric psychologist for assistance. That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Appropriate Age for Cell Phones

So what age should you get your child a cellphone? I got a phone call the other day from a patient's mother who was concerned about the internet and a website that her daughter had gone to, looking up information on eating disorders. Her daughter is in the sixth grade, and she was concerned about her interest in anorexia. But while talking to the mother she mentioned that the daughter had researched this subject from her iPhone, not the family computer!

I was concerned about her daughter's interest in unhealthy eating habits, but also concerned that a 6th grader had an iPhone and free access to all sorts of inappropriate internet information, with no real adult supervision. Our discussion turned to what is an appropriate phone for a sixth grader to have? I am not sure that elementary students need a phone at all. What happened to the days of going to the school office to use the phone to call home?  What about giving your child a phone that is programmed to call home, mom and dad at the office and that's about it?  Not only do kids have unlimited internet access with many of their smartphones, they also have unlimited text and are "texting" friends while in school, late at night and even while driving? I think getting a phone is a privilege and that the longer you wait to give your child a phone, the fewer issues you have to deal with about cell phone use at a young age. Maybe I am out of touch, but I even see six or seven-year-olds with phones. As the kids say, "go figure"? The phone call ended with the decision to replace the iPhone with another phone, to discuss what provoked her daughter's interest in eating disorders and to make sure that the family computer was in an area where the was adult supervision. I am sure her daughter is looking for a new pediatrician. That's your daily dose, we'll chat tomorrow. Send your comment or question to Dr. Sue.

Daily Dose

HPV Is An Equal Opportunity Virus

Human Papilloma Virus (HPV) is the most common sexually transmitted infection in the United States and most genital warts (condyloma accuminata) are caused by HPV.

In 2006 a vaccine (Gardasil) was approved for girls and women aged nine to 26 to prevent cervical, vulvar and vaginal cancers caused by HPV 16 and 18, as well as genital warts caused by HPV types 6 and 11. This vaccine has been shown to be quite efficacious in preventing these conditions, especially when given before adolescents and young adults become sexually active. When looking at national statistics among teens regarding their sexual activity and first intercourse, over 60 percent of teenage girls had intercourse before graduating from high school and the percentage just continues to rise during college. Among those girls, in one study up to 50 percent may be exposed to HPV by their partner after their sexual debut. Not all of those exposed to HPV will go on to develop warts or cancer, as many people can clear this viral infection on their own. The difficulty is, we don’t know who can clear the virus and who will go on to become infected. Obviously, girls and boys pass this virus to one another, and it is not through intercourse alone. Genital to genital contact as well as oral and anal sex may cause transmission of this virus. In my practice, I have many adolescent girls who test positive for HPV on pap smears, as well as both girls and boys who have genital warts. Prevention is the key. Ideally that is through education and abstinence, but as any parent knows, kids make mistakes, and some are more serious than others. Most of the patients in my practice begin taking their HPV (Gardasil) vaccine series between 11 and 13 years of age and upon completion of their three dose series are well protected. I personally have not seen any complications from the vaccine, besides complaints of pain with the injection and sore arms (most of my patients complain with ALL shots anyway). When the vaccine was released there were many questions as to why it was not offered to boys too. It would seem like that would be appropriate? It was in fact given in other parts of the world to boys and young men. I even vaccinated my three sons (completely off label from FDA recommendations) as I felt it would protect them and their partners one day. Of course they complained, and said they “were guinea pigs”. Well, validation came this week when the FDA approved the use of Gardasil to prevent genital warts due to HPV types 6 and 11. The vaccine was approved for use in boys ages 9 – 26, in the same 3 dose series as girls. Each year, about 2 out of every 1,000 men in the U.S. are newly diagnosed with genital warts. I recently saw a 24-year-old male with a wart on his penis, and he could not believe that it was a genital wart. Something about penis and wart just did not connect for him, how could that be a genital wart, I must be confused? Again, education and prevention is the key. The studies in men showed that Gardasil was nearly 90 percent effective in preventing genital warts caused by HPV types 6 and 11. So talk to you doctor at your next checkup with your sons and ask about HPV prevention in boys. HPV is an equal opportunity virus and now we can equally protect both girls and boys. That’s your daily dose, we’ll chat again tomorrow. Send your question or comment to Dr. Sue!

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Daily Dose

Does the Color of Mucus Really Matter?

1.30 to read

It is that time of year and everyone seems to have a cold, including me!! I am actually “on” my second cold of the month, so I am feeling like a toddler who gets sick every two to three weeks.  

This is really a good time to talk about mucus. I wonder how many people will keep reading now? But I do get lots of questions and comments from parents who are worried about the color of their child’s mucus. Runny noses and mucus color are discussed as often as color of poop. And just like poop, the color of your nasal mucus is usually not terribly significant. 

If you happen to have a cold yourself, you probably notice that your nasal discharge changes throughout the day, that is unless you are a teenager, and they swear they never look at mucus or stool color!! I think we notice “green snotty noses” among children between the ages of six months and four years, when they typically don’t blow their noses and many times the mucus is either wiped off of their face or they wipe it themselves on their shirt sleeve, (which then leaves a telltale sign of the color of the mucus). Once a child can blow their nose and dispose of the Kleenex, the color of the mucus does not seem to be a hot topic of discussion.

So, what does color of mucus mean? When you have a cold, the nasal discharge associated with that viral infection typically begins as a clear discharge, that changes over several days into a thicker and more purulent (green) discharge. The color may be due to the white cells that are in the mucus that are producing antibodies to fight the cold. 

As a cold progresses the green mucus then changes back into a more clear discharge and eventually goes away, but that is usually after a seven to 10 day course. It is also common to see thicker “booggers” in the nose in the morning or after your child’s nap as the dry air they are breathing makes the mucus thicker and they are not wiping or blowing their noses so the mucus is thicker. Same for us, we also usually have thicker greener nasal discharge in the morning, while the “snot’ has been sitting overnight. The best way to clear out any color mucus is by using saline nasal irrigation. It works great for all ages. By clearing the nasal passages, it will prevent a secondary bacterial infection which and cause a sinus infection.   

Most doctors use length of time of nasal discharge as more indicative of an infection than color of mucus. Typically in a pediatric patient an antibiotic for a “presumed” sinus infection is not even considered until a child has had over 14 days of a “gunky” green nasal discharge. Remember too, that the nose can clear up and the cold can go away, only to be followed in another week or two by another cold. It is the season. With that being said I am off to blow my nose again and wash my hands! 

That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

The Science Behind Febrile Seizures

1:30 to read

As we head into “sick season" and I have been seeing many children with fevers, I thought it would be a good time to talk about febrile seizures.With the "sick season" upon us, I have been seeing many children with fevers so I thought it would be a good time to talk about febrile seizures.

A febrile seizure is defined as a seizure associated with fever in the absence of other known causes of seizures. About 5 percent of children between the ages of six months and six years will have a febrile seizure. That doesn’t sound like a lot of children but seeing that I have a son that had febrile seizures it is that statistic that really doesn’t mean much when you have a child that is part of that statistical equation. Did that make sense? Reassuring a parent that a febrile seizure is benign and will not cause any long-term problems is a “hard sell” while they are watching their child seize. I even felt scared and helpless and I knew what was happening! When my son had his first febrile seizure at about 18 months of age, I will never forget a nurse saying to me, “Didn’t you give him Tylenol or something, as he has a high fever?” She did not realize that I was a pediatrician, and I tell this story to other parents whose children have febrile seizures, as parents always feel guilty. (What is that with parental guilt?). I hope she did not have realized how guilty that might make a parent feel, for as I already thankfully knew, giving anti-pyretics (like Tylenol or ibuprofen) does not necessarily prevent a child from having a febrile seizure.

We know that febrile seizures may occur in some children with a fever of only 101 degrees, while another child may be running a much higher temperature and not have a seizure. About 30 percent of children that have a first febrile seizure will go on to have another. That is the concern of many parents who have children who experienced a febrile seizure. Parents will try to do anything they can to “ward off” another seizure when their child gets yet another fever. I was reminded of this again while I was reading an article from The Archives of Pediatric and Adolescent Medicine. The study, done in Japan, looked at giving children with a history of febrile seizures, extra doses of fever reducing medications. Despite this, fever-reducing medications did not appear to reduce the incidence of recurrences, even when children received an extra dose of medication. It seems that children who have febrile seizures may respond differently to fever reducing medications during a febrile event. There seems to be an innate difference in mechanism of fever in those children who have seizures and those that do not. We have known that there is often a history of other family members having febrile seizures, so this may be further evidence or metabolic differences in some individuals with fever? So, despite a parent’s best effort to lower a fever, especially in a child who has already had a febrile seizure, a seizure may still occur.

Take home message: Febrile seizures are scary, but benign and children outgrow these seizures. Never feel guilty, even if you are asked if you gave Tylenol, or something to lower the fever. Looking at this study it probably wouldn’t have changed a thing.

That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Why Kids Bang Their Heads

Dr. Sue talks about why some kids bang their heads.I have had several questions both online and on–air from parents who “are concerned because their child will bang their foreheads when they get upset”. 

One listener wanted to know if she needed to take her child “to a specialist”.  Thankfully, she does not need to find the “headbanging specialist” whoever that may be, as head banging among babies and toddlers is really quite common.  Up to 20% of babies and toddlers may bang their heads on purpose, and not surprising to me, boys are 3 times more likely to bang their heads than girls! Head banging is a habit, and it typically “rears its ugly head” between the ages of 18 – 24 months.  Head banging typically resolves by the time a child reaches the age of 3, but by that time many parents are ready to bang their own heads. For toddlers head banging may actually be a self comforting mechanism for children to help themselves relax and fall asleep. Many parents will comment that the head banging often occurs in the crib rail or wall beside the crib. Head banging is often a common sign of frustration during the toddler years.  During a tantrum a child may bang their head on the floor as a way of showing strong emotion, when they are not yet verbal enough to use words to express feelings. The best way to put an end to head banging is by ignoring your child’s behavior. Toddler’s may get a few bruises on their foreheads, but they know exactly how hard they can hit their head without causing serious injury. You may not realize it, but toddler’s are really quite bright, and they are seeking attention through head banging (albeit negative behavior to get attention), so running to them each time just reinforces their behavior. The sooner they realize that you are not going to intervene or respond to their head banging the more quickly the behavior will stop. Just beware, that by the time your child is a teen, they usually don’t resort to head banging to vent their frustration, but use a barrage of words to convey their unhappiness with you!  Something to look forward to. That's your daily dose.  We'll chat again tomorrow!

Daily Dose

Good News About Peanut Allergies

1:15 to read

There has been a lot of news recently about peanut allergies and good news on all fronts. For several years there had been recommendations that children should not be given any peanut products until at least two years of age due to concerns about children and peanut allergies. At the same time, some physicians even recommended that breastfeeding mothers not consume peanut products. This was a difficult scenario for both parents and children as what young child did not eat peanut butter?

Many children's parents would not even let peanut butter in the house and were consumed with reading labels looking for peanut products. Remember, this was not in a peanut allergic child, or even in a family with a history of peanut allergies. I would have failed as a mother during this time as my kids ate peanut butter sandwiches almost daily.

I can remember a patient coming over to my house for one of those "house calls" I frequently do and at the end of the visit I offered her child (about 22 months) a peanut butter cookie that I had just baked. As she took the cookie from me, ready to take a big bite, the mother screamed, "She has never had peanut butter, don't let her have that!" Before you could even grab the cookie she took a big bite, a grin spread over her face and lo and behold, she ate the rest. (I am a good cookie baker, if I do say so myself.) No reaction, happy child and now the mother was convinced her child would not die if she ate peanut butter before two. Well, the recommendations have changed and children may have peanut butter, or peanut products before they are even one and seem to actually have a lower chance of developing peanut allergies. They should not eat a whole peanut, for risk of choking, but other products are fine.

I had never been convinced that withholding peanuts seemed to make a difference, and peanut butter is a childhood staple, full of good protein. Now, news from Duke University is also showing that very peanut allergic children may be de-sensitized to peanuts by giving them miniscule amounts of peanut protein on a daily basis. After 8 to 10 months of gradually increasing doses of peanut powder several of the children were able to tolerate peanuts in their regular diet and several more were able to tolerate up to 15 peanuts at a time without serious reactions. This is significant data for those children suffering from peanut allergies, and who have the risk of developing anaphylaxis and even death if exposed to peanuts. It seems that scientists are making inroads into developing oral immunotherapy to de-sensitize children with food allergies, and further studies are underway.

That's your daily dose, we'll chat again tomorrow. More Information: Experimental Treatment Gives Hope to Children with Peanut Allergies

Daily Dose

Start a ‘Thanksgiving Box’ For Your Family

If you have young children start a Thanksgiving blessing box, what a wonderful way to make family memories.I was walking with my "five women walking group", a ritual that occurs most weekdays at 5:30 am. I am telling you we could solve many world problems! But I am digressing. We share many stories of our families, as our children have grown up together despite going to various schools. One most recent one was about "the blessing box". This was a 3x5 index card box that her family had. Every year she and her husband and their two daughters would write down a Thanksgiving blessing (with a little coaxing by Mom) something that they were each thankful for.

Every year the cards were read at Thanksgiving dinner and put away in the box until the following year. This tradition continued and the mother, in anticipation of Thanksgiving and her girls returning home from college, had just pulled out the blessing box. She recounted this to us this week during our walk. She also had us laughing out loud (LOL, as her girls would text) at some of the blessings that had been written over the years. We also laughed as she told us to guess which daughter had written which quotation (one wrote, " I am thankful for my cat" while the other wrote, "I am thankful for pink fingernail polish"). Of course, we knew who wrote what. The point of this story is if you have young children start the Thanksgiving blessing box, what a wonderful way to make family memories. I only wish someone had told me about this tradition 20 years ago rather than last week! That's your daily dose, we'll chat again tomorrow.

Daily Dose

The Debate Over Allowances

Does your child get an allowance? As a parent myself I have had all sorts of differing opinions about giving children allowances.Does your child get an allowance?  As a parent myself I have had all sorts of differing opinions about giving children allowances. What age do you start, is an allowance attached to certain chores, how much do you give a child at different ages and what does allowance go towards?

I also found myself flip flopping over the years and can often not remember which strategy I thought worked best. I do know that I approached allowances differently at different ages. I really believe that an allowance is an important part of childhood. It is a wonderful way to teach responsibility, and the concept of getting “paid” for work completed and well done. It is also a good way to begin teaching a child about saving money that they have earned, and how far a dollar does go,  The “paid” part is always the tricky issue. Most parents believe that it is important to teach their children age appropriate chores around the house and to reward them for doing the job. Others feel  that household chores are just part of being a family member and do not come with compensation.  But does compensation always have to be a financial reward?  I think it differs for different age children and as a parent, you know your child best. Whether it is picking up their own clothes, making their bed, setting the table, mowing the grass, washing the cars...the list is somewhat endless and may be determined by the parent for a younger child and with the child’s involvement as they are older. Once you have decided what is going to be on the list (at one point my boys thought that brushing  their teeth, bathing and showering were household chores and should be rewarded, that was debated at length) you can decide  the amount of compensation, and whether it is a daily, weekly or monthly allowance. In the beginning I liked using a chart that allows younger children to visually see what they are expected to do, and then use check marks or stars as the chore is completed.  By adding up the stars you could then decide on a monetary exchange, in other words, each star might be worth a dime and at the end of the week or month they cash in. After that they may keep the money in a piggy bank and at some point even go to the bank to open their first savings account. They are now learning about saving money!!  Withdrawing can be another topic. As children get older allowance is often paid weekly. The question becomes whether allowance is just paid every week, without confirming that the table has been set all 7 nights or dishes washed or beds made. By the time children are adolescents, their allowance might also be tied to spending money for their weekend activities. It worked better at our house to keep the weekly allowance the same, unless there was a huge infraction in household cooperation or participation.  By doing this they were less opportunities for the teen to just ask for money at random times, and they knew that on Sunday they would get their allowance which needed to last for the week. This was the start to budgeting that would continue through college. Whatever you do, your child will learn valuable lessons from getting an allowance. The hardest part may have been remembering if I had already paid it or not! That's your daily dose for today.  We'll chat again tomorrow. Does your child get an allowance? If so, for what and how much? Let me know. I would love to hear from you!

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DR SUE'S DAILY DOSE

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