|Toilet Training and children with Cerebral Palsy|
The proper diet, the advantages of suppositories & enemas, massage interventions, drugs and their dangers, appropriate interventions and inappropriate behaviors are all explored in the passages and links below that detail toilet training and bowel movement issues in the context of the child with cerebral palsy. Read these excerpts over and follow the links to other sites. Do not hesitate to consult with your physician or health professional on the details of what you uncover.
“One thing that will help establish a pattern of elimination is keeping regular mealtimes. In this way, the stomach, bowels, and bladder will be empty and full at regular intervals. Not only that, but food tends to stimulate the bowel, and many people go to the bathroom after a meal, usually breakfast or dinner. So you may be able to predict your child’s bowel habits based upon mealtimes. After you’ve determined the normal pattern of elimination, you’ll know when to place your child on the toilet in order to achieve the best success.
Choose a time when your child is rested and in a good mood to begin. You’ll need a child’s-size potty chair or potty seat.
When you child has indicated (by one of the above gestures, or something similar) that she needs to urinate or have a bowel movement, take her to the bathroom and explain in simple language what is to be done. Use very specific common words to describe the act of elimination. Place the child on the seat and stay with her until the training session is completed. After about five minutes on the toilet, the child should be wiped and rewarded with hugs and praise for the desired behaviors.
If the child was not successful in achieving the desired behavior, praise her for cooperating and sitting quietly on the toilet or potty chair. During training, the child should sit on the seat without toys or playthings, since these would divert attention from what she is supposed to be doing.
Repeat this process until the child is able to tell you in advance that she needs to go, or is able to use the bathroom or potty on her own.
If your child is mentally retarded, it may be helpful to institute a bowel training program. This, too, involves establishing a regular pattern of mealtimes to help establish a regular pattern of elimination, but the difference is that routinely, about 15 - 30 minutes after one meal is finished, the child is place on the toilet for 15 to 30 minutes. Choose either breakfast or dinner and stick with it, since the point of a bowel training program is to train the child to produce a bowel movement at the same time every day or every other day.
Make sure that the child is comfortable, with feet flat on the floor or supported by a stool. Use simple descriptive common words to describe the desired activity. Again, be positive by praising the desired results, and praise the child for sitting on the toilet as you wished, even if there is no bowel movement. Be sure there is no distractions during the time.
If the child does not produce a bowel movement after two days, give him an enema. Put him on the toilet every day at the same time after the same meal, and allow only one day to go by without a bowel movement. That is, if the child doesn’t have a bowel movement one day, he should have one the next day, either on his own of by having an enema.
Continue this routine until the child is trained.” (The Cerebral Palsy Handbook: 328-329)
“Constipation can be one of the most incapacitating minor problems encountered by the young child or adult with CP. It is essential that you find a way to keep the bowels moving. If possible, methods should be found which will not further weaken or damage the intestinal track. Strong laxatives are the worst for this and the child can become reliant on them. There are a number of readily available preparations which are made from natural substances that do not do permanent damage to the intestines. ‘Fybrogel’ is a good example and can be bought over the counter or obtained with a prescription from your CP or consultant. Preventative measures include close attention to diet, gentle massage (in a clockwise direction) on her tummy, just below the navel, at regular intervals and especially when she needs to go. There are a number of herbal preparations which can be given to help avoid constipation. Changes to diet may help. If all else fails suppositories, which will encourage bowel movement if your child is ‘bunged up’. You should not administer suppositories as a matter of course but they can be used very effectively on an occasional basis without doing any long-term damage.
There may be certain foods you should avoid or could give more of to ease constipation. For example, roughage in the diet, plenty of fruit (especially plums or prunes), adding olive oil or ground sesame seeds or linseeds can all help. You may need to take care not to give your child too many dairy products as these can be binding. Ensure that your child gets sufficient liquid and drinks with her diet; a dietician can advise on the appropriate amounts.” (003: p. 41)
“Drugs used to ease constipation. These are called laxatives and care must be taken not to use them too regularly. They should never be taken to relieve abdominal pains, cramps, colic, nausea or any other symptoms even if associated with constipation.
A high-fibre diet, with plenty of fluids, is the most natural way to treat constipation. This is achieved by increasing the indigestible waste products in the diet by eating more fruit, leafy vegetables and by adding bran to the diet.
There are many preparations on the market but there are four main categories of laxative: stimulant laxatives (bisacodyl, cascara, castor oil, danthron, fig, senna, sodium picosulphate); saline laxatives (magnesium sulphate, magnesium hydroxide, sodium sulphate, sodium potassium tartrate, potassium bitrate, lactulose); lubricant laxatives (mineral oils, diotyl sodium sulphosuccinate, poloxamer); and bulk forming laxatives (agar, tragacanth, ispaghula husks, sterculia, bran).
Stimulant laxatives increase large bowel movement by irritating the lining and/or stimulating the bowel muscles to contract. They may cause cramps, increased mucus secretion and excessive fluid loss. Side-effects vary enormously from person to person.
Saline laxatives increase the bulk of the bowel by causing it to retain water. They take fluids from the body and can cause dehydration, and should therefore be taken with large drinks of water. Lactulose may cause nausea, diarrhoea and wind.
Lubricant laxatives soften the faeces, Mineral oils such as liquid paraffin should be used with extreme caution as it interferes with the absorption of vitamin A and vitamin D and can be dangerous if accidentally inhaled.
Bulk forming laxatives increase the bulk content of the bowel which stimulates the bowel to become active. They must be taken with plenty of fluids to avoid the risk of bowel obstruction.
When faeces are impacted, laxatives administered rectally may be useful. A number of preparations are available, the most harmless of which are probably glycerol suppositories.” (The Cerebral Palsy Handbook: p. 54)
“Most children have periodic bouts of constipation, or infrequent, prolonged, or difficult bowel movements. Children with cerebral palsy, however, are more likely to develop this condition. This is because children with spastic abdominal muscles or low muscle tone have difficulty contracting their abdominal muscles to produce the pressure needed to help with elimination. Children with cerebral palsy may also be unable to sense the fullness of the rectum which would ordinarily signal them to contract their muscles. In addition, lack of exercise can contribute to constipation.
If your child has constipation, her symptoms may include: straining with large, hard stools; abdominal pain; rectal bleeding or tearing; soiling underwear; poor appetite; or a swollen or hard abdomen. Constipation may also trigger behavior problems such as fear of toileting, and make toilet training especially difficult.
Changes in diet can often help children with cerebral palsy who are constipated. Adding certain fruits and vegetables, increasing consumption of fluids, and adding bulk to the diet with whole grains or bran can soften a child’s stool, making elimination easier. Reducing consumption of cow’s milk may also help if your child has lactose intolerance, or lacks the enzyme that breaks down milk sugar. Additionally, your physician may prescribe mineral oil to lubricate your child’s bowel, stool softeners such as docusate sodium, or laxatives such as psyllium (MetamucilTM). The chronic use of laxatives is usually not recommended, since dietary changes, bulk, and stool softeners are easier on children’s bowels. Always check with your child’s pediatrician before buying over-the-counter laxatives.
If your child has chronic constipation, she may need further evaluation by your pediatrician or gastroenterologist. These professionals can determine whether your child’s constipation is a side effect of medications she is taking such as anticonvulsants or iron supplements. For particularly stubborn cases of constipation, your child’s pediatrician or gastroenterologist may work together with a nutritionist or therapists to design a comprehensive program. Their treatment recommendations may include cleaning your child’s bowels with enemas, suppositories, or laxatives: following a regular toileting schedule; and making further diet modifications” (Children with Cerebral Palsy: p. 70 – 71)
“Having a child learn to be clean and dry is one of the most important things for any family. Children with CP may have extra difficulties with learning this because of the problems they have with maintaining positions. They may be fearful when placed on a toilet or pot because their balance is unreliable or because they cannot sit comfortably.
Normally a child will squat to pass urine or faeces. This position is the most effective one for using the abdominal muscles to empty the bowel. But for children with CP, squatting is very difficult because it is such a flexed position. In order to balance, they need to be lifted up off the ground a little. This can be done on a child’s pot which has a wide base; or the child can have a special chair, made of wood or APT, with a plastic covering on the seat.
When the child is first learning to use the toilet of a pot, he will need to be held securely by his mother so that he can feel safe. Once he has learnt how to pass urine or faeces in the pot and he is confident about it, he can start learning to balance more on his own. If he has some sitting balance but needs to hold on with his hands, the pot can be placed inside a cardboard box which has a bar across it that he can hold. The sides of the box and the bar to hold will give him security.
If, however, he is the kind of child who pushes back all the time, he may need to be supported from the front. If he already has a forward-tilting chair, perhaps this could be adapted to also be a toilet chair. A hole could be cut in the seat and the remaining surface could be covered in strong washable plastic. A flat board could be placed over the hold when he uses the chair other than in the toilet.” (Children with Cerebral Palsy: p. 154 – 155)
“The urologist or pediatrician can also recommend various strategies to help your child overcome her incontinence. For example, your might be advised to try behavioral modification techniques such as rewarding your child for days or dry nights with praise or with stickers, stars, or other treats. A conditioning technique involving an alarm system that senses moisture and alerts your child might also be used. Finally, medication is sometimes used in addition to other strategies. The most common medications are imipramine (Toframil TM) and DDAVP nasal spray.” (Children with Cerebral Palsy: p. 73)
“Toileting for the Child with Cerebral Palsy: This gives suggestions for teaching the child how to use the toilet. Available in English, Hindi, Bengali.”
"Encourage normal GI function through dietary management including adequate nutrition and regular exercise."
“Possible medical treatments for incontinence include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles. Specially designed undergarments are also available. “
“Children and adults with cerebral palsy may have difficulty using the toilet if their hip joints are stiff or if they have problems walking. Some do not have good control over their bladder muscles.”