The Montreal Children's Hospital

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Ask the expert

DR. RICHARD HABER, DIRECTOR OF THE PEDIATRIC CONSULTATION CENTRE, ANSWERS QUESTIONS WE RECEIVE FROM PARENTS THROUGH OUR E-NEWSLETTER WHERE KIDS COME FIRST

Q: My toddler has been going to the potty for two weeks to pee. However, she doesn't ever want to pass stool on the potty or the toilet, and only has bowel movements in her diaper or while she is sleeping. It almost seems like she is holding it in all the time and she becomes constipated. What can I do?

A: The age of your toddler is not mentioned but I am guessing around 2-2.5 years old. As you are attempting to ‘potty train’ your child, withholding stool or retentive behaviour is not uncommon. Nor is it uncommon for a child to be trained for urine and not stool. Naturally, if the child is displaying retentive behaviour she will become constipated. Again this is not uncommon and I see many children with constipation which began at the time of ‘potty training’. Selma H. Fraiberg, a child psychiatrist, describes what is going through the mind of a child who is being potty trained in her wonderful book, The Magic Years. It goes something like this: whenever I have a stool in the toilet my mother or father, the sun of my existence, tells me what a good little girl I am because I have produced this wonderful thing in the toilet—why then do they flush it away? If my stool, something wonderful I have produced, can be flushed away, then that horrible vortex of water could also flush me away! My advice is as follows. First, if your child is reluctant to stool in the toilet/potty then leave her be for a time. Then, gently try a program of putting her on the toilet after each meal for a few minutes to try and develop a regular time for a bowel movement. Be relaxed about it and when nothing happens let her jump off the toilet. Once a time is established try to make certain that you encourage your child to go to the bathroom at this time each day. If you see her manifesting retentive behaviour, try and gently lead her to the bathroom and place her on the toilet. Do not overly praise her if she succeeds in stooling in the toilet and do not punish her for failing to do so. Another counsel is to take the child to the bathroom with you when you are toileting to let her see that this is a normal and natural part of our lives and there is nothing to be afraid about. Some small details that are important: if you use a potty seat on the toilet, make sure your toddler has a little stool (piece of furniture not the bowel movement!!) to place her feet on as this makes performing a valsalva movement (forcing down when we evacuate our bowels) possible. Finally, encourage lots of fruit and vegetables (lots of fiber) to keep the stool soft and easily passed. Take courage 99.9% of children eventually become trained for both urine and stool!

Q: At home, we’re in the habit of having a glass of wine with dinner. Since our daughter turned 16, she has been asking us if she’s allowed to have a glass too. When we say no, she comes back with the well-known argument that a glass of red wine per day is good for the heart. Is this true?

A: A modest intake of red wine has been shown to have benefical health effects. I do not think it is harmful for your 16 year old to have one glass of wine with you during meals together . This will teach your daughter the proper use of alcohol in a social context; better that she drink it with you than binge drink with her friends on weekends. I would not recommend this on a daily basis but perhaps reserve it for weekend meals together and special occasions. A 16 year old needs to have her wits about her as she deals with homework and school projects during the week. I think you should be happy that your daughter communicates with you and trusts you enough to make such a request. You must be doing something right!"

Q: If we get our daughter's ears pierced, is there a risk that she'll get hepatitis B or C?

A: This is an excellent question and raises some interesting issues. I will broaden your question to include not only simple ear piercing but also body art in general. It is clear that body piercings and tattoos have spread more widely in our culture and are more accepted by the mainstream.

Tattooing and body piercings have a long history in multiple cultures and there is archaeological evidence for body art going as far back as 60000 BC. In Europe the practice of body art died out by the 17th century but it started up again among sailors in the 18th century who often had their ear pierced for an earring. Since this population was generally associated with unacceptable behaviours (alcoholism, brawls, debauchery etc), piercings began to be associated with unsavoury characters and criminals. Since the 80’s and 90’s, however, body art has become more popular in Western culture and has become socially more acceptable.

However there are medical complications associated with it, including infections such as Hepatitis B and C, HIV, staphylococcal infections, Pseudomonas infections and others. As well, depending on the body site pierced there can be complications of bleeding, cyst formation, dental problems among others. Complications associated with piercing the soft part of the ear can be: infections, bleeding, keloid scars, and cyst formation. Contact dermatitis is not uncommon particularly with nickel earrings but it may occur even with gold earrings. Generally these reactions are mild but sometimes may be more serious causing diseases such as bacterial endocarditis (infection of the heart). One study reported a 30% complication rate from simple ear piercing, the most common being minor infection, followed by allergic reaction. If the cartilaginous part of the ear is pierced there can be destruction of cartilage requiring plastic surgery to correct the defect. The Centers for Disease Control and Prevention lists the practices that need to be followed in order to avoid the infectious complications from piercings and tattoos. http://www.cdc.gov/Features/BodyArt/

More specifically in answer to your question it would be wise to be immunized against Hepatitis B before considering piercings. Regardless of the age of piercing, one should only have it done in a facility that uses sterile techniques(see CDC guidelines). If you can’t be sure that these guidelines are followed then avoid that facility and look for one that does. I have one last comment. What should be the age for ear piercing? There is no easy answer to this question but since it is really a cosmetic procedure, shouldn’t we wait until the child is old enough to express an opinion and give informed consent??

Q: My son is a young teenager in high school with a severe peanut/nut allergy. I have been told these are the dangerous years. Now how can I help him avoid contact through a shared desk, computer, banister? He does not put his hands in his mouth, yet washing his hands extensively has caused his eczema to explode, and I am really worried about the peanut contact. - A.

A: I certainly understand your concern for your son. While it is true that peanut allergy is one of the more severe allergies, we have to use our judgment because we cannot put your son in a ‘bubble’ and protect him from every possible exposure. The most severe allergic reaction is anaphylaxis and this only occurs after peanut antigen is introduced to a mucosal surface such as the mouth or respiratory tract. While we have all heard apocryphal stories of someone having a severe anaphylactic reaction and dying after touching a surface, there are no case reports documenting this. In one study, children allergic to peanut had peanut butter painted on their backs. There were no anaphylactic reactions. The reaction that was seen was a rash where the peanut butter had been applied. What can you do? First,washing with soap and water will remove peanut antigen from the hands. Secondly,your son must certainly avoid foods offered to him by a friend and in the school cafeteria he can make certain that there is no peanut sauce involved . In my opinion, the most important precaution is making certain that your son carries with him an epinephrine auto-injector such as an Epipen or Twinjet. He must know how to use it and your allergist can certainly help with educating him. In one study, a large number of allergic individuals, having an allergic reaction, failed to use their Epipen even though they had one. The message is: don’t hesitate to use the Epipen or Twinjet if you think you are having a reaction; if it turned out not to be necessary, no harm done but if it were necessary it could be life saving! Taking the above precautions, your son should be able to participate fully in his school activities with minimal risk of a serious reaction.

Q: My 29-month-old son has recently become afraid of the moon. It probably started because of a scary scene he saw in a kids' movie that had a bright light in it that he called the moon. Now he is scared to look outside the windows at night or walk outside in the dark if he sees the moon in the sky. What is the best way to help him deal with this fear? Should we simply console him and wait for him to outgrow it? - Anita, Mom

A: I would not make too much of this "phobia" as it will undoubtedly pass. One way of desensitizing your son would be to buy a children's book, e.g. nursery rhymes, featuring colourful pictures of a happy, anthropomorphic moon and reading to him pointing out the benign nature of the moon. Another suggestion would be to use a colourful yellow ball and call it the moon and play with him using the "moon". If he does act fearfully when he sees the moon outside, console him and reassure him that the moon is a friendly "person".

Q: My little girl who is 18 months old had an infection on her vulva; I applied an antifungal ointment and a cortisone cream prescribed by her doctor (3 days for the cortisone and 3 weeks for the other one). It stopped the infection but from time to time there are little dots that appear. I reapply the antifungal and when there are red spots, the cortisone. Will these go away once she is out of diapers? Am I doing the right thing by reapplying the cream even if I haven’t been back to see her doctor?Irina, Blainville

A: Diaper rashes are very common in infants wearing diapers. Most of these are caused by the ‘burning’ effect of stool and urine which together form an acidic mixture. This can lead to erosions of the skin and redness. The diaper area is also warm and humid and an ideal habitat for candida . A simple diaper rash can become overgrown with candida causing a fungal rash which is usually more confluent and redder. General measures for dealing with a diaper rash are frequent diaper changes, washing the area with mild soap and warm water and applying a barrier cream, the commonest of which is zinc oxide. Zinc oxide is contained in varying percentages in most common diaper creams. If your doctor diagnoses a fungal diaper rash then one can apply an anti-fungal cream on top of which one can apply zinc oxide. Usually one treats the fungal diaper rash until it resolves and then you return to the simpler measures mentioned above. Steroid creams may be added to the antifungal cream to reduce the redness and irritation but should not be used alone for long periods of time. With these simple measures most diaper rashes resolve easily. Of course, once the child is out of diapers the problem of ‘diaper rash’ disappears.

Q: Hi! Great idea to have "Ask the expert". Is it dangerous to let your toddler watch videos on the laptop? Is there any radiation or anything that could be bad for him? My son loves videos of cats but my wife says it can be bad, same for cell phones...What does the expert think? – Yorge, Dad

A: There is no strong evidence that computer or television screens are dangerous from the point of view of electromagnetic radiations. HOWEVER, there are major concerns about the influence of TV, computers and internet on the psychosocial development of toddlers, children and adolescents which have nothing to do with ‘radiation’. Recent Canadian Pediatric Society Guidelines (www.cps.ca) suggest that, from a developmental point of view, toddlers 2 years and under should not be placed in front of television/computer screens. Television programs do not enhance development and may be detrimental if a parent uses the television as a means of amusing the child or for ‘babysitting’ purposes instead of being with and present for the toddler. Babies develop best through their contact with a loving, nurturing adult. For older children, one hour of screen time per day is the current recommendation (screen time = TV, computer, video games, etc.). There is evidence that older children are influenced by the content of many television programs to be more aggressive or more sexually promiscuous (teenagers). Sitting with your child while watching a television program is a better idea since you're in a position to provide a counter-balance to the material presented. There is also evidence linking obesity to screen time. Raising children in this new communication era with computers, internet and smart phones is particularly challenging for parents with adolescents who are at risk of predators using the internet to lure children and adolescents into dangerous situations.

Q: Hello. I have a 13-month-old baby that eats really well; should I give him vtamins?
Thanks

A: For a healthy child with a normal diet there is no need to give vitamins. There is no ‘vitamin pill’ that can replace a normal healthy diet rich in fruits and vegetables. Having said that, there is an argument for giving additional Vitamin D during the winter months in our northern latitude. I would recommend Vitamin D 400IU per day.

Q: My teen (14) was a very happy child, but since the begining of the school year she became very serious, closed, doesn't laugh as she used to, eats less. How do you know if it's depression? - B.T., Beaconsfield

A: Depression is common among adolescents. The symptoms you are describing suggest a mood disorder and she should be evaluated by your pediatrician or family doctor. Here are some books dealing with the topic of depression in adolescents: “Helping Your Teenager Beat Depression: A problem-solving approach for families” by Katharina Manassis and Anne Marie Levac, Woodbine House, 2004; and “Rescuing Your Teenager from Depression” by Norman T. Berlinger, Collin Living, 2005.

Q: At what age should a child start to go to the dentist? - Liz, Mtl

A: I would suggest that a first visit should be around the age of 12 months. This is an opportunity for the dentist to meet your child and provide prophylactic fluoride treatment as well as giving advice about good dental hygiene.

Q: Hello. I am constantly thinking about what I need to do with my son. My son is 18 months old and therefore I do not know if we should get him vaccinated. What is the opinion of the Children’s Hospital?

Thank You.

A: Children appear to be more susceptible to the H1N1 virus and the best thing you could do to protect your son would be to have him vaccinated as soon as possible. You can consult www.pandemiequebec.gouv.qc.ca to locate the clinic nearest to your home.

Q: My grandson turned one on November 4 and we celebrated his birthday on the 1^st. We noticed that when he wants to see things higher up he’s lifting his head and his neck up instead of looking up with his eyes. When we’re sitting at his level though, everything is fine. Is there a problem with his eyes, or his eyelids? His eyesight is very good otherwise. Thank you, - Jean, grandfather

A: Without examining your grandson it is difficult to give a precise answer. Although he sees well, your description suggests an abnormality of the nerves/muscles involved in eye movement. I would certainly recommend that you consult a pediatrician and/or pediatric ophthalmologist (you would need to get a referral from your pediatrician for this).

Q: My little 13 month old puts her finger in her throat as she was going to make herself vomit. She seems to find it funny, since she laughs. We find it troubling! Why is she doing that? – Carmen, Laval

A: Self-induced vomiting in a toddler or young child is known as rumination. It is considered as a self-gratifying type of behaviour and is usually benign. The infants are not sick and appear to enjoy the vomiting. The literature reports that sometimes rumination is linked to some disturbance in the mother-child relationship. Without knowing more about your situation, one can only speculate. Perhaps this began when mother returned to her employment and the child was put in Daycare or perhaps there has been a major change in the family. If there is an underlying psychosocial cause, then addressing it should correct the situation. This should be discussed with the child’s physician to make certain the child’s growth is normal and there are no nutritional deficiencies caused by the rumination.

Q: My son is two years old. He is very solitary. I'm afraid this will not help him as he grows up. What can I do? – Gwen, Montreal

A: The answer to your question is difficult without more information. The diagnosis ranges between shyness (a temperamental characteristic) and a developmental problem. Does he have difficulties with social communication in the family? Outside the family? Is his language development normal? Does he hear well? Is his overall development normal? Are there any psychosocial problems in the family? Perhaps the best solution would be to first have him evaluated by a pediatrician in order to rule out any developmental disorders that require intervention. If this evaluation is normal, then your son’s shyness is part temperament and part immaturity that should improve with maturation.

Q. Hello. What do you think about a girl that is almost 2, doesn't have any hearing problems, that understands all we say, that can point objects we call but only says mama, caca and papa. She communicates by babbling and gestures!

Thanks in advance!

A: In your description of your two-year-old girl, she appears to have a few single words, “mama” “caca” “papa” but no two-word phrases although she does babble and express herself with gestures. She also understands well. She also hears well and sees well. Does she respond to her name? Is she exposed to more than one language? My opinion is that she is probably within normal limits for language development and my expectation is that she will gradually increase her vocabulary and phrases over the next six months. If this does not occur then definitely an assessment by a speech and language pathologist would be indicated. As well, although you believe she hears well, it would be prudent to consider a hearing test to be certain.

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