Behavior: Ask the experts

QUESTIONS WANTED

INFANT NEEDS SKIN CONTACT WITH MOTHER TO SLEEP

Q How do I advise the mother of a 9-week-old who will not sleep in her crib? As a newborn the infant had physiologic jaundice, which was exacerbated by difficulty breastfeeding. On the advice of a lactation consultant, mother and baby began sleeping "tummy to tummy" with a lot of skin contact to facilitate breastfeeding. Now the baby will sleep only if she is lying on top of someone, and the mother is exhausted. If the parents put the baby in her crib, she screams. The mother has tried letting her "cry it out," going in after five minutes, then after longer and longer periods to pat her on the back. The baby finally falls asleep 30 to 40 minutes later when she is exhausted, sleeps for 40 minutes, then wakes and screams some more. This goes on all night.

Stacy D. Rudy, CPNP

Virginia Beach, VA

A Two pieces of background information would be of interest. Doesn't the lactation consultant know that the American Academy of Pediatrics and similar responsible organizations advise against allowing young babies to sleep in the prone position because of the risk of sudden infant death syndrome? The consultant's advice may have been helpful in the short term, but it has resulted in a habit that must be undone. One also has to wonder about the extent to which the parents' concern about the infant's vulnerability, because of jaundice, feeding problems, and perhaps other issues, are making it hard to set reasonable limits on the infant's demands.

This brings us to the management advice. A reasonable first step would be to check the baby's weight to make sure that she is sufficiently nourished. It might also be helpful to have the mother keep a diary of how she handles the infant during a two- or three-day period. Gradually withdrawing attention, which the mother already is trying, is probably the best strategy and needs only to be pursued more resolutely for a few days until the baby gets used to going to sleep alone. Some parents say that putting the baby in the crib on or beside a heating pad or hot water bottle facilitates the transition away from parental body warmth. Since the mother soothes the baby by patting her on the back, the baby must be sleeping on her stomach in the crib. Discourage this right away.

William B. Carey, MD

Philadelphia, PA

DR. CAREY is Clinical Professor of Pediatrics, University of Pennsylvania School of Medicine, and Director of Behavioral Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia.

MORBIDLY OBESE TEEN

Q The mother of a 14-year-old boy who is morbidly obese refuses to recognize that the boy's eating habits are the underlying cause of his problem, even though an endocrinologist has ruled out any hormonal imbalance. The mother insists that her son is not eating enough and even expressed concern about starving him when a nutritionist suggested a reasonable diet. The boy's 15- and 17-year-old sisters and his mother, who is single but has a boyfriend, are all of average weight. How would you suggest approaching this problem? The mother is gradually moving from being in denial to being angry.

Magdi M. Emara, MD
Tampa, FL

A Who has the problem here? If the 14-year-old boy is obese because he eats too much, he is going to have to deal with the situation. It's time for this young man to have his own private, confidential appointment, anyway. If he's not concerned about his weight, there is not much you can do except to continue to talk with him at regular visits, build a relationship with him, and support him in the healthy lifestyle choices he does make. When he is ready to change his eating habits, you can evaluate what he is doing now and what changes he thinks are feasible. As your relationship with the teen develops, he may reveal more about his home and school life, and you may learn about what influences his eating behavior. This situation took a long time to develop; it also will take considerable time for your therapeutic relationship with the boy to evolve and for him to develop healthy new behaviors.

Stop trying to change the mother, which can only make both of you miserable. The boy's obesity is not your problem. It is not his mother's problem. The problem--the obesity is certainly a risk factor for illness--is the boy's, and he's old enough to begin to work on it himself. You can best help him by supporting the mother in making wise decisions and being there when she asks for your help.

Kathi Kemper, MD

Boston, MA

DR. KEMPER is Director, Holistic Pediatric Education and Research, Children's Hospital, Boston, MA.

4-YEAR-OLD GRINDS TEETH

Q The parents of a 4-year-old are concerned about the way their son grinds his teeth at night while he sleeps. I've checked for pinworms and he doesn't have them. How can I advise these parents?

Leonard J. Janchar, MD

Marion, OH

A The purposeless grinding of teeth, particularly during sleep (bruxism), is one of many fairly common repetitive behaviors of the preschool years. While tooth grinding is often harmless, it can damage the surfaces of teeth if it occurs during a prolonged period. Having the parents determine how long their son grinds his teeth each night will help to determine the risk to the child's oral health. If the tooth grinding lasts only a short time or is very intermittent, reassure the parents that no treatment is necessary. If the grinding is frequent or prolonged, intervention is worthwhile.

In some children--but by no means all--bruxism is a manifestation of anxiety or stress, and directly addressing its cause may eliminate the behavior. Other strategies that may be useful are to have a calm and quiet bedtime routine, reducing exposure to violent or highly stimulating television programs before bedtime, and offering the child a night-light, favorite blanket, or another item to provide reassurance and additional security. If the behavior persists, referral to a dentist is indicated. The dentist may recommend other behavior management strategies or prescribe a night guard.

Paul Dworkin

Hartford, CT

DR. DWORKIN is Director and Chairperson, Department of Pediatrics, St. Francis Hospital and Medical Center, Hartford, CT, and Professor, Associate Chairperson, and Head, Division of General Pediatrics, University of Connecticut School of Medicine, Farmington.

TODDLER REFUSES TO STOOL IN POTTY

Q A 31/₂-year-old girl in my practice refuses to stool in a toilet or potty. She has been using the toilet to urinate for a year. She has excellent bladder and bowel control--she is dry at night and wears panties during the day. When she needs to defecate, she asks her parents for a diaper; she then goes to the bathroom and performs a routine of jumping and standing. She just won't sit.

The child's parents have tried rewards, sticker charts, and encouragement. They even allowed her to wear a diaper while sitting on the potty, but she screams and carries on and withholds the bowel movement if she is forced to sit. The child's mother pushed the issue recently and the girl just withheld for days until she was so constipated that she had bloody stools and soiled herself once. After that, her parents decided to allow her to go back to her routine, and the constipation improved.

The child is bright, engaging, and healthy. She is not embarrassed by her behavior, even in front of her peers. The parents always empty the diaper in the toilet and flush the stool, so I don't believe she fears losing a part of herself. Please help!

Lori Leiman, MD

Weston, FL

A The first priority is to prevent the child from voluntarily holding her stools. This practice results in constipation, painful BMs, more holding back, impactions, and, eventually, psychogenic megacolon.

Withholding diapers and pull-ups is always worth a trial, but this strategy didn't work with this child, nor did a showdown. Here's what I suggest:

• Have the child begin every day in underpants.

• Make diapers available for BMs, but insist that the child bring the diaper to her parent if she wants to use it.

• Keep the potty chair in the room where the child is playing--making it more convenient than the diapers.

• Avoid reminding the child to use the toilet or forcing her to sit on it.

The key point in this strategy is for the parents to select the right incentive for using the potty. What is the child's favorite activity or toy? The parents must make her an offer she can't refuse. A trip to Disneyland after every BM in the toilet would probably work, but that's impractical. Instead, they might try one hour of Disney movies after each BM, an ice cream sundae, or one hour of computer game time. The best incentives are privileges, not possessions, and which one to use depends on the individual child. In coming up with something that will do the trick, urge the parents to aim high.

Barton D. Schmitt, MD
Denver, CO

DR. SCHMITT is Professor of Pediatrics, University of Colorado School of Medicine, and Director of General Consultative Services, The Children's Hospital of Denver, CO. He also is Director, Enuresis-Encopresis Clinic, The Children's Hospital, Denver, and a member of the Contemporary Pediatrics Editorial Board.

You like "Behavior: Ask the experts." We know because you've told us in reader surveys. In addition, our mail bag is full of your comments on our experts' responses to submitted questions. But we need more of these queries to keep this department running smoothly--or running at all. Please think about the most interesting or difficult behavioral or developmental issues that have come up in your practice in recent weeks and write us about them. We'll be grateful, other readers will be grateful, and you'll get some good advice about your patient.

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Behavior Q/A
Contemporary Pediatrics
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Marian Freedman. Behavior: Ask the experts. Contemporary Pediatrics 1999;8:34.