31 December 2001
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
As he attempts to pass the stool, his entire body stiffens, his face grows bright red, and he often cries as he concentrates so hard to have his BM. In all other aspects, he is normal, healthy, happy toddler.
It troubles his mother and myself to see him struggle so; in a consultation with our ped 3 months ago, the ped advised a reduction in dairy consumption to no more than 16 oz per day (which we've done), an increase in juice intake (primarily white grape and pear) to approx 16 oz per day. Despite these measures, his BMs continue to pain him. We are concerned that when we begin to toilet train that he will withhold due to the pain associated with the BMs.
My basic question to you sir is there anything we can do to reduce or eliminate the pain associated with his BMs? What might be the underlying cause for his condition?
Thanks for your time and consideration.
-DB
Dear DB: The process of having a BM is not necessarily a pleasant experience. I'm not convinced that the bright red face and stiffening represents anything more than pushing to have a BM. If the stools are soft, you have done all you can and you have to let nature take its course. If the stools are not soft enough, then you'll want to increase the fiber and fruit juice in your son's diet. I would include prune juice in his repertoire of juices. If your son is holding stool in, it may help to give him a lubricant. This can be accomplished by giving him one to two teaspoons of mineral oil a day. Higher doses can be given, but this should really be done on the advice of your pediatrician.
Sincerely,
Dr. Warren
Additionally, he has a herniated belly-button that is a little larger than a nickel, what should we do about that? Thanks for your response
-JF
Dear JF: All the books tell new parents that it's normal for nursing newborns to have a stool after each feeding, but few of them mention that after a month or two, many nursing babies may have bowel movements as infrequently as every 5 to 6 days. As long as his stool remains soft and he is comfortable, you should allow your son to develop his own natural rhythm and try to avoid stimulating bowel movements.
Umbilical hernias often close on their own by three years of age. They rarely cause any discomfort or problems, so surgical repair, which is mostly for cosmetic reasons, should not be undertaken before three years if there is no medical problem with the hernia. There is no treatment for umbilical hernias except surgical repair; however, I assure you that it isn't necessary to do anything about the umbilical hernia.
Sincerely,
Dr. Warren
I just wanted a second opinion regarding the supplementation with formula, and I was also hoping that perhaps you could explain why this may have happened. I really love breastfeeding and I guess I feel very saddened by the fact that
I wasn't able to fully meet my son's needs. Also, will my son still be getting all the immunological benefits of breastfeeding eventhough he obviously isn't getting a LOT of breastmilk? And, how will this supplementation affect my future milk supply?
Thank you so much for your concern and advice. I look forward to your reponse.
-TH
Dear TH: I can't be sure if your son's recent refusal to nurse has resulted in your milk supply decreasing, but based on the fact that he has lost weight, is taking 6 ounces of formula after a nursing, and has been frustrated when nursing, it is more likely that his frustration resulted from not getting enough milk at the breast. Since the onset of the problem was sudden and recent, perhaps your doctor can help you determine if there is a treatable reason your milk supply has dwindled.
In any event, your nursing went well for the first 6 months and provided your son the perfect nutrition as well as other benefits of nursing. I can understand and sympathize with your disappointment if you are unable to continue nursing, but I urge you not to take it as a personal failing. There are very many things your son needs you for besides nursing. Yes, there are some non-nutritional benefits from nursing, but at least your son had them for 6 months. I wouldn't want to minimize the importance of those benefits, but babies who take formula and never nurse do well, so your son should certainly do well. It has always been my feeling that the most important thing that happens between Mom and baby during nursing besides feeding the baby, is the bonding that occurs during nursing. If your son is getting frustrated, that bonding may continue better with the help of formula. If you find it cumbersome to nurse and bottle feed, you might look into getting a Lact-aid device which allows the baby to take formula while sucking your breast.
Sincerely,
Dr. Warren
My gut feeling, however, is that he likes the bottle because it is so much easier. I have tried different nipples in hopes that a difficult nipple (slow-flow) would make him want to nurse, but he pretty much refuses the slow- flow nipples. I don't want to be too hard-core and hold out until he gives in, because I don't know that it would work and I don't know that that would be a kind approach to this problem. My son will nurse several times in the middle of the night and sometimes when he is sleepy. So, should I just continue those feedings (which aren't always super vigorous), and supplement with the bottle as he needs it? We he still get substantial immunological benefits with a small amount of breastmilk? I wish so much that I could reverse this because it seems that he hates nursing even more now that the bottle is available (eventhoughh this behavior began before we started giving him additional formula). I guess that one good sign is that when I do get my son to nurse, although not very willingly, he only takes 2-3 ounces of formula afterward. I am assuming that he must have gotten at least 3 oz of breastmilk then.
I am very much hoping that maybe this is a phase and we will be able to nurse more successfully as I keep trying and that in time, the time spent on the breast will increase and the formula that he desires afterward will decrease. Do you think this is possible and worth trying? I really don't want to give up easily, but like you said, it is important that feeding be a positve, nurturing time.
Thank you so very much for your time, and even more than that, thank you for your understanding and encouragement. I really appreciate it and it provides some comfort during this challenge.
TH-
Dear TH: I really can't be sure why your son prefers a bottle at this point. Perhaps he does find it easier than nursing, but that wouldn't explain why he started to refuse nursing in the first place, unless you were giving him bottles all along. At this point, you face a similar dilemma to the one a nursing mother faces when she wants to wean her baby and the baby refuses a bottle. Your baby has a preference, and as long as it's available, he'll hold out for it. You could refuse to offer it (in your case, the bottle; for the nursing mother who wants to wean, the breast), but your baby will cry and demand what he thinks he needs. I can't imagine any illness, condition, or source of discomfort associated with nursing that would make a baby prefer the bottle.
If your supply is increasing with the nighttime feedings, it is possible that your son may increase his daytime nursing as well. As long as both you and your son are happy with what you're doing, you can continue whatever combination of nursing and bottle feeding suits you best. Of course your son will still get the immunologic benefits of nursing, but I cannot tell you how much. As I said in my last reply to you, I'm not minimizing the importance of the nonnutritive benefits of nursing, but a 6 months, your son's own immune system is maturing, and he has already received substantial benefit from the nursing. It's time to stop focusing on this aspect of nursing as if it's crucial that your son continue to get some minimum amount. You have done a good thing nursing your son, and he will never lose the benefits you gave him.
Sincerely,
Dr. Warren
-Susan
Dear Susan: If your daughter is truly gasping for breath, she needs to be evaluated to determine why. In my experience, healthy children don't gasp for breath with any regularity, but I have often seen children whose parents interpreted something the child did as a gasp for breath, when in reality, it was a sigh, a yawn, a noise. If in doubt, check it out. It's better to see your pediatrician and find out everything's okay, then to miss something. To help you decide if there is anything worrisome going on make note of what is happening when your daughter "gasps." Is she coughing? Does her color change (red, pale, blue)? Does she appear to be struggling? Is she frightened? Is she excited or happy? Does she stop what she's doing? Does it occur only at certain times, in certain places, or only under certain circumstances? Afterward is she happy? distressed? lethargic? limp? or normally active as if nothing happened?
Some children at 20 months still don't like food that requires much chewing. That's okay. But if your daughter has a hard time swallowing, in light of your other complaint, perhaps she should be evaluated to be sure that her swallowing mechanism is normal and that there isn't anything compressing her trachea and esophagus such as a vascular ring.
Sincerely,
Dr. Warren
-JJ
Dear JJ: Breast fed babies usually have soft, slightly runny stools. There is no reason that you should give your baby charcoal of an sort. I wouldn't advise it. The American Academy of Pediatrics recommends not starting solid feedings (which includes cereal) until at least 4 months. In a family with a strong history of allergies, I would recommend delaying until at least 6 months. Your breast milk is excellent and complete nutrition for your baby.
Sincerely,
Dr. Warren
-RO
Dear RO: It is possible that your daughter has developed an anxiety disorder surrounding food and vomiting. It may help to see a child psychologist to work on a program of desensitizing your daughter to eating anxiety. This could be accomplished by giving small amounts of food more frequently and positively reinforcing successful eating behavior by keeping a chart with gold stars. It is crucial that you not let your own anxiety make you rush or give excessive amounts of food.
Before you undertake such a program, it would be a good idea to consult a pediatric gastroenterologist to be sure that there isn't any reason your daughter might be vomiting. Even if she has a only slight degree of gastroesophageal reflux, if she is sensitive, it may make her vomit. Medical treatment may help control the symptom long enough for her to reestablish normal eating.
Sincerely,
Dr. Warren
Thank you
-JW
Dear JW: The posterior fontanel usually closes soon after birth. The anterior fontanel usually closes between 10 and 16 months. If the fontanel closes early, but head growth is normal, it will only require continued careful monitoring of head growth. If the rate of head growth slows, then further evaluation will be necessary to make sure that the early closure of the fontanel is not associated with closure of the growth lines of the skull. Your daughter's head circumference should be measured at every checkup and be plotted on a head growth curve. That is the easiest, most accurate way to be sure that head growth is normal. You should review this with your daughter's pediatrician.
Sincerely,
Dr. Warren
Thank you for your time
-CS
Dear CS: Any lead level 20 mcg or higher is considered lead poisoning. It is unlikely that there would be any acute effects from such a level, but there is a concern that it may cause subtle neurological damage which could be related to learning disabilities or lower IQ. Nobody can state with any certainty that your child will suffer any ill effects from a lead level of 20 mcg, but it is a risk factor for neurological or learning problems. Check these sites for additional information.
Childhood Lead Poisoning
What You Should Know About Lead Posioning
Health Answers
Sincerely,
Dr. Warren
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