Dr. Greene’s Answer:

Infant Potty Training, or Elimination Communication, or the Diaper Free Movement, is a an increasingly popular potty training alternative. Here, parents learn to recognize clues that their baby is about to “go” and provide them with a receptacle just in time.

Several readers of Raising Baby Green have reported that they started doing this when they introduced solid foods and greatly reduced the number of diapers used—and got their kids out of diapers entirely not long after they started walking.

This takes a lot of work, but it can be good for the environment and for the pocketbook.

When young children refuse to poop on the potty, they have often fallen in to what I call the D-D-D cycle, for Discomfort > Dread > Delay. They might enter the cycle from any point, perhaps from waiting to poop because they don’t want to interrupt playing, or perhaps from fear of the potty itself. But what these kids have in common is the uncomfortable passing of a large or hard stool. This can make them afraid the next time they need to go, which leads to stool withholding.

Then, when they finally do poop, it can be even more painful, reinforcing the dread and the delay. Researchers at the Children’s Hospital of Philadelphia followed 380 children from before toileting was an issue all the way through successful potty learning, to see how children fall into this cycle. The results were published online in the June 2004 Pediatrics. The average age to complete daytime toilet learning was 36 months, and varied from 22 to 54 months. Along the way about one quarter of the kids experienced Stool Toileting Refusal (STR). For as many as 93 percent of the kids, the first step on the D-D-D cycle was the uncomfortable passing of a hard stool. This suggests that constipation may be inadequately addressed in children before they start to learn about going on the potty, and that solving the constipation problem may prevent many toilet difficulties that are commonly encountered.

When is the best age to start toilet learning in children? A study published in the April 2003 issue of Pediatrics reports that starting intensive toilet training before 27 monthsdid nothing to hasten the time that toilet learning was completed – all it did was to lengthen the months of toilet learning. Intensive toilet training was defined as asking the child more than 3 times a day to use the toilet.

This study was conducted by researchers from Children’s Hospital Philadelphia among hundreds of middle-class children living in the Philadelphia suburbs. The results might have been quite different in other groups or in other countries. Even in similar groups, individual children mature at different rates and in different ways. Still, this report reminds us that kids will learn to use the potty when they are ready, and not before. Our job us to teach them and support them, not to force them.

Dr. Greene’s Answer:

The way to move from diaper to potty for most strongly resistant kids is with little tiny steps–especially when there has already been so much emotional energy, pressure, and discipline involved. Take care to make every step an act of the two of you agreeing and cooperating.

If, for example, your child is happy using the diaper, the first small step is to get her using the diaper in the bathroom. Next, get her to use the diaper in the bathroom sitting down; it could be on the edge of the bathtub, on a chair, or on the floor. The goal is to encourage her to sit. If you push too hard, she will resist. You cannot force progress on this one–she will not have to poop on a potty until she wants to.

With younger kids and other issues, you can just make things happen. For example, if she was fussy and you needed to leave, you could just pick her up and go. Or if she were hitting someone, you could give her a time out. But here, force and punishments do not work. In fact, they only make things worse. The challenge at hand is to learn to engage cooperation.

Related concepts:

UTI, Cystitis, Bladder Infection

Introduction to urinary tract infections:

When adults get bladder infections, they typically report burning with urination. Young children, however, may not offer such easy clues.

What is urinary tract infections?

Infections of the urinary tract are common in young children. Bacteria may enter the urinary tract from the opening and travel upward. Less commonly, they may enter the urinary tract through the bloodstream.
If the infection is in the bladder, it is called cystitis. If it is in the kidney, it is called pyelonephritis.
E. coli, a type of stool bacteria, is the most common cause of urinary tract infections. Many other types of bacteria can cause infections. Even viruses, such as adenovirus, can infect the bladder.

Who gets urinary tract infections?

Urinary tract infections are more common in girls, because the short, straight trip up to the bladder is easier for bacteria to traverse. About 1 in 20 girls develop urinary tract infections, most commonly around the age of toilet learning.
The most common age for boys to get urinary tract infections is before the first birthday. Uncircumcised boys get more urinary tract infections than their peers.

What are the symptoms of urinary tract infections?

Bladder infections can cause lower abdominal pain, increased urination, uncomfortable urination, tenderness over the bladder, blood in the urine (hematuria), or a fever. In young children, the only symptoms noticed might be fussiness and perhaps a fever. Perhaps the urine will look or smell different than usual.
A high fever (or a febrile seizure) suggests pyelonephritis.
Sometimes bacteria in the urine are discovered only on a screening urine test. In retrospect, they may have been causing symptoms, such as bedwetting, that weren’t recognized.

Is urinary tract infections contagious?

Urinary tract infections are not usually spread from person to person, but are caused when stool bacteria makes it into the opening where urine emerges.

How long does urinary tract infections last?

Most urinary tract infections clear up quickly – within days – when the appropriate antibiotics are started.

How is urinary tract infections diagnosed?

Urinary tract infections are diagnosed with urine cultures. They may be suggested by the history and physical exam or by a urinalysis test.

How is urinary tract infections treated?

Most urinary tract infections are best treated promptly with antibiotics to prevent possible damage to the kidneys.
The cultured urine will be tested against several antibiotics to see which work best against that specific strain of bacteria. Treatment should not be delayed to wait for this result. It should be started immediately and switched if necessary when the antibiotic sensitivity results are available.

How can urinary tract infections be prevented?

Some urinary tract infections can be prevented by reducing exposure to stool. This means changing diapers promptly, and in older girls, teaching them to wipe from front to back.
Most young children who have had a urinary tract infection should have imaging studies performed to look for urine reflux (urine that flows upward at times toward the kidney) and to look for any abnormality in the urinary tract. The studies could also identify any scarring that may have occurred.
Depending on the results of these studies, specific medicines or surgery may be needed to prevent further urinary tract infections.

Related A-to-Z Information:

Adenovirus, Dehydration, Diaper Rash, Diarrhea, E. Coli, Enuresis (Bedwetting), Febrile seizures, Hematuria,

Hypospadius, Inconspicuous Penis, Labial Adhesions, Pyelonephritis, Sexual Abuse, Spina Bifida, Vesicoureteral Reflux

Related concepts:

Confusional arousal; Partial arousal state; Sleep terrors

Introduction to night terrors:

Your little angel wakes up screaming in the middle of the night, calling for his mommy – but his mommy is right there, unrecognized. You try to comfort him, but he shrieks even louder, eyes bulging. He might be having a night terror.

What are night terrors?

Within fifteen minutes of your child’s falling asleep, he will probably enter his deepest sleep of the night. This period of slow wave sleep, or deep non-REM sleep, will typically last from forty-five to seventy-five minutes. At this time, most children will transition to a lighter sleep stage or will wake briefly before returning to sleep. Some children, however, become stuck and are unable to completely emerge from slow wave sleep. Caught between stages, these children experience a period of partial arousal.
Partial arousal states are classified in three categories: 1) sleep walking, 2) confusional arousal, and 3) true sleep terrors. These closely related phenomena are all part of the same spectrum of behavior.
When most people (including the popular press and popular parenting literature) speak of night terrors, they are generally referring to what are called confusional arousals by most pediatric sleep experts.
During these frightening episodes, the child is not dreaming and typically will have no memory of the event afterwards (unlike a nightmare). If any memory persists, it will be a vague feeling of being chased or of being trapped. The event itself seems to be a storm of neural emissions in which the child experiences an intense fight or flight sensation. Once it is finally over, the child usually settles back to quiet sleep without difficulty.
These are very different from nightmares.
True sleep terrors are a more intense form of partial arousal. They are considerably less common than confusional arousals and are seldom described in popular parenting literature. True sleep terrors are primarily a phenomenon of adolescence.

Who gets night terrors?

The tendency toward sleepwalking, confusional arousals, and true sleep terrors often runs in families. They tend to be more common in boys, and are much less common after age 7.
The events are often triggered by sleep deprivation or by the sleep schedule’s shifting irregularly over the preceding few days. A coincidentally timed external stimulus, such as moving a blanket or making a loud noise, can also trigger a partial arousal (which again shows that the event is a sudden neural storm rather than a result of a complicated dream).

What are the symptoms of night terrors?

Typically, a confusional arousal begins with the child moaning and moving about. It progresses quickly to the child crying out and thrashing wildly. The eyes may be open or closed, and perspiration is common. The child will look confused, upset, or even “possessed” (a description volunteered by many parents). Even if the child does call out his parents’ names, he will not recognize them. He will appear to look right through them, unable to see them. Parental attempts to comfort the child by holding or cuddling often prolong the situation.

Are night terrors contagious?

No.

How long do night terrors last?

Most often, a confusional arousal will last for about ten minutes, although it may be as short as one minute, and it is not unusual for the episode to last for a seemingly eternal forty minutes.

How are night terrors diagnosed?

The diagnosis is based on the history. When a question remains, a physical exam or tests may be run to rule out other possibilities.

How are night terrors treated?

When an event does occur, do not try to wake the child — not because it is dangerous, but because it will tend to prolong the event. It is generally best not to hold or restrain the child, since his subjective experience is one of being held or restrained; he would likely arch his back and struggle all the more.
Instead, try to relax and to verbally comfort the child if possible. Speak slowly, soothingly, and repetitively. Turning on the lights may also be calming. Protect your child from injury by moving furniture and standing between him or her and windows. In most cases, the event will be over in a matter of minutes.
Night terrors can also be treated with medications, hypnotherapy, or with other types of relaxation training if they become a significant problem.
A Novel Approach – The Greene Technique
When my youngest child was going though night terrors, I observed that he was also “working on” achieving nighttime dryness. In fact, night terrors are most common at the same ages that children are becoming aware of the bladder feeling full during sleep. It dawned on me that perhaps some of these kids just need to go to the bathroom, but are not yet able to wake up fully when their bladders are full. I’ve now treated many kids by having the parents take them to toilet while they’re still asleep. For many of these children, even though they do not recognize their parents, they will often recognize the toilet and urinate. For these children, the episodes stop abruptly and they return to sleep. The calm is dramatic.

How can night terrors be prevented?

Prevention usually involves trying to avoid letting the child get over-tired, and trying to keep the wake/sleep schedule as regular as possible. Taking the child to the bathroom before the parents go to bed can also prevent some night terrors.

Related A-to-Z Information:

Enuresis (Bedwetting), Epilepsy, Nightmares, Sleep Apnea

Related concepts:

Bed-wetting, Primary nocturnal enuresis, PNE

Introduction to enuresis:

Most children learn how to stay dry during the day before they’re able to stay dry at night. Millions of kids wet the bed long after they feel that they should be dry.
Sadly, most of these children feel that they still wet the bed because there is something wrong with who they are.  Many of them feel that it’s the result of either bad thoughts or bad actions. They feel that somehow bed-wetting is a punishment.
Similarly, many parents feel that their children’s bed-wetting is a result of a defect in their parenting. This feeling is heightened by well-meaning friends and relatives who bring up questions of emotional instability as the cause of bed-wetting.
In one survey of parents, 22 percent stated that they thought the reason their child wet the bed was laziness. This could not be further from the truth! Primary nocturnal enuresis is a common developmental phenomenon related to physical and physiologic factors. It does not come from emotional stress, poor self-esteem, or emotional immaturity.

What is enuresis?

Children who can control their bladders during the day, but who have never been dry at night for at least a six-month period, have what is known as primary nocturnal enuresis (PNE), the most common form of bedwetting.
Secondary nocturnal enuretics are completely dry at night for a period of at least six months and then begin wetting again.
In secondary enuresis, the key is finding out exactly what has changed. There might be a new psychological stress such as a divorce, a move, or a death in the family. It might be something physical: the onset of a urinary tract infection or diabetes, for example. It might be a situational change, such as altered eating, drinking, or sleeping habits. Clearly, something has changed. The first step in solving the problem is identifying any changes in your child’s life.
In any case, children who wet the bed have two things in common. First, they need to urinate at night. Not all children do. During the first months of life, babies urinate around-the-clock. Most adults, however, don’t need to urinate at night (although a small percentage of the population will need to urinate at night throughout life). Sometime in middle childhood, most kids make the transition from urinating around-the-clock to only urinating during waking hours. There are three reasons why some children may still need to urinate at night:

1. There is an imbalance of the bladder muscles. (For example, the muscle that contracts to squeeze the urine out is stronger, at moments, than the sphincter muscle that holds the urine in.)
2. They have bladders that are a little too small to hold the normal amount of urine.
3. They make more urine than their normal-size bladders can hold, for several reasons:
   • They may drink too much. Drinking in the two hours before bed increases nighttime urine production.
   • They may be consuming a diuretic medication, a substance that directly increases urine output. They may also consume diuretic beverages or foods like caffeinated cola drinks or chocolate.
   • They may make more urine in response to a chronic disease, such as diabetes.
   • They may make more urine than average because of their hormonal regulatory systems. Babies make about the same amount of urine around-the-clock. Most adults make less urine while they sleep. The reason for this is thought to be a nighttime surge of a hormone called Antidiuretic Hormone (ADH). Some bed-wetters may make less ADH or have kidneys that are less responsive to ADH.

If an individual regularly needs to urinate at night, one or more of the three reasons listed above is the cause.
The second thing children who wet the bed have in common is that they don’t wake up when they need to urinate. When infants need to urinate, there is no signal that goes from the bladder to the brain to wake them up. This is wonderful, since they are not yet able to walk to the bathroom and use the toilet. On the other hand, when an adult’s bladder is full at night, there is a signal that goes from the bladder, through the nervous system, up to the brain. This initiates a dream about water, or more specifically, about going to the bathroom. The dream alerts our reticular activating system, which either awakens us or causes us to tighten our sphincter muscles to hold the urine. This signaling mechanism comes into play sometime in childhood.
Children who wet the bed are dramatically more difficult to wake up than their peers, which confirms what parents have known for years!
Children who wet the bed at night both need to urinate at night and do not wake up when their bladders are full. These are the only children who wet the bed.

Who gets enuresis?

Research has shown that primary nocturnal enuresis is often inherited. If both parents were bedwetters, 77 percent of their children will be. If only one parent wet the bed, 44 percent of their offspring will. If neither parent wet the bed, only about 15 percent of their children will wet the bed. With primary nocturnal enuresis, one almost always finds another relative who was a bed-wetter. This corresponds to what is called an autosomal dominant inheritance pattern.
Bed-wetting is more common in boys.

What are the symptoms of enuresis?

In primary nocturnal enuresis, children have never achieved complete nighttime control. They have always wet the bed at least two times a month.
As a result, these children may suffer significant psychological stress and develop feelings of low self-esteem (including feelings of shame, inferiority, and fear of being discovered by others). These are the result, not the cause, of PNE.
Families of bedwetters can experience disturbed sleep, turmoil, and a drain on energy and resources.

Is enuresis contagious?

No

How long does enuresis last?

At age 5, about 15 percent of children have PNE.
Among those who still have PNE after age 6, only about 15 percent of them will achieve dryness over the course of the next year (without treatment).
At age 15, one to two percent of adolescents still have PNE. If left untreated, some will wet the bed for life.

How is enuresis diagnosed?

When bedwetting continues to age 5 or 6 (or at any age if it is troublesome to the child) it is time to discuss it with the child’s doctor or with a doctor skilled in treating bed-wetting. A careful history, physical exam, and urine test can usually determine the type of bed-wetting and the best treatment approaches. Sometimes it is important to measure the child’s bladder size. This is often done at home with a measuring cup.
It is also important to identify any constipation or encopresis (uncontrolled passing of stools). If one of these conditions is present, it should be treated first. The bed-wetting will often disappear when these conditions are treated.

How is enuresis treated?

A variety of effective solutions are available, alone or in combination. Different solutions work better for different children. Behavioral therapies include motivational programs, guided imagery, and hypnosis. Conditioning therapies involve one of several bedwetting alarms. Specific exercises can be done to strengthen the nighttime resting tone of the sphincter muscles.
Your doctor may recommend a medication such as the DDAVP tablet. The DDAVP tablet can help achieve dryness in some children with PNE. However, it also has the potential for serious side effects and should be used with caution and only under close supervision by a physician. The FDA has recently placed a ban on treating PNE with DDAVP in the nasal spray form.
Behavioral treatments are most effective and with the right approach for the right child, most school-age children can be dry within 12 weeks.
Treatment can improve a child’s self-concept, even if total dryness is not achieved.

How can enuresis be prevented?

Not much can be done to prevent bed-wetting, but adequate sleep may help. Some children will stop wetting the bed with as little as 30 extra minutes of sleep per night.

Related A-to-Z Information:

Constipation, Night Terrors, Sleep Apnea, Tonsillitis

Introduction to constipation:
As long as your child is in diapers, every single bowel movement will be right there for you to see when her diaper is changed. During the diaper years, the stools undergo several changes. The first bowel movements are the thick, sticky, tarry meconium stools formed while the baby is still inside you. During the first week these give way, in breastfed babies, to soft, yellow, breast milk stools. These usually look like yellow mustard with little seeds. By the time a baby is one week old, she has an average of 8 to 10 of these pleasant (as stools go) stools each day. Formula-fed stools are often tan or yellow at this stage, and a little firmer than breast milk stools. Either way, there are many dirty diapers!
For most breastfed babies, the number drops to about 4 per day by 4 weeks old (although many kids have a different pattern). Formula-fed babies usually stool less often at this age, and the stools do not change much with time until solid foods are introduced (because unlike breast milk, formula doesn’t change over time).
By 8 weeks old, the average drops to 1 per day. Most formula-fed babies will not go less often than daily, but many breastfed kids will poop even less often than this. I know many babies who only go every three days. If a happy formula-fed baby goes 4 days, or a breastfed baby goes 7 days without a stool, I recommend that he or she be checked by a pediatrician (sooner if the child seems to be in pain). Still, it can be completely normal to go only once every eight days — as long as the stool is soft when it comes out. Breast milk is an amazing food that leaves very little in the way of waste.
Beginning solids usually produces a noticeable change in the character of the stools. They may be either softer or firmer, but they will likely smell worse (kids also smile and laugh more at this age, more than making up for the unpleasantness). Most children’s intestines are very responsive to the foods they eat.
Toilet learning may also result in a significant change in the timing and consistency of stools.
Also, at school-age, when children begin going to the bathroom alone (and parents are less aware of the frequency and consistency of stools), some children may go through another period of constipation.

What is constipation?

When a child is constipated, the stool in the intestines has backed up more than it should. The longer stool sits in the colon, the more water is absorbed back into the body. When a child is constipated, the stool tends to be hard and passing it tends to be painful.

Who gets constipation?

Anyone can become constipated. Common times include during the introduction of solid foods, during toilet training, or when fluid intake is decreased.

What are the symptoms of constipation?

Babies will normally strain from time to time to move the stool along through the intestines. If you want to do something when babies grunt, push, or strain, try picking them up to get gravity to help them in their efforts, or try holding the knees against the chest to help them “squat” — the natural position for bowel movements. Straining is usually normal. Crying while straining may be a sign of constipation. Hard stools are often a sign of constipation.
A decrease in stool frequency might suggest constipation, but it may also be normal.

Is constipation contagious?

No

How long does constipation last?

Constipation lasts until the hard stool is passed, and the intestines begin moving stool along at the normal rate.
Constipation can become a vicious cycle that lasts until treated.
I call this the D3 cycle (discomfort – dread – delay).
Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty to poop. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in just to delay interrupting a vitally important game.
Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay pooping in order to avoid what happened last time. The longer he delays, the firmer the next stool becomes. When he finally does poop, the event is even more uncomfortable, which confirms his fears. What he dreaded was true!
He vividly learns from this experiment, but it’s the wrong lesson. So next time he is even more determined to hold the stool in. Discomfort leads to dread; dread leads to delay; delay leads to discomfort.

How is constipation diagnosed?

Constipation is diagnosed based on the history and physical exam. It can be seen on x-rays, but these are usually not needed. Children who have constipation that does not respond to treatment may need further evaluation to look for other possible causes of constipation, including Hirschsprung’s Disease, hypothyroidism, botulism, or food allergies.

How is constipation treated?

The simplest first step is to give the child more to drink to soften the stools. At the same time, readjust the balance of the foods in the diet to help. Bananas, rice, soy, and products made from white flour tend to produce firmer stools. Pears, peaches, plums, apricots, peas, and prunes make stools softer. By balancing the diet, you can often keep the stools comfortably mid-range.
If the stools are still too firm, juice is the gentlest medicine to soften them up. Apple juice twice a day is a good bet. If this doesn’t work, prune juice is even better. In addition, when your daughter is straining you might want to put her in a tub of warm water. This will relax her muscles and make the stool easier to pass.
Glycerin suppositories can be very helpful if diet and juice don’t work, but overuse of suppositories can lead to dependence on them. Constipation stubborn enough to make suppositories necessary should be discussed with your pediatrician. The same holds true for baby laxatives. (Hint: If your pediatrician does recommend a laxative, 1/2 teaspoon of unprocessed bran, mixed with food twice a day, is about as effective as many laxatives and much cheaper).
In some children, the D3 cycle is so entrenched that in order to break free they need a stool softener to take the process out of their control. This is especially common if the stools have been hard enough to produce anal fissures. One excellent way to soften the stools is with mineral oil. The oil makes the stools slippery enough that they can no longer delay and soft enough that the stools no longer hurt. The most common reason for mineral oil to fail is using the wrong dose for the child’s weight.
If constipation is triggered by cow’s milk protein allergy, or other food allergy, then avoiding the offending food can make a big difference.

How can constipation be prevented?

By staying familiar with a child’s normal stool patterns, parents can adjust the diet when the stools are starting to get too firm or too loose. Also, a high fiber diet can help to keep the stools regular for children who are drinking plenty of liquids.
For children who are learning to use the toilet, an effort should be made to avoid entering the D3 cycle. A relaxed attitude toward toilet learning and prompt attention to any discomfort, dread, or delay can prevent constipation problems.

Related A-to-Z Information:

Celiac Disease, Congenital Hypothyroidism, Diarrhea, Food Allergies, Infant Botulism

Dr. Greene’s Answer:

This situation is much more common in normal, healthy, happy children than most people would guess.

When kids begin to have trouble getting to the bathroom and then don’t want others to know about it (hiding dirty panties), the ongoing soiling is unlikely to be for psychological reasons. These kids would go on the toilet if they could, but the urge (if it comes at all) is just too late for them to make it. (This isn’t to discount a psychological association — the loss of control and sense of shame can be quite discouraging for kids.)

The loss of timely urge can come from two almost opposite reasons — with very different ways of handling them!

The most common scenario begins when the child doesn’t stool adequately for a couple of days, for whatever reason (physical, social, or psychological). It might feel too inconvenient at day camp (or school), or perhaps they get a bit dehydrated at some point and stooling hurts. Or they have a virus. Whatever the cause, stool backs up. The colon stretches. The normal urge to stool is lost, and stool backs up further. Soft, liquidy stools make their way around the plug with almost no warning — called overflow incontinence. These unstoppable stools are most common soon after eating — when peristaltic waves normally propel stool onward through the colon.

This situation is tricky because the underlying problem is constipation — even though it looks like urgency or even diarrhea. We call the condition encopresis. Sometimes modifying the diet can result in soft enough stools to break the cycle.

Often, mineral oil, milk of magnesia, or Miralax is needed to get things moving normally again. All three are available over-the-counter in the laxative section of drugstores.

Fecal incontinence may also come from the opposite direction — not a back-up of stool, but from stool moving through too quickly for the child to get to the toilet after the urge. There are a variety of possible causes for these quick stools, including infections (such as giardia) or colitis. Usually, in these cases there would be other symptoms as well.

My youngest son was having a confusional arousal, and his mother observed that these events are most common at the same ages that children are becoming aware of the bladder feeling full during sleep.

Perhaps these kids just need to go to the bathroom. We stood him in front of the toilet, and he urinated-still not awake. The episode faded abruptly, and he returned to sleep. The calm was dramatic. Was this a coincidence? Or might this be a revolutionary new help for parents whose kids have these frightening episodes.

If readers try this and let me know what happens, we will find out. If you give it a try, let us know the results, either way. I’ll correlate the different experiences and broadcast the results. Together we can learn more about the wonder and mystery of sleep in children.