Constipation: When Poop Becomes a Problem – PediaCast 599

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Description

Drs Karla Vaz and Traci Bouchard visit the studio as we consider one of the most common conditions seen in kids and teens: constipation. We explore causes, symptoms, diagnosis, treatment, and prevention. We hope you can join us!

Topic

Constipation

Guests

Dr Karla Vaz
Pediatric Gastroenterology
Nationwide Children’s Hospital

Dr Traci Bouchard
Pediatric Urgent Care
Nationwide Children’s Hospital

Links

All About Constipation (NCH)

Constipation Management Toolkit for Primary Care (NCH)

Constipation Guidelines for Primary Care Providers (NCH)

Clinical Pathway: Constipation and Fecal Impaction (NCH)

Healthy Habits Using the SMART Approach (NCH)

Why You Shouldn’t Worry About Pooping Once a Day (YouTube)

Poop Withholding and What To Do When Kids Won't Poop! (YouTube)

Poop Accidents (YouTube)

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast is brought to you by Pediatric Gastroenterology and Urgent Care Medicine at Nationwide Children's Hospital. 

[MUSIC]

[Dr Mike Patrick]
Hello everyone and welcome to another episode of PediaCast. We are a pediatric podcast for moms and dads.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 599.

We're calling this one constipation when poop becomes a problem. Welcome all of you to the program. We are so happy to have you with us.

Constipation is one of the most common reasons kids visit their medical home. Of course, you might not realize this fact because most people don't like to talk about it, but believe me, those of us in pediatrics, we see kids and teenagers with constipation nearly every single day. Constipation is also one of the most frustrating problems for families from stool holding to bowel clean outs.

We're going to help parents fully understand the causes of constipation, expected symptoms, diagnosis, treatment, and prevention. I will discuss what is normal and what is not. And of course, in our usual PediaCast fashion, we have two terrific guests joining us in the studio.

Dr. Karla Vaz is a pediatric gastroenterologist at Nationwide Children's, and Dr. Traci Bouchard is a pediatric urgent care physician also at Nationwide Children's. Before we get to them, I do want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

So, if you are concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. So, let's take a quick break.

We'll get our experts settled into the studio, and then we will be back to talk all about constipation. It's coming up right after this. 

[MUSIC]

[Dr Mike Patrick]
Dr. Karla Vaz is a Pediatric Neuro-gastroenterologist and Gut Motility Specialist at Nationwide Children's Hospital and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. She also serves as Director of the Gastroenterology Fellowship Program at our hospital. 

Dr. Traci Bouchard is a Pediatric Urgent Care Physician and Co-Director of the Global Health Advanced Competency for Pediatric Residents at Nationwide Children's. She is also an Associate Professor of Pediatrics at Ohio State. Both have a passion for supporting pediatric patients and their families impacted by constipation. See what I did there? Impacted by constipation. Sorry, I couldn't resist. 

It is an extremely common condition among children and teens, and we're going to explore the causes, symptoms, diagnosis, treatment, and prevention.

But before we do that, let's offer a warm PediaCast welcome to our guests, Dr. Karla Vaz and Dr. Traci Bouchard. Thank you both for stopping by the studio today.

[Dr Karla Vaz]
Thank you.

[Dr Traci Bouchard]
Thank you so much for having us.

[Dr Mike Patrick]
Yeah, absolutely. So, Dr. Vaz, let's start with you. What do we mean when we say a functional constipation?

[Dr Karla Vaz]
Yeah, that's a great question. I always think it's really interesting when we add that functional in front of something. And I think overall, what that really means is that with a normal function of your GI tract, you're constipated, essentially, okay?

And there are very specific criteria for it, but it's very common in childhood. About 30% of children across the globe are affected by constipations. That's one in three.

And it's one of the number one causes that we see children in GI for. What functional constipation is where you're having infrequent bowel movements or painful bowel movements, fecal incontinence related to fecal impaction. If you're having abdominal bloating and symptoms related to poor passage of stool, straining to pass stool, or even just having the withholding, which is what I like to call the poopy dance when kids are just kind of avoiding it as much as possible.

[Dr Mike Patrick]
Yeah, yeah. You know, when we think about functional constipation, you said that it's one of the number one reasons that you see kids in your clinic. And that strikes me because in the typical pediatric practice, the number of kids that get referred to GI for constipation is actually relatively low.

There's a lot of constipation out there that is diagnosed and treated just at the primary care level. And my only point with that is it really just shows you how common of a problem that this is. Do you think, Karla, that the American diet has something to do with that?

Like if we, you know, just as a society ate more fruits and vegetables and high fiber kind of stuff, would that improve it? Or is there something else going on to make this so common?

[Dr Karla Vaz]
Yeah, it's a great question. So certainly, the American diet is not exactly high in fiber. That being said, across the globe, even in societies with really high fiber diets, they still have the same incidence of constipation.

And so, we do want to ensure that kids have a good amount of, like that they have a normal amount of fluid intake and a normal amount of fiber intake, but there really isn't any evidence to support excessive fiber use.

[Dr Mike Patrick]
Yeah, very interesting. Just that something is so common across the globe like that, that we don't really understand exactly why it happens. Traci, when do parents usually start noticing constipation?

Are there certain ages when they really ought to be particularly on the lookout? Obviously, it can happen at any time, but are there particular times that it's a little more common?

[Dr Traci Bouchard]
That is another great question. So, from a primary care or urgent care standpoint, which I do both at any age, certainly during the toilet training period is when you see a dramatic increase in presentation to the doctor. Most people start bringing their child to us when they're having belly pain.

Now there's also many other causes of belly pain, but in the absence of some of what we call like our red flag symptoms, like vomiting, diarrhea, weight loss, which I think Karla's going to speak to in a moment, constipation is a very common cause of belly pain, particularly from that primary care standpoint, like you said, before they get referred to a specialist. Parents will also bring their child in when they're spending a lot of time in the bathroom, either because they're in there straining or the opposite, when they're refusing to go to the bathroom because they fear it's going to hurt. We see a lot of complaints when parents come to us.

I love that Dr. Vaz called it the poopy dance, especially during that toilet training phase when children will often do that exact posture she was talking about. They'll hide, the parents will find them behind the couch or something, kind of standing with their legs crossed, clenching their buttocks and shaking, is referred to as that poopy dance or stool withholding is what we call it. And parents will often confuse this as a problem with their intestine or their stomach versus the child actually holding it in too long.

Finally, we sometimes see parents present when they're having stool leakage and their underpants are pull up, often mistaken as diarrhea, but it's actually that overflow of stool from like a hard stool ball because the child has not gone for several days. And that's usually when we're seeing them. But belly pain, I would have to say, is probably the number one presentation that brings them to us.

[Dr Mike Patrick]
Yeah, yeah. And in terms of timing, so we see a lot of constipation when kids start school because they are doing the withholding, because they don't want to get up and make a scene, like I got to go to the bathroom and it's easier just to hold it and sort of wait until you get home. But then a lot of times when you do hold it, that the feeling like I have to go sort of goes away and then things start really backing up and so school, both when kids start school for the first time, but even after the summer when school starts again, they may not have had much constipation issue in the summer and then suddenly when school starts, it's an issue again.

Karla, do you see that sort of seasonality to constipation?

[Dr Karla Vaz]
We do. We particularly see more fecal impactions around then. I would say there's a couple other times when I see a lot of constipation present and one of them is actually in infancy when children start solid foods.

They go from either breast milk and formula exclusive diet to starting some of those solid foods and the consistency of the stool changes and the babies are just like, yeah, I didn't really enjoy that at all. And then they start and they get withhold as infants, which is really interesting. The other time is potty training; I would say during that time and then whenever they start regular school or start preschool.

That pooping on a toilet that's not your home toilet can be difficult. Even adults have travel constipation. They don't like to go if it's not at home.

So that's very typical time periods.

[Dr Mike Patrick]
Yeah, yeah. You have both mentioned going a few days without having a bowel movement. Can you see constipation also in kids who are having a bowel movement every day, Karla?

[Dr Karla Vaz]
Yeah, that's a great question and the answer is absolutely. So, it's very common for children to really not understand the sensation of I'm empty versus I'm incompletely empty, right? Like, excuse me, but just one, a poop came out, it might just be one little pebble came out.

So, check that box, I pooped today without actually emptying their rectum and then what ends up happening is that that stool that's behind, the colon's job is to absorb water. So that water will just still keep being absorbed from that stool. It becomes harder and harder and then if you have numerous incomplete evacuations, you end up with a fecal impaction or like a poop blockage basically.

[Dr Mike Patrick]
Yeah, yeah. And that can be very uncomfortable and so we definitely want to encourage our kids to completely empty their bowel and sit there just a couple more minutes longer and see if another one feels like it's on its way. Exactly.

And then do we see diarrhea with constipation?

[Dr Karla Vaz]
You certainly can, right? So many times, kids will present with, they're having diarrhea, they're having so much diarrhea that's in their pants, like we're seeing it in their underwear and that's really just looser stool that's kind of working its way around an impaction and then with the impaction sitting there, their anal sphincter is partially open all the time and so unless they're consciously thinking about it, it just kind of sneaks out. I like to call that sneaky poop.

[Dr Mike Patrick]
Yeah, yeah, absolutely. And I know from like primary care, urgent care, emergency medicine standpoint, a lot of times when we raise the possibility of it being constipation, parents kind of push back a little bit, like, no, they poop every day, no, they're having loose stools, but we want to get the word out there that you can have stools every day and still be constipated because your child might not evacuate all the stool every time and it slowly backs up or you can have that hard stool ball that isn't moving and then your intestine may be so full of poop that as new stuff from the small intestine comes in, there's nowhere for it to go but to stay as liquid and skirt around all that solid stuff and come out as what feels like diarrhea, but it's still constipation. So, Traci, you mentioned that abdominal pain is the most common reason that kids present with what ends up being constipation.

Carlo, what are some of the symptoms that go along with abdominal pain that should raise a little bit more concern that it might be something other than constipation that's causing the abdominal pain?

[Dr Karla Vaz]
Yeah, absolutely. So certainly, if you have blood in the stool or you start to have really significant abdominal distension, if you notice that they're unable to pass stool for a prolonged period of time, like we're talking a week or more, those are things I would be really concerned about. In addition, we always think about if they're having growth failure or poor weight gain, you should not be losing weight related to your constipation.

Those are certainly things I would be more concerned with. If you're having a lot of vomiting, you're having bilious vomiting, which is like forest green vomiting, those things are also very concerning.

[Dr Mike Patrick]
So really at any time that your child has abdominal pain, give your doctor a call. They'll be asking some of those questions about blood in the stool and are they vomiting? Are they losing weight?

Those sorts of things. So, if you're concerned as a parent, just call your doctor and let them figure out if this is something to worry about or if a short course of a stool softeners is all your kiddo needs. Traci, then how do we diagnose constipation in kids?

Abdominal pain is a pretty common complaint. As long as there aren't those warning signs going on, there certainly are lots of other medical conditions that can just cause abdominal pain without vomiting or blood in the stool. So how do we end up on the diagnosis of constipation in kids?

[Dr Traci Bouchard]
It's another great question. I think this is an important question for me as a primary care, urgent care doctor, because really the diagnosis is made from what we call in medicine history and physical, which means basically listening to the parent's description about the child's problem and stool habits, any pains, behaviors they're having, like we talked about the straining or the leakage accidents, and then having a really good physical exam, including examining their belly, and sometimes if needed, their rectal area, which is good for parents to understand that that may be part of the exam and not to be concerned or surprised if that is part of it. And a lot of the times, even in what seems like a quick visit, we are checking off in our head all of those other bad things that Dr. Vaz talked about that is probably not present and that we feel confident that this is constipation just from listening to them and examining them and that we don't often need to do a lot of testing. From an urgent care standpoint, this is sort of a low-tech diagnosis in that blood work, or x-rays are really not helpful if we really just think it's constipation.

And as I said, they're not having those worrisome symptoms of vomiting and weight loss or probably are too from a quick urgent care standpoint that would make me pause and do other things. But if they have none of those things and a very normal exam or just, we can feel stool sometimes when we touch your belly, we feel pretty confident that that's the diagnosis of constipation.

[Dr Mike Patrick]
Yeah, yeah, for sure. And when you say we listen to our parents and the history is really important, that's because constipation typically is sort of a long-term waxing and waning kind of abdominal pain. You know, I always think if you have something that's there for several months, it's probably not serious.

Although, I mean, there are exceptions, but if things aren't escalating. On the other hand, if you have a kid who never complains of a bellyache and they start to complain of one and it just gets worse and worse and by the next day, like they can hardly move, you know, then we're thinking appendicitis. So that history of the abdominal pain, you know, the character of it, how long it's lasting, is it constant or does it come and go?

Or if it's a, you know, a toddler aged kid and they have episodes where they're just screaming, you know, really upset and yelling with abdominal pain and it's episodic, that makes us think of another diagnosis. So that history is really important. Part of that history is what are the stools like?

And Karla, I have seen charts and we have rating systems. There's one called the ROAM-4 criteria. How do we assess stool quality and ask questions for parents to get to the right answer there?

[Dr Karla Vaz]
Yeah, so the ROAM-4 criteria are actually what define functional constipation. So, it's kind of what I talked about earlier, you know, the stool withholding, the, you know, are they clogging the toilet when they poop? Are they having hard stools?

Are they having infrequent stools? And then the length of time that that's been going on, are they having stool accidents? Excuse me.

So, there's a lot of things. That's what officially diagnoses functional constipation. But then, you know, what are hard stools?

What's normal? Ooh, well, that's a little bit different for every person. Okay?

And so, what we look at to try to determine the consistency of stools is something called a Bristol Stool Scale, or a BSS, which is frequently abbreviated. And so that kind of goes from Bristol 1, which is rabbit pellets or little pebbles, to Bristol 7, which is essentially water, like brown water. And in the middle, there is kind of where we're aiming for.

So, Bristol 3 is like a sausage with cracks in it. That's what I tell them to kind of describe it. Bristol 4 is like a long, smooth snake.

They break apart in the toilet. And then Bristol 5 is like a soft serve ice cream. So somewhere in that range is what we're aiming for.

And we just want kids to not be straining, and then for them to be having a complete bowel movement every day to every other day. Now that's a little bit different in infants, right? Like if you have a breastfed infant, they could not poop for two weeks.

And as long as when they do poop, it's fine. There's nothing to worry about. That's not constipation, okay?

But as long as when they do go, it's soft and easy to go when they're infants. And as they get older, if it's soft and easy to go, whenever they're, even if they skip a day or so, that's not a problem. It's really when they're skipping those like three to four days, more than that.

And then when they do go, they're having these hard stools.

[Dr Mike Patrick]
Yeah, so that Bristol, and I've seen it in chart form, which is kind of nice with pictures. And then you can have the childlike, okay, point to the one that's like your poop. And then that gives you an idea really quick.

[Dr Karla Vaz]
Kids love my poop chart when I'm in clinic. Yeah. Point to your poop.

[Dr Mike Patrick]
Yes.

[Dr Karla Vaz]
They love that. They think it's really funny.

[Dr Mike Patrick]
And it is. Sometimes when I've used that, sometimes I kind of giggle too. So, then the ROAM-4 criteria, that's a checklist that helps us distinguish between functional constipation and maybe there's something else going on that could be causing the constipation?

[Dr Karla Vaz]
Yeah, so you have to have two of the criteria and it has to be present for at least one month. And then you can't have any of those other warning signs as we discussed earlier. So that's really where the ROAM criteria come in.

That's your like official diagnosis of functional constipation. And those are easily accessible online. So, you can just check and say like, oh, yep.

You meet these two criteria: you're having stool withholding and you're not pooping for four days at a time. And most of the time it's not just two, it's normally more than that. When you do go, you have large stools that clog the toilet, you're having fecal incontinence, all of those things.

That's what the ROAM criteria are really there for so that we have a diagnostic algorithm for diagnosing constipation. And so, when we do research, we want to make sure that people meet the same criteria and that you meet those definitions.

[Dr Mike Patrick]
Traci, what is the role of x-rays in evaluating constipation? And you had mentioned that the history and the physical is usually how we're going to arrive at a diagnosis. Sometimes families come in and they may be surprised that we don't need to get an x-ray when their kids had belly pain.

From their perspective, like he's been complaining of belly pain on and off for a month or longer. Shouldn't they get an x-ray? How do you approach that and when do you actually get an x-ray?

[Dr Traci Bouchard]
Yeah, that is a great question that's near and dear to my heart. I did primary care for decades and now do urgent care. And so, I understand.

I think it's a great opportunity to just talk about in general, like what to expect when you go to the doctor. And that's a good thing for parents to know for many diagnoses but including belly pain and constipation. Because I think it is about expectation.

I know you're an ER physician and kind of understand that. I think sometimes we give parents the wrong impression that they're getting better care if they get x-rays or blood work. And that's not always the case.

And so, it's best that we explain why we do what we do. If taken a really good history, which means listening to the parents, which is always paramount when you're a doctor to listen to your families and do that good, thorough physical exam, it's a low-tech diagnosis. But we need to explain that to the parents when we do an x-ray or why we're not doing an x-ray, so they understand that we're not dismissing them or missing the diagnosis, which is an understandable concern especially when you're bringing your child to that next level of care.

It's been going on for months as we all talked about. This is a chronic problem and often quite frustrating and scary for the parents. So, they're coming in with that, something must be done.

But we want people to understand that oftentimes with our experience, if they don't have those scary signs we talked about and growth for me, I have a primary care standpoint. I look at every child's growth chart, even in an emergency room or urgent care standpoint and somebody falling off the growth chart is going to be a completely different conversation. But if they're growing well and they have that normal exam and that history that Dr. Vaz so well described, as it's been going on for weeks or months, we feel pretty confident they don't need an x-ray. And it's not just that we don't want to get the x-ray. I also try to explain to my parents that there is a cost to everything we do and there's radiation exposure and we're talking often young children, right? I think I see a lot of this in that going to school age as you talked about those four or five, six-year-olds or middle school children.

And I always look back at everybody's chart. I had a child once who I saw who was six years old who had had like five x-rays in the past 18 months. And that's a lot and all of those were normal.

So, we want to explain to parents, if they don't have any of those scary warning signs, particularly vomiting or poor growth, that the x-ray is probably not going to help us in diagnosing constipation and also will expose them to radiation. It increases the cost of the visit and the length of the visit. Sometimes you want to get out of that urgent care and we're waiting for an x-ray reading or waiting for the x-ray to be done.

In addition, I think it's kind of interesting, I've read a lot of studies on this that if you just were to x-ray 20 people, adults or children, you're going to see stool on most people's x-ray unless they just had a clean out for some other reason. And that does not necessarily mean they're constipated or would not necessarily explain their belly pain. And so, you don't want to also confuse the picture that they could have belly pain for appendicitis that we talked about, but you see stool on the x-ray, and you go, oh, that's just constipation.

So again, it's putting it all together with that important history and physical and deciding when an x-ray is needed. I would say probably vomiting would raise my concern, that hard belly that Dr. Vaz talked about and certainly bilious vomiting, which is that scary green color that we're seeing that would move that person into a category of something else, maybe like a blockage.

[Dr Mike Patrick]
Yeah, yeah. If we're worried about a blockage or maybe a kid's had a history of a stool impaction where they have that stool ball set in the rectum, in that case, if it's like all their other times that it's happened, then maybe you do get an x-ray just to show that there is an obstruction there, but not necessarily to show that they have constipation. So, it can maybe help evaluate if there's a more serious problem, but if it's just diagnosing constipation that's been there for a while, it's certainly going to be less helpful.

And I think once a kid gets an x-ray, then it becomes like the parents, like, well, we need to get an x-ray and see if they're backed up again. And then you do get that situation where you've had six x-rays in 18 months. And I mean, we don't want that much radiation.

If it's a one-time thing, okay, but you start getting them two or three times a year and we don't really know what the impact of that is in terms of incidence of cancer and those things that's very hard to study. Karla, I want to talk a little bit about treatment of constipation. Sometimes when kids come in and they're really full, we have to do what's called a clean out.

Can you explain exactly what that is and how it's accomplished?

[Dr Karla Vaz]
Of course. I just want to piggyback off the x-ray thing one time because always there will be stool in the colon. And so, I see frequently it's like, well, but they had poop on their x-ray.

And I'm like, well, where else would you expect it to be? It should be in the colon. I hope it's not anywhere else.

Like where else would it be? And so, I do feel like x-rays overhaul constipation very frequently because anybody who sees stool in the colon, they're like, oh, not supposed to be there. And I'm like, well, yeah, it is.

It's really supposed to be there. So just to piggyback off of that, that just because there's stool in the colon doesn't mean you're impacted. All right, so clean outs.

This is a really not fun topic, but it's crucial to treatment for constipation. So, if you really have a ton of stool in the colon, like you're completely backed up, you're having accidents, you really have to just kind of start fresh. If you put just a little bit of stool softener or a stimulant or something like that on top of having a really large impaction of stool, you're going to end up with a bunch of accidents.

It's not going to be successful. You're going to have cramping and nothing's going to work. And I've heard this repeatedly from parents, like, well, they gave us medicine, but it didn't work.

It didn't work. And I'm like, well, did you do a clean out? No.

So, it's really important to kind of just get all of that hard stool out so that you can really start fresh with medications that we know are effective, but you have to move all that hard stool first. It just doesn't work if you don't do that first. And how do we do that?

Yeah, so there's a number of different ways that you can do clean outs. Most of the time, we're going to attempt this at home. And most of the time we'll use a medication that's called PEG-3350 or polyethylene glycol, which is also known more commonly as MiraLAX.

In the hospital, it's typically called Golightly. It's a dissolvable powder that mixes with whatever you make, or it absorbs the water that you mix it with. And then it stays in the colon and just kind of flushes it out.

So, it's a softener. It just kind of flushes everything. But it's a large volume of that.

So, you know, when I tell parents like, okay, you need to take seven capfuls of this when the average daily dose is somewhere between a half a capful to one and you're going to do seven in one day, that's a lot. And so, you know, the child should stay at home that day. They should have a clear diet that day and really just kind of flush out their entire GI tract.

So that's one way that we do it. You could also do magnesium citrate, which is available over the counter. All of these actually are available over the counter.

And that is a smaller volume of liquid. So, if you have a child that's really volume limited, that can work well. And that's typically a lemon lime flavor or a cherry flavor.

Or you could do mineral oil, which doesn't work as well, I would say, but it is somewhat more palatable for our children who really just cannot get down things that are yucky. And mineral oil can be mixed in with like a milkshake or even regular milk. And it basically is just an oil that's not absorbed.

So, it just slipperies up everything and helps it get out. I was like, that's the only way I can really describe it. It's just, it makes everything really oily and everything slides on out.

But, you know, some children are so impacted that they need an enema to start their clean out or they need to be admitted to the hospital. And sometimes we need to place a nasogastric tube, which is a tube that goes from their nose to their stomach to really be able to flush their entire system. So, we try to prevent kids from getting to that point by addressing it in primary care and treating the constipation early rather than, you know, getting to be really impacted.

[Dr Mike Patrick]
Yeah, yeah, for sure. You know, when kids are really backed up and need something like an enema and, you know, a lot of MiraLAX, I think just, you know, the next step is going to be, hey, let's try to prevent this from happening again, which, you know, may be doable. Most of the time is doable, but sometimes it's not.

And so, from, you know, I don't want to put like blame on parents when I say, what can we do differently to prevent this? Cause then it sounds like the parent has caused it, which is not necessarily the case, but are there some things that we could do to lower the chances that this impaction or really getting full is going to happen again? Traci, what sort of strategies are available to prevent getting to that point?

[Dr Traci Bouchard]
Yeah, there's a lot a parent can do ahead of time. Certainly, speaking to your doctor early, if you're starting to see stool withholding or missing days as we talked about way before they see someone like Dr. Vaz, they've probably had some symptoms that they can manage. And it starts with those toilet training age years.

But I try to reassure parents that many children will withhold around that time. And that from a development standpoint makes sense because it's something they can control. There are many things children can't control at a young age and that's one of them, right?

What goes in and what comes out. So that's why when you get the picky eater stage and you also get the stool withholding. And if they can understand that that that's just normal for their child's development and not wrestle with it or fight with it or be angry about it, that it can make things easier.

But yeah, there's lots of behavioral strategies that they can start to do when they see their child withholding, whether that be at the toilet training years or even later as we talked about middle school or things that when the children are afraid to use another toilet. To just sort of remember, I tell parents that sometimes they have to be their child's brain and be the cue. We all naturally have a cue to go to the bathroom, our bodies kind of tuned in to do that.

Usually after we eat, preferably in the morning, that's when our colon kind of wants to empty, but we can turn that off, right? That's exactly what happens. We just say, I don't have to go, I don't want to go, this is not a great place to go.

So, you have to kind of be the child's cue that we need to go to the bathroom. So just something as simple as regular toilet visits, being the child's reminder to go. Start with, like I said, after they eat is a great time, and kind of being a little bit forceful, not like, do you have to go to the bathroom?

But we're going to go sit in the bathroom now and have them sit there for at least five minutes. As you talked to before, sometimes they could pass a little stool, like a little pellet, and they think they've had that bowel movement for the day, but they really haven't evacuated. So have them sitting there, not forever, but for five minutes.

Make sure they're comfortable. They now sell those little foot stools, so a child's not dangling on a toilet, which would sometimes keep them from going to the bathroom, particularly if they're very young or small, and have them sit there kind of leaning forward so that they are in that natural position to go. And they may need to do that several times throughout the day as their reminder until it becomes something that they're doing as a normal habit.

I think sometimes even a little reward system is fine and refraining from the opposite. I try never to punish a child for not going. While there may be a little bit of a battle, struggle there, it's truly not their fault, and it often doesn't help the problem at all, and can backfire and make the child either hold it in more or just have some other behavioral problems.

But small rewards are good, not a huge, super expensive toy, but each time that they sit on the toilet for that long enough time, even if they don't have the bowel movement, but they're following the direction, maybe a sticker or a sticker book, working up to something big, they can even engage the child in that, sort of making that sticker book or that calendar that they can put on the refrigerator, if that's appropriate, to sort of show that they're trying to go to the bathroom and that they're not holding it in.

[Dr Mike Patrick]
Yeah, you know, when you sign up to be a parent, no one tells you that you're going to be making sticker books for bowel movements, but it is certainly something that can be motivating for kids. I love it. So, we have talked about ways that we can hopefully, maybe not completely prevent constipation, but at least lower the chances that it's going to happen.

And we've talked about what we do when things get really bad, but there's a lot of kids in the middle there, Carlo, what medical treatments are commonly used, like on a daily basis, once you've done that clean out, just to keep things going?

[Dr Karla Vaz]
Yeah, absolutely. So, we kind of talk about maintenance medications. So, medications that are going to keep us having a complete, soft, easy to pass bowel movement on a daily basis.

So, I kind of put these into two different classes. One are what I call mushers, okay? So, things that make things soft.

And then another class is the pushers, or what make things get out, okay? And so, there's a number of different medications in each class. And it really depends on what their symptoms are prior to them becoming impacted, or just at the first presentation.

Like if it's that their poops are soft, but they're only going once or twice a week, then maybe they just need something to help poop get out. They don't actually need a softener. They just need something to help it get out.

[Dr Mike Patrick]
Pusher.

[Dr Karla Vaz]
They need a pusher, exactly. And then, but if their poops are hard, maybe they're going every day, but they're only going a pellet. They probably need something to soften things up.

And sometimes children need both.

[Dr Mike Patrick]
A musher and a pusher.

[Dr Karla Vaz]
A musher and a pusher, exactly. So, I like to think about it that way because they really do work in different ways. And the one thing I think it's really important to address too is that there's this like old wives' tale that if you use medications for constipation, your colon's going to become dependent on them, and they're never going to work.

Your colon's never going to work again. And that's just really not true. We've been using medications for constipation for decades, and some even longer than that, and that's really just not the case.

I think the challenge is, if you start taking these medications and you're pooping on a daily basis, and then you stop taking them, you might not poop on a daily basis. And that's just where you went back to your normal. Your normal was that you weren't pooping, right?

So then that kind of reinforces that idea that like you're dependent on them. It's like, no, it's kind of like diabetes. If you stop taking your insulin, you're going to get really sick again.

So as far as like mushers go, brand name is MiraLAX, and that's the PEG-3350. We also use a medicine called lactulose, which is a non-absorbable sugar that comes as a syrup. So that's very easy to administer.

I frequently use that in infants because it's a very small volume. Other things you can use are magnesium hydroxide. That comes as like milk.

That's milk of magnesia commonly. And that can work well. It also has a little bit of a stimulatory effect, but it softens things.

Some children do well with just mineral oil on a daily basis. The challenge with mineral oil, I would say in general, is that that's something you definitely don't want in your lungs. So, if you have any concerns for aspiration, you really can't use mineral oil.

But those are the general like softeners that we use, or the mushers. As far as pushers, there's really two different ones we use. So, one would be Senna products, which come as Senna tablets, Senna liquid, and then also Ex lax.

There are also generic chocolate chews that you can get. And then bisacodyl, which comes as a capsule, and you can't open that. Or it's a very, very small capsule, but you can't split it.

So, for younger children, they typically don't need a ton of a pusher. And so, Ex lax and Senna tend to be the easiest ones to administer. And so, we use those on a daily basis, and it's totally fine.

You know, what's really important to know is that as long as you keep your rectum empty, you know, you're emptying it on a daily basis, constipation typically resolves. This is not something that they're going to have forever. But early on, when you've had a fecal impaction, you've kind of remodeled that rectum to where it's so enlarged, you've lost sensation to even tell when you need to go until you have a huge amount of stool there.

And so, a lot of times you just need a pusher to just have that sensation to go. And once the, you know, over time, and this is not like a month, this is years, typically your rectum will kind of form back into a more normal shape. You'll have increased sensation and you won't have constipation anymore.

But early on, treating it earlier means that you're going to not need to treat it for as long and kids are going to get back on track faster. So, you know, I really don't like it when I see kids that are 16 years old and they're having stool accidents and they've been constipated their whole life, you know? And it's not uncommon, unfortunately, you know, where it's just like, oh, well, I got some MiraLAX and that made me have a bunch of accidents, so then we stopped it, but never had to clean out, you know?

And so, I think it's really important to address it really early.

[Dr Mike Patrick]
So, you've brought up two points that I want to just revisit because I really feel like they're important for parents to understand. One is that, you know, when you're taking something and it's working and you feel great, then you feel like, I don't need it anymore, but you feel great because you're taking the medicine. And so, and then I think with constipation, it's particularly troublesome because you stop it and you're still okay for a while because your bowel hasn't filled back up, but that process is still happening again.

And so, if you have a kid who, you know, you do stop it and they do great for months and months and that's okay, fine, you had a short bowel constipation and now you're over it. But if you keep needing MiraLAX, like, you know, every six months you need it, you probably should just be on it all the time. And as you said, it is very safe to use.

There's a lot on the internet. If parents Google MiraLAX, you're going to see a lot of stuff, but none of it is evidence-based, right? We would not use something on a daily basis in kids that we thought could cause a problem, correct?

[Dr Karla Vaz]
Correct, absolutely. And we've actually done the studies here where we looked at children who were on MiraLAX on a routine basis, and we measured what could potentially be in your blood if you were absorbing it. And we measured that in both children who were on and off of it.

And we actually found that there was more of that byproduct in children who weren't taking it than in children who were. So there really is just no evidence to support that it's causing systemic problems.

[Dr Mike Patrick]
And then the other thing that I wanted to point out is, yes, things are going to get worse before they get better, especially when you're doing the clean out, because yeah, the MiraLAX is going to cause you to have loose stools. It's like a colonoscopy prep. I mean, you're trying to get everything out.

And when it becomes more of a clear liquid, then, I mean, not completely clear, but you can see the toilet bowl through the liquid, then you can probably start backing off on it at that point. But as long as it's that really dark brown, you can't see through it. See, this is why I start giggling when I talk about poop.

But if you can't see through it, keep going, because you're trying to get it out, right? I just think that's so important for parents to understand.

[Dr Karla Vaz]
Yeah, that's another key also for the reason you need to do a clear diet, particularly for older kids, because if you continue to eat, it's never going to clear.

[Dr Mike Patrick]
Yeah, because you're just making it as fast as it's coming out. Exactly.

[Dr Traci Bouchard]
And I think what's important to tell parents too, like when we send them home, is that they're going to have some bloating and gas if they haven't passed that stool for a while, and not to mistake belly pain as the medicine making it worse. And I try to tell them that all of that poop, which is basically your body's garbage and waste products and gas, has been in there for a while, and it's going to start moving, and you're going to get a little bit, if not a lot, of discomfort, cramping, gas, however you want to describe it, and that's not necessarily a bad thing or a sign that it's making it worse. And that's key, because that's when, as Dr. Vaz said, that's when they said, oh, MiraLAX didn't work, and then they get worse.

[Dr Mike Patrick]
I think to the point of that pain, it can be pretty severe because I have heard, I don't know that anyone has actually counted, but I have heard that the intestine has as many nerves as the brain. So, it's full of nerves, and if it gets stretched because it's full of poop, that causes significant abdominal pain. And back before ultrasounds and CAT scans, kids who had pain with a certain pattern in a certain spot would just, you would assume that it was appendicitis, and there were a lot of kids who had their appendix taken out back in the day who really were constipated and didn't have appendicitis at all.

You know, we have better tools now to distinguish between constipation and appendicitis, but my point is just that pain with constipation can be significant enough that a doctor may think it's appendicitis.

[Dr Karla Vaz]
You're absolutely right. There are a ton of nerves in the GI tract, and they're, actually, functional constipation is under a classification of disorders that are called disorders of gut-brain interaction and how you feel the intestine. The intestine, actually, has basically stretch receptors, so it doesn't hurt if you actually cut the intestine.

It hurts when you stretch it out. So, if you have a lot of gas, you have a huge fecal impaction, that causes quite a bit of pain until you get that moved through.

[Dr Mike Patrick]
So important. Traci, what do you advise families in terms of diet and amount of fluid intake as a part of the treatment plan?

[Dr Traci Bouchard]
Yeah, I think it's a very important point as well, although I find it fascinating, as Dr. Vaz said, that constipation is seen worldwide with varying different populations with different diets, and it can be even in those high-fiber diets. That being said, though, there are many of our patients here that have that, like, white diet, I call it. You know, it's a very high carb, a lot of processed food diet with low fiber that's certainly not helping things.

And also, inactivity, I think. You know, your gut is a muscle as well, and it needs movement and activity. So, we know that, you know, being sedentary, for example, the extreme case, if you're in the hospital, you're going to have a hard time pooping.

So just sitting on the couch watching TV all day is not helpful. But as with many things with parents, it's also, you know, multifactorial diet is clearly important. So, we just try to kind of, you know, partner that with the other developmental things they're going through.

These things are often happening at that age when they're picky eaters anyway, that middle school or toddler age. So, I really spent a lot of time educating them on, you know, some simple ways. They don't have to be, you know, chef to introduce some really healthy foods into their child's diet.

And then to mimic that, you know, if you're eating poorly, probably your child's not going to be eating a lot of fruits and vegetables, but they don't have to be, you know, fancy about it. They can just make fresh fruit and vegetables part of their regular diet. They can put it in cereal.

They can make a smoothie. They can do a yogurt parfait, a fruit pizza, you know, just some basic stuff. Even buying it canned is probably better than just, you know, not eating fruit at all.

And my go-to, I always tell, I know a lot of us recommend like prune juice, for example, a very old school way of cleaning out a child or making them go to the bathroom. But a lot of kids don't like prune juice and I understand that. So, my go-to for most children, even the pickiest of eaters is mango or mango juice, which is both naturally high in sugar and fiber and easily found.

Mango juice, even Juicy Juice makes, and that often is an easy way to kind of help, you know, flush the system a little bit with fluids. Lots of water, for sure. I try to tell people to avoid soda or pop at all costs, maybe for holidays, birthdays, or special occasions, but there's almost no role nutritionally for soda or pop, as you call it, for any child.

And yeah, just lots of water, a little bit of milk and juice when needed. Yeah.

[Dr Mike Patrick]
When do you refer to GI from a primary care standpoint? At what point in a child's constipation journey are you like, okay, we need to get Dr. Vaz involved?

[Dr Traci Bouchard]
That's a great question. I mean, there's probably two categories you often refer. The main first category is those children, as we've talked about a lot today, that sort of make us concerned from a medical standpoint, those red flag symptoms.

So, something that doesn't, you know, we see constipation a lot, as we've talked about, this is quite a common problem. So, like a lot of things in medicine, when someone is outside of the box, so to speak, you know, that doesn't make sense to me as a doctor. You know, when I see an infant who's just on formula, who's very impacted and still is not moving through the colon at all, I worry about some kind of gut motility issue.

Any child that's not growing, like I said, that is always a red flag, maybe from another cause, but it gives me a pause to say, I may need somebody else to look at this and do a further workup. A lot of vomiting, bilious vomiting, would be concerning for me. Really bloody stools, which can happen with hard stools, as we talked about, if you're really stretching that rectum and the skin will crack, you'll see some small amount of blood.

But if they're having true bloody stools daily, we might want to have a better look that someone like a gastroenterologist can help us with for tests that I'm not able to do, you know, a colonoscopy, an upper GI series. The other large category is sometimes when we just have, you know, constipation is a chronic problem, and we try to explain that to parents. This is not a quick fix, like going to the doctor for strep throat, where you'll get your medicine and be done in 10 days.

This is often a long-term solution. And so, we want to partner with them and help them get through this. But sometimes we have children and families where it really is a struggle, whether it's the child's behavior or some especially developmentally delayed children that following those directions for diet or clean out is very hard due to sensory issues.

And the parents are quite frustrated or not understanding. We will refer to GI because they do such a great job as Dr. Vaz explained all, you know, she has a great way of explaining it to parents. And sometimes they just need that reassurance and another set of ears and eyes to explain the process and to follow them.

As we said, this is not a one-time visitor fix. So those are our two categories where I would refer.

[Dr Mike Patrick]
Yeah, and I also love how she explains things. I mean, I had not heard of mushers and pushers before. This is the very first time I've heard those terms.

[Dr Traci Bouchard]
I'm going to use that in clinic.

[Dr Mike Patrick]
I love it.

[Dr Traci Bouchard]
I didn't want to say that.

[Dr Mike Patrick]
That is so great. So, Karla, what can families expect then if they get referred to GI constipation that's become problematic and you know, everyone's frustrated. By the time they get to you, I'm sure the parents are just like, we just want this done and over with.

What can they expect when they see you?

[Dr Karla Vaz]
Yeah, so I think one of the things that's unique in a subspecialty clinic is that we have a little bit more time to really sit down and explain things is very helpful to families. I also explain things to the kids and we take the history. So, you know, many times I am just taking a history, doing a physical exam and then prescribing a clean-out and maintenance medications.

Truly, like if I see you for the first visit, like that's what I'm going to do. I would say the vast majority of kids that I see have never had a clean-out or haven't had an effective clean-out. Maybe they've been prescribed a clean-out, but they never actually got cleaned out.

So, I would say that's probably what you're going to see in the vast majority of visits. That being said, I sometimes see children and they have a huge mass of stool in their abdomen, and we need to take them to the procedure room to really just remove that from their bottom and then admit them to the hospital to get them cleaned out. So, I think that it really does vary.

Testing wise, Traci, you mentioned colonoscopy and that's actually something parents request frequently but it really serves no purpose for us in managing constipation but there are other tests that we do. So, it's not uncommon for children when they are trying to poop, particularly if they have a history of stool withholding, that they will sit on the toilet, they will push really hard with their abdomen, right? And they're straining and grunting and they're really putting a lot of effort into it but they're pushing with their abdomen and squeezing their anus.

So, they're squeezing their bottom but pushing with their abdomen. And so obviously that's not very effective. And so that's called pelvic floor dyssynergia.

Basically, the muscles are really working against you. And so, we actually diagnosed that with a test that's called an anorectal manometry. And that's a test where you basically insert a tiny balloon into the bottom and then we ask them a bunch of questions.

We blow up the balloon to simulate a poop. There's a whole bunch of stuff that goes into it, but it's done while the child's awake. It's typically about 15 minutes and it's accomplishable in most children.

I would not say all children are going to be amenable to us doing this but that can really help us understand a number of different things including like do they have a nerve problem? Like do they have Hirschsprung disease? Do they have internal anal sphincter achalasia?

Like can their anal sphincter basically just not relax? Like that's a problem. And we need to deal with that differently, but it also helps us understand if they have pelvic floor dyssynergia because we have programs that can help with that.

So, we have biofeedback where we actually use EMG leads or stickers that go on their belly and stickers that go around their bottom, nothing in their bottom. But basically, I tell kids that they get to play a video game with their butt and they love that. And so, we teach them how to basically relax their pelvic floor and increase their intra-abdominal pressure to have a bowel movement more effectively.

And they run through a series of different games with biofeedback to really help them. Also, there's pelvic floor physical therapy that can help teach kids how to use their muscles more effectively. So, I would say that if any test is going to be done for a constipation, it's probably going to be an anorectal manometry, but the vast majority of children are not going to need testing.

[Dr Mike Patrick]
Yeah, yeah. And like a colonoscopy, you might consider that if there's a lot of blood in the stool. Like with inflammatory bowel disease or Crohn's disease, those sorts of things, if we're worried about that then you might need a colonoscopy.

But that's not the usual case.

[Dr Karla Vaz]
Correct, not for most children with constipation.

[Dr Mike Patrick]
So, Karla, what kind of resources are available for parents who maybe want to learn more about this and also with their kids? Like, is there some kind of resource that parents can share with their kids that helps explain what causes constipation and then the treatments that are available?

[Dr Karla Vaz]
Yeah, so we've actually worked with Partners for Kids, Nationwide Children's, to create cute little cartoon videos. They're little snippets that are TikTok friendly where it explains what constipation is, why you need to listen to your body, why do we need to sit on the toilet? Why do we need to sit on the toilet with our feet elevated?

What are poop accidents and why do we have them? And like, why do we need to have a clean out? All of that stuff is explained in this series of three little videos.

They're available on YouTube and kids really love them. My kids think they're hilarious.

[Dr Mike Patrick]
Yeah, they are actually really great videos. We'll put a link to all three of those in the show notes for this episode, which is 599 over at pdacast.org. We're actually going to have a lot of resources for you there in the show notes, those three YouTube videos for sure.

We also have a constipation management toolkit for primary care. So, this is going to be for primary care providers that can help you manage your kids with constipation issues. We also have some guidelines, clinical pathways about how we do things at our hospital with regard to constipation and fecal impaction, healthy habits that can help prevent constipation from happening.

All of these things are going to be in the show notes, again, episode 599 over at pdacast.org. Well, this has been a fascinating conversation. It always is when we talk about stool.

It just, you know, just one of those things. And that's another thing too, is that a lot of parents think their kid is the only one going through this, but we know it's very common and people just don't want to talk about it. Like if you're at a birthday party, you're not going to talk about your kid's stool habits, but you might talk about their chronic cough or their wheezing or their asthma or their diabetes.

But for whatever reason, poop makes us giggle and not want to talk about it, even as adults. Exactly. Once again, Dr. Karla Vaz, Pediatric Gastroenterologist at Nationwide Children's Hospital and Dr. Traci Bouchard, Pediatric Urgent Care, also at Nationwide Children's. Thank you both so much for stopping by today.

[Dr Traci Bouchard]
Thank you so much. It was our pleasure.

[Dr Karla Vaz]
Thank you so much for having me.

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[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. We really do appreciate your support.

Also, thanks again to our guests this week, Dr. Karla Vaz, Pediatric Gastroenterologist, and Dr. Traci Bouchard, Pediatric Urgent Care Physician, both at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android.

Our landing site is pediacast.org. You will find our entire archive of past programs there, all 599 of them to be exact. There are show notes for each of the episodes, our terms of use agreement, and the handy contact page if you would like to suggest a future topic for the program, or if you just want to say hi.

I love hearing from listeners, and I do see each and every one of those contact page entries, so please do use that. Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media.

You'll find us on Facebook, Instagram, Threads, LinkedIn, X, and Blue Sky. Simply search for PediaCast. A couple of other podcasts I want to tell you about that I host, one is PediaCast CME.

That one is similar to this program. We do turn the science up a couple notches and offer free continuing medical education credit for those who listen, and that includes physicians, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements.

Shows and details are available at the landing site for that program, which is pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

And then that other podcast is called FAMEcast. Now this one is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at the Ohio State University College of Medicine. So, if you are a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you.

And you can find FAMEcast wherever podcasts are found by simply searching for FAMEcast. It's also available at famecast.org. 

Thanks again for stopping by, and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

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