Parenting Solved

Tickling - A Cure for Constipation?

Open your mind here. I had a mother report today that she is correcting her four-year-old daughter'€™s constipation with tickling (and a healthy dose of Miralax). It seems her child is one of millions of toddlers with stool withholding, the annoying behavioral pattern of desperate stiffening and avoidance after encountering a painful turd. It'€™s a silent epidemic that I confront head-on every day.

So here's what mom does: When it'€™s clear that junior miss is passionately engaged in her potty dance (eye brows to the sky, head back, torso arched and up on tippy toes) she places her square on the pot and begins to tickle her unmercifully. And each time her daughter eliminates.

It'€™s brilliant really. What'€™s happening is the child initiates avoidance when she recognizes stool in the rectal vault. She withholds to avoid pain. Mom recognizes the cue and stimulates to the point where the child loses the iron-clad control of her pelvic floor. The laughter creates intra-abdominal pressure which exceeds the pressure of her external sphincter. Voila.

No word on the long-term effects of tickling on the toilet. But for now it represents a simple solution for one toddler in crisis.

For the record, this is my first Parenting Solved Hack.

Green Stool - Problem or Preoccupation

For stoolgazing parents nothing raises eyebrows like a bright green diaper. And it’s those shades of neon green that often stir a call to the pediatrician. So what’s the deal with green stool? Is it a problem or preoccupation?

Well take a seat and let's talk about the color of poop. Stool gets it’s color from bile released in the intestinal tract just beyond the stomach. Bile happens to be green. As it makes its way along the length of the intestinal tract, bile undergoes a transformation in color from its original green to a shade of yellow ultimately reaching a rich chestnut hue. I liken this transformation to the ripening of a banana.

Stool that reaches the end of its journey green or yellow typically means that the journey has gone a little quicker than expected. It’s typically nothing of concern although we can see this at times during a tummy bug. Green watery diarrhea in a child can be a problem in this case not because of the color of a baby’s poop but because of the potential for dehydration. So stool color has to be looked at in the context of a child’s other symptoms. If your child isn’t otherwise ill, a green diaper shouldn’t be cause for alarm.

Still the green stool spooks even the professional. I had a mother recently come very close to abandoning breastfeeding after being told by a lactation consultant that her baby’s green stools were the result of too much foremilk. The mom, desperate for her baby to produce the perfect diaper, tried to no avail to manipulate her baby’s feeding. While it was perhaps the only instance where I’ve seen micromanagement by an LC divide the mother-baby dyad, it’s just one example of the perils of stoolgazing.

So don’t let your preoccupation with stool characteristics become an obsession. And the next time someone frets over a green stool, send them this link.

Potty Train Your Child in Just One Day

If you’re tired of diapers, check out Teri Crane’s bestselling book, Potty Train Your Child in Just One Day. This easy-to-read book literally makes a party out of the process of potty training. Through a systematic approach that engages children in a fun, positive way the book provides an opportunity for tight-bottomed toddlers to relax and enjoy something which all too often is stressful. I think that the success of this book is due to the fact that it offers parents a manageable process that they can actually get their hands around.

And if you’re in northern Ohio or beyond, Teri Crane offers her Potty Boot Camp which introduces parents to the concepts outlined in her book. You can check out her website for appearances and seminars.

On a personal note, Teri pioneered the idea that parenting authors can successfully promote books under the fluorescent glare of a big box store like Babies R Us. After she was profiled in Publisher’s Weekly I contacted her to figure out her approach. Since then Teri has generously served as something of a book marketing mentor for me. This lead to my relationship with Babies R Us which has created some great opportunities for Colic Solved. Congratulations on your success as well as serving as a valuable resource for frustrated parents (and frustrated authors!)

Unfortunately Teri’s book is about to be trumped. I’m announcing the publication of Potty Train Your Child in Just Three Seconds which is due for release next spring. A 7,500,000 initial print run is expected. Sorry Teri.

Mead Johnson Discontinues Low Iron Formula

In a memo to health care providers, Mead Johnson Nutritionals announced yesterday that low iron preparations of Enfamil Lipil are being discontinued. While the company’s formal release doesn’t suggest when we’ll see low iron Enfamil disappear from store shelves, the word on the street seems to be that this will occur sometime in the late spring.

Mead Johnson Nutritionals should be commended for setting a new standard for infant nutrition. For too long the voodoo practice of attributing constipation to normal concentrations of iron in infant formula has driven the market for these inappropriate formulas. Hopefully Ross Nutritionals (makers of Similac) will follow the example set by Mead Johnson and make low iron formulas a thing of the past.

For a more detailed review of why low iron formulas are risky, check out my post, Low Iron Formula – Bad for Babies.

Scent of a Diaper

In Scent of a Woman the blind character played by Al Pacino was able to tell all about a woman based on her scent. It seems moms can do the same thing – sort of.

Australian researchers have found that mothers report the odor of their own baby's soiled diapers as “less disgusting” when compared to the scats of others. The study reported in the journal Evolution and Human Behavior theorizes that this lack of disgust at our own kid’s diapers confers some sort of evolutionary advantage – in other words the fact that we’re not so turned off by our own kids allows us to nurture them and propagate the species.

Interesting side note: At birth the gut is sterile. Over the first several weeks of life the gut is colonized with millions of bacteria. As it turns out, the bacteria that colonize the colon come from mom and dad. So stool characteristics often match that of the family a baby is born into. Perhaps were less turned off to things we’re accustomed to.

This is the stuff that pediatric gastroenterologists find when they surf.

Low-Iron Formula - Bad for Babies

The idea that the iron in infant formula predisposes infants to constipation is perhaps the oldest urban legend kicking around pediatric offices.

The belief that iron in infant formula can create problems for babies may be an extension of the misery experienced by pregnant women when supplemented with iron. When they’ve experienced the effects of iron supplementation, new mothers will often take matters into their own hands. Pediatricians themselves desperate for relief from colicky parents will often gamble with the low-iron card. It’s estimated that low-iron formulas account for 9%-30% of elective infant formula sales in the United States.

So what are the facts? Let’s look at a typical 6 kilogram 3-month-old infant consuming an average of 28 ounces per day formula. An infant fed Enfamil Lipil low-iron receives 4.2 mg of iron per day. The same volume of standard Enfamil Lipil provides 10.1 mg of iron daily. It’s estimated that babies need about 1 mg of iron per kilogram of bodyweight. The baby in our example therefore requires 6 mg of iron daily. The Enfamil low-iron cuts our baby short.

For parents who like to live on the edge there’s Similac low-iron formula. It provides about one third of the iron available in Enfamil’s low-iron formula. In the case of our baby discussed above, Similac low-iron provides a meager 1.3 mg of iron per day.

So what’s the big deal? Iron happens to be very important for brain development. Studies have documented the long-lasting developmental effects of iron deficiency early in life. And what about the association between iron in formula and constipation? There isn’t one. This association was disproved in clinical studies some years back.

What’s important to take home here is the fact that standard infant formula contains appropriate levels of iron, not “extra” iron as is often assumed. Low-iron formula as you see from our example, puts babies at an unacceptably high risk for iron deficiency and should have no place in feeding babies.

It’s been suggested that low-iron formulas should be removed from the market. But so long as misconceptions about formula and constipation exist, there will be demand. And where there’s demand there’s a market.

Grunting Baby Syndrome

It may be the bane of my professional existence but it isn’t found in the major pediatric textbooks. It’s the source of stress and confusion for so many young parents. And too often it’s misunderstood if not mismanaged. It’s grunting baby syndrome.

The baby with grunting baby syndrome will push, squeeze, grunt, change color and carry on only to produce a soft bowel movement. Parents will report that their baby is constipated and seek help. Very often we’re lead down the down the primrose path searching for a solution. But there is no problem. The grunting baby’s problem is one of primitive incoordination. While we all take for granted our understanding of the need for simultaneous relaxation of the pelvic floor and abdominal pressure to poop, not all babies have this figured out. And it’s this lack of coordination that makes us believe that our babies are in trouble.

A common trap for parents and even pediatricians is to stimulate the GBS baby with a thermometer or a cotton swab. When the anus is stimulated, babies exhibit what’s referred to as an “anal wink.” When this happens the bottom relaxes ever so briefly but just enough to allow rectal contents to be eliminated.

The reason this is a trap is that it actually works. And because it works so well we do it again and again. But as the baby becomes accustomed to pooping with stimulation it comes to be that the baby can only poop when stimulated (thus the trap).

The baby with grunting baby syndrome is best left to work out her issues on her own. The simple timing of elimination is something that we all sort out early on and we shouldn’t interfere. As difficult as it may be to watch, the short-term relief of rectal stimulation is never a good long-term solution. Parents of babies with GBS will often look for help after weeks of continuous bottom tweaking and failure of a baby to poop on her own. After a thorough history, physical, and exclusion of other causes I educate the family on GBS and suggest a slow withdrawal of stimulation with the understanding that baby will figure it out.

As far as I can tell, the first formal description of GBS as a clinical entity was made by Dr. Carlo Dilorenzo, Professor of Pediatrics at Ohio State University in the textbook, Pediatric Gastrointestinal Motility Disorders.

Stoolgazers

One of my most indelible memories as a pediatric gastroenterologist was the mother who decided to bring a trash bag full of soiled diapers to her child’s visit. Not a diaper pail or tissue basket sized bag but a Texas-sized trash bag normally used to line a 55-gallon drum or haul grass clippings. Over the course of 2 months this poor woman had catalogued and saved every soiled diaper with date, time, consistency, color, odor and the absence or presence of visible blood noted compulsively the outside. Upon taping the diapers shut, they were frozen in anticipation of her appointment. Filthy diapers cryogenically immortalized for my expert review.

Call me self-centered or even negligent but on the day of her daughter’s consultation I didn’t inspect a single diaper. My goal was instead to complete the visit as quickly as possible and get the family out of my office before the bag defrosted. One of the first rules of pediatrics is to never be present within 100 yards of a bag of frozen diapers when exposed to heat. As it turns out this child’s diagnosis was made quite comfortably on the history and subsequent fresh stool samples.

In another equally bizarre scenario a CPA-turned-stay-at-home-mother makes repeated visits to my office with ‘stool portfolios’ consisting of beautifully created pie graphs and tables representing her baby’s bowel actions. She somehow thinks that a graphic presentation will make her point clear and expedite some sort of resolution to the stress brought upon their household by the presence of undigested vegetables in the pull-up.

As strange as these stories may sound, they are common among a class of parents that pediatric gastroenterologists refer to as stoolgazers. Stoolgazers are parents obsessed with their child’s every move … or movement. Compulsively attendant to the shape, size and shade of their baby’s excrement, they read the best and worst into everything that comes out of their baby. The stoolgazer is tenacious in trying to understand what it all means and how it relates to their child’s overall well being.

So how abnormal are these parents who carry spreadsheets detailing their child’s every deed? Probably no more so than other parents whose fixation involves some other organ or aspect of development. As anyone knows who has ever been involved with raising a child, concerns over speech, growth, feeding and behavior are the rule rather than the exception. And when a mother seeks the reassurance of a subspecialist to ensure that her daughter’s speech delay is nothing to worry about, we think nothing of it. It’s just that these worries seem less bizarre and aren’t nearly as amusing when sharing stories of parental angst. Despite my poking, however, it should be understood that parental anxiety is considered by most a good thing. Parents who are on their toes have a tendency to keep their children safe. Attention to the details has a way of keeping children alive.

Our fixation on feces has historical precedent. Before medical technology evolved to where it is today, physicians were dependent upon their sense of sight and smell for diagnosis. Dr. J. Forsyth Meig’s Practical Treatise on the Diseases of Children in 1874 suggested that doctors “ought by all means to inspect personally the appearance of the matters ejected … no description of a mother or nurse, however intelligent, can impart to the physician the precise and accurate idea of the state of those discharges which even a very rapid inspection would give him.” Note the grandiose paternalistic position of Dr. Meig who seems to think that no one, especially a woman, could ever examine a diaper as astutely or quickly as he.

Even as late as mid-20th Century A Chart of Infant and Children’s Stools by Motonobu Furukawa was published with over 250 close up color photographs of human excrement during various disease states. While a fascinating read for the socially deprived gastroenterologist, this book is long out of print. Simple observation, for better or worse, has been replaced by sophisticated diagnostic procedures.

But the stoolgazer remains and the pediatric gastroenterologist is often called upon to ease their pain. We try first to determine whether the stool characteristics described so compulsively could add up to something. If suspicious, simple laboratory testing is all that’s needed to eliminate the short list of potentially concerning maladies. In most cases, however, my encounter amounts to a therapy of sorts where the parents are educated and taught to accept their child’s stool for what it is: green, slightly loose, slightly firm or containing something that doesn’t represent a threat. Like alcoholics anonymous, we strive to get parents to admit that there’s a problem but one that doesn’t involve the child or her diaper.