By: Cindy Baranoski MS, RDN, LDN Manager of Nutritional Therapy
Maybe you heard about this in the news last week, or maybe not. Either way, trying to make sense of what we should be offering our children to drink is always a dilemma. From the moment a baby is born, the question becomes, breast milk or formula. Breast milk being the optimal choice, but that’s not always possible, so formula is available.
Children less than 12 months of age should never be offered a bottle of straight up milk, but after 1 year, it is the go to drink recommended by everyone. Juice is often offered, but it is not the same as eating the fruit or vegetable. And sometimes in infancy, prune juice is given to help with stools, but that’s not a rule. Many children do not like milk, once done with breast milk or formula, and parents begin to offer anything to help ensure their child is hydrated.
Bring in the new options available for children to drink and it can be confusing to know what is best to offer. For example, plant based milks are all the rage now for many reasons, including allergies, family preferences, cultural reasons, and last resorts for a picky eater. They are flavored, unflavored, sweetened, and unsweetened. And the selection continues to grow, including rice, almond, coconut, soy, oat, hemp, split pea, cashew, and blends to name only a few. Though these may seem like a great alternative to cows milk, each one of them can be found fortified, unfortified, with added protein, or original version. Most plant milks are going to be lacking in protein, fat, and potentially key vitamins and minerals found in cow’s milk. Diet modifications can be made to help ensure what is lacking in a plant milk can be found in other sources in the diet. But if cow’s milk cannot is not the choice for whatever reason, plant milks with diet modification can work.
Juices have changed as well, with many companies offering non sugar
sweetened fruit and/or vegetable juices. Some companies offering cold pressed
and fruit/vegetable smoothies with additives, such as greens, protein and
vitamins. Use of sweeteners such as grape juice or artificial sweeteners
replace sugar and high fructose corn syrup. Juice is not the best option for
anyone to be consuming regularly, or in quantity, when the food brings so much
more nutrition to the diet that has yet to be identified or quantified.
And then there is water, but not just tap water, but bottled water, flavored water, sweetened waters, artificially sweetened waters, vitamin boost waters, and sparkling waters. As a general guideline, plain old regular water with nothing added or changed, is the best choice.
To help, the Academy of Nutrition and Dietetics, The American Academy of Pediatric Dentistry, the American Academy of Pediatrics and the American Heart association have made some updated recommendations.
Artificially sweetened beverages
“Low-calorie” or “Zero- calorie” drinks
Toddler and flavored milks
Sugar sweetened beverages
Less than 1 year of age: Do not offer juice
1-3 years of age: 4 ounces a day or less a day
4-5 years of age: 4-6 ounces a day or less a day
1-2 years of age: 16-24 ounces of whole milk a day
2-3 years of age: 16 ounces of skim or low fat milk a day
4-5 years of age: 20 ounces of skim or low fat milk a day
6-12 months of age: 4-8 ounces a day
1-3 years of age: 8-32 ounces a day
4-5 years of age: 12-40 ounces a day
Finally, whenever something is happening out of the ordinary with any child, and there is a struggle or question of fluids, seek the advice of a Registered Dietitian Nutritionist to help guide what would be best. Looking at the child as a whole, their full diet, development, family choices, help with recommendations being made for fluids. This will ensure children receive optimal fluids, contributing to best growth and development.
As the leaves begin to turn, it will soon be time to break out those sweaters and coats. This is a great time for your child to practice dressing their coat independently.
As an occupational therapist, I am always looking for ways to help my clients reach their maximum independence. As children become more independent, they develop more confidence and are more likely to try other challenges as well. For my clients that have fine motor difficulties, practicing dressing skills is a natural and routine way to help them develop their fine motor abilities. Independence with dressing occurs one step at a time, so we can start with dressing a coat as the first step.
Once a child is able to stand securely, or sit securely if they have postural difficulties, it is a good time to start. Here is the “over the head” method that I would start with:
Place the coat on the floor or a low table
Lay the coat flat with the inside facing up
Stand facing the top or collar of the coat
Bend over and place the arms in the sleeves
Lift the entire coat up and overhead
When the arms come down you are all set!
Zipping up a coat requires more precise fine motor skills and strength. I would start by having the child zip up the coat once you have engaged the zipper. When assisting your child with any fasteners, always stand behind them to give them perspective on how their hands should work. You can use a zipper pull to make it easier for your child to grasp the zipper. A quick online search yields many cute options, but you can also use a key ring that you have at home. A magnetic zipper is also a nice alternative while your child is working on manipulating a zipper. Several clothing companies offer this.
It is important to assist your child, while not jumping in too soon. Be sure to leave extra time, and focus on one step at a time. Once they are independent with this, then you can focus on promoting another dressing task. Good luck and stay warm!
To learn more about Easter Seals DuPage & Fox Valley occupational therapy services, visit eastersealsdfvr.org.
I often get asked the question “Should my child use a sippy cup?” It’s a difficult question to answer. Sippy cups were initially invented in the 1980s by a mechanical engineer who was sick and tired of cleaning up his son’s juice mess around the house. He uniquely devised a prototype for the no spill mechanism and just like that problem solved! He eventually sold his patent to Playtex ® and the rest is history as this became the go to type of cup for babies learning to transfer from bottle to cup.
I am sure you probably see tons and tons of children walking around the mall, playing at the park, and in the car with their sippy cups. This is the era of “to go” cups. Everyone, including adults bring their drinks (coffee, tea, water) to their next destination. I understand the convenience of sippy cups for parents and quite frankly I get it, but hopefully I can convince you to try out some other convenient cups that will support your child’s oral motor and speech development.
So why are they really SO bad?
Promote immature tongue movement pattern or suckle
Sippy cups promote an anterior-posterior tongue movement pattern, similar to the way an infant extracts liquid from a bottle or breast (suckle pattern). We want to begin to promote a more upward and backward swallow pattern for infants and toddlers by way of an open cup or straw cup. Sippy cups promote a suckle pattern especially with continued use.
Promote inappropriate tongue position for swallowing
The spout on the sippy cup can anchor the tongue tip down during swallowing. The only way for the tongue to move is forward. During a mature swallow pattern the tongue tip elevates to the area behind the upper teeth (alveolar ridge) as the tongue moves upward and backward.
Promote speech sound errors
Continued and overuse of sippy cups (and pacifiers!) promote the tongue to rest forward in the mouth. This inappropriate resting tongue position can directly impact your child’s ability to produce certain sounds. For example, a child may produce the ‘th’ sound (a frontal produced sound) in for an ‘s’ sound (‘tho’ for ‘so’). It is important to note that not all children who use sippy cups will have speech sound errors. My thought is though let’s set our children up for success by using developmentally appropriate cups!
Poor dental development and Dental Caries
Sippy cups can cause cavities and tooth decay. If your child is sipping on fruit drinks, milk, or any other sugary drinks, sugar can be left on their teeth which will cause the enamel to erode away. Sippy cups (and pacifiers!) can also cause misshaped oral cavities and affect resting tongue position.
Risk of Injury
In my research on sippy cups, I came across a study proving sippy cups can be dangerous?! Who would have thought?! A study conducted in 2012 by Dr. Sarah Keim at Nationwide’s Children Hospital in Columbus, Ohio stated every 4 hours a child in the U.S. is rushed to the hospital due to an injury from a sippy cup, bottle, or pacifier. Dr. Keim stated this likely occurs due to the child learning to walk. As they are learning to walk, they trip and fall often. If they have a bottle, pacifier, or sippy cup in their mouth they can injure themselves.
So what’s the alternative?
Many parents think I am crazy when I suggest an open cup for a young child. Yes, it may seem a bit ambitious, but an important step in the development of good oral motor and feeding skills! When children drink from an open cup they are developing a more mature swallow pattern. A smaller open cup (with a smaller rim) will allow your child to have better motor control of the liquid. You can first try giving your child an open cup to practice without liquid (place a preferred pureed on the rim of the cup) or you can use thickened liquid in the cup for a slower flow.
It may take your child some time to learn how to extract liquid from a straw, but be patient and the skill should develop! When choosing a straw cup choose a straw that is thin versus thick. Also make sure the straw is not too long. It is possible for young children to drink from a straw cup with a suckle pattern. Some children are able to extract liquid from the straw by placing the straw under their tongue. To avoid this, you can slowly cut the straw ¼ inch at a time until the straw is short enough that the child cannot place his/her tongue underneath it.
Here are a few of my favorite open cups and straw cups!
To learn more about development milestones and speech-language therapy services, visit eastersealsdfvr.org.
The popularity of using breathing exercises with children is on the rise. And, with good reason, because they work! When we focus on breathing fully and deeply, we move out of our sympathetic nervous system (fight or flight) and into our parasympathetic nervous system (relaxation and receptivity). Breathing exercises are effective for the frustrated 4-year-old, the anxious teenager, the overwhelmed parent and the stressed out teacher. There are an abundance of fascinating studies that have found that our body posture, facial expression and breathing, send messages to our brains about how we are feeling. Therefore, we can take control of our feelings by doing something different with our bodies.
Research has found that something as simple as mindful breathing can have the following benefits:
Increase our focus
Promote instant feelings of calmness
Regulate our mood
Increase our confidence
Increase our joy
Some families find it helpful to have mindful breathing integrated into their regular routines. For example, every time they are sitting in the car or at every trip to the bathroom they will participate in a simple breathing exercise. Taking a few minutes at the beginning of an activity can also be an effective way to get a child in a calm, ready to learn state or to reduce stress in anxiety provoking situations. Breathing exercises can also be an effective way of curbing a looming behavioral meltdown.
When teaching a child a breathing exercise, choose a time when the child is ready to learn. If a child is in an anxious or frustrated state, he will have difficulty processing the directions. Make the learning fun and multi-modal.
Use a real object, picture or imaginative visualization to teach a breathing exercise. I may show my little friend a stuffed bunny and ask: “Do you know how bunnies breathe!? A bunny takes 3 quick sniffs through its nose and then blows one deep breath through its nose. I wonder if you could breathe like a bunny?” or “Imagine you had a balloon! What color would your balloon be? Let’s take a biiiiiiiig breath through our nose and blow the air out of our mouth into our balloon. Wow, you made your balloon sooo big with those 3 big breaths!”
Here are my favorite, kid friendly, breathing exercises.
Teaching your child how to tie shoes can be frustrating for parent and child. This tricky dressing task relies on a variety of different components to work together such as: fine motor skills, bilateral hand skills, visual perceptual skills, sequencing, and attention.
Here are some easy tips and tricks I’ve picked up over the years to help your child be more successful with this tricky self-help task.
SET UP FOR SUCCESS
Practice Off the Foot
It is much easier to learn how to tie a shoe when the shoe isn’t on your foot. You can lace up an old shoe for your child to practice on, or you can make a “learning shoe” with cardboard or an egg carton.
Different Color Laces
Buy two pairs of laces of two different colors. This will help your child with the visual perception piece. She or he will be better able to see the laces and differentiate, and avoid a tangled mess.
Visual Check List
Print out the sequence pictures from this blog to make a flip-book and follow along as you teach. This can help your child sequence through the steps.
One or Two Steps at a Time
Learning all the steps at once can be overwhelming. Read your child’s motivation and/or frustration levels to know when to push forward and when to call it a day.
Set aside time to practice. Rushing out the door is NOT the time for learning. Set aside a time to work on shoe tying when you can go at a slow and stress free pace.
Ok great! Now you are set up and ready to learn the magic formula to teach your child how to tie their shoes…
MISS LAURA’S MAGIC FORMULA
Hold the laces
2. Make an “X”
3. What lace is on top? (blue)
4. Top Lace (blue) goes through the tunnel
5. Pull Tight
6. Make a loop
Not too big… Not too small…Not too far away
7. Blue lace goes aroouuund town
8. Drop it!
9. Thumb pushes bunny through the hole
10. Grab both bunny ears
11. Pull tight
Elastic shoelaces are great because they look just like regular laces and allow your child to slip on their sneakers without untying. This can be used as a great compensatory strategy or a temporary substitute while your child is in the process of leaning to tie shoes.
Despite your best efforts, if your child is still having difficulty, perhaps it’s worth an occupational therapy screening or evaluation to determine if there is an underlying fine motor, visual motor, bilateral coordination, or visual perceptual problem. An occupational therapist will be able to adapt this shoe tying task to better fit your individual child’s needs.
What is Constraint Induced Movement Therapy (CIMT)?
Constraint-Induced Movement is a therapeutic approach for children with one sided weakness such as hemiplegia, brachial plexus or other unilateral impairment. CIMT was originally utilized in the adult rehabilitation setting to treat post-stroke patients. However, it was found that children with one-sided involvement could also benefit from this type of treatment. Numerous research studies have shown that by restraining the unaffected limb and intensifying use of the affected limb, pediatric constraint induced movement therapy produces major and sustained improvement in motor function in children.
Children with one-sided involvement often experience “learned non-use” of the affected side. Forced use of the affected side helps to regenerate neural pathways back to the brain, increasing awareness of that side. This leads to increased spontaneity of use of the arm and improved function. The forced use is attained by the child wearing a constraint cast on his/her uninvolved arm for a period of time each day (preferably a minimum of two hours). The cast is made by an Occupational Therapist and is removable. When the cast is worn, this allows for mass practice of therapeutic activities with the involved arm.
What should a child hope to gain in an intensive program utilizing CIMT?
Typical goals of a CIMT program include improved quality of gross and fine motor skills and improved bilateral hand use for daily living tasks.
Family education will be provided on use of the cast at home, and home program activities will be provided to promote successful use of the involved arm and hand.
A skilled occupational therapist will help to develop specific functional goals for your child based on his/her specific needs.
Who is appropriate for constraint therapy?
Typically, children with a diagnosis of hemiplegia, cerebral palsy or brachial plexus injury (though any child with one-sided involvement could be considered).
This is generally used with children from 18 months to 10 years of age. Younger children have a more plastic neurological system and greater gains may be seen with them than with older children.
After finishing a session of CIMT, one parent couldn’t believe her child’s progress after four weeks of therapy.
My child’s time in constraint camp improved his fine motor skills and he had fun while doing it! He will always use his right side, but by putting on the cast, it strengthened his weak side and now he uses it more to support activities.
What does a session of constraint therapy look like?
At this center, a child is seen for 4 weeks of intensive therapy, 3 times per week. Each session lasts 2 hours per day. The fourth week focuses on bilateral training without use of the constraint cast in order to practice functional activities with both hands.
The therapy sessions of the CIMT program offered at this center should look like FUN! We work hard to provide a variety of play-based activities that promote repeated use of the affected limb.
Messy tactile play is used to promote increased awareness. Activities like giving farm animals a bath in shaving cream, building sand castles, and finding play bugs in dirt are just some examples of the way kids can get messy with their involved hands.
Activities to promote shoulder strengthening are incorporated through climbing over obstacle courses with ladders, slides, and tunnels.
A variety of grasp and release activities are used. Use of the “just right” size of objects is needed so the child can be successful.
Activities on a vertical surface such as finger painting on the wall are beneficial for getting shoulder movement along with wrist and finger extension.
The child will be constantly engaged in activities that will require use of his/her affected arm.
Two sessions of CIMT are offered this summer as part of our Community Based Therapy Programs. For more information on registering, contact our Intake Coordinator at 630.261.6287. Check out the additional Community Based Therapy programs like Aquatic Therapy, Fun with Food and social skills programs here.
Walking on the balls of the feet or “toe-walking”, is quite common in children just learning to walk. The good news is that many children out-grow it within a few months of walking. However, if your child is toe-walking beyond the age of 2, it is worth talking to your pediatrician about it, as there may be an underlying cause associated with this.
There are a few main reasons why children toe-walk:
Shortened Achilles tendon
A shortened Achilles tendon (bottom part of the calf) can cause less flexibility at the ankle, making it more difficult for a child to get his heel down when walking. When this is the case, physical therapy can help stretch the calf muscle group and strengthen muscles in the core and front part of the lower leg. This therapy can help the child learn to walk with a more typical “heel to toe” walking pattern. Sometimes your therapist will recommend a brace to wear during the day and/or at night in order to help get a child’s heel down when walking and stretch the Achilles tendon at night. In some cases, a series of casts may be used to help gain range of motion at the ankle. Surgery may be recommended for correction in rare cases or when “toe-walking” persists into later childhood.
“Toe- walking” can also be a sensory-seeking behavior. Children who need more proprioceptive input will lock their knees and ankles. Children may also lock these joints to feel more stable and better prepare them for physical activities, such as running. Some children walk on their toes as they are hypersensitive to different textures or temperatures on the floor. “Toe-walking” can become a habit and if done frequently, can lead to tight Achilles tendons. This is why, if you or your pediatrician feel like your child has sensory concerns, that they are evaluated by an occupational therapist to help with strategies.
Underlying Medical Diagnosis
If “toe- walking” persists beyond the age of 2 or if it is accompanied by muscle stiffness, difficulty with communication or language delays, coordination problems, or if your child toe-walks just on one side, it is a good idea to speak with your pediatrician about it so you can find out if there is an under-lying cause. Diagnoses including Cerebral Palsy, Muscular Dystrophy, Spinal Muscular Atrophy, Charcot-Marie Tooth and Tethered Cord have all been linked with early “toe-walking”. Some (but not all) children with Autism and other Pervasive Development Disorders (PDD) have also been noted to toe-walk.
Idiopathic “toe-walking” is used to describe a child who toe-walks without any known reason. Children who walk on their toes may have frequent falls, lean more forward when they walk, and show more difficulty with balance. “Toe-walking” may also be hereditary, where more than one child in the family toe-walks. Early recognition and intervention is fundamental to prevent a shortened calf muscle and help develop a normal walking pattern and balance reactions.
Many children “toe-walk” as they learn to walk, and with a proper heel-to-toe walking pattern, they learn fairly quickly. However, if you are concerned that your child is toe-walking beyond the age of 2, or is showing other difficulties with development, it is important to speak with your pediatrician. They may refer you to a physical or occupational therapist who can further assist you and your child.
Using visual schedules allows your child to see what is going to be happening in their day and the order of events. Visual schedules can be customized to meet the needs of each child. Getting started with a visual schedule can seem overwhelming, so this blog will help you recognize if your child would benefit from a visual schedule with ideas on how to get started.
7 Benefits of visual schedules:
Provides structure and predictability: Visual schedules prepare a child for what is coming up, which can reduce anxiety.
Eases transitions: Visual schedules are helpful in easing transitions from one activity to the next.
Reinforce verbal instructions: Most children process visual information better than auditory information. Words disappear after we say them and the visuals give language a lasting component.
Supports literacy development- Consistent exposure to written words can enforce reading of sight-words and provide an opportunity to practice reading through decoding.
Supports development of executive functioning: Visual schedules enforce planning, sequencing, completing tasks independently and the natural consequences of time management.
Supports conversation skills: Many childrenn have difficulty recalling and retelling previous events. Providing the visual framework of the schedule can help kids answer open-ended questions like: “What did you do today?” or “What was your favorite activity?”
Helps caregivers: Having a plan in place can be calming for adults. Creating a schedule helps the caregiver prepare for the day and use time effectively.
Decide on the format
Visual schedules come in all shapes and forms. When selecting a visual schedule format, consider which would be most functional for you to use, along with what would be most beneficial for your child. Some schedule forms take more preparation while schedules like line drawn images or written words can be done quickly and on the fly.
Here are some different types of visual schedules:
Apps on phone/tablet Tangible pictures with Velcro Line drawing images Written words
Decide on the length The length of the schedule will be based on your son or daughter’s needs and abilities. Some children may be able to use a whole day schedule while others will be overwhelmed by this amount of information and will need to see just one or two items at a time.
First/Then-This can be an effective format to introduce visual schedules without overwhelming the child with too much information. It can assist a child in getting through the non-preferred first activity by seeing that next, she will get a preferred choice.
It is beneficial to include your child as part of the process of creating the schedule. The slowed down, one step at a time, verbal explanations paired with visuals helps the child understand and prepare for upcoming activities. It can also be a nice opportunity for the child to have some autonomy and make choices about what their day will look like. Don’t feel that making a schedule means that you have to rigidly follow it. Life is unpredictable and having a change in plans is something that we all have to adapt to. The visual schedule can be a great tool to teach your kids about flexibility.
In my house growing up, meals were serious business. My parents had rules around “dawdling”, and playing with food was an absolute “no no”. Now, in my work as a pediatric occupational therapist, I advise the families that I work with to break these rules (and for good reasons).
Many of the children that I work with have sensory processing difficulties. Sensory processing challenges occur when a child has difficulty interpreting and responding to the sensory experiences in daily life. It is estimated that 1 of 20 children are impacted by a sensory processing deficit (Ahn, Miller, Milberger, McIntosh, 2004).
For some children with sensory processing difficulties, they have heightened sensitivity to textures, smells and tastes. These sensory over-reactions negatively impact a child’s ability to tolerate diets with a wide variety of textures, looks, smells and tastes. I have clients who eat foods that are similar in color, for instance all shades of white (crackers and chips). Other children eat foods that are munchable in texture, so graham crackers, chicken nuggets, and macaroni and cheese. One little boy that I worked with could not even be in the kitchen while his mother was cooking because the smells were so offensive to him. I remember clearly that he told me “food is not fun for me like it is for you”. That was a profound statement from a child of 5 years of age.
The good news is that I have seen great results in helping a child to expand their diet with work in therapy, and with the parents’ work at home. Many children do well with an individual while others do their best in a group with other children. I always start with a thorough occupational therapy evaluation, and assess the child’s sensory processing skills, motor coordination and fine motor skills. I work closely with speech therapists and a dietitian who specialize in working with children with feeding challenges. I want to rule out any oral motor and medical concerns before starting any kind of therapy with feeding.
The goal of my therapy sessions is to explore foods in a fun and low pressure manner. So dawdling and playing with food are an integral part of the work with my clients. Picture making towers of cucumber slices, while my client knocks them over repeatedly. Picture using those cucumber slices as goggles to look through. How about blowing peas off the table and into a bowl? I love making shapes and letters with cooked spaghetti noodles. These types of games provide my clients with the sensory experience of the food, but in a way that is very low pressure. The goal is not to eat the food initially, but to explore the foods in any way that the child can tolerate it. As the child is more comfortable with the touch, smell, look and taste of a food, the more likely they would be to eat the food.
For parents at home, I do suggest a time where the parent and child are having fun with exploring food, in any way that they can. I encourage families to have the child help with carrying food to the table, or pick out the vegetables at the market. Can the child mash potatoes? How about toss a salad? A child is much more likely to explore a food if they know that their parent is not expecting them to taste it.
Consult your child’s therapist to determine if your child would benefit from a sensory approach to feeding or contact Easter Seals DuPage & Fox Valley for information about our summer feeding groups.
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).
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.