Toddlers 101

Potty-training can be tough business, but with some patience and these suggestions from Dr. Schmitt, you and your child will come through with flying colors!

Any child who is over 3 years old, healthy, and not toilet trained after several months of trying can be assumed to be resistant to the process. More practice runs won’t help. Instead, your child now needs full responsibility and some incentives to rekindle her motivation.

Transfer all responsibility to your child. She will decide to use the toilet after she realizes she has nothing left to resist. Have one last talk with her about the subject. Tell her from now on she doesn't need any help. Then stop all talk about this subject ("potty talk"). Pretend you're not worried about this subject. When your child stops receiving conversation for not going, she will eventually decide to perform for attention.

Stop all reminders about using the toilet. Let your child decide when she needs to go to the bathroom. Reminders and asking if she needs to go are a form of pressure, and pressure continues the power struggle. She needs to gain the feeling of success that comes from doing it her way.

Give incentives for using the toilet. Special incentives, such as favorite sweets or video time, can be invaluable.

Make the potty chair convenient. Be sure to keep the potty chair in the room your child usually plays in. This gives her a visual reminder about her options whenever she feels the need to go. Don’t remind her even is she's squirming and dancing to hold back the urine.

Diapers, pull-ups, or underwear. Whenever possible, replace pull-ups or diapers with underwear. Help your child pick out some underwear with favorite characters on them. Then remind her "they don't like poop or pee on them." This usually precipitates the correct decision on the part of the child.

Remind your child to change her clothes if she wets or soils herself. As soon as you notice that your child has wet or messy pants, tell her to clean herself up. If she is soiled, you will need to help with the cleanup. Your main role in this program is to enforce the rule: “People can’t walk around with messy pants.”

Don’t punish or criticize your child for accidents. Respond gently to accidents, and don’t allow siblings to tease the child. Pressure will only delay successful training, and it could cause secondary emotional problems. Your child needs you to be her ally.

Ask the preschool or day care staff to use the same strategy. Ask your child's teacher or day care provider for unlimited bathroom privileges so she can go any time she wants to. Keep an extra pair of clean underwear at the school or with the day care provider.

Call your pediatrician’s office during regular hours if:

• Your child holds back her bowel movements or becomes constipated
• Pain or burning occurs when she urinates
• Your child is afraid to sit on the toilet or potty chair
• Resistance is not improved after 1 month on this program
• Resistance has not stopped completely after 3 months

Barton Schmitt, MD, FAAP, professor of Pediatrics, Children’s Hospital Colorado

Constipation is common in children – in fact, it’s a top reason for Emergency Department visits. But it doesn’t have to get to that point.

Constipation Triggers. Frequently, constipation is caused by the child’s diet:

• Not drinking enough fluids
• Consuming too much milk and cheese
• Eating a diet low in fiber

Other causes include:

• Changes in schedules
• Unfamiliar restrooms
• “Holding back”
• Stress or emotional upset at school or at home
• Not getting enough exercise
• Playing too hard and ignoring the body’s signals to use the restroom
• Too much pressure around potty training

Passing stool should be pleasant and free of pain. And just because the poop is not hard, doesn’t mean the child is not constipated. Sometimes it can be a cycle where the child doesn’t poop because it hurts. So she waits longer, leading to larger stools that hurt even more to get out.

Treatment:

There are several things a caregiver can do to help the child pass stool. From simple dietary changes to flexing and exercise, these tips can help alleviate the issue.

The focus of medical treatment for constipation is changing the child's behavior and making sure the he or she is not afraid of having a bowel movement. Sometimes stool softeners are used for a period of time to help retrain the bowel and help the child have more regular bowel movements.

Refer to this page for more information on constipation, its symptoms and possible treatments, or contact your child’s doctor.

Barton Schmitt, MD, FAAP, professor of Pediatrics, Children’s Hospital Colorado

Toddlers are learning how to do many things and they like to be in control! This means mealtimes can feel like a battle for parents of picky eaters. Good news – you can manage picky eating and help your child develop healthy eating habits.

Toddlers grow more slowly

Your child is growing more slowly now than the first year of life. This slower growth means your toddler has a decreased appetite. With less appetite, it’s natural for a toddler to become choosier about what he or she eats. Food jags – when a child only wants to eat the same food for days in a row – become common. These food preferences can change suddenly and erratically. Continue to provide toddler-sized portions of a variety of foods at regular intervals during the day.

Create calm meals

• Toddlers love routine! Serve meals and snacks at about the same time each day – typically every 3 hours, or 3 meals and 2 snacks per day.
• Toddlers should always sit at the table to eat or drink. If not using the high chair, use strap-in chairs or booster seats.
• Serve food only at meal or snack times. Sit at the table with your child during meals and turn off the TV.
• Allow your child to pick up the food and feed him or herself. Remember your child is learning and exploring so allow for some play time here too.
• Serve a variety of foods including foods that your toddler has refused to eat in the past. Your toddler may need time to get used to a new food before they touch, taste or eat it. Talk with them about the color, number, squishiness, roundness or anything worth noting about the food they are exploring.
• Toddler-sized portions are small. About 1/3 cup for cereal/rice or pasta, ½ slice bread or tortilla, ½ small fruit, 1/3 cup for vegetables, ½ cup milk or yogurt and 1 tablespoon or ½ oz. for meat are good starting portion sizes. For a picky eater, a large portion of any food can be the difference between being eaten or not.

What about good nutrition?

After age two, toddler nutritional needs are not as critical as when they were babies. At this age, the focus is on developing good feeding skills and a healthy feeding relationship between parents and child.

Here are some ideas to keep in mind:

• If your toddler has stopped eating, don’t make them stay longer at the table in hopes that he or she will eat more. Aim for no more than 20 minutes per meal. With planned meals and snacks, your toddler will likely be more hungry and interested in food at the next meal or snack.
• If your toddler skips a food group at one meal, make the next snack count. For example, if she picked the chicken out of her pasta at lunch, serve ½ cheese stick along with fruit for her snack to make up the protein difference.
• Juice is often over-consumed by toddlers. Encourage water between meals and ½ cup low fat milk with meals.

What if you are still worried?

While picky eating is a normal stage of toddlerhood, some children go on to have more problems with eating. These children may have sensory, mechanical or medical conditions, or behavioral challenges that can make feeding problematic. If you suspect there is something going on that is more than just picky eating, discuss your concerns with your pediatrician. You may be referred to an occupational therapist or speech therapist specializing in feeding therapy for an evaluation. A registered dietitian can also help optimize nutrition and ensure appropriate growth.

Helen Seagle, MS RD, Department of Clinical Nutrition, Clinical Dietitian Supervisor, Clinical Dietitian in Lifestyle Medicine, Children’s Hospital Colorado

A food allergy is defined as an abnormal immune system response. Most childhood food allergies develop in the first few years, although new ones can develop at any time. Some children outgrow their allergies. Allergies to milk, egg, wheat and soy are more likely to be outgrown. Peanuts, tree nut, fish and shellfish are less likely. Children with other allergies or who have immediate family members with allergic diseases (eczema, asthma, hay fever, food allergies) are at higher risk.

Allergic reactions can be immediate (minutes to 2 hours) or delayed (several hours to days after exposure).

Immediate symptoms can include:

• Itching of mouth, lips, tongue, throat, eyes, nose, skin, or other areas
• Swelling of lips, tongue, eyelids, or the whole face
• Difficulty swallowing
• Nausea and/or vomiting
• Wheezing and/or shortness of breath
• Hives

The most serious immediate allergic reaction is anaphylaxis. This is a whole body allergic reaction that can result in trouble breathing and reduced blood flow and requires immediate medical attention. Symptoms of this sudden, potentially life- threatening allergic reaction include:

• Hoarseness
• A feeling of tightness in the throat
• Difficulty breathing
• Any combination of symptoms from two or more of the body systems, such as hives and stomach pain

If your child is experiencing anaphylaxis, use an auto-injectable epinephrine device immediately and call 911.

Symptoms of delayed reactions to foods can include:

• Abdominal pain and/or stomach cramps
• Poor appetite
• Diarrhea
• Eczema or rash

Even severe allergies are manageable if diagnosed properly. More information is available on food allergies. If you think your child has an allergy, contact your pediatrician or the Children’s Colorado Allergy Program.

Dan Atkins, MD/DO, Children’s Hospital Colorado Allergy and Immunology

David M. Fleischer, MD, Associate Professor - Pediatric Allergy Department, University of Colorado Denver School of Medicine, Children’s Hospital Colorado

Summer time is vacation time – even for families with toddlers!  Keep the following in mind as you get ready and everyone will have an enjoyable trip.

Keep it Simple

Toddlers do better when you have one destination per day or only one or two activities per day. Traveling from home to your destination is plenty for the first day.  Save the beach or that visit with cousins for the next day when your kiddo is rested and ready to go.

Be Prepared

For a day excursion, even if it’s just for a few hours, bring a change of clothes, a familiar sippy cup and a special toy or blankie. Pack snacks for twice as long as trip is scheduled to take (just in case of delays) and bring baby wipes. Even if your child is potty-trained, baby wipes are great for cleaning up spills, fingers and surfaces. Knowing you’re well-prepared will help you relax and that helps your toddler feel comfortable.

Schedule Intentionally

As much as you can, plan your trip or activities to match your toddler’s schedule.  Drive time at naptime helps everyone arrive refreshed and ready for adventure!

Attitude is Everything

Start your trip with a positive attitude.  Expect everything will take longer. Plan accordingly and you’ll be less stressed.  If you’re at ease, your child will be too!

Destination Expectation

Plan ahead with your family, friends or hotel to make sure you and your child have what you need. Is there an appropriate place for your child to sleep?  If a home is not baby-proofed, are a few rooms safe for your child to play and explore?

There are endless tips and suggestions online for traveling with children of all ages.  Pick the ones that make sense for your family and have a great trip!

Ayelet Talmi, Ph.D., IMH-E® (IV-C), Associate Professor, Departments of Psychiatry and Pediatrics Associate Director, Irving Harris Program in Child Development and Infant Mental Health University of Colorado School of Medicine