Fiona McMahon PT, DPT
I spend a lot of my time at work talking about poop. In fact, poop discussions run in my family. My great grandmother, a nurse in the 1920’s, would always inquire about her charges and her children’s movements when they’d complain of any ailment. This scatological interest was passed to my grandfather, a civil engineer, designing and working in wastewater treatment plants, to my mother who was a nurse practitioner, who dealt with digestive issues and famously asked a guest at her parents’ dinner party when she was a child, “how are your bowel movements, lately?” This familial interest in the distal end of the alimentary canal was bequeathed unto me and I now spend much of my working life trying to help people of all ages with issues defecating to live more comfortable and full lives when it comes to bowel movements.
Anyone who has had any issues concerning their ability to poop, or to hold it, can attest to how much havoc issues with bowel movements can cause in one’s life. This is especially true when it comes to children. Children often have continence requirements to attend school, camp, and other activities. Not to mention other children may not always be very kind to another child who is experiencing difficulty with their bowels. Aside from the obvious issues of constipation and incontinence, kids with bowel issues can experience other symptoms like pain in their belly or with defecation, foul body odor, problems with their bladder, including incontinence, as well as skidmarks in their underwear or itchy bums. It really does all come down to poop.
The largest driver of bowel problems in kids is constipation. Constipation is surprisingly common and occurs in 4-36% of children. It accounts for 3% of visits to the pediatrician and 30% of visits to pediatric gastroenterologists. Constipation can be tricky to diagnose and many people who have children who are constipated, do not identify constipation as the culprit for issues like bowel and urinary incontinence, and pain. According to Afzar and colleagues, constipation would be missed nearly 50% of the time in children, if infrequent bowel movements was the only criteria used in assessing constipation in children.
So what criteria do we use to assess constipation in kiddos? We obviously look at how often a child is defecating. Two or less bowel movements a week is considered constipation, but it is important to keep in mind that a child with difficulty evacuating may move one or two small pellets multiple times a day and still be severely constipated. Check out the Bristol Stool Chart here to determine if your child’s BM’s are normal. Types one and 2 indicated constipation. Bowel incontinence is also an indicator of constipation in children. In fact, 90% of children with constipation experience fecal soiling. Kiddos with large fecal masses felt in the rectum by a doctor or through the abdomen, those with history of painful bowel movements, and those who produce large toilet clogging poops are exhibiting symptoms of constipation. Children with constipation may also exhibit retentive posture in an effort to prevent painful bowel movements. They may go up on their toes, squeeze their butt cheeks and thighs together, cry, and rock back and forth. Retentive postures can trick parents into thinking their child is trying to defecate when in fact they are working hard to keep everything inside. If you see any of these symptoms in a child under 4 years lasting for a month, and over 2 months in kids over 4, you are dealing with constipation
Constipation can be divided into two different types, functional and constipation due to an organic or pathological cause. Around 95% of constipation in both adults and children is considered functional. Functional constipation can occur for a variety of different reasons in children. One of the most common reasons is that children can get in the habit of delaying or trying to prevent defecation. Children are often just as busy as the rest of us. They may simply be too busy in the morning to have a full bowel movement. Once they arrive at school, they are faced with bathrooms that have doors that may or may not lock, or they may have to contend with intimidating multi-stalled public toilets. Either way both are not conducive to pooping. After school is usually filled with activities and a mad dash to do homework. You can see that it may be very difficult to schedule in a good time to use the toilet. Kids also delay going to the bathroom because it hurts or may be uncomfortable to go. The more they delay their bowel movements, the more uncomfortable it can be to go. Thus creating a negative feedback loop that just feeds back on itself and worsens the constipation symptoms.
Weeks of delay whether it be secondary to pain, scheduling, or plain old distraction, can cause a big build up of poo in the very end of the digestive system, the rectum. The accumulated fecal matter may be backed up through the entire length of the colon. This big build up of feces in the rectum causes it to stretch out. A stretched out rectum is not good at holding feces in, or sensing that it is time to go to the bathroom, making the problem even worse. Furthermore, soft poo will easily slide by the hard fecal blockage and create smears or “skidmarks” in the underwear, or even more severe incontinence mistakenly labeled diarrhea. Chronic fecal impaction, and fecal withholding can alter how the muscles that control continence work (the pelvic floor), which may further worsen this constipation syndrome. Skidmarks, constipation and fecal incontinence are not anyone’s fault, especially the child’s, but it is a problem that can be solved.
So what to do about all of this? Is it too late if your child has been constipated for a long time? Tackling poo problems in kids is daunting for both parents/guardians alike. The first step is educating yourself, your doctor, and your child. My motto for the kiddos that I treat is, “Accidents are not your fault, but it is your problem to solve.” Letting children know what is happening in their body can help them further internalize this message and become more invested in the process to remedy their symptoms.
Next you have to tackle the poo situation inside of your child’s tummy, This is where a two pronged approach is key. Both physical therapy and your doctor will get you on the right track. Your doctor will screen your child for that 5% of constipation cases that are caused by organic causes like Hirshprung’s disease, thyroid issues, and notably cow’s milk allergies and gluten intolerance/ celiac disease. It is important to be screened for these allergies and food intolerance as they represent a large portion of organic constipation cases. Once organic causes are ruled out, your doctor will start medication to help clean out the bowels. Miralax (Polyethylene glycol), is a mainstay of pediatric constipation treatment and is generally best tolerated. Miralax may be first given in large amounts to clean out the bowel, and then followed with smaller maintenance and then slowly tapered off as the rectum reduces from it’s stretched out size. It is important to remember that when starting miralax, especially at “clean out”, doses will likely increase episodes of incontinence at first, so prepare both yourself and your child. Make sure to consult your doctor before attempting any sort of clean out on your own.
Next up is physical therapy. Our main goal is to keep poo moving and avoid buildups so your child’s body can heal. We will teach you ways to massage the colon through the belly to keep poo exiting and to reduce back ups and the need for laxatives. We also work to teach your child to sit on the toilet in a way that will help the poo as easily and painlessly as possible. More often than not, kiddos with constipation have pretty weak cores that make defecating difficult. As pediatric physical therapists, I humbly assert that we are the masters at dreaming up fun ways to gain a little core strength in session and at home to help make bathroom trips easier.
What Beyond Basics does that is truly unique from non pelvic floor physical therapists, is we train the muscles of the pelvic floor (the muscles that control both the the anal and urethral opening to better open and close). Kiddos with chronic constipation tend to have pelvic floors that are tight and uncoordinated. Paradoxical contraction occurs when a child tries to open their anal canal, and they truly believe they are doing so, however they are I n fact clamping it shut. We can treat this problem at Beyond Basics.
If your child would benefit from physical therapy, or an evaluation, to make pooping a bit easier, give us a call. Stay tuned for our next blog, where we will go over some practical at home tips for improving both you and your child’s pooping situation!
Afzal N, Tighe M, Thomson M. Constipation in Children. Ital J Pediatr. 2011; 37
Poddar U. Approach to constipation in children. Indian Pediatri. 2016;53(4) 319-27