Friday, August 14, 2015

Constipation/The poop, the whole poop, nothing but the poop


One day your kids will be completely out of diapers. Believe it or not,  the day will come when they no longer want you to wipe their butt after a poop (that age tends to vary greatly from child to child.) The years pass and at some point you tend to lose track of your child's bowel movements completely. That being said, it is the rare parent that gets a completely free pass. If you are a patient of Noe Valley Pediatrics, I am betting that at some point before your child goes off to college, you are going to have a conversation with me about your child's BMs.

It is quite common for kids to occasionally complain about tummy aches. In my experience, a full 90% of these are constipation related. Of course we never want to ignore other possibilities. Abdominal pain could be all sorts of other things that need attention. Tummy aches that come from constipation tend to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body.

If I have a patient with a complaint of a tummy ache, I am going to want to know the frequency and consistency of the stools. Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can't get through. What they will pass is some very runny substance that is getting around the solid mass of impacted stool. Because of this, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing. When was the most recent poop? Was it normal size? Smaller than usual? How often are they pooping? Are they sitting for a long time trying to get it to come out? Are the stools coming out in little hard pieces?

I have a theory that many children don't like to poop at school or camp. If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the urge passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. They may pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be "yes".

I like to do a little 'Nurse Judy poop math' (this can't possibly surprise any of my followers.) Figure out how large your child's average size stool might be. Let’s say it is the size of a hot dog. Assume your child doesn't have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache!

It is time to sit and talk to your child about a very important rule. There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option. These kids need to be cleared out. All the prune juice into the world is not going to be able to blast through an impacted mass of stool.

Massage and a warm bath are step one. Some kids actually maybe able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation, you will be happy to see them poop anyway that you can make it happen. Some people find that adding a few teaspoonfuls of either baking soda or epsom salts to the warm bath water will can also help.

If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. Another option (which I prefer) is a liquid glycerin called Pedialax. The directions on the box advises that  these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in the small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes. Once you get some of the hard stool out, we can start to focus on making some adjustments to the diet.

Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/
toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to avoid those until they are having softer stools. Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps (if you do this, make sure they are getting enough calcium.)

Fruits and veggies are great. Smoothies might be useful if they won't eat them raw.
Make sure they are drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to get you back on track. Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet. See if you can somehow hide some molasses and flaxseed oil in some oatmeal or baked goods. Kids will often eat something if they had a hand in baking it. Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion.

Make sure your child is getting enough magnesium. Natural Calm (available at Whole Foods and  natural food stores) is source that many folks like.  An appropriate  dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form.
Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day. The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1-11/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps.

Here is an important new consideration to the discussion that is not found anywhere in my old constipation post.  Go on line and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “third world problem”.  It turns out that our sitting position is not really helping our body with elimination. You might want to experiment with a little foot stool in front of the toilet or potty that gets your child in a better position. You can try it too!

If you have a young child, check out the book Itsy bitsy Yoga.  Some of the stretching positions might help move things along.

Acupuncture is another option
Check out www.theacupunctureden.com

If massage, position and good diet don’t  seem to be doing the trick, talk to your doctor about getting your child on Miralax. Miralax is an over the counter fiber that is heavily used by pediatric GI specialists to deal with constipation. Miralax has recently had some articles about it that made some folks uncomfortable about it’s use. There are no studies about its safety for long term use and one of the biggest concern is the lack of testing in pediatrics.  While that is true, official studies aside, it has been used for years and years without any known contraindications The specialists don’t seem to have concern about the safety. Miralax doesn't get absorbed into the system. What it does is pull the fluids into the intestine to make sure the stools are softer. We have some patients who are on it for an extended period of time with no ill effects. That being said, I never want anybody on medication that they don't need.

If your child has been give a dosage for a course of Miralax, I am perfectly happy if you do a daily adjustment of the dose depending on that day's stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose.

If you are pretty sure you child is not constipated and they have an abdominal pain that is more steady than intermittent, they need to be evaluated!

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