Daytime Accidents After Previously Being Potty Trained

Today I am featuring a discussion with Dr Kristine Godsil, Pediatric Physical Therapist, about how to address accidents after you thought your child was completely trained. This can be a frustrating time and one that can stress parents out. Listen as Kristine and I discuss some “at home” treatments and how physical therapy can help your child re-gain success.

Episode Transcript:

Hi, welcome back. This is Bev Garrison with First Breaths to First Steps. I am here today with Dr. Kristine Godsil. She is a physical therapist, does a lot of work with kids and we thought we would talk today about what the role is of a physical therapist. When your kids have daytime accidents -when they were previously potty trained. We hear this so much in the setting of, “oh my gosh, we were doing great. And now we’re not doing great.” Usually some sort of stressor has come into place, but there can be some things that we can work on with our physical therapists. Welcome today, Kristine. Thank you. Thanks for joining us.

The perfect answer of when my child will be trained without accidents is the million dollar question, right? So much rides on this pivotable moment. Unfortunately they have to be ready? It’s not really you. It’s your child. , it can be that maybe we have some premature expectations. But what we’re talking about today is we’ve had a run of being fairly successful and we achieved and, had signs between 18 and 24 months that we were ready to train. But now we’ve kind of had some regressions. What do we do if we see potty regression? You’re potty trained child has reverted back to wanting to need a diaper. Any sort of factors may cause this, usually I find it’s more of a stressor at home, but regressions can be fixed, especially if you knew that the child was able to achieve initially. They usually can get back as long as we retrain some habits and get back into training. I recommend for parents try to stay calm, try not to push it’s hard. The two things that kids can control is what goes in their mouth kind of what comes out the other end. And so you don’t want to have a power struggle over that being positive with your reinforcement, trying to take away any negative connotation.

Seeing a healthcare provider, just to make sure it’s not a sign of infection. If you’re becoming wet or, leaking urine or things like that. Sometimes it can be maybe that child has a urinary tract infection, which makes you have to go more frequently. Could be a sign that maybe your blood sugars are off, which also makes you have to go more frequently. So you want to make sure that you rule out those medical causes that could be making this an issue.

Sympathizing with them, trying to get back to your training and clearly laying out some expectations, but more in a positive manner rather than negative manner. But today we’re going to talk with Dr. Godsil Activcor PT about physical therapy for child bowel and bladder issues, AKA pooping and peeing issues. Physical therapist can help to educate children and their families about the proper bowel and bladder habits. They can also speak to dietary modifications and pelvic floor awareness. The pelvic floor.

We’ll talk about like, what is that? What are they talking about? And how do we teach them to learn control about those muscles? So can you start out by defining for me what the pelvic floor is and how that plays a role in effectively being able to eliminate poop or pee?

Yeah, absolutely. The pelvic floor is a subset of muscles that lay in the pelvic bowl of your pelvis. So it’s, what is the, at the bottom of this core system everybody talks about. And so how that plays a role into elimination, whether that’s pee, whether that’s poop The pelvic floor muscles help with the stop and start a flow of urine. Anytime the body needs to maintain the system.

Like we’re seeing with the leaking. And that could be with sneezing, coughing, or laughing with jumping on the playground, those kinds of things. So we want to know how that relates to the child and their activities. Like when is the leaking happen? Is it days at night time? Is it certain activity? Is there around a certain kind of stressor? Like you’re saying and then looking at the core system involved.

What I mean by that? It’s a pressure system that is in the abdominal cavity. And so the bottom is the pelvic floor. The top is the diaphragm. Our front is the abdominals in the back, our back muscles. We want to make sure that all of that works in tandem with one another so that we can go to the bathroom, well. That we can laugh and sneeze and play without any sort of accidents. Making sure that all of those are working in tandem with one another.

I think parents are always kind of surprised, but children can learn where their pelvic floor muscles are and how to contract and relax them, how to use them properly to avoid accidents. What’s an example of say we have some daytime wetness. What are some examples of how you’re coaching that child to kind of come. In tune with those muscles involved in PT?

Yeah. One of the easiest ways is working on your breath thinking about that relationship between the diaphragm and the pelvic floor that has to move when we take a deep breath in your diaphragm has to descend as you inhale, which makes the pelvic floor also relaxed. And so it works in this ebb and flow together. Seeing, how does the child breath? I’ll joke with them of like, okay, take three deep breaths and do it as normally as possible. Like someone’s not watching you. And usually I get a giggle and then when we go through some breathing. What I’m looking for is, is their upper chest moving the most. How, what does that look like to do their ribs come out to the side? Like they should to help expand. Is there any air getting down to the belly? Cause that would mean that that diaphragm is descending. Looking at all of those three components and making sure. Is that working or does that line up with what the child or the parents are saying?

The other thing that we can use for pelvic floor muscle control, if it’s not just their breath. If it’s not the child’s constipated or whatnot. What we’re looking at for any pelvic floor dysfunction is we can use biofeedback. And biofeedback on a simple level is truly just something coming in contact with the body that lets the muscles do their job. There’s a biofeedback machine. What we can use are these little pads that go onto the surface of the pelvic floor muscles. And then it gives us direct information on how much that activity those muscles are going through. We can see in real time, are those muscles holding on a lot of tension at baseline, or when we’re trying to contract them, do they not move at all. Trying to see that in real time.

I’ve used even something as simple as a Q-tip of having some awareness of being “okay, I want you to move your muscles here. And just that swipe of Q- tip is a certain biofeedback and sometimes that’s enough for a kid. We use a couple of different techniques to meeting the child or the parents where they’re at.

I always go through with pediatric pelvic floor therapy. It is, contra-indicated do any internal work. So that is not in the scope at all when we’re doing treatment. That’s why everything is on the outside or surface level. And truly making sure that there’s consent by the family and the child itself because like you’re saying stressors can be why these regressions happen. Adding stresses situation should never be a part of the solution. Making sure everybody’s comfortable and knows what’s happening so we can get down to the bottom of what’s going on.

It is kind of nice there because I explained to parents, “I know it sounds kind of funky, but biofeedback is a non-surgical method. We always want to try to do everything we can before we would need to . intervention. Helping us learn those muscles of the pelvic floor and that bladder and or bowel control can be super important. And if you can do it externally that and be able to help them retrain their little brains that are going so fast, it can be super helpful. Especially, you know, you can see that none of them really with leaking, but holding and releasing, urine or stool you know, like I said, those two things those kids controls what goes in their mouth and what comes out the other end. Having them learn that, putting them a little bit in control of that can be helpful .

Have you ever used a bowel or bladder diary as far as, “are you constipated?” How often are you going? Are you holding things like that?

Yeah, I do. And I probably use it a lot. Because it’s, again, all information is good information, especially with pelvic floor, especially when it comes down to pediatrics. Making sure upfront that we’re getting buy-in from the family and from the child itself. Generally when we do a bladder diary, it’s after it’s before or after our first session. What it takes a look at is how often are we going? Whether that’s pee or poop. What is the consistency of it? Is there a certain color, those kinds of things. And then how long? Because all of that information is telling me whether or not we’re completely empty in our bladder. Are we going a sufficient amount of time? Does it look like we’re having enough intake of fluids or the right kind of food? Those kinds of things. I’ll even have that in tandem with a bowel chart. There’s something called the Bristol stool scale. Mine has a dragon on it, cause it makes it fun for the kid, but it takes it down a little bit of looking at.

What does this stool actually look like? And then what does that mean? In real time, that’s nice for the parents to look at too of ” oh, okay. If it’s like little rocks, then that means that we’re probably getting to that point of more constipation.” We need to look into how’s their water. Are they having any sort of constipating includes those kinds of things. If it’s runny at home, what is changed in their diet and what can we change about it in real time? When we look at those charts, one of the questions on mine is what’s happening when it happens? Whether they’re going to the bathroom and there’s a strong urge or were they playing. What are they playing? And that’s when they leaked either stool or pee. That’s going to keep my mind going “okay, is this, is this leaking because we’re constipated and the body just doesn’t know how to, tap into those signals correctly.” Or is it truly because, we’re leaking stool because we don’t have enough fiber or we don’t have enough of the, this or the, the lack of control from the pelvic floor. Trying to put all those pieces together. There’s a lot of things that go into play for this system. It’s brain, it’s bowel, it’s bladder, it’s muscular. And then it’s environmental. Making sure all of those things come together so the child is successful . Not only is a stressful event, sometimes that happens, but it puts more stress on the child . Especially if they’re school age. No one wants to have accents at schools. No one wants to have to be running to the bathroom constantly or worrying about it. Making sure that they’re set up for success and know that it’s okay and that’s normal and what we can do about it. I think those are helpful of being able to see something in real time. And then how can we translate that to treatment.

I did want to bring up the reason Dr. Godsil and I are talking about urinary accidents and stool accidents is because the two are sometimes very commonly intertwined. I explain to parents. If we’re constipated that can play a role in you being able to have some bladder control. The nerves that work back at your bowel, come around the front and work onto your bladder. So if your bowel or your poop chute is what I like to call it. If you’re “poop chute” is distended. Full of poop and you’re not really having that sensation to go. You will also upfront at your bladder and not have sensation to go. There’s a certain capacity. At some point in time, you’re going to hit that bladder capacity and leak urine.

You did talk a lot about some dietary influences there always say kind of things “F” fluid, fruit, fiber. The reason we love fruit, especially for kids is it’s palatable. It’s sweet. They like it, but it has its own built-in water. So it’s awesome. It’s the perfect food, right? Like, think about a Clementine in orange, really fibrous. But also has all that great juice with it, all that great fluid with it. Those are the two things that we’re looking to increase. I do say that there’s a point to where you can be realistic with the diet, but just make better choices like Mac and cheese. It’s a food group in this age. It, it is what it is. My 20 year old babies still like it. But you can pick a pasta that has more fiber. You know, you can make small changes. Hey, if you’re going to have Mac and cheese, then we need to have strawberries, raspberries, blueberries with it. Pair those foods with movers. Cheese dairy tends to be very constipating pasta rice, things that are white and sticky Which are our favorite foods. I think at the end of the day, they’re also going to eat what they’re going to eat. We talked about, they have control about what goes in. I think sending the message that yes, if we’re going to have this food, that constipates us like Mac and cheese, like bread, like pasta. We need to balance that with having something that helps us to move our bowels. Fruit vegetables, making sure we’re getting enough water. That’s a really good thing that you touched upon because parents were like, oh, that’s all they ‘ll eat. And I’m like, well, you know, they really will expand some things. You can get creative with that.

On how right. How you present it, how you serve it. You can make smoothies. You can, you know, that gets a lot of fruit in there, so it can help you to move.

Yeah. And I would say too, anytime I talk about dietary or nutrition things, I’m always upfront. I have nutrition in my background in a sense from strength and conditioning and from PT school, but I’m not a nutritionist and I’m not a dietician. I’m coming from it from what is the standard baseline that could be helpful. But like we see with kids or even adults, right? Not everybody’s bodies function on the same way. So it’s going to be a little bit of trial and error. And if we truly need somebody to step in to be like, okay, this is what’s going to be the most beneficial and help with elimination. Then that’s where we might get a nutritionist or dietician involved. When we talk about any sort of like constipating foods or any sort of like bladder irritants. I always like to remind them too, that this is just like research based of what can be, I’m not showing you this list of foods to be like, your child can never have these ever again. It’s what to be mindful of. Are they drinking apple juice constantly everyday? Cause that can a bladder irritant a because of the sugars that are involved with it maybe just one glass and then we’re going to watch to see how that urge or that frequency changes along with like our bladder diaries or, the behaviors that happen.

I think the most ones that are surprising is peanut. Bananas and marshmallows are all constipating. And most parents will be like, oh my gosh, they have that all the time. Right? Peanut butter is a food group in my household as well. So I’m not going to stop it, but you need to be, you need to be knowledgeable of it. It’s one of those things, like you’re saying. K Get creative. If your child doesn’t want to be told exactly what is on their plate, have them pick something. If that’s Mac and cheese or what not, and then be like mommy or daddy gets to pick the next thing that goes on your plate. Maybe that is apples or berries or something, that’s going to have more of that water content.

Then if that’s not enough , I’ll have the child also play that mommy, daddy gets to pick something on their plate. And then the kid also gets to pick something that goes on mommy or daddy’s plate. Making sure that, there is that sense of control, that sense of ownership. Because a lot of kids, , it’s hard when they’re getting told what to do on this realm of things.

It’s that lack of control, like you’re saying they want to be able to know what’s going in their body and eliminate it. How can we have that natural, give and take so that they don’t feel alone in it ? Yeah. Ownership for sure. Yes. Them having ownership is instrumental in helping them make that turn, make that, go down a different path . If they completely feel out of control, it’s going to be a tough sell. Yes.

I did want to touch base on apples. Sometimes I find apples are a mixed bag, right. We have pectin in them, which is what is in Kaopectate, which is what we give you for diarrhea. If you’re serving an apple, you need to serve it with the skin on because the fiber is in the skin. So think about that because the inside of the apple is that fleshy, white, it’s sticky food. Sometimes that can be constipating. And especially for kids, a lot of times they don’t want the skin on it. We have to change our mindset with that. You can also look at dried fruit as well, but just make sure you’re drinking a lot of fluid. Then that becomes like a reason, like a fruit. Sometimes it’s all about the presentation. I won’t eat that, but I’ll eat that fruit leather or I’ll eat a smoothie or I’ll actually have pancakes with blueberries in them. It’s all about the presentation. Yep. Kind of that balance. Like you’re going to have pancakes today. We’re going to put blueberries in it. Yeah. Yup. It’s a little bit of give and take, because again, kids are going to eat what they’re going to eat. We gotta get creative in that realm.

The diet is such a. Huge role in that, that we really do need to , try and make some changes. If you’re doing peanut butter, Can you give it to him with celery? Exactly. Yeah. Eating carrots. They’re both crunchy, but carrots are kind of sweet and they actually pretty good with peanut butter. Let’s get creative here, people! Let’s take some things that they like and pair it with some things that we know are going to help them move their bowels. Or increase their fluid. Can be super helpful.

Sometimes water is kind of boring for kids. Well, maybe put some fruit in it, put an orange slice in it, put some strawberries, have them help you. “Oh will look how pretty your water looks!” It becomes an activity at that point. Yes. And they are actively involved in. Hey, I put the strawberries and I chose oranges to put in that. Yes. And that gives them somewhat of a little piece of ownership in that. Totally, totally.

And like you’re saying, putting fruit in it or, you know, splashes, right. But we can call it a splash of lemon juice, a splash of apple juice, whatever their favorite is. Then they get to decide what it is that day. It is that simple of making a little bit more fun and then it’s not as boring.

Go to Target by the water bottle that they really like, you guys go home, take your measuring cups, measure. How many cups go in that? Yeah. It’s an activity, but then, you know, How much you’ve got to have, right? I sent you to school with one in your very favorite water bottle by lunchtime. We need to be filling that up and you should be almost done with that by the time I pick you up. Right. It gives them a visual about where they should be. Yeah. This isn’t a job that they can complete or not, whether that’s, and it doesn’t have to be good or bad. It’s something they get to look and .To learn from for the next day.

I think we pretty much covered it all. The take home message really with any sort of daytime accidents is, trying to keep it positive, trying to be calm. Which is so hard as a parent. You’re so frustrated. It can be a very frustrating situation. But get in there, try to get some positive reinforcement with your child, discuss it with them. They more than likely have the capacity to tell you about that experience. And, workshop that. Find out if there’s anything that’s stressing or changing, that may give us an explanation. Just knowing, although it may not provide a solution, can be helpful and get us in the same mindset. On the same playing field.

Your advice about biofeedback is a great. It’s a non-surgical option that can really be helpful .Using a bowel and bladder diary, also dietary and nutritional education is huge. Really leaning into those things that we can so easily do at home. Super important. You got it. Yeah. And just with anything with pediatrics, kids get better pretty quickly. Especially with pelvic floor pediatrics. It’s not your one time a week for six months. It’s generally a lot of this homework. Most people are out there that will do a consultation. Even if you had questions, they were like, I don’t know if my kid fits into this window. You can generally get on a phone call and just see if, it would be something that would be worthwhile. All of us are out here to figure out what’s going on and help you guys.

Coming from a 25 year history of a pediatric career, it’s important to work with those pediatric providers. Those providers that are very used to working with children because they are not little adults. And this definitely is a realm where you want to seek out a physical therapist like yourself. That does work in pediatrics because it’s a sensitive topic. And that kid’s got to buy into the plan with you. And if you are not used to working with kids, It’s going to be hard. Right! Absolutely. You want to set up for success. The same PT that helped rehab your knee may not be the PT that helps your child learn how to poop and pee. Yeah. Right.

Thank you so much for joining me today. If you found the information in our podcast today, helpful, you can click on the link below and get a copy of the transcript notes.

If you’re interested in working with me with your new baby from “FIRST BREATHS to FIRST STEPS and helping you do parenting right, you can reach me at .Until next time be well.