Tips in Pediatric Care for Neurogenic Bowel, Neurogenic Bladder, and Skin Care

Much of pediatric care is provided with the same physiological foundations as adults. However, pediatric care is adapted to the differences in the physiology of the developing child. Not as some think, just on a smaller scale, but actually based on anatomical and physiological differences. These are some tips that parents or caregivers can use to improve the basics of rehabilitation care of the bowel, bladder, and skin.

In neurogenic bowel and bladder care, some individuals incorrectly assume that nothing special needs to be done as babies and children wear diapers. This is an accepted practice even for older children as their bodies develop toward bowel and bladder control. However, for a child with neurogenic bowel and/or neurogenic bladder, simply diapering is not an effective method of care.

Neurogenic bowel and bladder are miscommunications of the nerves due to some head injuries, spinal cord injuries, or neurological diseases. In this situation, messages to eliminate stool are not communicated within the body as in a child under age two or under the child’s own control after toilet training. This is due to the message to empty the bowel not being produced by the brain or getting through the spinal cord to the bowel.

In the neurogenic bowel, the stool is being produced, although travel time through the intestines may be slowed. Storage of stool may be delayed in emptying and the bowel will not empty completely. Even though the child may have some incontinence of stool, more will be held up in the bowel, over-stretching the bowel wall, with stool backing up within the bowel. The over-stretching bowel wall will become less elastic, like an over-stretched rubber band that does not snap back to its original size. The over-stretched bowel becomes ineffective in moving stool over time. This can lead to bowel issues in adult life.

Even as an infant or whenever neurogenic bowel is diagnosed a bowel program is started to maintain bowel health, mimic bowel function, and contain stool expulsion until a socially acceptable time such as a routine bowel program. Depending on the needs of your child and their nervous system issues in the bowel, the bowel program may be done every day for infants or every other day for older children. Your healthcare provider will guide you to the right schedule for your child’s individual needs.

Tips for the bowel program are to use the right amount of suppository for a reflexive bowel. A reflexive bowel is found in children with upper motor neuron injury. This may include some children with brain injury or other neurological diseases and spinal cord injury in the cervical and thoracic areas. In children, a glycerin suppository is used. In infants, it may be cut in fourths-the long way. As the child grows, they will use one-half of the suppository-cut the long way until they are able to use the whole suppository. A glycerin suppository is gentle for the young gut. Insertion of the suppository should be done with a well-lubricated small finger of an adult, to protect the delicate tissue of the bowel.

Manual stool removal can be performed for children with lower motor injury, including some children with brain injury, other neurological diseases, or spinal cord injury in the lumbar or sacral areas. As infants usually have a bowel movement after every feeding, this may need to be done twice a day or more.

With manual removal or digital stimulation after a suppository, the parent or caregiver will insert their well-lubricated, gloved, small finger into the rectum. To reach the internal sphincter for digital stimulation, look at the length of your child’s index finger. That distance is usually in coordination with the depth needed to relax the internal sphincter. The digital stimulation should be gently performed in a swirling motion to relax the internal sphincter. Aggressive digital stimulation can cause the internal sphincter to tighten or the bowel wall to become irritated with manual removal, both instances should be avoided by use of gentle movements.

Take advantage of gravity when the child is able to sit upright or is supported by ergonomic equipment for sitting. You can also hold your child upright by supporting their body upright against yours, like in a cuddle.

Neurogenic bladder issues have the same consequences as neurogenic bowel. Urine overfilling the bladder makes the bladder muscle less able to effectively expand and contract over time. Urine will collect in the bladder. Some overflow urine may be expelled automatically, but the bladder will not completely empty. Even though the child may have some incontinence of urine, more will be held up in the bladder. Although the bladder wall is elastic, the more it is stretched, the less it will be able to snap back to normal size, sort of like that over-stretched rubber band.

The urinary tract consists of an upper urinary tract, the kidneys that make urine, and the ureters that allow the urine to flow down into the lower urinary tract, the bladder. The kidneys make urine but there is no storage capacity there. Ureters only allow transportation of urine to the bladder, no storage there either. If urine is overfilling the bladder, it may spill out of the urethra, or it can back up the ureters and into the kidneys. This can cause the ureters to over-expand. There is no room in the kidneys so collected urine will press on the delicate kidney tissue, damaging it. Not keeping up with an appropriate catheterization schedule can lead to permanent kidney damage.

Catheters come in various sizes, even very small sizes for infants. As your child develops and grows, a larger size catheter will be needed. If there is leaking urine around the catheter (as opposed to through the catheter) a larger size is needed. Your healthcare professional will keep you advised when the catheter size should be increased. This can vary not only by the age of your child but also by their unique size.

Be sure to use a generous amount of lubricant to ensure no damage is done to the delicate tissue of the urethra as you insert and remove the catheter. There are many variations with pre-lubricated catheters, although most use a tube of lubricant gel. Do this by dropping the gel onto the catheter without touching the opening to the lubricant tube or touching the catheter to the tube. Even a sterile catheter can become contaminated by contact with anything else, including the lubricant tube. The lubricant can also become unsterile for the next use.

Skin Care in pediatrics is a camouflaged issue. Young people have great skin turgor due to the ability to hydrate themselves. After a neurological injury or disease, the ability to hydrate the skin can be challenged. Even though young skin looks flawless, pressure injury begins inside the body, where you cannot see.

Infants, children, teens, and even adults are constantly moving their bodies, in big positional changes as well as minuscule changes. When the body senses pressure, a slight movement is made to adjust. This ability can be missing in paralysis when sensation is affected. Older individuals will move or wiggle to readjust sitting or sleeping. Even infants move around in their cribs. Some parents find they leave their infant in one spot only to find them in another spot across the crib later. This ability may not be available to some children. Therefore, turning and use of pressure dispersing equipment is imperative.