TOW #39: Toilet training

Hope you are enjoying the fabulous spring weather this week! With all of the blooming, we can talk about a topic of toddler “blooming” (so to speak!)… toilet training. I'm grateful we've been done with the process for awhile at our house… and I can say it was pretty different for our two girls-each responding to a different general philosophy as described below. Attached are the case and discussion, thanks to our own fabulous gen peds development expert, Dr. Heather McPhillips, and a summary article.

Materials for this week:

Take home points on toilet training:

  1. Age of toilet training: Toilet training in the US has moved later in toddler years (combination of factors including availability of better disposable diaper options and children in child care settings). Average age at which toilet training begins has increased from earlier than 18 months to between 21 and 36 months. Some believe there is little benefit of intensive training before 27 months of age. Only 40 to 60 percent of children now complete toilet training by 36 months of age; the average age is 37 months.
  2. Earlier start is associated with longer time to potty train, but earlier completion: Generally the earlier that children start, the longer it may take to fully potty train. Earlier start has also been associated with earlier completion of toilet training. Girls usually begin and complete toilet training about 2-3 months before boys.
  3. Child-centered toilet-training approach: this is the most commonly used approach now in the US. As described by Dr. Barry Brazelton and recommended by the AAP, this approach suggests that children are more likely to be developmentally ready after 24 months. This approach follows the child’s lead, looks for developmental readiness cues and provides positive encouragement for attempts at toilet training but avoids forcing / coercing or any negative comments.
  4. “Train in a day” type approach: as described by Azrin and Foxx, this potty training "bootcamp" is often done in a dedicated day/weekend using an operant conditioning model with positive reinforcement and negative reinforcement for accidents. One element we found helpful at our house was to set a "potty timer" to remind when to go make an attempt-about every 45-60 minutes to avoid accidents.
  5. Different approaches work: both common approaches have been shown to work in practice to effectively teach typically developing children how to potty train. Different approaches are used around the world and can all be effective in context. In developing countries, some parents potty train children as early as 6 months based on parent use of watching infant cues and minimal to no use of diapers. We can help explore with families what they are comfortable with trying in their home.

TOW #38: Adolescent transitions of care

A big shout out for work on this topic goes to our own Dr. Peter Asante R3, a passionate advocate for improved transitions of care who has worked on this issue at Children's and in Toppenish as part of the REACH Pathway. Peter did a fantastic RCP on transitions of care last week and provided the teaching points below.

Every year, about 500,000 adolescents transition from pediatric to adult care. For children with special healthcare needs, this is the highest risk time for health complications and poor outcomes. Some studies have also shown that continued care at pediatric medical centers (after age 21) can lead to higher risk of mortality. Thus, it is important for medical providers to work with adolescent patients and their families to carefully transition from pediatric to adult care.

Materials for this week:

Take Home Points:

  1. Transition is a TWO Step Process: 1) Self-management: when the adolescent patient learns how to gradually assume the care of their own chronic medical condition, 2) Transfer of medical summary/ documentation.
  2. 2011 joint guidelines on transitions of care recommend the following schedule as a general guide:
  • Age 12-13: Start discussing the transition process with teens and parents. Provide a copy of office Transition Policy.
  • Age 14-15: Jointly develop a Transition Plan with youth and parents. During this time, providers should create a safe space within clinic visits for teens to start practicing self-management skills.
  • Age 16-17: Review and update Transition Plan, and prepare for adult care.
  • By age 18, youth understand and have experienced an adult model of care. Before actually transitioning to an adult provider, the teen and family can visit adult medicine practices, meet new providers, and decide who will be the best fit for their needs. Some may not be ready until closer to age 21.
  1. Six Core Elements of Transition include establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring, and integrating into an adult practice. Using these elements helps with implementing the goal of starting the conversation with families early and providing a standardized process. provides customizable forms on their website, which can be used to create many of the important documents needed in transition – e.g. Transition Policy, annual Transition Readiness Assessments, Plan of Care, Medical Summary & Emergency Care Plan.
  2. For medically complex adolescent patients who see multiple specialist providers for their care, this process will probably be more complicated, so it is encouraged that you start this process early!
  3. Other resources on transition to adult care include

TOW #37: Allergic rhinitis

‘Tis the season for stuffy noses – increasingly the allergic kind now, so a good time to review allergic rhinitis.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  • Epidemiology: Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
  • Clinical definition: Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks.
  • Differential: Top concerns include acute viral rhinitis, sinusitis, allergic rhinitis, nasal polyps, adenoidal hypertrophy, and foreign body.
  • Physical exam: Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease seen across the bridge of the nose in children who chronically push their palms upward under their noses (to wipe mucus).
  • Work-up: usually nothing is needed. Skin testing may help evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is better than blood testing, but still has false positives and requires clinical correlation with symptoms/triggers.
  • Management: Treatment options for AR are allergen avoidance, pharmacotherapy and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids -approved for kids >2. Next best are antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists (equally good as antihistamines). Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.

Enjoy the beautiful blooms – hopefully without too much sneezing!

TOW #36: Failure to Thrive

Next up in TOW-land: failure to thrive, another bread and butter pediatric topic to review. Some of the approach to this topic has evolved, including starting with less medicalization/work-up and reserving hospitalization to limited situations.

Materials for next week:

Failure to Thrive (FTT) take-home points to review:

  1. Diagnosis of FTT starts with appropriate growth measurement and correct data input on the growth chart/EMR. Re-measure when a child plots below the 5th percentile (or any measurement not tracking) to ensure accuracy. FTT can be missed or misdiagnosed due to incorrect measurement/ data input. In children less than 2 years of age, we use recumbent length (not height). Measure head circumference until age 3.
  2. Plot the growth trajectory on the appropriate chart. Use the World Health Organization (WHO) charts for children aged 0 to 2, Centers for Disease Control and Prevention (CDC) charts for children over 2, or a need-specific growth curve (e.g., premature infants, Down syndrome) available from the CDC.
  3. FTT is not considered a syndrome but is a physical sign of inadequate nutrition to maintain growth. It has several definitions: most common are being less than 3rd percentile weight-for-age on more than one occasion or crossing two major percentiles (90th, 75th, 50th, 25th, 10th, and 5th) downward. Being <80% of the ideal weight-for-age or <60% of the weight-for-length are also considered markers of FTT. Weight measurement is considered most important for defining FTT as it can provide an assessment of growth velocity trends. Be aware that shifts in percentiles can be normal in healthy developing children. In one study, between birth and 6 months of age, 39% of healthy children crossed two major percentile lines (up or down), as did 6% to 15% of children between 6 and 24 months of age.
  4. Use the history and physical to help differentiate FTT etiology: inadequate caloric intake, inadequate absorption, excess demand or inadequate utilization (or some combination). There are no routine lab tests for FTT and only 1-2% of diagnostic tests ordered in the hospital for FTT evaluation help to establish an etiology. If no obvious concerns on history or physical suggest medical disease, we can start nutritional and social therapy before obtaining more work-up (which might inlude CBC, urinalysis and lead levels). FTT due to low caloric intake will result in decreased weight followed by decreased height (stunting), and finally, if severe, decreased head circumference. Inborn errors of metabolism have a pattern of more symmetric decrease of all three growth parameters.
  5. Hospitalization for FTT should be limited to more severe cases not responding to intervention or for short stay where coordinating multidisciplinary care is considered most helpful. Note that in-hospital weight gain has been studied, and has not been shown to be sensitive or specific indicator for non-organic FTT.

TOW #35: Lower extremity disorders

March seemed to come in like a lion this week… but lots of signs of spring are showing! The UW cherry blossoms on the quad are scheduled to be in full bloom March 14th! As children "bloom" and begin walking, we and parents are assessing lower extremity disorders. So, here are materials to review about lower extremity / gait problems:

Take home points on lower extremity disorders to review:

  1. Lower extremity disorders of children are common: including clubfoot, flat foot, in-toeing, and toe-walking. They present commonly to pediatric offices and are a source of significant parental concern, but most are benign and resolve with time.
  2. The causes of in-toeing vary with age based on the different bones affected in the lower extremity. In babies, in-toeing is most often caused by metatarsus adductus, which is a flexible bending of the forefoot relative to the hindfoot, usually caused by intrauterine positioning. It is distinguished from clubfoot by passive flexibility to a neutral position and full mobility at the ankle. In toddlers, in-toeing is most often caused by internal tibial torsion. In children older than 3-4, in-toeing is most often femoral anteversion, and is sometimes exacerbated by sitting in a "W" position.
  3. Toe-walking carries a risk of Achilles contracture so flexibility of the Achilles should be evaluated and parents should be taught stretching exercises. Rule out muscular dystrophy (tire easily with running) and CP (usually can’t heel walk).
  4. A careful history and physical examination often yield the diagnosis. In most cases, imaging is not needed. Use a prone exam with knees bent at 90 degrees to evaluate hip internal and external rotation (which should be symmetric). Use thigh-foot angle to evaluate tibial position. Also evaluate for any leg-length discrepancy or hip misalignment. Be aware of Vitamin D deficiency as a possible cause of tibial bowing, especially after 18-24 months when physiologic bowing should be improving.  
  5. Most of these disorders can be monitored and resolve with growth. Flat foot, in-toeing, and out-toeing, usually only require observation and reassurance for parents. In comparison, clubfoot has a non-rigid curvature of the lateral foot and prompts referral for serial casting and occasionally surgical correction. For out-toeing, referral to ortho should be done at age 3-4 years in case casting is necessary, which is ideally completed before the start of kindergarten.