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TOILET TRAINING THE CHILD WITH SPINA BIFIDA
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Toilet training is an important part of growing up. In the U.S., kids learn bladder control when they are 2 to 3 years old. By age 5 they fully control their bladder during the day. Bowel training usually happens before bladder training. This is because stooling occurs less often and is more predictable. To toilet train successfully, children must be ready. They must be able to sit, follow directions and stay dry for at least two hours.
Children with Spina Bifida usually have damage to nerves that control the bowel and bladder. These nerves exit the spinal cord between the sacral levels two and three. In some cases, there is "sparing" of these nerves. This may allow children to have some bladder and bowel control. Most people with Spina Bifida need catheterizations and/or drugs for complete bladder and bowel control.
Getting Started
If it is not necessary to start a catheterization or bowel program, families can safely wait to see what toileting abilities their children might develop on their own. For children with Spina Bifida, the age of toilet training is usually delayed, but children should start training before going to school.
Preparing for toilet training starts early. Prevent constipation in infants and young children to preserve bowel tone and function. Later on, regular bowel movements will make it easier for children to learn control. Fruit, fruit juices, water and additives (like fiber supplements) can keep bowel movements regular. Drugs can be used, too. It is helpful to let young children go into the bathroom. This teaches them that the bathroom is a private matter.
Bowel control happens before urinary control. So it is helpful to begin toilet training by focusing on bowel patterns. Keep a record of bowel movements for about three weeks to see if there is a pattern. Start toilet training by placing children on the toilet 15-20 minutes after eating. Make sure that feet are supported. Then teach them to "grunt" or "bear down." Praise them for working with the toilet training program. At first, give rewards for cooperation. Then change the reward for having a bowel movement in the toilet. At the end, change the reward again for "accident-free" days. Regular toileting times are the key to this "habit training."
If habit training does not work, try a "cleanliness program." This program uses digital stimulation, suppositories or enemas. Doing any program on a schedule increases its success. SBA has publications and names of clinics that can help with choosing and starting a bowel program.
Special Considerations
Some signs may help adults learn children's potential for bladder control. Those with the best chance for bladder control produce a good urine stream, are dry between urinating and have an urge to void. The chance for bladder control is much lower for those that leak urine constantly, never have a good urine stream or do not have an urge to void. There is no harm in toilet training any child as long as parents remain upbeat and realistic.
Toilet training for the bladder is the same as "normal" training except for intensity and age. Putting children on the toilet first thing in the morning and then every two hours during the day may increase dryness. Also, practicing "pottying" is helpful. This includes removing clothes, sitting on the seat, getting dressed, flushing and washing hands. Rewards can help with cooperation, voiding in the toilet and having accident-free days.
Clean Intermittent Catheterization (CIC)
If timed toileting does not lead to dryness, CIC and drugs are needed. CIC involves inserting a small plastic tube into the bladder to drain urine. It is usually done every three to four hours. If a child is not dry between drainings, drugs may help with dryness. CIC and drugs do not lessen a child's given ability for bladder control. Rather, CIC empties the bladder at intervals while drugs relax the bladder and/or increase the tightness of the sphincter. If using CIC with drugs does not result in dryness, surgery may be needed.
Conclusion
Toilet training has many implications for a child's development. For children with Spina Bifida, it is important to assess their needs. Then you can start a bowel and bladder control program. It is important to know that no one with Spina Bifida should live with uncontrolled bowel and bladder problems. Good health care and tailored programs can help.
Resources:
* Fact Sheet Contributor: Jean Brown, MS, APRN, RNC
* 1.800.621.3241 ~ www.spinabifidaassociation.org
* "Bowel Continence and Spina Bifida," S. Leibold, et al., SBA, 1995.
* "Toilet Training for Individuals with Autism and Related Disorders," M. Wheeler, Future Horizons, Inc., 1998.
* "Bladder and Bowel Management for the Child with Spinal Cord Dysfunction," L. Merenda, J. Brown, Journal of Spinal Cord Medicine, SCI Supplement, Vol 27, 2004, p. 16-23.
* "Incontinence: Toilet Training a Child with Special Needs," C. Keeler, Exceptional Parent, October 2000, p. 82-86.
* "Incontinence: Toilet Talk," G. Paley, et al., Exceptional Parent, November 2000, p. 96-102.
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