"My husband and I are both professional people," the mother of the two-year-old shared over the phone, "and it seems like all we talk about is poop."
"Not to worry," I reassured the mom, one professional to another, "poop is my life." For in the pediatric world, there's usually either much too little or way too much pooping going on.
Today we'll stick to talking about the "too little" pooping problem. Constipation is a common pediatric condition, with a significant physical, psychological, and it turns out, financial impact on affected children and their families.
According to Dr. Olivia Liem and colleagues writing in the Journal of Pediatrics, the cost of medical care for constipated children in this country runs at least three times higher than services required by their peers. The team also notes that about 30 percent of constipated children go on to wrestle with stooling problems past the time of puberty.
A few children will experience constipation as a result of a medical disorder such as celiac disease, underactive thyroid, or a spinal cord abnormality. However, in a joint North American and European clinical guideline published in the Journal of Pediatric Gastroenterology and Nutrition, specialists explain that for most constipated children, an underlying disease process is never found.
The GI experts refer to this larger category of children and adolescents as suffering from "functional constipation." Children with functional constipation are generally healthy, with normal height, weight, and growth patterns as well as normal physical and neurological exams. These patients also show two or more specific stooling characteristics such as having BMs two or fewer times per week, and eliminating BMs that are painful or toilet-plugging.
The gastroenterology guidelines encourage a normal fluid and fiber intake for constipated children and note that the evidence does not support the use of pre- or probiotics in the treatment of pediatric constipation.
Drugstore shelves are bursting with a variety of other products marketed specifically for functional constipation. One product which has made its way to the forefront of pediatric treatment is polyethylene glycol -- one brand name version is MiraLAX -- a powder mixed in liquid and then taken by mouth. PEG is an osmotic laxative which draws water into the gut, resulting in the production of softer and more frequent stools.
In reviewing the medical literature, the guideline authors find that rectal enemas and high-dose PEG are equally effective when "fecal disimpaction" is needed, but since PEG is able to be taken orally, it is the preferred choice in this situation. PEG also appears to be more effective than other oral agents in the ongoing treatment of pediatric constipation, and it is now considered first-line for this maintenance therapy.
Constipation is challenging to treat and there are rarely "quick fixes." In fact, the collaborative GI societies recommend a minimum of two months of maintenance therapy.
Discontinuation of constipation treatment is not advised until the child has been symptom-free for at least one month, and when treatment is stopped, it should be done gradually.
University of Michigan specialists encourage parents to maintain a positive outlook when dealing with constipated children. A calm approach with routine set times on the toilet, particularly after meals, can help.
The group notes that holding on to the toilet seat can increase muscle tension, making bowel movements harder to accomplish, so kids' hands should be on their knees and little feet should also have the support of a stool to help with pushing.
Interestingly, some researchers promote the anatomical value of the full squatting position for stooling purposes. As Japanese researcher Ryuji Sakakibara and colleagues note in the Journal of Lower Urinary Tract Symptoms, squatting was historically the position mankind assumed when going, with toilet sitting only recently introduced with the invention of the modern day sanitary sewage system.
The Japanese study concludes by suggesting that "the greater the hip flexion achieved by squatting, the straighter the rectoanal canal will be, and accordingly, less strain will be required for defecation."
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights