How Do I Know If My Child Is Ready for Potty Training?

By Jill Campbell, Psy.D.

There are many different reasons why parents’ feel the need to potty train their children.  Some parents feel pressure from their peers or family members, some fear that they are not doing a good job as a parent if they wait too long to potty train, others are pressured from their child’s daycare or preschool.  In addition, many parents are just tired of having to change diapers and eager to get on to this next stage in their child’s development.

For your child to be successfully toilet trained, however, he or she must be physically, cognitively and emotionally mature enough to understand and to control what is happening in the toilet teaching process.  If you begin to toilet training before your child is ready, chances are it will lead to a lot of frustration.  A child who is toilet trained much before the age of 2, usually has a parent who knows when to put the child down on the potty, and wait for the child to go.

Mark Wolraich, the author of the "American Academy of Pediatrics' Guide to Toilet Training," says that children typically begin to toilet-train between the ages of 18 months and 4 years. Some learn quickly and others take months. Many learn, and then regress. Accidents are common. Most children are daytime independent by age 4, but about  20% of 5-year-olds will still have some daytime accidents. Nighttime accidents can continue for much longer.  Wolraich says that the push for early training is more a reflection of parents' need for accomplishment than of any understanding of child physiology. "It's almost like a super-mom/dad issue," he said. "There's not been any evidence that children who get trained earlier are any smarter or more accomplished later in life.”

The AAP states that most child development experts believe that toilet training works best if it can be delayed until the child is ready to control much of the process herself.  Please remember that your child’s readiness for toilet training is not an sign of his or her intelligence, or your level of parenting ability! When your child is truly ready, physically, cognitively and emotionally, toilet training will happen much more easily.  It is important to go by your child’s cues for readiness.  The right time to begin this process will vary from child to child.

Signs of Readiness:

The more readiness signs that your child is demonstrating, the quicker and easier the toilet training process should be.  Look over the list below to help determine where your child is at in the readiness department.

Physical Signs:

Your child must have voluntary control of his or her sphincter muscles.  This means being able to open and close very specific internal muscles.  This gives your child the ability to delay excretion for a brief period of time. The AAP states that children’s sphincter muscles reach full maturity somewhere between 12-24 months with the average age being 18 months. While this is usually possible by about 18 months, this voluntary control only truly begins when a child can distinguish the sensations that precede a bowel movement or urination.  Due to this fact, most children will not be reliable until after the age of 2.

Your child is no longer excited about walking and being on his feet all the time.  He is at the maturity level where he is ready to sit down and learn a new task. Most children are at least 18 months, often older, before this happens.

Your child is more aware of his body and of the “need to go” (urinate or have a bowel movement) and shows it by facial expression, body gestures, telling you, and possibly going off somewhere (a corner of the room, behind furniture) when he/she feels the need to eliminate.

• Your child is able to stay dry for at least two hours at a time during the day.
• Your child often wakes up dry after a nap.
• Your child urinates a lot at one time vs. a little throughout the day.
• Your child usually does not have a bowel movement through the night.
• Your child starts to urinate and move her bowels at more predictable times.
• Your child does not like to be in dirty diapers and wants to be changed.

Cognitive and Verbal Signs:

Another sign that your child may be ready to be toilet trained is that he or she has good receptive language skills.  That means your child has the ability to understand what you are asking of him or her.

Your child can follow simple instructions.  For example, “Go to your closet and bring me back your red shirt.”

Your child can say the words “yes” and “no.”  She needs to have the ability to make her own decision about whether or not she is ready to use the potty.

Your child can express and understand one-word statements, including such words as “wet,” “dry,” “potty,” “pee,” “poop,” and “go.” Your child may even begin to tell you, “I peed.” Or “I pooped.”

Your child starts putting things where they belong. He may begin to pick up his toys. He may put his blocks in the box where they belong. He may start arranging and organizing things like his toys or his books.

Emotional and Social Awareness Signs:

Your child wants to please and imitate you. This natural ability to observe others and the desire to imitate them will help with the toilet teaching process.

• Your child expresses interest in using the potty or toilet.
• Your child wants to wear “big-kid” underwear.
• Your child has a desire to master one’s own body and environment.  “I want to do it.”

Motor Skill Signs:

• Your child can walk to and from the bathroom and help undress.
• Your child is able to pull underpants and pants up and down.

Tax Day 2007, My Birth Story

by Cheryl Petran CEO, Owner The Pump Station & Nurtury™

I was due on April 15^th, Tax day - but my little tax deduction decided to show up early. She was not about to make it easy on me – it was a taxing labor to say the least. I was grateful for what seemed like a pretty easy pregnancy.

I was due for a visit to my OB at 8 am Thursday April 12^th. My contractions started around 4 that morning. I had a feeling I would not sleeping at home that night. I arrived at my Dr.’s and was 2 cm’s dilated. She was confident she’d be seeing me at the hospital by the end of they day. She decided to monitor my daughter’s heart beat, all was good – then, I rolled over so they could adjust something (don’t remember what). That’s when things started to get scary – my daughter’s heart rate started to crash. They repositioned me on my back and her heart rate got back to normal. My Dr. said I should go home, get my bags and meet her at the hospital in about an hour. Lucky for me my Dr.’s office, hospital and home were all within 6 blocks of each other. Finally, living in LA - I didn’t have to worry about hitting traffic.

I was checked into the hospital by 10am and contractions were getting worse but I was not getting any more dilated.  I had never written up a birth plan as I was told by many – it would only disappoint me as things never seem to go the way you want in labor. I decided to “manage expectations” – don’t have any and I won’t be disappointed. I think it was around noon when she decided to give me Pitocin to help things move along a little faster. Again, they rolled me over and my daughter’s heart rate crashed again.  They re-adjusted me again- her heart rate was fine.

This was about the same time I told my husband not to worry about me not eating – I told him to go ahead and have some lunch.  One of my more memorable labor moments – laughing while he ate the Izzy’s Reuben as I sat there rocking and fighting off the urge to take an epidural. I know myself, I probably was not going to make it without it but I was determined to go as long as I could. I’m a big ole baby when it comes to pain.

A few hours later my parents had shown up and I still had not dilated any more. The pain was getting worse but I was fighting it. I knew I wasn’t going to make it much longer. It was then that my new Hungarian Dr. Friend (HDF) showed up with a heavy accent and an explanation of what I might expect from taking the epidural. I remember his words before he left the room “when you’re ready – I’ll be right outside – ready to come in and give you the shot”. I was relieved and decided to try and hold on longer. It was now about 3pm I think when I just couldn’t take the pain any more I asked the nurse to send him in – remembering his words – “when you’re ready I’ll be right outside…..” Liar, Liar Pants on Fire!

It was 30 minutes before he re-entered the room. I should have sent out my cry for help about 45 minutes earlier.  He prepped me for the epidural and asked my family to leave the room. My husband was going to stay – but I told him he should go with my parents and get some coffee. They left the room, the Anesthesiologist returned and prepped me for my shot. I was told by many – don’t look at the size of the needle and you’ll be fine. I should have listened.

Not sure what happened next but – I got the epidural, her heart rate crashed again and I was quickly inverted head and upper body positioned back, lower body up and I seem to remember some type of face mask.  Doors were closed and my husband came rushing in, not knowing what exactly had happened. My Dr arrived within a few minutes (she too lived a few blocks away) and said that’s it – we need to do a C-section. We were told that she was concerned about her working to get thru the birth canal – she could barely handle me rolling over so let’s not take any chances.

I was then prepped for surgery – more drugs. By the time I was brought in I was starting to feel sicker and sicker. My HDF was behind me over my head monitoring my meds. He was telling me to relax all would be ok. I was feeling sicker and humiliated at the thought that all of my privates were currently exposed to the world.  I’m generally very modest, still haven’t subscribed to the “Selfie” craze.  I began to vomit – my HDF started giving me ice chips. I kept thinking about being naked to the world (my world) at that time. I was still vomiting. Not one of my prettier moments.

The next thing I knew my husband was showing me a photo of my little girl. In the phone she just looked so big – I remember thinking, “wow, that big baby came out of me?”  I was still vomiting and now shaking non-stop. I was in no condition to hold my baby. Daniela Mary Petran was born at 7:12 that evening.  She was 19” long and weighed 6 lbs and 5 oz. She was not big – so basically the camera begins to add weight at birth? That’s just not fair.  

The next thing I remember is waking up in the recovery room around 11pm. I finally got to hold my baby but I was shaking incessantly. I gave her back to my husband (or was it the nurse??) I was terrified I’d drop her. I’m pretty sure they put her to breast but can’t remember as everything was so foggy.

It was a long and scary day. Taxing. For the longest time I thought of how I missed that precious opportunity to hold my baby skin-to-skin at birth. I had an insanely difficult experience breastfeeding – developed a horrible case of mastitis.  I felt I failed at so many things early on as a new mom. I wondered if I had damaged my little girl in those early moments of her life.

7 years later, I’m pretty sure that didn’t happen. On Sunday morning I landed in Boston with my little “tenacious D” (that’s what we call her). She was there holding her baby – tightly swaddled and staring into her eyes. She’s a good Mommy, she practices skin-to-skin, swaddling, soothing techniques (thank you Dr. Karp) and breastfeeding her doll. Yes, she breastfeeds her doll. She is a caring and nurturing mommy. I did something right.

I’m hopeful that some day when she has babies of her own she has a more pleasant birth experience. But if she doesn’t well that’s ok too…. Payback…..

Breastfeeding and Contraception – The Progesterone Controversy

Sara Twogood, MD

As an OBGYN, I was well aware of the intense post partum changes that I should expect from my own body.  The biggest challenge of all, and one that my medical experience didn’t prepare me for, was the sometimes painful, emotionally turbulent, and occasionally wonderful experience of breastfeeding. Happily, I was going to the breastfeeding support groups at The Pump Station & Nurtury™. They provided me with a wonderful blend of camaraderie and information. Much of that information was new to me, but I soon came to realize that there was at least one area about which my group-mates often had questions in which I was well versed. At almost every class, someone would ask about contraception choices – what was the best to use while breastfeeding? What was safe? Knowing I was an OBGYN, our group leader would defer these questions to me. There are certainly many possible choices, but the most controversial seems to be the questions surrounding progesterone. The lactation consultant would inextricably tell women that it would decrease milk supply, citing expert opinion and legitimate sources. The medical literature I was familiar with told me that progesterone would have no effect at all on breast feeding.

So which one was it? Are progesterone methods of contraception friend or foe to the breastfeeding woman?

I did a thorough medical search and found a ton of information (some helpful, some useless). I am clearly not the only person trying to answer this question.

Before I go through this information, let me get you up to speed with progesterone contraception.

Progesterone forms of contraception:

·      The progesterone only pill: AKA “mini pill”. It is a miniature version of the combined oral contraceptive pill (our beloved “the pill”). It’s miniature because it only contains one hormone – progesterone. The combined oral contraceptive contains a combination of estrogen and progesterone. Everyone agrees that the estrogen component decreases breast milk supply, so we aren’t talking about this pill now.  The other difference is that the progesterone only pill does not have a placebo week – you take a hormone pill every day, and your period comes when it wants to (ie irregular bleeding is common … as it is with all of these forms with progesterone only). 

·      Depo provera injection: an injection you get every 3 months. It gets a bad rep because it’s been linked to weight gain (not sure if it’s causal or an association only) and depression (in a small percentage of patients only). Some patients love it. Some hate it.

·      Nexplanon: the implant. Former incarnations are Norplant and Implanon. It’s a small rod placed under the skin of your arm and secretes a small amount of hormone daily over the course of 3 years. It’s one of the most effective forms of birth control on the market today.

·      The Mirena IUD also contains progesterone. You probably recognize the name of this IUD from commercials, although I can’t guarantee your life will be like the ads - all flowers and sunshine - with its use.

Progesterone types:

There are many different types of progesterone used for contraception – names like norethindrone, levonorgestrel, norgestimate. They vary slightly depending on the delivery method (swallowed, injected, etc), but are sometimes lumped together for ease of analysis.

What do the studies show?

I don’t want to bore you with the extraneous details (I bored myself reviewing some of this information) … but here’s the gist:

Lactation is made possible, in part, because of a sudden drop in maternal progesterone levels the first few days post partum. Addition of a progesterone at this time may, theoretically, halt this natural process.

Current evidence to support either argument is weak. The studies are not uniform. The outcomes are not consistent.

·      A large international study conducted by the WHO tells us that the use of progesterone contraception, in various forms (including the pill, the injectable, and the implant), will not affect breast feeding performance or rate of infant growth.

·      A small cohort of women reported a significant decrease in milk production after taking the progesterone only pill. When most of these women stopped taking the pill, their milk supply returned.

·      In a different study with the progesterone only pill, there was no change in milk volume in the first months after initiation. At 18 weeks of use, there was a 12% drop (compared to a 6% drop for women not using hormonal contraception). However, supplemental feeding was the same in both groups.

·      In a study of urban women, when Depo Provera (the 3 month injectable) was given immediately after delivery, there were no detrimental effects on duration of lactation, frequency of lactation, or timing of introduction of formula within the first 16 weeks post-partum.

Still confused?

I don’t blame you. I haven’t given you an answer because there is no straightforward answer.

My Counseling:

I believe that large studies show us, overall, that progesterone only contraceptives CAN be a good option. They are unlikely to have a detrimental effect on breast feeding or infant outcomes. This is the information your OBGYN will site. I know I have. BUT, and I urge to remember this, some women may be sensitive to progesterone. Lactation consultants see this sensitivity consistently and with more frequency than the literature suggests. Although the data is unpublished and at this point anecdotal, I believe it is enough to question progesterone only methods. Breast feeding is hard enough as it is ... your choice of contraception should not make it harder.

I suggest you proceed with caution:

·      Non hormonal methods of contraception will avoid any risk to your milk supply.

·      If you do decide a progesterone form of contraception is right for you, follow these guidelines:

o   Wait about 6 weeks after delivery before starting, so your milk supply is established.

o   Use a rapidly reversible form, like the pill. You can stop and reverse the effects (hopefully) if you do notice a drop in supply. With the option of Depo Provera, if you notice a drop in your supply, you can’t reverse the effects any faster than the 3 months it will persist. The implant and IUD are quickly reversible, but it would be a shame (both physically and cost effectiveness) to remove these shortly after insertion.

Get educated on all forms of contraception. Come to my class, Sex and Contraception for the Post Partum Woman July 18th at 1pm at The Pump Station-Hollywood to learn more!

I write about additional reproductive and fertility issues on Dr. Sara Twogood’s LadyParts Blog. Visit me at LadyPartsBlog.com

News from The Pump Station & Nurtury

Hello Pump Station & Nurtury™ Friends & Families, We have some exciting news to share with our great Moms and Dads in the Conejo Valley and across Los Angeles. Over the years, we have expanded from our flagship Santa Monica location into Hollywood and then the Conejo Valley so we could support more new moms with our world-class educational programs and lactation support, and maybe even sell a cute onesie along the way. We're more motivated than ever to continue our mission, and we've been working hard to figure out the best way to do it. As part of our planning, we've been listening to what you've been saying - which is that new moms want more of what we have to offer, closer to you. So we're excited to announce that over the next year we'll be opening up several new classroom locations across the Conejo and San Fernando Valleys, as well as in the South Bay and Pasadena areas, along with local lactation support services. As you know, we're a small, family-owned business, and while we've enjoyed some success thanks to your support over the years, we can't open up and operate stores all over Los Angeles - it's just too expensive. So we're rethinking how we do things, and one of the important issues we've been looking at is our Westlake Village store. As some of you may have heard, our lease at that location is up at the end of the summer. We have decided to close that location in August, but we're not going anywhere! We are finalizing partnerships with other great family-oriented businesses in the area to continue to offer our parenting support classes, and we will still be there to help new moms with our breastfeeding support services. We should be able to announce these within the next couple of weeks - we're just letting you know what's going on since the word was starting to leak out and we didn't want you to be concerned. So...we're still offering the same great classes, and consultations plus our breastfeeding support groups, with the same great teachers and nurses in the Conejo Valley. We'll just be doing it at more places. For anyone who is currently enrolled in any of our classes, we're continuing them as before. If for some reason our new locations don't work for you, we'll happily refund your remaining session balance once the move takes place, but we hope you continue to help us help you with your little ones. We have a lot more to talk about in the next few months, including new customer-service-friendly systems and a completely revamped website on top of our new classes and locations. If you have any questions please don't hesitate to ask our wonderful staff and they will do their best to address your concerns. Thanks for all your support; we hope you have a wonderful summer! Cheryl Petran CEO of The Pump Station & Nurtury™

Back to Sleep: SIDS & the Misconception of Choking

by Wendy Haldeman, MN, RN, IBCLC, Co-Founder of The Pump Station& Nurtury^™

New parents experience numerous emotions upon the birth of a new baby; overwhelming love, awe that something so small could be so very perfect, and fear that something might harm this little being. One such concern is the possibility of sudden infant death syndrome (S.I.D.S.) also known as crib death. The scary thing about S.I.D.S. is that the cause(s) is unknown. The good news is that there are a number of ways parents can protect their infants.

Research found that when babies were placed on their backs to sleep the baby was less vulnerable. The National Institute of Child Health and Human Development began a campaign in the 1990s called “Back to Sleep”. As a result over a 10-year period the incidence was reduced by 50%. In the past few years the rates for S.I.D.S. have not changed with over 2,000 infants experiencing crib death in 2010. Despite mass public awareness that infants must sleep on their backs, a new study has found that in the U.S. almost 30% of babies are placed on their sides or stomachs for sleep.

The Misconception of Choking

If parents are aware that back sleeping is much safer for their infant, why do they continue to go against this recommendation? Ask any parent and they will tell you that they are more afraid that the baby will choke. This misconception is perpetuated by anyone who raised a child prior to 1990 as everyone believed that babies were much more likely to choke if placed on the back. This is simply not true for healthy, full-term infants.

Image Credit: http://www.healthybabiesjacksonville.org/fear-of-aspiration/

Babies are anatomically protected in several ways against choking while lying on their backs. First off, when a human is placed on the back, the trachea (wind pipe) is on top of the esophagus (food pipe). If stomach contents come up the esophagus, the baby will cough to prevent anything from getting into the trachea. Infants placed on their stomachs are actually more likely to choke then if they are lying on their backs. Second, nature further protects young babies in a unique way. Until a baby is about 9 months old she is able to breathe and swallow at the same time. This is possible because the larynx (upper end of the trachea) and hyoid bone are higher up in the infant’s throat. As the baby matures, the larynx and hyoid bone move down, allowing for increased vocal ability.

Placing babies to sleep on their sides can be just as risky as stomach sleeping. Infants can easily roll onto their stomachs from a side position. To prevent this parents will often roll up blankets or use some other device to prop the baby. Unfortunately, blankets and sleep positioners can also become a smothering hazard. Bottom line, infants belong on their backs while sleeping with nothing in the crib except for the baby.

What you can do to help prevent SIDS
Although back sleeping appears to be the most effective measure a parent can take to provide for healthy sleep there are other strategies that can be effective in reducing the risk of S.I.D.S. Don’t smoke around the baby. Provide good air circulation around the baby’s little body. Avoid overheating. Babies who sleep in their parent’s room for at least the first 6 months are less likely to experience crib death. Pacifiers are also thought to help reduce the risk. And lastly, we would not be The Pump Station & Nurtury if we did not also mention that numerous studies have shown breastfeeding to be an important factor in protecting babies against a number of things including S.I.D.S.

Tips to Help Your Child Swim Like a Fish By Age 3

by Lisa Cook, Founder & CEO of KidSwim

Original Post from www.KidSwim.org, June 13th, 2014

Want a three year old fish? Here’s how to get one!

1.    Start them at six months of age. Don’t wait! It is perfectly safe for most babies to hit the pool by six months. If chlorine and sensitive skin is a factor, use a private pool as the chemicals are much lower. Overall though, I have seen very few reactions in all my years of teaching that would keep a baby from enjoying the water.

2.    Ideally you want your baby to experience the water consistently (consistency is THE KEY to swimming at an early age and becoming water confident by age three or four) starting at 6 months all the way up to age 3 with only small gaps of time off. (no more than a two month break)

3.    When it comes to a child's brain, spaced study is preferable to learning in shorter, more concentrated blocks of time. This means that babies and young children learn better and retain more by small doses over long periods of time rather than intense doses for short periods of time.

4.    Don’t be Martin Scorsese, meaning, don’t direct your child. Once they start exploring and experimenting, let them take the lead. Additionally, don’t be their teacher. Your job is to bond with them in a new environment. When your child transitions into formal lessons, let the teacher teach. You should simply enjoy the time in the pool with your kids whenever you get it, without an agenda.

5.    Playing IS learning. Don’t mistake play for ‘goofing around’ or ‘lack of focus.’ We all know children learn through playing and the pool is no different. In fact children are more incentivized to learn to swim when it’s attached to playing.

6.    Breathe! Breathe! Breathe! I can’t say this enough times in enough languages. Breathing is the SINGLE MOST IMPORTANT skill for being water safe. If you skip it and rush your child through a program that does not teach breathing, you are doing them a huge disservice in their later years of life.

7.    Stay with what works. When you find a teacher you like and your child adores, do your very best to stay with that teacher until your child is at least 4.

8.    The most crucial component of creating a swimmer by age 3 is starting at 6 months and keeping them exposed to swimming and pools during the ages of 18-36 months.If you can do this fairly seamlessly, you will have a 3 year old who is familiar with all things water, with swimming, and beginning skills so you can simply move forward without regressing.

9.    Age 2 is the most challenging year for children to accomplish new skills. They are battling their own egos and are emotional creatures. Many children learn to swim by age 2 but may plateau for a good six months before having another breakthrough. Don’t be discouraged and remember that in the big picture, it’s a small price to pay for the happy water lover you’ll get by age 3-4.

10. Don’t compare apples to apples. Remember that your ultimate goal is down the road, having a child who, by age 6 or 7 is swimming confidently, adept at all strokes, diving, treading, etc... There is nothing that indicates how well your child will or won’t swim at age 2 or 3... and if your friend’s child started swimming at 2 but yours didn’t swim until they were 3, I can guarantee that by the time both kids are 6 you wouldn’t even be able to tell which was which.

One last tip - please approach this adventure with a sense of fun. Of course safety is the biggest factor and we as parents must always be vigilant, but it is our responsibility to be the lifeguards for our children.  It is not our child’s responsibility to be their own lifeguard at such a young age. For them, it should all be about fun and exercise.  Lastly, avoid using floatation devices at all cost. They give children a false sense of security and they become a crutch that you eventually have to wean them off of.  Better to not even introduce it in the first place.

 _______________________________________________________________________________________________

 Looking for a swim class for your infant, child or yourself? Check out Lisa's classes! Click here...