Saturday, 26 December 2015

Bowel Health - Poop in the overnight diaper or pull-up

When a toddler has poop in the overnight diaper or pull-up, this implies that the child withheld the stool all day and that the poop came out while the child was asleep (unconscious).

Stool withholding is a fundamental learned behaviour in children with constipation.  

When I hear a story about overnight poops that have persisted for many months, this usually implies that the child is "really good" at stool withholding. In my experience, this is often a sign of more serious constipation. 

Saturday, 19 December 2015

Bladder Control - Large bladder in a 10 year-old boy.

Recently a ten year-old boy was referred for a "large bladder." The large bladder was discovered when an abdominal ultrasound was performed to look for a cause of tummy pain. The ultrasound showed that the top of the bladder was up to the belly button and the estimate of the amount of pee was about 500 ml (16 oz). 

The tummy pain story sounded like intestinal colic (spasms) due to constipation. The Mom confirmed that the boy had intermittent constipation. The boy reported he pooped about three days a week. Dad reported that the boy plugged the toilet with 90% of poops.  

The ultrasound in my office confirmed that the top of the bladder was at the level of the belly button. The boy peed about 525 ml (17 oz). 

The average size for a bladder in a ten year-old is about 350 ml. 

I see large bladders fairly often in my office. Constipation from infancy (first two years of life) is the most common cause of large bladder. When there is significant constipation during infancy, the tiny pelvis is so filled up with poop that there is no room for the bladder to expand. The bladder is literally "pushed up and out" of the pelvis. Once the bladder is above the pelvic bones, the bladder can expand. I often see a bladder that extends to just below the belly button. Occasionally I see a bladder that reaches the belly button. Once I saw a bladder that went above the belly button. The bladder is meant to fill up and stay in the pelvis.

This boy was unique in my experience because he did not have any bladder symptoms. He was late to toilet train because of the constipation, but once he stopped wearing his daytime diaper, he peed regularly on his own initiative, Mom did not see pee holding postures and she did not need to remind him to pee. The boy did not have urgency and he did not wet by day, not even minor dampness. He was dry at night and did not need to wake up to pee. This is the first child I have ever seen with a large bladder due to constipation and without any bladder symptoms! This makes me wonder if this is more common than appreciated. 

The main reason why this boy did not have bladder symptoms is because he did not drink very much and he never really filled his large bladder. The Mom convinced the boy to drink for the previous ultrasound and again for the visit to my office, but he otherwise he never drank very much and never likely filled up his bladder. 

His hydration story was terrible. The most water he drank during an entire day was about 180 ml (6 oz)!!! He did not drink anything at breakfast. Mom reports that sometimes he would take "a sip" of milk before school. His first drink of the day was a chocolate milk box at lunch. After school he had about 3 oz of water. At supper he had 3 oz of milk. In the evening he might have another 3 oz of water. Milk is good nutrition but poor hydration. The optimal amount of water for a boy his age is at least 50 oz of water. Yikes!! Very poor hydration. Perhaps the only times he ever filled his large bladder were for the two ultrasounds?

Not drinking is a classic strategy to minimise bladder symptoms and this boy was an expert at not drinking. He has obsessive compulsive and anxiety traits that likely played a role in his hydration, bladder, and bowel behaviours.  

Saturday, 12 December 2015

Bowel Health - Toilet trained toddlers who ask for a diaper to poop.

Toilet training for pee is often achieved before poop. Some toddlers make the transition for pee but are reluctant to sit on the potty to poop.

If a child is no longer wearing a diaper during the day and is reluctant to sit on the potty to poop, the child will start holding the poop in. Parents might note stool withholding postures (clenching the bum cheeks, squeezing the thighs together, walking on tip-toes).  

Some of these children will wait until a diaper is put on to sleep (night or nap), or as a precaution when the family is going out. Shortly after the parent puts on the diaper, the poop often comes out. 

Some parents learn from this behaviour and start to offer the child a diaper to poop. Some toddlers are articulate enough to ask for diaper. 

When a child is reluctant to poop on the potty and chooses the diaper route, this is usually a clue that the poop is difficult to pass. These children know that their poop is a problem to pass in the diaper. When the parent suggests that they should poop on the potty, the child considers this a bad idea. When they already have problems letting the poop out in a diaper, the potty does not look like a better alternative. 

If a parent notes this behaviour they should routinely offer the diaper as a transition phase. This is far better than allowing the stool withholding behaviour to persist. Stool withholding behaviour will make the bowel health much worse. The pattern will become more random, the child will start to miss days, and the poop will become harder and more and more difficult to pass. 

During the transition phase when the child is in underwear by day but still pooping in a diaper, the parent should soften the stool by encouraging the child to drink a lot more water and to eat foods with more fibre. Once the stool is soft enough, the transition from diaper to potty will be straightforward. If the child is not keen on fibre, a stool softener can make a big difference. 

Saturday, 5 December 2015

Bladder Control - Getting up from the supper table to pee

Many parents presume that when a child leaves the supper table to pee that this has nothing to do with a full bladder. Parents often believe this behaviour is a tactic to avoid eating either because the child would rather play or because the child does not prefer to eat the food offered. The behaviour can infuriate some parents, especially when the child does this on a regular basis.

These children really need to pee. To the child, at that moment, the bladder does suddenly feel full.

Every time we eat, even a modest amount, the food lands in the stomach, and this initiates the Gastro-colic Reflex. This basic and automatic reflex makes perfect sense. When the food we eat enters the stomach, the brain instructs the bowel to contract and to move the previously ingested food lower down in the intestine to make room for the next meal.

Down at the bottom of the intestinal tract, the muscles in the descending colon and rectum contract and push the poop in this location deeper into the pelvis.

The bladder is located at the bottom of the funnel-shaped pelvis where there is the least available room. When the poop in the rectum pushes on the bladder, the increase in bladder pressure is recognised as a signal to pee. The signal is actually a signal to poop and pee, but most often the child leaves the table and only pees.

To minimise this behaviour the parent should instruct the child to pee before they sit down to the dinner table. A trip to the bathroom to wash the hands before dinner is an important personal hygiene behaviour. If the child pees first, washes their hands, and then sits down, getting up from the table to pee can be avoided.

The get-up-from-the-supper-table-to-pee behaviour is also a clue that the bowel health needs to improve. This behaviour is much less common in children who have a poop after breakfast because there is less poop hanging out at suppertime to press on the bladder. This behaviour is much less common in children who have soft poop because the impact of soft poop on the bladder is very different compared to the impact of hard or pasty poop.