Constipation--I Pooped Today!

CONSTIPATION

• WHY IS CONSTIPATION SO PROBLEMATIC?
• HOW DO WE DEFINE CONSTIPATION?
• WILL KIDS REALLY GO DAYS OR WEEKS BETWEEN NORMAL BOWEL MOVEMENTS?
• CAN A CHILD STOOL DAILY AND STILL BE CONSTIPATED?
• IS THERE  A TARGET AGE FOR THIS PROBLEM?
• IS THERE A REASON FOR THAT IN THIS AGE?
• YOU TALK ABOUT CONSTIPATION BEING A CYCLE.  HOW DOES THIS CYCLE GET OUT OF HAND?
• AND THAT’S WHAT MAKES THIS A SNEAKY PROBLEM—CHILD IS ACTUALLY APPEARING OKAY FOR LONG STRETCHES BECAUSE THEY CAN HOLD A LOT OF STOOL IN A DISTENDED COLON OVER MONTHS AND YEARS…
• WHAT IS NORMAL STOOLING FOR INFANTS?
• HOW DO WE TREAT CONSTIPATION FOR INFANTS?
• WHAT IS A MUSHER?
• AND WHAT IS A PUSHER?
• HOW DO YOU USE MUSHERS AND PUSHERS FOR INFANTS?
• WHAT IS NORMAL STOOLING FOR OLDER KIDS?
• LET’S TALK ABOUT TREATING CONSTIPATION IN OLDER KIDS.  THERE ARE THREE STEPS TO THIS: 
  • A COLON CLEAN-OUT, 
  • DAILY MEDICATION AND THEN 
  • RETRAINING THE BODY.
• CLEAN-OUT FIRST.  IS THIS LIKE A COLONOSCOPY CLEAN-OUT?
• NEXT COMES OUR DAILY MEDICATIONS FOR MAINTENANCE
• HOW DO YOU USE MUSHERS AND PUSHERS HERE? 
• SIDE QUESTION: HOW SUCCESSFUL IS INCREASING FRUITS AND VEGETABLE CONSUMPTION IN PICKY KIDS? 
• LAST BUT MOST IMPORTANT IS THE TACTICAL POOP
• WHO DOESN’T WANT TO WATCH A VIDEO ABOUT POOPING?
• MENTIONED BEFORE, BUT HOW LONG SHOULD WE PLAN TO TREAT?
• ARE THERE THINGS THAT LOOK LIKE CONSTIPATION BUT AREN’T?
• WHAT IS THE PROCESS FOR JOURNALING PAIN?
• WHAT IS IT ABOUT JOURNALING THAT IS HELPFUL? 
• AND THIS HELPS TO REALLY NARROW DOWN THE DIFFERENTIAL OF PROBLEMS TO AVOID EXCESSIVE TESTING LIKE BLOOD TESTS AND IMAGING STUDIES.

THIS HAS BEEN A FUN AND HELPFUL JOURNEY THROUGH THE WORLD OF CONSTIPATION.

CONSTIPATION AND HOME BOWEL PROGRAM FROM PRIMARY CHILDREN'S HOSPITAL:

https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=520408179

PCMC Video:

https://youtu.be/pNagQup0Upg

Transcript

CONSTIPATION

• WE ARE GETTING TO THE TOPIC EVERYONE HAS BEEN WAITING FOR—CONSTIPATION
• Yes—this is the topic I talk about most often every day
• YOU EVEN HAVE A T-SHIRT ABOUT POOPING
• I have my “I pooped today” stick figure t-shirt you got for me from Jackson Hole. 
• MAYBE WE SHOULD MAKE THAT T-SHIRT THE COVER ART FOR THIS EPISODE
• Let’s do it
• WHY IS CONSTIPATION SO PROBLEMATIC?
• So common, impacts, no pun intended, so many things—stomachaches, headaches from not eating, fatigue, etc.  
• HOW DO WE DEFINE CONSTIPATION?
• I see several problems that fall under constipation—painful bowel movements, blood with bowel movements, abdominal distension and gas, pain after eating, nausea, and leaking stool accidents
• IT SOUNDS LIKE A SNEAKY PROBLEM THAT RESEMBLES A LOT OF OTHER PROBLEMS.
• True
• But the simplest diagnosis of constipation revolves around infrequent or painful stooling especially if it takes a long time to get stool out
• WILL KIDS REALLY GO DAYS OR WEEKS BETWEEN NORMAL BOWEL MOVEMENTS?
• Yes
• Never saw a child literally FILL a toilet with stool until during an ER shift during residency
• CAN A CHILD STOOL DAILY AND STILL BE CONSTIPATED?
• Yes
• With slow transit constipation, stool is moving through slowly—some comes out frequently but there still is so much backed up in there
• IS THERE  A TARGET AGE FOR THIS PROBLEM?
• 4-6 years of age; also a similar age for when I have patients with hyperactive bladders due to holding in urine
• IS THERE A REASON FOR THAT IN THIS AGE?
• Underlying FOMO.  Prioritizing play over eating and using the bathroom so it leads to voiding accidents and stooling accidents.
• YOU TALK ABOUT CONSTIPATION BEING A CYCLE.  HOW DOES THIS CYCLE GET OUT OF HAND?
• Cycle—starts with a painful bowel movement, then they hold stool in to avoid the pain—stool becomes bigger and harder and more painful, then they go longer still to avoid stooling and things only get worse
• SO A BEHAVIORAL PROBLEM BECOMES A PHYSICAL PROBLEM…
• Yes—choices they make lead to a stretched out colon which both defines the problem and makes the problem worse as more stretching occurs
• AND THAT’S WHAT MAKES THIS A SNEAKY PROBLEM—CHILD IS ACTUALLY APPEARING OKAY FOR LONG STRETCHES BECAUSE THEY CAN HOLD A LOT OF STOOL IN A DISTENDED COLON OVER MONTHS AND YEARS…
• yes—it isn’t until problems like stool leaking out around all the hard stool in their colon do kids come in
• These kids are mostly on their own for stooling now and so we are not keeping track of their stooling.
• I ask people if they know when their child last stooled but I will tell them that it may have been years since my youngest child last stooled since he was 2—I would have not idea the answer to this question—judgment free.
• What this looks like is stooling accidents alternating with infrequent hard stool

• LET’S DIVIDE THE DISCUSSION INTO CONSTIPATION FOR INFANTS AND CONSTIPATION FOR TODDLERS.
• WHAT IS NORMAL STOOLING FOR INFANTS?
• Initially they are stooling with every time they eat and that gradually transitions over a couple months to once daily and as infrequently as once weekly for breastmilk fed kids and every three days for formula fed kids
• Treat the baby and not the calendar
• Not bloated and not in pain then no need to treat
• AND BABIES SOMETIMES SEEM TO STRUGGLE WITH STOOLING INITIALLY
• Initially they seem to be very uncomfortable with their intestines moving so often when they didn’t have any bowel movements at all for 9 months when they are inside of mother
• Some even strain while keeping their bottom closed when they first start stooling and really make this big show with this tug of war and so it looks like constipation and then soft stool comes out.  These kiddos just need time to work out how to pass a bowel movement
• HOW DO WE TREAT CONSTIPATION FOR INFANTS?
• To start us off let’s talk about Pushers and Mushers
• YES—WHAT IS A MUSHER?
• Something that makes stool softer
• AND WHAT IS A PUSHER?
• Something that works to actively move stool along—a motility agent
• HOW DO YOU USE MUSHERS AND PUSHERS FOR INFANTS?
• For MUSHERS, the 1st step is to increase fiber and fluids through diet.  Increase fruits and vegetables in diet when age-appropriate.  
• Prune juice or similar 1-2 ounces/day, 1-2 times every day. Now prune juice can be both a musher and a pusher
• 2nd step for MUSHERS is to use supplemental fiber such as Benefiber in water or juice--start with 1-2 teaspoons and increase dose until stool is soft.   Adjust dose to give a daily soft stool.   
• 3rd step is a PUSHER to use daily miralax at a dose that gives a daily soft stool.  1-2 teaspoons is usually sufficient.  Adjust dose to give a daily soft stool. 
• WHAT IS NORMAL STOOLING FOR OLDER KIDS?
• Should have a daily soft stool.  Have no abdominal pain.  And little gas.  Kids with lots of gas—especially bad smelling has—probably have stool that has been fermenting for a long time
• LET’S TALK ABOUT TREATING CONSTIPATION IN OLDER KIDS.  THERE ARE THREE STEPS TO THIS: 
  • A COLON CLEAN-OUT, 
  • DAILY MEDICATION AND THEN 
  • RETRAINING THE BODY.
• CLEAN-OUT FIRST.  IS THIS LIKE A COLONOSCOPY CLEAN-OUT?
• Yes, this is how we do a reset.
• At least 3 days to spend with your child at home
• near a bathroom. Your child will not be able to attend school.
  • Use age and weight appropriate large doses of miralax ranging from 4-14 capfuls in gatorade or similar over 8 hours each day plus ex-lax at the start and finish of the 8 hours 
  • like a colonoscopy clean-out
• NEXT COMES OUR DAILY MEDICATIONS FOR MAINTENANCE
• Daily medication—6 months
  • Keep the colon empty 
  • Keep the stool soft 
  • get the colon down to a normal size—resolve accidents, blood in the stool, and abdominal pain 
• HOW DO YOU USE MUSHERS AND PUSHERS HERE? 
  • Mushers
  • 1st step is to increase fiber and fluids through diet.  Increase water and fruits and vegetables. 
  • Water goal of some number of cups daily. 
• SIDE QUESTION: HOW SUCCESSFUL IS INCREASING FRUITS AND VEGETABLE CONSUMPTION IN PICKY KIDS? 
  • I am realistic about the success with increasing these things in a kid’s diet—worth trying.
  • 2nd step is to use supplemental fiber such as benefiber--increase dose until stool is soft.  Usual dose is 1-2 tsp in a cup of water or juice daily 1-2 times daily.  May go up to 1-2 TABLESPOONS 1-2 times daily if needed.  GOAL IS A DAILY SOFT STOOL. 
  • I often say Water + Fiber = Happy Poop
  • Pusher
  • 3rd step is to use daily miralax at a dose that gives a daily soft stool—1/2-2 CAPFULS DAILY FOR OLDER KIDS.
• LAST BUT MOST IMPORTANT IS THE TACTICAL POOP
  • Tactical Poop comes from the show Bluey—SCHEDULED toilet time to retrain the body—Most important
  • break habit
  • regular scheduled time sitting on the toilet
  • after meals—natural reflex between stomach and intestine
  • 2-3 minutes after every meal even without urge to go
  • Keep it Positive
  • Start daily times toileting 15 minutes after each meal. Favorite show: 2 min for trying, 10 minutes for success
  • Can use Alexa to remind you for fun
  • I share this all on a handout out that we can put on the website along with a helpful video
• WHO DOESN’T WANT TO WATCH A VIDEO ABOUT POOPING?
• I know right?!
• MENTIONED BEFORE, BUT HOW LONG SHOULD WE PLAN TO TREAT?
• 6 months
• ARE THERE THINGS THAT LOOK LIKE CONSTIPATION BUT AREN’T?
  • IBS, celiac disease, Hirschsprung’s,  
  • I will involve GI specialists if we cannot figure out a solution together. 
• WHAT IS THE PROCESS FOR JOURNALING PAIN?
  • It is so helpful to have a pain journal before coming in to a visit when there is a chronic problem. 
• WHAT IS IT ABOUT JOURNALING THAT IS HELPFUL? 
  • For a busy parent trying to recall all the times their child complains is difficulty—kids complain all the time.  So trying to recall past complaints is like asking—what did you have for lunch two weeks ago Thursday?  But if we keep a prospective journal, our ability to see patterns really improves.
  • So I ask for a pain journal: 2 week journal of symptoms
  • where it hurts, when, what it feels like, how long it lasts, what makes better and what makes pain worse
  • Document stooling frequency.
  • Pattern helps predict the problem.
  • We can figure out the pain pattern together and work on a diagnosis.
• AND THIS HELPS TO REALLY NARROW DOWN THE DIFFERENTIAL OF PROBLEMS TO AVOID EXCESSIVE TESTING LIKE BLOOD TESTS AND IMAGING STUDIES.
  • Exactly

THIS HAS BEEN A FUN AND HELPFUL JOURNEY THROUGH THE WORLD OF CONSTIPATION.

Yes, a fun trip like a day at Disney in Constipation-Land

CONSTIPATION AND HOME BOWEL PROGRAM FROM PRIMARY CHILDREN'S HOSPITAL:

https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=520408179

PCMC Video:

https://youtu.be/pNagQup0Upg