Constipation! Everthing you need to know. With Dr Tanaz Danialifar MD

Episode 68 of Ask Dr Jessica is all about constipation!  Todays episode features Dr Tanaz Danialifar, a pediatric gastroenterologist and she answers the most common questions about constipation.  She explains how to manage constipation with use of medication, diet and behavior modification. Dr Danialifar is a board certified pediatric gastroenterologist, she attended Yale Medical School, she completed her training at Childrens Hospital of Los Angeles, and she currently practices at Keck School of Medicine at USC.   She is an expert is treating a range of pediatric gastrointestinal issues, including constipation, chronic abdominal pain, reflux and inflammatory bowel disease.  

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does 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 child's health care provider.

Transcript

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Hey everybody welcome to ask Dr. Jessica the podcast from my goals have quality conversations to help you along your parenting journey. I'm your host and paediatrician Dr. Jessica Hochman. Today's episode will be about a very common topic of concern, and that is what can we do about constipation. Today's guest is Dr. Tanaka is Danielle afar and she works as a paediatric gastroenterologist at The Children's Hospital Los Angeles. She has wonderful credentials. She's a graduate of Yale Medical College, and she's a frequent lecturer. Which, incidentally is how I first met tonight's by being an attendee years ago at a lecture she gave on can you guess? That's right constipation. She's a mother of three young children and she truly has a gift when it comes to being a caring, knowledgeable Doctor. Thank you so much for listening. And please pass this episode along to anyone who you think may benefit from hearing this conversation. Welcome to now Daniela Farr. How are you? I'm great. Thanks for having me. I'm so happy to have you on this podcast, we're going to talk about a topic that I get so many questions about constipation. Believe it or not, it's one of my favourite things to talk about. And most paediatricians and most paediatric gastroenterologist are shocked when I say that, but I've really loved taking care of constipation. And I think when you have some important information and basics, it's such an easy problem to treat. And it is so satisfying and rewarding for the families. I'm so curious, can you explore this a little bit more? Tell me why? Why do you find it so satisfying? Is it because you can fix it, I can fix it, I and I often see parents and children who've been struggling for many, many, many years. And the stigma is really significant. So a lot of people recognise constipation, as my child can't go to the bathroom, my child's struggling to go to the bathroom. But when it's ongoing, those children start to have a lot of abdominal complaints, their appetite gets down a lot of behavioural issues related to that discomfort. And in the most severe situations, they actually start to have very frequent leakage. And so it's not unusual to see school aged children, I've taken care of even middle school aged children who are coming in with incontinence or leakage of poop. And with the right steps and the right things, these children who have been struggling for years and years can have so much improvement in not a very long amount of time. If we see kids, where this goes on for years and years, it's a shame, they don't connect with you sooner. And you know, it's not necessarily that they need me sooner. I think if if as a parent, and when I see families in clinic, the biggest thing I would tell you is be aggressive and consistent and treating constipation in the young child. Because if you do, so, you're gonna nip it in the bud, and you're not going to struggle with issues for a very long time. One of the most common problems that I see is parents will give treatment, they'll give laxatives, the constipation is better, they stop the treatment, it comes back, they restart treatment, and they go in these on and off cycles. And in my experience, probably the most common factor that makes constipation a difficult and ongoing issue. Are the behavioural issues that happen as a result of long standing constipation. That's so interesting, so less about the diet and more about the behaviour. Yes, I am not one that really pushes diets when I'm managing constipation. And I'll tell you why. One of the most common ages that we'll see constipation becomes prevalent is in toddlers. And it's often really linked with toilet training, toilet avoidance, there's this very weird, irrational fear of poop in the toilet among toddlers. I think a big part of that has to do that toddlers are controlling, and they have no control over anything in their lives. And the one thing they can control is what comes out of their butt. And so one of my thoughts is that adding in dietary modifications, it's not that they don't work. But the extent that you want to use them, too, is just another point of contention that you're having with your child. And I would rather we're minimising those things and all the behavioural focus is on what's happening with toileting. I also find the reality of the situation is that when I advise parents to alter their toddlers diet, it's really easy advice to give but really hard to follow. I mean, to tell a child, oh, you need to eat more fruits and vegetables. That sounds great. But in actuality, I know it's hard for parents, it's hard for kids to make adjustments. And that's exactly what I'm talking about. I think, you know, I was a Okay, doctor, before I had kids, I think I became a much better doctor after I had kids. And a lot of that is the reality of how do you implement the advice that we're giving people? And so I really try to have that guide the decision making, and that also goes into how we choose medications and all that stuff. The other problem is that dietary therapy will help if you are mildly constipated if you had some firm poops but you're still going to the bathroom. We can make some modifications. Or if you're very obviously not drinking water. Another big culprit is children who drink excessive amounts of milk, right? So I'm saying in excess of 18 to 20 ounces of milk a day, those are easy changes. But beyond that, when you're more significantly constipated, dietary modifications are generally not going to get you where we need the stool to be. And one of the most important things that I do when I manage constipation, when I manage the behavioural aspects, is get the stools even softer than what we think of as a normal stool. And it's really beyond what you'll achieve with diet. That's such good advice. So for parents that are listening to this, and they're hearing, okay, I really want to make sure my child does not get constipated. What are the signs that parents should look for? And you mentioned some some behavioural concerns, and what else should parents be looking for? If you've never googled the Bristol stool scale, I would stop right now and ask you to do that. It's a very easy to follow chart. And it has numbers, descriptions and pictures of what a healthy poop should look like. And it will grade it from what's a liquid diarrhoea and it gets softer, it gets more and more formed. And the middle range is like a skinny hot dog, or little pieces falling apart. That's where we really want the poops to be. As you move up from that you get into these big fat chunky, then clusters of grapes and little nuggets. So if your child poop child's poops look like little nuggets, big fat logs with, like cracks all around them. That's an important thing that you want to look for. And many of us are not looking at our children's poop, I'm gonna be honest, I have a 10 year old, a seven year old, a six year old, I'm generally not in there. So a poop check as kind of every once in a while to remind your child to look at their poop is very helpful. Frequency of going to the bathroom, I say we want to be five to six days of the week, right? So generally every day to every other day, if you're having many, many days in between that's problematic. Children who spend prolonged periods of time in the bathroom, anyone with pain when they're going to the bathroom. And one that we don't often think about is accidents. A child who starts having really frequent stooling accidents, many of those children are constipated and are withholding. And the last one is just good old fashioned abdominal pain, especially pain that will often occur after meals, it can be very crampy. What happens is after a meal, the stomach will stimulate the colon to start squeezing. And if you're constipated, you've got those hard chunky poops. It's a very uncomfortable feeling. So anytime at home when my kids tell me Mom, I have a stomach ache. The first question I asked them is when you go to the bathroom, where's your poop look like? And that's kind of where we will always start when we talk about belly pain. So let's say a parent notices one of these signs, their concern their child's constipated, what's the first thing that they should think about? What what kind of action steps should they take? I think that really depends on kind of where you are in the spectrum. If your child is having occasional abdominal pain, some mistakes, some hard stools, checking on the diet as a very easy first starting point, right? Are we getting enough water? Could I do better with fruits and vegetables? Are we eating really excessive amounts of starches in ways that are easy for you to make modifications. The next thing if you've done those things, and you're still having firm poops are having a lot of MS days is use a stool softener. Don't hesitate to use a stool softener. Use it early use it consistently. So one of the biggest pitfalls that I see is once someone is already constipated, people will then take a stool softener. Let's say it's milk of magnesia me relax. And then they say oh my god, it doesn't work for me. Because the poop that sitting in that child's colon the poop that's at the very end is poop from three days ago. So the mural X you took today is not going to all of a sudden make you have a bowel movement. You really think about stool softeners as ongoing therapies, you give two or three days till you see a change consistently keeping the poops soft. I feel like I have to do the scrunchie talk Jessica, don't you think so? I was just gonna say i i heard you give a lecture on constipation a few years ago and I loved it so much that I commonly quote you. I talk about the I Will you call it the scrunchie talk or the rubber band analogy. And I love it. So yeah, I would love if you would explain. Yeah, I feel like once once you hear the scrunchie talk, it all makes sense. And I'm so happy scrunchies are back in fashion because I used to give this crunchy talk and nobody knew what I was talking about. But the idea here is that you're cold In which is kind of where the poop is held and where it will sit before it comes out is a very elastic and stretchy organ, it's meant to stretch when it fills with poop, and then you will empty, you'll go to the bathroom and it should shrink back down to normal, what happens and someone who has been constipated over a period of time, that's generally you're talking about months that you're now having changes, is the colon becomes like a scrunchie, that's lost its elasticity. So you know that scrunchie that's now loose and floppy, it's stretched out, it's bigger. And then we have a couple of problems that happen secondary to that. And understanding those problems will really help you manage what you do after that. So the first problem is that urge the kind of, but feeling that I need to go to the bathroom will come when you have totally filled your colon. So if you have a colon, that's stretched out three times the size of normal, and you have a normal size poop, that child will not actually recognise urge to go to the bathroom. And that's what propagates this every three or four days bowel movements. The problem is as stool or poop sits in your body, it gets bigger and harder. And then when you ultimately go to the bathroom, it's painful, uncomfortable, difficult colds come out. So you're now reinforcing the problem. Because a you often don't completely evacuate because they're hard to move. And B that really causes behavioural issues, because those children are having pain and discomfort, and then they start to do everything they can to hold their poop. And the second thing that happens is the muscles of the colon actually don't work at their optimal capacity when it's so stretched out. So you have a relatively weakened muscle. And so your ability to move things becomes impaired. And that all of that will improve. The best part of all this is if you can keep the colon empty consistently, it will shrink back down to normal, it will recover function. But that's a tough process that takes time. So when I say the biggest pitfalls, people go on and off and on and off medicine, it's because they haven't actually really healed or rehabilitated the colon. And once you do, you're going to have lasting ongoing success. And not every constipated child becomes a constipated adult, especially if you treat it early on. So my big question is, how long should parents expect to take stool softener? So I understand that, you know, there's hope that if they take ongoing treatment, we will see long lasting improvement, but can you give parents an idea of how long to expect? It really depends on what stage you're in the age of your child and what the behavioural factors are. So I'd say the most kind of common situation that I find is those toddlers that were really struggling around toilet training time. So for those children, what I suggest is you are going to stay on a laxative until the child is having daily spontaneous urge on their own. And there's no withholding behaviour. And so you really want to be completely completely toilet trained. I really recommend people who have constipated toddlers stay on some version of a laxative until they finish toilet training and they've really solidly toilet trained. Do you have a favourite laxative speaking of laxatives. Honestly, my favourite laxative is the one that the child will take. That's really really what guides my decision making. And a lot of families have strong feelings about laxatives, which I want to incorporate into my practice. So I'll tell you the three most common that I use. The first one is MiraLAX. It's also known as polyethylene glycol. And it got a very bad reputation a few years ago, because there were a lot of reports of behavioural issues and neuropsychiatric issues reported to the FDA. None of that has actually ever been founded. What we saw was when the media started covering it, more and more people started reporting it. But it's such a widely used medication that the numbers actually don't really add up. The FDA funded a study at Children's Hospital of Philadelphia to really look and see do you significantly absorb polyethylene glycol in your body and what happens? And it actually didn't get very far because they can't even measure levels of it in the bloodstream. They did do a study where they gave it to mice, and they looked for behavioural changes and changes in their bacterial environment. It was a really nicely designed study, and that found no significant changes. So I feel very comfortable using it. I feel very comfortable using it in the long term. But I respect parents who don't want to use it and I'm not trying to push it on them because we have alternatives. With regard to the behavioural concerns, I think it's it's it can be a chicken and an egg phenomenon because many kids that have behavioural or developmental concerns tend to be or may be more often constipated. So it's hard for my understanding to know which, which is the, you know, what's the cause? Yeah. Which is truly the cause. Absolutely. That's such an important point. That's a really, really big part of it. And my Inkling is it's likely that behavioural concerns that began at all, but yes, no, and a lot of times, that's often the case. But listen, rare and random things happen. Is it a widespread issue? No. If it were, we would have seen it. It's probably like the most commonly prescribed medicine among paediatric gastroenterologist and many paediatricians as well, I think that's a very good point that if if there is a concern in that, in that realm, and I behavioural concern that it's likely very rare. Yeah. Why do I not like mirror locks? Mirror locks works when it's taken appropriately, which means the right amount of powder in the right amount of water that you drink within about 30 minutes. How old are your kids? Jessica, I don't remember if seven, nine and 12. Would your seven year old drink four to eight ounces of liquid in one sitting? It'd be really tough. It's tough, right? And so a lot of people are sending them your locks in the water bottle to school. Who knows how much you drink, it doesn't really have the same effect. Many people will put it in the bottle with milk. Not my worst option, but also not how it optimally works. So it's a challenging medicine to administer appropriately. And that's that's the main reason I may shy away from it. I think a lot of doctors really are in favour of Mir electric speak highly of it because it's tasteless, odourless, it's easy to mix in anything. But you're absolutely correct that to mix it in enough water or fluids can be can be tricky. Yeah. And for those who are using it, a full scoop of MiraLAX needs eight ounces of water, a half a scoop of near lax needs four ounces of water. So it is it is pretty significant. And it's one of the reasons people often think that it doesn't work for them. Now, you mentioned also that very little got absorbed in the animal studies that you looked at, I've always learned that one of the benefits of mere relax is very little gets absorbed, if at all, is that is that true? That's That's true of every laxative. So any locks that have that we use, the way they work most of these what we call osmotic laxatives is that they draw water into the, into the intestines, because they sit in the intestine, they change the concentration. That's how almost all of them work. So we worry very little about systemic absorption of laxatives. What do I like other than mere lakhs these days, I use a lot of magnesium. I like it because it comes in every dosage form you could imagine. It's very, quote unquote safe and natural. And I say that not to be kind of belittling, but I think people feel better with a naturally occurring compound, right. Magnesium is part of our diets. It's part of our food that we eat, it's something very kind of health helpful. And it actually has really beneficial side effects. Magnesium is often used for sleep and calm and reduction of anxiety. You can use magnesium as a powder, like brands such as mag calm, for example, as a gummy as a chewable kind of candy as a tablet as a liquid. So in any age range, I feel really comfortable that I can find a version of magnesium that my patient is going to be okay with. If you're looking for magnesium over the counter, it's generally not branded as a stool softener. And if it is, it doesn't say that it's branded as a stool softener. So I'll give you an example. pedia lab sailing chewable laxative, it's one of my favourites, it's a watermelon, kind of like a sweet tart texture to watermelon shoe. It's very easy to use in young children, school aged children is actually the active ingredient is magnesium, but you wouldn't look at it on the shelf and know that you're buying magnesium. The version of magnesium we often see on the shelf will say on the bottle for sleep or for stress and people get confused with what they're buying. It's actually the exact same thing. The side effect of too much magnesium is diarrhoea, so in a constipated person. That's exactly what we take advantage of. We push the magnesium we push your limits of absorption of magnesium. There's some common probiotics that people are taking for constipation. What do you think? There's really no evidence to suggest that they work consistently. So my thing about probiotics is sure maybe Eat? Why not? I don't know. Anecdotally, you will hear some people tell you probiotics were a game changer for them. Is it true of the large scale population? Generally not. So I don't think there's a downside, I think the future is that everything is going to come back to our bacterial environment, right? And we'll eventually get to a place where we really map out what bacteria you have in your body, and what you're missing for what specific problem, but the probiotics available on the market are a handful of bacteria. And not everyone may have that as no particular problem. Right. Now, I think it's one of those industries is one of those solutions. That sounds good, but in actuality, I don't find that it's very helpful for most kids that take a probiotic. Right. Yeah, I think I think many of us feel the same way. But there's very little downside. So I don't generally discourage my patience, do you? I don't, my husband would say there's the possibility in the future that we might find it leads to bacterial resistance. But I agree, I don't think there's a lot of downside to trying a probiotic. Right. So you had mentioned there three that you like in your arsenal that mural acts you mentioned magnesium, did we forget the third or was it prolapse close? It's lactulose lactulose is a unsung hero. Parents generally don't know about it, because it requires a prescription. And I think I talked to a lot of paediatricians about it, and once they get comfortable using it, they will start to love it. lactulose is a it's It's sugar, but it's a sugar our bodies is not are not capable of absorbing, so it sits in your intestines and it pulls a bunch of water. Think about if your kid ate drink too much juice or you gave them a lot of grape juice or prune juice. It's it works in that same way. It's given as a syrup liquid in a small volume. So like you know, a tablespoon ish depending on the size of your child. So in a child who takes syrupy medicine, it's a very easy to give medication and very easy to titrate I love it for younger kind of like the infants and toddlers it's my go to favourite thing to use. This is so great because honestly whenever I hear gi doctors talk about laxatives, I feel like the answer tends to be mere Laxmi relax me relax, you know, we should put me relax and the water metre Alexa solution. It's nice to hear that there are alternatives that you find helpful. And I'm a fan of me relax, but it's nice to hear this. Yeah. And I think so much of it has to do with think about your child and think about what are the factors that that are there, right. And so I have kids who really hate syrup medicines. And so a lot of the chewable versions I found are the alternatives I found I found as I was trying to come up with things for my own children. So you don't if your paediatrician prescribes you something, and you are struggling to give it to your child, call them and let them know. And we'll come up with an alternative. We have our favourites. We all have our kind of go to medicines, but there are many choices out there. If your doctor doesn't hear from you what your issues are, then we can't help but if we do help, it sounds like there's a lot of good options. Yeah, and especially when when I'm treating constipation, if I'm seeing certain patients, I'll see them back every two weeks in the initial phase, because a lot of it has to do with troubleshooting and finding our happy place. And where I get really kind of frustrated is you know, I'll see someone after a month and they'll say, okay, you know how things going they're like, oh, yeah, he really hated the medicine. We haven't been taking it. And so a quick phone call. So many of us use patient portals or email, a quick message along the lines of like, my kid won't take this or this isn't working. What should I change? Will will go a long way. I think I have a lot of patients that are reluctant to take recommended laxatives because they want a natural option. Do you think there are natural remedies that we can offer parents that are not as inclined to use a you know, an over the counter medication? I think magnesium falls into that category and I think that's why I've used a lot of it and parents feel really comfortable with it. Very old school people used to give mineral oil for example mineral oil isn't absorbed and and it works. It's very gross. It's actually really challenging. Some people used to give castor oil within the diet, you can make some manipulations. One of the things I really like to use are chia seeds and flax seeds. So flax seeds once they're ground into flax meal. It you can easily mix them in with foods so it will go into muffins it'll go into oatmeals you may mix them into your smoothie, and even savoury foods. Chia seeds the way I like to Use them are to pre soak them so you'll if you see if you've ever purchased chia seeds, they're dry kind of tiny seeds and once they sit in water, they'll absorb the water and they get kind of this gelatinous coating very similar to the tapioca balls in boba right? Have you ever had a drink with chia seeds? You know what I'm talking about? Yes, yes, no and I love boba. Yeah, it's a family favourite. It's it's an it's either a love it or hate it kind of texture chia seeds. But what the way you want to use them as you want to soak them in water, and then mix them. So at our house, my kids like the texture of chia seeds. We will soak chia seeds in a jar with water, rosewater and a little bit of sugar. And so they will sit overnight, they're kind of get that really expanded not enough so that it's a putting a texture, it's still liquid, and then they'll have a glass of that. Flaxseed oil. There's there like two or three actual research studies on it can be helpful. You give one to two tablespoons a day. So there are things out there. There are a lot of other kind of dietary things. So celery juice is hot. You hear a lot of adults that are drinking celery juice on an empty diet on an empty stomach. There is no research but again, anecdotally for some people, it's a game changer. I just don't see how you're getting your five year olds to drink celery juice every day. What about rectal suppositories? Good question. There is a time and place for them. And I think generally, if you're now getting to four or five days without a bowel movement, it you just got to get it out. And so you do need to use them. But the if you can prevent your child from ending up in that place, you're going to be much better off. So I'm not against the use of them. But a few things happen. One is many of these children are already kind of toilet avoided having kind of drama for lack of a better term around that part of their body. And we just reinforced that by sticking something in there. But the second thing is that the word dependence is not the right word. But when you when a child gets a lot of rectal stimulation in order to poop, they start to really rely on that very intense sensation to initiate a bowel movement. And what we really want them to do is recognise urge and then be able to kind of trigger and sit down and have a proper bowel movement. So I don't love using them too much. But I think that there's a time and a place for them. I'm just wondering when you had your own kids because you're a mom of three Are you Are there certain strategies that you've implemented with your own kids because you see constipation so so often. You know, what's funny is my my daughter, when we toy the trade my daughter, she's Uh, she's always been very smart, very sassy, very controlling kid. And we did amazing with pee. And then she started with holding stool on the toilet, she would not poop in the toilet. And I was like, oh my god, like, this is what I do for a living. And then she got the stomach flu. And I went to work and I told the nanny, just just forget about the toilet. And I came home and she was fully toilet trained. And what happened is, once the poops are so loose and soft, you really can't hold them. And once those kids get out a couple of poops and they're like, oh my god, okay, like that was okay. They really take off from there. So I think the the biggest thing is really finding ways to get your kid on the toilet, get the poops really, really soft and take them from there. And that's one of the reasons I love scheduled toilet sitting. Have we talked about scheduled toilet sitting? Now let's talk about it. The idea here is children will withhold for various reasons. And then also, as we talked about, a lot of times you lose your recognition of urge until there's a lot of poop. So for many children a set time you're gonna put them on the toilet is important. And what that looks like depends on your age, middle school and high school students across the board don't want to poop at school. You agree? I totally agree. Yeah, almost like you know, I've heard everything the toilet papers bad The bathrooms are dirty. The girls are like talking about weird things. Like there are so many reasons these children don't want to go to the bathroom at school. No. And I remember clearly when I was in middle school, I did not want to use that restroom. It smelled different. It was never clean. I don't blame them. And then they're busy. They're not coming home right after school and then they get home and The urge is gone. Right? So you'll feel urge and if you don't evacuate. Eventually your body's going to recalibrate and the poop sits there and the urge is gone. So for high school students I'm a huge fan of a once a day, I love after dinner, give yourself five minutes on the toilet. For younger children, it looks a little bit different. So the child that you're, you have a lot of withholding behaviours, and what does withholding actually look like? So this is what parents often think is these children are struggling to get the poop out. And then I'll describe it to them. And I'll say no, they're actually struggling to hold the poop in. So this is the kid who hides in a corner in their closet every time they need to go to the bathroom. And they're doing weird things with their body crossing their legs, stiffening their whole body standing up against a wall, and they're uncomfortable, and they're writhing and all of these things are happening. That child feels urge and is doing everything they can to hold that poop in, because maybe they had a painful bowel movement. Maybe they're afraid of the toilet, who knows what happened. And often parents will recognise that and then we'll say, okay, you know, Lucy, let's get on the toilet. And Lucy is already in this, there is no way I am letting this poop come out of my butt, right, she's full blown into the tantrum, you're not going to get around the toilet at that point. So the idea with scheduled toilet sitting is that if you proactively put them on the toilet, before urge has kicked in. And if you can get the poop soft, and you can get them to bear down, they're going to just have these kind of very surprising poops. And that's what we take advantage of. So for younger children, I generally will say three times a day as a starting point, after meals, we talked about that reflexive kind of movement of your intestines that happen after meals. And a toilet said is not, let's take 15 books and mom's going to read books to you while you sit on the toilet. A toilet seat is active toilet sitting, which is challenging to get a toddler to do. So the first part of it is what you look like when you're sitting on the toilet. If you get into a deep squatting position, and you try to squeeze your butt, it's very challenging. So you want your child sitting on the toilet in that squatting position. That's why the Squatty Potty is so popular. I love them. If you don't have one, you stools use the yellow pages use whatever you have in your house. So knees at the level of the chest helps them relax and open their pelvic floor. And it's not unusual. Kids don't love getting in that position because they know the poop is gonna come out. The second part is how do we get them to push? How do you explain to a four year old what to do? You actually don't You don't talk about poop at all, you really try to divert their attention. So my favourite games are things like blowing up balloons. And the parents are like, Oh my God, there's no way you could blow up a balloon. I know he can blow up a balloon. But that manoeuvre what you're doing with your body is exactly what you need to be doing when you're actually trying to pass the bowel movement. But now the attentions on the balloon and not on what's going to come out of my butt. So balloons bubbles, straw in a cup of water harmonica. And one of my favourites is you take the parent who and we ask them to click say which who farts more your mom or your dad and the building? Oh, it's my mom, you take someone in the bathroom with you. And whoever farts first wins the game. Because a fart is exactly the same thing that you need to do with your butt as a poop is. And we do a lot of that kind of stuff. Older children, the teenagers also I give them kind of toilet sitting instructions in terms of positioning and active bear down. A lot of teenagers sit on the toilet for you know, 30 minutes on their phone scrolling. And that's you might as well be sitting in a chair. So I'm all about active toilets. It's one of the biggest kind of things I hear from parents is the only way I can get them on the toilet is with the iPad. Is that one you hear often? Absolutely. Yeah, definitely. Yes. So what ends up happening is you're prolonging the sitting. And it's all passive, they're not actually engaging. So my recommendation in those situations is toilet minutes earns iPad minutes. So if you do your active toilet sitting, you can earn your iPad minutes as your reward for having done that, for example. You're generous. It doesn't actually I have to be honest, we don't do that at my house. But we don't have anyone that's toilet avoided at my house. You can use other behavioural reward systems as well. So in our office, we have this little calendar and there are these poor emoji stickers. And you mark every time you do a toilet sit, you get a sticker and if something comes out, you get two stickers. And then we will talk about the rewards. So we have a closet up front it's called the poop closet. And kids know if they bring me back their completed calendar, or I love pictures of poop. Some kids will do all they'll do all kinds of things. They get a ticket and they get to choose toy from the closet. You can do that at home. So we have negotiated with the parents all kinds of things one of my patients Since earned a laptop, one earned a trip to Disneyland, one earns us cell phone. So a lot of children and especially what you'll find is children in that six to seven year old age range who are still having accidents. But they're not necessarily ashamed of it yet. They're not super motivated. And so giving an external motivation, an external source of motivation is really helpful for those kids. What I love about hearing you talk about this is I think that for so many families, they are worried about the social implications, so they don't talk about it, and they don't realise how common this is. So hearing you talk about all these different stories, I hope people listening realise if they're going through it, they're not alone. That's a really, really good point, there's typically a parent who gets very frustrated with the situation. And listen, I'm not telling you, I don't yell at my kids. I'm not saying that I don't get frustrated with my kids. But if we can check ourselves and recognise that that pattern of behaviour is feeding into the whole toilet drama, it will go a long way. So keeping calm, cool collected, and making it not a power struggle between the parent and the child is helpful. I really find that one of the ways I'm most helpful is I'm just an external person. And so what I will tell the family is and I'm maybe you do this in your clinic, as I'll tell them, say Dr. DE wants to see the picture of your poop. Oh, Dr. D, gave you the calendar. The parents just need to be sometimes removed from the whole pattern of behaviour. That makes sense. Now just to end, remind everybody, there's hope. There's hope if they're going through this situation, right? Absolutely. Absolutely. I'll tell you, I, I take care. I almost don't even see him anymore. But I saw this boy initially as a 15 year old, he was in high school. He was playing club baseball. And he had been to Boston, he'd been all over it and all kinds of testing. And he was still struggling with severe constipation, and very, very frequent stooling accidents. And we work together we did. He was so severe. We started with rectal therapies, and we made progress and worked our way up and psi each other regularly. And over the course of nine months to about a year. The next summer. He went to sleepaway camp completely, completely problem free. There is a lot and and that's why I love doing this as people are so frustrated. And so they're really struggling. But it's not that hard to fix it. I think the biggest takeaway I will give people is it's generally not one thing. So I never sent someone out of my office with just a prescription without a behavioural plan. And many people will come and they'll say, oh my God, you're telling me to do something I've already done before. Like I've already done scheduled toilet sitting, or I've already used laxatives, but most people haven't done them all together. And it's that combination of addressing the behaviours, making the proofs so soft, you cannot hold them in. And they'll never ever, ever be painful, and really being consistent and having some kind of reward. That's where you see the most benefits usually. Where can people find you? If they want to come and visit you in your clinic? How can they find you? You know, a lot people find me on the playground at school. I do a lot of toileting consults on the playground. I work at Children's Hospital Los Angeles, and I generally only see patients out of our satellite office in Santa Monica. And so it's fantastic. I love treating this issue. For people who live far away. We do telehealth visits as well and they're equally as effective. You just have to go buy the toys at Target or Amazon. Because if you know a lot of kids will come back fairly frequently to visit the closet if we're working on the behaviour piece of it. But I really genuinely enjoy doing this in my practice. And I love talking to parents and paediatricians about it, because once you find the right technique, it's a game changer, right? Absolutely. I quote you all the time in my office, I'm sure any of my patients listening who had kids who've had constipation have heard me use the scrunchie analogy. I'm gonna have to brand some. Dr. DE PUE Mogi scrunchies. Thank you so much for coming on and talking about this. I I know a lot of people listening will find this very helpful. Thanks for having me. Thank you for listening and I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica See you next Monday.