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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Disorders of Elimination

Toilet training is an important concern for parents with young children, who often regard the acquisition of bladder and bowel control as a significant childhood developmental milestone. Furthermore, the entry into daycare or some other program, may be reliant on the achievement of appropriate toileting. For children, control over elimination may be an important means of pleasing their parents, developing mastery over their own bodies and not being a 'baby' anymore. Typically, control over elimination takes the following pattern; nighttime bowel control, daytime bowel control, daytime bladder control and finally nighttime bladder control. Although there are variations as to when children are ready for toilet training, based on their own developmental timetables, in most cases daytime bowel and bladder control are usually established between the ages of 18 and 36 months. Elimination disorders in children are diagnosed when a child has not established bladder or bowel control by a particular chronological or developmental age, i.e.. within a reasonable expected time frame, or they previously had control but regressed (CounsellingNH.com, 2007; Wicks-Nelson & Israel, 2000; Collins, 1990).

ENURESIS

Enuresis can be defined as involuntary bed wetting (nocturnal enuresis) or the release of urine at other inappropriate times (diurnal enuresis), that persists after the normal bladder reflux activity of infancy has been replaced by more mature patterns of unconscious cortical control. Enuresis is relatively common among young children, but it rarely persists into adulthood unless there is an underlying physiological or psychiatric disorder. There is a significant variation in the age at which children become reliably dry at night.  Most children develop nighttime bladder control between the ages of 3 and 7 years of age. While 1 in 6 continue bed wetting at 5 years, and approximately 1 in 20 are wetting at the age of 10. There is usually no need for medical intervention unless bedwetting persists after age 7, or it starts again once your child has previously been dry at night for 6 months or more. If your child is a regular bed wetter, it is probably that they have not yet learnt sufficient bladder control- this will improve with time. It is rare for bed wetting to be the result of a physical or psychological problem, but a child may relapse due to a urinary tract infection, an emotional upset such as bullying, or constipation. There are 2 main types of enuresis. Primary enuresis, in which the child is at least 5 years of age and has never established bladder control. Secondary enuresis, occurs when a child has bladder control for at least 6 months, then relapses and begins wetting.  Bed wetting tends to run in families (Advameg, Inc., 2011; Houston, Joiner & Trounce, 1966; Collins, 2003; Dr. Peters, M., 2009).

Causes:

In most cases, there appears to be no single clear physical or psychological explanation for enuresis. Bed wetting usually represents a delay in maturation that resolves over time. Research has shown that children who are nighttime bed wetters only, may have a nervous system that is slow in registering the feeling of having a full bladder. As a result they do not wake up in time to relieve themselves. The disorder is more common in boys than girls, it appears to be familial, and sometimes occurs in the context of a sleep disorder, such as sleepwalking or night terrors. A small number of children have abnormalities in the anatomical structure of their kidneys or bladder, that have an impact on their bladder control. While others seem to have a lower-than-normal ability to concentrate urine, due to low levels of antidiuretic hormone (ADH), the hormone responsible for regulating fluid balance in the body. As a consequence, they have large amounts of dilute urine, causing the bladder to overflow at night. Children with diurnal enuresis tend to fall into 2 groups; those who are unable to control the urge to urinate and those who delay urinating until they lose control. Some children have both nocturnal and diurnal enuresis. Secondary enuresis, in which children are dry for 6 months and then begin wetting again, often follows a stressful life event, such as moving house, the birth of a sibling or divorce. Occasionally enuresis is due to individual or family psychopathology (Advameg, Inc., 2011; Merck & Co., Inc., 2006).

Diagnosis:

A diagnosis of enuresis is usually made when parents express their concern to the child's doctor. The doctor will take a medical history and thoroughly examine your child to rule out any possible underlying medical conditions, including any structural abnormalities of your child's urinary tract. Sleep disorders also need to be ruled out as a possible cause. According to the American Psychiatric Association, a diagnosis of enuresis can only be made if; your child has reached the chronological or developmental age of 5, inappropriate urination occurs at least twice a week for a minimum of 3 months, or it is causing your child significant distress or interferes with their school performance and/ or social life. The behavior must not be the result of an underlying medical condition or a side effect of medication (Advameg, Inc., 2011).

Contact your doctor if:

You are concerned about your child's bedwetting, especially if your child is over the age of 7 or has previously been dry at night.

You think that your child is experiencing constipation.

Your child has a fever, is urinating frequently and is experiencing a burning sensation on urination (Dr. Peters, M., 2009).

How to help your child:

Most children outgrow bedwetting eventually, but in the meantime, there are several possible steps you can take to help your child;

Rather than regarding bedwetting as a problem or punishing your child for insufficient nighttime bladder control, try to understand the many factors that may be contributing to your child's enuresis. There is usually no one cause nor treatment for nocturnal bedwetting. It is important for parents to adopt a positive attitude to the problem, to accept it as a temporary developmental delay, and to support and parent it as if it were any other developmental stage.

Never punish your child for bedwetting as this will increase their anxieties and only make the problem worse. Explain that the problem is not their fault and avoid giving them mixed messages. For example, don't tell your child that you are not angry about their bedwetting, then complain about the nuisance of washing their sheets. Avoid parent-child struggles for compliance because pressure and disgust only prolong bedwetting.

Explore your child's attitude towards her bedwetting. Children do not like wetting their beds nor waking up in a wet, odorous bed and they are painful aware of the social stigmas surrounding bedwetting. Provide your child with information, encouragement and support. Explain the principles of bladder control and that there are individual differences in the rate of maturation of bladder control. Explain to your child that bedwetting does not make him or her a baby nor does it make them different to other children. Perhaps explain that, 'You are a big girl or boy now, but your bladder has not yet grown up, so we need to work on this problem together to keep you dry at night.'

From a psychologically point of view, ask your child wether they have certain fears or dreams at night and explore wether there is something bothering them in their environment. It is important to encourage your child's maturation and success in other areas of development, to avoid making them feel that they are a 'baby in everything'. Do not allow bedwetting to interfere in their normal social development. For example, allow them to go to summer camp or sleep over at a friend's house. This provides strong motivation for them to remain dry at night. The mother of your child's friend is likely to understand and be supportive of the problem, having parented bedwetting herself at some stage. Allow your child to take their own sleeping bag and rubber mat, to alleviate some of the embarrassment if a bedwetting accident occurs.

Constipation can put pressure on the bladder so try help your child have regular bowel movements.

Do not restrict fluids but encourage your child to try avoid drinking  2-3 hours before bed time. Avoid giving your child any caffeinated drinks in the evening.

Encourage your child to use the toilet before bed, because most bedwetting accidents occur in the first third of the night. Possibly wake your child to pass urine before you go to bed.

If your child is experiencing an emotional upset, such as a change of school, moving house, or feels insecure about the birth of a sibling; spend more quality time with them or give them a relaxing massage.

Do not put nappies on your child at night, as they may not then recognize the need to get up and go to the toilet. Rather use a waterproof backed oversheet or plastic mattress cover, to make stripping the bed easier for you.

Always praise your child on dry nights and try linking their progress to rewards. Give them a star on a star chart for every dry night and offer a reward for a certain number of stars. This acts as a form of motivation. Some children become completely dry at night after a few weeks of using a star chart without any other form of treatment. If your child becomes upset and discouraged because the chart reflects poor results, cease using this method.

If methods of encouragement and praise are unsuccessful, you can purchase an enuresis alarm, also known as a pad-and-buzzer alarm system, from your doctor or local clinic. These systems are usually advised for children over 7 who regularly wet their beds, as a last resort and preferably under medical supervision. The device has a moisture detecting pad that is placed under the bottom sheet where the child's hips lie, and activates a buzzer if urine is passed. The alarm wakes the child so he or she can go to the toilet. Over a period of months, the amount of urine passed before the buzzer sounds becomes less and less, and the child becomes conditioned to wake before the buzzer sounds or to sleep through the night without wetting the bed. Remove the alarm once your child has been dry for 6 weeks, but re-implement the device if bed wetting resumes (Collins, 2003; Dr. Peters, M., 2009; Leary, 1990; Wicks-Nelson & Israel, 2000).

Prognosis:

Most children usually stop bed wetting without requiring any medical intervention. However, the use of DDAVP, a spray made from naturally occurring hormone that has the effect of concentrating urine, may be particularly helpful. Children treated with this medication often improve within a few months. Generally, the older a child is, the longer it takes for the condition to improve (Collins, 2003).

Essentially, your child needs to take responsibility for their own nighttime bladder control, since the bladder is part of their body and they need to master its functioning, just like any other bodily function. Self responsibility together with possible medical and parental support, as well as positive reinforcement, are key to parenting your child through dry nights (Leary, 1990).

ENCOPRESIS

Functional encopresis refers to the frequent passage of solid stools into the underwear or other inappropriate places, either involuntarily or intentionally, after your child has already established bowel control and is not suffering from a physical disorder. According to the American Psychiatric Association; a diagnosis of encopresis is given if at least one such event occurs per month, for a period of  3 months minimum, in a child of at least 4 years of age. The behavior is not a result of the direct physiological effects of a substance, such as laxatives, nor due to a general medical condition, except through the mechanism of constipation. the subtypes of encopresis are based on the presence or absence of constipation. Most encopretic children are chronically constipated and are said to have constipation with overflow incontinence or retentive encopresis. Holding onto stools and not wanting to pass them voluntarily, leading to constipation, may also be a feature. If a child resists the urge to defecate, the fluid in the retained stool is absorbed, making the stools harder and painful to pass. The child then holds onto the stools for longer and a vicious cycle ensues, resulting in a constipated, uncomfortable child. Sometimes the fluid surrounding the hard stool may leak out into the underpants. Many parents mistake this leakage as diarrhea, rather than an effect of constipation. The treatment of encopresis, therefore often begins with the treatment of constipation. Encopresis occurs in approximately 1.5-10 % of children and is more common in boys than girls (American Psychiatric Association, 1994; Leary, 1990; Dr. Stoppard, M., 2005; Wicks-Nelson & Israel, 2000).

Causes:

The initial cause of constipation/soiling may involve several factors; such as diet, fluid intake, medication, environmental stressors or inappropriate toilet training. The colon and rectum may become distended due to the accumulation of hard feces. Over time, the bowel loses its ability to respond with a normal defecation reflex to normal amounts of fecal matter (Dr. Stoppard, M., 2005; Wicks-Nelson & Israel, 2000).

Because encopresis begins in a child who has previously had bowel control, it should be regarded as a symptom of a problem rather than a developmental delay. Encopresis often follows an emotional upset, such as the arrival of a new baby, divorce or separation of parents, losing contact with friends on relocation, etc. Seen in this context, encopresis should never be punished or derided. Children may be fearful of or reluctant to use unfamiliar bathrooms, may find it difficult to deal with changes in their routine, such as when starting school and having to adjust to scheduled toilet breaks, not taking the time to use the toilet or in some cases, merely refusing to go to the bathroom. These factors may all contribute to constipation. Toilet training methods also appear to have an impact on the development of encopresis. This includes the failure to apply appropriate toilet training methods consistently or the use of over-fussy or over-authoritarian toilet methods. For example, parents may place too much emphasis on a baby or child passing stool into a potty or they may provide inadequate positive reinforcement for appropriate toileting. These types of coercive attempts at toilet training are likely to be met with resistance by the child.  From a behavioral perspective, retentive encopresis can be explained by avoidance conditioning principles. In other words, the attempted  avoidance of pain or fear causes a child to retain their stool, resulting in constipation and therefore further stool retention. In cases where encopresis and chronic constipation are resistant to medical treatment, other possible causes, such as a painful anal fissure, congenital abnormalities (e.g.. spinal chord lesions), Hirschsprung's disease, cerebral palsy, malnutrition and psychopathology in the child and family, need to be explored. In older children, who intentionally soil and smear their feces on walls or clothing, or hide their feces around the house, the problem may be a clinical behavioral one, such as conduct disorder or oppositional defiant disorder (Advameg, Inc., 2011; Dr. Stoppard, M., 2005; MedicineNet. Inc., 1996-2011; Merck & Co. Inc., 1992; Wicks-Nelson & Israel, 2000).

Symptoms that may accompany encopresis:

  • Loss of appetite
    Abdominal pain
    Loose, watery stools
    Scratching or rubbing the anal area due to irritation from watery stools
    Decreased interest in physical activities
    Withdrawal from friends and family, due to possible teasing from the former and scolding from the later
    Refusal to socialize with other children, such as not wanting to go to parties or stay over night at friends
    Self esteem problems
    Poor school performance
    Depression
    Secretive behavior associated with bowel movements
    Chronic constipation  (MedicineNet, Inc., 1996-2011).

Diagnosis:

If you child is presenting with the symptoms of encopresis, your doctor will require a full medical history and perform a thorough physical examination. Your doctor may use certain tests, such as x-rays, to rule out any underlying medical conditions or possible causes for constipation, such as a disorder of the intestines. If no other underlying physical cause can be found, your doctor will make a diagnosis based on your child's symptoms and current bowel habits (MedicineNet. Inc., 1996-2011).

Consult your doctor if:

Your child has chronic constipation. This condition is easily treatable.

You are unable to find a reason for the involuntary soiling. Your doctor will be able to refer you to a person, most appropriate for discovering the cause of the disorder (Dr. Stoppard, M., 2005).

Treatment:

Encopresis can generally be quickly and effectively treated with a combination of medical, psychological and dietary interventions. Generally, the earlier treatment for encopresis is initiated, the better.

A medical examination needs to be performed to rule out any organic causes for the disorder, such as problems in the structure or functioning of the physiological and anatomical mechanism required for bowel control.

Both the parents and child should be educated about the physiology of encopresis (i.e.. stool retention results in the distention of the bowel wall, eventually causing decreased sensation and muscle control) and chronic constipation.

All blame should be removed from the child who is unable to control his or her bowel movements. Family tension regarding the child's symptoms should be reduced and a non-punitive atmosphere established.

If the primary cause of encopresis is constipation, substances such as fibre, increased fluids, enemas, mild laxatives and lubricants (e.g.. mineral oil) may be given, to empty the colon and decrease painful bowel movements. Your doctor may order an x-ray to determine the progress of the colon cleaning. Thereafter, your child may be prescribed stool softeners, such as lactulose, for 6 months or more, to help them establish regular bowel habits. Your doctor will also advise you on how to reduce constipation in the future.

Teach your child proper bowel habits. Encourage them to sit on the toilet at the same time every day, preferably after meals.

If your child has become constipated either voluntarily or due to painful defecation and they have become unaware of their need to defecate, behavioral techniques are often helpful in teaching them new ways to behave and to become more attuned to bodily cues.

If the cause is presumed to be psychological in nature, the child may benefit from consulting with a mental health worker. Children with encopresis may suffer from shame, depression, guilt or low self-esteem as a result of their illness. Therefore, psychotherapy may be particularly helpful (Dr. Stoppard, M., 2005; Mayo Clinic, 1998-2011; Merck & Co., Inc., 1992; Nyu Child Study Centre; Wicks-Nelson & Israel, 2000).

How to help your child:

  • Never punish your child for encopresis or show disgust if they soil their pants. This will only make matters worse.
  • Avoid the use of laxatives or enemas without the advice of your doctor.
  • Treat your child with kindness, understanding and sensitivity, since their encopresis is likely to be causing them considerable distress. Your child may become a target of scorn at school, because of the odor present if he soils himself. Provide your child with spare underwear to take with to school and discuss the problem privately with his teacher.
  • Help your child avoid constipation by providing a diet rich in fibre and liquids.
  • Encourage your child to take regular exercise.
  • Place a foot stool in front of the toilet. The change in leg position may be more comfortable for your child and also places pressure on the abdomen, making a bowel movement easier (Nyu Child Study Centre).

Prognosis:

In most cases, once constipation is controlled, the problem of soiling disappears. However, the relapse rate for encopresis is high, so it is important to stick with the treatment program for several months. Approach the problem with patients and make use of positive reinforcement. Do not punish, blame or criticize your child if they have an accident, instead persist with the program, offering unconditional love and support. Children who engage in power battles over toiling, generally outgrow the urge to have bowel movements in inappropriate places. Encopresis that is a consequence of a serious behavioral or psychological problem, resulting in smearing or hiding of feces, is dependent on resolving the underlying disorder (Answerbag, 2003-2011; Mayo Clinic, 1998-2011).