1. Healthy Bladder, Healthy Bowel Information Session for Children with Additional Needs

2. Welcome Aim of today’s session is:
To look at how bladder and bowels work.
To provide information and awareness to help you support your child with their toileting needs.
Welcome
Introduce Self and session
Explain where toilet is
Explain re evacuation procedures
Staff will be available at the end of the session for any questions or to go through again any part of session
Session will be divided looking at day time & night time wetting and constipation/soiling. 2

3. How the kidneys and bladder work
Ureters
**ASK PARENTS TO LABEL – Labels fly in one at a time**
Can use a torso to help demonstrate.
The urinary tract is the body system of eliminating some of the body’s waste.
Kidneys – filter the waste products from the bloodstream and makes urine (wee).
Ureters – are tubes that carry urine from the kidneys to the bladder.
Bladder – stores urine until it is passed out of the body – it expands as it fills with urine. When the bladder is about half full a message is sent to the brain to go to the toilet.
Urethra – this tube allows urine to exit from the bladder.
Between the bladder and the urethra is the sphincter muscle. This muscle prevents urine from leaving the bladder until you go to the toilet - when you relax the muscle it allows the urine to flow out.
Urethra
Bladder 3

4. Bladder Development
In babies, the bladder sends a message to the spinal cord which signals back that the bladder should empty. Young babies do not have control over when or where they empty their bladder. It is more of a reflex action. As the baby/child develops, the bladder starts to send signals to the brain instead of the spinal cord. When this happens the child can be toilet trained. “Children with additional needs may not recognise the signals but toilet timing may be appropriate. All children can be supported to promote a healthy bowel and bladder” (Burton L.2015)

5. General information about the bladder
The bladder acts as a holding vessel for urine.
It should fill and empty in a cycle.
Usually pass urine 6 – 8 times a day
Urine usually pale yellow in colour
How much the bladder holds depends on age
Most children can be introduced to the potty/toilet from the age of 2 -3 years. This is when the bladder and brain work together. For children with additional needs it may take a little longer to develop toileting independence.
Pass urine - 3 – 4 hourly.
Urine is usually a pale yellow, although sometimes can be darker with the first wee of the day or when not had much to drink.
Amount Bladder holds (bladder capacity) – the amount it can hold is dependent on age (see following slides for how bladder works and capacity). 5

6. How the Bladder works
The bladder is a muscular sac – like a stretchy, crumpled bag with lots of creases. Its muscle walls relax to allow it to fill with urine. When the bladder is full a message is sent to the brain to signal the need to empty.
When urine is passed the bladder is relaxed and contractions squeeze out the urine.
Drinking regularly through the day can help to increase how much the bladder can hold. Going to the toilet frequently can also reduce the efficiency of the bladder. 6

7. How much a bladder can hold
Age
Bladder Capacity 5
180mls 6
210mls 7
240mls 8
270mls 9
300mls 10
330mls 11
360mls 12
390mls
Once children reach puberty the bladder capacity is calculated by body weight
Bladder capacity = age x
A Healthy Bladder:
Should not be aware of its presence until it is nearly full
It should give timely reminders of the need to empty, allowing plenty of time to access a toilet
It should not leak!
It should fully empty
This can differ for those children with medical and physical needs. 7

8. Information on the bowel

9. How the bowel works Stomach Small Intestine Large Intestine Appendix
**ASK PARENTS TO LABEL – Labels fly in one at a time**
Food enters the stomach, churns the food, adds gastric juices to make a liquid.
This enters the small intestine where nutrients are absorbed.
The large intestine transports the waste products (poo) to the rectum where a soft formed stool is passed via the anus.
Appendix
Rectum

10. Signs and Symptoms
Many parents/carers do not recognise the signs and symptoms of constipation
These are:
- small or large hard stool
- opening bowels less than three times a
week
- stomach pains
- pain/straining when opening the bowels
One episode of pain can cause a child to become afraid of going to toilet. This avoidance can lead to a build up in bowel and then becomes even harder to pass.
Children are regularly admitted to hospital due to constipation.

11. - overflow soiling - excessive wind - general lethargy - poor appetite - disturbed sleep - changes in behaviour - night time soiling

12. Which one is the ideal poo?
Bristol Stool Chart
Which one is the ideal poo?
Type 1 - has spent the longest time in the bowel. They are hard to pass and often requires a lot of straining.
Type 7 – has spent the least time in the bowel. Has the need to pass urgently and accidents may happen.
Ideal poo is 4.

13. What happens when your child is constipated
Many children with additional needs are prone to developing constipation for a variety of reasons.
Cause of constipation – rigid diet (specifically ASD); low fluid intake; avoidance in passing stool (poo); medical condition; can be unknown. But can become a problem over many months and years. It can take a long time resolve.
Children soil:
because they have sensory needs (e.g; smearing)
They have no sensation (e.g; spina bifida)
- They have emotional needs
Most children do not soil deliberately however some children may soil for attention.
Soiling
This is most commonly related to constipation with ‘overflow’ and the child has no control of this and is often unaware – a smell is often noticed by parents/carers.
Children need to be treated sympathetically when this occurs.

14. How you can help your child…

15. Encourage movement and exercise Encourage fluids
Avoid giving your child dark coloured drinks, drinks containing caffeine and carbonated drinks
A diet that includes fruit, vegetables and fibre
Establish a toileting routine
Ensure the toilet area is comfortable
Remember praise and rewards
Exercise – helps with movement of bowel
Diet – Healthy diet with 5 portions of fruit and vegetables; higher fibre type foods e.g. Weetabix, porridge oats, fruit’n’fibre, shreddies. Wholemeal products – flour in scones, cakes etc./wholemeal pasta & rice; pulses (baked beans, kidney beans, chick peas, lentils); Jacket potato with skin on.
(Parents to be given Tips on Increasing fibre & fluid in diet leaflet)
Avoid too many bananas and excessive amount of milk.
Fluids – 8 glasses of water based drinks (unless advised by a medic). To help encourage fluids can include in addition to drinks – jelly, ice lollies; smoothies
Toilet routine – encourage your child to sit on the toilet 10 – 20 minutes after meals and praise for trying
Toilet Comfort – it needs to be an environment that encourages the child to sit and stay. Can offer books, puzzle books.
Give lots of praise for compliance. Can use reward system e.g. silver star for sitting on toilet, gold star for doing a poo with an agreed number of gold stars earned to result in a SMALL treat.
Medication – should be given to clear bowel. It is important medication is given regularly and continued even after bulk of poo has gone. This is to help keep poo soft and easy to pass. Follow doctors instructions and stop only on advice of doctor.
All this to continue even during holidays. May take some time so be patient. 15

16. Fluids Age in years Gender Total Fluids per day 4 – 8 Female Male
1000 – 1400mls
9 – 13
1200 – 2100mls
1400 – 2300mls
14 – 18
1400 – 2500mls
2100 – 3200mls
However some children may be strict fluid intake regime due to their medical condition – for those please speak with your child’s doctor/consultant.

17. Toilet Readiness 17

18. Changing continence products…

19. Introduce the toileting process as a normal everyday activity
Change your child in the toilet area
Use consistent toileting vocabulary and/or signs and symbols
Involve your child in the changing process of their continence product
Empty poo down the loo to show them where it should go
Flushing and handwashing routine
Let your child watch other family members using the toilet where appropriate
Encourage your child to sit on the potty/toilet if able
Remember praise
Children should have continence products changed (removed and replaced) in toilet area.
This enables child to associate wees and poos in the toilet area. If there is a pattern to when a child does a poo encourage them to use the toilet/empty bowel in nappy in the toilet area.
Parents can apply for a radar key from their local authority which allows access to public disabled toilets
Consistent use of language & praise –Use clear language when going to change e.g. ‘let’s go to the toilet’ and when changing e.g. “ Good girl you‟ve had a poo! – use vocabulary such as ‘wet and dry’ to teach your child about being wet and dry.” Use family language and this needs to be consistent in all settings.
Signs and symbols – can be used to aid with routine and changing of products and association with wees and poos.
Show a picture of a toilet to child at each product change/ or visit to the toilet area. These picture cues will help children who may have communication problems.
Involvement of removal of continence product –Child may help with this where able. If possible change child’s nappy with them standing up as this enables them to take an active part
Empty poo down the loo – both child and parent do this together to show child where poo belongs. If child unable to help with flushing parent describes what they are doing and shows the child e.g. ‘Now we are saying goodbye to the poo’. Can use food colouring to water system to aid with flushing.
Handwashing – children should be encouraged to ‘wash’ hands after change of product. Can use hand wipes as alternative to using soap and water if unable to access sink.
Role model – helps to show normal behaviour – including sitting or standing to go to toilet, flushing and handwashing. Helps to reduce anxiety.

20. Is your child ready for toileting?

21. Becoming toilet trained is the interaction of two processes:
- Bladder and Bowel function
- Social Awareness
For children with additional needs it is often a lack of opportunity and social awareness that results in delayed toilet training rather than a problem with bladder or bowel.
Talk to your child’s doctor about your child’s condition affecting their ability to control their bladder or bowel
Does your child wee and/or poo at the same time every day?
Can they stay dry for 1 ½ - 2 hours?
Are you ready?
Children achieve independence in self-care at varying levels depending on their level of understanding and development.
Appropriate opportunities and/or goals should be encouraged. E.g; a child who is reluctant to sit on the toilet may tolerate this if listening to a favourite piece of music/ or using a toilet toy
Can they stay dry 90 mins– 2 hours – can use folded piece of kitchen roll in nappy (start with first nappy of day). Check and record hourly if wet/dry. This will identify how long your child is staying dry for.
Poo – consider constipation.
GP - Your doctor can offer advice on medication, changes to diet or more specialist help, rule out urinary tract infections (UTI) – can cause to wee more
Changes – new house, new baby, starting school, moving class, bereavement, change in staff at school
Some children may not be independent with toileting but may be clean and dry if toilet timed. Some may require help with continence products. However this does not prevent them from being given the opportunity to go to the toilet on a regular basis as part of their self care.

22. Preparing the toilet area
Toilet comfortable
Adaption to toilet – involve OT
Position on toilet & foot stool
Toilet toys
Sitting on the toilet needs to be a relaxed time
If using a potty instead of toilet the potty should be in the toilet area.
Toilet Comfort – make toilet comfortable, nice and safe – books, puzzle books, warm, music. If child has poor sitting balance OT can assess and provide appropriate equipment eg potty, toilet seat, steps etc.
Position on toilet – Ensure sitting with knees higher than hips and lean forward – may require use of foot stool. May need encouragement to try and go – use balloons/bubbles or blowing games. For some children the advice from the physiotherapist may be helpful for positioning.
Toilet Toys – should be pliable and washable. Used to aid with keeping child on toilet/in toilet area and also associates with toilet time e.g. Child knows that they can play with a toy duck when going to the toileting area for nappy change/sitting on loo. For some children duplicate toys may be needed for different settings.
Encourage child to sit on the toilet for 2 minutes – use a timer/song

23. Moving from a nappy to the toilet…

24. Encourage nappy changing in the toilet area in all settings
Encourage nappy changing in the toilet area in all settings
Encourage/teach your child to wipe their bottom and to empty the formed poo into the toilet, flush away and wash their hands.
Progress to sitting your child on the toilet still in their nappy with the lid down.
After a while, get them to sit on the toilet with the lid up using a training seat/insert seat to help them feel more secure (you may wish to begin with cutting a hole in the nappy).
Begin to loosen nappy gradually until it can be removed altogether.
Toilet paper can be put in the toilet before a poo to help reduce noise/splash.
Stickers can be used as a reward for stages of progress.
If there are no medical concerns about starting toilet training, it’s worth spending a few days noting when your child naturally wees and poos e.g., after eating, at a certain time of day or at fairly regular intervals. This pattern will be a guide in knowing when to place your child on the toilet or potty. If there’s not already a natural pattern, you’ll need to establish one once toilet training begins.
This should be worked in all settings - failure to be consistent will give confusing messages and child may fail.
Consistent use of language & praise –Use clear language when going to toilet e.g. ‘let’s go to the toilet’; “ Good girl you‟ve had a poo! – use vocabulary such as ‘wet and dry’ to teach your child about being wet and dry.” Use family language and this needs to be consistent in all settings.
Signs and symbols – can be used to associate with wees and poos and may be used as a cue for the need to go to the toilet.
Show a picture of a toilet to child at each visit to the toilet area. Teach child about being wet and dry– can use books about going to toilet; use signs indicating toilet routines (visual timetable) - these picture cues will help children who may have communication problems.
Set up Toilet routine – use child’s routine (as previously established) for wee’s. 20 – 30 minutes after breakfast and evening meal for poos– praise even for just trying
Involvement of pulling pants up and down – ensure clothing is easily manageable. Avoid tights, belts and buttons if child unable to manage these. Child may need help with this.
Involving the child. - many children with physical disabilities learn to direct the care provider and assist during aspects of the procedure. For example, a child who has cerebral palsy and has difficulties with mobility may be able to inform the care provider when they need to
go to the toilet.
Sitting on the toilet – can be a gradual process for some children in removal of nappy. Trainer pants/pull-ups could also be used for when nappy is removed. Boys who wish to stand may need something to ‘aim’ for e.g. a ping pong ball. Sit on toilet for 2 mins – aiming for this (long enough to do a wee/poo). May use a song or timer to aid with this.
Empty poo down the loo – both child and parent do this together to show child where poo belongs. Can also flush toilet together. Can use food colouring to water system to aid with flushing.
Wiping – learning to wipe – front to back for girls after wees. Consider using moist toilet wipes.
The degree of supervision needed may vary depending on the complexity of the care and the developmental level of the child.
Flush toilet – only flush when there is something to flush (otherwise can become a game of just flushing toilet). Give child advance warning e.g. ‘Ready, steady Flush!’ Can flush together. May need to remove toilet paper or roll out an amount before e.g., 4 sheets.
Role Modelling – may need to take turns with parent to sit on toilet; use a doll; parent sits in bathroom with child rather than stand over them.
Child may begin to hold onto urine for longer as the bladder increases with age. Thus the need to go to the toilet for wees can change over time (may not need to be as often).

25. Things to think about…

26. You and your child are not alone Anxiety/expectations Listen to advice
Praise! Praise! Praise! – work with your child
Change in diet/fluid intake
Constipation/UTI’s
Illness
Toileting when out and about
Attention seeking behaviour
Distractions
Sensory issues
Does your child’s condition affect their ability to control their bladder or bowel movements
Anxiety/expectations – can be both parent and child; expectations of other carers – aim for consistency in settings
Illness – if a child is ill they may revert back to wetting and soiling
Toileting when out and about – have you got a changing bag – wipes, spare clothes – radar key?
Attention seeking behaviour – some children will use negative behaviours for attention
Distractions – is child too busy to go to the toilet e.g.; iPad. Continue to be consistent with toileting routine
Sensory – some children enjoy being in a wet or soiled nappy/clothing and are reluctant to change/go to the toilet

27. Further information and help
Text Parent/Carer ChatHealth: (City)
(County)
Contact your local Healthy Together Team or your child’s GP
Inform how parents/carers can access School Nurse
Fledglings – has brochure for many products. Includes toileting aids, signs and symbols cards, bed protectors etc.
Bowel and Bladder UK formerly Promocon has information and booklets on continence including information for those with special needs.

28. Name of Originator/Author:
Alison Barlow
Johanna Broad
Updated by:
Louise Burton
Stephanie Cave
Date Reviewed:
25th May 2018