Childhood bladder and bowel issues are more common than one would think. Understanding toileting accidents can help improve how you approach problems. I remember going through this experience with my own son and wondering what the heck was going on? He was 3 years old, and he would not poop. I knew he was scared. I knew he was getting stressed out. Also, I knew he was going up to 7 days without pooping!! I remember questioning if he needed more fiber, fluid, exercise. As time passed, I worried that there would never be a day when he did not need to take Miralax. I worried how much he was being mentally affected by all the stress around pooping. I think every family member weighed in at some time; all with good intentions but no real facts or practical help.

I will spare you all the various ups and downs along our journey. I will skip ahead to inform you that we did survive that stage of his development relatively unscathed. But I regret that we (my husband and I) were not aware of this topic. I regret that we didn’t get help for our son sooner. The experience led me into learning more about this therapy area. Now I am helping families talk more openly about poop and pee issues!!

Understanding Childhood Bowel and Bladder Disorders and Accidents

Elimination disorders are disorders that are typically related to body part function. They are not necessarily due to a specific condition or disease. The most common disorders include:

• Urinary incontinence
• Urinary retention
• Constipation
• Constipation leading to encopresis (poop that is backed up into colon for longer periods of time)
• Fecal incontinence
• Bedwetting

Many of these disorders appear around the time of toilet training and in preschool age. The symptoms vary by disorder and by child. The intensity and severity are also child/family specific. If the specific disorder is not addressed, the disorder and the subsequent behaviors and physical symptoms can occur indefinitely. It is important to know that most children do not “outgrow” the disorder. Therefore, they need help.

First off, it is necessary to seek medical advice (see symptom guide provided) and increase your understanding of what is happening for your child. As a parent, I wish the two following recommendations were addressed after our son was diagnosed with encopresis:

1. Medical interventions that are needed.
2. Rehabilitation treatment options are available and successful.

Understanding Treatment Options for Toileting Accidents

1. Bowel/bladder retraining – habit training, pelvic floor muscle training or re-training, biofeedback, postural training, and breathing education/training
2. Dietary/fluid education
3. Feeding therapy
4. Behavioral modification
5. Understand that potty training needs to be reviewed. A plan needs to be established that fits the child’s needs

Had I known and understood these two areas before, I would have handled our experience differently. We would have had success earlier on. If you have concerns for your child, please view the symptoms guide. Then, use the resources provided to choose your best course of action.

How do we treat here at MOSAIC?

If we recognize a disorder, it is important to look at the age and development of the child we are treating and establish realistic***goals. Occupational and physical therapists specifically trained in this area can establish comprehensive treatment plans. Firstly, we are looking to increase your child’s and family’s success and independence in the area of toileting. Secondly, we will collaborate with you in addressing the daily routines and training needs for your family. Thirdly, we will assess your child’s environment. The therapist will provide you with the best positioning for sitting on the toilet. They will also provide support to improve your child’s daily experience. Finally we will address behaviors surrounding resistance and avoidance. We will also teach you how to support improved habits and patterns.

Collaboration with your child’s primary care provider will occur. This provides continuous care for diet and medication follow through. We may design specific physical pelvic floor muscle training exercises. Exercises will improve strength and “coordination” of the muscles needed to support elimination of urine or stool. We will develop a home program with you to support the individual goals for your child. In addition, we will include toilet training support and education in our treatment approach. However, you should be aware that toilet training is more about the parent than the child.

***Realistic goals are about measuring success through reduced symptom occurrence and physical improvements. Therefore, goals are NOT about being toilet trained by a specific date. Toilet training includes a child’s ability to respond to bodily urges in a timely manner. This often does not fully occur until later in development (ages 4-5).

Resources

In conclusion, for more help understanding toileting accidents, check out bedwettingandaccidents, GIKids, The Poo in You, and the Bristol Stool Scale. Or, call MOSAIC to set up an appointment with a physical or occupational therapist trained in this area.

References

1. An Introduction to Pediatric Bladder and Bowel Disorders, Part 2 Tiffany Ellsworth Lee, MA, OTR, BCB-PMD, PRPC

2. An Introduction to Pediatric Bladder and Bowel Disorders, Part 1 Tiffany Ellsworth Lee, MA, OTR, BCB-PMD, PRPC

3. Physical Therapy Management of Pediatric Incontinence Jennifer Stone, PT, DPT, OCS, PHC

You have probably heard of RICE after an injury (Rest, Ice, Compress, and Elevate). But recent scientific evidence reveals that icing injuries is actually outdated advice! And here’s why: ice helps to decrease inflammation, but for healing to occur, our bodies need inflammation. Let’s take a look at how tissue healing works for a little science lesson: Whether you just had surgery or sprained your ankle, your tissues will go through 3 phases of healing:

1. Inflammatory phase
2. Proliferation phase
3. Remodeling phase

There is a lack of evidence of the actual times these phases occur at. But, tissue healing processes should be viewed as a continuum with overlapping timeframes. All tissues will go through the same pattern of healing, but the timeframe may be different depending on the type of injury.

Inflammatory Phase (Day 0-6)

The first part of the healing process is the inflammatory phase. This is where bleeding occurs due to widening of blood vessels (dilation) and the release of a chemical called histamine. Histamine helps other cells come into the area of healing, like white blood cells. Any dead tissue will be cleaned up.

Proliferation Phase (Day 4-24)

Cells that help build new tissue start to place new, immature tissue in random fashion. This tissue does not have the same tissue properties as healthy tissue. It is weaker than healthy tissue.

Remodeling Phase (Day 21-2 Years)

The new tissue that is “weak” (or immature) is being converted to more mature tissue. Why is this important to know? When we load tissue too fast, we may cause a disruption in this healing process. Likewise, we can also not load the tissue enough. This is especially important to help immature tissue become mature tissue. Tissues will adapt to the load we put on it!

What Should I Do?

We need inflammation to help the healing process. RICE may delay healing instead of helping! What should I do when I have an injury? Give it PEACE & LOVE!

Seek out physical therapy at MOSAIC to help rule out fractures, dislocations, or anything that may require emergency medicine. If you have questions, reach out to our adult physical therapist!

References:

1. https://theprehabguys.com/the-truth-about-icing-injuries/

2. Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE.

3. British Journal of Sports Medicine. 2020;54:72-73.

Your baby is crying again, arching their back, and is inconsolable. You try to feed them, and they suck for a minute but then baby pulls away and starts to cry. Baby takes a pacifier for a few moments. You breathe and try to lay them down, just to have baby start fussing again and wanting to be picked back up. Or, has your little one ever spit up after a feeding, even an hour or two after eating? Maybe they just burped, and something came up that gave them a sour face? Or baby started to move their tongue in and out and then you notice them swallow hard and fuss a little bit? All these babies are likely experiencing infant reflux.

What is Reflux?

Reflux, or Gastroesophageal Reflux (GER), occurs when contents from the stomach go back up in to the esophagus, the muscular tube that connects the throat to the stomach. The contents are then either pushed back down to the stomach as the esophagus contracts, or move up the throat and may become spit up or sometimes vomit. A lot of people experience reflux, and it does not bother them. Others may find it briefly uncomfortable. Sometimes it may be necessary to use medications to help reduce the discomfort.

Why Does My Baby Have Reflux?

Most infants have reflux because the opening from the lower esophagus to the stomach (aka the lower esophageal sphincter) does not mature until a baby gets closer to one year of age. It has been reported that as many as 60-70% of babies 3-4 months old experience vomiting related to reflux at least one time in a 24-hour period. Gastroesophageal Reflux tends to peak in infants around 4 months and spitting up tends to decrease around 12 months.

For many infants reflux does not cause a lot of problems, and they do not experience fussiness when they spit up, continue to gain weight appropriately, and stay on track to meet developmental milestones. When complications arise from reflux it is referred to as Gastroesophageal Reflux Disease (GERD). If left unmanaged, GERD may lead to: failure to thrive, respiratory infections and/or possible asthma, scarring or strictures in the esophagus, ulcerations, inflammation of the esophagus, or abnormal and feeding aversions to bottle, breast, and solid foods. As children get older they may be called “picky eaters” or limit what they eat due to discomfort or pain.

Signs and Symptoms of Infant Reflux

Signs and symptoms of GERD in infants may go beyond spitting up and/or vomiting. The following may be some indications that your infant is experiencing GERD:

• Difficulty latching or staying latched on a bottle or breast
• Aggressively attacking the nipple for 1-2 ounces then pulling away, arching back, and crying
• Prevalent coughing, choking, wet burps, or aspiration (when contents enters the lungs)
• Sour smelling breath
• Wheezing, difficulty breathing, frequent upper respiratory infections
• Coughing when laying on their back during naps or at night
• Being irritable and fussy
• Preferring to be fed in a more upright position
• Arching their back or making a bobbing motion with their upper body
• Not rolling over when developmentally appropriate
• Failure to gain weight
• Difficulty transitioning to solid foods

Strategies to Help with Infant Reflux

Feed baby in a side lying position to decrease infant reflux

This position mimics the natural position of breastfeeding.

• To get in the correct position, place your legs together and feet on a box or something where your feet are approximately 1 foot off the ground.
• Hold your baby so that they are lying on their side, with their toes and nose in the same direction, ear towards the floor.
• Support their head and neck so it does not lean back with one hand, and use the other hand to hold the bottle.
• In this position the baby can take a break when they need to, and it eliminates any pooling of the milk in the back of their throat, like if the baby was positioned with nose towards the ceiling. It is a safer feeding position as gravity assists the baby so that they can pace their feedings better and minimize coughing and choking.  This also promotes a nice suck, swallow, breathe pattern.
• A YouTube video, the Beckman Bottle Feeding in Sidelying, is nice resource.

Keep baby upright

Hold your baby in a more upright position for 30 minutes following feedings, if possible. Gravity can help contents stay in the stomach in this position. Be careful not to jostle or bounce your baby too much while the food is settling. Walking around and moving about are fine as this may also be comforting.

Try smaller, more frequent feedings

Feed your baby slightly less than usual if you’re bottle-feeding. Or, cut back a little on the amount of nursing time if you’re breast-feeding. Increase frequency of feedings to ensure appropriate weight gain.

Take time to burp your baby

Frequent burps during and after feeding can keep air from building up in your baby’s stomach.

• To burp, face your baby out, at an angle, with their feet resting on your thighs.
• Brace their upper chest with one hand and gently pat their back, 1 tap per second.
• Your baby may push against your legs, helping them to release any gas they may have. A YouTube video, the Beckman Happy Baby Burping Position, is another great resource.

There are a variety of strategies to help with reflux, but if signs/symptoms persist or worsen, please contact your pediatrician. For additional general information on reflux, MOSAIC has competent feeding therapists that can address your questions. They may be able to assist your family if your infant or child is having difficulty with eating at any age.

What are the effects of stroke on speech and the ability to swallow? We often don’t think about the act of speaking or swallowing. After all, we have been doing so since before we can remember. A stroke changes all of this. A stroke is an injury to the brain that occurs when blood flow is blocked or reduced. Severity of symptoms following a stroke vary from mild and transitory to severe and permanent. After a stroke, you may not be able to speak clearly or at all. You may be unable to follow directions or conversation or have difficulty coming up with words or putting words into a sentence. A stroke may also cause you to have difficulty swallowing. During the rehabilitation process you will likely work with a speech–language pathologist and hear the following medical terms.

Effects of Stroke – Aphasia

Aphasia is a language disorder that occurs after a stroke. It may make it difficult to talk, understand, read, and write.  When talking, a person who has had a stroke may not remember the word they wish to say. They may say a different word such as “cup” when they mean “plate,” mix up sounds in words such as “pick diller” for “dill pickle,” or use made up words. They may even have trouble saying longer sentences. A person who has had a stroke may not understand what is said when they are listening to family or friends. This is especially true if the person is speaking quickly or in a noisy room. They may no longer understand jokes. It is not uncommon to also have trouble reading books or forms, spelling words, writing notes or cards, and doing math calculations.

Dysarthria/Apraxia

Dysarthria and apraxia make it difficult for stoke survivors to say sounds, resulting in speech that is hard to understand. Dysarthria is a weakness in the muscles of the mouth, lips, tongue, and in muscles that control breathing. It makes it difficult to say sounds clearly or loudly enough. Apraxia also makes it difficult to say sounds correctly, but for a different reason. Apraxia is not muscle weakness; it is difficulty getting the muscles of your mouth, tongue, and lips to move the correct way to say sounds.

Dysphagia

Dysphagia is difficulty chewing and swallowing. It involves the muscles of the mouth, throat, and esophagus (tube to stomach). People with dysphagia may drool, lose food from their mouth when chewing, have food left in their mouth after swallowing, complain of food getting stuck in their throat or of pain when eating, and cough or choke during meals. Often people will lose weight, become dehydrated, or be unable to swallow pills.

A speech–language pathologist treats all of these impairments. The specific technique used will depend on the impairment and the severity of the impairment. Family members may also participate in therapy sessions to better understand the effects of a stroke and how to help a person recover function. If a person has a severe stroke, a full recovery might not be possible. Family members will be taught to help that person compensate while remaining as independent as possible. Recovery time from a stroke varies, but beginning treatment early will help a person who has had a stroke regain lost skills more quickly.

Check out Speech Therapy Treatment for Adults for more details on how speech therapy can help. For more resources or to learn more about strokes, visit stroke.org.

You have probably heard the terms gross motor skills or gross motor milestones. But what do those phrases actually mean? A simple way to think about gross motor skills are to think of them as BIG movements or movement of large parts of the body. More specifically, gross motor skills are skills that involve the large muscles in the arms, legs, and torso (core). Gross motor milestones are gross motor skills that typically develop at a certain age.

Most of the time we think about the gross motor milestones, such as:

• Rolling
• Sitting
• Crawling
• Walking
• Jumping

But there is SO much more to gross motor development. Gross motor skills encompass movement, balance, and coordination. Babies and kids need to master all of these areas in order to participate in activities. Activities are more complex movements that requires multiple gross motor skills put together. Things like riding a bike and playing sports. Gross motor skills build on top of one another. If one is missing, or the quality of it is poor, it can change the quality of the next skill or even delay it from happening.

Jumping

Think about jumping. What does a child need to be able to do? Stand. Squat and return to standing. Generate enough power in their knees and ankles to get off the ground. Arm swing. Have enough balance to land without falling. Vision. The child must see where they are jumping to so they don’t run into or land on an obstacle. If a child is missing any of these skills, they will not be able jump.

Basketball

Now think about playing basketball. There are tons of skills a child needs to be successful. The ability to run and jump. To catch and throw a ball. To shoot a ball. Each of these requires mastery of multiple skills to be able to do them. And then the child needs to be able to put all of these skills together and do them simultaneously. However, that doesn’t take the social emotional or cognitive requirements into consideration. Movement is so incredibly complicated (an amazing) when you really think about it. Which is why, as physical therapists, we focus so much not just on can you do it? But can you do it well?

And why we constantly talk about tummy time! Above all, doing supervised tummy time with your baby from day one prepares them for successful development. If you have questions about when your child should be doing what, check out the CDC’s Milestone Moments. To learn more about how to help gross motor skill develop, check out our articles here.