The Hard Truth About Kids and Constipation with Ben Freiberg, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

If you just finished potty training your kid, congratulations, that's a big deal! But before you celebrate too much, know this: Your child might not use the skill as much as they should at first. On average, 1 in 5 toddlers are dealing with constipation, and many of those no-go situations come during or just after potty training. It's a number 2 issue that can quickly turn into your #1 concern. That's why we invited pediatric gastroenterologist, Ben Freiberg, to come chat with us today. Dr. Freiberg is one of the many experts at Cleveland Clinic who joins our weekly podcast to share tips to keep your family healthy. Now, let's see what we can do to get things moving for your plugged-up kiddo. Dr. Freiberg, thanks for joining us on the podcast to talk shop today.

Dr. Ben Freiberg:

Glad to be here. Looking forward.

John Horton:

So, in doing some research in advance of our chat, I read where 1 in 20 visits to a pediatrician is because of constipation. That's a lot of plugged-up kids. Is it really that common of a problem?

Dr. Ben Freiberg:

Surprisingly enough, it is. Or unsurprisingly enough to many parents, I would assume.

John Horton:

Well, let's start then, just I guess, with a basic question: When you're looking at this and being regular and what's constipated and what's not, given that poop schedules are so different person to person, how do you know if your kid is dealing with constipation?

Dr. Ben Freiberg:

There's definitely a couple of things to recognize with it. When we talk about constipation, to your point, different people have different definitions of what constipation is. Some people will say that they're constipated, it means that they're going every day but are having hard poops. Other people might say that they're constipated, but what they mean is that they're just not going frequently enough. So, it's really important to really get an understanding of what that individual means. But in terms of what normal is, there's actually a big range of what normal is in terms of our bowel habits. So, the little infants, they're the ones that are usually pooping with basically every single feeling that they get.

And as they get older, we see that that frequency starts to dwindle down, and then you become into the more what we would consider normal range, where it really is a big range, where you have the individuals that are going to the bathroom twice a day. It's nice and formed, it's not loose, it's not watery, and that's considered normal. And then there are the people that are going every other day. It's not hard, it's not painful, they're not clogging the toilet, they're not seeing blood in their stool, and that's perfectly normal. So, we really do have this big range of normal. We don't have to be pooping every day. We can poop a couple times a day. We might be pooping every other day.

John Horton:

Now, are there clues that you should maybe look for in your kids?

Dr. Ben Freiberg:

Absolutely. So, one of the biggest things is going to be consistency and frequency. So, if they're having hard stools, if they're telling you that when they go to the bathroom, it's very painful, if they're seeing blood when you're wiping, those are going to be clues that the stools might be a little bit more constipated. And similarly, that frequency. So, if you are going once or twice a week, if you're having large volumes to the point where you're clogging the toilets, that's also going to be clues that you might be somewhat constipated. But again, each individual is going to be slightly different in terms of what their constipation is.

John Horton:

Now, what typically causes constipation?

Dr. Ben Freiberg:

So, there are a lot of different things that go into developing constipation. Usually, we see it happening at different stages in life. The first point in life that we often see it start to develop is around 4 to 6 months of age, where you start to introduce more solid foods into the diet. The stools themselves become a little bit harder. And just like with any of us, we don't want to experience pain, we don't want to experience any sort of discomfort. So, we might start to hold it in a little bit. Similarly, around the year/age where we start introducing more dairy, more milk into the diet, the stools will become a little bit harder. They might become a little bit more painful. And again, we might start to see a little bit withholding around potty training as well. The toddlers want to get a little bit more autonomy, want to be a little bit more self-reliant.

So, I always say in a struggle for the potty between the kid and the parent, the kid is always going to win. So, if they start to not want to go, unless they're in a certain place or a certain location, they might start to hold it in a little bit. And as we get older, again, more related to the diet and maybe that situational, where we might not want to go in the bathroom in school, or if we're outside and don't want to go at the mall or at the movie theater, things like that, we might hold it in and miss that opportunity.

And in addition to this, what ends up happening is that the colon acts like a balloon. So, it starts to stretch out to hold all that stool, hold all that poop. So now, that normal amount of poop that might've signaled us to go to the bathroom, it floats there until it gets to be a really big brick. And at that point, it's hard, it's painful, so it makes it really difficult for us to go.

So, it's all these factors, our diets, our bowel habits, whether or not we withhold. And then just the elasticity, the stretchiness of our colons able to expand to hold all that stool there.

John Horton:

I think I saw in one thing where it's called "functional constipation." So basically, your lifestyle can cause the issue if you're just not going or you're just hesitant, I guess.

Dr. Ben Freiberg:

Absolutely. Yeah. I see a lot of kids that just refuse to go if they're at school or if they're out with friends at a friend's house, things like that. And our bodies typically give us one or two opportunities a day to go use the bathroom. And if we miss it, then we need to wait till the next point. But at that point, you're starting to build up the tank, filling it up. And the more you fill it up, the harder it's going to get, the more discomforting it's going to be, which will make you not want to use the bathroom again.

John Horton:

Now, I know most of the time when you're dealing with constipation, it does seem like it's those functional issues, but there are times where it could be a more serious medical issue, correct?

Dr. Ben Freiberg:

Absolutely, for sure. So, there are a couple of medical conditions that can lead to constipation. The biggest one that we will see is an entity called Hirschsprung's Disease. With that, what ends up happening is that the nerve endings, as we develop, don't make it all the way down to the bottom. So that bottom gate, as I describe it, is just really, really tight and we need to exert a lot of pressure to pop it open, to get that stool out, to get that poop out. Usually, this is found in early infancy where typically, that infant passes what we call, meconium - this really tarry stool, that first couple of stools there - and if they don't pass it within the first couple of days, that really clues us in there. So that's really the biggest one that we often see.

Medications can often cause you to have constipation, so make sure to look at the medications that you take to see what sort of side effects they might have. And as I described, as the colon gets really, really stretched out, it just loses that functionality. So, we need to give it some time, a little bit of a break to recover, to really heal itself up and really go back to its normal form, to its normal shape.

John Horton:

When should you reach out to your child's pediatrician about constipation? Are there some telltale signs that this is a bigger problem that needs to be looked at?

Dr. Ben Freiberg:

I would advocate the sooner the better because you really want to try to nip it in the bud. So, work on the behavioral side of things, making sure that your child recognizes the body's cues to go use the bathroom. If there is some sort of aversion to using the bathroom, to address those things. Oftentimes, if it is cut early, we can manage it with just some simple dietary changes, increasing the fiber, increasing the fluid in the diet. But if we need to, it is better to start early on with the medications - do that for a few months and slowly get them off the medication, so that way, you can work on the diet and keep them more regular that way.

John Horton:

Are there some signs that would signal that, "Hey, I need to go talk to somebody"

Dr. Ben Freiberg:

So, the biggest sign is how your child reacts to it, when he needs that sensation of needing to go to the bathroom. So, if your child is hiding in the corner - and oftentimes, people will describe it as a little poopy dance - it might not actually be that they're trying to get it out, it might just be that they're actually trying to keep it in because they recognize that it is hard or painful. So definitely, if you're starting to see that, have your pediatrician involved.

If you're looking at the stools and you're seeing that they're very hard or you're seeing some blood on when you're wiping or a little bit of blood in the toilet bowl or on the stool itself, then that's also going to be clues. And as the child gets older, they're not going to want to tell you when they go to the bathroom but try to stay on top of it. So, pay attention and see. Are they going regularly, are they going at least three to four times a week or are they somebody who's going once, maybe twice a week? So those are going to be some of the biggest telltale signs there.

John Horton:

All right. One of two big questions - since that seems like the appropriate number given our topic - if your child is constipated, how can you get things moving again and how can you just prevent constipation from happening in the first place?

Dr. Ben Freiberg:

Diet, diet, diet. That's going to be the biggest thing. So, we really do rely on fiber and fluid in our diets. Unfortunately, oftentimes, we just don't eat plenty of fiber. We don't eat plenty of fluids. How often are you able to get your kids to eat fruits and vegetables? It's a tough question, but there are definitely a lot of simple things that you can do. Whole-grain bread, whole-grain pasta, brown rice instead of white rice, berries- especially now that it's the summer months - that's the biggest bang for your buck. Making sure that they stay hydrated, drinking plenty of water. But if you're starting to see that you're not really able to manage it by just dieting alone, start them on some medications just to make sure to keep the stools nice and soft and to make sure that you're going regularly.

John Horton:

Is it effective to try to set up a poopy time for kids or does everyone's body just, it happens when it happens?

Dr. Ben Freiberg:

Absolutely. So, I love poopy time for the kids. As adults, I think most of us would agree coffee will just send us rushing to the bathroom. But really, if you do it around mealtime - so I typically say at least twice a day - after breakfast, after dinner - have your kids sit on the potty, five, no more than 10 minutes. If they poop, great. If they don't poop, that's OK. You're going to try again later. Because naturally when we eat, we want to make room for that food. We call it the gastrocolic reflex that our stomach tells the colon, "Hey, I'm getting filled up, let's start to empty out." So, if you have them sit down for those few minutes after meals, that's going to be probably the most optimal time. And then, for sure, if your kid is saying that, "Hey, I need to go to the bathroom," it's time to make sure they go to the bathroom.

John Horton:

Well, that's some great advice and a lot of really helpful tips that can be put to good use, Dr. Freiberg. So, before we part ways today, is there anything else that we should mention when it comes to constipation in kids?

Dr. Ben Freiberg:

This can definitely be a pretty stinky subject, but the sooner, the better. If you start to see any of these signs, if you're starting to see that poopy dance, if you're starting to hear your kid complain of painful stools or you're starting to see that they're clogging the toilet, hard stools, some blood when you're wiping, that's for sure a good time to go. At the very least, meet with your pediatrician and start talking about medications, about helping to manage it and then, long-term wise, or even to prevent it, diet. Fiber and fluids.

John Horton:

Great advice, Dr. Freiberg. So, thanks for making some time to come and hang out with us today and look forward to talking with you again.

Dr. Ben Freiberg:

Glad to be here.

John Horton:

Constipation is a common issue for little kids. Thankfully, it's a problem that typically can be solved pretty easily with a little attention to what they're eating and making sure they take the time to sit down and empty out. Consider it the last step for a complete potty-training victory. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.