19 | The Scoop on Poop: Managing Constipation in Kids

Do you work with children struggling with constipation? We've got answers. Join us for a riveting discussion with Emily Dollar, a certified registered nurse anesthetist and family nurse practitioner. Known as the "Enco Expert" on Instagram, Emily brings to the table a wealth of practical advice on tackling constipation in children. I know you're thinking, "Colleen, I already know how to manage constipation." But stay with me, because we're going beyond the typical recommendation of "drink more water, eat more fiber."

What you'll learn today:

• How to know if a child is actually constipated and the various symptoms of constipation. Did you know that a child can poop daily and still be constipated? 
• How bladder accidents, like bed wetting, can actually be related to constipation.
• Knowing the limits of a physical exam and when to order an x-ray.
• Dietary solutions and hydration strategies for managing constipation. 
• When to initiate a stool softener

I know you'll find something you can walk away with today that will improve the health of your patients! If you have a colleague or friend who struggles with knowing how to discuss nutrition or weight with their patients, and you think they might benefit from my podcast, I would love if you could share this episode with them. My goal is to help as many clinicians as possible realize that nutrition matters and it is possible to educate our patients toward a healthy lifestyle, despite all the barriers we face.

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Transcript

Emily: 0:00

Technically, constipation is having infrequent bowel movements, but you can also have a bowel movement every day, and if it's uncomfortable, then that technically, is constipation as well. So you can in fact have a child that's having, you know, regular bowel movements and then surprisingly be full of stool, are you?

Intro: 0:18

ready to transform the way you communicate about nutrition with your patients. Welcome to Exam Room Nutrition. The podcasts were. The worlds of nutrition, medicine and communication collide. Whether you're a seasoned physician or a healthcare student, this podcast is for you. So stick around and let's make our patients healthier, one Exam Room at a time.

Colleen: 0:40

Welcome back to the Exam Room Nutrition podcast. I'm your host, colleen Sloan. I'm a registered dietitian and pediatric PA. I'm so excited for our conversation today because this topic always gets my patients giggling and squirming when we talk about it, because it can sometimes be embarrassing, but it's a topic that everybody does. So what is our mystery topic for today?

Colleen: 1:01

We are talking all about who we're going to help you answer your patient when they ask you my child is so constipated, what do I do? I know you're thinking, colleen, I already know how to manage constipation, but before you tune me out, I promise you'll learn something new. Today we're going way beyond the basic recommendation of drink more water and eat more fruits and vegetables. I think it's really important for you to understand exactly what the definition of constipation actually is. Today you're going to learn helpful questions to ask your patients to determine if a child is actually constipated. We're also going to be talking about the link between bedwetting and constipation and what you might find on physical exam and when an abdominal x-ray is warranted. Of course, we're going to get into the dietary interventions and hydration goals for constipation relief and which medication you can prescribe. That would be extremely helpful for your patients. You don't want to miss the end of today's episode, where we discuss the worst thing to say to patients struggling with constipation. Didn't I tell you this episode is full of practical strategies that you won't want to miss.

Colleen: 2:07

Before I introduce my guests, I have a favorite to ask If you have a friend that struggles with finding the words to say around nutrition or weight, could you please share this episode with them? Grab the link and shoot them a text. I love for them to listen as well. My goal is to help as many clinicians as possible realize that nutrition matters and it is possible to educate our patients toward a healthy lifestyle despite all the barriers that we face. Well, I'm so excited for you guys to meet our guest today. She's known on Instagram as the Enco Expert.

Colleen: 2:38

Emily Dollar is with us. She's both a certified registered nurse anesthetist and a family nurse practitioner. She has a telehealth practice that helps children struggling with constipation, stool accidents and bedwetting, and she sees clients all over the world and helps children find relief and allow them to live full lives accident-free. Emily, thank you for being here today and I appreciate the gift of your time. Welcome to the show, thank you. Thank you for having me, so let's jump right in, and I think it's really important that we actually define what constipation is, because although our parents might say my daughter or my son is constipated, and then we ramble off all these suggestions and guidelines and maybe medication and diet changes, I think it's important to really know if we are truly dealing with a constipated child or not. So can you help us define constipation and maybe explain what normal stooling patterns look like?

Emily: 3:28

Sure. So technically constipation is having infrequent bowel movements. But you can also have a bowel movement every day and if it's uncomfortable then that technically is constipation as well. So you can in fact have a child that's having regular bowel movements and then surprisingly be full of stool and that kid's going to have chronic tummy aches or incomplete emptying where they're having multiple bowel movements today. So you're like how in the world can this kid be constipated if they're having five poops a day but they're just actually not able to eliminate it all effectively in one sitting? So it can be a wide range of symptoms that look like constipation.

Emily: 4:09

Poops should never be difficult for any of us, adults or kids. You should be able to feel the urge to have a bowel movement, sit down on the toilet and it come out. There should never be any straining or much effort or whatnot. So there are some red flags for constipation. When parents say things like they're having huge stools that are just large and they clog the toilet Constipation. If they're only having a poop, you know, two to three or even four times a week constipation. If they're describing their poop says hard or small, like little pebbles or even like dried and kind of cracked constipation. But it can also swing the other way. If they're having those frequent, three to five times a day having diarrhea, that can also be a red flag.

Colleen: 4:54

So I know I like to ask my older patients when I'm assessing how their stilling pattern is. I can ask them when you go to the bathroom to go poop, is it easy or is it painful? Is that a good way to frame that question, or can you suggest a different way to maybe pull some more information out from the child?

Emily: 5:12

No, I think that's a great question and you can just ask them like is it comfortable, is it easy or does it take a lot of work for you to have your poops? Or sometimes they also to have withholding symptoms. So it comes across as like they always have a poop emergency or a pee emergency right, or they never get much warning if they have to go. So those are red flags too for the parent to say they always seem to have to go urgently and so urgency and then, like you said, painful or difficult stools are also all signs of constipation.

Colleen: 5:46

So I know you talked a little bit about urgency with urinating or voiding. Is constipation and bedwetting? Are those two related?

Emily: 5:54

So they really are.

Emily: 5:55

We tell our patients that you know they're going to outgrow bedwetting or it's kind of a normal up until they're like five and six and then maybe up to like seven.

Emily: 6:05

But children that really struggle with constipation have such a higher incidence of daytime accidents but urine accidents but then also bedwetting. So there's a huge correlation there and really until you kind of resolve some of the constipation they don't have much opportunity to outgrow the bedwetting. And then you're looking at kids that are seven, eight, nine, 10, even 12, you know having bedwetting. At that point you really kind of got to get an x-ray and see what's going on. I think we rely a lot on abdominal palpation and kind of their symptomology, how they tell us it's going. But especially if you have an unresolved and ongoing bedwetting after the age of six or even seven, you really kind of got to investigate a little further and you don't really have to have a urology consult so much as just get a quick x-ray to kind of see if there's quite a bit of stool sitting there in the rectum which is pushing on the bladder, which makes it super irritable and decreases its capacity to hold urine overnight.

Colleen: 7:03

I like to describe this to my parents as a poop baby. Especially to moms, you know, we kind of it clicks immediately when they're like how? I don't understand, how is my child wetting themselves? Related to that, they're constipated. And then I will describe it like look, they've got literally a poop baby that's sitting on their bladder. When you were pregnant and you had a baby sitting on your bladder, you kind of had a difficult time or you urinated more often. So it's kind of a fun silly way to kind of connect the two. Now I know you talked about abdominal x-ray. How about how we can physically assess for constipation? Walk us through a little bit more on the physical exam.

Emily: 7:37

It can look very different. You can have skinny kids with like six pack abs and you can palpate their abdomen and it's kind of unreliable when we go back and look. We're about 85% of the time inaccurate when we compare our physical abdominal palpation exam versus an x-ray to see if they have mild, moderate or severe constipation. So I think we depend on the physical palpation a lot more than we should. Even those of us with skilled hands, you know, are not very reliable when we compare that to the actual X-ray and to like.

Emily: 8:11

The rectum is so far down right in the pelvis If they have erectile impactions it's too far below where we're palpating anyway to kind of be able to feel that. Now you can feel fairly reliably if they're having stool all the way back up into the cecum in the right upper quadrant. A lot of times you can feel a bulge there, but it's just unreliable and their body habituses are so different. Right, we have these thin little athletic kids versus these kind of pudgy kids that might even be a little bit bloated. So when in doubt we always recommend getting at least an initial X-ray.

Colleen: 8:46

That's extremely helpful. So now that we've had the conversation with our parent and the child because if the child is I think personally, at least over five, they can explain if it hurts their bottom when they try to push the poop out Now we know we have a child who is constipated, in fact. So let's move into the nutrition portion, so giving our parents and patient some form of relief and guiding them on how foods can help or can harm. So are there certain foods that we should initially talk about that might help relieve constipation?

Emily: 9:22

Yes. So the most important which is not really a food but it's the first thing we recommend is water and hydration. You can totally revitalize and revamp and just completely change their nutrition, but if you don't ensure that they're adequately hydrated it's all for naught. So the single most important thing that we can do is recommend enough water, and most parents, and certainly kids, have no idea how much water is enough. So we recommend at least a half an ounce per body weight for the kid. So like for an average three year old, that's about like 12 to 14 ounces of fluid a day. For average five year olds you're looking at a little closer to 20 ounces and all enough from there. They always seem to have their favorite cups or thermoses or whatever that they kind of drag around with them every day or they take within the school or practice or whatnot. So just kind of know how many ounces is that, and then you and the kiddo, especially if they're older than five or six, can kind of know and they can tell it, report back to the parent. I've already had one and probably a half of my thermoses today until you kind of know where the kid is. But you kind of got to have a mental goal in mind, at least of where you're trying to shoot for, and that's minimum hydration.

Emily: 10:35

But there are also other foods, fruits that start with a pea All those are excellent to help with tummies, like prunes, obviously. Plums, pineapples are full of water, so very good fruits. Any kind of citrus fruit is really good, certainly a kiwi, they say three kiwis a day keeps the doctor away. But kiwi has such good soluble and insoluble fiber. It is the first fruit that I recommend and it's not a common one that a lot of kids are getting, so it can kind of be a fun one for them to start experimenting with and it really does a great job of keeping them not only hydrated but with both types of fiber to help them.

Colleen: 11:15

That's so interesting because we typically jump to like prune juice or prunes. Now, are there any certain foods that families should avoid or that maybe we need to ask a little bit more questions to see if they're overeating certain food groups that might be contributing to their constipation?

Emily: 11:30

For sure. So you know, dairy seems to get a bad rap in my field. With peach GI it's kind of widely regarded as like an inflammatory type food and so they're struggling with constipation. That's kind of one of the first things you can suggest as well. And you know, in our day and age we're super fortunate where there are a lot of easy substitutes for dairy. So it's not like they're not able to have any kind of mac and cheese anymore, even pizzas. They have all kinds of dairy-free options for that.

Emily: 11:59

So those are kind of some simple substitutions. They make Ripple brand makes a P-milk which is pretty readily available in the United States, pretty much in a grocery store and it has a super fun kids you know packaging, but it has quite a bit of protein in it when it's a non-dairy supplement. And then you can also do just super easy run-of-the-mill stuff too, like almond milk or oat milk or whatnot, to kind of have them with their cereal or whatever before they go to bed if they still like to have a little glass of milk. And then there's lots of dairy-free cheeses too. That dye a brand is super common and they make all kinds of stuff like the pizzas I was talking about or like mac and cheese, so they can still kind of have their fun favorites, kind of decrease some of that inflammatory dairy.

Colleen: 12:43

Now, how much milk would you say is too much? I tend to ask this question kind of right out the get-go when I'm trying to collect information about the child's diet to see if that could be contributing to it. So I tend to ask them how many sippy cups or cups of milk does your child drink in 24 hours? For you know your typical let's call it your five-year-old what would be the red flag? Would it be like okay, yeah, that's too much dairy.

Emily: 13:08

I would say about eight ounces, just one cup a day. But if they're really, if they're having mild constipation, I wouldn't think too much about it. I wouldn't really recommend that they change that. But if they're having moderate to severe constipation or they're having to take a stool softener every day, I would recommend just eliminating that, if you can, that's really helpful.

Colleen: 13:26

We know our toddlers love milk, so that's a common age for them to come in with constipation. Is the you know 15 months or the 18-month-old to have just transitioned over to milk and they're still drinking excesses amount of milk. So let's leave our listeners with, maybe, what you educate or prescribe for your patients, at least initially, when we've got a constipated kid. You've talked about the importance of hydration. Maybe you're going to substitute some of these milk alternatives. What would be your next step? As, like the nutrition prescription portion of it, do you go into any fiber supplements? Do you put them on a stool softener or do you initially just really focus on increasing those fruits and vegetables?

Emily: 14:07

I really like to go ahead and add a stool softener. They're seeking my help. They've already usually done all the other things that you've recommended, which most of us providers are pretty good at doing right. Stay hydrated, stay active, do some jumpings and bicycling, swimming, you know. Increase your healthy fruits and vegetables. They've kind of already done all that by the time they get to me. So an easy first line is a stool softener.

Emily: 14:30

A Mirolax is readily available here in the United States, so that's kind of an easy one. It's fairly tasteless, so you can add it just to water or whatnot and have them have some of that every day. Some parents are a little bit hesitant about the Mirolax, which is totally fine with me. There are lots of other healthy alternatives. So there's some magnesium products over the counter that are easy to do. There's a million of them in Target. There's PDLX chewable tablets. There's some Dolcolax chews that are kind of fun that they can have. There's some that are kind of a little bit harder, like a Minto type kind of texture. Some of our kids struggle with autism or sensory processing disorder or whatnot. They're a little bit averse to different textures of things, so there are a lot of different textures of the softeners for them to try, some that are not detectable, like the Mirolax you can mix pretty easily in water, and then other things that they can chew, or gummies or whatnot, over the counter.

Colleen: 15:25

And then for, let's just say it may be a mildly constipated child. Do you start slow with these stool softeners, like once a day, and then they can increase it if they don't notice an improvement? How do you recommend the medication management aspect of it?

Emily: 15:40

We go by what's on the back of the product. So that's a pretty reliable source for these medications. You know, it'll say on the back of those, the PDL-AX tuibles or the Dulk-ALEX tubes, it'll say like between one and three depending on their age, and it gives like an age recommendation. So you can certainly start with one of those a day and if they're still not going every day or they're struggling, then you can certainly increase that up to the maximum. On the back of the bottle, all those over the counterwinds that I mentioned are magnesium products, so you wouldn't want to go over the recommended amount of that. And then the MIRLAX. If you kind of get to a certain point it can kind of backfire on you a little bit and start causing even two loose stools. So it can be a little difficult.

Colleen: 16:20

How long do you recommend that they stay on a daily stool often, or is it two weeks? Is it months? Is this lifelong? Because I know I get this question all the time. Well, how long does my child have to keep taking this medicine?

Emily: 16:32

I tell them forever An ounce of prevention is worth a pound of cure. So if we, especially in this young patient population like you were talking about, like the 15 months once we're introducing solid foods and then certainly through potty training and then again whenever it's another risk time frame when they're entering into pre-K4 or kindergarten, so they can be prone to constipation and have those painful stools, so if we can sort of keep them on a softener, at least for six months, then you can sort of lean back a little bit and if they're struggling again I put them right back on it, no problem, and I don't feel guilty about that at all. I think it's important for them to prevent constipation and prevent having any kind of painful stools that can kind of make them backtrack and have some significant physical symptoms. We don't want that for them.

Colleen: 17:20

Yeah, I noticed that a lot and it is that cycle of stool holding because it hurt and then it just compiles and worsens the situation of hard poop so that the next time it hurts them so they're going to hold it even more. I had a kid who was just so stubborn. He held it for a good like three weeks and poor boy was in so much pain. So I think I'd like to close with the severe end of constipation, that extremely constipated child who's a really bloated. You can feel stool all over the different quads and some of the abdominal exam. How can we provide them relief without having to send them to the emergency room, maybe like a bowel clean out? What do you recommend for a situation like that, so you can?

Emily: 18:01

do one of two or both things. You can prescribe an oral clean out. We usually do between four and even eight caps of mirror locks in about four ounces of fluid per cap and you can do that in a shorter timeframe so that it's most effective like within four to five hours, and you can give them one or two X-Lex. So it's kind of like you and I having to do like a colonoscopy prep, but it mirror lets is a great job of pulling all that water into the stool and making it all easy to pass so they get that quicker relief.

Emily: 18:35

Some kids are totally fine with doing a little suppository or an enema and that won't clean them out like that meralax will. But if they have a rectal impaction it can give them some pretty immediate relief. It's pretty instant. Usually within 10 minutes they'll have a bowel movement. So they make the liquid glycerin suppositories. They're way more effective than the solid suppository and for children under five there's the Petylaxx sprain which has the little penguin on the box. But for children five and older they would just have the regular ones which are the fleet brand liquid glycerin suppositories and they can do those in addition to the oral clean out at the same time if they need to give quick relief on a child that's just super miserable and nauseated and have poor appetite, you know.

Colleen: 19:21

Yeah, I feel so bad for these kids because you know they're so uncomfortable and it really is so much fear and pain that they've had to deal with. So I really love educating parents on the importance of the things that you've discussed and really it's just so amazing to see that they can get relief. So thank you for explaining all that. It was extremely helpful. What I like to finish and close out with is kind of a fun question of more along the lines of what not to do when we're educating our parents and patients. So what would be the worst thing we as clinicians could say to our parents or patients struggling with constipation that they're just gonna grow out of it.

Emily: 19:59

Just give them time and it'll get better. And it's so common with their age group and you just kind of send them on their way, telling them to be hydrated and fruits and veggies, and that is a great first line, certainly response. But if they come back to you again, I think it's important to be more aggressive than we all are, generally speaking, than the average provider is. It's okay to be aggressive If they're coming back.

Emily: 20:24

Constipation is like the second most common reason for Pied's visits. It's so common and they're just going back home and doing those things, those moderate and mild things that we recommended, and then they're not getting any relief but they're just continuing to do that and then, unbeknownst to us, they're kind of continuing to suffer and be miserable. So if they come back to you on a second visit, I really do advocate for an X-ray. See what you're working with. You'd be surprised at the amount of stool in there. So I think they deserve to have a little bit more investigation and a little bit more intensive approach and it's okay to consult them out to Pied's GI early. It's fine, they're used to seeing it and they can manage it a little bit more closely.

Colleen: 21:07

Emily, thank you so much for being here Again. I am so grateful for the gift of your time. I can't give you this time back, so I truly appreciate your expertise and you sharing everything with us. But in the meantime, guys, during clinic, be sure you're asking your patients about their bowel movements. Are they soft? Are they pooping every day? Is it painful? Do they have to push? Are they not going every day? And for the older kids elementary school kids are they maybe stuelling in their underpants? Cause those are telltale signs of constipation. And today we learned some extremely useful strategies where you can provide your patients with relief. Emily, thanks again for being here. Thank you, colleen. All right, guys, now it's time for my nutrition notes.

Colleen: 21:47

In this segment, I like to share nutrition tips, an interesting quote or a unique case that I think might add value to your day. So today I'm actually going to share with you a nutrition tip, as Emily talked about at the importance of hydration, and she did touch a little bit as well on the fruits that can help with hydration and that have added fiber, those fruits that start with a pea, which I thought was extremely helpful. Today I wanted to leave you with some hydrating vegetables. These vegetables have tons of water in them, so for those kiddos who maybe don't like to drink water or you're struggling with getting them to drink adequate fluids, this is a good way to get some more fluids into their diet. So cucumber is 96% fluids. Iceberg lettuce is 96%. Romain lettuce has 95% water.

Colleen: 22:32

Tomatoes are a great source of fluid as well Asparagus, bell peppers, cabbage, cauliflower and spinach. These foods can be eaten raw, so you might be surprised that your toddler likes raw cucumber or raw tomatoes. Cut it up onto the plate and give it to them and see if they go for it. Sometimes you compare it with some fun dips just to make it a little bit more enjoyable. If they are not a fan of it raw, you can always cook them. The spinach is a great way to include into pastas and to different casseroles. You can even blend it into a smoothie to increase some other fruits and veggies as well.

Colleen: 23:09

Well, that's it for today, guys. I hope it was extremely useful for you and that you found some practical solutions to help your patients deal with their constipation. If you would like to get more information from Emily, please follow her on Instagram at ankleexpert, and if you'd like to have her on again. That would be our pleasure. So go ahead and send us a message at exam room nutrition on Instagram and we'd love to continue the conversation. So keep having those nutrition discussions and continue to make our patients healthier, one exam room at a time.