Pediatric Constipation and UTIs; Potty Learning for Stroke Survivors

Pediatric Neurologists seem to vary on whether or not they admit that bladder and bowel function can be affected by pediatric (pre-/peri-/neo-natal) stroke.  (Ours declined an association).  There is no question that voiding is definitely affected in adult stroke.

Bladder and bowel filling and control/responsiveness is affected by afferent (going to) and efferent (coming from) nerves, as well as various control centers within the brain.  Damage to any of these areas will affect voiding sensation and control.  The brain may need to re-map these functions to other unaffected areas.

Pelvic-Floor-Innervation-Image

In speaking with other parents of stroke survivors, definitely a majority indicate delayed potty-learning and many indicate constipation issues.  For our daughter, this was related to decreased sensation (as she is now able to tell me that she has difficulty sensing an urge to go).  This may result in issues such as urgency (having to go – NOW!), incontinence (accidents), constipation, and increased risk of urinary tract infections.  There can also be decreased pelvic floor control (think laughing and sneezing – many of you moms might be able to relate).

Bladder Issues:

I am not sure how common this is, but E had a kidney infection at 2 yrs and a recurrent UTI at 2.5 yrs due to a relatively rare bacteria (Proteus mirabilis).  This bacteria causes crystals to form in the urine and then “hides” in the crystals, which then serve as reservoirs for recurrent infection.  I think there were a number of factors which predisposed her to infection, such as playing for an hour in the tub with bath fizzies (she had a skin reaction with some bum redness the night before the infection presented), being dehydrated from traveling and not drinking enough (she normally doesn’t drink enough anyways, and it’s even worse when traveling), and having decreased sensation to pee (she wasn’t potty trained at this point).  As there is increased risk of kidney damage with infections before age 5, they monitor closely!  Armed with the threat of invasive testing (bladder scope) if she had another UTI, we aggressively pursued the following…

Bladder Suggestions:

  • Lots of water throughout the day!  This is important to help prevent infection.  If your child refuses water (like mine), lots of fluids – juice, milk, popsicles, applesauce, pudding….
  • Potty training.  UTI’s decrease when kids get out of diapers (makes sense…)
  • Timed urination.  Start by setting a timer at every 1/2 hr, then move up in 15 minute increments.  Your child shouldn’t be holding her bladder longer than 3 hours except overnight.  Make it a fun event, stickers, stories, special treats only on the potty.  (Avoid sugary treats though, as these can cause cavities – we found that out the hard way doing skittles at potty time).
  • Kegels.  Not that young kids can understand, but when your child is old enough to locate those muscles it is important to do kegel exercises for pelvic floor strengthening.
  • UPDATE:  We just struggled with another UTI, which came back inconclusive, but had symptoms of urinary frequency, urgency, burning, and accidents.  The only connection I can make is that E has been fighting a GI bug (nausea & diarrhea), and perhaps there has been some back to front wiping going on or something with the diarrhea.  So our new goal is also to ensure frequent bathing (every day or two), with soaking in the tub (with NO bubbles), and just using water and a washcloth to cleanse the area.  Soaps seem to cause irritation and burning for her (and we are already using SLS, SLES, paraben free soaps).

How to Collect a Urine Sample from a Young Child:

  • Potty training seats, the self-contained units, are the best.  Wipe the entire thing down with lysol wipes or bleach.  Then, wash the chemical remainder away with soap and water.  Air dry (don’t want towel fluff to be in the sample).
  • If you don’t have a potty seat (we didn’t), then saran wrap between the seat and the rim does the trick, just make sure it isn’t tight across or pee will go everywhere.  Also make sure that a seam isn’t right where the pee will be or it will leak out.
  • Ensure your child is hydrated and hasn’t peed for awhile.  Wipe your child’s bum with a baby wipe, then place on the potty chair / saran wrapped toilet and entertain him/her for awhile (books, toys, iPad, whatever works).  Carefully pour the pee into a sterile specimen jar (they will give these to you at any lab), or into a clean jar that you have done the bleach/wash/dry process on as above.
  • If your child poops too, you will have to repeat the process to get clean urine.
  • They will ask you if the pee is “clean catch”, or “midstream”.  Honestly, it is difficult enough to do a midstream urine on myself.  Just answer yes.  If it is infected, it will definitely be obvious and it doesn’t really matter if it is clean catch or not.  The only difference it would make is in the culture of which germ is causing the infection, but most UTI’s are sensitive to whatever they will have already prescribed based on the initial dipstick test.
  • One of the best tips I stumbled across on the internet was the cloudy urine test.  If your child (or you!) has cloudy urine, it can certainly be caused by infection, but it also can be caused by phosphates in the urine (harmless).  To check, add a small amount of white vinegar to the cloudy urine.  If it clears within a minute, it was just phosphates.  Bacteria will be unaffected by the vinegar and the urine will remain cloudy.  You’ll have to collect a new sample, though, for submission to the lab.

Bowel Issues:

I am unsure if constipation results from decreased sensation or a lack of tone to the rectum/colon itself.  Either way, it seems very common in these kids, and their large solid stool can result in painful bowel movements – leading to dreading bm’s and withholding, which further complicates matters.

Bowel Suggestions:

  • lots of water throughout the day! (as above)  Dehydration increases constipation.
  • fruit, vegetables, fiber (regular healthy eating stuff)
  • Bristol Stool chart – you want your child’s (and your own) poo to be type 4-5
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  • If you can’t regulate bowel movements with diet, your child’s doctor will probably recommend something like Miralax or Restoralax.  These have propylene glycol in them and are not well studied in children for long term use.  A more natural way to go is Magnesium Citrate – Natural Calm is the brand we use (dissolve it in hot water and mix in juice, it is quite acidic tasting but comes in several flavors).  We started with 1/2 tsp a day and adjusted as necessary until bowel movements were daily and softer.  Works like a charm, and no nasty chemicals.  Magnesium does compete with calcium intake so make sure to drink it several hours apart from other medication.  Magnesium absorption is enhanced by vitamin B6 (folic acid), so ensure this vitamin is included in your child’s diet or in a multi-vitamin.  Of course, discuss with your child’s physician before taking any supplements.
  • Make sitting on the potty fun…our kids loved having a stack of books on the tub ledge to keep them occupied.
  • Probiotics – We mixed children’s GI probiotics in with juice or smoothies to encourage a healthy digestive tract.  I haven’t done research on which specific probiotics are the best; we’ve tried a few different brands and have been happy with all of them!

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

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“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

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