Constipation and Other Common GI Problems in Children

Podcast Transcript

Dr. Scott Steele: Butts and Guts, A Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And it's always great to have a returning guest on, and I'm very pleased to have Dr. Ben Freiberg, who's a pediatric gastroenterologist here at Cleveland Clinic Children's. And this marks his second appearance on Butts and Guts. So, Ben, welcome back to Butts and Guts.

Dr. Ben Freiberg: Thanks for having me back.

Dr. Scott Steele: So, we're going to talk a little bit about something that if you're a parent out there or if you got any family member that's a child in there something that is not talked about a whole lot, but it's very, very common, and that's constipation and other common GI problems in children. So, before we jump into that, let's just go back a little bit. And for those who didn't hear your first guest appearance on Butts and Guts, tell us a little bit about yourself, where you're from and how to come to the point that you're here at the Cleveland Clinic.

Dr. Ben Freiberg: Sure. So, I'm actually originally from the Northeast, up in Boston, still a Red Sox fan. Sorry guys. But ended up doing my fellowship in the Northeast and got recruited here to the Cleveland Clinic to be our neuro gastroenterologist, basically our motility specialist, trying to figure out ways to help children that have issues with dysmotility, people that have issues swallowing, having issues with constipation, things like that. So yeah, glad to be here in the Cleveland area.

Dr. Scott Steele: Well, we're glad that you're here. And so, let's start big. And constipation's a term, I'm a colorectal surgeon, so constipation's a term that gets thrown out all the time. "I'm constipated, I got constipation, I'm doing that." So, what do you consider constipation, and how common is constipation in children?

Dr. Ben Freiberg: Yeah, that's a great question. So, for me, constipation really has a wide spectrum of what it can be. We can be dealing with kids that are struggling to poop because their poops are very hard. We can be talking about kids that are just having infrequent bowel movements, that they're going once maybe twice a week to have a bowel movement. Really, there is this big range of what constipation is, and that's why it's always important to have that discussion with the parents when they're coming in saying that their kids might be constipated, to really fully understand what does that mean and what are the bowel movements truly like to figure out if they are in a normal range, or yes, they are truly constipated.

Dr. Scott Steele: So, you mentioned a little bit about hard bowel movements, difficulty going, but what are some symptoms of constipation that may be seen specifically in kids?

Dr. Ben Freiberg: Typically, it depends on the age. So, the younger the age, we often see that they might be withholding a little bit. So, they might look like they're pushing and straining to poop when really, because of the pain that they're having with the pooping, they're actually holding it in. So, you might see them kind of hide off in a little corner behind the couch somewhere turning red and really squirming and tightening up their legs and their knees. So, that might be one sign right there. In the older kids, as I mentioned, it's the frequency of the bowel movement, so if they're going once maybe twice a week having the bowel movement there. Or, the consistency of the bowel movement. So, I like to describe them as either big bricks or little rabbit pellets that they might be seeing. Or oftentimes, I'll have parents come and describe them as, they're pooping like an adult would poop or they're clogging the toilets. Those are the big things that I would say would lead me to a diagnosis of constipation.

Dr. Scott Steele: So, there's a lot of parents out there that follow the kids closely, but they may not even discuss their bowel movements at all. But how long after some of these constipation-like symptoms occur for the child should a parent talk with their pediatrician?

Dr. Ben Freiberg: I would say to have that conversation kind of early on. So, the one thing that we want to try to avoid is that withholding pattern that might develop in the younger children. And that way, we can start providing remedies so that we can soften those bowel movements and they don't go on to develop worsening pain with bowel movements, possibly even having bloody stools because they're having fissures from the hard bowel movements, things like that. So, I would say try to have those open conversations with your children. But I do recognize, especially as the kid gets older and they want their autonomy, it's not something that's often discussed in the household.

Dr. Scott Steele: Yes, absolutely. So now, truth or myth: Changing a child's diet is the only way to treat constipation and their GI issues.

Dr. Ben Freiberg: I would say that's a myth. Definitely early on, we can help adjust the bowel movements, help to soften off the bowel movements with dietary changes. So, we know that dairy products, milk, cheeses, those types of things can be very constipating. Even certain fruits such as bananas can be constipating a little bit, as well. So, making sure that we increase the fiber in the diet, to make sure there's enough fluid in the diet as well. Early on, we can make sure that the stools can be nice and soft. But once we get to a point where they've been going on with constipation for a long time, what happens is that the colon can blow up like a balloon. So, those small dietary changes might not be enough and we might need to do some medical interventions there.

Dr. Scott Steele: So, let's have you walk us through that. What does that all entail? Is this just simply, "Hey, I'm going to buy some over-the-counter laxatives." Or, what are some other treatment option ways to address this?

Dr. Ben Freiberg: As I mentioned, the first step I like to do is try to increase that fiber in the diet. So, finding ways like whole grain breads, whole grain pastas, brown rice instead of white rice. And then sometimes what parents or physicians will do is start to add a little bit of fiber gummies into the diet, as well. But after that, I would say have those discussions with the pediatrician because the one thing we don't want to do is either overdo medications or underdo medications. So, once we're talking about starting a laxative, I would definitely have that conversation with the pediatrician to try to figure out what sort of laxative might be best, do we want to do single therapy or combined therapies, things like that.

Dr. Scott Steele: Bringing this forward then, is there a greater likelihood of constipation when that child grows up to adult life when experienced in their childhood or adolescent years?

Dr. Ben Freiberg: It really depends on how well it's managed early on in life. So, we see that if they are well managed early on and we can get them to a point where they're having regular bowel movements, that we can get them off of medications, then we can maintain them with diets through adolescents and into their adult years. It's when we don't do a great job managing those bowel movements early on that we see that they continue to struggle through childhood, through adolescence, and into adulthood. The aim for us in the pediatric GI world is to make sure that we are able to shrink the colon back down to a more normal size so that the colon just doesn't hold and retain that stool, that it does empty out appropriately. And once we're at that stage, we are better able to manage constipation, as I mentioned, later on into their adolescent years and into adulthood.

Dr. Scott Steele: Is there a point of no return, where you just, no matter what you do, as you said, that colon blows up like a balloon? Is there a point where you're just like, whoa, we got to be able to intervene?

Dr. Ben Freiberg: There definitely are points like that, yes. So, it is important to have that open conversation with your pediatrician, but there will definitely come a point where even on single therapy, or if you do do dual therapy, you might need more in stronger intervention. So, having that discussion about a referral to pediatric GI. And as I mentioned, for myself in the motility world, we do have access to a lot of testing to see what is the functionality of the colon. How well is the colon doing? How well is the colon operating? And then to check to make sure, are we possibly missing any other diseases that might cause children to have constipation? So, for instance, Hirschsprung's Disease is often associated with constipation, where the way I like to describe it to parents is that the gate remains very, very tight, so it makes it very hard for children to push and get that poop out because they need to exert a lot of pressure to pop that gate open. So, we can do those testing at the younger age to see whether or not some of those underlying diseases might be a cause for their constipation.

Dr. Scott Steele: So, Ben, I know that the focus is on constipation. I know it's very broad and we can't go all inclusive, but are there other common GI problems that are seen in children? And how does a pediatric gastroenterologist kind of approach them?

Dr. Ben Freiberg: I would say either with or just under constipation would be abdominal pain. So, we often have parents bring their kids in to see their pediatrician that they're complaining of belly pain kind of throughout the day or intermittently when they're eating. So, definitely getting them to be evaluated for that I think is very important. But I will say, that not always is there an underlying concerning diagnosis for these episodes of belly pain, that oftentimes that it can just be a little bit of hypersensitivity of those nerve endings that can lead to the belly pain, and managing that hypersensitivity while making sure we've ruled out any potential concerning the diagnosis, as well.

Dr. Scott Steele: Yeah. And just like we say in adults, in children, it's important to understand your body, understand your symptoms. And if they're lingering, please don't ignore them and reach out to your healthcare provider and be able to go from there. So again, since you're returning guests on here, it's time for our quick hitters. I'm not going to give you the same one, so encourage everybody to go back and listen to the prior episode of Dr. Freiberg. But, if I was to grab your phone right now and hit play on whatever your music app of choice is, what would I hear?

Dr. Ben Freiberg: Oh boy. I'll say my collection, I'm a very big Billy Joel fan, so you'll probably find that.

Dr. Scott Steele: Fantastic. And so, what's your favorite ice cream?

Dr. Ben Freiberg: I would have to say it's a chocolate-based ice cream, so either like a rocky road or chocolate chip, cookies and cream, or even just plain old chocolate. I'm happy with any of those.

Dr. Scott Steele: I always like when my guests give me one of several. It means you're an ice cream eater. And then, you got a rainy, blah, miserable day, whether it's here in beautiful Cleveland, Ohio, or more appropriately Boston, what's your go-to? Are you going to a movie, a book, a walk in the rain? What do you go to? Curl up on the couch?

Dr. Ben Freiberg: Probably would end up curling on the couch, putting on a good show, whether it's a movie or binge watch a TV episode. I think that would probably would be my go-to there.

Dr. Scott Steele: And then finally, what was your first car?

Dr. Ben Freiberg: Oh, that was a Toyota Camry.

Dr. Scott Steele: Fantastic.

Dr. Ben Freiberg: I do remember that, yes.

Dr. Scott Steele: Yeah, that's awesome. And so, what is your final take home message regarding either constipation or common GI problems in children?

Dr. Ben Freiberg: So, as you mentioned, I think it's very important to have those open conversations, and that if there is any concern there, to really bring it to the tension of the pediatrician to see what can be done, what's either simple at home management strategies can be taken, or do we need to start any sort of medication, and do we need to refer to the pediatric gastroenterologist to see if we need to do testing, escalation of medications, what have you.

Dr. Scott Steele: That's great words of wisdom. And so, to learn more about the Department of Gastroenterology, Hepatology and Nutrition at Cleveland Clinic Children's, please visit clevelandclinicchildrens.org/gi. That's clevelandclinicchildrens.org/gi. You can also call us at (216) 444-5437. That's (216) 444-5437. Ben, thanks so much for joining us on Butts and Guts.

Dr. Ben Freiberg: Thanks for having me back.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.