Your Child’s Stomach (Part 1) – PediaCast 503
- Drs Mary Ann Abrams and Alex Rakowsky visit the studio as we consider your child’s stomach. Our plain language panel explores spit-ups, colic, belly ache and constipation. We hope you can join us!
- Belly Ache
- Primary Care Pediatrics at Nationwide Children’s
- What To Do When Your Child Gets Sick
- Discount Code: POD917 (40% Discount)
- Pediatrics in Plain Language Survey
- Pediatrics in Plain Language Playlist – SoundCloud
- Parenting 101: Baby Basics – PediaCast 241
- Newborn Care – PediaCast 441
- Constipation – PediaCast 292
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 503 for September 30th. We're calling this one "Your Child's Stomach". I want to welcome all of you to the program.
Our Pediatrics in Plain Language Panel joins us again this week as we consider the gastrointestinal tract, which includes the stomach and the intestines. We're going to talk about what's normal, what's not so normal. And when things are not normal, what should you do, when should you worry?
We're going to clue you in and let you know as we explore things like baby spit-ups and colic, belly aches and constipation. That's what we're going to talk about in this first part to our discussion on your child's stomach.
And then, early next year, we're going to actually follow this up with part two because it's a big topic. There's just so many things that can happen in your child's stomach. It's a big area, there's lots of organs involved. And so, in part two, we will further that conversation and talk about infections in the intestine, vomiting and diarrhea, blood in the stool, hernias, food allergies.
So, lots to cover, and so we're going to break it up and do, again, spit-ups and colic in babies, and belly aches and constipation in older kids. Although, babies can certainly have constipation as well. And probably belly aches, they just can't tell us.
So, we're going to talk about all of these things. And we'll do it in our usual plain language fashion, because when our Pediatrics in Plain Language Panel visits the studio, we do take extra care to speak with words everybody can understand, even if you know absolutely nothing about medicine and healthcare.
Of course, sometimes, we have to use medical jargon, or it slips through by accident. But when that happens, we hold each other accountable and try our best to explain exactly what those words and praises mean. We also try to cover really basic concepts of child health and wellness, the things that are really important to know as a parent.
Some of our past episodes include your child's breathing, your child's mouth and throat, your ears and nose, your child's eyes, fever and illness, newborn baby care, keeping kids safe, reading and family literacy, and fitness facts and ideas.
So, lots of plain language content for you and you can find all of these past episodes packaged together on SoundCloud. Simply search for PediaCast in the SoundCloud app or on their website and then look for the Pediatrics in Plain Language playlist.
And you can also check out the show notes for this episode, 503, over at pediacast.org. I'll include a link to the playlist there, so you can find it very easily.
So, our Plain Language Panel, as you will recall, is made up of two wonderful primary care pediatricians at Nationwide Children's Hospital, Dr. Mary Ann Abrams and Dr. Alex Rakowsky. They will join us in a moment.
But first, a couple of quick reminders, don't forget, you can find PediaCast wherever podcasts are found. We are in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show so you don't miss an episode.
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Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.
So, let's take a quick break. We'll get our Pediatrics in Plain Language Panel connected to the studio and then we will be back for Part 1 of our discussion of your child's stomach. It's coming up right after this.
Dr. Mike Patrick: Our Pediatrics in Plain Language Panel is in the house once again. You will recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio University State College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital. Dr. Alex Rakowsky, also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's.
Let's give a warm welcome back to our friends. As always, it is really great having you both here. Thanks for stopping by.
Dr. Alex Rakowsky: Hi, Mike and hi, Mary Ann.
Dr. Mary Ann Abrams: Hi, Alex and hi, Mike. Great to be back.
Dr. Mike Patrick: Great to have both of you here this morning. So, Mary Ann, we always start by asking you, what is plain language and why is it important. And you always have some great nuggets of information for us. What do you have this week?
Dr. Mary Ann Abrams: Well, I was thinking about that. And first off, to start as usual with sort of the definition of what plain language is. And we talked about it as being living room language, words that your grandmother would understand, just the words that people understand without a lot of fancy technical terms or jargon, or lots of extra information. Because sometimes, we may have plainer language, but we give so much information that people are overwhelmed and then they can't get the core key message.
So, then I started to think, it's not always long complicated words. It can be short words. And it can be jargon words which means words that have a special meaning to people in their field. So, whether you're a lawyer or a mechanic or a plumber or an accountant or physician, doctor, we all have our special language.
And that's appropriate, we need that technical language and the words, they have special meaning, jargon. But we have to remember to translate that into plain language. And thinking about, just a couple of words that came to my mind in terms of what we're talking about today, I thought of two.
We're talking about the abdomen or the stomach, the belly area of the body, and all the different parts of the body, the organs that are in that area. And something that we often ask our patients about or talk to people about when we're talking about the part of the body and other parts, we talk about their diet. And we say, "Tell me about your diet. What's your diet like? What's your child's diet like?"
And to the common everyday person who may not be a dietitian or a healthcare worker, a diet usually is something that means sort of strict rules that may or may not, it's usually not very, perceived at least, as not very flavorful, or tasty or it's hard to stick with.
But when we use the word 'diet', when we're talking about it generally with patients, it's just a nice four-letter catch-all term for what the people eat, what are you feeding your child, what are you eating?
So, I think when we kind of toss that word out, right away, we might be confusing people. And they have to spend time thinking about why is she asking me about a diet when we're here to talk about my baby's growth or whatever by toddlers. So, it goes to show that even a short word, four letters, that you hear every day can have special meaning and may not be the definition of plain language.
So, another example, I think, and we will talk about it in more detail as we move through this podcast is just the word 'diarrhea'. So, everybody thinks they know what diarrhea is. But it's kind of complicated, and from a healthcare perspective, we think about what's causing it and how bad it is, and what's going to happen if it continues.
The World Health Organization has an official definition. But when parents call us, if their child has a loose watery stool or a poop, they're thinking it could be really scary. So, it just kind of points to the fact that even a common term like that has a specific definition and we need to tease that out.
So, I kind of put that into that plain language category because what can appear to be common everyday term has a lot of subtle details that we need to sort out. We can't just say, "Oh, he's got diarrhea," or "My child has diarrhea."
Dr. Mike Patrick: Really good points. Even the word constipation, as we're talking about your child's stomach is a common term that's used. And for a lot of parents, it's just "Oh, my child hasn't gone to the bathroom or hasn't had a bowel movement in a really long time. And so, I'm going to call that constipation."
But you can have regular bowel movements and be constipated. You could even have diarrhea and be constipated, which we'll talk about that a little bit more. But it's a really good point that you bring up.
We are following loosely along a book called What to Do When Your Child Gets Sick, which is brought to you by the Institute for Healthcare Advancement. They're nonprofit. And it's a really well-written book, just all about your child's health that's really written in plain language. So it's very very easy to understand.
And they've been nice enough to give us a 40% off discount code, it is POD719. And the book's only 7.77 if you use that discount code, so really affordable. And we'll put a link to that in the show notes for this episode over at pediacast.org.
If you like this pediatrics, well, even if you don't like them, but if you have comments about these Pediatrics in Plain Language podcast episodes, we do have a survey for you to take, so you can share your thoughts with us. And I'll put a link to that over in the show notes as well.
So again, if you like them and if you have constructive criticism for us, we appreciate that as well. And then, all of these Pediatrics in Plain Language Panel episodes are bundled in a playlist over at SoundCloud. We've done many of them over the last few years.
Most recently, we talked about your child's breathing, their mouth and throat, their ears and nose, their eyes. We talked about fever and illness and newborn baby care, reading and family literacy, lots of different topics in plain language. And again, that playlist is over at SoundCloud and I'll put a link to that in the show notes.
So, as we consider your child's stomach, we wanted to start with babies. And the first thing that came to mind was spitting up. A lot of babies spit up.
And so, Alex, tell us about baby spit-ups. Why does it happen and when is it a concern?
Dr. Alex Rakowsky: So, considering that we have a lot of parents listening, I wanted to start off that this is very common. So even before I get to the definition, I just want to say it's really common.
So, some studies have shown that 80% or 80 out of 100 infants will have spitting up and it can actually peak in the second month of life. So, people tend to think of it as just a strictly a newborn kind of issue, but it can progress and kind of stay longer. In fact, in most infants who have spit-up, it goes a little bit longer.
So, spit-up, there really is no true definition. But essentially, after a child eats, they have a little bit of milk come out of their mouth. It’s kind of what we call dribbles out, it’s kind of just leaks out of there. It's not forcefully, like thrown out of the mouth for a couple of feet or a couple of inches. It just tends to kind of dribble out.
So classic spit-up is just sort of like a little bit of milk coming out. But there are types of spit-ups where some kids actually going to have a lot of milk come out and it can be a little more forceful.
So again, common. And just to kind of describe why so, when we swallow, we have a food tube or little tube that takes the food down to the stomach called the esophagus. And the esophagus has a little door at the very end, to the stomach. And when the food gets into the stomach, the stomach closes off that door, so then the food doesn't go back into the esophagus. And that door is called the sphincter.
In adults, the sphincter usually works pretty well. But in infants, the sphincter is not really all that tight yet. So, any little pressure and that door opens up and the food comes up. My esophagus is probably around a foot long. A baby's esophagus is about two and half inches long.
When I bend down, I have enough stomach muscle, I hope, that my gut is not kind of forced to a weird position. So, I'm not forcing food up to the esophagus from my stomach. Infants don't have that kind of tone, so when they kind of bend funny, all of a sudden, the stomach gets pressured, and things come out that door.
So, there's a lot of reasons why kids spit up, just like thinking about it like a plumbing issue. It's a short line, the door doesn't really work well. And the stomach's also small. It's about the size of twice of a baby's fist, so it's not a whole lot. So, the most common cause of spit-up is going to be too much fluid in the stomach, or too much fluid and air in the stomach.
So, the baby's stomach can maybe handle 3 to 4 ounces and they have 4 ounces of formula or 4 ounces of breast milk and they have an additional ounce or two or air. There just isn't enough room, up it comes.
So, the way you treat it tends to be like mechanical things. You try to burp the child in the middle of the feed. You hold the child upright after feed for 10 to 15 minutes. And I'll give a little anecdote about that in a second here.
You can maybe give, for kids who really struggle with bad spit-ups, smaller amounts but more frequent feeds. So instead of having a four or five-ounce bottle every three hours, you're doing a three-ounce bottle every two hours, just to kind of have the stomach kind of handle it.
And then, a lot of it is also positional. So as the latch go when breastfeeding, you're not getting as much air or using the proper nipple. If the child eats quickly, try to stop the child from eating so quickly by slowing things down. Break the latch and have the child reattach.
So, a lot of the treatment tends to be just kind of getting rid of that air and then letting that fluid kind of sit there. And then after a feed, put the child down in a position where you're not going to sort of ball up or bundle up. So, a car seat may not be a good place to put a child right after a meal because it's going to come up.
And then, just like anecdotally, speaking as a dad here, my wife, we have seven kids, so she would breastfeed in the middle of the night. And then my job was to walk around the house for ten minutes to help with the spit-up. And ten minutes seems like an hour in the middle of the night.
And I've even gotten one of those track timers. I'll set it up for 15 minutes, just walking around the house. And I thought it was already an hour and a half, until my wife say no, actually, it's a 15-minute time.
So, for parents out there, especially if it's the middle of the night, get yourself a timer or put on your cell phone and literally walk 10 to 15 minutes. It's hard to do it in the middle of the night, but that's a real common time to spit up because their tone's down, they eat a lot, they bend forward, out it comes.
And you got to worry about, when do you worry? So, the red flags tend to be what we call forceful vomiting. Where the vomit comes and it comes flying out. Especially after feeding, a child looks hungry afterwards. In other words, that child isn't getting a lot of the fluid.
And then you worry about something called pyloric stenosis which just looks like a blockage from the stomach to the next part of the gut called the small intestine. So that's something to consider. If you have a child who spits up in the middle of a feed, like forcefully spits up in the middle of feed or seems to gag, then you worry about something wrong with the esophagus, like a TEF fistula or some kind of webbing.
So, talk to your doctor about it. And then anytime that you worry about it, then talk to your doc. And our job is then to rule out all of the sort of weird stuff, like something called the trachea airway, E, esophagus, F, fistula like a connection, or a web or some kind of sphincter problem.
But most times, it's just mechanical, tincture of thyme, not T-H-Y-M-E, but T-I-M-E, just give it time. And most kids are going to outgrow this by four to six months. As long as they're growing okay, they'll outgrow it.
Dr. Mike Patrick: When you say 80% of kids are affected, it almost becomes then, that's normal. It is not normal. I mean, if we're thinking about percentages, it's actually more uncommon for kids not to spit up, right?
Dr. Alex Rakowsky: Yeah, I'm an older pediatrician, so I've seen my fair share of things. When we have kids who aren't growing well, I almost want to see spit-up, because that means they are getting enough food.
So usually, feed a little bit more. And if they have a little bit of dribbling, that means you probably fed a little bit better. That's not recommended. But it's sort of a good sign that you're getting enough volume down there. Because some moms, "I just breastfeed for five minutes and they're not growing well," so maybe you need to give more.
So, it may be a sign that you're getting enough volume down there. So yes, I consider it to be a normal thing as long as they're growing okay.
Dr. Mike Patrick: It seems this is one of those things where the thinking has really changed over the years. It used to be we would thicken babies' formulas which then would help it stay down, but babies would get a lot more calories in. They'd gain a lot more weight and then that could cause issues down the road.
We used to use acid-reducing medicines because babies were fuzzy with their spit-ups and maybe they really had colic or they had some other reason for crying and not necessarily the spit-ups being an issue.
But we've really gotten to the point now, where we look at it as this is sort of a normal thing for lots of babies, as you said, as long as they're gaining weight okay, that they're not choking, or the food particles aren't getting down into the lungs and causing an issue there. And as long as it's not projectile, there's no blood or green bile in what they're spitting up.
And if it happens right after they eat as opposed, as you said, during feeds or it's been a couple of hours and you're in between feedings and suddenly, they're vomiting, that's a little bit more of a concern and probably not that reflex.
Dr. Alex Rakowsky: I'm going to say like every 100 patients that we'll see for spit-up, there will be two or three that just aren't responding to the mechanical or just aren't getting better with time. And then, you really start to think, "Do I thicken their feed? Do I change the formula? Do I talk to the gut specialist?"
So, when in doubt, try the mechanical changes first, the positional changes, the timing, burp them. But definitely, talk to your medical provider if things aren't going to where you think they should be going.
Dr. Mary Ann Abrams: I'd like to add a couple of things to what Alex just said and Mike as well, about how things have changed. Because even though we're actually not doing some of these recommendations, people will still get advice from well-meaning friends or relatives or grandparents if a baby is, I'll just call it burping frequently or off and on.
And in terms of position, as Alex described, especially at period after the feeding, but we used to recommend things like elevating the head of the bed and having them in a swing or a car seat or how we lay them down. And everyone has said the wrong way to lay them down because it's so important that babies are always on their back, alone, in the crib.
Those positional changes, other than keep them upright while trying to feed and burp and cuddle them after they've eaten, haven't really been shown to be effective. And depending on what position you might try to put the baby in, it could actually be hazardous in terms of sudden death.
And we used to prescribe medications, and now, those really aren't necessarily effective, but they can also have side effects. And knowing that they do tend to outgrow it. I think, Alex, you said tincture of time. By four months or so, their muscles are getting stronger including that muscle that keeps that little door closed to the top of the stomach between the esophagus. Four to six months, and it sort of gradually disappears.
So then, you start worrying about other things as a parent. And I think some people, too, worry about having babies sleep on their back and then having a little bit of spitting up. Could they choke and have a problem with that? And again, the evidence, the research shows that the safest way for a baby to be laid down is on their back.
Dr. Mike Patrick: Absolutely. I love Alex's idea of if you have a baby with a spitting up issue and you're worried about that, keeping him upright by just taking a walk with him after those feedings. And then you're right there with your child and they're upright, I love that. That's a great tool.
Dr. Mary Ann Abrams: I think that's a great one, too.
Dr. Mary Ann Abrams: Yes, that is right.
Dr. Mike Patrick: One of our sons, they got steps. They got like 10,000 steps easily, so yeah.
Dr. Mike Patrick: Let's move on to colic. So, this is a short word, right, Mary Ann? It's a short word. A lot of people use the word colic, but we may not all have the same idea of what this means. So, Mary Ann, what is it when we say a baby has colic.
Dr. Mary Ann Abrams: Well, colic is pretty common also, although not as common as spitting up. Spitting up, maybe 80% colic, maybe up to 40% of babies depending on how it's defined and how it's looked at. But it can be even probably more bothersome. And it's not bothersome to the baby as much as it is to the parents and the people taking care of the baby.
Again, despite tons and tons of research, we really don't know what causes it and it may be different for different babies. But what colic is, is prolonged crying, it's usually in the evening. It's usually for several hours and it's usually several days a week.
And there's really nothing else that anyone can find that's wrong with the baby, whether you take him to the doctor and have him checked tip to toe. Or do all the things that you've been taught and tried and all kinds of good things for your baby. Some babies just have these crying episodes.
And it's hard on the parents because no one likes to see the baby cry and you're worried. Is there something wrong that I'm not recognizing? Is my baby in pain? Is he or she unhappy or is there something inside going on?
And it can be very stressful because the crying sometimes can be a little bit more, almost sounds like a baby's mad or a little bit more high pitched. Just a little bit of things that we are programmed as human beings to respond to the crying baby and try to comfort them.
And yet, when you try to comfort the baby in this situation, it often doesn't work. And you get a lot of steps in, try to walk in, cuddle them, but it just goes on. And then, it just kind of stops.
And colic sort of kicks in after around one to two months. And fortunately, most babies outgrow it by say four months or five, again, gradually. And there are some things that we have done and can try. But again, you don't want to cause more problems than by trying to do things that don't necessarily make a difference and could be dangerous.
So, cuddling a baby, rocking them, holding them, walking around, soft soothings, little voices or lullabies or singing, all those kinds of things, they work. Going for a car ride, but the baby is safely strapped into a good car seat.
Sometimes, white noise. And the definition of white noise can change from one baby to another, or from the same baby from day one to day four, whether it's a dryer running or some soft music or a fan. There are a lot of things to try.
But we also have to take care of ourselves as parents. And if you know the baby is safe and you checked her over, it's okay to put them on their back, in their crib, alone. And take some time for yourself to walk away, and maybe close the bedroom door, go to another room, whatever.
Because sometimes, depending on if there's a lot of other stress going on in the household or worry, it can really be hard on the parents. And sometimes that could get taken out on the baby.
Dr. Mike Patrick: Yeah, excellent points. For a lot of parents, one of the first things they think about when they have a baby with colic is that they must have a belly ache. And the reason for thinking that makes sense because a lot of times, these babies when they're crying and sort of angry, you kind of ball up your belly and lift up your legs.
And then, of course, if you're tensing up, because you're angry or you're crying, you're upset, the center in your brain that makes you cry also makes you kind of ball up and get tense. And so then, your legs lift up and then you pass gas because you're tensing up your stomach muscles and that pushes air out,
And so, when you see your baby crying with a tense belly and they're passing gas, it's easy to think "Oh, their belly must hurt." And for some babies, maybe that is the case, but it doesn't make a lot of sense that that would happen mostly in the late afternoon and early evening. If you would think their feeding is making them uncomfortable, you think that would also happen in the morning and not just at certain times of the day.
Another hypothesis, and we don't know this for sure, because babies don't answer when we ask, but a hypothesis for this is that it's more brain related. And the way I like to think about this, and again, maybe it's on target and maybe it's not, we don't know.
But I think it does bring parents some comfort to think about it this way. It's that at some point in a young baby's life, usually around a month, they are starting to be more aware of what's going on around them. And there's lots of stimulation with other kids and barking dogs, and the television and the doorbell. Just during the day, there is a lot of added stimulation.
And by late afternoon, early evening, their brain just had enough of the stimulation. And so, by crying, they can block everything out and kind of retreat back into the wombs, so to speak.
And so, while it looks like they're upset and parents are getting very anxious, because their baby's crying and they don't know why, from the baby's point of view, their crying is actually allowing them to get some solace from all the stuff that's going around.
And so, I like to explain it that way to parents because I think that gives you some comfort that this is actually a coping mechanism for your baby. And then, by the time they get to, as you said, four or five months, then they're able to deal with things a little bit better and the colic goes away.
On the other hand, if it's a sudden change or if it is happening at a different time of the day than what's usual for them, there are some significant things that can cause babies to be in pain and to cry. And so, colic is not necessarily something you want to just diagnose on your own at home. It really is best to see your child's doctor and let them tease out all of the details of this crying and really make sure that there's not something else that's going on.
Babies don't come with user manuals, but we did a podcast called Parenting 101: Baby Basics. And that's when we really spent a lot of time going into all the normal things and when to worry for babies, including lots more information on spitting up and the colic.
Alex, I know you are anxious to add to this conversation.
Dr. Alex Rakowsky: Yeah, I love how you and Mary Ann brought up the fact about thinking about the parent's perspective here also. We had one child with colic and it's really frustrating because you can't do anything. And you're like, "What did we do wrong? Why can't we help our child?"
And I think as pediatricians, part of our job is just to hold hands and do the exam, reassure the parents. And if they want a MyChart or come in on a weekly basis because they themselves are really worried about it, I think that's part of our duty to do.
We just had a recent case of the mom who's been stressed out because of COVID and job losses and things like that. And between myself and the resident, I think we either saw her or MyChart with her almost 20 times in a two-month's period, as the child went through colic.
And I think it just made her a better parent, the fact that she could write out something which she thought she couldn't handle. But she needed that and now, at the six-month visit, she just seems so much reassured as a parent, like “I can do this.”
But colic can really stretch a family and it can really stress out a new parent. And it's early. In other words, just like your first big test is like one month in of their lives. And you have to be there for them, as do family or friend or someone else that can help out. It's vital to have that.
Dr. Mike Patrick: And I love that Mary Ann added, it is okay to lay them down in a safe place on their back, alone in their crib, and walk away, and let them cry. And in fact, they've even looked at cortisol levels in babies which we know go high when you're under a lot of stress. And these babies who are crying with colic, they do not have high cortisol levels. We really don't think that they are upset and agitated.
And I know cortisol is a big word, not plain language. It's a chemical in your blood that often spikes high when you are under stress of any kind.
So, something to keep in mind that they probably aren't really upset. Again, I mentioned that other… Oh, go ahead.
Dr. Mary Ann Abrams: I just want to commend Alex and the rest that work with him. Because we can explain what colic is when a parent calls or comes in and we can use plain language, and we can be impacted. And they can understand, and they can go home.
But by definition, colic is it is short, but it is a chronic condition that, when you're in the midst of it, seems like it will never end. And you're already tired and sleep deprived and probably preoccupied maybe with other children or situations. And at nighttime, everything seems worse.
So, you can feel worse as a parent. You can be more worried about your child. You can be more short-tempered, all these things. And just having that ability to be reassured, to know that you can come in if you need to or say, "Is it still okay?" and to be able to say, "Yes, it is. And if tomorrow, you want to bring your baby in or if you feel you need to bring her in now, that's fine."
I think that's one of the good things that is kind of happening, the ability to use the portal. You talked about MyChart, that's the name of the patient portal at Children's or telehealth. So, some advantages that can maybe go a lot way to helping parents as they live through their baby's colic.
Dr. Mike Patrick: Yeah, absolutely. I had mentioned that episode of PediaCast Parenting 101: Baby Basics. I'm going to put a link to that in the show notes so folks can find it easily. It's Episode 241 so it's pretty far back on the feed, but we'll put a link to it in the show notes.
Moving on to older kids, as we think about your child's stomach, one of the most common things that parents will bring their kids in for is a belly ache. So just stomach pain in the abdominal area. And there are lots of things that can cause that, right, Alex?
Dr. Alex Rakowsky: We'll deal with all these easy ones today, I see. So, belly ache is another one which I'm convinced everybody will have at some point in their life. Another words, I think part of being human is to have a belly ache at some point.
So, it’s broad and people are going to define it in different ways. I think to kind to put some order to belly ache. It's important to kind of ask the parents where it is located? In other words, is it top, bottom, right, left? When does it occur, after eating, before pooping, after pooping, middle of the night?
What's the character? No, I know, Shakespeare and kind of thing, but is it stabbing? Is it dull? Is it pushing? How long does it stay and how quickly did it come on? I worry about like a sharp stabbing new onset pain in the right lower quadrant, the right lower part, which we'll get in a second.
Then anything related, fever, vomiting, the stool looks different. It's green. It's mucousy, like somebody spit in it, rather black. So, a lot of times when we're thinking about belly ache, it's important to kind of figure a little more detail. And then based on that, you can start looking at common causes.
And there had been some nice studies done, actually one by our colleagues in Cincinnati, our buddies in Cincinnati, and they know it's constipation by half of the chronic belly ache in older kids. But the other half was some bizarre things. It could have been irritable bowel syndrome, or it could have been anxiety. It could have been just a food malabsorption issue.
But again, the majority of time, majority being 50% or more, in older kids, I really kind of look into kind of constipation questions heavily.
Other things that can cause belly ache are sort of psychosomatic. And I don't want to make it sound like they're making this up, or where the brain's responding to something and it's presenting itself on the body. That's a real empathy, so you may be…
Dr. Mike Patrick: Hold on, hold on. Psychosomatic, you got to explain that one.
Dr. Alex Rakowsky: So, psycho meaning your brain, and then somatic means body. So essentially, you have some response showing itself as a body issue because of something behaviorally going on in your brain.
So, for example, butterflies in the belly when you're about to give a talk or a podcast. Like a burning sensation in the morning when you have to present before your class. Or you're taking a bus ride, and there's a bully sitting next to you every day, you're going to have a belly ache.
And that doesn't mean that there's something wrong with the belly, that means that you have a legitimate behavioral response and the body's resenting that response a lot of times with the gut. So sometimes, the belly aches, if you get a history of "I don't have a belly ache on the weekends or when I'm not sitting next to the bully," then that might be an easier answer.
So, I think it's really important for belly ache to kind of figure just more of the history, to kind of figure what's going on. But again, I'd worry if it's sudden sharp, stabbing, right lower area because that's where the appendix lives in the vast majority of people, but it can also be right central in some people, and even left lower.
The stools are abnormal. And again, blood, meaning red or black, or spit-up looking like a mucousy stool, or constant green stools over and over again, then you worry about something wrong with the actual gut or something going on with the actual intestine.
And then also, it's debilitating or just making the child not function because this pain is so bad. And that's when you kind of have to jump on board and it's like let's start working this up a lot more aggressively.
Dr. Mike Patrick: There's so many organs in the abdomen, so many places that pain can come from. As you mentioned, appendicitis, kids can also get kidney stones. You can have inflammatory conditions of the bowel. So, there's swelling as your immune system is kind of revved up and causing issues inside the bowel wall, the intestinal wall.
But even things outside of the abdomen can also cause bellyache like pneumonia and strep throat can also do it. Urinary tract infections…
Dr. Alex Rakowsky: Kidney stones.
Dr. Mike Patrick: Yeah, kidney stones, yeah. And in girls, we worry about their ovary getting twisted and even young girls, before puberty, can have that happen.
And this is again one of those things, if you have a child with sudden change and they've not had this abdominal pain before, you definitely want to see someone to really go through again all of the history and the physical exam. And try to narrow this down and figure out what's going on. You don't want to do it yourself at home.
Now, you did mention that constipation is one of the most common causes of abdominal pain in kids. And I've talked about the fact that constipation can mean lots of different things. So, kind of run us through constipation in your mind, Alex.
Dr. Alex Rakowsky: Yeah, just like what Mary Ann, of colic and spit-ups, it's hard to define some of these things. So, if you look at the broad definition of constipation, it is essentially a change in your stool character. Again, not talking Shakespeare here, but if your stool is usually like softer and brown, now it becomes pebble-like and hard, then that's a change. So, you worry about constipation. Or a change in how often you stool.
So there really isn't like a true definition. Gastroenterology experts have a traditional definition of constipation. But I'm trying to think like what do parents think of a constipation? It's where the stool has changed, or they don't stool as often as they used to.
And with the sort of precaution that straining in and of itself is not constipation. A lot of infants strain in the first couple of months of life, especially as they learn how to poop and open all those sphincters to kind of get the poop to fly out. That's not constipation. As long as it's a normal-looking stool, that's not constipation.
A breastfed infant who doesn't poop for ten days because they're absorbing all the breast milk and that has a normal looking stool, that's not constipation. But when you get into older kids where they have some kind of pattern to what the stool looks like, how hard it is, and how frequent it is, then you can say a little more easily "this is constipation."
So, I'm trying to be broad here. There are more specific definitions, but again, for primary care, it's really a change in frequency and character of the stool.
Dr. Mike Patrick: Especially in the beginning because you may have in-frequent bowel movements, and your intestines start to fill up with poop.
And so, I do like to think about constipation as just too much poop that's just hanging out in the intestine and is not moving through. Because if your intestine's full of too much poop and you're making new poop at the same rate that you're pooping, the net effect is that there's still a lot of poop in the intestine. So, you can have a kid who poops a nice soft bowel movement a couple of times a day, but they really need to be getting more out than they're making in order to start there being less in the intestine.
And then, you can have diarrhea with constipation, too. How does that happen?
Dr. Alex Rakowsky: So exactly what you mentioned, where you have the trucks coming to the port and you're unloading the trucks but not quick enough. So now, all of the sudden, you have the trucks backing up and now, that's constipation. And in case then, you have, "We need to get this truck through quickly because we need this quick." So, in goes the truck through a way it usually doesn't go through.
And the diarrhea is because you have so much stool kind of built up there where the stool just doesn't pass so you have some of the liquidity part just kind of run through the sides and out it comes.
In fact, that's a bad sign. So, I have a child who had the history of having hard stools and now not stooling a lot. And then, they come in because they have breakthrough diarrhea. That's probably a child who have a lot of stool buildup because that means that gut can't handle this. It's got to get stuff out of there, so it just kinds of flow to the sides. That's completely an abnormal stooling pattern that you got to worry about.
Dr. Mike Patrick: Yeah, Mary Ann?
Dr. Mary Ann Abrams: Yeah, just to add a couple of points to what Alex is just saying. He probably might have gotten through it. If that is what's happening for a child, we probably would send them to a specialist because if that backup is so bad that the stool that looks like diarrhea kind of leaks down and comes around that hard stool, sometimes, they don't even know it. And over time, it can decrease the normal sensation they have when they know they need to go to the bathroom.
And it can lead to a lot of problems with school and friends because you're basically, maybe at school, a child who's having stool accidents. So that is something that really does need attention.
A while back, I remember one of the specialists that I was working with and learning from, and this is another thing that's hard on parents, because the way he put it, people they talk with their friends about all the issues going on with their children. "I think he has ADD," and, "I think he has eczema." I think she has this and that.
Nobody talks about this with their friends because it's embarrassing and they don't know what can be done about it. So, there's no support at least. They don't know if everybody's going through it.
And I think another point to this is especially given the kinds of food, the diet we eat in America, in the United States, kids and parents aren't getting a lot of fiber and that's what helps us have healthy bowel movements.
So, it's a lot more common than people think. And they maybe think a hard rocky stool every three days is normal, when really, you should have a nice well-formed stool every one to two days. And you have to ask real specific questions too like does it clog up the toilet? Because otherwise, people may not even perceive that it is true constipation.
And the last thing that I think is really helpful, is this is going back to the pain. If after you've checked the child and had been reassured that it's not serious, and if you do think it might be related to gas or some constipation, I like to talk to parents about how our intestine, how our gut is made.
And it's obviously a long tube and we have all kinds of nerves in our body and the nerves in the intestine are very very sensitive to being stretched. So, if they are stretched by a lot of hard stool and a lot of gas, that really hurts. But you could kind of cut with a scissors and that kind of nerve isn't there.
So, the feeling of pain, we're not saying it's not real pain, but we're reassured if we just think it was an episode of gas or one or two days of constipation. If that can explain why it hurts so much but that their child is still healthy, and we can take some of these steps to help them be even more healthy.
Dr. Mike Patrick: That's a really good point. Just that in some cases, it can be such severe pain. Before CAT scan, CT scans and ultrasounds made it really pretty easy to diagnose appendicitis, pretty much anybody with severe pain in the right lower portion of the belly would go get their appendix out.
And there was this significant number of kids to the tune of 15%, 20% of them who had their appendix taken out but at the time of surgery, their appendix was normal, and the final diagnosis was that they were constipated. But it cause so much pain that people thought it could be appendicitis. And so that's something really important to keep in mind.
Alex, how do we treat constipation?
Dr. Alex Rakowsky: Yes, I think it was our job as providers to rule out the bad stuff. So, I'll start off with that. And like a food intolerance, celiac disease, for example, where you're not absorbing or having problems with certain foods. Bowel problems, gut piping issues, kind of using the plumbing example again.
Or Mary Ann mentioned the nerves of the stomach. So, if you’re missing some nerves or your nerves aren't working well, you can something called Hirschsprung's disease where the gut just doesn't function the way it should.
So that's our job. But that's going to be a small amount of kids because they're treated differently than the vast majority of kids who have constipation.
But there's really two main causes of constipation. One, and probably the most most common, is you don't have enough fluid and fiber in your diet. And I think everybody thinks, well, I have this much fluid and fiber and the other two kids don't have constipation. Why does Johnny have constipation?
I think everybody's gut need a different amount of fluid down there and a different amount of fiber. So, the first is getting a good history and then figuring out how much do you drink, increase more water and then let's add stuff that has fiber in it. So pulpy fruits, whole grain cereals, and other things that can kind of help you get more of what you need for you to kind of get the stool out quicker.
And then a second common cause, especially in small kids is toileting anxiety where, "I refuse to go on school because the toilet's too high." It's like you have your K-8 schools and toilets are three feet off the ground and you have this two-and-a-half-foot toddler trying to poop there. He's afraid of going to the toilet.
So that's a legitimate concern. Or at home, they feel rushed. So, they don't have time to basically sit down and kind of like let down, to use like a breastfeeding term, to kind of let their stool come out.
So, I think the second part for every child I see is you got to have your protected toilet time.
So, from 6 to 6:15, Jill gets the toilet on the first floor and nobody can bother her. She gets her crayons in there. She has a book in there. If she poops, great. If she doesn't poop, great. But after a while, her body knows this is my poop time.
And you kind of retrain the brain. So, more fluid, more fiber, retrain the brain, and get rid of the anxiety. That's not working, then you start adding things that have what we call osmotic effect. Osmotic means there's drawing more water in there.
And that tends to be pulpy things, and also more like higher sugar content. So, some classic fruits, juices. I like the peas, the prune, papaya, pineapple, peach, apple. There I got my P's in there and mango that has a silent P. So, it's a p-mango.
So, prune, papaya, pineapple, peach, apple, and then p-mango. You can get all those. And don't get kid's stuff because that's essentially watered down and they strain the fiber out and they boil the sugar. So, you're drinking like prune-flavored water which is kind of disgusting.
So, get the real adult juice. And you can just drink a little bit of the adult juice, see what happens. And if that's not working, then you have to worry about meds. And then, again, looking at things, the types of med, I think you can break them down to three categories.
And to do it really simply, the first is to add more osmotic effects or get more water in there and kind of get more slushy so the stuff comes out. And the classic one there is MiraLAX where you're given this powder and it kind of increases the slushiness down there and pushes things out.
The second is to increase the nerve activity, which we do less commonly and that's like the like senokot or the little chocolatey things that you can chew on, the Ex-Lax. And their job is to essentially push things up by sort of increasing that sort of nerve activity.
And then, there's the add oil. So, some people add mineral oil to the dye, which I've seen the parents hate it because, in the stools, when they have the accident, and their underwear has this like oily kind of thing too that you can never get rid of.
But those are the three main classes. I usually try dietary changes. Toilet time, I think that's important, we tend to forgot about that. And then, next step, the juices, and then next step, the meds.
If somebody's really constipated, you're going to jump to meds. But you got to work your way back also. Change the diet and more fluid, get toilet time. So, it's the three kinds of ways to kind of work on this.
Dr. Mary Ann Abrams: One other thing about the toilet time, again, some parents can be very concerned about toilet training and making sure the child's toilet training. Or they can become impatient or if a child has an accident, they could get angry. I think the idea of helping parents be a little bit more flexible in toilet training.
Because just like a child may not want to go to the bathroom at school because it's embarrassing or uncomfortable, there's not enough time. If they have a really bad experience during when they're at home, being toilet trained or maybe having an accident after they're already toilet trained, that can also make them hesitant to go to the bathroom, too. So just looking on that piece.
Dr. Mike Patrick: Speaking of constipation, we did an entire hour-long episode on constipation with one of our GI docs back in Episode 292. And I'll put a link to that in the show notes for anyone who may be interested in just to hearing all about constipation from the GI Specialist point of view. Really goes into a lot of detail. And so that'd be a good one for you, if that's something that is impacting your family. And again, you can find that in the show notes.
Dr. Mary Ann Abrams: As we're sort of coming full circle on this belly pain, belly aches, abdominal pain. Sometimes, we do a very complete evaluation. And when I say that I start with what we call the history of physical, asking all the details and examining the child and making sure they're growing well and healthy.
And there's nothing that looks like it's concerning in terms of some underlying cause, some disease or problem that's causing this belly pain.
And again, we used to then do a whole lot of tests and do more tests and more test to make sure and to reassure. But what we've sort of learn with that is that by doing more tests that sort of send a signal to the child and the family that the doctor's really worried because they did the swab tests and then they did X-rays and then they did an ultrasound. And now, they're doing this extra stuff.
It's a very reasonable approach if the child looks healthy, is acting healthy, is growing well to say I don't see something seriously wrong, but to know they may indeed have belly aches. Because just like Alex described, sometimes, you feel pain or butterflies in your stomach that's coming from somewhere else.
So, the message is there usually is nothing seriously going wrong with your body. And what our job is to help you keep going to school. It's important that you get up and play and run around and not become someone who feels or is made to feel like there's something wrong. And to help them be reassured enough that they can try some different approaches, "This is how you can manage when you feel the pain, but it's really important that you stay active and keep going to school or playing with your friends."
And they can work through it, accept that, and come up with some ways to manage it like whether it's taking some deep breaths or even gently patting their stomach or thinking of something that makes them feel better.
Dr. Mike Patrick: All right, well, we have covered a lot about the GI tract and we still have lots that we could cover, which we are going to do in a part two episode. In that one, we'll talk about vomiting and diarrhea, blood in the stool, hernias, food allergies, intestinal infection. So, stay tune for that coming soon.
But in the meantime, before we go, Dr. Rakowsky, Alex, please tell us about Primary Care Pediatrics at Nationwide Children's Hospital.
Dr. Alex Rakowsky: Yes, we are a very large system. I think we're the largest academic sort of attached primary care system in the country. We currently have 14 clinics, 6 of them work with our residents, either pediatric or internal medicine pediatrics. And we have two other clinics that have family medicine residents rotate through there.
We also have school clinics, and we do some telehealth as well. So, we see upwards of a close to quarter million patient visits per year and about 120,000 unique patients. So, a large number of patients go through our system. Pretty easy to get into, we try to add more evening and Saturday hours just to kind of help out.
But it's a busy system and I'm proud of the work that we do and probably how the residents enjoy their time in the clinics and seeing things.
Dr. Mike Patrick: We'll put a link to Primary Care Pediatrics at Nationwide Children's in the show notes. If you are in Central Ohio and looking to get connected with Primary Care Pediatrics, you can always call 614-722-KIDS, 614-722-K-I-D-S. And they will set you up with one of our primary care pediatricians that's in your community around Central Ohio.
So once again, and as always, it is a pleasure having both of you join us. Dr. Alex Rakowsky and Dr. Mary Ann Abrams, both with Primary Care Pediatrics at Nationwide Children's, thank you both so much for stopping by today.
Dr. Alex Rakowsky: Thanks, Mike.
Dr. Mary Ann Abrams: Thanks, Mike. Thanks, Alex. Great to be here.
Dr. Alex Rakowsky: Thank you, Mary Ann.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.
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