Suddenly my child’s peeing all the time… what’s up?

When children suddenly start peeing all the time, we need to consider the many potential causes. There are many reasons kids have frequent urination. Sometimes it’s as simple as they like to flush the toilet or splash in the sink. This is common in newly potty trained kids. But peeing all the time can also signify a medical problem that needs to be addressed. Learn the potential risks of why children run to the restroom frequently or start to have accidents. This can help parents decide if they need to rush to the ER.

Associated symptoms to identify

Frequent urination can be associated with other things that give us a clue as to what is going on. Sometimes they do not seem connected to the urine, so you might not associate the symptoms. Discuss the issues that apply to your child with your child’s physician.

Behavioral changes

Behavioral changes can be a clue. For instance, look for signs of anxiety. Remember that anxiety does not always look like fear. The frequent urination might be due to worrying about not making it to the bathroom in time and having an accident.

Pain

Pain while urinating might signify an infection. Infections often have other symptoms as well.

Pain might also be from skin irritation due to improper wiping in girls. In uncircumcised boys, pain can develop from improper cleaning under the foreskin. Staying in wet swimsuits too long also can lead to skin irritation and painful urination.

Pain in the abdomen, back or side can indicate problems with the kidneys or an infection. Sometimes this is due to constipation. It will require a physical exam and possibly testing to determine the cause. Schedule an appointment with your child’s primary care physician. If the pain is so severe that he or she cannot sleep, walk, or move easily, go to the ER.

Change in urine odor and color

A change in urine smell and color is important to note. Red, brown, cloudy or smelly urine can be signs of kidney damage, infection, bleeding problems, dehydration, and other serious conditions.

Some foods, such as asparagus and coffee, can change the smell of urine. Color changes can also happen as a result of foods, such as beets or berries turning urine red, or rhubarb or fava beans turning urine brown.

Many medications and vitamin supplements can change the color and odor of urine. It will be important to discuss your child’s recent foods, medicines, and supplements with his or her physician.

Other signs of illness

Other signs of illness can offer clues. Think about fevers, cough and cold symptoms, swelling of the eyes or legs, joint pains, and more.

One example to consider would be Rhinovirus. Rhinovirus typically causes upper respiratory tract infections with cough, runny nose, and pink eye. It can also sometimes cause vomiting and diarrhea or urinary tract infection symptoms.

Causes of frequent urination

Diabetes

Frequent urination can be a sign of diabetes. This is a potentially life threatening issue and needs to be addressed immediately.

Symptoms of diabetes will include being very thirsty and frequent urination. Kids might appear dehydrated despite the high urine volume. They can have weight loss, dry mouth, and low energy. Kids with untreated diabetes usually appear sick and tired.

When sugars reach a critical level, diabetics develop fruity breath. This is associated with a pattern of breathing called Kussmaul breathing. This is a medical emergency. Diabetes can be a rapidly developing problem. If you notice this breathing pattern, get to an ER immediately.

Testing for diabetes initially uses a sample of urine. Urine is tested for sugar. If there is sugar in the urine, blood will also be checked.

Children with newly diagnosed diabetes are referred to an endocrinologist. Endocrinologists are specialists in diabetes and other hormone issues. Newly diagnosed diabetics often spend a few days in the hospital for stabilization of medical issues and teaching of how to manage at home.

Urinary tract infection

Urinary tract infections (UTIs) commonly cause frequent urination. Other symptoms, such as fever, pain with urination, and urinary accidents, often occur. Bacteria and viruses can cause UTIs.

UTIs are more common in girls and in boys who are not circumcised.

A urine test can help to determine if there is a UTI. A quick urinalysis can suggest an infection, but a culture is needed for actual diagnosis. A urine culture takes up to 2 days to grow bacteria. Bacterial UTIs are treated with antibiotics. Viral UTIs self resolve after a few days.

Constipation

Many parents are surprised at all the things pediatricians blame on constipation. I can’t say how many parents deny that their child is constipated when they are. An x-ray often shows the abdomen is full of poop even when kids poop every day.

Note: I don’t always get an x-ray to diagnose constipation. Studies are only needed to help with diagnosis if the exam findings are not clear. Usually it’s obvious from the description of the stooling pattern and the look of the poop. Kids often cannot describe their poop accurately, so I use a Bristol Scale. You can use this at home to talk to your kids about their bowel movements.

Many children with constipation don’t initially seem to be constipated so a trial of Miralax is often recommended. This treats the constipation if it exists and is part of the diagnostic evaluation. Diet changes and changes to toileting habits are also important. These take longer to make a difference so I still recommend Miralax.

If treating the constipation helps, continue to treat until it is no longer needed.

Pollakiuria = increased frequency of childhood

Increased frequency of urination, also called pollakiuria, is common and not harmful. Other terms that have been used to describe this condition include extraordinary daytime urinary frequency and increased frequency of childhood.

The cause of this is unknown but often is triggered by a stressful event. Kids with this have a normal physical exam and urinalysis.

Pollakiuria involves frequent urination during the day. Kids will feel the need to urinate frequently, even though there’s really no physical reason.

Most children do not change their nighttime urinary pattern. If they previously wet the bed, they still will. If they previously stayed dry all night, they will continue to stay dry at night.

Pollakiuria is seen more often in boys, but also occurs in girls. It’s most common between 4 and 10 years.

Despite the frustrating symptoms, it’s not a serious illness and it self resolves. It generally lasts 1-6 months and can be quite problematic due to the frequent bathroom trips needed. Some kids pee as often as every 30-90 minutes.

To diagnose this, a child should be seen to discuss the symptoms and to do a physical exam. Often constipation aggravates this issue, so close attention to stool patterns and the abdominal exam are important. A urinalysis should be done to rule out diabetes or urinary tract infection. Pollakiuria is a diagnosis of exclusion. This means there is no test for it, but we rule out other potential causes of frequent urination.

This problem typically starts suddenly and ends suddenly. It can last for months.

What can you do to help if there’s no treatable cause?

If there is a treatable medical condition, treating that condition will usually help the frequent urination. While it seems like there’s nothing to do to help if there’s no cause found, don’t get discouraged! There are things to do that can help.

Contrary to what many intuitively think, drinking plenty of water is beneficial. Don’t limit water!

Don’t punish kids for needing to use the restroom or for having accidents. It may not be under their control at all. If it is a behavioral issue, the child needs support, not punishment. Punishment or belittlement will only make them feel bad. This worsens the situation. It can be hard to not get frustrated, but take a big breath and try to remain calm. Use words that are neutral and not judgmental.

Be sure the teacher knows what’s going on. If your child needs to go to the bathroom frequently, he needs to be allowed.

Remind your child that he or she is healthy. This can help to reduce the anxiety and stress in their minds. Stress can make this condition worse, so reassurance is very important!

Show your child that it’s possible to wait for a longer period of time to urinate. Explain that there will be no urine leakage because that fear increases anxiety about not going to the bathroom. The more confidence they develop, the better their bladder control. Practice waiting a little longer before going to the bathroom and celebrate small improvements.

Foods to avoid if your child has frequent urination:

The foods and drinks listed below may or may not increase frequent urination.

Avoid these for at least for 2 weeks. Slowly re-introduce one at a time to see if they lead to increased urination.

  • Highly acidic foods such as salsa, sodas, teas, coffee, cranberry juice and orange juice.
  • Caffeine acts as a diuretic and increases urine. It’s found in coffee, tea, chocolate, sometimes ice cream or other treats.
  • Spicy foods such as chili peppers, jalapeño peppers, horse radish, curry and salsa.
  • Artificial colors.
  • Carbonated beverages.

Most importantly…

The most important thing to remember is to first rule out medical causes that need to be treated.

Once those are ruled out, this is a lesson in patience. Don’t belittle your child or use harsh words when they need to use the bathroom again. And again. This will pass.

Work on having your child hold their urine for a few minutes longer with encouragement. Frequent urination usually stops as suddenly as it started.

New back to school recommendations for strep throat!

Many years ago I heard about research showing that throat cultures clear within 12 hours after the first dose of antibiotic for strep throat. I’ve been waiting since then for a change to our recommendation that kids must stay home from school for 24 hours after starting antibiotics. Guess what? The new Red Book (an infectious disease book from the American Academy of Pediatrics) is out and the back to school recommendations for strep throat have changed! This can help many parents get back to work when their kids can return to school and daycare earlier. But it doesn’t mean you should rush in to demand antibiotics for every sore throat!

Redbook return to school strep guidelines, 2018.
Red Book return to school strep guidelines, 2018.

I have summarized the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America previously. These official guidelines have not been updated, but the Red Book represents the AAP official recommendations.

What is Strep throat?

Strep throat is not just any sore throat. Many viruses can cause sore throats but strep throat is caused by group A streptococcus bacteria, also known as Streptococcus pyogenes.

Strep throat is not common in kids under 3 years. The incidence of strep throat peaks in young childhood and is less common in teens and adults.

A strep test is needed to diagnose strep throat in kids. Physicians and other healthcare providers can use Centor Criteria for adults, but a clinical diagnosis alone is not recommended in children.

Strep throat typically causes a sore throat, fever, swollen tonsils, and swollen lymph nodes (gland) under the jaw. Some kids will get a sandpapery rash on their trunk. When this happens, it is called scarlet fever. I also see a significant number of kids who get a stomach ache and vomiting with strep.

Pos strep
Strep throat sometimes causes white patches on the tonsils. This is called exudate.
Streptococcal pharyngitis
Red spots on the roof of the mouth is considered very specific for strep throat.

Does strep throat need to be treated?

Most parents and kids want antibiotic treatment so that the miserable symptoms of strep go away faster, but do we need to treat strep?

You might be surprised, but antibiotics are not prescribed to treat strep throat symptoms. Antibiotics are used to prevent serious complications from the strep bacteria. Pain relievers, such as acetaminophen or ibuprofen, can be used to treat the fever and sore throat symptoms. School aged children, teens, and adults can also use throat lozenges for sore throats. (Do not use these in kids who are still at risk of choking.)

So the simple answer is we don’t always need to treat strep with antibiotics. In the days before antibiotics, most people got better. Even now there are some people who don’t go to a clinic when they’re sick, so they recover on their own.

Use antibiotics wisely

There are a lot of reasons to use antibiotics only when necessary.

One major reason is to help delay antibiotic resistance.

Some people have allergic reactions or side effects to antibiotics, so we should not use them lightly.

They also can increase total healthcare costs. Although penicillin and amoxicillin (which are recommended for strep throat) are inexpensive, treating strep throat does increase healthcare costs. The sheer number of illnesses that present to clinics for evaluation, the cost of testing, and the cost of the treatments can all add up. Of course, returning to work a day earlier can make an impact on our economy as well.

If your child has symptoms not characteristic for strep and is not otherwise high risk, you can monitor and treat for a few days at home.

But antibiotics make us feel better faster, right?

Antibiotics tend to shorten the symptoms by about 16 hours.

They have been shown to prevent serious consequences of strep infections, but those are rare, so the risk/benefit ratio may not support treating every case of strep. (Though I still do treat strep when I see it.)

Look at risk/benefit ratio for all treatments

If you want to read an example of the risks/benefits of treating strep throat, see this (slightly technical) case report.

Remember that this report simply highlights one case, it cannot be generalized to everyone with strep throat. It shows how doctors work through the risks and benefits with everything we treat. We don’t always state things like this out loud, but they go through our mind as we develop treatment plans.

It’s common in medicine to have case reviews such as this. Any one case does not change our treatment guidelines, but they can help us start to understand issues. They often serve to initiate further studies.

Are there risks to not treating?

Untreated Strep infections can lead to complications.

The character Beth in the classic book “Little Women” died of heart complications after scarlet fever.

(If nostalgia hits you, you can get the entire series of the March family on Kindle for less than a dollar!)

Complications from untreated strep can include tonsil abscesses, ear infections, sinus infections, arthritis, heart damage, and kidney damage. While some of these can be severe, thankfully the more severe complications are rare, even without treatment.

There is also a condition called PANDAS (pediatric autoimmune neuropsychiatric disorders) that some experts think is related to strep. This can involve the sudden onset or worsening of tic disorders, obsessive compulsive disorder, mood changes, and change in quality of school work. Throat swabs can be normal, but a blood test can help to identify a recent strep exposure. Testing is not recommended for everyone with tics or OCD, but talk to your pediatrician if symptoms start out of the blue and you’re concerned.

Don’t let the new recommendations make you rush in…

Strep throat is rarely an emergency. Don’t rush to the ER after business hours to have your child checked as soon as you notice symptoms. You can use pain relievers as well as cold drinks, smoothies and popsicles to manage the symptoms at home initially. Just because the back to school recommendations for strep throat allow return 12 hours after antibiotics start, coming in too soon might not help in the long run.

The test commonly used to identify strep is most accurate after symptoms have been there for awhile. This is because it tests for the antibodies your body makes against the strep bacteria, not for the bacteria itself. A culture done at the same time may grow the strep bacteria in a few days, but antibiotics are not recommended until either the rapid test or culture is positive, so you’re not getting a head start on antibiotics if the initial rapid test is negative.

Do not use telehealth to get your sore throat treated. In children it is not recommended to diagnose strep throat without a throat swab test. This should be done in a medical clinic to avoid inaccurate testing.

Treating early in the course might diminish the opportunity for your body to fight strep off the next time it’s exposed. Yes, treating may allow a return to work, school or daycare in 12 hours, but if you can prevent the next occurrence (of course no guarantees…) wouldn’t you want to?

When should you not test or treat?

Kids under 3 years old

Strep throat is not common in kids under 3 , so it’s not recommended to test them.

I admit that if an older sibling or caregiver has strep and they have strep symptoms, I will test 2-3 year olds.  The recommendation is to not bother. Even if they have strep, treating does not tend to alter their course. Kids in this age group tend to not develop the severe consequences of strep like older kids, even when not treated.

Viral symptoms

Although both viruses and strep bacteria can cause fever and sore throat, there are clues that it is not strep. When strep carriers get sick, they can have a false positive throat culture. The strep that shows on testing is not the cause of their symptoms and leads to over treatment.

If there is a cough or runny nose, the sore throat is most likely a viral illness. A strep test is not recommended.

When there are blisters in the mouth or a characteristic hand, foot, mouth rash, they have a viral illness. A strep test is not recommended.

Recent strep

Because the rapid strep test looks at antigens the body makes in response to strep and not the bacteria itself, recent strep can affect rapid strep testing. The antigen can remain in the throat for a time after treatment, so a strep culture is recommended for several weeks after treatment of strep throat.

It is not recommended to do a throat culture after treatment unless a person is high risk for complications, such as rheumatic fever.

contacts of someone with strep

It isn’t recommended to test people who have been exposed to strep unless they have symptoms. If they do not have symptoms, a positive test is more likely to be a falsely positive (not true) test. It could lead to unnecessary antibiotics.

If a sibling over 3 years of age develops symptoms, it is recommended to test and not just treat.

Pets?

Pets do not get strep, so no need to swab your pet!

Why not just test every sore throat?

Studies show that 1 in 4 kids can have strep in their throat at any given time. They are simply carriers, but not truly infected with strep. Contrary to popular belief, strep carriers are not likely to spread strep infections.

If a strep carrier has a viral illness, they can have a positive test but the strep is not the cause of their illness. Antibiotics are not needed for this at all. A positive test leads to using antibiotics that are not needed, which can increase the risk of side effects and allergic reactions. They give a false sense of security of treatment, but if it’s a viral illness, antibiotics are not treating anything. Kids can be sent back to daycare or school while still contagious simply because they’re “being treated.”

“My child always has a negative rapid test but the culture is positive. Can’t we just treat?”

There are many reasons this can happen.
One of the reasons is that the child is a strep carrier, so has no strep disease. In this situation, there aren’t antigens to make the rapid test positive, but the culture will grow the bacteria. If you recall from above, carriers do not need to be treated with antibiotics in most cases. I often find that these kids continue to feel sick several hours after starting antibiotics for strep. Most kids with strep feel better really quickly after antibiotics are started!
It’s also possible that the child is brought in for testing early in the course of illness each time so the antigens have not yet developed. This is one reason to not rush in at the first sign of possible strep. Let the body do its thing first.

My back to school recommendations for strep throat:

If your child has some of the symptoms of strep (sore throat, fever, tender bumps in the neck, vomiting, or rash) consider strep throat.

Symptoms of typical viral illnesses make strep less likely. These might include runny nose, cough, red goopy eyes, or diarrhea. No testing is recommended.

It can be difficult to tell if a runny nose from allergies despite the strep throat or if the runny nose is part of the viral illness that includes a sore throat, so if in doubt, bring your child in for evaluation. The doctor can determine if testing should be done. Do not use telehealth for this. I recommend seeing your primary care physician during normal business hours.

If there is strep throat, penicillin or amoxicillin are the preferred treatments unless there is documented allergy.

Your child may return to school 12 hours after the first dose of antibiotic if they are otherwise well. (If they are not feeling great, they likely have something else going on!)

 

ASK to save a life!

June 21, the first day of summer, is National ASK (Asking Saves Kids) Day. The ASK Campaign encourages everyone to ask if there are unlocked guns in the homes where children play. The Asking Saves Kids (ASK) Campaign encourages parents to ask a very important question before playdates: “Is there an unlocked gun in your house?” It’s a simple question, but it has the power to save a child’s life.

1 in 3 homes with children in America have guns. Ask to save a life.
Click to enlarge. Source: http://askingsaveskids.org/

Keeping a gun in the home increases the risk of injury and death, yet 1 in 3 American homes with children have at least 1 gun.

Every year thousands of kids are killed or injured by guns. When parents think of asking about guns in a playdate’s home, they often can’t imagine how to enter into that conversation.

It doesn’t have to be awkward to ask before your child visits friends. I’ll show you how.

But first let’s review why this is so very important.

Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they're stored safely! #ASKingSavesLives
Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they’re stored safely! #ASKingSavesKids

Gun Safety

One question could save a child's life. Ask.
Click to enlarge. Source: http://askingsaveskids.org/

Many parents buy a gun to help protect their family, but a gun in the home increases the risk of a family member being hurt or killed by a gun more than preventing a crime.

Kids have natural curiosity and if they find a gun, they are likely to play with it, even when they are taught to not touch guns.

Toy guns and real guns are so similar, it can be difficult to tell them apart.

Several studies over the years show that gun education programs fail. Diane Sawyer’s Young Guns episode showed that even soon after gun safety education, kids will play with a gun and not follow the rules they just learned.

Regardless of the reason for or type of gun, there are guns in 1 in 3 homes with children in America. Too many of those guns are not locked. A gun in the home increases the risk of homicide, suicide, and accidental injuries.

Don’t mistakenly think that your gun is needed to keep your family safe. For every time a gun in the home was used for self-defense, there were 4 unintentional shootings, 7 criminal assaults or homicides, and 11 attempted or completed suicides.

Accidental shootings

Accidental shootings occur far too often, especially in young children.

See the table below that lists the numbers of leading causes of injury deaths by age. In children under 15, there were 73 unintentional firearm deaths in 2016. That number does not include homicides and suicides.

10 Leading Causes of Death by age in 2016
Click to enlarge. Source: https://www.cdc.gov/injury/wisqars/leadingcauses.html
Homicide

Sadly there have been too many kids who have been killed by intentional gunfire, both at home and in public areas. The higher the number of guns in a community, the more gun deaths there are.

Our kids must practice active shooter drills at school because school shootings are occurring with more frequency. Many of these shootings are kids who bring their parent’s gun to school.

Suicide

Suicide attempts with guns are usually fatal. Sadly too many people consider suicide as an option when they’re down.

Having a gun in the home when a teen is depressed increases the risk of death by suicide. Over 80% of teen suicide by firearm is done with a family member’s gun.

Keeping guns locked with the ammunition locked separately is important even when you don’t have young children. It can deter teens from accessing guns in a time of despair.

Hiding guns

Parental perception of what kids know about guns is lacking.
Child knowledge of handling of guns in the home. Source: https://www.bradycampaign.org/sites/default/files/Kids-and-Guns-Report%202016_final.pdf

Hiding guns is not a safe plan. Nearly 80% of kids know where the family gun is hidden. Parents usually don’t realize the kids know.

I’ve seen more than a couple surprised parents when they learn that their child knows where the family gun is stored in a drawer or closet. They presumed the child had no idea about the gun, but kids know things. It’s bad enough if they know your secret hiding place for birthday gifts, but if they know where the unlocked gun is, natural curiosities can take over.

It’s not political

I don’t care if you’re a Republican, Democrat, Liberal, or other political affiliation. This isn’t about politics. It’s about keeping kids safe.

This is not about the Second Amendment. Americans have a right to bear arms. But with rights comes responsibilities.

This is about the responsibilities that come with the right to bear arms. Adults have a responsibility to keep children safe.

When having the discussion, keep it about safety. Don’t make it about politics. That turns people off and gets them on the defensive. Don’t judge whether it’s okay to own a gun. Focus on the issue of making sure all guns are safely stored unloaded and locked.

Make it less awkward

Parents must have awkward conversations. Don't let that stop you from keeping kids safe.
Click to enlarge. Source: http://askingsaveskids.org/

As parents there are many awkward things we must deal with. Being awkward or difficult doesn’t make it okay to just ignore it if safety is involved.

By introducing safety concerns that are not judgement issues, it can be more natural to then talk about more sensitive topics.

Use these non-controversial openers to start the conversation before playdates.

Pets

Allowing a dog who is not friendly and patient around kids to be with the kids is a red flag. Ask if there are pets and how they respond to kids, especially kids they don’t know. If you’re not comfortable with that pet, ask if the parent can keep the kids and pet separate.

When kids are afraid of animals, the other parent needs to be aware.

If there are any pet concerns, see if they can keep the pet in another room while your child is there. If not, have their child to your home instead.

Allergies

If your child has allergies to animals or foods, the other parent needs to be aware. Talk about the allergy and what can be done to help your child not suffer.

When the parent is not able to keep your child safe from allergens in their home, ask if their child can come to yours instead.

Other safety risks

There are numerous other safety risks that could be used as introductory concerns. You can’t ask everything, but pick the things that are most important to you.

Will the kids be riding bikes or scooters? Are there enough helmets for everyone or should your child bring his own?

Is there a wooded area that will require bug sprays or tick checks after the play date?

If they play outside, how closely are they supervised? Do you need to send along sunscreen?

Does your child need to wear sneakers or will they be staying indoors and the flip flops are okay?

If a parent will be responsible for driving your child, do they have an appropriate car seat or booster seat?

Do they have a trampoline or pool? If so, what are their rules and safety measures?

Be first

Be the first to ask a child to your home. With the invitation, list everything you think another parent might be interested in knowing. Hopefully they will reciprocate by giving similar information when they invite your kids over, but if not, ask.

“We’d love to have Johnny over. We have a German Shepard, but he’s really good with kids. If Johnny needs him to be put in the master bedroom, just let me know. We also have a trampoline, but if the kids get on it, a parent is always outside. If that’s not okay, let me know. And we have a rifle, but it’s in the gun safe and the ammunition is locked separately. Is there anything we need to know about Johnny?”

Take the ASK Pledge

Pledge to ASK if there are unlocked guns where your child visits. Encourage friends and family to do the same!

Pledge to ASK if there are unlocked guns where your child visits: http://www.bradycampaign.org/take-action/pledge-to-ask
Pledge to ASK: http://www.bradycampaign.org/take-action/pledge-to-ask

Resources

The Truth About Kids and Guns from The Brady Campaign

CDC’s WISQARS™ (Web-based Injury Statistics Query and Reporting System)

WISQARS Interactive Visualization

jose-alonso-589704-unsplashphoto credit:Jose Alonso

Bumps, ridges, and soft spots on a baby’s head. When should you worry?

Parents often worry about lumps and bumps on a baby’s head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head. All of this is normal.

Skull anatomy

Let’s begin with a brief overview of a baby’s head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the bony plates move together or even overlap one another.

Infant skull bones
Infant skull bones

Sometimes you don’t really notice much with these bones, but other times they overlap one another noticeably after birth. When a baby has a lot of head distortion due to overlapping of skull bones, we call it molding. It can make the head look pointed – which is often called cone head.  It can also make the head look flat on one side.

The good news? Even really odd looking heads are usually normal. Molding tends to resolve without intervention over the first few days of life.

Soft spots

There are 1-2 “soft spots” at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. It is often so small at birth that it’s not recognized.

Many parents fear that touching a soft spot will somehow damage the baby’s brain. Normal touching won’t hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain.

Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby’s head. There’s a lot of variation here, so if you question the size of your baby’s soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby’s development, and the shape of the head.

Bruises and bleeding

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise.

Bruises can cause yellow jaundice.

Any bruise can increase the risk of yellow jaundice in a newborn, so your doctor might watch your baby more carefully for this over the time that the blood is resorbed. This is because yellow jaundice is caused by breakdown of blood cells. Most babies show yellow color in their eyes and face. Even if it progresses to their chest and abdomen it can usually self-resolve with proper hydration, but it should be monitored. If the level gets too high it can be managed. Talk to your doctor if you’re concerned.

Cephalohematoma vs caput saccedaneum.

The two most common types of bruising are cephalohematoma and caput saccedaneum.

A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn’t affect the baby’s brain. It covers only one of the bones, and never crosses one of the suture lines.

Caput succedaneum is swelling of the scalp in a newborn. It develops from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it’s not limited by the lining of the bone (periosteum). You will notice a soft, puffy swelling on the baby’s scalp, usually in the area that first came out during birth. Some will show bruising.

Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

The picture below attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding. Babies who have deeper bleeds need proper medical management. For information about subgaleal hematoma, see Seattle Children‘s website. Epidural hematomas are very rare in newborns.

Scalp hematomas

 

Flat spots

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on.

Babies always need to sleep on their back until they start to roll on their own, but this can encourage a flat head. It’s important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. I recommend starting tummy time on day one. The earlier you start tummy time the less they seem to hate it!

When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

Lymph nodes

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby’s (or even an older child’s) head. This is usually an occipital lymph node.

Lymph nodes of the head and neck
Lymph nodes of the head and neck

When I say it’s just a lymph node, some parents automatically worry about lymphoma.

Don’t go there.

Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don’t worry about them.

TL:DR

In short, most lumps and bumps on your baby’s head are normal. If you’re worried, bring your baby in to have your pediatrician look and feel.

Bumps, ridges, and soft spots on a baby's head is often normal - but when should you worry?
Bumps, ridges, and soft spots on a baby’s head is often normal – but when should you worry?

Should your child have an Athletic Heart Screen?

In recent years I’ve been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren’t of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you’ve not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow “A B C” so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn’t recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn’t an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*
Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope†
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡
12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)§

  • AHA indicates American Heart Association.
  • *Parental verification is recommended for high school and middle school athletes.
  • †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
  • ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
  • §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn’t matter, but I know it does, so if people can’t afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician’s office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it – use it! Just be sure to schedule well in advance – everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor’s office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don’t necessarily schedule near your child’s birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician’s office and ask!

Should your child have an Athletic Heart Screen?
Should your child have an Athletic Heart Screen?

Is your teen driver a safe driver?

Summertime is a common time that teens learn to drive, but also the most dangerous time. Teens have more free time during the summer, so have more opportunity to drive than during the school year. Car crashes are the #1 cause of death in teens. We are now entering the “100 Deadliest Days,” the time between Memorial Day and Labor Day. This is when the average number of deadly teen driver crashes climbs 15% compared to the rest of the year. Make sure your teen is a safe driver before you let him or her hit the road alone.

Teens tend to be impulsive risk takers. Even cautious new drivers are inexperienced, so they are at risk of not knowing how to handle a situation. In addition to riding along with your teen as they learn the rules of the road, you should talk to them about expectations and safety. Continue the talks as they gain confidence because the risk of accident actually increases in the late teen years.

May is Global Youth Traffic Safety Month to educate about safe driving.

Driving Contract

After talking to your teen, get your thoughts down in writing. There are many driving contracts available online.

This contract from the CDC has areas to write in your specific details.

The idrivesafely contract allows you to enter details for each point covered.

The AAA Driving Agreement has a nice chart depicting privileges that vary based on circumstance.

NOYS Global Youth Traffic Safety Month
From https://noys.org/global-youth-traffic-safety-month/

Special Situations

Overconfidence of the teen driver

Research has shown that after the first few driving years, teens risk of having an accident actually increases. This may be due to teens gaining confidence and taking more risks.

According to the 2017 study, 75 percent of high school seniors “feel confident” in their driving abilities, and 71 percent use a phone behind the wheel. Driving while drowsy, speeding, having multiple passengers and browsing music become more prevalent as new drivers gain confidence.

Distraction

Distractions are a common cause of accidents. Younger drivers have the highest proportion of distraction related fatal crashes.

Over 70% of teens admit to using their cell phone while driving despite recognizing the dangers of this distraction.

Parents need to model safe behavior and stay off their phone while driving. Texts can wait. If it’s that important, pull over to check your phone. Have your teens agree to no cell phone use in a driving contract.

One of my favorite ads shows just how quickly accidents can happen.

Other passengers are another source of distraction. Teens easily distract one another. Limit the number of passengers your teen is allowed to chauffeur.

Even changing the radio station can be a significant distraction. Ask teens to set the station and leave it – or to make a soundtrack and play it for the road.

Speeding

Speeding is a contributing factor to many crashes. Speed limits are set for safety and going faster makes it harder to maintain control of the vehicle.

Talk to teens about the importance of not only following speed limits, but also about adjusting speeds to road and weather conditions.

It is better to arrive alive but late rather than to speed to attempt to get there faster. Talk to your teen about calling if they plan to be late rather than just trying to speed home to make curfew.

ADHD

The symptoms of ADHD, such as an inability to pay attention and impulsivity, can make driving even more dangerous than it is for a typical teen. There are more car accidents among teens with ADHD than the general population, but newer studies show ADHD drivers on medication are at a significantly lower risk than those not taking medicine. Talk to your teen about medication management if he or she has ADHD.

Safety tips for safe driving

  • Buckle up – it’s the law but even more important, it’s the safest way to travel. Make sure any passengers are properly buckled before you drive.
  • Avoid carpooling to reduce the distraction of others in the car. The more kids in the car, the higher the risk.
  • Avoid eating while driving.
  • Ignore your cell phone. (Parents be forgiving if your kids don’t answer your call or text right away.)
  • Know where you are going and how to get there before you get on the road. If you aren’t sure you’ll remember, set a GPS before hitting the road and turn the sound on to minimize the need to look at the screen.
  • Don’t drive when you’re tired. Drowsy driving is equated to drunk driving. If you have trouble staying in your lane or keeping your eyes open, you’re too tired to safely drive.
  • Adjust seats, mirrors and climate controls before driving.
  • Set your music for the road before you start driving.
  • Watch for pedestrians and bicyclists. Five percent of teen deaths in crashes are pedestrians and 10% are bicyclists.
  • Don’t drive under the influence of alcohol or any drug that affects your ability to focus behind the wheel. Car crashes are the leading cause of teen death and about 25% involve an underage drinking driver.

Follow the law and parental expectations

It goes without saying that teens must follow the law when driving. They must respect the rules of the road for their own safety and the safety of others.

In addition to the laws, household rules about passengers, nighttime driving and cell phone use can be individualized to your teen’s abilities and weaknesses. Even if a teen can legally drive alone, if he or she hasn’t demonstrated the ability to do it safely, parents should not allow it. More supervised hours can make a difference in their experience and if they in general do not show the ability to make safe choices, they should not have the ability to drive a vehicle unsupervised.

Sun and Water Safety: Don’t take risks. Follow these tips.

Memorial Day signifies the start of summer, the opening of pools and trips to the beach. Regardless of where you’ll be outside or around water, it’s always important to be safe. Make sun and water safety a priority! Bug safety will be covered separately in a future post.

Safe in the sun!

Keep kids safe in the sun with many methods, not just sunscreen.
Keep kids safe in the sun with many methods, not just sunscreen.

Protecting your child in the sun is very important. Make sure you understand how various sunscreens work, how they should be used, and what else you can do to protect your kids from the sun.

Infants under 6 months

Babies under 6 months of age should be kept out of the direct sunlight as much as possible.

Move your baby to the shade or under a tree, umbrella or the stroller canopy. Be careful near reflective surfaces, such as water. Shade may reduce UV exposure by only 50% if there’s reflected sun.

Dress them in lightweight but long sleeved clothing and wide brimmed hats to keep the sun off their skin.

It’s okay to apply sunscreen to small areas of the body that you cannot cover with clothing, such as face and hands.

Make sure infants stay hydrated in the heat. Do not give extra water to infants until they are on solid foods. Breastfeed more often or give extra formula to prevent dehydration.

Mineral vs chemical sunscreens

The sunscreen does not have to be baby specific, but chemical sunscreens are absorbed more than mineral sunscreens. One of the concerns of young infants using sunscreen is they absorb chemicals too much, so mineral sunscreens are preferred for them.

I think most things marketed for babies are really for parent’s piece of mind. They aren’t necessarily better for baby. And they can mark up the cost just because it says it’s for Baby. But one of my favorite sunscreen brands for babies – Blue Lizard – actually prices competitively for the baby product. I like this brand because it was developed in Australia to be used safely at all ages. All of their products are mineral based.

Mineral based products use zinc oxide and titanium dioxide to reflect sun rays. There is minimal absorption. The downsides are they are not as light on the skin and they can wash off when sweating or swimming.


Chemical sunscreens, on the other hand, are absorbed into the skin. They absorb the sun rays that enter the skin. These are best for older children who are exercising outdoors and swimmers since they do not wash off as easily.

What is SPF?

SPF= Sun Protection Factor

The SPF increases the time you can spend in the sun, depending on your skin type. If you would typically burn in 1 hour, an SPF of 15 will keep you from burning for 15 hours, if you reapply every 2 hours. If you would burn in 20 minutes, an SPF of 15 used every 2 hours would protect you 15 x 20 minutes, or 5 hours. This is why fairer skinned people need higher SPF levels.

The sun protection factor (SPF) should be at least 25 and should cover both UVA and UVB rays. The sooner your skin burns, the higher the SPF you should use.

How should sunscreen be used?

For all infants and children over 6 months, be generous with sunscreen. Apply sunscreen at least 30 minutes before going outside, reapply it every 1-2 hours if sweating or swimming (even if it states it is waterproof), and use sunscreen even on cloudy days. One full ounce should be used to cover an adult.

Reapply the sun screen every 1-2 hours.

Try to keep children out of the sun between 10:00 am and 4:00 pm, when the sun’s rays are strongest.

Clouds are not sufficiently protective against the sun. UV rays on cloudy days may be reduced by only 20% to 40%.

Does sunscreen cause cancer?

I don’t know why this is a popular question these days. Well, yes, I know why people question it. The rumor that chemicals in sunscreen are dangerous is commonly circulated online. That’s why it’s questioned, but I don’t know what started this rumor.

Sun causes cancer.

Sunscreens have been studied extensively and have been shown to be safe. Use them.

What about eyes?

We often neglect our eye health, but there are ways to prevent sun damage to our eyes. This sun damage can lead to cancer, cataracts, and growths in the eye.

Sunglasses should be used to protect the eyes from sun damage. Hats with wide brims also keep sun out of the eyes.

Be sure your sunglasses are rated to protect against UVA and UVB 100%. Darker glasses don’t offer more protection necessarily. They must be rated to protect against UVA/UVB.

Bigger frames are better. Especially the ones that wrap around the sides of the face.

Higher cost doesn’t mean better protection – look for the rating! Even inexpensive sunglasses can provide protection. This is good, since most of us need several pair due to them getting misplaced or broken – especially the ones for our kids!

For more on sunscreens:

SMART SUN PROTECTION: UNDERSTANDING THE BEST SUNSCREEN OPTIONS from Dr.Michelle Ramírez at Dream Vibrant Health.

Which Dermatologist-Approved Sunscreen You Should Use To Keep Your Skin Safe from Dr. Dhaval Bhanusali, a medical and cosmetic dermatologist

Sunscreen Safety: Is It Worth The Hassle? from Dr. Nidhi Kukreja at The Growing Parent.

Water

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How can I protect my child around water?

All parents should take a basic CPR course! Young children can drown in only a few inches of water, even if they’ve had swimming instruction.

Children who are swimming – even in a shallow toddler’s pool – should be watched closely. Even if there’s a lifeguard at the pool, there is too much to monitor when there’s a pool full of kids. You must watch your own kids until they’re strong swimmers.

It’s recommended that infants and toddlers have an adult within arm’s reach. For young children, you should continue to pay constant attention and be free from distractions. It’s easy to be distracted when talking to another person or checking your phone. Don’t consider it watching kids if you’re pool side reading a book.

Inflatable pools should be emptied and put away after each play session. (This also reduces unwanted mosquitoes!)

Enforce safety rules – no running near the pool and no pushing others underwater.

Water wings, tubes and other floating devices are not approved flotation devices and should be used only under direct and close supervision. Because they give a false sense of security, I don’t recommend them.

Be sure the deep and shallow ends of any pool your child swims in are clearly marked. Never allow your child to dive in the shallow end.

And then there are teens…

Talk to older kids and teens often about water safety. As they gain confidence in the water, they take more risks.

Teens are especially notorious for risk taking behaviors. Let them know your expectations. Teens might roll their eyes, but studies show they do best with rules and clear expectations from parents.

Of course they should not drink alcohol ever, but risks increase around water. They should never swim alone, even if they are captain of the swim team. If they are going to a river or lake, they need to be careful of inherit risks there, such as diving into shallow waters and boat safety.

As always, be sure you know where they’re going and when to expect them home. If they’re in water they won’t have a cell phone available at all times, so you might want to schedule “check in” times.

Drowning Risks

Drowning is a real risk. Dry drowning? Not so much.

Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens.

If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue. From this site, signs of drowning:

  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs – Vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back
  • Appear to be climbing an invisible ladder

What about swimming lessons?

The American Academy of Pediatrics does not recommend swimming lessons for children under one year of age because they cannot really learn skills to keep them safe.

Even young children who have had swimming lessons should not be unattended at the pool because they are not able to always make safe choices.

How can I protect my child around the backyard pool?

Inflatable pools should be emptied and put away after each play session. (This also reduces unwanted mosquitoes! Who wants mosquitoes in their backyard?)

If you have a swimming pool at home, it should be completely surrounded on 4 sides with a tall fence that has a self-locking gate. The house cannot serve as one side of the barrier. Keep the gate closed and locked at all times. Be sure your child cannot manipulate the lock or climb the fence.

If your pool has a cover, remove it completely before swimming. Never allow anyone to walk on the pool cover. Your child could fall through it and become trapped underneath.

Keep a safety ring with a rope beside the pool at all times. If possible, have a phone in the pool area with emergency numbers clearly marked.

Spas and hot tubs are dangerous for young children. They can easily drown or become overheated in them. Don’t allow young children to use them at all due to these risks. If older children use them, they should be supervised. Be sure they are well hydrated. After using a hot tub, be sure everyone showers. You don’t want hot tub folliculitis!

What about at the ocean or lake?

Talk to kids about the pull of undertow if you’re wading into the ocean. (If you don’t know what this is, walk into the water without your kids first.)

Use coast guard approved life preservers correctly whenever needed. All people should wear a life preserver when riding in a boat unless they are inside a cabin. Children should wear a life preserver when they are near the water’s edge or on a dock, even if the law doesn’t require it.

A life preserver fits properly if you can’t lift it off over your child’s head after he’s been fastened into it. For the child under age five, particularly the non-swimmer, it also should have a flotation collar to keep the head upright and the face out of the water.

Adults should not drink alcohol when they are swimming or boating. They are not only at risk of dehydration from the alcohol, but they also risk lives. It presents a danger for them as well as for any children they might be supervising. Don’t ruin a fun time with a tragedy.

Keep it fun in the sun!

Sun and water safety are not only important, but if you’re not careful, it can ruin a vacation. Practice sun and water safety every day!

 

Body Safety and Sexual Consent – Start Younger than You’d Think!

We hear about child molestation and rape far too often these days. While we can’t anticipate all the situations our kids will be exposed to throughout their lives, we can teach them how to protect themselves in all situations and if there’s trouble to speak up. Teach them to respect themselves, to respect others, and to never keep secrets. Talk about consent often, starting in the toddler and preschool years!

Start in the toddler years?

What about their innocence?

It’s never too soon to talk about body safety. You don’t need to cover all the specifics at young ages, but there are many age appropriate things to talk about at each stage.

The message and words change over the years as your child grows, but start young!

Teach proper body part names.

We call eyes “eyes.”

An elbow is an elbow.

Why should we call a vagina a “hoo hoo” or a penis a “wee wee”?

If kids ever need to talk about those body parts and the other person doesn’t know the slang, it’s more difficult to get the point across.

Wouldn’t you feel awful if your preschooler tried to tell a teacher that another adult touched her inappropriately, but the teacher thought “hoo hoo” was just a fun term, so didn’t act on the issue?

Teaching kids about private body parts is important.  Let them know that their swim suit area is private. No one should be able to look or touch there without permission from Mom or Dad and from the child himself.

Teach respect of personal space.

Many kids love to hug and kiss everyone they see.

Other kids hate to be hugged or kissed.

Sometimes they just don’t feel like it, but other times they’re okay with a big bear hug.

All of these feelings are okay, but we must be mindful of how these interactions are approached and consented.

Ask permission.

Teach your kids to always ask permission before entering someone’s personal space.

They can say something as simple as, “Can I give you a hug and kiss goodbye or should we high-five or blow kisses?”

Encourage kids to demand permission before being touched. You can model this kind of expectation by asking before touching.

~ Can I be a tickle monster and get you?

~ It’s time to wash your back. Should I do it or do you want to do it yourself? Now it’s time to wash your penis, do you want help?

~ Do you want me to rub your back to help you fall to sleep?

Be sure others ask similar questions of your child.

Talk to family members about this when the child isn’t present. You don’t want it to be an ordeal in front of everyone, so a little discussion ahead of time can help the adult understand and follow your expectations.

If adults continue to enforce a hug or kiss, it’s a red flag that they don’t appreciate boundaries. I would not recommend allowing your kids to be alone with them. They might simply be innocently wanting a hug from a cute kid, but they also might be testing to see how the child reacts in preparation for more intimate touches.

Don’t force your kids to be kissed or hugged by anyone, even family members. If they don’t want Grandma or Uncle Buddy to get too close, they shouldn’t be forced to give a hug or kiss.

Think about the message that sends.

They should not have to submit to being touched. Ever.

Teach proper hygiene.

Once kids are potty trained, they can start learning to wash their own genitals. It will take practice before they can do an adequate job, but if you don’t start teaching them, how will they ever know what to do?

If they still need help toileting or bathing, be sure they know that only adults who have permission are allowed to help. This means you must tell them that it’s okay for any specific person to help.

Wipe properly.

Many girls wipe inadequately after urinating. Some rub too hard, which irritates the genitals. They often miss some of the urine and the inner labia stays moist, which leads to redness and pain.

Teach them to wiggle the toilet paper between the skin folds.

Many kids will need help wiping after a bowel movement for many years, but you can show them how to wipe until the toilet paper no longer has streaks on it. Using a flushable wet wipe is often helpful.

At bath time teach them to wash their genitals.

For girls this means using a mild soap and rinsing between all the skin folds with water well. Soap residue can really irritate the sensitive labial skin.

For boys, washing the genitals and between the buttocks is important too. If he is uncircumcised, teach him to gently pull back on the foreskin to rinse the head of the penis. If it does not yet retract, do not force it.

Encourage questions.

As kids get older, they have lots of questions about their body. You want them to ask you or another trusted adult for answers, rather than going to the internet to find answers.

Answer questions as truthfully as you can. Don’t feel like you have to answer more than what’s asked.

Where do babies come from?

Of course when they ask how babies are made, you need to answer it to a level they can understand.

Young kids don’t need to know that a penis goes into the vagina to release sperm and fertilize an egg. They can’t comprehend that.

Think about what they’re asking and answer that question truthfully without going into details they won’t yet understand.

If you’re not ready to answer the question when it’s asked, buy yourself time. Tell them that it’s a great question and you want to think about it. Be sure to give a specific time that you’ll be able to answer the question. Think about it, prepare what you’ll say, and discuss it at the chosen time.

Model healthy relationships.

When kids see healthy relationships, they learn that that is what is appropriate and acceptable in a relationship. Show respect in what you do and say to all people around you. Demand respect in how others treat you.

If you’re in an unhealthy relationship, work with a counselor so you both can learn to work together to improve the relationship. If that’s not possible, especially if the relationship isn’t safe, think about how to safely separate. It isn’t easy, but if your kids grow up watching an abusive relationship, they are more likely to end up in the same situation.

Teach kids to ask for help.

It can be really hard for kids to learn when it’s best to work out problems and when to ask for help. No one likes a tattle tale, but there are times kids need help from adults.

When safety’s an issue, an adult should be part of the solution. If a friend is doing something dangerous, such as running into the street, it’s best to tell an adult.

If kids are simply frustrated that another child won’t share a toy or play the game your child wants to play, that is something that kids can at least start working out on their own.

Praise kids when they make smart choices about asking for help when needed and when they solve their own conflicts appropriately.

No means no. Stop means stop.

Teach kids that we always need to respect others when they say no or stop.

For example, if Sissy says to stop tickling her, stop.

When friends or adults don’t listen if they’re told no or stop, kids need to think about if they feel safe and if they still want to be around their friend. If they don’t feel safe, they need to talk to you or another trusted adult.

Books can help talk about these difficult topics. Some suggestions for saying “no” appropriately and “stop” when needed:


For teens, I love this Cup of Tea video. It explains so well that no means no!

No secrets!

Remind kids that they’ll never be in trouble for telling you things. There are never secrets in families. We might keep surprises, but never secrets.

You might need to change your wording at times… If you’re buying or making a gift for someone, it’s a surprise, not a secret. Surprises are fun. We can build up suspense for the fun by not telling. But secrets make us feel bad because we can’t share them.

Remind your kids that if anyone asks them to keep a secret, it’s best to tell their parent.

A great book on this subject is Some Secrets Should Never Be Kept!

Believe kids.

Sometimes it’s hard to believe what our kids tell us. But if we don’t believe them or we discount their stories, they will stop telling us things.

I know that I’ve been challenged to believe many things my kids tell me, but instead of downplaying the story or telling them to stop lying, I try to ask more questions.

Once my daughter told me about an accident the bus had while she was on a field trip. I didn’t believe her (surely the school would have alerted parents) and asked more about what she was saying without outright saying she was lying or telling stories. I asked for more clarification, thinking she’d contradict what she had said, but she kept to the same story. It wasn’t too much later that the school sent out a message that the bus had been in an accident and there were no injuries. I told her that I got the message and she just beamed. She knew I didn’t believe her! But it was an opportunity to let her know that sometimes I might not believe stories initially, but I was proud that she told me and continued to try to show me the truth.

If your kids ever tell you they don’t want to visit or stay with a certain person, find out why. If they say they’re scared, don’t discount it. Even if you trust the person, believe your child. Molesters are adept at grooming families to gain trust. Kids generally don’t make abuse up.

Men and women are different.

When kids are young, teach in general terms about males and females.

You can talk to young kids about why men and women look different than kids. Many will question why men have facial hair, women have breasts, or how a baby will get out of mom’s tummy. They might want to know why you have feminine hygiene products in the bathroom or what they’re for. Answer the questions to their level of understanding.

Talk about puberty before changes happen. Younger kids are more open to learning new things. Once changes start, kids are confused and more self conscious. Puberty starts in girls around 8-12 years of age and in boys about 2 years later. When you notice changes, reassure your kids that it’s normal and they’re just growing up!

For more on menstruation specifically, check out my Q&A about periods.

Some of my favorite books on puberty:

 

Online activities.

The internet has opened the doors to a lot of knowledge and sharing of information. It can be used to better ourselves, but it can also leave kids open and vulnerable. It can lead to bullying. Sometimes it encourages feelings of inadequacy. Online predators can take advantage of our kids.

This is a huge topic and cannot be covered here, but in short: teach kids to never share anything online that they wouldn’t want the public to see. It is okay for parents to monitor online activities, it’s not threatening their privacy. It’s helping them stay safe.

Think of supervising online activities like supervising learning to drive.

You would never just give the car keys to your teen and expect them to safely drive. You first have them learn the rules of the road and pass a written test to get a learner’s permit. The learner’s permit allows them to drive while being supervised. After many hours of supervised driving, they may get a license that allows them to drive alone, but you probably wouldn’t let them take a long road trip alone yet. They start out with quick trips around town, then onto highways, and finally longer trips. The specific timeline of that depends on the teen. Some need longer times at each stage, others show maturity and responsibility more quickly.

Common Sense Media has a number of helpful articles about online safety.

Our actions impact others.

Kids can learn how their actions affect others and that they can’t alter anyone else’s behavior without first changing their behavior.

While this doesn’t seem initially to impact sexual consent, it does. What happens if we all do what we want when we want, without caring what others think or feel? We take advantage of others and hurt people. We don’t want our kids to grow up without empathy or social conscience. It also helps kids to identify their own feelings in response to other people’s actions, which might help them avoid people who make poor choices.

Talk to kids when you see opportunities to talk about the impact of behaviors. Find examples they can identify with.

For example, if a child was being noisy at the library, what kind of impression did they make? How did the noise affect everyone else’s experience at the library? What situations can they think of that they were noisy when they should have been more quiet? How can we be more mindful of our own noise level?

What can kids do if they see a bully? Is it hard to recognize the significance of bullying when everyone’s laughing at another child? Should they join in the laughter when someone’s being teased? Can they stand up for the person being bullied? When should they talk to an adult?

rewind

A fun game to play that can help kids learn how to change their behavior to get a better outcome I call Rewind. You roll play and rewind a situation and play it out differently. When kids complain about the outcome of an event, have them role play it to try to get to a better ending. The trick is they have to be the first to change what they say or do. In the real world we can’t just expect someone else to change a behavior.

For example, if your son is upset that no one would play hop scotch at recess, he can’t simply expect that someone will join him the next day. Other kids might not realize that he wants to play. Maybe he can ask kids to play with him. Roll play what to say if he’s turned down. Think about why other kids don’t want to play hop scotch. Are they all busy playing basketball? Talk about being open to taking turns: maybe another child will play hop scotch with him if he plays basketball with the other child first. The trick is that he just can’t expect others to change their behaviors unless he changes his first.

Respect

One word that summarizes most of the above is respect.

Respect Yourself

Respect yourself enough to eat right, sleep adequately, and exercise. Take care of your body and mind. Be the best you can be. Don’t do things that you know could harm your body or cause you to get into trouble.

Respect Others

Respect others and their wishes. If you’re kind and respectful towards others, they will appreciate it.

This does not mean that kids have to do everything other people ask them to do. They should never do anything that makes them feel uncomfortable or that they know is wrong. See the last respect point…

Demand that others respect you

Just like you should respect others, they should respect you. If everyone respects other’s thoughts and feelings, we would have no abuse or bullying in our lives.

We can’t change other people’s actions all the time, but we can leave situations where people are not kind and respectful. Kids need to know that they should talk to an adult if someone is not being respectful to them.

We hear about child molestation and rape far too often. Teach kids to respect themselves, respect others, and to never keep secrets. 
We hear about child molestation and rape far too often. Teach kids to respect themselves, respect others, and to never keep secrets.

Kids to Parks Day

Each year Kids to Parks Day is celebrated on the 3rd Saturday of May. It’s a day we can help kids and families connect with their local, state, and national parks and have fun! This year it’s Saturday, May 19th.

Why should we have a national day to celebrate taking kids to a park?

Because anything that encourages families and friends to explore the outdoors together is a great thing!

Where should you go?

If you’re wondering where to go, check out this great page from the National Park Trust called Explore Parks Near You. You can click on the state you want to explore to find parks.

Of course if there’s no national park near you, you can visit any nearby park or trail. The point is to get outside and enjoy nature.

What can you do?

Parks may offer a number of activities. You can investigate if they have hiking or biking trails, water activities such as swimming or fishing, camping, or more.

Check out these Boredom Busters and the ideas in this Park Adventure Booklet for your next park trip. You can also try to do all thirty of these 30 Things. If your kids are into creative games, you can have them go on a scavenger hunt.

What should you bring?

Always make sure you’re prepared when you’re going into nature.

Sunscreen and sun protection from hats and clothing is a must when outdoors. Use at least an SPF of 25 and reapply sunscreen every 2 hours until evening hours.

Sunglasses might also be appreciated and help protect the eyes from damaging rays. Be sure your sunglasses provide 100% UV protection from both UVA and UVB rays. Don’t forget the kids! We get 75-80% of our UV exposure before we turn 18.

Use bug sprays and sunscreens appropriately. Don't buy a combination product. Use the sunscreen first, and then spray bug spray over it if needed.
Use bug sprays and sunscreens appropriately. Don’t buy a combination product. Use the sunscreen first, and then spray bug spray over it if needed.

Bug sprays can help prevent bug bites. If you’re in an area with ticks, still do daily tick checks even if you use insect repellant. You can use this handy online tool to find the best bug spray for your needs.

Be sure to bring water bottles for everyone. Dehydration is a risk when you’re active, especially if it’s warm outside. Caffeinated (and for adults, alcoholic) beverages don’t rehydrate as well as water.

Wear appropriate shoes. Many kids want to wear their favorite sandals, but if you’ll be outdoors walking, they will need a more sturdy shoe. If you’ll be around water you might even pack a second pair in case they get wet. Walking in wet shoes is begging for blisters.

Bring a camera to take memories, but don’t spend the day trying to get the perfect picture. Snap a few pictures, but make the day about enjoying the outdoors, not about taking pictures.

If you’ll be hiking, bird watching, or looking for wildlife, it might be helpful to have binoculars.

Bring healthy snacks or pack a lunch if you’ll be out during typical snack or meal times. When kids are hungry, they get angry. You don’t want hanger to ruin a fun day!

If there are areas appropriate for sporty activities, bring some balls or frisbees.

What should you not bring?

Leave the electronics at home. This is a great day to unplug!

If you have allergies in the family…

If someone (or many) in your family suffer from allergies, be prepared! I have many tips in a previous blog that covers allergies.

#KidstoParks

Get your kids outdoors on Kids to Park Day!
Get out and into nature!

Food Strike! What can I do when my child won’t eat anything anymore?

“What can I do to help little Sally eat? She used to eat everything, but now she hardly eats anything at all.” I call this a food strike, and it’s very common. But kids are smart, they won’t let themselves starve. The way you handle it as a parent can either encourage unhealthy eating or healthy eating.

Eat it or wear it.

This question always reminds me of the Judy Blume book, Tales of a Fourth Grade Nothing, one of my favorite books growing up.

The younger brother in the book, Fudge, refuses to eat. After many failed trials of bribing and forcing food, his father finally loses patience and says “eat it or wear it.”

Needless to say, Fudge ends up with the bowl of cereal on his head and goes around for days saying “eat it or wear it!”

I would not advise this approach.

When is a food strike a real concern?

Most of the time picky eating is a normal phase. Sometimes it’s simply that toddlers and young children don’t need as many calories because they’re not growing as fast as during infancy. Or it could be that they’re filling up with empty calories due to inappropriate snacking.

Of course there are some instances that are cause for concern.

Red Flags include:
  • Recurrent or persistent illness
  • Frequent vomiting or diarrhea
  • Food allergies
  • Very limited food types over an extended period of time
  • Problems swallowing or choking
  • Falling off growth curve
  • Sensory issues (trouble with textures, tastes, smells, and more)
  • Anxiety about eating or around foods
  • Body image problems

There is a great series of posts covering picky eating on a dietitian’s blog. Some articles are authored by a nutrition therapist. I will include some of my favorites below, but you can find them all on the site.

If you notice one or more of the red flags above, be sure to talk with your child’s pediatrician.

Encouraging healthy eating

If hungry, kids will eat. Don’t let them fill up on things that aren’t giving a nutritious balance. Even just milk all day can be harmful because it lacks many vitamins and minerals. A little milk with other foods is better!

Healthy food choices

Offer veggies, fruits, cheese, nuts, etc at scheduled snack times. Think of snacks as mini-meals. If kids are offered healthy foods at meals and snacks, they will eat them when they’re hungry.

Limit pre-packaged foods

Many prepackaged foods are preferred over fruits, vegetables, dairy products, nuts, and other healthier options.

If kids have a choice between cucumbers and hummus or a bag of chips, what do you think they’ll pick?

Healthy drinks

Limit drinks other than water and milk.

Drinks fill kids up and don’t offer balanced nutrition.

Limit milk to no more than 24 ounces per 24 hours.

Too much is overwhelming

Put only a small amount of each food on the plate. It might be overwhelming to have a full plate.

Different personality types can even respond differently to different plate sizes. See Children’s Personalities & Bowl Bias: Extravert and Introvert Children Are Not Equally Influenced by Plate Size!

Turn off the tv and put down the screens

Have a dinner conversation with the family. This not only sets up healthy eating habits, but also healthy family dynamics. Teens who eat with their families are less likely to have risky behaviors!

Set a good example!

Talk about how much you are enjoying the healthy foods at the table. (Not how healthy they are, but rather how good they taste.)

Keep foods separate on the plate

Kids might eat a food if it’s not touching another but refuse it if it’s contaminated.

Scheduled eating

Set a time for meals and stick to it. If your child doesn’t eat, clear the table.

When they complain of being hungry, don’t be condescending. Simply say, “I know how you feel. I’m hungry too when I don’t eat. Dinner is coming up soon. I’m sure you’ll be ready!” Don’t offer filler foods. Keep the discussion calm and without blame or judgement.

Kids are smart, they’ll pick up on the fact that they need to eat at meal time or be hungry.  They won’t starve to death!

Hide healthy foods

Puree a can of beets into spaghetti sauce. It makes a cool color without changing the flavor much at all.

Blend carrots, spinach, kale, or cauliflower into smoothies. I’ve even used frozen peas when there was nothing else. Strawberries, bananas, kiwi, and other fruits are much more flavorful than many veggies and kids tend to like their tastes. If your kids balk at the color, try to match the fruit and vegetable colors to hide the vegetable.

Puree onions, carrots, zucchini, spinach, and other vegetables in recipes rather than chopping them… kids won’t pick them out!

With all of these hidden foods, chances are they won’t even know they’re there.

Try foods in different forms

Frozen peas are crunchy– maybe they don’t like the squishy texture of cooked peas.

Raw broccoli is much different in taste and texture than cooked broccoli.

Many kids love cheese over vegetables or foods dunked in ketchup or yogurt.

It’s fun to eat with fingers for a change. Let them get messy!

Try cutting things into pieces and serve with toothpicks. Everything’s more fun on a stick!

Cut sandwiches with a large cookie cutter for fun shapes.

Use small cookie cutters for bite sized sandwiches or fruit pieces.

Take a look at Pinterest to find ideas on how to make foods fun if you really have a lot of time on your hands.

Rewards?

Try not to use food as a reward. This can set up unhealthy eating habits.

Don’t reward for eating. Most kids will get the intrinsic reward of satiety. They don’t need stickers or dessert for eating a meal.

Praise small steps

If kids try a new food (whether they like it or not) praise the fact that they tried!

Set realistic expectations 

Don’t expect kids to eat as much as infants/toddlers or teens/adults. Calorie needs go down when not in growth spurts. Just make the nutrition needs balance.

Don’t worry as much about volume as variety of healthy foods! Parents can decide what kids eat, but kids should decide how much to eat.

Most kids don’t need supplemental meals in a can (Pediasure and other brands) ~ they are getting the nutrition and calories they need, there is just an imbalance of perception of what they need.

I always prefer a healthy, active, thin child over a child who is overweight and not active (and often undernourished due to poor quality foods).

Will they get enough vitamins?

Vitamin supplement use and need is debated. It’s very difficult to study vitamin supplements. Baseline diet variations could make a big difference as to whether or not the supplement is needed. The time that needs to be studied is very long, because many health issues develop over many years. This means we need to wait a long time to see results and there’s a bigger potential that study participants are lost to follow up.

Vitamin D is one vitamin that I believe should be supplemented by all. Very few foods have vitamin D. Milk and a few other foods have been supplemented, but that alone will not give sufficient levels. Sunlight is a great way to raise vitamin D levels. But sunlight availability is unreliable and amounts needed vary based on skin type and quality of the light. Not to mention that sunlight can damage our skin.

In general I think it’s a good idea to give a multivitamin with iron if kids aren’t eating well. I prefer for them to get nutrients from foods, but if they refuse, then there’s no need for them to become deficient in nutrients. Iron deficiency actually causes anorexia, which increases the problem by not eating well!

If your family uses vitamins, be sure to lock them up as if they’re medications so kids don’t accidentally ingest too much.

Last thoughts

Most kids grow well during their picky eating and food strike phases. Just be patient and aware of any red flags that need to be evaluated.

If you are concerned, schedule an appointment to discuss foods, growth, nutrition, and concerns. Bring a typical food log of foods and drinks (with approximate volumes) for at least one week. Your physician can either identify a concern and develop a plan of action or reassure you that your child is normal!

Food strike! What do you do when your child stops eating?Resources:

How much food should I eat? (KidsHealth.org)

Choose My Plate 

How to Handle Picky Eaters (Zero to Three)