Spotting the Signs Of Childhood Constipation

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Senthilkumar Sankararaman, MD:

When your child's digestive system is not working quite right, it could affect their sleep, their mood, and your entire family's joy and peace. I am Dr. Senthilkumar Sankaraman. I'm a pediatric gastroenterologist at Cleveland Clinic Children's and today we are talking about the struggles of childhood constipation. We will explain why some kids start holding it in, how their brain and body gets stuck in a vicious cycle of discomfort and pain, and then the steps you could take as parent to bring them some relief. Joining me is my friend and colleague, Colleen McNatt. She's a pediatric nurse practitioner in Cleveland Clinic who specializes in childhood constipation. Welcome to Little Health Colleen.

Colleen McNatt, CNP:

Thank you. Thanks for having me.

Dr. Senthilkumar Sankararaman, MD:

We are so excited to having you here. Please tell us a little bit about yourself.

Colleen McNatt, CNP:

Sure. So I have been at the Cleveland Clinic for about 20 years this year and the first 10 years I spent as a PCNA on the nursing units and an RN and then for the past 10 years, I've spent as a pediatric nurse practitioner in pediatric GI.

Dr. Senthilkumar Sankararaman, MD:

That's awesome. Did you grow up in Cleveland area?

Colleen McNatt, CNP:

I did. Yep. Born and raised.

Dr. Senthilkumar Sankararaman, MD:

So now going into our topic, what is constipation?

Colleen McNatt, CNP:

So constipation is, you know, for children, they should be going poop at least three times or more per week. Now this really varies when it comes to infants, children. So infants, this is probably something that we see in the pediatric office more often is, okay, my baby's not pooping, right? It's been two or three days and my infant hasn't pooped. Well, that's pretty normal. So infants can go seven to 10 days without a bowel movement, especially if they're breastfed. But children, they should really be going about three times per week.

Dr. Senthilkumar Sankararaman, MD:

That makes sense. And then also, does it matter if someone is pooping almost every day but they poop with so much stain and pain, does it still qualify or considered as constipation?

Colleen McNatt, CNP:

So if a child is having pain with bowel movements, that's never normal and that actually is going to lead to functional constipation where a child is holding their bowel movements. And if they're holding their bowel movements, that's gonna lead to more issues with leaking, abdominal pain, fear of the toilet, and then that's gonna cause issues of potty training.

Dr. Senthilkumar Sankararaman, MD:

How common is constipation in children?

Colleen McNatt, CNP:

Constipation is very common in children. This makes up for over 30% of the visits to a pediatric office, which leads to the consult to pediatric gastroenterology. So we do see a lot of kids with constipation.

Dr. Senthilkumar Sankararaman, MD:

So that leads to my next question. What causes childhood constipation? Why it's so common in, specifically in kids?

Colleen McNatt, CNP:

So that's the million dollar question, right? I think it's hard to pinpoint exactly what causes your child's constipation, but there can be very, various factors. This may include or not be limited to poor diet, poor fiber intake, poor fluid intake, behavioral factors, which is the holding of bowel movements. You know, it can take one time that they had a bowel movement that was a little bit large or painful and then they decided in their smart little brains that they don't ever want to poop again and then they start this holding cycle. That's probably what we see the most in pediatric GI. Other things could be lack of physical activity, sedentary lifestyle, dehydration, the toilet training issues, medications, disease processes, or even change in routine.

Dr. Senthilkumar Sankararaman, MD:

And some parents do complain about kids having, or their kid having accidents or leakage. Could you help us understand that's also from constipation? If yes, how that happens.

Colleen McNatt, CNP:

Yeah, so this can be very confusing for parents. We will end up seeing patients in the office that have diarrhea and loose stool and it can end up being actually constipation. So if a child has a fear of holding and they're, you know, they're getting backed up with stool and that becomes a fecal impaction in the rectum, all the stool that comes down above it is loose and leaks around and they cannot control it. And some of them will have a large amount of diarrhea, some of them will just have leaking that's stained in the underwear, but it's, you know, it affects their everyday life.

Dr. Senthilkumar Sankararaman, MD:

And also we sometimes see kids when there are major changes in their milestones. For example, kids being started on solid foods or kids undergo potty training or going to school. Why constipation is more common during these times?

Colleen McNatt, CNP:

So any change in routine can lead to con- or constipation. Dietary changes altered digestion, potty training or starting a new school, a new daycare, moving to a new home, birth of a sibling, a divorce. All of these things can cause stress and anxiety in children. And this can lead to constipation issues because they may start withholding stool because of a different environment due to fear, which can lead to constipation issues. Even something fun and positive like a vacation that can lead to withholding because of the change in routine. You know, change in diet, whenever you have a change in diet, you're starting solids or you're, you know, switching to whole milk or, you know, your diet has changed and you're going backwards in your diet and not eating as many fruits and vegetables as you did when you were little. That can cause like a slowing of the digestion and then it leads to a hard stool.

And like I said earlier, one hard poop and they decide never to poop again and that's the vicious cycle that starts with constipation.

Dr. Senthilkumar Sankararaman, MD:

That makes so sense. Thank you. And sometimes parents see their kids crossing their legs are hiding and think their kids are trying to poop. Could you help us understand what exactly the kids are doing, specifically the toddlers they exhibit this pattern?

Colleen McNatt, CNP:

Yeah. So this is something I saw in my clinic probably on a daily basis, new patients coming in for straining with bowel movements, difficulty passing bowel movements, which it does look that way when your child is squatting down, crossing their legs, stiffening, they turn really red, they sweat, they cry and some of them get their body in a position that looks like they're trying to poop, but they are actually doing the complete opposite. They are trying not to poop. So they are squeezing their buns as hard as they can to try to not let the poop out and that causes them to do those different behaviors with their body that look like they're trying to poop, but they're actually trying not to poop. And once we identify that, you know, a lot of parents that I see are like, "Oh, that makes a lot of sense." Like it does look like they're trying to hold their poop and then we can start treatment.

And once we get the parents on board and they understand then, you know, things usually improve after that once we get started.

Dr. Senthilkumar Sankararaman, MD:

And to clarify, the kids are trying to hold to prevent the pain or with the hope that it will prevent the bowel movement and the pain, right?

Colleen McNatt, CNP:

Yeah. They're trying to hold their poop in because they're scared to poop. They're afraid it's gonna hurt when it comes out.

Dr. Senthilkumar Sankararaman, MD:

What happens to the body when a child holds the poop for a longer time?

Colleen McNatt, CNP:

So when kids hold their stool in for too long, the stools become increasingly firmed, water gets pulled out of the stool by the large intestine. A child will then develop fecal impaction, which is essentially a large ball of stool that is in the rectum. This can lead to abdominal pain, that can lead to the leaking of stool. Your rectum can become distended and floppy per se, and this can lead to chronic constipation issues.

Dr. Senthilkumar Sankararaman, MD:

Thank you. And what, what can parents do when their child refuses to go?

Colleen McNatt, CNP:

So the probably most important thing at first would be to try to stay patient when your child's have, refusing to have a bowel movement. That can be the most difficult part. First, the parent needs to come to an understanding that the child's not being disobedient but has a true fear of pain which is leading to these behaviors. Parents should focus on eliminating the pressure surrounding toileting in general. They should maintain a very positive environment and give positive reinforcement when it comes to having bowel movements or toilet training. Also may be necessary to just take a little break from toilet training while focusing on the most important part right now, which would be making the stools really soft and painless to pass.

Dr. Senthilkumar Sankararaman, MD:

The other question we see often in the clinic is children who have daytime pee accidents or even started wetting, uh, wetting the bed again, which was never a problem before, could this be a constipation issue?

Colleen McNatt, CNP:

This could definitely be a constipation issue. If they are fecally impacted and they have a lot of stool burn in, this, you know, everything kind of gets a little stretched out in the rectum, it presses on the bladder and it causes spasms and they can have leaking of urine, they can have accidents. And also when kids are trying to hold their poop, they also tend to hold their urine because you kind of can't relax to pee without relaxing to have a bowel movement so that can lead to the leaking and also the urinary issues. But of course, you know, if this is something that's happening out of nowhere and, or is continuing to happen, you should, you know, they should always seek care with their pediatrician to make sure it's not in fact a UTI.

Dr. Senthilkumar Sankararaman, MD:

That makes sense. Thank you so much, Colleen, like just kind of learning so much about constipation, especially, specifically the younger children. So now the next big question is, how can we help them?

Colleen McNatt, CNP:

So the number one thing, if your child is very constipated, they likely need to have a clean out or some stool softeners to help because once they get into this pattern of withholding, they, you know, their little buns are very strong and they're going to continue to hold and continue to be constipated. So medications such as stool softeners and laxatives can be initiated with your physician, you know, if you're going to need a clean out, this should definitely be prescribed first. Oftentimes we use modic laxatives such as polyethylene glycol, which is known as MiraLAX or magnesium citrate. These medications draw water into the stool to soften it and it can be easily adjusted based on stool consistency. So the first thing that we always do when you come to CGI is, okay, you're really constipated, you're having all these issues that have led you to this referral.

We want to start with a total clonic cleanse and get everything flushed out and then we discuss what is going to work as a daily treatment.

Dr. Senthilkumar Sankararaman, MD:

Are these medications safe, especially, specifically for younger children?

Colleen McNatt, CNP:

These medications are safe and effective and they can be used for long-term, but it should always be prescribed by a physician, especially if using longer than one week.

Dr. Senthilkumar Sankararaman, MD:

The other question we often get from parents is, are there natural alternatives or any food-based alternatives for managing constipation?

Colleen McNatt, CNP:

Yes, there are a lot of natural and food-based alternatives that can be used such as increasing fiber intakes, so whole grains, beans, making sure your children are staying hydrated with water, that they're consuming fruits that contain sorbitol. I always tell people, think about the Ps. You know, I tell parents to think about the P fruits, pears, prunes, plums, peaches, those are always very helpful for constipation.

Dr. Senthilkumar Sankararaman, MD:

That's easier to remember as well. Yeah. And then does change in posture when kids kind of sit in the commode or toilet or booster seat, does that help in pooping?

Colleen McNatt, CNP:

Yeah, posture, this significantly, uh, affects how children poop as proper alignment, relaxes the pelvic muscles and it straightens up the rectum for easier passage of bowel movements. Dangling your legs, slumping on a regular size toilet can cause constipation and straining so you want to make sure that the kids have proper toilet posture with their feet up on a stool, their knee should be a little bit higher than their hips, something that you can get as a stool or a squatty potty to put around the toilet to put their feet up on and that can be very helpful to help them pass a little easier.

Dr. Senthilkumar Sankararaman, MD:

The next thing we are going to talk about is poop school. I know it's very unique in Cleveland Clinic, uh, is one of the places we have this very unique poop school and, um, I know that you're closely involved with the development of poop school and work there for, working there for a long time. So just help us understand like what do you do, what is poop school, what do you do and how you help children, uh, with constipation in the poop school?

Colleen McNatt, CNP:

So I love Poop School. Just gonna say that. Joined that a few years ago. So Poop School, the official name for it is Shared Medical Appointment SMA Toileting Clinic. So this is for ages three to seven and it is for children who have a functional type of constipation. So they're choosing to withhold their stool because of X, Y, Z, whatever reason the pain, you know, the pains with the bowel movements, which actually goes back to different situations that could have occurred that started the constipation in the first place. The Poop School is available virtually or in person and it's for four weeks in a row, on day per week for four weeks. And it's a collaborative kind of clinic with a GI doctor and then you have a psychology team that also sees the patient. The first visit, you're gonna see everybody just to kind of as a meet and greet, you're gonna see the GI doctor and see if your child requires a clean out, if they need to start a medication and then after that you'll meet the rest of the psychology team and that's who you're going to be with for the remainder of the poop school.

And you're going to be with the other parents, with the other children. The in- person poop school, the parents and children separate for a little bit and parents go with the psychologist, the children go and they do fun activities, they learn about poop, why pooping is good, they do activities with poop and then they all come together at the end and they draw up some behavioral plans too to help week by week help improve. And it, and it's very successful and fun for parents and children. They learn a lot.

Dr. Senthilkumar Sankararaman, MD:

That sounds really fun. Great things you guys are doing. So the next question is for pediatric doctors as they manage milder constipation, what are all the red flags or concerning symptoms that they need to refer to as gastroenterologists? In other words, what are all the red flags that mean it is not just your constipation or your more straightforward functional constipation, as you mentioned, but something more serious.

Colleen McNatt, CNP:

So it's very important to recognize those symptoms that are occurring that are red flags for pediatricians. Some of the red flags that would require further evaluation by a gastroenterologist would include severe abdominal pain, vomiting, bloody stools, unexplained weight loss, and then fever and also prolonged time between bowel movements. So if a patient comes in to see a pediatrician and they say, you know, "My child has not pooped in, I don't know, maybe a month or two to three weeks," you know, that's a very prolonged time in that it requires immediate intervention.

Dr. Senthilkumar Sankararaman, MD:

So now kind of moving on, a little bit fun questions. What is your most favorite food?

Colleen McNatt, CNP:

My most favorite food is probably pasta.

Dr. Senthilkumar Sankararaman, MD:

That's awesome. That's good, yeah. And, um, any favorite things you do, uh, you like to do in Cleveland?

Colleen McNatt, CNP:

So in Cleveland, you know, we have the lake here and I grew up, you know, going on boats and camping in Sandusky and all of those things were really fun for me so I'm hoping that in the future that will be something I can provide for my children.

Dr. Senthilkumar Sankararaman, MD:

Cool. Thank you so much for your insight, for your thoughtful explanations and all kind of like suggestions you gave. Thank you so much. We are so glad to have you here.

Colleen McNatt, CNP:

Thank you.

Dr. Senthilkumar Sankararaman, MD:

We hope you feel better prepared and less stressed about your child's toileting or bathroom struggles. If you would like to schedule an appointment with your pediatric gastroenterologist at Cleveland Clinic Children's, please do call at 216.444.KIDS. That is 216.444.5437. Thank you for listening.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.