Nitrates in the Water Supply

     Nitrates are a normal in the water and in some foods. High levels in the tap water occur when Spring rains cause the fertilizer to run off into the water supply. Infants, especially very young infants less than 4 months of age, are at risk to develop a startling blue-ish color to their skin. The AAP (national organization of pediatricians) does NOT recommend worrying about breast fed infants receiving nitrates thru breast milk as it is essentially unheard of for moms to have any significant levels pass into the breast milk. However, for anyone less than 12 months of age, until the alert passes, anyone less than 12 months of age should be given bottled water. Methemoglobin causes an infant to turn blue. And this is not likely at all. We have never seen a case at Hilliard Pediatrics even though these alerts happen every couple years. However, if your child turns blue, take them to the Nationwde Children's Hospital emergency room immediately.
     Although the Dublin Road Water Plant reached an advisory level last week (about June 30th, 2016), the advisory has been lifted now -- as of July 6th, 2016. Here is the initial article about it in the dispatch. And here is the follow-up article about the level being lifted.

Mom Docs helping Moms on the go -- a great website

     I am more than happy to point families to other doctor's awesome websites. One of those that is well worth checking out is "Mom Docs helping Moms on the go", a blog on St. Louis Children's Hospitals website. It is located here and I recommend it!

Flu Vaccine Update for 2016-2017 Season

     We were made aware in the third week of June 2016 that the Centers for Disease Control was officially recommending that for the 2016-2017 flu season that only the flu shot be given, not the Flu Mist. This is based on the protection for the last few seasons. In these studies, the flu shot was much more protective than the Flu Mist. Although this information contradicts what we had been told from past years, the study was so convincing that it will greatly change what we do for the upcoming flu vaccine season.
     As of now, the last week of June, we anticipate only stocking and giving the flu shot. The Flu Mist may be used again in the future. We will keep you updated about this issue here and on our Facebook page in the coming months.
     We feel as distressed about this as many of you will feel.

Toilet Training Your Child

Introduction I talk to parents and children quite a bit about toilet training. It is a big accomplishment to finally be potty trained as a toddler. I know it can be a frustrating path to get there. I hope this information is helpful to you.

Signs of readiness

     Here are signs to look for to know your child may be ready for potty training:

- Your child is dry at least 2 hours at a time during the day or is dry after naps.

- Your child can tell you when they are about to urinate or a have a bowel movement.

- Your child can follow simple instructions.

- Your child can walk to the bathroom and help undress.

- Your child does not like wet diapers and wants to be changed.

- Your child asks to use the potty or toilet.

- Your child asks to wear big kid underwear.

First steps towards potty training

- Buy a potty. We generally suggest a potty that allows the child’s feet to reach the floor. But children with older sibs may prefer going on a toilet with a potty seat on top.

- Be a good role model. Many toddlers will follow you into the bathroom. Let them see you go on the toilet and wash your hands afterwards. You can help prepare them to use the potty by saying “You can sit on your potty too”.

- Decide which words you will use. When I was growing up, it was a naughty word to say “poop” in my house. But that is the word my kids used to describe bowel movements – we said “pee” and “poop”. You might say “urine” or “number 1” or another word that works for you. You might use “poop” or “BM” or “number 2” or “poo”. Try to avoid words that put a negative spin on toilet habits – keep it neutral – so it is best to avoid dirty, naughty, or stinky.

- Watch for the signs. Toddlers may grunt, look like they are concentrating, squat down, stop playing, or other signs before they have a bowel movement. You will learn your child’s signs. This is a good time to offer to have them sit on the potty. Signs of urinating are trickier – some children give you no signs. Occasionally kids will pat the front of or tug on their diaper.

- Teach proper hygiene. Show your child how to wipe. Girls should spread their legs apart while wiping and should wipe front to back. Wiping front to back helps prevent bacteria from spreading from their bottom to their bladder and vagina. Teach your child to wash their hands after the use the toilet.

- Make it part of the routine. Take your child to the potty when you see the signs of needing to use the potty, first thing after sleeping overnight or napping, and when your child is getting ready for a bath. Even if they do not use the potty or go right after getting up from the potty, do not stress – it takes time to do it right.

- Give lots of praise for successes. Everyone will be less stressed about potty training in your home if you can remember to offer praise, hugs, and high-fives when your child goes on the potty AND act as if it is perfectly fine if there are accidents, lots of sitting without any actual “potty business”, and other issues. Punishment will just make your child upset and can make it take longer to be successful at potty training. Many parents find it helpful to make a sticker chart, offer a small treat (raisins, animal crackers, an M&M candy), or put a penny in a piggy bank for successes on the potty. These kind of small rewards work best if you do it for each small step: sitting on the potty dressed, sitting on the potty without diaper on, peeing on the potty, and then pooping on the potty. Although some parents have good success with just praise, a special sticker on a chart or a special treat can go a long way to help encourage better interest in potty use.

Grandma swears you as a parent were potty trained when you were 18 months old and your child is 18 months old and not yet potty trained

     First: don’t let this stress you out. Nowhere on your child’s college application does it ask when your child was potty-trained. It will happen and everyone is on a different schedule.

     Second: don’t tell the grandparents, but their memory may be fuzzy for the details.

     Third: more kids had a stay-at-home parent years ago and some children had a good chance to potty training earlier.

 Potty trained but not potty motivated

     This is a common issue. Your child has shown signs of success, has peed and pooped on the potty, but will not do it regularly. This is the best time to practice patience. A researcher at the Children’s Hospital of Philadelphia studies potty training and did a study with potty resistant children. He had one group of these families regularly do sticker charts, encouraged the kids to regularly sit on the potty, made a plan for rewards for success, and talked about it regularly. The other group put the potty training “on the back burner” – the potty was there but they did not regularly talk about it, they did not plan to make trips to the potty regularly, and stopped any talk of stickers/M&Ms/pennies in a piggy for success. Three to six months later, the group that put the issue on the “back burner” was almost twice as likely to have their children now potty trained. The researcher (and I agree) said this was a classic “issue of control”. The child wanted to be in control over this potty training issue. Once the pressure was off, they chose to use the potty. So if a family says their child cannot start pre-school in 6 weeks because they are not potty-trained, the most likely thing to work is the put it on the back burner.

     Although peer pressure can result in bad things, watching an older sibling or a classmate in daycare use the potty well can be a powerful motivator.

Your child will pee on the potty but you are having no success with having them poop on the potty

     This is so common that for many children it is practically an official step in potty training (although some children skip this step). And helping kids through this is often a two part job: helping the child be motivated about pooping on the potty AND solving any constipation that happens. First off, constipation sure can happen because all of a sudden we are expecting the child to hold their poop until the go on the potty. Once they go, they may have waited long enough that it is a larger, harder to pass bowel movement and it is not as comfortable to pass as usual. This motivates many children to wait longer to have a bowel movement the next time. This cycle of waiting and then a less comfortable bowel movement pushes them into a stretch of constipation. Children at this age have a mind-set called Magical Thinking that can allow them to think “it hurt the last time so I am never going to poop again”. This is not how it works in real life obviously. Many of these children then need help from us to keep the bowel movements softer: more water and juice intake, more fiber (whole grains like oats and wheat), less of the foods that tend to constipate (bananas, cheese, and carrots – 3 staples of toddlers diets), and potentially Milk of Magnesia or Miralax® (see our Constipation protocol). After a few weeks of keeping the bowel movements (emphasis on weeks – this will take time) softer AND with encouragement, hopefully the cycle of putting off the bowel movements will be improved.

     Now let’s tackle how to encourage the actual pooping on the potty! Many of these kids will not tell you when they need to go or will but they will poop in their diaper or pull-up. Many times we will hear that a toddler will ask for a pull-up or diaper so they can poop in it. What to do as a parent? As you can tell, the child does have control over their bowel movements. They just are not going on the potty. Instead of letting that frustrate you, we can channel that into going on the potty. One strategy is to encourage small steps in that direction. Encourage your child (bribes may be needed) to go into the bathroom when they poop in their pull-up or diaper. Then when that is going well, encourage them to sit on the potty in their pull-up or diaper. When that is going well, encourage them to try sitting there without a pull-up or diaper on. This may take a few weeks to accomplish, but once it happens it is likely a big breakthrough. Make sure to give lots of praise and maybe a special surprise.

     Dr. Barton Schmidt, MD, a pediatrician in Colorado, recommends that if you cannot get past the stage where the child takes off the diaper or pull-up to poop on the potty to cut a vertical hole in the diaper (do not tell your child). When they are sitting on the potty and poop, the bowel movement will fall out of the diaper or pull-up into the potty and you can say “Hey, the poop must have wanted to go in the potty!” This has worked for a number of my patients.

Staying dry at night

     There is a whole handout on Bedwetting with more information. But realize many children take a while to stay dry at night even if they are dry and clean during the day. Although some kids become dry at night when they are potty trained during the day, do not let anyone at home stress about it – it will happen! Make sure your child empties their bladder and does not drink much before bedtime.

When do I buy pull-ups?

     Pull-ups are an odd piece of the puzzle. For some kids, they are a nice transition to big-kid underwear. For others, they are no more than a more expensive diaper. If your child is nearly there (keeps their diaper dry most of the time and poops sometimes in the potty) but when they are out playing or you are out running errands they have been known to have an accident, it is appropriate to try putting them in a pull-up during the day. Also kids who are doing great during the day who still wet at night will often do well with a pull-up. That way they can pull it on and off as needed if they use the toilet or potty overnight. If your child does not seem to treat the pull-up any different than a diaper and they are not independently running to the potty (with the pull-up being easier to take off by themselves so they can go potty), it will be cheaper to just use diapers.

Do I have my son stand up to pee?

     Yes. But realize that the little fella’s aim is not going to be so good. And get used to saying “Point your penis so that the pee goes in the potty” and cleaning up the pee that does not make it to the potty. Many boys start by sitting and then transition to standing later. Even while sitting to pee, you often have to say “Point your penis so that the pee goes in the potty”.

When should we put potty training on hold?

     Big changes in a family’s life (even happy ones) can mean emotional upheaval for everyone. Moving, a newborn at home, a major illness, or a death in the family are good examples. These are good reasons to hold off on or pause potty training efforts for a month or two.

Should I worry that my child is having accidents again when they were potty trained for months?

     The good news is that with patience, this phase often passes within a few weeks or months. If your child is not constipated and is not complaining of discomfort when they urinate, this will likely pass. We want to see children in the office if they are having pain with urination (to rule-out a bladder/urinary tract infection). If your child is constipated, treating the constipation can help with the accidents. It turns out that our bladder is right next to the lower intestines and the pressure on the bladder from being constipated can contribute to accidents. If you have questions about how to treat constipation, see the Constipation protocol.

Grandma says she can potty train my child in a weekend

     No offense to grandma, but this is probably not what you and I mean by potty trained. We mean a child who can and does go to the bathroom, can usually get their clothes on and off to use the potty, routinely pees and poops in the potty or toilet, and initiates the whole thing themselves (without you having to remind them all the time). What grandma will do is put them in underwear, take them to the potty every 30 minutes, give them lots of love and praise, and the child will keep their underwear clean and dry (except for maybe an accident or two). But then real life happens the next few days after this weekend, your child is probably not going to have magically turned the corner. See below.

When do I put them in underwear (no pull-up or diaper) and see how it goes?

     This is successful with a nearly-there toddler who has a lot of success but seems to not be able to get over the hump of routinely making it to the potty on time. The hope is the “ugh – this wet/dirty underwear feeling is gross” motivates them to regularly pee or poop in the potty. And it can work. Remember to give a big pep talk about “Spiderman/Elsa/Paw Patrol/the Princesses do not want pee or poop on them. We need to keep your underwear clean and dry!” If you and your child are quickly getting frustrated after a few hours or a few days of this strategy, stop and go back to diapers or pull-ups.

My child does great at daycare but then over the weekends we struggle with success going on the potty

     This is a common issue. Your child sees all their friends go at daycare and there is a routine a school. When real life and no awesome peer models (the other kids going on the potty is a huge motivator) interfere, many 2-3 year olds are not as motivated over the weekends or holidays. Hang in there. Keep up with the gentle reminders (avoid sounding as if you are desperate for them to go, even if you feel that way!) and a small reward for success (a star on a chart, a small treat, etc.).

Conclusion

     If you have questions or concerns that are not covered in the above information, do not hesitate to call during routine office hours to discuss with the nurses on the phones. Our number is 614-777-1800. Good luck! Your child will get there!

                                                                                                                   

New Meningitis Vaccine Requirements for Ohio Schools 2016-2017 School Year

     The Neisseria meningitis vaccine helps prevent the leading bacterial cause of meningitis in pre-teens, teens, and young adults. The vaccine we use is called Menveo (manufactured by GSK) and we have routinely been giving it to our 11 year olds and high schoolers (usually 16-18 years of age) for a few years. Although many colleges have required the vaccine (two doses), the middle schools and high schools have not required the vaccine in years past. That is now changing.
     For the 2016-2017 school year, the State of Ohio is now requiring that the first dose be given before the start of 7th Grade and the second dose be given before 12th Grade. Our office schedule has meant the vast majority of pre-teens and teens have been up to date for school, but there are some of our patients who were not receiving the second dose until 12th grade. If your child has not received the dose, they can either do it at a well visit before their senior year starts or come in for a shot-only visit this summer (call to schedule these ahead of time). We can print out their shot record for proof to the school that your child is up to date.

Melatonin Use In Children

     Problems with falling and staying asleep happen to about 1 in 5 children and teenagers. One of the dietary supplements available for help with this issue is melatonin. We naturally have melatonin in our system that is produced in the pineal gland. It helps regulate sleep onset, meaning it is released to help us fall asleep. We are still discovering other things that melatonin does in our system.
     By 3 months of age, melatonin in infants start to regularly be released in the evening. This helps the 3-6 month old infants sleep better at night. By the teen years, it is released later. This contributes to teens staying up later and sleeping in. By the senior adult years, it is released earlier. This contributes to senior citizens going to bed earlier and waking up early in the morning.
     Some people naturally make plenty of melatonin. Other people's body does not make enough melatonin for them to easily fall asleep and stay asleep. For those children (and adults), taking melatonin about an hour before sleep can allow them to fall asleep faster, increase the total number of hours slept, and decrease the number of night time awakenings.
     A number of studies have looked at otherwise healthy children, children with autism or autism spectrum, children with developmental disabilities, and children with mental retardation. All of these groups have shown improvement with melatonin if they had sleep issues. Side effects in the short term are limited. The most common feeling is a "fuzzy" or tired feeling in the morning and many people do not experience this side effect. Occasionally, people experience headaches, nausea, or dizziness after using the melatonin, but the chances of these symptoms is not greater than taking a placebo (sugar pill). Although long term side effects are still being studied, no alarming information is coming out of studies that have looked at 3+ years of use. Exceeding the maximum dose may increase the risk of heart arrythmias.
     Because melatonin is available over the counter as a dietary supplement, it is not tightly regulated by the Federal Drug Administration. Many manufacturers make a melatonin product. Because these products are not tightly regulated by the FDA, some of the products may be better than others. One major manufacturer's melatonin product was found to contain no melatonin! If you are taking an appropriate dose of a melatonin product and it is not helping, consider trying a different company's melatonin. It is available in many forms, all over the counter: liquid, pills, dissolvable tablets, and gummies.
     The usual dose range is from 1 mg to 10 mg. I recommend starting with the lowest dose. There are melatonin products that are 500 mcg (1/2 mg) -- although the dosage may be so low that it would not help with sleep, it is fine to try this lower dose first. Increase to a higher dosed if a lower dose is not adequately helping. It is fine to use the melatonin every night or just as needed. Give the melatonin 30-60 minutes before you want your child to fall asleep. Remember: not everyone will respond to melatonin. It may be a big success or you might not notice any difference at all.
     A personal perspective: we have used melatonin in my house. I have taken it occasionally if I was struggling with insomnia on a particular night (which I am lucky enough to not have very often). It works very well for those nights. I might feel a little more "fuzzy" or drowsy the next day, but then I did not fall asleep at my normal time. I have also taken melatonin if we were taking an over-night flight. It has also helped me sleep during those nights also. On a humorous note, I took it once in an airport before a flight on a family vacation. My family was not pleased when the flight was delayed by about 45 minutes. Their worry was that the melatonin I had taken would kick in and they would have to help me on the flight. As the melatonin kicked in, I was so sleepy that they did indeed had to assist me into the plane. One of my three sons is not our best sleeper. We have often said that he is "not wired for sleep". He has tried melatonin on occasion and it has not helped him. Admittedly, we have not increased his dose past 6 mg, but he has not thought that melatonin made him any more sleepy. So our family's experience with melatonin has been mixed.
     So who do I recommend try melatonin to help with sleep? Certainly a child with autism, ADHD/ADD, or developmental disabilities who struggles with falling or staying asleep may benefit from melatonin. Other children with difficulties with falling or staying asleep may also benefit from trying melatonin. If you start with a low dose and notice a nice improvement, you may continue the dose as needed. If you do not notice a difference, the dose may be increased to a maximum of 10 mg. If any dose causes side effects that bother you, decrease the dose or stop the melatonin. Call during regular office hours if you have questions or concerns.

New stimulant options for treating ADHD

     There are three new options for treating ADHD. Each of these are new forms of two stimulant medications previously available, methylphenidate and amphetamine. The new medications are Dynavel XR, Evekeo, and QuilliChew ER. All of these are Controlled (CII) Prescriptions.
     Dynavel XR is a liquid form of amphetamine. It is the first liquid form of the medication in Adderall, Adderall XR, and Vyvanse. It is taken once daily with breakfast. It is expected to last about 12 hours. A syringe and special bottle allow for accurate dosing. The medication is bubblegum flavored. We have found that children who responded well to an amphetamine product but struggled to swallow a pill previously needed to open up an Adderall XR or Vyvanse capsule and swallow the small beads in the capsule on applesauce. The availability of Dynavel XR allows these children to swallow a liquid medicine instead.
     Evekeo is a shorter-acting amphetamine tablet. It lasts 4-6 hours and most children will need to take it 2-3 times in a day: once in the morning, once at the lunch hour, and potentially once in the late afternoon so they can get through homework or other activities. The tablets are scored to that the 5 or 10 mg pills can be split into smaller doses of 2.5 or 5 mg. This allows for flexible dosing.
     QuilliChew ER is a long-acting chewable methylphenidate product. It is the same medication as in Quillivant liquid and Concerta tablets. The medication is expected to last long enough throughout the day that the average child will need just one dose. Occasionally, someone might need a second dose of QuilliChew ER or another medication to get them through homework or late-day/evening activities. QuilliChew ER is cherry flavored.
     These new medications add options for children with ADHD. Feel free to discuss these with your doctor if your child has ADHD.