Pants-Wetting, Meat-Eating, Floor-Scooting, Doctor-Choosing – PediaCast 401
- We answer more of YOUR questions this week! Topics include toddler urinary accidents during the day, meat consumption in young kids, crawling and scooting instead of walking, and choosing the right doctor for your child’s care. We hope you can join us!
- Urinary Accidents (Enuresis)
- Toddler Meat Consumption
- Crawling and Scooting (Instead of Walking)
- Choosing the Right Doctor
Announcer 1: This is PediaCast.
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 once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 401 for April 17th, 2018. We're calling this one "Pants-Wetting, Meat-Eating, Floor-Scooting, and Doctor-Choosing". I want to welcome everyone to the program.
I know that's a mouthful. You may have guessed it from the title. We have a listener question edition of PediaCast for you this week. It's one of my favorite episodes to put together, I mean in general. Well, this was a good one. This was really, really good.
But just in general, the answer to listener questions shows are my favorite episode type to put together because I get t hear what's on your mind and the questions that you have, which is the reason really that we started producing PediaCast 12 years ago in an effort to be helpful to you, the PediaCast listener. And I have to say sitting here as I record the 401st installment of PediaCast, it doesn't get old. I absolutely love answering your questions.
And I'll get to the exact nature of this week's question, a quick preview for you. They're really interesting ones. But first I want to make a quick comment about listener questions in general. You know, our download numbers continue to rise. PediaCast's popular as ever with listeners in all 50 US states, over 200 countries. And yet, the number of questions that I get continues to drop.
And I think there are couple of reasons for this. First, we have 401 episodes, the archive is chockfull of information. And it's true that just about any question you have could be answered at least in part by listening to one of our past episodes.
However, your question is unique. Your situation is unlike any other. You bring a new wrinkle, a new focus. Your family may have different priorities that come into play. So, if something is on your mind, please let me know even if we've covered that before.
You might find the answer to your question in the archive. Maybe from the episode back in 2006, 2012, even 2016. Even if that's the case, go ahead and send me your question because the answer today maybe different, again, based on your family's context but also the current stay of pediatric research and evidence. Things change in medicine and we want to keep you up to date.
The second reason I think listener questions are down and this is reflected on the observation that listener interaction with all podcasts is down, not just PediaCast. If you listen to podcasts about podcasting, one recurrent thread is that listener participation has declined even though download numbers and reach have skyrocketed. And I think the reason for this is that podcasts are becoming mainstream. TV viewers don't write in to Kimmel or Fallon. You consume mainstream media rather than engage with it, which I find rather sad, really.
How do we get that indie feeling back in podcasting? And I think one way is for audiences to become engage whether it's PediaCast or any other podcast you enjoy listening to. Send in your comments and your questions to the host. Talk the podcast up on social media, write a quick review, tell the world in your blog and your social media channels, Twitter, Facebook, Instagram. Follow the podcasts in social media and engage with other listeners there.
For PediaCast specifically, be sure to let your friends and family know that this is the podcast that is interested in engaging. We love hearing from listeners. We love answering your questions. And then be that example and send in your comment or your question because I would rather produce another hundred listener episodes compared to the pediatric news and expert interviews that we do.
Now, don't get me wrong, those are important, too. And we get lots of great information into your hands through news and interviews. But the listener questions, those are near and dear into my heart. And of course, we make it really easy for you to send in your question or your comment.
Just head over to PediCast.org, click on the Contact link and ask away. And we'll try to get your question, your comment, your topic suggestion, whatever it is. Point me in the direction of a news article, a journal article. Folks have done that before. I'll give you my take on it. And we'd love to have your participation in this program.
All right, so what are we talking about today? What questions do you have for me this week? The title of today's episode did provide an apt description. Pants-wetting, it's a common problem. Toddlers who are potty trained still wetting on their pants, maybe just a little, while they're playing or rushing to the bathroom. And an often associated issue of the same toddlers or others, going to the bathroom frequently like three or four times when you're out at the restaurant. So, we'll consider that common occurrence
And then meat-eating, what do you do when a toddler just wants to eat steak? I mean that's it. Just lots and lots of steak. They would eat it for every meal if you gave it to them. Or maybe in your house, it's a chicken nuggets or mini corned dogs.
How much of one thing is too much? So, we'll answer that question and I'll have some tricks and tips for you too on getting kids to eat more of the other things like fruits and vegetables.
And in floor-scooting, as parents and doctors, we like to see kids up on walking sometime between 9 and 15 months of age. Twelve months is sort of middle of the road in terms of when it typically happens. But many of these kids even after walking successfully for the first time, would still rather scoot across the floor or crawl rather than walk.
So, is prolonged floor-scooting and crawling harmful for babies and young toddlers? Will it delay regular walking skills? Or could it be a sign of a developmental delay? So, we'll explore these questions and consider the possibilities.
And then finally, doctor-choosing, should you absolutely choose a pediatrician to help manage your child's health and wellness? Or could a family practice doctor do the job just as well? Oh, boy, it's your question, not mine. We don't shy away from any legitimate parenting questions on PediaCast. It's a legitimate question, so we'll answer it. And in fact, we'll answer all of these questions after the break.
First though, I do want to remind you, the information presented in every episode of PediaCast is for general, educational purposes only. We do not diagnose medical conditions or come up with a treatment plans for a specific individual. So if you have a concern about your child's health, always be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
And then we can talk more about the issues here on the podcast, provide some additional education, get your questions answered. But in terms of diagnosis and specific treatment, always talk to your child's regular doctor.
Let's take a quick break and I will be back with answers to your questions, that's coming up right after this.
Dr. Mike Patrick: Our first listener question this week comes from Sayaka, I hope I'm saying that correctly in Japan. Sayaka says, "Hi Dr. Mike, thank you so much for the great show for more than a decade. Also, thank you for making a show that is mutual. Parents can actually join in with questions. I sent a question and you answered it in Episode 269. I appreciate that so much.
"So, here's my question about a pee related problem. My son is a healthy, very active four-year-old who has mild ADHD. He graduated from day time diapers when he was two and a half. Occasionally, he wet after graduation, but not really that much.
"However, around age three, started peeing a little before he goes to the bathroom. It sometimes happens when he's concentrating on playing. It seems that it's a waste of time to go to the bathroom for him. So he pees a bit so he can have more time before he really needs to go to the bathroom.
"Other times, he simply pees a tiny bit before he gets to the toilet. Because he only pees a little and after a while he does go to the bathroom, he doesn't think he has failed. While I, as a mother, have to wash his pants and trousers every time and it makes me so tired.
"The weird thing, he does seem to be able to control when he needs to, like when he goes with his grandparents to the aquarium. No, there, he has no problem. Also, for some occasional period like say two weeks, he has no problem at all.
"Now, as a four-year-old he is also a frequent pee-er and he sometimes goes to the bathroom every hour. His pediatrician once inspected his pee looking for infection or something, but no problem was found. He said it's somehow common for the ADHD kids not to be able to control pee properly.
"So, can he really not control his pee or is he just too lazy to go to the bathroom? If he can't control his pee, how long until he is able to do so? And is there any treatment or training? Also, is it true that ADHD kids tend to wet their pants more often?
"I hope you can give some advice since this problem is becoming a conflict especially during busy evenings. I am sometimes so angry about it and I scold him. I'd love to avoid being angry, scolding, and ruining happy moments of his childhood. Please help.
"Thanks for reading this long question. I do respect your effort towards the show. I'm sure so many parents are thankful for you. Take care, Sayaka."
Well, that's a terrific set of questions there, Sayaka. And I really do appreciate you writing in. So we have several issues here. And I think we're really best served by breaking them down one at a time.
And even before we do that, I want to mention again that we do not give specific medical advice for particular kids. So we can't talk about the observations that Sayaka has made, potential causes of this observations, potential ideas for treatment or management of potential causes.
But at the end of the day, you need a diagnosis and a concrete treatment plan based on that diagnosis. So you definitely want to bring all of this up with your child's doctor because he or she will be able to put the symptoms in the context based on your child's past medical history, your family history. He or she will be able to clarify questions, perform a physical exam, perhaps check another urine or any other tests that are appropriate.
So, regardless of what we say here today, which will be generalizations, talk to your child's doctor again even if you have done so in the past. Because if things aren't working out, the doctor needs to know because that may change sort of the management strategy.
Okay, so with that very important disclaimer out of the way, let's break this down into a few pieces parts. First is this idea of enuresis. And enuresis is just a fancy word the medical folks use for accidental urination. So enuresis, and it's a common thing that we see. So the way that you've described it, Sayaka, is very common.
And a lot of times what will this, a very common cause of it is kids holding their pee because they're busy. They're playing, they're having fun. And you know just as well as I do, if you get that first little urge that hey, I got to pee and you suppress it, you kind of hold it back, eventually that feeling goes away for a little while. And then it comes back full on as your bladder continues to fill and stretch and become full.
And then, at some point you can't hold it back anymore and you get what we would call overflow incontinence. So there's just too much urine in there and some of it's going to leak out. Now, when a little bit of it leaks out, then the bladder is not quite as stretched as before and that feeling may go away again. Or if a lot is coming, the kid may run to the bathroom, but on the way there some of it does leak out and sort of overflows because the bladder was so full.
Now, that is how you sort of described it, Sayaka. And that's common, this holding idea is very common in terms of an explanation. What will be more of a concern is kids who go more than just a little bit without warning and don't necessarily try to get to the bathroom. So they just have general incontinence. They're just wetting themselves large amounts during the day. They try to hide it from you. They don't go to the bathroom at all.
If those kind of things are happening in a kid who has been potty-trained, especially if it's new or maybe you just have had a hard time getting them to be potty trained, you definitely want to talk to your doctor because there could be a physical problem, spinal cord, and brain issues can cause this.
It could be a developmental problem, could be a behavioral problem. Again, unlikely given this history, but in kids who are having more difficulty, more leakage, more wetting than you would expect, not trying to get to the bathroom, definitely talk to your doctor and have your child examined if those things are going on.
So in this situation where we think it is just overflow incontinence, kids putting it off, the bladder's filling, the feeling goes away, they continue to play, then it's too late, a little leaks out, they run to the bathroom. What I have found to be helpful with this is in the beginning, just frequent reminders. Take the time out to do it. Sort of make it the culture in your house that you have to go try.
And in the beginning, maybe every hour, every hour you need to stop what you're doing and just try to go pee. And then once they're successful in staying dry all day long, then the next day, maybe go to two hours. After every two hours, you're going to try, they got to try to go. And then you can maybe move it every three hours. Every three hours they got to try, and if they start to have accidents, then back to two hours again. And just get them sort of use to taking time out from what they're doing when they get that feeling to go to the bathroom.
So, I think that's one way that you can sort of begin training. And this is probably what happens when your child goes with the grandparents to the aquarium. Grandpa has to go, too. And so, there's an opportunity to go. The rest of the family is going to interrupt the trip around the aquarium and it's time for a potty break.
We're all going to try to go to the bathroom. Then we're going to regroup and we'll continue looking at the fish and the sharks. So that sort of the frequent reminder thing is kind of happening organically when he goes with the family to visit the aquarium.
Now, the other thing with this that can be helpful is a reward kind of system. So, I love rewards. So if your child does go the whole morning, the whole afternoon, or the whole day without wetting, the other thing to do then is to give him a sticker. Have a little sticker chart.
You want them to succeed in the beginning and then make it a little bit more difficult as days go on. So you kind of stretch what they can do. So it may just be if you can go the whole morning without wetting, you don't put up a hassle when we say, "Hey, it's time to try to go. Even if you don't go, that's fine. You just got to try." If you can't, you can't."
But if they stick with that plan for a whole morning, let them have a sticker on their sticker chart. Or maybe it's the whole afternoon and then they graduate, "Okay, now you got to go the whole day without wetting or putting up a fuss when it's time to go try. And if you've done well the whole day, then you'll get a sticker. And collect five stickers and you get a price."
Something like that. You can get creative, make it fun, make it a game. That can really help them out, too.
Now, in terms of the urinary frequency component of this, it is frequent that we see kids who just seem like they have to go all the time and they just pee a little bit each time. And you may be out of the restaurant and by the time dessert comes, your kids gone to the bathroom four times and they just pee a little bit each time.
This happens frequently and there are several reasons. For one thing, the bathroom might be really cool. Maybe there's fancy sinks, there's cool decorations and cool music and, "I get to be a big boy and go to the potty." So, there maybe behavioral component of wanting to go to the bathroom. That's possible.
But a pretty common cause at this age is actually constipation. And especially when it's small amounts frequently.
Now, first what does constipation mean? Because a lot of folks will say, "Well, my kid's not constipated. They have a regular soft bowel movement every day. How they can be constipated?" Well, the definition of constipation is really a large intestine that's full of stool.
And if your child is making stool and eliminating stool at the same rate but at their baseline is they're constipated, there's a lot of stool in there. You can easily have a kid who their large intestine is full of stool but they poop regularly every day. But remember, they're making new stool every day, too. And if you don't get to the point where more is coming out than they're making, you're still going to have this net result of too much stool in there which we will call constipation.
Now, the second piece to remember is that the bowel and the bladder, the neurons, so the sensation of I've got to pee or I've got to poop, the sensation from those neurons kind of gets mixed up as it goes into the spinal cord and goes up to the brain. And so, sometimes the brain can have a little bit of trouble telling where those signals are coming from.
And so, it could be that they feel like they have to pee, but really it's because of stool kind of stretching the rectum. And so getting that stool out so that there's less stool in the large intestine can help reduce those signals that are going to the brain, which the child is interpreting as, "I got to go to do number one."
Now, the other thing too is that as the stool fills up the large intestine, that can also kind of push on the bladder. Sort of stretching it from the outside, and then again those signals travel up to the brain. And the brain thinks, "Hey, I've got a full bladder because my bladder is being stretched." But it's not really full of pee. It's because the large intestine which is full of stool is pushing at it from the outside. So, these are some reasons that constipation and having a large intestine full of stool can make your child feel like they have to pee.
And of course, here's a child who maybe this has been an issue. And so they are trying to do the right thing and interrupt what they're doing because they feel those first little twinges which is what the whole first part of this talk was trying to help them with. And so now, they're going to go to the restroom a little too frequently because they want to do the right thing and not wet their pants and they feel like they have to go. But they don't really have a full bladder. So they're not even close to overfilling and having that overflow incontinence.
So, this all goes hand in hand. And oftentimes, putting a child on a stool softener, having them also try going to the bathroom. So we said, "Hey, you got to try. If you don't go, that's fine. We're talking about urine." But maybe a couple of times during the day and best times would be after meals, especially up to an hour after meal, "Okay, now, you have not to only try to do number one but you need to try to do number two as well."
Because you've probably experience this yourself. If you sit down and use the bathroom and you get one stool out. But if you sit there a little bit longer, oh, here comes number two and number three stool, turds, coming out.
However, if you would just wipe after number one and went on your way, number two and three wouldn't have had the opportunity to come out. And so, you have a really active kid who just wants to get back out and playing. One turd comes out and they're done, and they're ready to play again.
Maybe they need to sit there just a little longer just to see if more will come out. So, that eventually more is coming out than going in, being formed. And so, slowly we start to have less stool in the large intestine and it can take some time to sort of fix this.
Now, urinary frequency can also be caused by infection. It can be caused by diabetes mellitus or sugar in the blood or glucose in the blood being too high that can also cause urinary frequency. Usually in that case, it's large amounts of urine and kids are getting dehydrated because they're going to the bathroom frequently. But it's not just little bits, it's a full bladder each time because of the high sugar taking water with it into the urine.
And then another less way, less common condition call diabetes insipidus which is more related to the brain and regulation of water. And so you can't really save water even if you're getting dehydrated, your kidney just lets lots of water through, but the blood sugar is not high.
So there are other things that can cause urinary frequency. So you don't want to just go to it being constipation without seeing your doctor having them ask you more questions, doing the physical, maybe checking the urine and going from there.
In terms of the ADHD association, as you think about the symptoms that kids with attention deficit hyperactivity disorder have, they have issues with attention and hyperactivity and impulsivity. So, are these kids more likely to sort of put off going until it's too late? It is possible. They are impulsive and they feel that little twinge, "Okay, I got to go. I'm going to go to the bathroom."
So, I mean, just from types of symptoms that these kids have, it is more likely that they're going to have these kind of problems and putting it off and going more frequently. But the ADHD is not really causing a problem with the kidneys or the bladder or the urine. It's just that their behavior issues can make it maybe a little more likely for those sort of things to happen.
Of course, there's hope in all of these. Again, see your doctor to make sure it's not something more. That reminders to try to go, every one to two hours in the beginning. And then you can go further out with the urine and with stools after meals. The sticker charts really help.
Also, make sure you get babysitters and the preschools on board with the plan. So whatever the reminder plan, the sticker chart, whatever it is, if folks are watching your kids, you want some consistency and uniformity throughout all of these, whether even if it's a baby sitter that's coming. So make sure that they're on board and they know what's going on.
And then, of course, think about constipation. Even if your child has a regular daily soft vowel movement, they still may need stool softener and encouragement to go and try often.
So, again, thanks for the question, Sayaka in Japan. Really hope that helps.
Next up, we have Victoria in New Zealand. Victoria says, "Hello, Dr. Mike. Thank you for your informative evidence-based podcast. I work in a scientific myself and can appreciate the amount of work that goes into finding reliable information based on strong evidence. All of us busy parents appreciate the work you do.
"My question is regarding my two-and-a-half-year-old son. He loves to eat meat. He demands it at every meal and if we let him, he would eat a large adult portion of steak in one setting. He's not having a growth spurt. He has always been a meat eater, even though the rest of the family has moderate meat consumption.
"He's not really into sweets and weighs 12 kilograms which is the fourth percentile for his age, so he is petite. We did baby-led weaning and maintain a hands-off approach with food, no pressure.
"Is there such thing as too much meat for a toddler? Would too much protein harm his kidneys? Or does his body really know what it needs? What is the recommended serving of meat for a skinny toddler? Thank you, Victoria."
Well, thanks for the question Victoria in New Zealand. And you bring up several interesting and important points. First, I just want to talk about protein in general. You know, protein is important because our body breaks it down into amino acids which then get incorporated into new proteins that our body needs.
So protein consumption is very important. Now, there have been some studies that show that high amounts of protein in the diet, and we're talking protein mega amounts of protein, has been associated with worsening kidney function in people with previously diagnosed kidney disease.
And in that case, we're usually talking about large amounts of protein intake which is typical like protein powder and high protein shakes. So, if you have known kidney disease, your doctor will likely advise you to avoid vigorous protein supplementation.
Now, that said, there is no evidence that I have come across in researching your answer, the answer to this question, I looked again. There is no evidence to suggest that protein intake from normal dietary means from food, not supplementation, there's no indication or evidence that protein from food poses any risk to healthy kidneys.
So the typical steak loving toddler with healthy kidneys is extremely unlikely to harm his or her kidneys by eating steak.
So I just wanted to get that very important observation out of the way. Another important aspect of Victoria's question is this notion that the body knows what it needs. So we can let toddlers pick what they want to eat because they will choose what their body needs.
I've come across this idea before and it is just not true. All of us, from baby to toddlers, to school-aged kids, to teenagers, to young adults and older adults, we have preferences what we'd like to eat. And it's based mostly on taste, to smell and texture. And it's not always what's in our body's best interest, right?
So as parents, it's important to choose a wide variety of foods for our kids and offer those rather than letting them choose everything on their own. Because with a little research and smart plan, you have a better chance of fuelling your kids with the best nutrients for their body compared to the meal or snack they might choose for themselves.
Now, on the other hand, kids are at this age where they want to start to exert control over their surroundings and their environment. They're growing in their autonomy. And so that kind of sets up then the perfect storm for conflict because you want to give your child what's best for them, and they want to make their own choices. And we really don't want a food fight or any other conflict around meals and snacks because they generally don't end well, and especially as we consider toddlers.
So one piece of advice that I've used to counsel parents, and I think it has served many families well over the years, and that is to sort of define what the role of the parent and the role of the toddler is at snacks and mealtime. And I think the roles that work out best is parents choose which foods are offered. And you give them some choice. And then toddlers choose which of those foods they want to eat and how much of each food that they're going to eat within reason.
So, there is still some autonomy. The toddler still has some choices, but the choices are among foods that the parent is offering. So you can offer different things that includes some fruits and vegetables and grains and meat and dairy. And your child can take you up on some of those things. And other ones, they're not going to eat as much of or maybe not at all.
And if there are foods that your child doesn't take you up on, keep offering them. Keep modelling good choices by eating those foods yourself because sometimes, it can take offering a particular food 20 or more times before a child decides that they're going to try and need it. So, don't give up. But also don't get frustrated.
Now, what do I mean by within reason in terms of the amount of each food? Well, if a child wants to gorge themselves on one food, there's no room to choose any of the others. And so you probably do want to limit the portion to some degree. If a toddler eats an entire adult size T-bone steak, there's no a lot of room left over for fruits and vegetables, grains, and dairy.
So you do want to sort to be smart with it and not because that food by itself and a large amount is going to be particularly harmful, but more than there's going to be less interest in those other foods. And you can also have them eat, okay, you can pick what order they're going to eat things in.
And each kid's a little different, each family's different depending on your particular fight or conflict that you're up against. And that's why talking to your doctors so they can get the whole story and maybe offer you some specific advice with that.
What if a toddler doesn't want any bite of any vegetable ever? That's a common complaint. Do you force a bite? Is there a minimum serving? It depends on the kid and the context and what's going on in the family. A no-thank you helping works for some, a reward system for trying new foods like a sticker chart kind of thing works for others.
But you have to be careful because you don't want to create a fight that you can't win. You don't want nightly grief at the dinner table. And you don't want set kids up to use food to gain rewards on a regular basis because that can result in its own set of problems.
So you do want to use some common sense, which I think you're doing, Victoria, because you said if we let him, he would eat a large adult portion steak in one sitting. So, I'm assuming that you don't let him. Instead you give him a toddler-size portion and hopefully other foods to go with it.
Now, another thing that Victoria ask about is how much meat should a toddler eat? And that's more difficult to answer. A good rule of thumb is that protein and grains should make up half of the dinner plate, about a quarter each of grains and protein. Maybe grains a little bit more than the meat. And then fruits and vegetables should make up the other half, with vegetables making up a little bit more than a quarter compared to fruit.
And then, with meals, dairy makes up sort of a side serving and slightly less than a quarter of the plate. So, if you visualize that, you take a plate, divide it into quarters and you got your meat, your grains, your fruits and your vegetables. So, fruits and vegetables should be half of it. And then a little bowl like side serving of dairy which is about the size of a quarter of a plate.
It's an easy thing to visualize. You can find more detail about that at choosemyplate.com and I'll put link in the Show Notes for this episode, 401, over at PediaCast.org.
Now, that's what you should offer. And then you're going to let toddlers choose how much of each portion they want to eat within reason.
And here's a nifty trick, a lot of toddlers like to graze. So, if they don't want to eat all of that in one sitting, they're more of the grazing type, they'd rather have more frequent small meals, instead of offering snacks, offer them components of the meal when they're hungry.
So, one snack can be the rest of the protein. Another can be the grains. Another can be the fruits and vegetables. And the younger of an age that you start that sort of plan, the easier it goes. So, instead of snacking all day, and we want to offer healthy snacks, but maybe it's component of that meals. So, over the course of the day, they get their meal.
So, that's one little trick you can use. One final point in all of these, a child's weight does sort of play a role. We eat to be healthy, we eat to grow. And if kids aren't growing enough or if they're growing too much, we may have to make some adjustments on food, and the way that we offer, the things that we offer, how much that we offer.
And again, each family and kid is unique. So you really do want a doctor who's going walk you through this in person to get your family's story and offer you the best advice.
Now, in this case, Victoria's son, she said, is petite. He's at the fourth percentile for his age. So, does that make a difference in all of these? Well, maybe. And this is where the doctor has to use all the data points and make some connections. Is the rest of the family petite? Were mom and dad petite as kids? Those are things to consider because maybe the fourth percentile is normal for this family.
Are there any other health issues to consider? Do we want to beef up calories or are we good to go where we are? And sometimes these answers are not easy and the right answer is not the same for every toddler and every family.
So, again in all of these, it's really important that you're working in real life, not through a podcast, with the doctor you like and trust and who takes the time to walk through all of these data points, with the ultimate goal of helping you and your family make meal and snack time decisions that make sense for your family's unique situation.
So, hope that helps Victoria. And as always, thanks for writing in from New Zealand.
Dr. Mike Patrick: So we had two international questions, and now we're going to go to our domestic audience here in the United States. We have a question from Annie in Manasquan, New Jersey.
Annie says, "I've heard ramblings about infant butt-scooting being a potentially harmful thing and/or relating to developmental delays. A family member even mentioned their friend's child was sent to early intervention for still scooting across the floor at the age one. Is there any objective, evidence-based information to support this claims and worries?"
So, great question, Annie. Thanks for writing in. So, this is all about transportation, right? Your baby is trying to get from point A to point B. And options for these babies are you're either going to scoot across the floor or you're going to crawl across the floor. Or maybe you're going to be picked up. If you complaint too much and you point, and you cry, maybe someone will pick you up and move you to where you want to go. Or you can walk.
And so, it's really all about transportation and getting from point A to point B.
Now, from the baby's point of view, they're going to use the easiest and fastest method for them because their goal is not learning to walk, right? Their goal is to get across the room because there's something they want or something they want to do. They're being smart and the crawling or and scooting is the means to an end, not the end thing itself.
Now, on the other hand, from the parents' point of view and the doctor's perspective, walking is the thing. It's not about transportation, it's about meeting a developmental milestone. We want babies turning into toddlers and we want them beginning to walk between 9 and 12 months of age. And we want them walking well by 15 months of age.
Although I should point out from all points in times past, there'd been plenty of normal babies who start walking more like 12 to 15 months of age. And they're walking well by 15 to 18 months of age.
We do all start to get a little worried about those late bloomers but there plenty who bloom late. And then they're fine and they do well. And then, you have to ask, were they really delayed or was that just part of their normal development?
It's a question your doctor will consider and it's another example of using all of the data points and making connections, getting the context of your family, doing a physical exam. Considering is your child delayed in other areas? How does this compare with other children in your family? When did mom and dad start walking?
Are there barriers to promoting normal development? One of those barriers may be allowing 12-months-olds to crawl and scoot everywhere because for many, it's unlikely that they're going to just start pulling themselves up on their own and start walking. Yep, some do. But many don't, and as long as it's easier and faster to crawl and scoot as a form of transportation, the longer it's going to take for them to walk.
And so not working with your child and sort of having what I'd like to call walking lessons, they're not going to do it on their own, they're going to be delayed.
Now, is that really developmental delay? Or is it just lack of opportunity for normal development? And again, it's not true for all kids. Plenty are absolutely fine with pulling themselves up and starting to walk all on their own. But even the most tenacious of them need a little boost in the beginning.
And so, the way that I've always approach this issue is to say let your baby get from point A to point B however they want. Whether it's crawling, scooting, walking, being picked up and moved. However they want to get where they want to go, let them choose the method that they want to use.
However, several times a day, let's go for a walk. Let's practice. Let's first begin learning to bear weight, then holding on to the coffee table. Then walking alongside holding on to the coffee and then those first few clumsy steps with all obstacles out of the way.
And let's keep providing opportunities to walk and get better at it. But not necessarily at the time when your child wants to choose their mode of transportation. Let them choose, let them crawl, let them scoot, whatever they want to do. But several times a day, take him for a walk, right? Let them have some walking lessons.
And eventually, when your child has to decide which mode of transportation to use, they'll choose walking because they're doing it well. And they can do it quickly. And when their proficiency at walking is good, makes it more of an efficient choice for them to get where they want to go.
And so, Annie, scooting across the floor in and of itself does not cause a developmental delay. And in isolation, I've not heard any evidence to suggest that it's a symptom of a developmental delay. But it is important to provide opportunity for a baby to learn how to walk.
But don't interrupt their scooting and crawling. Let them do it, but provide those opportunities for walking. And eventually, they'll begin choosing that method of transportation.
Now, some parents aren't comfortable with that. Some don't have the time or the interest or the skill set to do this. And there may be other developmental concerns your doctor has. Perhaps, there are other areas of delay or concerns on the physical examination.
And in these cases where there are other concerns or where there is a barrier to providing those walking lessons, whether it's parents interest, busyness in the family, just don't have the time to do it, really don't have the means and the know-how to provide these sort of walking lessons, so in those cases, early intervention can be extremely helpful in removing those barriers. And sort of assessing other areas of development and to provide developmental opportunity in the boost that a child may need.
So early intervention does not necessarily mean that there is a developmental problem, it can also be used to help boost normal development when families need that extra help. And of course, if early intervention doesn't do the trick or delays are persisting, there are other concerns, there's problems on the physical examination, then it's time to see a developmental specialist who typically work in multi-specialty clinics associated with the children's hospital.
So, in answer to your question, Annie, which in a nut shell is this, is there any objective evidence-based information to support that scooting across the floor as an infant is harmful or leads to developmental delay? And my answer would be no. Scooting and crawling in and of itself is not harmful. It does not cause developmental delay. But the caveat is this, maybe many babies won't learn to walk on time on their own, they need lessons and practice and opportunity.
Let them scoot to their heart's desire but also help them walk. And if that process is taking longer than 12 to 15 months of age, you're going to let your doctor know about that. And that's why we schedule a well child examination at 9 months, 12 months, 15 months. So we can really assess those things, talk to parents about them, talk about how to help your child learn to walk and providing referrals to early intervention or developmental specialist when the need arises.
So, hope that helps, Annie from New Jersey. And as always, thanks for the question.
Our final question this week comes from Sarah in Kansas City, Missouri. Sarah says, "Hi, Dr. Mike. I am investigating changing my children's doctor and wanted to know your thoughts on when it's okay to start using a family practice doctor versus a pediatrician.
"There are only a couple of pediatric practices in my area and they are all very large leading to similar problems as our current doctor's office which are, the problems, are lack of consistency of care, seeing a different doctor each time my child is sick, lack of timely access for non-acute issues like nutrition.
"My children are two-and-a-half and just turned one. They're generally healthy, no chronic conditions, and on track developmentally. Is it reasonable to switch us all to a family practitioner? Or would that type of provider not have the right skill set to see the kids this young? At what age is it appropriate to move care to the family practice setting?
"Thanks as always for your guidance and sharing great knowledge through the PediaCast platform. I absolutely love your show from both the parent and the pediatric therapist perspectives."
Well, thanks for writing in, Sarah. It's a terrific question. And unfortunately, there's not one right answer. So let's begin by considering both pediatricians and family practice doctors in terms of their training and their scope of practice. And I think that that will set just sort of a foundation then for discussion on sort of the differences and what's right for particular families.
So, from my training stand point, pediatricians of course go to undergraduate school, do pre-med. Then you go to medical school, all doctors do this. So, medical schools is four years after you give your bachelor's degree. And then you're going to embark on residency training where you'll really learn your specialty.
For pediatricians, residency training is three years. And during that time, they learn all aspects of child health and wellness. If you want to specialize in a pediatric specialty like pediatric cardiology or if you want to become a neonatologist or an emergency room physician, then you're going to do a three-year fellowship after the three years of residency training.
So, after four years of medical school, just to be a general pediatrician, you would do three years of residency training. If you're going to specialize it, it's more beyond that.
So, during those three years of residency training, before you become a general pediatrician, you're going to learn all aspects of child health and wellness. From the newborn nursery and the neonatal intensive care unit, to outpatient clinics, where you going to learn child development and behavior and illnesses, to the pediatric emergency department and the multitude of childhood injuries that are seen there.
Also the pediatric intensive care unit and all the in-patient services, where you're going to learn to manage more complicated things like severe asthma, diabetes, even congenital heart disease. And then on the adolescent clinic where you're going to learn the ins and outs of transitions in young adult care.
So, pediatricians are well prepared to take care of young babies, including premature babies and continuing care for that child through the teenage years. And many will continue caring for children as they become young adults and even attend college.
Now, the exact length of time that a pediatrician will see you kind of varies. Some ask their patients to begin seeing an adult doctor at age 18 when they're graduating from high school. Others at 21, others say you're fine as long as you're still in college.
I remember, so I do pediatric emergency medicine and urgent care now, but I did spend ten years as a general pediatrician in a private practice. And personally, I love taking care of young adults. So, a lot of pediatricians do enjoy that and encourage their patients to stick with them at least through the college years. And sometimes, we'll extend even beyond especially if the patient has a complex pediatric disease like severe cerebral palsy, as one example.
And then, of course, some pediatricians are also internal medicine doctors. So you can do a combined residency where basically you become a pediatrician and an internal medicine doctor in shorter amount of time than it would take you if you did both of those residencies separate, but a little bit of a longer training program to learn everything about pediatrics and internal medicine. And of course, then they can continue seeing their patients well into adulthood and really for the rest of their lives.
Now, compare that to family practice doctors. Again, undergraduate degree, four years of medical school, and then family practice doctors residency training is also three years, just like the pediatricians. They spend time in pediatric settings, in-patients wards, outpatient clinics, sometimes emergency departments and even intensive care units.
But of course, they're going to spend less time in pediatrics because during that three-year period, they're also going to spend a lot of time learning adult medicine, some surgery. Especially simple surgical procedures, some family practice doctors do those. They also learn about obstetrics and gynecology and even psychiatry.
The exact mix of each programs a little different but there are minimum standards that are met. So, a family practice doctor is really in a position to take care of patient and families from birth until death because of the breadth of their training in both pediatrics and adult medicine, and then specialties like surgery, ob-gyn, and psychiatry.
So, what does all these mean? Well, coming straight out of residency, most pediatricians are better equipped to take care of complex issues in kids because they've seen a lot more of that during their three years of residency training compared to a family practice doctor.
However, we continue to learn and grow as doctors as we practice. And the more kids and individual family practice doctors sees and the more complex kids he or she sees, and the sorts of continuing medical education he or she takes, and the better the doctor is at using resources to look things up on a fly and refer to appropriate specialist and services when needed, then the better he or she will become at taking care of even the most complex kids.
Are there family practice doctors out there with pediatric skills on par with the board-certified pediatrician? Absolutely. On the other hand, there are family practice docs who prefer seeing adults. They don't have a lot of pediatric experience. They'll see kids, but they don't do it often and they may not be as quick uncovering a problem or offering age-appropriate health and wellness advice.
So you want to do your homework as you choose a doctor. And this holds true for doctors in any specialty including pediatrics. The sort of questions you want to ask, where did they train, how long had they been in practice?
And longer isn't always better. There's kind of the middle of the road where maybe some doctors who've been in practice a very long time might not have kept themselves up to date. Again, that doesn't mean that someone near the end of their career is not up to date. A lot of doctors go to great lengths to stay up to date, but others don't.
And of course, when you first come out of practice, you're going to know more about the most current evidence-based things. But maybe you're going to be a little bit less on the experience. So there's kind of a happy medium there in terms of how close you are to coming out of your practice, how long you've been in practice. And a lot of it just depends on the individual doctor.
Also, I would ask what percentage of their practice is taking care of patients like you or your child? And then, of course, what do other patients and families say about the physician and the practice?
So lots to consider, but at the end of the day, you'll probably find a competent doctor to take care of your child whether that ends up being a pediatrician like me or a family practice doc who has lots of pediatric experience. And I certainly know lots of family practice doctors, many of whom I would trust with my own kids in a heartbeat.
Now, there is one other piece to this question from Sarah that is very important. And that is the consideration not only of competence, the competence and your pediatric skills and knowledge are very important, but the other thing that's really important is the personality of your physician and the practice culture and how well that matches your own family's personality and expectations of practice culture.
So competence is importance, but these other things like personality and how the practices run is also very important. And in fact, that's the reason Sarah is looking for another solution because she's not happy. And based on her question, that likely stems from her expectations of what the medical practice should be like are not being met. So her kid is seeing different providers each time, that feeling of busyness and rushing my kid through long waits for non-acute matters.
And in many other cases, we simply don't click with the doctor, our personalities clash. It doesn't mean that there's a right or wrong personality. But one personality type is going to get along with a particular family better than another personality type. And there are going to be families who don't like that second one and prefer the first one.
So there's something to be said for feeling comfortable and valued in your medical home. And for that to happen, personalities do need to mesh and expectations do need to be met or at least compromised upon in a way that's agreeable to both parties.
You want someone who you feel like they care, that they listen, that they're available. And that can become harder to find in our medical climate today where we're really pushed to see the maximum number of patients in order to meet expenses. And that is an issue.
And so I applaud your effort, Sarah. And I think you're looking around for the right reasons. And when you do find a medical home that provides competence and the practice culture that matches your family's needs and values or the doctor's personality that you can really click with, when you find that, I would share that information with other parents in your area.
And I would I also suggest providing feedback to the practice you were leaving. They need to know what being a member of their medical home looks like and feels like from your family's perspective. Now, they may say, well, that's not the kind of family that we're catering to. Or they may say, especially if they hear from enough parents, we need to make some changes in our practice so that parents can feel valued and can enjoy being a part of this medical home.
Because without that piece of insider information, they may not know in what areas or in what ways that change is needed. Your individual feedback may not result in immediate change, but if the practice you're leaving sees the pattern of dissatisfaction, perhaps change will come, which will then benefit those who will call that practice their medical home in the years to come.
So I hope that helps, Sarah from Kansas City. As always, thanks so much for the question.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that so much.
Also, don't forget, you can find PediaCast in all sorts of places. I'm not sure how you came across us today, how you're listening, how easy it was for you to find us. There might be some easier ways. We are on iTunes, in the Apple Podcast app, Google Play, iHeart Radio, really most mobile podcast apps that cater to podcast of all sorts, you should be able to find PediaCast there. If not, just search the app for PediaCast. If you can't find us, let me know and we'll try to get the show added to that particular app's lineup.
We also have a contact page where you can ask your question, suggest the topic. As we talk about in the intro, very important, and I just love getting questions for you. And we'll try to get what's on your mind on the program. Just give me a shoutout. It's easy to do, head to the PediaCast.org, click on the contact link and ask away.
One other thing, and I've mentioned in previous episodes, but the reviews of this podcast are really important. In my own personal life, and this is probably true for many of you, I really use reviews to decide if I'm going to invest my time in something and invest my money, too. So if there's products that I'm looking into. I may look at Amazon or Best Buy or other, I tend to be more geeky and looking at electronic and technology kind of things. But whatever it is you're looking for, you've probably read some reviews about products before you gave them a chance.
Not just products, also services. We read things like Angie's List and Yelp to determine if services of a particular interest, movie reviews, TV shows. Before I sit down to watch something, I think about what other people have said about it, and what are the reviews are saying. And the same thing is true with podcasts, people really do read and look at those reviews before they decide if they're going to take a podcast for a spin.
And so, if you wouldn't mind, wherever you regularly listen to PediaCast, if you've listen to a few episodes, you feel like you're really a part of the audience and you have something to say about the show, please consider taking two or three minutes and just writing up a quick review of the program. So that other parents can learn about your experience, and hopefully, they'll take us for a spin. Because we love to give evidence-based pediatric information out to as many parents as possible.
It's not about building a huge audience. We have a big audience, and we have listeners in all 50 states, over 200 countries. But there are a lot of parents out there who are looking for evidence-based information, trustworthy recommendations for child health and wellness. And those who have not heard about us, we sure would like for them to have the opportunity to find out about this program.
Also, it helps if you connect with us on social media. We're on Facebook, Twitter, Google+, LinkedIn, Pinterest, just search for PediaCast. On LinkedIn, you have to search my name, Michael Patrick, Dr. Mike. And we'd love to connect with you there. You can also engage with other listeners in those spaces, and of course, share our online content with the folks who follow you.
And then those face-to-face recommendations are really important. Be sure to tell your family, friends, neighbors, co-workers, babysitters, grandparents, anyone who has kids or takes care of kids. And that include your child's teacher and their pediatric medical providers.
And speaking of their providers for doctors, nurse practitioners, physician assistants, we do have Continuing Medical Education for them as well. It's called PediaCast CME, which CME stands for, Continuing Medical Education. Similar to this program but for that podcast, PediaCast CME, we turned up the science a couple of notches and we also offer free Category 1 Continuing Medical Education for those who listen. Shows and details are available at the landing site for that program, which is PediaCastCME.org.
That show's also on iTunes, Google Play, iHeart Radio, Spotify, and most mobile podcast apps. For that one, simply search for PediaCast CME.
All right, that's all the time we have today. Thanks again for stopping by and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast. ing. We'll see you next time on PediaCast.