Incontinent Preschool student

[krystalkae]

I need advice on a situation I've been dealing with since last spring.

We have a preschool age student who is at school 3 full days a week. He started to become incontinent of his bowels last spring. The child has seen a number (large number) of doctors because the parents feel it is a medical issue. He has had anal biopies to check muscle function, a number of xrays and MRI's - all of the doctors they have seen tell them it's nothing medical. He is now also seeing a psychologist while the parents wait to seek yet another opinion at an appointment in March. The psychologist has suggested to basically re-train him and start by just having him sit on the toilet. When I told him at school we were going to have him sit for just a few minutes, he yelled "NO" and backed into the corner. The child is not very verbal and actually does not talk to me at all. Before he would say a few words.

The incidents have increased from 2-3/day to 5-8/day - the parents have him on miralax because their initial thought was that he was severely constipated so there is no form to his stools at all. He is also incontinent at home and daycare.

The child is supposed to go into kindergarten next year and actually has a brother a year younger then him who is old enough to start kindergarten as well but they've both been held back due to this child's incontinence issues.

I'm not sure how much longer I can clean him up 5-8 times a day.

Do you have any other suggestions on what to tell the parents or how to handle the situation? Our school policy is that you may not be in school unless you are potty trained but an exception was made since he was seeking medical help.

[Alicia777, MSN, NP]

Reward system? With stickers or small (dollar store) prizes? I know it's 'not your job' to train him but just might make life easier for you..

[pixierose, BSN, RN]

I'm a certified SPED teacher and now just a nursing student so I would take this as a non-nursing point of view, but from this angle my concern is you seem to be becoming a punisher of sorts for the little tyke. He used to say a few words, now he isn't (except for the ever popular 'no!'). Looks like a no-win situation for both of you.

I agree with Alicia in a reward system IF your are assisting them with the training process. The thing is, the toilet training needs to be consistent across the board. The parents can't have you train him at school and then throw the kid in a pull-up when he's home. If he's on a schedule, they keep to it. They keep to the positive reinforcement reward system. It ain't all on you.

[txbootsy]

I would get your school diag, special ed team lead, and assistant principal in a meeting stat. There needs to be services for this child.

[tining, BSN, RN]

Cut Miralax to 1/2 dose, every other day, or only when he does not have a BM in 2 days - ASAP. I love Miralax for children, but sometimes it can be too much - especially at his age.

What medication is he taking?

What food is he eating? Decrease those fiber foods - mango, raisins, prunes/juice, etc.

Ask parents if they had these problems or any other BM problems as a child or adult - maybe a poop obsessed family.

Have parents buy an old-fashioned wash board. Have him clean his own undies - at home for 1 - 2 minutes. This worked for my son in 2 episodes. I have suggested this to several parents with great results. He does not have to seriously wash the undies, but when faced with this chore he may think twice and ask to go to the potty. Unfortunately I think he is so loose he does not have time to get to the BR - that is not his fault.

I would not say a word to him positive or negative - "Let's get you cleaned up" is about all I would say.

[DEgalRN]

I would get your school diag, special ed team lead, and assistant principal in a meeting stat. There needs to be services for this child.

I'm sorry, that's rough, and I have no clue what you should do (really helpful, right?). But, I agree with this advice. Get your admins involved in this! They can provide you backup and help you. Can they push for a 1-1 nurse since the parents are seeking a medical explanation? Or a para that can take the child to the bathroom at regular intervals and have that battle instead of you?

[krystalkae]

Tried the stickers/reward system..NO LUCK!!

[SnowyJ, RN]

if anyone has luck, let me know. I have a 2nd grader here with encopresis. He won't even try to sit on the toilet, too fearful. We have tried rewards, he goes to a psychologist, etc. No luck so far. It is very damaging socially for him.

[krystalkae]

It's funny you say that - one of our head special ed teachers works within the preschool class on a daily basis - she's well aware of the situation. We've had a meeting between the parents, myself, the principal, the preschool teacher, and one of the para's that works in there.

I have no idea what to do anymore...

[OldDude]

We use the 3 watery stools in an 8 hour period constitutes diarrhea rule. If you have a MD note stating this is normal for this kid then he/she would qualify for special ed under OHI - and ultimately be provided an aide to take care of the child under that department. Unfortunately you got pulled into this and it's gonna be hard for you to get out of it but I certainly would give it my best effort if I were you. I do NOT get directly involved in changing kids potty accidents - pee or poop. I call parents to come to school for that if the kid can't change themselves. If the PK teachers want to clean up and change their kids that's their business. Not me.

[krystalkae]

The mother is the director of nursing at our local hospital..and doesn't seem open to my suggestions.

I've asked about his Miralax dose and the idea of cutting back to make some form to his stools again but I don't think the were open to the idea.

I don't think it's a matter of not being able to get to the bathroom anymore - there was an incident where the teacher found him squatting in the gym - with his pull ups/pants on but going to the bathroom.

The student has a cousin that was diagnosed with tethered cord syndrome and had surgery a week and a half ago - she is 6 months older then the student as was having similar accidents at school. They have been told my multiple doctors that it's not tethered cord but are going for yet another opinion.

I am not able to enforce any type of schedule with him at school because he refuses to do anything except use the urinal - and there have been a few times when he's come down wet in addition to being soiled.

[pixierose, BSN, RN]

Toilet training can be a tough job for a lot of 3 year olds. But, no form to his stools = near impossible for successful toilet training. Until his stools have some form, and there is some regularity to his bowel movements, toilet training isn't going to be successful.

Time to have another meeting. What's the team saying?