Admit it.

Before you became a parent, you never really gave much thought to other people’s poop.

Now you are captivated and can even discuss it over meal time: your child’s poop with its changing colors and consistency. Your vocabulary for poop has likely also changed. Before your baby’s birth, you probably used some grown-up word like “bowel movement” or “stool” or perhaps some “R” rated term not appropriate to this pediatric site.

We pediatricians have many conversations with new parents, and some not-so-new parents, about poop. Mostly this topic is of great interest to parents with newborns, but this issue come out at other milestones in a child’s life, namely when starting solid foods and during potty training.

Poop comes in three basic colors that are all equal signs of normal health: brown, yellow, and green. Newborn stool, while typically yellow and mustard like, can occasionally come out in the two other colors, even if what goes in, namely breast milk or formula, stays the same. The color change is more a reflection of how long the milk takes to pass through the intestines and how much bile acid gets mixed in with the developing poop.

Bad colors of poop are: red (blood), white (complete absence of color), and tarry black. Only the first stool that babies pass on the first day of life, called meconium, is always tarry black and is normal. At any other time of life, black tarry stools are abnormal and are a sign of potential internal bleeding. You should always discuss with your child’s doctor black poop, blood in poop (this is not normal), and white poop (which could indicate a liver problem).

Normal pooping behavior for a newborn can be grunting, turning red, crying, and generally appearing as if an explosion is about to occur. As long as what comes out after all this effort is a soft (normal poop should always be soft), then this behavior is normal. Other babies poop effortlessly and this, too, is normal.

Besides its color, another topic of intense fascination to many parents is the frequency and consistency of poop. This aspect is often tied in with questions about diarrhea and constipation. Here is the scoop:

It is normal for newborns to poop during or after every feeding, although not all babies go this often. This means that if your baby feeds 8-12 times a day, then she can have 8-12 poops a day. One reason that newborns are seen every few weeks in the pediatric office is to check that they are gaining weight normally. Good weight gain means that calories taken in are enough for growth and are not just being pooped out. While normal poop can be very soft and mushy, diarrhea is watery and prevents normal weight gain.

After the first few weeks of life, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days. Some breastfed babies actually decrease their poop frequency to once a week! These babies’ guts digest breast milk so efficiently that they are left with little waste product.

As long as these less-frequently-pooping babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then parents and other caregivers can enjoy the less frequent diaper changes. Urine frequency should remain the same (at least 6 wet diapers every 24 hours, on average) and is a sign that your baby is adequately hydrated. Again, as long as what comes out in the end is soft, then your baby is not “constipated” but rather has “decreased poop frequency.”

True constipation is poop that is hard and comes out as either small hard pellets or a large hard mass. These poops are often painful to pass and can cause small tears in the anus. You should discuss true constipation with your child’s health care provider. A typical remedy, assuming that everything else about your baby is okay, is adding a bit of prune or apple juice, generally ½ to 1 ounce, to the formula bottle once or twice daily. True constipation in general is more common in formula-fed babies than breastfed babies.

Adding solid foods generally causes poop to become more firm or formed, but not always. It DOES always cause more odor and can also add color. Dr. Kardos still remembers her surprise over her eldest’s first “sweet potato poop” as she and her husband asked each other, “Will you look at that? Isn’t this exactly how it looked when he ATE it?” If constipation, meaning hard stools that are painful to pass, occurs during solid food introductions, you can usually help soften up the poop by giving more prunes and oatmeal and less rice and bananas.

Potty training can trigger constipation resulting from poop withholding. This withholding can result in backup in the intestines which leads to pain and poor eating. Children withhold for one of three main reasons:

1. They are afraid of the toilet or potty seat.
2. They had one painful poop and they resolve never to repeat the experience by trying to never go again.
3. They are locked into a control issue with their parents. Recall the truism “You can lead a horse to water but you can’t make him drink.” This applies to potty training as well.

Treatment for stool withholding is to QUIT potty training for at least a few weeks and to ADD as much stool softening foods and drinks as possible. Good-for-poop drinks and foods include prune juice, apple juice, pear juice, water, fiber-rich breads and cereals, beans, fresh fruits and vegetables. Sometimes, under the guidance of your child’s health care provider, children need medical stool softeners or laxatives until they overcome their fear of pooping. For more information about potty training we refer you to our post with podcast on this subject.

Our goal with this blog post was to highlight some frequently-asked-about poop topics and to reassure that most things come out okay in the end. And that’s the real scoop.

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®

Gas is another topic most people don’t think much about until they have a newborn. Then suddenly baby burps and farts become a huge source of parental distress, even though parents are not the ones with the gas. It’s the poor newborn baby who suffers, and as all parents know, our children’s suffering becomes OUR suffering.

So what to do?

Here’s what to do if your young baby is bothered by gas:

• Start feedings before your infant cries a long time from hunger. When infants cry from hunger, they swallow air. When a frantically hungry baby starts to feed, they will gulp quickly and swallow more air than usual. If your infant is wide awake crying and it’s been at least one or two hours from the last feeding, try to quickly start another feeding.
•  Burp frequently. If you are breastfeeding, watch the clock, breastfeed for five minutes, change to the other breast. As you change positions, hold her upright in attempt to elicit a burp, then feed for five more minutes on the second breast. Then hold your baby upright and try for a slightly longer burping session, and go return her to the first breast for at least five minutes, then back to the second breast if she still appears hungry. Now if she falls asleep nursing, she has had more milk from both breasts and some opportunities to burp before falling asleep.
•  If you are bottle feeding, experiment with different nipples and bottle shapes (different ones work better for different babies) to see which one allows your infant to feed without gulping too quickly and without sputtering. Try to feed your baby as upright as possible.
• Hold your infant upright for a few minutes after feedings to allow for extra burps. If a burp seems stuck, lay her back down on her back for a minute and then bring her upright and try again.
•  To help expel gas from below, lay her on her back and pedal her legs with your hands. When awake, give her plenty of tummy time. Unlike you, a baby can not change position easily and may need a little help moving the gas out of their system.
• If your infant is AWAKE after a feeding, place her prone (on her belly) after a feeding. Babies can burp AND pass gas easier in this position. PUT HER ONTO HER BACK if she starts to fall asleep or if you are walking away from her because she might fall asleep before you return to her. Remember, all infants should SLEEP ON THEIR BACKS unless your infant has a specific medical condition that causes your pediatrician to advise a different sleep position.
• Parents often ask if changing the breast feeding mother’s diet or trying formula changes will help decrease the baby’s discomfort from gas. There is no absolute correlation between a certain food in the maternal diet and the production of gas in a baby. However, a nursing mom may find a particular food “gas inducing.”  Remember that a nursing mom needs nutrients from a variety of foods to make healthy breast milk so be careful how much you restrict. Try any formula change for a week at a time and if there is no effect on baby gas, just go back to the original formula.
• Do gas drops help? For flatulence, if  you find that the standard, FDA approved simethecone drops (e.g. Mylicon Drops) help, then you can use them as the label specifies. If they do not help, then stop using them.
• Do probiotics help? Unfortunately there is not a lot of data about probiotics to treat gas in infants. Probiotics can help other pediatric conditions such as the duration of acute diarrhea, and while deemed mostly harmless in otherwise healthy infants, they have not been shown to affect gas. A 2010 American Academy of Pediatrics summary of the use of probiotics in kids can be found here. A  2016 review of use of probiotics used for colic (but not specifically gas) in breast fed infants showed that probiotics MIGHT decrease crying, but concluded that more research is needed before probiotics can be recommended. Now, if you actually do have a REAL little piggy (not just a nickname for your baby),  animal studies show that probiotics may cut down on gas.

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®, updated from 2011, 2015

NOTE: Recommendations about rear facing car seats have been updated since the publication of this post. Please link here.

This photo above is a horrific yet terrific reminder of why we strap our kids into car seats. This child was buckled into a car seat when the unthinkable happened— a potentially lethal car accident. As you can see, the child’s bruises directly line up with properly-applied car seat restraints. Thankfully, the injuries to this child are only skin-deep. On the other hand, the photo below shows what happened to the car.

Please remember always to travel with your children properly restrained.

For maximum safety in cars:

• Keep children in rear facing car seats until age two years. Usually they will outgrow the baby car seat that you brought them home in and you will need to install a new rear facing car seat before they reach two years. Check the weight/height limits for the seat.
• Keep them in the car seat until age five years, or until they outgrow the weight or height limits set forth by the car seat manufacturer.
• Use a booster until your children are 4 feet 9 inches or until the car’s shoulder seatbelt falls naturally across the chest (not the neck) and the lap belt lies low across their hip bones (some kids are in boosters to age 10 years and beyond).
• Keep infants and children in the back seat until at least age 13 years.
• Don’t drive while distracted or sleep deprived. Children learn from watching their parents. Emulate now the way you want your 16-year- old to drive.

Your can read more details on car seats and seat belts on the CDC (Centers for Disease Control) website here.

Read about guidelines for child safety restraints on airplanes here.

Julie Kardos, MD and Naline Lai, MD

© 2017 Two Peds in a Pod®, photos used with permission

A few years ago, we asked our dad readers to help us write our Father’s Day post.  We thought you would enjoy hearing from them again. The dads completed this thought: “Before I became a dad, I never thought I’d…”

…Learn to curl hair for cheerleading competitions

…BE RESPONSIBLE

…Become a stay at home dad AND love it so much after everything I’ve been through!!

…Learn all of the names of Thomas The Tank Engine’s friends and the many songs associated with them.

…Have a toys r us in my house.

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

…Volunteer in a dunk tank and have pie thrown at me.

One of our readers summed up his thoughts on becoming a dad:

Since I’ve become a father, nearly seven years and two beautiful daughters later, my life has become a series of jobs that I never thought I would have to tackle. These include:

Beautician: I never thought in a million years that I would be learning how to do pony tails, side pony’s, braids (not that I can braid yet), and painting little finger and toe nails.

Disney Princess Aficionado: At one point in my life I thought I was cool because I knew a lot about beer, how it was made, where it was from, where the best IPA’s were being poured. Now I am “cool” because I know where Mulan lived, and because I know the story about Ariel falling in love with Prince Eric.

Doctor: I am well versed here and can cover almost everything from the simple band-aid application and boo-boo kissing, to the complex answering of why daddy is different and why he gets to go to the bathroom standing up.

Cheerleader: Both of my daughters enjoy participating in sports. It’s been such a great experience to cheer them both on from the side line. I enjoy watching them grow with the sport and gain confidence game after game.

Becoming a father was one of the best choices I have made with my life. I love being a dad, and I look forward to the future dad challenges, good and bad, and being the best mentor I can be.

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

©2014, 2017 Two Peds in a Pod®

Today we bring you a fierce depiction of maternal love, written by poet Catherine Pierce PhD- who is Dr. Kardos’s sister-in-law.
We hope your Mother’s Day is full of flowers and free of tornados.
–Drs. Lai and Kardos

The octopus parent never had a problem splitting attention among the kids until the 9th came along.

You sit down to breast feed your newborn, when your three-year-old announces, “I have to go potty! And I need HELP!”

You are giving your newborn a bottle and your two year old starts eating the dog’s food out of the dog’s bowl.

 Ways to entertain the first born:

Turn Feeding Your Newborn into a special treat for your older child. Say, “Oh YES! It is time to feed the baby, now we can…” Complete with whatever special treat your older child would enjoy:

…look at the Elmo flap book and open EVERY SINGLE FLAP as often as you want.

…listen to you sing every song from Frozen.

…listen to you tell every joke that you’ve ever learned.

…watch Peppa Pig together! And I will not fall asleep this time.

…bring out the special colored pencils for you to use that we only take out while we feed the baby.

… continue this long chapter book that we save for the times we feed the baby.

… take out this special puzzle that we only take out when the baby eats.

You get the idea. Now, instead of your saying, “Sorry Honey, we have to stop playing now because Baby has to eat,” you can make the experience a special privilege for your older child.

If your older child is napping during a feeding, then of course you can reward yourself with reading Two Peds in a Pod’s back posts during the feed!

Julie Kardos, MD and Naline Lai, MD

®

Nearly seven years ago, on the swimming pool bleachers at the local Y, I happened to sit next to Lexi Logan. Above the echoing din of kids splashing, I discovered that although she was trained as a painter, Lexi was interested in branching out into photography. Coincidentally, Dr Kardos and I were interested in branching medicine out into a new media called the internet and were dismayed at the lack of publicly available photos to accompany our blog posts. Lexi and I intersected in the right place at the right time. Since that chance meeting, Lexi has generosity shared dozens of photos with Two Peds in a Pod.

The woman in the photo below, between your Two Peds (Dr. Kardos with the curly hair, Dr. Lai with the straight hair), is our photographer extraordinaire, Lexi Logan. Her work, which you can check out at www.lexilogan.com,  speaks for itself.  Local peeps may want to contact her to take their own family photos.

This Thanksgiving we say thanks to all those parents we’ve ever sat next to on bleachers. All the kid-related information we have learned, from navigating chorus uniforms, bus stop times, best teachers, fun summer camps, and even starting up blogs, has been invaluable.

In particular- thank you, Lexi!

We wish all of our readers a very healthy and happy Thanksgiving,

Dr. Naline  Lai with Dr. Julie Kardos

©2016 Two Peds in a Pod®

Can you pick out the jaundiced one?

Pediatricians often cringe when they find newborns swathed in a yellow blanket. The color always seems to accentuate a baby’s jaundice and we’re not fond of jaundice.

Jaundice, an orange-yellow coloration of the eyes and skin, is caused by a blood breakdown by-product called bilirubin. We all break down blood, but it’s more difficult for the newborn’s liver to process it into a form that his or her body can get rid of.  Eventually, we get rid of bilirubin  by peeing and pooping it out. Bilirubin is what gives the yellowish color to urine  and stool.

Why do we care about jaundice? In the 1950s and ’60s, infants who had died from a neurological issue called kernicterus were found to have extremely high levels of bilirubin (jaundice) – up into the 100s of mg/dl. High levels of bilirubin can cause hearing and vision issues. Even at lower levels, jaundiced babies tend to be more sleepy and eat sluggishly.

Nowadays, for a full term baby,  we generally let the bilirubin level rise to 20 mg/dl at most before starting treatment, and often we treat even earlier. More than 60% of newborns appear jaundiced in the first few days of life,  but most never need any special treatment because the jaundice self-resolves. Conveniently, the first line of treatment is simply feeding more: the more milk that goes in, the more pee and poop that comes out, bringing the bilirubin with it. If improving intake does not lower the bilirubin enough, the next step is shining special lights  (phototherapy) on a baby’s skin.

Jaundice first starts noticeably in the eyes and face. As bilirubin levels rise, the yellow (jaundice) appears more and more down the body. Yellow in the face of a newborn is expected. If you see yellow in the belly, call your pediatrician. Levels naturally rise and peak in the first few days and we have graphs and apps to predict if the bilirubin may reach treatable levels.

Some babies are more likely to have higher bilirubin numbers and thus appear more yellow:

• Premature babies, because they have immature livers.
• Babies who have different blood types than their moms. Certain blood type differences can cause some breakdown of blood even before a baby is born, therefore increasing chances of an elevated bilirubin after  birth.
• Babies who acquire bruising during delivery; they have more blood to break down.
• Be aware, there are a few other less common risk factors,  and if needed,  your pediatrician may address them with you.

Hydrating your baby will help jaundice. You should watch the number of wet diapers your newborn has in a day. Wet diapers are a sign of good hydration. In the first week, she should have about one wet diaper for every day of life (so on day of life one= one wet diaper, day of life two=two wet diapers, etc). Also  watch for bilirubin to start coming through the stool. At first, your baby will poop out the black stool called meconium, but as milk starts going through her system, expect the stool to turn yellowish. (click here for more information about the colors of newborn poop) . As with the urine, look for one bowel movement for every day of life (so day of life one=one bowel movement diaper, day of life two= two etc). Eventually some newborns poop every time they are fed, although some max out at 3 or 4 bowel movements per day.

So, if you hold up your newborn baby in a yellow blanket to show your pediatrician and call the baby “our little pumpkin” you’ll know why she raises an eyebrow.

Click here for other fun medical color facts.

Naline Lai, MD and Julie Kardos, MD

© 2016 Two Peds in a Pod®

Revised from July 24, 2016 at 10:58pm

The prom preparation aftermath

It’s not your imagination: baby and toddler nails are funky and warped. Now add the fact that babies and toddlers wiggle and squirm, and taking care of your young child’s nails will appear to be a daunting task.

Even soft newborn finger nails leave significant scratches on newborn faces. Newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to underlying skin. A nail clipper can not get underneath the edge of the nail easily. We recommend using an emery board or nail file for the first few weeks of nail trimming. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first three months at a rate of about one ounce per day, and they grow in length at a rate of about an inch per month. Their finger nails grow rapidly as well and therefore need trims as often as two or three times a  week. Toe nails grow quickly as well but because they do not cause self-injury, infants seem to be okay with less frequent toe nail trimming.

Once the nails are easier to grab, you can advance to using nails scissors or clippers. Dr. Kardos used to hold her babies in a nearly sitting position on her lap facing outward. Once you have a good hold, gently press the skin down away from the nails and then clip or cut carefully.

Unfortunately, no matter how careful you are, many well-intentioned parents end up cutting their child’s skin at some point. Both Dr. Kardos and Dr. Lai have nicked their kids accidentaly. Dr. Kardos recalls snipping a bit of skin from one of her twins when he was a few months old. Picture a tiny benign paper-cut that seems to cause a disproportunate amount of bleeding. He wasn’t even all that upset, but the guilt! If you accidentally cut your child, wash the cut with soap and running water to prevent infection and apply pressure for a few minutes with a clean wash cloth to stop the bleeding. Avoid band-aids: they are a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing  kids heal wounds rapidly.

While Dr. Lai gave most of her kids manicures while they were sleeping, Dr. Kardos trimmed her kids’ nails while awake to get them used to the feeling of a “home manicure.” She likes to think this practice avoided some later toddler meltdowns over nail trimming. However, as she found out in one of her three kids, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet, trim we must! Clip an uncooperative toddler’s nails about 10-20 minutes after she has fallen asleep- this, or wait until you have another adult at home with you. Have your helper hold onto your child’s hand or foot while distracting the toddler with singing, book reading, or watching a soothing video together. Then you can (quickly) trim nails.

However, even in infants, the sides of big toe nails grow into the skin. Luckily the nails are very soft, and with some soaking in warm water, you can pull the skin away from the nail and cut the nail to avoid having them dig in and result in infection, or paronychia.

While it’s tempting to complete your child’s mani-pedi with a coat of nail polish, keep in mind that a young children spend a lot of time with their hands, and their toes, in their mouths.  We’ve seen kids as old as ten years bite on their toe nails. Unfortunately, the nail polish on your bureau may contain toxic hydrocarbons such as toluene and formaldehyde. Even non-toxic nail polishes will still contain dyes, and just because a manufacturer uses the term non-toxic, it doesn’t necessarily mean a product is absolutely harmless. There are no specific standards for the use of the term non-toxic.  Bottom line, the only route that avoids any chemicals is not to apply any polish in the first place. (If you are wondering about any cosmetic, the California department of public health keeps a database of cosmetics with ” ingredients known or suspected to cause cancer, birth defects, or other reproductive harm.” )

Who ever thought parental obligations would include cutting someone else’s finger and toe nails? If you haven’t perfected the process yet, take heart.  You’ll have plenty of practice over the years, and if you are lucky, you’ll get a chance like Dr. Lai did last weekend to help prep nails for the prom.

Julie Kardos, MD and Naline Lai, MD

© 2010, rev 2016 Two Peds in a Pod®

Squeezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. Few babies begin with a flat head. But as parents put babies on their backs to sleep in accordance with Sudden Infant Death Syndrome prevention guidelines, babies are developing flat heads. 

Called positional plagiocephaly, a young infant’s head flattens when prolonged pressure is placed on one spot. Tricks to prevent positional plagiocephaly all encourage equal pressure over the entire head. Because babies’ heads are malleable, parents can prevent and treat the flatness. In fact, the flat shape begins to correct itself as babies spend less time lying down and more time sitting and crawling. Additionally, increased hair growth hides some of the flatness.

To prevent positional plagiocephaly, place your baby prone (belly down) frequently WHILE AWAKE, starting in the newborn period. This tummy time decreases pressure on the back of the head. Some babies are not fond of tummy time and will cry until they are back on their backs.  For those kids, check out our post on making tummy time more tolerable for your baby.

Encourage your baby to look to both sides while lying down. Too much time turned to one side will cause flattening on that side. Alternate how you place the baby in crib so that sometimes she turns to the right and other times she turns to the left to face into the room and away from the wall. If your baby seems to prefer looking only to the right or only to the left, place toys or bright objects toward the non-preferred side. If bottle feeding, switch off which arm you use to feed your baby, so that the baby sometimes turns to the right and sometimes to the left . If breastfeeding, start and end on the side that the baby tends to avoid. These actions will help prevent neck muscles from becoming too tight on one side and thus allow your baby to turn easily to both sides.

Some babies wear helmets to correct their abnormal head flattening. Neurosurgeons, who are head and brain specialists, and plastic surgeons prescribe these helmets for babies who have extreme flattening. Fortunately, the majority of babies with positional plagiocephaly do not need to wear helmets.

You also may have heard of babies who need corrective surgery for an abnormal head shape. This condition, called craniosynostosis, is rare. Pediatricians monitor the size and shape of the head , check the soft spot on the top of the head and for ridges on the skull at every check-up. A baby’s skull develops in pieces as a fetus, and these pieces eventually come together at predictable places called sutures.  If the pieces come together too early or the soft spot closes too soon, corrective surgery may be needed.

So, avoid head flatness by rotating your baby’s position frequently (think rotisserie chicken!) and provide plenty of “tummy time” when awake. Start when the baby first comes home.

If you are worried about your baby’s head shape, just head on over to your baby’s pediatrician and bring up your concern. It is unlikely that your concern will “fall flat.”

Julie Kardos, MD and Naline Lai, MD