By: Cindy Baranoski MS, RDN, LDN
Poop. Pooping. Pooped. A word that is usually reserved for little babies, and usually not for anyone older. Though we all do it, discussion after infancy wanes and it is just assumed we do. Terms like ‘bowel movement’, ‘stool’, and ‘number 2’ replace the cute and friendlier term of ‘poop’. However, one of the most common challenges seen in all people, and especially our children, is the ability to produce a stool that is soft, formed, easy to pass, and on a regular basis. Otherwise known as constipation, this quirk in the gastrointestinal system is connected to a myriad of more problems that need to be addressed. Often the underlying root problem of constipation is overlooked, as parents, doctors, therapists all aim to solve the other problems. As a wise doctor once said, “You have to be able to make the package and deliver it”. So let’s look at what contributes to constipation, how this creates further problems, and some ways to make a package and deliver it.
The Gastrointestinal System
In simpler terms, the GI system is a long tube that starts at our mouth and ends at our anus. The process starts when we eat and drink, whatever that might be. Digestion begins in our mouth using our jaw, teeth, lips, cheeks and tongue, and then saliva is released into our mouths to help break the food down. We swallow this food down our throat, through our esophagus and into our stomach. In the stomach churning begins, pushing the food around and breaking it down further, as more secretions from the stomach are released to help water it all down as it makes its way to the end of the stomach, and in a timely fashion, is released into the beginning of the small intestines. At this point more chemicals are released out into the body, sending a message to the brain that nourishment is coming in, and beginning to decrease our hunger, while also telling the GI system to move things along.
In the intestines, more secretions, from the gall bladder and pancreas, are received by the newly arrived stomach contents, which further breaks the particles of food down in this very fluid environment. Muscular contractions, known as peristaltic waves, move the contents along the small intestines, and these minute particles of food and fluid are pulled into our system in the small intestines to provide the nutrition needed for our bodies to function. About two hours after eating, chemicals are released into the body again, telling the brain that it might be getting hungry. Back in the intestines, the peristaltic waves continue to push the mix out of the small intestines and into the large intestines. There a spectrum of bacteria are found to further help the digestive process by feasting on any fiber in the diet creating a small amount of gas, and water begins to be pulled back into the body, thus creating what will become flatulence (gas) and poop. As the formed mass sits in the rectum near the anus, nervous tissue senses the presence and helps further push the contents out of the body.
What causes constipation?
Unfortunately so many things can mess this finely tuned process up, and contribute to constipation. With children, abnormal anatomy function is one, and includes low and high muscle tone, neurologic disorders, Hirschprungs disease, anal atresia or stenosis, lack of activity and immobility. Medications can also mess up the process, and a few known include analgesics, anticholinergics, anticonvulsants, antidepressants or antipsychotics, chemotherapeutics, and long term use of laxatives. Factors such as fatigue, anxiety, changes in routine or lifestyle, lack of routine, negative associations with eating/stooling, improper positioning, behavioral withholding, encopresis and inability of a child to let a parent or caregiver know they need to use a toilet. Diet is most often deemed the culprit, and lack of fiber or fluid is the go to blame. Although these two areas do contribute to constipation, other associated areas of diet include, poorly chewed foods (oral motor delays, low strength and endurance with eating), difficulty swallowing liquids (thickened liquid diet, dysphagia, nipple size, breathing coordination), excessive fluid losses (drooling, vomiting, fevers, renal conditions), and dairy or soy protein sensitivity (IgG, IgE testing, improvement when removed from diet).
Read Cindy’s Tips for Constipation here.
What is normal?
No specific ‘normal’ has been defined, as every individual can have their own normal when it comes to stooling. Some children may have a bowel movement every two or three days, while others may have two to three daily. In general it has been documented that a child may be at risk if they have a bowel movement less than three times in a week, and if this occurs over the course of more than 2 weeks. The goal is to have a soft, formed, easy to pass stool on a regular basis. Remember – make the package, and deliver it.
What might give one cause to consider if a child has constipation? Frequency of stooling is a clear identifier. But when a parent describes challenges with stools using terms such as rabbit pellets, Snickers bar, little smears, dry rocks, marbles, can pick it off of his diaper, goes into the corner and cries, paces the room first, we know when he’s pooping, and grunts loud and long an intervention should be considered. Other signs that a child is constipated can be very poor eating, small little portions of food or drink, behavioral challenges, vomiting, GE reflux, spit up, aversion to eating, and enlarged abdomen.
Causes of constipation are so many, and the resolution to this is not as simple as giving a child more fluid or fiber. In fact, more fiber with not enough fluid can compound the problem by increasing constipation. So when trying to help find the right solution, a multidisciplinary approach may be the best. Speaking to the child’s pediatrician is the first place to start, and sometimes the solution. Asking to consult with a
gastroenterologist may be the next step, or seeking the help of a registered pediatric dietitian/nutritionist to review the diet and make adjustments where needed. If the child is seen by any therapist, physical, occupational or speech, inquiring about tone, breathing, oral motor skills with eating and drinking can be helpful.
Physicians are often needed initially to help with the immediate concerns of constipation and alleviating the situation. Use of lubricants, bulk producers, stimulants and stool softeners can be very helpful. These include laxatives such as enemas, Senokot, Ex-Lax, Metamucil, Mineral oil, Colace, Miralax, and Lactulose.
Diet changes, assisted by a registered dietitian/nutritionist can include increasing sources of fiber in the diet through grains, fruit and vegetables. Increasing fluid intake through drinkable fluids, or higher watery foods such as fruits and vetetables, or pureed versions of these foods. Trialing off of dairy products, but incorporating other foods to help replace these nutrients. A physical therapist can help if the contributing factor is poor tone, and use of an abdominal binder, SPIO suit, abdominal massage, positioning, breathing coordination have been shown to help in some children. Occupational therapists can help children become more aware of their body, and learn to know when they need to stool if their awareness is poor, or help with managing behaviors that persist once the constipation has been resolved. Speech language pathologists trained in feeding can also ensure the child is managing their eating and drinking well, check respiration as well, and give solid points on positioning with feeding. Bowel management programs do exist, and these programs can help with management of stooling in a broader manner that includes much of what has been listed above, as well as management of timing through the day.
The bottom line (no pun here) is that everyone should be able to stool comfortably and easily on a regular basis. Food and fluid need to go in continually to help with growth and development of all children, and what goes in will ultimately have leftovers that need to come out. With little babies, management is much more controlled, as a parent has access to seeing what has come out in the diaper. But as children age, parents have less access to their child’s bodily functions, children are less vocal about what may or may not be happening, and challenges with pooping can go unnoticed and unresolved. The screaming, crying, pulling, difficulties with eating in infancy are clear signs of constipation that are not going to be seen as children age. But do know that older children who have constipation are going to demonstrate their discomfort somehow. Ensuring an older child is pooping comfortably on a regular basis is a must, and involves a bit more, uncomfortable at times, conversation. But in the end (again, no pun) it can solve a load (really?) of problems.
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