Category: Unit 2: Identifying Constipation & Other Elimination Issues

Urination Questions and Concerns

Posted on by chayahlichtig

What are signs that your child’s urination is healthy? This video describes the signs of healthy urination, and indicators that your child’s urination is not functioning quite right.

A full transcript appears below.

00:00:00:00 – 00:00:26:00
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Hi, my name is Haya Lickteig. I’m an occupational therapist and I’m the director of the Vermont Continence Project. In this video, Urination questions and Concerns, we are going to talk about some signs that you may need to pay more attention to your child’s bladder function or may want to check in with your child’s medical provider. First, let’s review how the bladder works.

00:00:26:03 – 00:00:55:12
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Urine is made in the kidneys and drips down, drop by, drop through tubes called ureters. Urine then collected in the bladder, which is basically a muscular pouch like a water balloon while urine is collecting, the walls of the bladder are relaxed and stretching out. At the same time, a muscle at the bottom of the bladder, the urethral sphincter is contracting to hold the bladder shut.

00:00:55:15 – 00:01:19:05
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When the bladder gets a certain amount of stretch. It sends a message to the brain that says the bladder is full. The muscles then reverse their actions. The muscles at the bottom of the bladder. Relax, allowing the urine to flow out while the walls of the bladder contract or squeezed in to make sure that all the urine comes out.

00:01:19:08 – 00:01:53:23
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This is similar to releasing the neck of a water balloon and giving the widest part a squeeze to clear it out. While our body controls that sphincter muscle that holds the urine in. It doesn’t voluntarily control the muscle on the inside that squeezes the bladder, an indication that this process is working well is that a person can urinate very soon after sitting on the toilet and that their urine stream has a steady sound which gets sore, start soft, gets loud and then soft again.

00:01:53:25 – 00:02:21:12
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Holding urine between large urination is also a sign that things are working well. While it’s too complicated to explain why problems occur here. There are some important signs to look for that your child may have a problem or concern with bladder function. If your child urinates very frequently, like more than once an hour, that’s something that we’d want our health care provider to be aware of.

00:02:21:14 – 00:02:50:05
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If your child regularly goes 4 to 6 hours or more between voids, that’s also something that you’d want your health care provider to be aware of. Parents also see this sometimes when their child wakes up dry, but then doesn’t urinate immediately. Some other signs that you may be on to be aware of are that your child’s urine flow is choppy or weak, which you probably would only know if your child is urinating in the toilet.

00:02:50:07 – 00:03:14:28
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Your child has trouble making urine come out even when they say they need to go or they appear to need to go. This can also look like a child pushing while trying to pee. If you remember, the act of urinating is not a pushing maneuver. It’s the act of releasing a muscle, and the pushing should be completely done by your body’s own processes.

00:03:15:00 – 00:03:42:08
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If your child has frequent UTIs, it can be a sign of constipation. Since fecal bacteria coming from the anus can get into the urethra, especially for girls. But it can also be a sign of withheld urine, meaning that the bladder isn’t emptying completely, leading to urine that is staying in the bladder too long and becoming too concentrated. So what to do?

00:03:42:10 – 00:04:21:17
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A common saying in the world of pelvic health is that the bowel drives the bladder and this means that most bladder symptoms for most people may be tied to something happening in the bowel. We frequently tell parents that most of their child’s bladder symptoms may get better when you treat their constipation. If you’ve treated your child’s constipation comprehensively and consistently for 2 to 3 months or more and you see no improvement in your child’s bladder, that’s when another referral may be appropriate.

00:04:21:20 – 00:04:53:25
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We’d suggest discussing your treatment options with your child’s provider for some of the available options. Include a consultation with a pediatric urologist or working with a pelvic floor, physical therapist or occupational therapist with expertise in working with children. If you have a child with any of these symptoms, it’s essential to address them before any kind of sitting program.

00:04:53:28 – 00:05:23:05
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Many of these issues can come from a history of withholding, and a structured program will probably make that worse for your child. If your child already sits on the toilet willingly, it’s really important to use all of the postural supports that we discuss in other videos, such as a footstool and a seat reducer. Thank you for taking the time to watch this.

00:05:23:07 – 00:05:40:01
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The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.

 

Paying for Incontinence Supplies

Posted on by chayahlichtig

In this video, we discuss some of the ways parents fund the things they need for their child’s incontinence, such as medication, diapers, and even equipment.

Associated Resources:

A full transcript of the video appears below.

Hi, I’m Tammy Willey. I’m a family resources consultant. And today we’re gonna talk about paying for incontinence supplies.

Did you know Vermont Medicaid covers supplies of medication for underlying medical conditions that contribute to incontinence?

Let’s be specific.

Medicaid

Your child is likely covered if they have Medicaid. Dr. Dynasaur and Katie Beckett are other common names for Medicaid, and if they have an underlying medical condition, constipation, some developmental diagnoses, and other qualifying medical diagnoses.

Coverage for over-the-counter products, such as diapers and pull-ups, and medications, such as MiraLax and other medications, are available with a prescription from your doctor. Products will be distributed via an online supply provider: ActiveStyle.com, while medications will be through your local pharmacy.

Not Medicaid

And if you don’t have Medicaid, contact your insurer to see if supplies related to your child’s medical condition are covered under your policy.

Also, consider Medicaid’s secondary coverage.

Contact a family support person at Vermont Family Network or visit their website to access a document called “Six Ways to Access Medicaid and Other Healthcare Benefits.”

There’s also something called the Medically Necessary Supplemental Fund. This fund helps pay for items that are medically necessary, but not covered by insurance or Medicaid. It can cover expenses of special equipment such as the Squatty Potty, handheld bidets, and other items. It has income guidelines and families can reach out to Joanne Wechsler at vermontfamilynetwork.org to find out if they qualify.

Additional Resources

Additional resources are available at Children with Special Health Needs. This organization helps families of children with chronic illnesses and developmental disabilities get support to navigate funding and care coordination support.

Remember, these resources exist to help families.

Don’t hesitate to get more information and have some help offsetting some of these costs.

Could it Be Constipation

Posted on by chayahlichtig

Check out this video for a detailed explanation of how to know if your child’s incontinence may be caused, or worsened, by constipation. In Elimination Basics, we explained how our bodies develop continence, and how constipation interrupts that.

Associated Resources:

“The Bowel Symptom Checklist” (pdf) helps you keep track of any symptoms Kelly mentions in this video. This form is very useful when you speak to your child’s healthcare provider.

Want to know more about constipation?

  • “Unstuck” – Children’s Mercy Hospital  (website): myths, facts, and lots of graphics. Children’s Mercy hosts one of the country’s top childhood incontinence clinics.
  • “Constipation: A Parent’s Guide”:  Chayah’s favorite guide to constipation. (yes! I have one!)
  • “The Poo in You” (video): if you didn’t watch last week, check it out now!
    • “Bedwetting + Accidents”, Simple Families – (podcast) – Listen to pediatric urologist (bladder doctor) and world expert on urinary incontinence, Dr. Steven Hodges, explain the link between incontinence and constipation. His area of special interest is bedwetting, and his website is www.bedwettingandaccidents.com/ Please note that Dr. Hodges recommends a specific protocol, and that we are not endorsing it (only your PCP can make that decision with you!)

Is constipation connected to any other diagnoses? Yes! Many. Here’s a sample based on concerns from recent group membership:

A full transcript of the video appears below.

Hello, my name is Kelly Savitri, and I’m a nurse with the Vermont Continence Project. Welcome back to our series about supporting the body during toilet learning. In this video, I’ll describe the many symptoms of constipation that indicate whether this could be a factor in your child’s struggle with toileting.

In the elimination basics video, I explained how chronic constipation affects the stretch receptors in both the bowel and the bladder, making it so that children have difficulty recognizing the sensation of needing to pee or poop. This is illustrated in the green part of the constipation cycle. If you haven’t yet watched elimination basics, I suggest you go back and watch that now so that you understand why this is so important.

In our video called Taking Bowel Data, we introduced you to the Bristol Stool Scale, which is a way of identifying the usual consistency of your child’s poop. Now, I’m going to explain to you how to interpret that data to have a better understanding of what is going on inside your child’s body.

First, let’s look at Type 1 and 2. This is usually what we think of when we imagine constipation. Remember, the longer that the poop stays in the colon, the harder and drier it becomes. Whether it is large or small, this kind of poop is often difficult for a child to pass. It may be painful or it might only come out when a child is distracted like when they’re watching TV, for example.

On the other end of the spectrum, we have Type 6 and 7. This very soft poop is often what we call sneaky poop. If this is what you are predominantly observing, it might mean that there’s an impaction of hard poop in the colon, and this very soft or liquid poop is sneaking around the blockage and leaking out often without the child even noticing it. This can be large or small, and it often comes out as streaks or smears in their underwear. When adults see this, they often think their child is having diarrhea, but it might actually be a symptom of incomplete evacuation.

Type 4 is what we think of as the “Goldilocks Zone”: It’s not too hard and not too soft. Honestly, when kids are struggling with toilet learning, we don’t usually see Type 4, but this is the goal that we will be working toward as we focus on healthy bowel function. If your child does have Type 4 stool, however, it’s important to know that this doesn’t mean for sure that your child isn’t constipated. Lots of research has shown that a child can have Type 4 stools every day and still have incomplete evacuation.

Sometimes kids’ bowel movements are all over the chart. They may have Type 1 and Type 7 at the same time, or they might have a day that is Type 6, followed by a day that is Type 2 or vice versa. Those are bowel patterns that really could benefit from medical intervention. It may mean that some stool is staying into long and your child needs help to develop a consistent healthy bowel pattern. It could also indicate other digestive health issues like lactose intolerance, for example.

Now that you’ve identified the usual consistency of your child’s poop, let’s talk about frequency. This can be really confusing. I often hear parents say, “How could my child possibly be constipated? I’m cleaning poop like four times a day.” We usually think of constipation as a condition when there’s no poop coming out, but sometimes there’s some amount coming out regularly, but the colon never fully gets emptied. That’s why when your child is having many bowel movements throughout the day, it’s helpful to think about it as incomplete evacuation rather than constipation. This is definitely something that deserves further investigation.

Ideally, your child would have one full soft bowel movement daily. It’s okay to miss a day occasionally, but if your child is having fewer than three bowel movements per week, it is definitely a sign of constipation.

The size and shape of your child’s bowel movements are a clue about the size and shape of your child’s colon. Poops that are very large or shaped like a ball indicate that your child’s colon is likely very stretched out. Very small or narrow poops are a sign that there might be something blocking the colon. This could be an impaction from old hard poop blocking the way or it could be a sign of a medical problem. Either way, it should be discussed with your child’s healthcare provider.

Consistency and frequency are just two indicators of bowel health. There are a lot of other signs that we want to look out for. All of the following are symptoms that you should discuss with your child’s healthcare provider: Straining or discomfort with bowel movements, fear or avoidance of using the toilet. If they’re unaware of the need to stool or unaware of the odor or unaware that they’ve gone, stool accidents while sleeping because this indicates that their body has to be completely relaxed in order to poop, and it is a sign that they might be withholding during the day. Many small pees throughout the day, history of urinary tract infections, a round belly or a gassy system, a limited food variety, or a low appetite.

Now we know that this is a lot to remember, so we’ve created a document called the Bowel Symptom Checklist that you can print out, and this is meant as a resource for you to bring to your child’s healthcare provider to help you have a conversation about how you might improve your child’s elimination health. The checklist is formatted with the official diagnostic criteria for functional constipation at the top.

Future videos will discuss constipation treatment, but it’s very important that the process is directed by your child’s provider. So if your child is experiencing any of the symptoms we discussed here, we encourage you to set up an appointment with their provider as soon as possible. Now that you have an idea of what to look for, our next video is going to talk a bit more in depth about what causes constipation and why treating it is an essential part of toilet learning. So please watch The Constipation Cycle.

Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider.

The Constipation Cycle

Posted on by chayahlichtig

How does constipation develop, and why is it so hard to fix? This video explains the constipation cycle, and how to break the cycle. We suggest that you watch “Elimination Basics” and “Could it Be Constipation” before this video.

A full transcript of the video appears below.

Hello. My name is Kelly Savitri and I’m a nurse with the Vermont Continence Project. In the videos called Elimination Basics and Could it be Constipation?, we talked about how constipation interferes with toilet learning and some of the signs that this might be a problem for your child. In this video, I’m going to describe some of the causes of constipation and why treating it is an essential step in gaining continence skills.

In Elimination Basics, I introduced you to this graphic, where the green part of the cycle represents the physical changes that interfere with a child’s ability to recognize and respond to their body’s signals about peeing and pooping. If you haven’t watched that video yet, I suggest you go back and watch it now.

Today I’m going to describe the triggers that cause constipation and the emotional and mental consequences that affect our children’s toileting behavior, which is represented by the yellow parts of this graphic. Some children are more affected by the green part of the cycle and some are more affected by the yellow part, but either way, the treatment is the same. So please keep watching to see what information is most relevant to your situation.

So first, how did we get here? Constipation is extremely common. About 15% of children experience constipation at some point and the most common time that it happens is around the age of toilet learning. It frequently goes undiagnosed. Often, children first exhibit constipation when there’s a big change, like transitioning from a home daycare to preschool, a new housing situation, or a change in their family situation. Children also become constipated after traveling. It might have to do with changes in their routine or being in unfamiliar bathrooms. There are lots of ways that travel can cause a disruption to a child’s elimination patterns. Finally, diet plays an important role in bowel function. We’re going to go into this in a lot more detail in future videos, but we know that many young kids are picky eaters and the foods that they usually prefer are not leafy green vegetables. If your child lives off mac and cheese and chicken nuggets, there is a high likelihood that this is a factor. Finally, some children are just so interested in playing or doing whatever activity that they’re engaged in that they don’t want to stop to use the bathroom. They learn to ignore the signal that their body needs to poop, and eventually it goes away.

One of the reasons that constipation is so common around the age of toilet learning is because this is a time when children gain the ability to control their bowel movements. Usually there’s a trigger, like I just mentioned. They go on a big trip or move to a new school and they get constipated. This causes them to have a hard, painful bowel movement. It creates an association for them that pooping hurts. When a child has a painful association with pooping, they will try to avoid that experience. We call this withholding. It can be conscious or unconscious, but the underlying motivation is trying to avoid pain. Eventually, the feeling of needing to poop will go away.

Of course, that poop continues to sit in the large intestine. It becomes harder and drier and they become more constipated. When they finally do poop, it hurts again and the cycle continues. Children who are withholding often exhibit posturing, which is when they put their body in a certain position to try to avoid pooping. This can be squatting, holding onto a table or shelf, standing on their tiptoes, or even lying flat on the floor. This is a sign that your child has a painful association with pooping. If your child used to exhibit posturing and doesn’t anymore, it doesn’t mean that they are no longer withholding. It just means that they can’t feel it anymore.

It only takes one painful pooping episode for a child to associate poop as a scary and painful experience. We see this a lot when kids have major resistance to using the toilet. Sometimes they refuse to even go into the bathroom. This can be so frustrating for parents and it can set you up for major power struggles. It’s helpful to remember that the emotion underlying the behavior is fear rather than stubbornness or defiance.

So how do we break the cycle? The easiest and most successful place to disrupt this cycle is to make poop so soft that it doesn’t hurt. Children also have a hard time withholding poop that is very soft. This is why constipation is usually treated with laxatives. Using a laxative will help erase your child’s negative associations with toileting. When your child no longer associates pooping as a painful experience and they learn that they don’t need to avoid it, you can focus on helping them with the other skills associated with toileting. Also, laxatives are necessary to clear impacted stool and help the rectum fully empty on a regular basis, which will allow those overstretched muscles and stretch receptors to return to their normal function.

We have other videos that talk more specifically about constipation treatment, but for now, just know that using a laxative now doesn’t mean that your child is going to have to be on it forever. There will be an opportunity to wean away from laxative use when the cycle is broken and your child is feeling successful with their ability to recognize and respond to their body’s signals.

If your child is struggling with toilet learning, I hope that these videos about constipation have given you some insight into what might be going on for your child. I hope that you will use this information along with our resources, such as the bowel symptom checklist, to talk to your child’s healthcare provider about formulating a constipation treatment plan that is right for them.

Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider.

Talking to Your Child’s Healthcare Provider About Incontinence

Posted on by chayahlichtig

This video explains how to organize your thoughts and concerns about your child’s incontinence so you can discuss them with their pediatrician or other healthcare provider. We suggest watching “Elimination Basics“, “Taking Initial Bowel Data“, “Urination Questions & Concerns“, “Could it Be Constipation“, and “The Constipation Cycle” before watching this video (and before taking your child to the doctor).

Associated Resources:

“The Bowel Symptom Checklist” (.pdf) is very useful when you speak to your child’s healthcare provider.

“The Constipation Traffic Lights” (.doc) is a treatment planning form you can bring to your appointment. It can help guide your conversation about how to treat your child, if they are diagnosed with constipation. It is shared in Word document form so your healthcare provider can fill in their specific plan.

A full transcript of the video appears below.

Hello, my name is Kelly Savitri. I’m a nurse with the Vermont Continence Project. In this video, I’m going to offer you some advice about how to talk to your child’s healthcare provider about your concerns regarding your child’s incontinence.

Many people think of their child’s incontinence as being mostly a developmental issue and that their child will learn when they’re ready. Some parents never mention their child’s incontinence to their provider or only do when they have a routine visit scheduled. We hope our videos have given you a hunch that medical concerns are also an important part of planning for your child’s continence and toilet learning. Since your provider is the only one who can diagnose, prescribe, and make a treatment plan for your child, they are an essential member of your team.

Functional constipation frequently goes undiagnosed for many reasons. At the Continence Project, we have worked with many different providers, and we have encountered a wide range of experience, knowledge, and comfort with diagnosing and treating incontinence concerns. Sometimes children have complex medical needs, and other concerns are higher priority, such as issues affecting the heart, lungs, or kidneys. So there isn’t as much time during an appointment to talk about incontinence. Many of the children who get referred to our project have neurodiverse diagnoses, such as autism, or they may have developmental delays. Often providers expect children with these kinds of diagnoses to have difficulty with toilet learning, so incontinence is not treated as a concern until they are much older. Finally, diagnosis of constipation tends to focus heavily on frequency. So a simple question like “How often does your child poop?” may not give a provider all the information that they need.

Sometimes we need to build a case by looking at all of the symptoms on the bowel symptom checklist put together. This is why we encourage caregivers to do some preparation before they go to their child’s healthcare provider. We like to think about this process in three parts, things you do before the appointment to prepare, things you do during the appointment, and things you can do afterwards.

To prepare before your child’s visit, take data on your child’s bowel patterns and bring this along. Healthcare providers like to know how long something has been going on and how severe the issue may be. Also, complete the Bowel Symptom Checklist and write down notes of anything else you feel is important to tell the PCP. When you schedule the appointment, tell the office what your concerns are. If your child’s PCP has an online communication system, such as UVM’s MyChart, you can share your observations and concerns and a completed copy of the Bowel Symptom Checklist through the portal. This way, you won’t need to explain as much in front of your child, which might embarrass them, and you’ll give the provider more time to consider your concerns. You may also want to print out a copy of the Constipation Traffic Lights form. If your child’s PCP does diagnose constipation, you can ask them to clarify how to know if the treatment is working.

During your child’s visit, remember that there is nothing to be embarrassed about. Most incontinence has some sort of medical cause, and a doctor is a great person to discuss it with. You may need to press your PCP about your concerns. For one thing, you may need to emphasize to your PCP that this is a big concern for you and that you need their help.

Use the Bowel Symptom Checklist to present your concerns. If you believe your child is constipated but their PCP doesn’t, consider asking them what they think might be causing your child’s incontinence struggles and their digestive symptoms. Once you’ve presented your case, your provider will make recommendations about a treatment plan. Remember that you are a partner in this process. If you have doubts or concerns, please voice them. Ask how long you should wait before expecting results. Also ask what kind of results you should expect. This is where the Constipation Traffic Lights are very helpful. Once your PCP defines what counts as green zone for your child, you will know whether your plan is working.

If the PCP prescribes medication with or without a clean-out, consider setting up a check-in with your PCP or another member of the office staff, such as a nurse, after the clean-out is complete or after they’ve been on medication for one or two weeks. Ask your provider what the best method is for you to ask questions about the treatment plan once you’ve started. They may recommend calling to talk to a nurse, or they might suggest messaging them directly on the patient portal. If so, make sure you know how to use that technology. After the visit, expect treatment to be an ongoing process that will require follow-up communication between you and your provider. If you’ve started a medication plan and have any questions as to whether it’s working, reach out to your PCP sooner rather than later. Remember that getting the right dose of medication might take some time. Utilize the traffic lights action plan to give you some idea of when to increase or decrease the medication depending on your child’s bowel movements.

Don’t settle for poor results. If your child continues to strain, stool less than once per day, have incomplete BMs, or they have excessively loose stools, work closely with the PCP to try something different. Most of the time we see families have fabulous success in creating healthy bowel patterns for their child with the help of their PCP. Every once in awhile, the usual treatment just doesn’t seem to be enough, and it’s possible that there is something more medically complex going on. In these situations, it may be necessary to ask for a referral to a gastroenterologist for further investigation.

Here’s some additional tips. Remember, if your child is on Medicaid, whether that’s Dr. Dynasaur, Katie Beckett, or another form of Medicaid, ask about getting a prescription for the diapers or briefs and medication they need. Most children who are incontinent are eligible, and chronic constipation is an eligible diagnosis. See our video on paying for necessary incontinence medication and supplies for more details about that.

Many provider offices are very busy, and communication can be difficult. Ask your provider if the office has a care coordinator or another person who is available to answer questions in a pinch if you’re having trouble.

Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider.