(Scroll to the bottom for a video option with Dr. Shriver)
Becoming a first-time mom in 2008 quickly (and sometimes agonizingly) provided me with an important perspective on my job as a primary care pediatrician. With my own babies, I’ve struggled through sleepless nights, waded through dirty diapers, and spent endless hours worrying about coughs, fevers, and fussiness. These tribulations shaped my perspective as a pediatrician and gave me empathy to help my patients and families through struggles.
But it wasn’t just the parenting experiences that shaped my medical practice. The wise and insightful training from my pediatric mentors had a huge impact on the way I practice medicine. One of the most influential mentors I had, Dr. Barton Schmitt, taught me about what he called the “seven deadly sins of childhood.”(Schmitt B. Seven Deadly Sins of Childhood:
Advising Parents About Difficult Developmental Phases. Child Abuse & Neglect: 1987; 421-432). OK, so, they aren’t really “sins.” He taught me that certain common but difficult childhood developmental phases can cause extreme stress on parents. In worst case scenarios, these issues can lead to child abuse. Now that I am a mom and a pediatrician, I understand the power of knowing the seven deadly sins of childhood and how important it is to discuss them with families. Gazing at this “crystal ball” of common childhood difficulties is a way to promote positive parenting and keep kids safe and healthy.
So, what are the seven deadly sins?
OK, so this term is a bit “20th century.” Doctors try not to use the term colic anymore. The outdated term “colic” refers to a prolonged increase in fussiness and crying in infants in the first 3 months of their life, with no obvious source, that is difficult to soothe. I was taught about the “3s” of colic in my training: starts at 3 weeks, ends at 3 months, more than 3 hours per day, more than 3 days per week. In the 21st century we call this “the period of PURPLE crying”. Why was the name changed? One reason is that the word “colic” implied some sort of disorder or illness in the child. Using a word like “period” lets families know this is a normal developmental phase many infants experience, and, reassuringly, it has a beginning, middle and end. PURPLE is actually an acronym that stands for:
- Peak of crying (may peak at 2 months but go as long as 3 months)
- Unexpected (parents can’t predict or explain when the crying will occur)
- Resists soothing (babies may cry despite being fed/burped/changed/swaddled/cuddled)
- Pain-like face (babies may look and sound as though they are in pain even though they are not)
- Long-lasting (crying can last for 3 or more hours per day)
- Evening (fussiness is most common and prolonged in the evening or nighttime hours).
What can caregivers do to make it through this period?
- Know you are not alone. Both of my children went through a “period of PURPLE crying,” and boy, it was exhausting and nerve-wracking! Hearing the non-stop cries of my infant sent waves of electric shocks up my spine.
- Get some tools! We read The Happiest Baby on the Block by Dr. Harvey Karp (there’s a video, too!). We learned the 5 S’s for soothing a fussy baby: Swaddle, Sideways, Suck, Swing, Shush. This resource saved our sanity as new parents. My hubby said it was the best thing he did to prepare for new fatherhood (even better than infant CPR!). It didn’t work every time, but it helped us understand what was happening to our child and gave us tools to help work through the difficult time. Our “shushing” noise was the bathroom fan, although we learned about vacuums and hairdryers as well. Now, in the 21st century...there’s an app for that! Also you can buy a shusher. I love these! They sound like a dude’s voice shushing. It’s pretty cool.
- Take a break. If you’ve fed, changed, and cuddled your baby, and you’ve tried the 5 s strategy, and nothing’s working, then put your baby in her crib or car seat, leave the room, and cool down for a few minutes. She’ll still be there when you return!
Dr. Schmitt taught me that nonstop crying is the most common reason for serious physical abuse. This is the most common time for Shaken Baby Syndrome. Now I share my medical wisdom and parent experience with my families to help them successfully navigate this treacherous and potentially dangerous period of child development. Knowing what to expect in those first three months is essential!
2. “Trained Night Feeding/Crying.”
Aside from constant fussiness, there’s nothing more frustrating for parents of infants than multiple nighttime awakenings. Trained Night Feeders/Criers are infants older than 4-6 months who wake up (often many, many times) to eat or just to be held. It is unbelievably difficult to resist the urge to go in and comfort your baby when they cry for you. But the truth is, 95% of babies are developmentally able to sleep eight or more hours a night after six months. Some infants can’t soothe themselves back to sleep. Some just love the cuddle time. Some infants are sick with ear infections or colds at this age and continue to call to their parents even after they are better.
Months and months of interrupted sleep for parents is enough to make any of us lose our cool. So, what do we do?
- Establish good sleep hygiene for the infant. This means a bedtime routine that happens at the same time each night and involves the same soothing nighttime activities. For example, snuggling with your infant in a soft chair, feeding her, cuddling her, reading to her, and singing to her can be part of the routine.
- Try to put her to bed drowsy but awake. This is a challenge, because a lot of babies fall asleep nursing! Nobody said teaching babies to self-soothe would be easy! Keep the mantra “drowsy but awake” in your head and keep trying.
- You may need to shorten daytime naps if they are long. Infants 4 to 12 months need 12 to 16 hours of sleep per day including naps.
- Try infant sleep training. There are several methods for sleep training for infants older than 6 months. The “Controlled comforting” method involves putting your child to bed drowsy and waiting a set amount of time before returning to comfort her. Start with 5 minutes, then go in and soothe her gently without picking her up. Stay for less than a minute and then leave. Return if needed at greater and greater intervals (10 min, 15 min, 20 min) until she soothes herself to sleep. The “Camping Out” method, a great one for anxious infants, involves lying in on a mattress or cot next to your baby’s crib until she falls asleep. Over time, move your mattress farther away from the crib, eventually out of the doorway and into the hall over a period of 1 to 3 weeks. This method works great for older children who are fearful or foster children who may initially feel nervous in a new environment. The “Cry it Out” method involves putting your infant to sleep drowsy but awake, and then letting them cry until they eventually put themselves to sleep. Parents need to decide which method works best for them. The AAP Parent website has a lot of great sleep books for parents. Remember, the AAP says it’s not safe to bed share. Always place your infant on her back for sleeping, and provide a safe sleep environment with a firm, flat mattress and no other pillows, blankets, bumper pads or stuffed animals.
3. Separation Anxiety
Does your toddler cry when you try to sneak away for a moment to go to the bathroom? Mine did! That’s a normal part of child development called separation anxiety. Even infants as young as 6 months can exhibit this behavior. The “bathroom dilemma” usually resolves when children reach 16 months of age, but toddlers will still experience “stranger anxiety”, or crying when left with an unfamiliar caregiver, until about 2.5 years old. It’s essential for parents to understand these normal child behaviors so they don’t think the child is spoiled or anxious.
What do we do about this stage?
- Understand normal development. Toddlers are going to do this! Trust me; I see stranger anxiety every day in my clinic when families bring their 15 and 18 month children in for exams!
- Reassure children. This isn’t bad behavior; it’s normal! I always place the child on a caregiver’s lap during these exams to help ease the child’s nervousness. (Note: it doesn’t always help!). Many children experience separation anxiety at daycare. Caregivers should have a warm but brief goodbye with mention of when they will return.
- Games like Peek-a-boo and hide-and-seek actually help children develop needed independence skills.
- Parents who understand this challenge can try to leave rooms slowly rather than abruptly to try to prevent crying fits.
- Don’t use “go to your room” as punishment at this age. Separation is not an effective form of discipline early on and can be very upsetting to toddlers.
4. Normal Exploratory Behavior
What’s a toddler’s favorite game? Take stuff out of boxes, cupboards and purses! Toddlers love to explore, and in doing so, they love to make messes. This constant mess-making can really drive caregivers nuts. But sometimes this exploring is more than just messy—it’s dangerous! I’ve cared for toddlers injured by toppling TVs during this developmental stage.
What do we do?
- Keep them safe. Make sure you’ve installed gates on stairs, locks on windows and cabinets, and removed curtain cords and tablecloths. Keep your bag or purse up high so your child can’t get to it. And secure TVs and other large furniture so they won’t fall on your child.
- If it’s valuable, move it! Don’t leave your crystal vases or expensive stereo system within reach of your toddler!
- Keep a close eye on them, and know how to distract them.
- This is a good time to use the word “no”! I try to use it selectively with my children so they actually pay attention when I say it. I save it up for times when their behaviors put them in danger.
- Exploring builds brains. Make sure you give them opportunities to play with kitchen utensils, Tupperware, pots/pans, newspapers, and other fun (but safe!) items.
5. The Normal "No's"
Between 18 months and 3 years, children tend to be a bit…contrary. Much to our chagrin as parents, they love to refuse our requests to put clothes on, get into the car seat or go to bed. Although this behavior is supremely frustrating for parents, it is a normal part of a child’s development. It allows a child a chance for self-determinism and independence. Child refusals can drive a parent up a wall, but they don’t have to!
How do caregivers deal with this “no” phase?
- Maintain a good sense of humor and perspective. They are not being naughty, but simply testing the limits of their independence. Try to keep mentally wearing that T-shirt that says “Keep Calm and Parent On.”
- Minimize rules. Make sure the dictates you have for your kids make sense and are important. If you have too many picky rules, your child may stop listening to you.
- Give your child choices. Rather than asking, “Shall we read a bedtime story?” ask “Which bedtime story should we read?” Likewise, avoid “Will you put your shoes on?” and instead say “Which one first? Shoes or coat?” Choices help a child feel independent and can (sometimes) avoid parent/child struggles.
- Kids need transition time. When you are approaching bedtime, or time for daycare, or another transition, give your child a 3-minute and 1-minute warning to help them prepare for the next activity. They will be less likely to refuse!
6. Decreased Eating/Picky Eating
Toddlers and preschoolers are notorious for “eating like a bird.” Parents can pull their hair out over eating concerns, so it’s helpful to know that it’s normal for a child’s appetite to fall off a bit between 18 months and 3 years. Some children will begin to refuse foods they previously liked. It’s a guessing game if a child is going to like their meal on any given night.
How can caregivers manage these food concerns?
- Consult the doc. Make sure your child’s growth chart is progressing. Your pediatrician will advise you that eating less in toddlerhood is normal because children are growing at a slower rate.
- Monitor milk (and other beverages). Kids who drink more than 24 ounces of milk per day will eat less food, so limit the milk intake. 21st Century advice from the AAP: limit or eliminate juice altogether.
- Promote healthy meal hygiene. That means encouraging 3 meals and 2 healthy snacks per day. Try to eat as many meals as possible together as a family for the benefit of routines, relationship building, and modeling of good eating behaviors.
- Don’t panic, don’t force it. Make mealtime enjoyable. A caregiver’s job is to provide healthy meals, and the child’s job is to decide the quantity. Don’t make mealtime a torture but give positive reinforcement for good eating behaviors. Reject the old-school “finish your veggies or you can’t leave the table” mantra. I often tell families that good nutrition is a marathon, not a sprint. The goal is to instill healthy eating habits and education on nutrition for your children so that when they make their own food choices, they are healthy ones.
7. Toilet Training Resistance
In an ideal world, our toddlers would say, “Hey mom, I’m ready to potty train!” and immediately and effectively use the toilet. In the real world, parents run into many stressful barriers to successful toilet training. Toddlers can be daytime wetters, daytime soilers, or stool holders (like my second child!). I didn’t realize how aggravating this issue was until I lived through it.
Here’s my best advice for this frustrating developmental issue.
- Assess readiness. Most toddlers will be ready to potty train after 24 months, although a handful will be ready sooner (as soon as 18 months). Some children may be intellectually ready (they know they have to go, and they know what a potty is used for, and how to stay dry), but it is important to gauge emotional readiness as well. Is a child cooperative and interested in pleasing parents? That’s a good sign of readiness! If a child is still in the “Normal No’s” phase, or if a new sibling has joined the family, it may be better to wait.
- Talk about the potty. There are great books to read about potty training (10). Parents can discuss their own bathroom use.
- Make the potty accessible and fun. Some kids will like a toddler-sized potty, while others will prefer a child seat on an adult-sized potty. A 21st century tip: some potty chairs will make noise or sing!
- Try positive reinforcement and get creative! Avoid rewards with candy and treats. Sticker charts and praise work well for most kids. In the past I’ve expressed my delight by taking a photo of my child’s “accomplishment” and texting it to Grandma! One story I tell to toddlers in my clinic is that when we put our poops in the potty, they go down to the pipes below the house and have a super-fun Poop Party! The poops in the diaper are sad because they don’t get to go to the party.
- Stay cool and don’t stress your toddler out about accidents. Hey, poop happens! Yelling at toddlers about stooling will not improve outcomes.
- Watch for stool holding and constipation. Talk to your doctor if you suspect your child is holding on to stools. They may need stool softeners to help them through the process.
In summary, raising infants and toddlers isn’t always easy. My own experiences and mentorships have shaped my advice to my patients and families. Understanding the “7 deadly sins” and how to cope with them can help children (and parents) grow up safe, happy and healthy!