Published in Mom’s Guide to San Diego – January 2013

By Jennifer Humora and Children’s Physicians Medical Group Pediatrician, Whitney Edwards, M.D.

When the first Mom’s Guide was published five years ago, my daughter was potty-trained. Mostly. She did not have accidents, she did not sleep in a Pull Ups. But she absolutely refused to poop on the toilet. I would have to strap a diaper onto her for every bowel movement, and, of course, I wondered, “Is this normal?”

“Parents often come to the pediatrician’s office with concerns about various behaviors and developmental milestones, worried that their children might not be normal,” says Children’s Physicians Medical Group pediatrician, Whitney Edwards, M.D. “Some things that families commonly lose sleep over are completely normal, while other behaviors which may just strike people as ‘cute’ can actually be quite worrisome.”

Mom: So, is it normal for a 3-year-old to refuse to use the toilet for a bowel movement, and what should a parent do?

Dr. Edwards: This is both normal and common, but can be very frustrating for families. This age is all about power and control, and one of the very few things kids have ultimate control over is where they defecate. Sometimes, too, children can be fearful of the toilet. Start by asking WHY he or she doesn’t want to. You may get a surprising answer that can guide your response (like the child who told his parents if he started using the toilet, he would have to go to preschool, and he didn’t want to). In general though, removing the power struggle aspect will resolve the problem. Use a casual motivator, like if your child wants to go somewhere new, you might say off-handedly, “I’d love to do that too, but that’s something that will have to wait until you can use the potty,” then pick up a toy or character underwear that will be a reminder of that activity and put it somewhere visible, but out of reach. Let your child know that using the potty is her decision, so she needs to let you know when she’s ready to change from diapers to underwear, then don’t bring it up again. If your child seems particularly fearful, complains of pain, or if this strategy isn’t working after a couple of months, consult your pediatrician.

Mom: What about the “m” word? Masturbation?

Dr. Edwards: This is probably the single thing people ask me about the most. This is normal in both boys and girls, and best approached by letting the kids know that, yes, you know it feels good, but that’s something they should do in private, either alone in their bedrooms or in the bathroom. On the other hand, inserting objects in either the anus or vagina is NOT normal behavior and should be brought to your pediatrician’s attention right away.

Mom: I’ve known a couple of children who walk on their tip toes quite a bit. One seems to have outgrown it. One had a corrective surgery. What should a parent do if they notice this behavior?

Dr. Edwards: Frequent toe walking is not normal and should be evaluated by an orthopedic surgeon. Discourage persistent toe walking if you see it and alert your pediatrician if it continues. Early intervention (which may involve short term casting) greatly decreases the chance that a child will need surgery. Sometimes toe walking can also be the first sign of more serious underlying problems, so a specialty evaluation is very important.

Mom: When should a parent be concerned about speech development?

Dr. Edwards: Your pediatrician will screen for speech milestones at each well child visit. In general, babies coo and babble by 6 months, start to use one or two words by one, have a vocabulary of 10-15 words and begin to combine two by 18 months, use more than 50 words & answer “no” to questions appropriately at two, and are speaking in complete sentences and are clearly understandable to strangers by three. Parents with concerns about their children’s speech and development can have free evaluations done through the First Five program. Kids who are identified to have developmental issues may qualify for services through a number of community organizations, including the San Diego Regional Center.

Mom: How can a mom get her child who is potty trained during the day out of Pull Ups at night?

Dr. Edwards: Being dry at night has very little to do with being toilet-trained and typically is not behavioral. Like night terrors and sleepwalking, prolonged bed wetting is generally a manifestation of deep sleep.

(This is different from the situation in which a previously dry child begins to wet the bed again, which deserves an evaluation.) 20-30% of five to six year olds are still not dry at night. If your child is still wetting the bed at age six, or the bed wetting is causing problems in the family, discuss options with your pediatrician.

Mom: Our best friends’ 3-year-old son has eaten virtually nothing besides baby yogurt and peanut butter crackers for the past year. What should they do about his diet, if anything?

Dr. Edwards: It’s always a challenge to know when to give unsolicited advice to friends, but assuming that your friends have asked for advice, strongly recommend that they talk to their pediatrician. In short, this is a parenting issue, not a medical problem. Generally we divide up responsibility for feeding toddlers in the following way: parents are responsible for WHERE kids eat (at a table or high chair, not walking around the house, not in front of the TV), WHEN kids eat (it doesn’t have to be rigid, but essentially kids should have three meals and generally two snacks a day at times which have been predetermined by a parent) and WHAT is on the plate (a healthy mixture of appropriate portions of a carbohydrate, a protein and fruits and vegetables). The kids get to decide WHETHER or not they eat what you offer, but if they refuse, they don’t get something different, and the next chance they have to eat is at that already determined next meal or snack time. Be sure, too, that they aren’t filling up on drinks. Offer water throughout the day but eliminate juices and other sweet drinks and limit milk to not more than 16 oz per day. Developing healthy eating habits is one of those parenting challenges which is simple, but not easy.

Of other concerns that have you wondering, “Is my kid normal?!”

Dr. Edwards says, “Whenever you’re in doubt, consult your pediatrician. If you’re able, try to capture a short video of the behavior you’re concerned about. Rarely will kids demonstrate the behavior while in the exam room. If the behavior is too brief and unpredictable to be able to fi lm, it’s less likely to be particularly concerning.”

Dr. Whitney Edwards is a Children’s Physicians Medical Group pediatrician with a practice in Hillcrest.

 Jennifer Humora is the publisher of The Mom’s Guide to San Diego.