Foreskin, Feeding Transitions, Temper Tantrums – PediaCast 182

Join Dr. Mike as he discusses the flu vaccine preventing death, the rise of child abuse during the recession, switching kids to low-fat milk, talking about obesity, college student sleeping habits, foreskin care, feeding transitions, and toddler temper tantrums.  

Topics

  • Flu Vaccines Prevent Death

  • Child Abuse Rises with Economic Recession

  • Switch Kids to Low-Fat Milk

  • Parents Find It Difficult to Talk About Obesity

  • College Student Sleep Habits

  • Foreskin Care

  • Feeding Transitions

  • Toddler Temper Tantrums

Transcript

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. I'd like to welcome all of you to the show. We're calling this one 'Foreskin, Feeding Transitions, and Temper Tantrums'.

Now, from the title, you'd think it's an all-baby/toddler show, but we're actually going to talk about older kids and even college students, too, so stay tuned, we've got a little something for everybody. Obviously, this is a news and listener edition of the program, so we're going to talk about News Parents Can Use and answer some of your questions.

01:09

Before we do that, though, a little bit on feedback. A couple of shows ago I had asked for feedback on the program, and I continue to ask for it because we want to make PediaCast the best show it can be. Lots of you have great ideas and we like to hear from you.

So far, I've heard that you like the shorter shows. We were sometimes doing hour-long or hour-and-fifteen-minute-long megashows with news and listener questions and interviews and research topics, you get the picture. But we've moved to the shorter format with 20-to-30-minute shows with the interviews and 30-to-40-minute shows when we do the news and listener questions. So we're going to stick with that.

I also heard, while you enjoy the interviews, you'd like more of the news and listener episodes. So we have another one of those for you today, and of course we'll continue to crank out both types of programs just as fast as we can.

02:09

Of course, we need your help to do that. In particular, we need show ideas. So if you have a question or topic, make sure you let us know. I'll run down the list on exactly how to get in touch with us in just a couple of minutes.

So, Fall. Autumn has arrived and the kids are back in school. I love fall. It's just a great time here in the Midwest, and those of you in New England and in the Smoky Mountains and these regions of the country, Fall is just a wonderful time of the year. I've never been to Boston in the Fall. I need to change that. I'd like to see New England in the Fall. Really, I would.

Corn mazes, apple cider, white-powdered donuts, Pumpkin Spice Latte from Starbucks, these are just a few of my favorite Fall things. I always talk about getting out there and doing stuff with your kids. If you are in the Midwest, and other parts of the country where corn is grown, corn mazes are great.

03:10

Now, when we lived in Ohio before we moved to Florida, we did corn mazes. And then when we got to Florida, we found out that there was a corn maze. So we were like, 'Hey, cool. This is like a fun throwback to Ohio. Let's go do it.' Well, you could practically see above the corn, because corn in Florida isn't like corn in Ohio, or corn in Iowa. You know what I'm saying?

So get out there, have fun, do some fun Fall things before the season slips us by and it's Winter.

All right. What are we going to talk about today?

The flu vaccine can prevent death. Child abuse is on the rise with the economic recession. Also, you should be switching your kids to low-fat milk, but when do you do it? Parents find it difficult to talk about obesity. We're going to discuss college student sleep habits, and then we're going to answer listener questions about foreskin care, feeding transitions, bottle to sippy cup and breast milk to cow's milk, those kind of transitions, how do you go about doing that, and then finally we'll wrap things up with the all-important and pervasive topic of toddler temper tantrums. That's coming your way.

04:22

If you would like to contribute to the show with an idea or a question or a comment, it's easy to get a hold of me, and I do read each and every one of your comments and questions. Just go to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com. If you do that, let us know your name and location. The Skype line is also open. In fact, we're going to have one of our listener questions from that today. You can get a hold of me, 347-404-KIDS. That's 347, 404, K-I-D-S.

I also want to mention, over at pediacast.org, we do have a brand new website with a great search function that has been missing as a PediaCast resource for a while, because our search function just didn't work that well with all the shows and topics that we've had in the past. But the new site has a wonderful search function, so check that out if you haven't. If there's a topic you want to hear about, just search for it, and hopefully the correct episodes will pop up for you.

05:19

We also have a new resources page with some helpful links and a new PediaCast flyer that you can download and print out in PDF form to hang up in doctors' offices, daycare centers, the Y, wherever you would like to help spread the word about PediaCast. In the show outro at the end, we'll talk a little bit more about that.

Before we get to the news, I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

06:04

And with all that in mind, we will be back to cover News Parents Can Use, right after this.

[Music]

Dr. Mike Patrick: All right, we are back to cover some news.

Influenza resulted in 115 child deaths in 2010. According to a report from the Centers for Disease Control, the majority of these deaths might have been prevented. How, you ask? Well, with something as simple as a flu shot. That's right. More than three-quarters of childhood influenza deaths occurred in kids who were not immunized.

07:00

Now, we know certain medical conditions make serious illness and death from the flu more likely, conditions like asthma, cystic fibrosis, diabetes, and heart disease are good examples, and in the past, we've encouraged parents who have children with these illnesses to be sure that they get their kids a yearly flu shot.

Now in the last couple of years, we've recommended yearly flu vaccine for all kids six months and older, even those who are healthy with absolutely no underlying medical conditions. So why is that? Well, it's because half of all childhood influenza deaths occur in healthy kids with no underlying medical problems, and, as it turns out, most of these healthy kids who died from the flu had not been given a flu vaccine.

So let's save some lives in the upcoming 2011-2012 flu season. Moms and dads, most doctor offices have or will soon have their supply of flu vaccine, both the injection type and the FluMist intranasal type, so be sure to have your children vaccinated before flu season hits, even if your kids are healthy.

We have more on the flu coming your way soon. Early next month, Dr. Dennis Cunningham, an infectious disease specialist here at Nationwide Children's, will be stopping by the PediaCast studio to talk more about influenza. So stay tuned for that.

08:12

Child abuse is on the rise, and it appears the culprit could be the economy. A study appearing in this month's issue of the journal "Pediatrics" looked at hospital data from kids under the age of five in Kentucky, Ohio, Pennsylvania, and Washington, and their data included kids from here at Nationwide Children's Hospital.

They looked between 2004 and 2009, and 422 of these children with an average age of nine months were diagnosed with abusive head trauma. The majority ended up in an intensive care unit and 16% of the kids died from their injuries.

Researchers separated their data into two groups, those who were injured prior to the economic crash, which they defined as December 2007, and those who were injured after the crash.

Here's what they found: the rate of abusive head trauma prior to December 2007 was 8.9 cases per year per 100,000 kids. During the recession, that number jumped to 14.7 cases per year per 100,000 children.

09:10

Dr. Rachel Berger, a child abuse expert at Children's Hospital of Pittsburgh and co-author of the study, admits the exact nature of the relationship between the increased cases of abusive head injury and the economy remain unclear.

She surmises, however, that having fewer resources in an economic downturn leads to more stress and it might be forcing more moms to leave their babies in the care of others, including fathers and male caretakers. Men are known to be the most common perpetrators of child abuse and simply aren't prepared to deal with the baby who cries and cries and cries. This leads to baby being shaken and struck in the head, which is the primary cause of abusive head injury.

As a reminder, when a baby is crying and crying and crying and you've met their basic needs, so they aren't in pain, they're not hungry, they don't need the diaper change, they're not sick, they're not having trouble breathing, then there's nothing wrong with putting them in a safe place like their crib and walking away, although not too far, and letting them cry. And that's a far, far better approach than shaking or hitting them.

10:11

More to come on child abuse; very soon, in fact. Next week, Dr. Jonathan Thackeray, Nationwide Children's very own expert on child abuse, will be stopping by the PediaCast studio to talk more about it.

We have another report from the CDC, this one involving milk.

Seventy-three percent of children and teens regularly drink milk, but only 20% of them choose low-fat milk defined as skim or 1 percent. Milk is an important source of calcium, vitamin D and other nutrients, but too many kids over the age of two and teenagers choose whole milk or 2 percent milk, and that's contributing to the obesity problem faced by many kids.

The report also showed ethnicity and income play a role in milk choice. White children drink low-fat milk more often than black or Hispanic children, and those in higher-income groups drink low-fat milk more often than those in low-income groups.

11:00

In summary, the report's authors state, quote, "The overall low consumption of low-fat milk suggests the majority of children and adolescents do not adhere to recommendations by the 2010 Dietary Guidelines for Americans and the American Academy of Pediatrics." These guidelines advise parents to switch their kids to low-fat milk, which, again, is skim or 1 percent, at age two.

So moms and dads, what type of milk are your kids are drinking? If they're over the age of two and they're drinking 2 percent milk or whole milk, you might be contributing to their obesity problem. Of course, be sure to discuss milk selection with your pediatrician because there are instances when your doctor would like you to use 2 percent or whole milk for a longer period of time.

One more thing, I realize the jump from whole milk to skim milk is a big one for many people. Whole milk is 3.25% milk fat, and if you're using that now, it's a huge leap to go from whole milk to skim milk. So you may want to adjust down to 2 percent first for a couple of months and then go down to 1 percent for a couple of months, and then try skim.

12:03

Whole milk and skim milk are completely different both in taste and thickness, I get that. So adjust slowly, but you'll get used to it. Really, you will. And your heart and your blood vessels, and your waistline, will thank you.

Speaking of the obesity problem in America, it turns out most parents don't like discussing healthy weight with their kids. A WebMD-Stanford study surveyed 1,299 parents with kids between the ages of eight and 17 and 1,078 eight-to-17-year-olds. What did they find? Well, for parents and kids, talking about weight is difficult. In fact, it's more difficult than talking about sex, smoking, drugs or alcohol. Wow.

Despite their low comfort level, many parents do worry about their kids' weight. Thirty-seven percent believe overweight is a real risk for their kids. That's more than the number who worry about drugs and alcohol, and nearly as many as those who worry about alcohol and sex. Oh, I said that wrong. I'm sorry. Thirty-seven percent believe overweight is a real risk for their kids. Actually, that's more than those who worry about drugs and smoking, and nearly as many as who worry about alcohol and sex. Sorry about that.

13:10

Why are parents uncomfortable talking about weight? Well, many don't want to hurt their kids' feelings or damage their self-esteem. Parents don't know how to talk to their kids about weight, and many are worried the discussion will lead to an eating disorder.

How about the kids? Well, they don't want to talk about it, either. In fact, 72% of the kids surveyed said a weight discussion would be more embarrassing to them than it would be to their parent.

So who should do the talking? Well, 19% of parents said it's primarily the doctor's job, and that's compared to 1% who said doctors should take on sex, drugs and alcohol and 2% who said doctors should talk about smoking. I got my percentages right that time.

Doctors agree the topic is important, but they put the responsibility for it back on the parent. In a separate Medscape poll of 624 pediatricians, pediatric nurse practitioners and pediatric physician assistants, 90% named weight as one of the most important topics parents should discuss with their kids. That's more than named sex, drugs, alcohol or smoking.

14:10

OK, so we all agree it's an important topic. But nobody really wants to talk about it, which is one of the reasons obesity continues to be a very large issue in our society. Literally.

Look, I'm overweight. Seriously, I need to lose weight. I'm not grossly or morbidly obese, but I could lose 20 pounds easily. Many parents out there need to lose weight and lots of kids and teens out there need to lose weight as well. So it's time we all started talking and doing something about it, even though it is an uncomfortable discussion.

So how do you get started? Well, I say come together as a family. Don't single out a specific person. Approach it as a new family health plan. You're all going to do some things in your life to make yourselves healthier, to start new habits, and to do this as a family. And then talk to your doctor and continue the discussion amongst yourselves about how you can eat better, snack less, exercise more, all of you, together, as a family team. Don't focus on weight or a single person. Focus on healthy living and the weight will take care of itself.

15:15

Moving on to sleep and college students. According to a study published in "The Journal of American College Health", university students aren't getting enough sleep. The study was a joint effort between researchers at Brown University and the University of Arizona.

Thousands of online surveys from college students were collected. These surveys asked basic sleep questions such as when do you go to bed, how long do you sleep, how well do you sleep, what keeps you from sleeping, you get the picture. The surveys used the data to obtain a Pittsburgh Sleep Quality Index score for each participant. Any score higher than 5 indicates poor sleep.

So how well were the college students sleeping? Well, male students scored 6.38 on average while female students scored 6.69. So the answer, they were sleeping poorly.

16:00

The typical student bedtime was 12:40 am and students reported taking 20 to 30 minutes to fall asleep. Most woke between 8 and 8:30 in the morning and many reported sleeping less than seven hours each night. Common sleep obstacles included roommates, dorm noise, fraternity activities, and academic stress.

Now, despite these stats, 70% of the survey participants self-described their sleep habits as fairly good or better. Yeah, right. They are kidding themselves.

Next, researchers began a campus-wide media campaign on the benefits of good sleep hygiene. This included posters, student newspaper ads and newsletters with sleeping facts and better sleeping tips. The campaign told students that poor sleep undermines memory and concentration, it affects class attendance, and alters mood and enthusiasm.

Finally, researchers conducted another online survey in which 971 students participated. Ten percent of those respondents said the campaign helped. They went to bed earlier, they fell asleep faster, they stayed asleep longer, and their Pittsburgh Sleep Quality Index scores improved.

17:06

OK, so that's great for the 10% that the campaign helped. What about the other 90%? Well, apparently, they didn't get the message. Of course, I understand. I was a college student once. And if you were a college student once, you understand, too.

All right, that wraps up our News Parents Can Use. We are going to take a quick break and we will be back to answer your questions right after this.

[Music]

Dr. Mike Patrick: All right, welcome back to the program.

18:01

We have three listeners coming your way. The first one involves foreskin. This is kind of a touchy topic for parents who have kids that are circumcised in terms of adhesions, is in particular the question, and then there's also the issue of how to care for uncircumcised foreskins, which was not really brought up in the listener question, but I'm going to try to remember to mention something about that as well.

This question actually came in via Skype. I'm excited about that. We are getting some use on the Skype line. Not nearly enough, though, so if you have a question, makes sure you utilize that. At the beginning and then at the end of each show, we do go through the phone number that you call to leave a message.

So let's go to the Skype line. This is our listener's question on foreskin.

Listener: Hello, Dr. Mike. I just have a question concerning my six-month-old son. He was circumcised about a day after birth, and, long story short, we were told to retract the foreskin that was lost and he has developed adhesions, and explained that to our doctor. Well, the doctor did go through the process as far as retracting skin and kind of causing adhesion there along the head."

19:14

"I just want to find out, now it's been about two weeks since the doctor has done this and he's redeveloped the adhesions, and my husband and I are very confused as to different things that we've been hearing about from different folks as to whether it's good or not good to retract or if the adhesions will actually go away on their own as time goes on."

"I do have a 12-year-old nephew that evidently, because he wasn't retracted we're thinking, after having been circumcised right after birth, at the age of 10 had to have a surgery in which he had developed skin bridges. So my husband and I, again, just adding to the confusion, he had to go through a surgery where they had to cut skin because we're presuming it hadn't been retracted."

20:08

"I apologize. I know this is kind of a confusing call, but any information or advice you could give us on the topic would be greatly appreciated. Thank you. Bye-bye."

Dr. Mike Patrick: All right. Well, we really appreciate the listener for using the Skype line and calling in with the question. In the future, make sure you mention who you are and where you're from. But we're not going to chastise you too much, because we appreciate the question.

So the foreskin and adhesions. Do you retract? Do you not retract the foreskin? How aggressively do you retract? Do you do it to the point where it bleeds? Could it cause skin bridges and then surgery down the line? So we have lots of questions and things to think about here.

First, let me just start with sort of describing the problem and what most typically leads to a problem. When a baby is born and you have them circumcised, most of the time it looks great right after, well, not right after it's done because then it has to heal before it looks great, but once the healing process takes place, then it looks fine.

21:07

Sometimes what will happen as your baby grows, the foreskin starts to get pushed over the head of the penis or the glands and sort of that rim where the head is separated from the foreskin itself. It starts to push beyond that. The reason that happens is because a lot of baby boys will start to develop a fat pad over their pubic bone. So at the base of the penis, they'll get a little bit of fat.

Now, the shaft or the penis itself sort of internally is still attached down by the pubic bone, so the length of the penis is the same as it's been. But the foreskin, which is actually attached to the skin now that's on top of that fat pad, because of the fat pad, that elevates the foreskin and kind of pushes it so that it's longer and it starts to overlap the head of the penis. Depending on how big the fat pad becomes, it can really push so far forward it almost looks like your child's not even been circumcised anymore.

22:13

Now, as they get older, hopefully, as long as you switch them to low-fat milk and encourage other healthy habits, hopefully as time goes on they'll lose that fat pad, and then at that point, the skin goes back down, the foreskin basically returns to its original location as that fat pad goes away.

A lot of kids, the natural tendency is for the foreskin to start out in the right position, kind of move forward during infancy and toddlerhood and early childhood, and then into older childhood, it moves back to the original position, and then as an adult, everything looks great. That's very typical.

Now, one thing that can happen is that this foreskin, especially in infancy, toddlerhood and early childhood, the foreskin can start to move, when it's moving past the head, it can start to adhere to the head, and this is what we call adhesions.

23:18

This is where it becomes difficult what do you do about that, because most kids, I don't have the study to show this, but just anecdotally from my own practice, if you took hundreds of kids and they all had foreskin adhesions, most of them, if you do nothing, this problem is going to fix itself. The two layers that are adhering are sticky and stick together, but then as kids get older and they go through puberty, it becomes more of a slippery surface between those two and it sort of all un-sticks on its own and it's not a problem.

However, this is one of those situations where a small number of those kids are going to have problems, and what can happen then is the adhesion becomes a more permanent fixture, and actually the two layers' epithiliis, there's new epithelialization, so new skin growth that's bridging where the adhesion is. It's not just mucosa that has bonded together that can separate but it's actually skin now is growing.

24:25

And then what can happen is erections can become difficult and painful because of these skin bridges when the penis needs to elongate. And then often you have to have surgery to fix those. So you want to avoid that. But at the same time, you have to realize that most kids with adhesions, that's not going to happen.

Then the question becomes, what do you do about this?

Well, I think that if you want to avoid the chance of the skin bridges and possible surgery in the future, then the best thing to do is when you first notice that the foreskin is adhering to the glands, to the tip of the penis, is just, when you change the diaper, gently pull it back, put a little layer of Vaseline around it so that as it overlaps, there's a nice slippery surface, and that keeps it from adhering.

25:18

Now the question becomes, what if you don't do that, and now you do have adhesions?

Well, you can gently pull back. Use the Vaseline to try to prevent the adhesions from being there. But what do you do when it's really adhered? I would say the best thing to do is talk to your doctor about that. Pediatricians in the office will feel comfortable, especially in younger kids, being a little bit more aggressive in pulling back those adhesions sometimes to the point where there is some bleeding.

Now you don't necessarily want to yank on it and be real aggressive with it at home without talking to your doctor and your doctor's showing you an appropriate way to do it. So this is something to discuss between you and your doctor, and if it needs to be done more aggressively to the point where there's going to be bleeding, let your doctor take care of that, and then, to prevent that from happening again, again, using the Vaseline to create that slippery surface so that the two layers can slide against each other rather than sticking together.

26:18

Now, what do you do if your doctor can't do it aggressively or they try and it starts to bleed quite a bit so they want to stop what they're doing, or sometimes we'll have kids, who, they adhere and it self-reduces in one location and it's raw and bleeding and you really want to just try to get the rest of it down but your doctor's having a hard time with it?

Sometimes a steroid cream can be used. This is the same thing with, and I think we've talked about this in the past, with labial adhesions. But the only thing that you're doing with that is you are kind of mimicking what happens in puberty. And remember I said when kids go through puberty, a lot of times the layers become less sticky, more slippery, and they're able to more naturally slide against each other, not stick together.

27:08

So what you're doing when you use a steroid cream, and it's a special steroid cream, not one that you buy over the counter, so this is something that would have to be done in conjunction with your doctor, but using the steroid cream can help change those layers so that they become more slippery and it stops being a problem.

The only issue with that is, once you stop using the steroid cream, the layers go back to how they were before and they become sticky again, so sometimes you'll have kids who kind of go in and out of the adhesion process and needing the steroid cream and then not needing it and then needing it, and if you have to use the steroid cream too much, that can cause side effects and problems as well.

So there's lots to consider with risks and benefits and talking to your doctor, and there's not necessarily one single approach that's the right approach. It really is going to take an individual's situation, the parents' comfort level, how much do they want these adhesions to be broken apart.

28:04

Now, sometimes kids begin to have lots of problems with the adhesions and they keep recurring, they keep breaking, causing pain, causing bleeding, so sometimes they do need to see a urologist, which your pediatrician can refer you to, and then sometimes they become so severe that a skin bridge occurs, so the adhesion becomes more than just mucosal layer stuck together but actually new skin and new epithelium that bridges the shaft and the glands, and then as they get older when there's erections, that can become painful and problems, and those need to be oftentimes corrected surgically.

So, again, I kind of feel like I'm beating around the bush here a little bit. It's an important topic. There's not one answer and that your best advice is when you're having these issues is discuss it with your pediatrician who can see what these adhesions look like in your kids and come up with sort of an action plan for dealing with them.

29:05

Probably the easiest approach is, right from the get-go, pulling back on that foreskin and creating a slippery layer with the Vaseline just to prevent the whole process to begin with.

Now, I did mention that we had talked a little bit about uncircumcised kids, too, and foreskin care, and I think, if memory serves me right, that we talked about that not too long ago. Although I had a discussion with an actual patient. I don't remember. [Laughter] Sometimes, PediaCast and my own clinical practice sort of blend in my head and I can't remember where I talked about something.

But foreskin in babies, I think that you create, there's less issues down the road if you do, right from a fairly early age, start retracting that foreskin and start pulling it back, exposing the glands, a little Vaseline here and there, and just keeping things sort of apart and slippery.

Now sometimes that doesn't happen and things do get stuck together. In that case, you don't want to force anything. You want it to be kind of a natural separation, and that's going to happen as they get older and, again, go through puberty.

30:11

So basically, you can have mega-adhesions when you're uncircumcised, and probably the best approach is to not allow those adhesions to happen in the first place. When you give them a bath, you just pull back as far as you can, a little Vaseline, and then pull it back forward again, and get them as they get older to get used to doing that on their own to help keep it separated.

But again, if that doesn't happen and it does become adhered, you don't want to force things. You certainly don't want to force it to the point you retract and then it gets stuck behind the glands, because that can cause a serious medical condition called paraphimosis, and we want to avoid that.

So this is just something with kids' foreskin that, again, it's different from case to case depending on your child's situation. If you have questions about, make sure you talk to your doctor when you go in for your next visit.

31:04

All, right, we are going to move on from foreskin to transition from formula bottles to sippy cups and from breast milk to cow's milk.

This question comes from Theresa in Lawrenceville, Georgia. Theresa says, "My son is about to turn one and I'm happy to continue nursing at home but so ready to stop pumping at work. However, I'm worried how to make the transition from bottles of warm breast milk to cups of cold cow's milk. Some people seem to suggest mixing the two and gradually shifting concentrations while others seem to treat it as a completely new and different thing to introduce."

"He has been offered a sippy cup of water a couple of times a day for the past few months, but he doesn't really seem very interested in learning to drink from it, although he does like to teeth on the spout when it's ice-cold. As for the cow's milk transition, he loves yogurt and cheese and has had no adverse reactions to them, so I'm not really concerned about allergies or anything, but I don't know if he'll accept a sudden switch from warm breast milk to cold cow's milk."

32:06

"So I guess this is really a couple of questions. How do I teach him to drink from a cup, and what's the best way to transition from breast milk. Thanks, Theresa."

Well, thanks for the question, Theresa. Really, we have three transition issues here: breast milk to cow's milk, warm to cold, bottle to sippy cup.

I find with babies and children, and many adults as well, that it's best to change one thing at a time. In general, there are many of us who don't handle change very well, and the more drastic the change, the more resistance that we put up to it.

I also want to point out that there's no rush for any of these changes at 12 months. A lot of parents think, 'My kid's a year old. I've got them off the bottle. I've got to get them on the cow's milk. It's got to happen now.' Sometimes this proves to be difficult and takes a while, and you really shouldn't sweat it.

I would start with the switch from breast milk to cow's milk as the first one of these switches that you're going to make.

33:03

Now, again, must you do this at 12 months? No. If you want to do it at 12 months, is that OK? Yes. I'm going to go with the assumption here that you want to do it, since you wrote in and asked about it. The first thing I would do is just try it. In fact, I would try it cold, just in case. If he takes it, great. And you might even want to just put it in a sippy cup.

So here I've said, do one thing at a time, do it gradually, but you might want to just try it. Just try the cold cow's milk and the sippy cup and see what happens. The folks who are saying it's a new experience, it's definitely different than putting water in the sippy cup and maybe he'll get the hang of it, and you'll have done it all in one fell swoop.

Now, more than likely, it's not going to work out that way. I wouldn't beat yourself up over it if it doesn't work. And if it doesn't work, I wouldn't keep trying and trying and trying so that everyone is frustrated. Just try it a couple of times if it works great. It probably won't, and if it doesn't, then you go with the gradual way that we're going to talk about now. So I think most folks are going to need to do the one change at a time rule, but for some kids, you're not going to have to.

34:18

All right, how do you do this?

Well, I would probably keep it warm so you don't want to make that change. Keep it in a bottle. So really what we're doing now is switching warm breast milk in a bottle to warm cow's milk in a bottle. Again, I would just try the big switch from the breast milk to the cow's milk. If he does it, great, then you've saved yourself more of a headache, and if it doesn't work, then you start going into the gradually mixing it in.

How do you do that? Well, you start with a small amount of cow's milk. I'm always surprised how at kids can always tell the difference between taste and resist it, so it may not be a kind of thing where you can do half and half right away, either, or even three-quarters/one-quarter. You may have to start with 95% breast milk and 5% cow's milk, and do that for a week, and then go to 10% for a week, and then go to 15% for a week. You really just do it over a several-month period, and that's the way that your child will not be able to tell. You can fool them that way and gradually increase the proportions.

35:26

Now, I want to make another important point. The reason that we're doing this gradual change is simply for taste and preference in kids who are resistant to cow's milk. It's not like dogs and cats where you have to mix in a new food or they start vomiting and having intestinal problems.

Some babies do have a problem with cow's milk such as protein allergies or lactose intolerance, but those are things that can't be solved with gradual introduction. So it really is OK to try the big switch and see how it's received. You're not going to hurt their GI tract by doing that.

OK, once you've got them switched over from the breast milk to the cow's milk, warm and in a bottle, I think the next thing that you probably want to work on is going from warm to cold, although, again, you don't have it.

36:12

If your kid really likes the cow's milk warm and you don't mind warming it up, do that for as long as you want. I can guarantee you're not going to be warming up cow's milk in a bottle when they go to kindergarten. The transition's going to happen.

Again, there's not necessarily a rush to make it so that they're drinking cold milk. So keep doing it warm as long as you want. But when you get to the point when you want to stop giving it warm, then start giving it cold.

Again, you might get to the point where you just have to warm it up a little bit so that it's not warm-warm, it's just warm, and then it's just kind of warm. I'm trying to be careful here because none of us should be making it so hot that you're going to burn your baby's mouth or in the microwave. You understand that those are issues as well. So you just start making it a little less warm each time and working it that way, and pretty soon they'll be taking it cold.

37:05

And then, how do you go from bottle to sippy cup? This is probably the hardest one of all, in my experience.

Again, obviously kindergarten teachers aren't having kids showing up drinking their milk in sippy cups or in bottles or sippy cups. It happens. The transition is going to happen, and it doesn't have to be right when they're 12 months old. So keep that in mind.

Now, oftentimes you have to be creative with how you're going to do this. One thing that I found is that if you put the milk in the sippy cup and add a little bit of flavoring like Nestle strawberry flavor, vanilla flavor, chocolate flavor, now it's a novelty. The only time they get that is when it's in the sippy cup. Well, now the sippy cup becomes something 'Hey, I want to figure out because this stuff tastes really good.'

Now, the problem that parents face when doing this is now it's important, once you've got them on the sippy cup with the cool-flavored drink, is now you've got to wean the flavor off, and you really do need to do that because you're increasing their sugar, you're increasing their calories, and we all know that that can lead to obesity issues.

38:15

On the other hand, if you're using these things for a two-month period, you're not going to make them fat for life because you put Strawberry Quik in their milk for two months. But on the other hand, you're going to get a kid who now want their milk with strawberry in it in their sippy cup every time, and you're just going to have to wean out the amount that you put in. So make it a little bit less each time, and within a couple-month period you're going to have the flavor back out of there and they're going to be on the sippy cup. That's one idea.

You could, the only time you warm it is when it's in the sippy cup. OK, you can either drink cold milk in the bottle or warm milk in the sippy cup, and sometimes that's the incentive that a kid would need to go with the sippy cup rather than the milk. Again, there's no right or wrong, there's no one way to do this, and you really want to try to avoid the battle of the wills.

39:00

This happened to me when, I would've been a second-year resident when my first baby was going through this transition, when my daughter was, and she was a strong-willed, and is a strong-willed, person, and I remember a time when, 'OK, you are going to do the sippy cup. You're older now.' And she was older. She was probably 18 months older, maybe even almost two, and still went in the bottle. I know, so sue me. So we really wanted to make the sippy cup transition.

And I remember a day putting the sippy cup in front of her on a high chair and she threw it to the ground. I would pick it up, back it back on the high chair, and she would throw it to the ground. It was literally a battle of wills, and I'm pretty sure she won that night. You want to try to avoid that. Try what's going to be successful for your kid and be creative with it.

And each kid is going to be different. I've talked to some parents who say, 'You know what I did? I just got rid of the bottles.' So, yeah, they were upset. They only wanted the bottle, but they didn't get a bottle because there weren't any bottles in the house. I suspect that they probably did have some losing battles of will. But for some families, that's the way that they are able to get it done.

40:18

And you certainly don't want to resort to being angry and snapping or acting out at your child and abusing or neglecting them in some way, so you want to try to avoid the battles as best you can.

But, again, I think the key point is here a lot of parents feel like it has to be done now, and it isn't until they relax and just more go with the flow when the transition finally does occur.

Hope that helps, Theresa.

Let's move on to April in California. April says, "Hi, Dr. Mike. I have a very a high-energy two-and-a-half-year-old. He's cute as can be, but he's going through the terrible twos, if you will. It's been very interesting and difficult the last couple of months because my son, since day one, has always been a very calm and sweet boy."

41:00

"Now don't get me wrong. I love him to death, and I know I'm part of the problem because I'm new with this new parenting thing. But about two months ago, it seems like he completely changed. This kid can throw killer tantrums. I mean, full-out, screaming-bloody-murder tantrums. Once, while he was in timeout throwing one of these tantrums, he even stripped down naked. I know he's only two trying to figure out the world and learning how to deal with disappointment and continually striving for more autonomy."

"When he gets to this out-of-control point, I put him in his crib, zip up the crib tent, and let him take a short, OK, sometimes longer, timeout to cool off. It helps me, too, because I get to take a timeout as well because I get extremely frustrated and embarrassed when he acts this way. I only if I react, then it's only going to make it worse."

"Is there a better way to handle the situation? I try not to set him up for failure. For example, I don't go grocery-shopping when he's tired or hungry. I try to give him a heads-up before something's going to change. 'Two more minutes until we have to leave the park!' I try to give him choices. 'Do you want to walk down the stairs by yourself or you want mommy to carry you?' But I just don't know if I'm doing the right things."

42:06

"For instance, he was playing at a friend's house this morning, and when I went to pick him up, he threw this huge tantrum. And as we were leaving, I had to carry him, he's a big kid, down the stairs to our apartment all the while he's screaming and trying to escape my arms. He got away and ran away from me while I was trying to open our apartment door."

"So what are my choices? Well, I figured I had to chase him because he was close to a parking lot. So I chased the two-year-old down, he is fast, and picked him up and dragged him back up the stairs into our house, into his bed for a timeout, so we could both cool off. I was about to lose it."

"I know I need to learn better ways for handling these types of situations because my anger only makes it worse. Do you have any tips? I was browsing through all of your episodes trying to find an episode on toddler tantrums, but I couldn't find one. Have you already done one on this? If not, would you mind talking about it?"

"I know I'm not alone, well, I don't think I am, but sometimes I feel like my child is the only one that throws these extreme tantrums, especially because none of his little friends throw tantrums this large. Please help. April in California."

43:06

OK. April, lots of parents out there right now are smiling and nodding their head in a 'I feel your pain' kind of way. They know exactly what you're talking about.

I'll be honest with you, April. I really don't need to talk too much about toddler tantrums because your comments really sum up the whole talk. Seriously, you're doing all the right things, and this, too, shall pass.

I want to encourage listeners, if you are dealing with toddler tantrums, rewind and listen to April's words again because they're full of wisdom and I really do think she's doing things the right way. Those of you who don't want to rewind, keep listening because I'm just going to kind of break down what April said and what she's doing right and provide you some reassurance.

Toddler tantrums, who, what, when, where, why and how. Well, not all kids have them. Many do, and of course, if yours has them, you're not alone.

44:00

One of our kids had tantrums in a much more severe and often way than the other child. I won't mention which child that is, although my kids know. What you've described doesn't shock me at all, April, in terms of severity. We see these a lot. They do tend to occur in kids who are a little more high-spirited. And they're not only high-spirited as toddlers, they're high-spirited as children and as teenagers and as adults. I mean, it's their personality.

So for a lot of kids, it's just them learning to get themselves under control and learning to deal with disappointment, learning to communicate. A lot of times, tantrums happen because a child really feels like they can't communicate what they're trying to say and it leads to frustration. When they're tired, it happens more. And again, some kids are just more emotional than others and/or more ready to willingly demonstrate that emotion to you and to strangers. Again, there's the personality part of it.

45:07

I do want to point out these higher-strung, emotional kids have great points, too. They tend to be passionate about things as they get older. They demonstrate lots of affection. They're living life to the fullest. They're a really go-get-'em kid. There's lots of rewards also that go along with parenting a spirited child, but one of the downfalls are these severe temper tantrums.

Now, on the other hand, there are some kids who use temper tantrums as a tool. They know they're going to get when they throw one. It's really not as much a sense of frustration as a way that they know that they can get what they want, so they throw them often, and you see parents who give into these tantrums, and that just encourages them to continue to do them because it's working to get what they want.

Now, again, not all kids with tantrums is this the case. But those of us who deal with lots of young kids, the doctors, nurses, preschool teachers, they see this everyday and understand what I'm talking about. You really can get the sense when kids use tantrums at home to get what they want because then when we're around them, they do the same thing.

46:13

You see parents in the exam room, you see a kid having a tantrum, the mom gives them what they want, immediately they're quiet. Then you think, 'OK, this is maybe a problem for this family at their house' It's not so much of a frustrating inability-to-communicate kind of tantrum, it's a tantrum being used as a tool.

I don't think that sounds like what's going on with you, April, because the way you described this, you're not giving into the tantrums. You're providing him a safe place to have his tantrum and then reconnecting with him when the tantrum is over. And that, I really think, is the right way to go about this, because when you give in, you are reinforcing that behavior because the child's using it as a tool.

I like that you're putting him in a safe place, so in his crib with the crib tent, and you're letting him have his tantrum, and once it's over then it's important to reconnect in a loving way after he settles down.

47:06

And sometimes, what they're having a tantrum over is something you really don't mind them having, but now they're having this tantrum and you're like, OK, fine, they want this toy. 'It's fine that they have this toy, but I don't like the fact that this is the approach that they use to get it.'

Sometimes for those kids, again, you put them in a safe place, let them have their tantrum, and when they cool down, say, 'I love you. This is more appropriate behavior. Here, you can have the toy,' and ask nicely for it. Sometimes you can start to change those behaviors when they realize that the tantrum isn't going to get them what they want. Again, this is when kids are using it for a tool and not so much out of frustration.

So my point here, I guess, April, is I really feel like you're not doing it wrong. You're doing it right. When they're having the tantrum, you put them in that safe place.

The other thing that you're doing right, April, is recognizing what sets off your child and trying to head off the tantrum by not going to the grocery store when he's tired or hungry, by giving him choices, 'OK, we have to go down these stairs. That's not the option, but I'll give you some options on how you can go down these stairs.'

48:17

It's not an option of whether you are going to watch TV or play with toys or a game but you can pick which toys or game. I mean, you're giving them options, giving them some autonomy but with appropriate choices and kind of guiding them that way. That takes skill and practice and sometimes lots of creativity to do that.

But I think it's important, April, that you're recognizing what sets off your child, and as far as practical, avoiding those situations as best you can. Now sometimes, good intentions, and still things go downhill.

What about when your child throws a tantrum in public? It draws attention, it's embarrassing, you don't want people to think you're abusing or neglecting your child, but at the same time, you don't want to give in and reinforce that tantrum behavior even out in public.

49:06

Again, avoiding the store before nap time helps, setting up expectations, trying to anticipate what they're going to want to help them succeed on your terms.

One thing we used to do with our kids when we went grocery-shopping is say, 'With each grocery-shopping trip, you can pick one treat or something that you want, but just one,' and set it up ahead of time. 'OK, we're going to go. You get to pick one.' Once we started to do that, by the way, it's my wife who came up with that and it worked splendidly, so kudos to her, but once you do that, the expectation is 'I know I'm going to pick something special and I get the autonomy of picking what it is.' That's appropriate. But at the same time, it doesn't have to be mega-healthy. I mean, this is one item we're talking about. So it really gave them a sense that they were picking something, but it wasn't, 'I'm going to pick something on each and every aisle.'

When we would go on vacation, let's say we're going to Disney World, we'd give them Disney dollars and say, 'You can pick some souvenirs, but this is the fun that you get to pick your souvenirs.'

50:13

So it's not like every gift shop you go to you're, 'I want, I want, I want. I want this and I'm going to throw a tantrum when I don't get it.' You can have that, but then your money's going to be gone and you're not going to be able to get something else. A lot of times at that point, you go home with Disney dollars because they didn't want to spend their money on the souvenirs. When it's Mom and Dad's money, it's fine, but when it's their money, they were going to hang on to it. Again, the joys of parenting, and sometimes you do have to come up with creative means.

But you'll get through it, April, and I mean it when I say great insight, great job, and I think you're doing it correctly. It's normal to get frustrated and to even have some feelings of anger, and when you get that way, again, you don't want to act out on your child. I think it is the best policy to put them in a safe place, separate yourself from them, give yourself time to cool down, let your child have time to cool down, and then reconnect in a loving way.

51:09

I think if you're doing that, you'll find that these tantrums start happening less and less often and your child starts to have the behavior that you want. But they're still going to be spirited, and you just have to deal with that.

And probably there's some genetic component to that, April. You understand what I'm saying? Your mother would call it, 'What goes around comes around.' She's getting even now through your child. You understand what I'm saying.

All right. We are going to take a quick break, and then I do want to tell you about a new tool that we have to help you spread the word about PediaCast. So we will be back to do that right after this.

[Music]

52:24

Dr. Mike Patrick: OK, we are back to wrap up the show.

I think it's funny that at the beginning of the show, I'm like, 'Our news and listener shows usually last 30 to 40 minutes.' Here we are past the 50-minute mark. I don't know, I think it's a nice mix, because the interview shows, we can be on task and make it short and snappy and get to the topic and treat it business-like, but at the same time, there is something nice about being able to just kind of hang with you guys for a little bit of a longer period of time and talk about what's in the news and answer your questions. So I appreciate you sticking around for this long of a show.

I want to thank all of you for being a part of the PediaCast audience and to help us spread the word about PediaCast so that more parents can find out about it and get evidence-based information that you can trust.

53:13

One way that you can do that is, of course, through iTunes reviews. We haven't had very many of those lately, so if you have not done a review on iTunes for PediaCast, we'd really appreciate it if you just took five minutes of your time to do that.

Mention us in your blogs and Facebook and tweets, and of course, tell your doctor, tell your family and friends.

One of the ways to help you do that, we now have a flyer, a PediaCast flyer. It's a PDF file that you can download, print out, and it's perfect for bulletin boards, at doctor's offices, YMCAs, daycare centers, churches. I wouldn't put it on the telephone poles in your neighborhood because that might make people a little more angry or to saturate it with information. But I think it's a good resource.

Basically, if you want to know what the PediaCast studio looks like and me behind the microphone, there's a picture of that in the flyer. It just has some basic information on what we're trying to do here and how parents can connect with us at pediacast.org and also on Facebook and Twitter.

54:13

So if you would be so nice as to visit the pediacast.org site, it's on the Resource page. If you look up at the top tab, we have the Show Notes page, the PediaCast player or Listen Now, the Contact page, Terms of Use, and there's a new tab up there now called Resources. It has some helpful links from the American Academy of Pediatrics, the Centers for Disease Control, FDA recall information, that kind of stuff, and then there's also on that Resource page the PediaCast flyer. Again, PDF format, you can just download it and print it out. We'd appreciate it if you'd share that with others.

I want to remind you, pediacast.org, Contact link is probably the best way to get a hold of us. You can also email pediacast@gmail.com. Just remember to let us know your name and where you're from. And finally, the Skype line, 347-404-KIDS, 347, 404, K-I-D-S. No, we don't answer that phone; it goes to voicemail. But you just leave your message as a question and/or comment or topic idea, and we'll get your voice on the program.

55:18

Again, that's been under-utilized, so I wouldn't say that if you call in it guarantees that we'll cover that question on the show, but there's good likelihood.

All right, and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everyone!

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

2 thoughts on “Foreskin, Feeding Transitions, Temper Tantrums – PediaCast 182

  1. New listener, and I was really dismayed at your advice to retract an uncircumcised baby's foreskin.  My understanding is that back when circumcision was the norm, and doctors got unused to dealing with a natural penis, they developed this (very bad) advice, leading to all sorts of problems with adhesions etc. that would eventually lead to a recommendation of circumcision.  Forced retraction is not done in other parts of the world where natural is the norm. The only one who should retract the foreskin is the boy himself, and if that doesn't happen until puberty, so be it.  That is normal.  I would humbly ask that you review more up-to-date recomendations on this and see if maybe you should change your advice…

  2. Pingback: Finger Foods, Bed wetting, Head Lice – PediaCast 200 | PediaCast

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