Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.

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Stool toileting refusal occurred in one in five children in this study population. Two behaviors associated with stool toileting refusal may require the intervention of the pediatrician. The first is stool withholding causing constipation which can result in rectal impaction and primary encopresis. The second is lack of successful toilet training by 42 months of age. A child who is still untrained at this late age can be a source of family conflict and stress requiring the advice and support of the pediatrician.

ABSTRACT.Background. Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal (STR), but whether they are the result of STR or occur before this behavior is not known.Objective. To determine whether constipation and painful defecation occur as a result of STR or occur before STR.Methods. Three hundred eighty children between 17 and 19 months of age participated in a prospective longitudinal study of toilet training. Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training. Information obtained in follow-up interviews included parents' reports on the presence and frequency of hard bowel movements, painful defecation, and child toilet training behaviors. Children were defined as completing daytime toilet training when they were experiencing <4 urine accidents per week and <2 episodes of fecal soiling per month. Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in >2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview.Results. The mean age at the completion of daytime toilet training was 36.8 ؎ 6.1 months (range: 22-54 months). Ninety-three children (24.4%) developed STR. Parents of children who developed STR, in comparison with the rest of the sample, were more likely to report that the child had experienced hard bowel movements (67.7% vs 50.9%), frequent hard bowel movements (29.0% vs 14.3%), and painful defecation (41.9% vs 27.9%). Of the children who experienced both STR and hard bowel movements, 93.4% demonstrated constipation before the onset of STR. In that group, parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR. Of the children who experienced both STR and painful defecation, 74.4% experienced the first episode of painful defecation before the onset of STR. Children with frequent hard bowel movements demonstrated a longer duration of STR (9.0 ؎ 6.5 vs 4.8 ؎ 3.0 months).Conclusions. When hard bowel movements or painful defecation is associated with STR, the first episode of constipation usually occurs before the STR. The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively. Therefore, hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior. Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR. Pediatrics 2004;113:e520 -e522. URL: http://www. pediatrics.org/cgi/content/full/113/6/e520; toilet training, constipation, stool toileting refusal.ABBREVIATIONS. STR, stool toileting refusal. P revious studies documented associations between a variety of toilet training problems an...

Children with stool toileting refusal do not have more behavior problems than controls who are toilet trained. Parents do report higher rates of constipation and painful defecation, but it is not clear whether this is a cause or effect of stool toileting refusal.

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Immediate cognitive and physical rest in the concussed patient is almost universally recommended in the concussion literature. The authors conducted a prospective observational in a primary care pediatric office to examine the effect of delayed cognitive and physical rest had on recovery time in pediatric concussion. The authors found that patients who started cognitive and physical rest immediately after injury were more likely to recover within 30 days compared to patients who delayed cognitive and physical rest for 1-7 days after their injury (67% vs 35%, P = .016). Within the group of patients who recovered within 30 days those with immediate cognitive and physical rest recovered 4.6 days sooner than those with delayed cognitive and physical rest (10.29 ± 5.83 vs 14.42 ± 6.15 days, P = .005). These data support the recommendation that cognitive and physical rest should be implemented immediately after injury in concussed patients.

BackgroundThe objective of this study was to prospectively determine the prevalence of asymptomatic celiac disease among children presenting with fibromyalgia. The secondary objective was to investigate if their symptoms resolved on a gluten free diet.FindingsAll children seen in the Amplified Musculoskeletal Pain clinic between the ages of 12 and 17 years of age who fulfilled the 1990 American College of Rheumatology diagnostic criteria for fibromyalgia were invited to participate. A total immunoglobulin A (IgA) level, IgA antiendomysial (EMA) and IgA anti-TTG antibodies was obtained on all study subjects. A visual analog scale for pain and a functional disability inventory were obtained on all patients. If a patient had elevated EMA or TTG a small bowel biopsy was done. Patients with celiac disease were placed on a gluten-free diet and observed to see if their symptoms resolved.50 patients, 45 females, completed the study. Only one patient was found to have celiac disease. On a gluten-free diet her tissue transglutaminase antibody level returned to normal but her visual analog scale scores increased and her functional disability inventory was 40 initially and 21 at follow up.ConclusionsIn this pilot, single center study at a tertiary children's hospital patients with fibromyalgia do not seem to have occult celiac disease at an increased rate over the population as a whole.