Kids' Wellness Matters Podcast Ep. 26: What To Do When Your Child Won't Poop

Everyone poops. And when it comes to kids’ health, poop is a big deal. In this episode,  Dr. Peter Osgood, a pediatric gastroenterologist at Lurie Children's and the founder of the iPoop Constipation Management Program, explains that constipation is one of the most common issues addressed in pediatrics and offers solutions to help “get things going.” 

“Don't be too scared about overtreating. We can definitely use laxatives very safely. We can use them in the short term and the long term. Sometimes we may tell you that they need a very high dose of things to really get things going. But again, it's all intended to be very, very safe. And there is a light at the end of the tunnel.” 

-Dr. Peter Osgood 

Show Notes 

• Most children stool between one to four times daily. Constipation is defined as fewer than two bowel movements per week, or if stools are painful and difficult to pass.  

• Infant stooling patterns have an even wider spectrum of variability, ranging from stooling after every meal to once every two weeks, depending on if the child is breastfed or formula fed.  

• When it comes to consistency concerns, like hard or painful stools, parents can use the Bristol Stool Chart to help gauge stool health, with “type 4” (soft and easy to pass) being the goal.  

• The iPoop program was designed to help parents more quickly assess and remedy the extremely common issue of constipation, including creating a custom treatment plan and ruling out red flags.  

• The toddler years, especially during potty training, can be an especially trying time for both parents and children, as toddlers are still learning body awareness when it comes to stooling and how to lean into these normal digestive functions.  

• A painful stool can cause a child to understandably become resistant to pooping. Such a child might engage in stool withholding, which can look like tensing the entire body, stiffening legs or verbalizing strong disinterest in pooping. 

• Culprits behind constipation can include fiber intake levels, dehydration, changes in routine (such as travel), and change in diet.  

• While common myths about laxatives instill doubt in some parents, research shows they are safe and effective.  

• Unfortunately, constipation can become chronic for some children, leading to fecal soiling, which can cause social anxiety and emotional distress for many children. In such cases, more thorough evaluation is needed to rule out a deeper, underlying cause.  

• No matter the cause, it is crucial for parents to create a positive experience for children around stooling, helping children understand that pooping is completely normal and doesn’t need to be embarrassing.  

• Dr. Osgood’s advice to parents is to not be scared about overtreating, to not withdraw therapy too quickly, and to be proactive about working closely with their child’s doctor on creating a custom treatment plan.  

Transcript 

[00:00:00] Dr. Nina Alfieri: Welcome to Kids' Wellness Matters. I am Dr. Nina Alfieri. 

[00:00:07] Dr. Rob Sanchez: And I'm Dr. Rob Sanchez. We are both parents and pediatricians at the world renowned Ann & Robert H. Lurie Children's Hospital of Chicago. 

[00:00:15] Dr. Nina Alfieri: On this show, we'll chat with a wide range of experts about caring for children from newborn to young adults because kids' wellness matters. 

[00:00:30] Dr. Rob Sanchez: Let's just get this out of the way. Today's topic is full of potty talk. Specifically number 2. 

[00:00:36] Dr. Nina Alfieri: Yep. Which in my mind is sometimes number one. That's right Rob. Everyone poops. And when it comes to kids’ health, poop is a big deal. In all seriousness, constipation is actually one of the most common things we see in pediatrics, right Rob? You know, it can affect everything from a child's comfort and appetite, their potty training and even their ability to go to school and play without anxiety. And because it's hard for kids to describe, oftentimes it underlies a lot of behavioral changes or other things going on with the kids. So it's always important to think about. 

[00:01:10] Dr. Rob Sanchez: And yet as common as it is, it can be one of those things that parents sometimes feel embarrassed to talk about, you know, as if it's not a quote unquote real medical issue. But it is. And if your kid is having issues with it, such as withholding or experiencing discomfort, it can become a big problem. Which is why I am so glad we are talking about it and the conversation you had to really shed some light on this, you know, important potty issue. 

[00:01:37] Dr. Nina Alfieri: Absolutely. I'm so thrilled to be joined by Dr. Peter Osgood, who's one of the leading minds in treating constipation and in thinking about intestinal motility. Dr. Peter Osgood is a pediatric gastroenterologist at Lurie Children's and the founder of a brilliantly named clinic, the I Poop Constipation Management Program, and it is helping kids and families get real relief when they need it most. 

[00:02:01] Dr. Rob Sanchez: He's gonna help us flush out the facts. Yes, pun intended. And breakdown parents need to know about poop treatment options, common myths, and a lot more. 

[00:02:10] Dr. Nina Alfieri: Welcome Dr Osgood. 

[00:02:14] Dr. Peter Osgood: Thank you, Dr. Alferi I'm very happy to be here and I’m very glad to work with you and so many other colleagues at Lurie Children’s. 

[00:02:22] Dr. Nina Alfieri: Well, let's start with the basics. So what's actually normal when it comes to kids pooping? How often should kids poop? And what are signs that something might not be going right? 

[00:02:32] Dr. Peter Osgood: Sure. At least as we start to talk about childhood and up, most toddlers, young children in school age and adolescents are gonna be stooling anywhere from one to four times per day. At least 90% of children go at least every two days. Those are general. common frequencies for us. The poop should be soft, and if the child is developmentally appropriate to be potty trained, these should be controlled and voluntary and occurring on the toilet. Now the definition for clinical constipation is when someone is stooling two or less times per week. Or if the stools are becoming excessively painful or difficult to pass, or if they're showing signs that the stool is retained, so they're having bad abdominal pain, they have an obvious mass in their rectum or belly from the retained stool, or the stools that they're passing are excessively large and clogging the toilet. Sometimes when this occurs, these patients actually end up with a great deal of fecal incontinence. So it’s actually quite common that we have families coming to our office saying that their child's, for example, has diarrhea that keeps occurring in their underwear, when in fact it's the exact opposite. And this incontinence is completely involuntary. It's happening when children simply have too much stool accumulated in their body and they don't have the physical control. 

[00:03:50] Dr. Nina Alfieri: I think that's such a key point, and I remember that being a big “aha” moment for me when I was training as a pediatric resident because a lot of times, you know, we worry a lot about the diarrhea, but really the core of the problem is the constipation, which is really needs to be treated for the stooling to be normal. So, I appreciate that and wanna star that because I think that's really important. Can you talk a little bit about the difference between like newborn and infant stooling and stooling and older kids and teens? What's normal for babies? A lot of parents come into my office worried about grunting with pooping and newborns. So what's the deal with that? 

[00:04:24] Dr. Peter Osgood: Newborns are a bit of a different ball game. It can be very widely variable in that age range. Especially for breastfed children, they may poop with every single feed, or they may poop once every two weeks, and it's an incredibly wide spectrum. Many babies do grunt or strain when they're trying to poop. And that's often just a normal developmental finding. And the way I usually explain it to parents is that they are still learning how to use all the parts of their body and they don't know what to do. So oftentimes they're bearing down and squeezing every possible muscle in their body, grunting, straining, turning red until eventually something gives and the poop comes out. Lots of times those babies need some support. Many parents have to use a thermometer or a suppository for some rectal stimulation. And that can help the child pass the poop. But it's not always pathologic. It certainly can be. So we start to worry about it if children are showing other worrisome signs, which I think we'll talk about probably a little later. But there are definitely a few red flags that go up that make us think that this constipation could be a sign of something bigger. 

[00:05:33] Dr. Nina Alfieri: That's really helpful. And one of our chief residents at the conference always says, if the poop is not the Chicago Bulls color, so not white, black or red, and it's soft, you're good. And I think that's a great rule of thumb. And another plug for infants with trouble pooping, tummy time can be really helpful to build up those muscles and help them with beefing up so they can poop easier. So you talked a little bit about the frequency of stooling. Tell me about the consistency of stooling. How do gastroenterologists think about different types of stool and how does that help you with diagnosing and treating constipation? 

[00:06:05] Dr. Peter Osgood: Oftentimes we're trying to get an assessment of patients and really understand as objectively as possible what's going on in their day to day. It's often hard for families and especially young kids to really describe what the poop is like. So we often actually use a visual scale to help them reference what they're seeing, and then we can help make a decision as to whether this is normal or not. So oftentimes we use the modified Bristol stool chart. Which is actually a, a visual scale of different consistencies of stool ranging anywhere from tiny little hard pellets to larger hard masses to the normal soft, easy flowing pieces of stool to progressively looser or liquid stools. So that ranges anywhere from one to seven where one is, you know, completely solid and hard little pieces, and seven is complete liquid. The kind of ideal range for most of us is to be right in the middle. So the Bristol four is a nice, soft formed piece of stool or a Bristol three would be a slightly drier, bumpier version. And either of those are generally considered okay, as long as we’re going enough and not having any downstream effects. 

[00:07:16] Dr. Nina Alfieri: That's great. It's helpful to have a scale to compare to, because like you said, it can be hard to describe. Tell me a little bit about the iPoop program at Children's. What is the program? What's the goal of it and how can it help families? 

[00:07:29] Dr. Peter Osgood: Constipation is one of the most prominent concerns that patients are referred to in gastroenterology for in childhood. 

 It probably makes up at least a quarter of our referrals. And we recognize that a lot of families really struggling with this, especially if their child is constipated and refusing the toilet or they're having trouble getting through their school day because of their symptoms, or if they're having incontinence and they're not able to maintain their normal social needs the way they're supposed to. So the iPoop program was really developed as a way to get children in to help address this problem very quickly and specifically with the idea that we would assess them, see if there's any red flags that go up that make us worry that there could be a bigger disorder at play and help them get rid of any retained stool start a regimen that will get them going more regularly and then bring them back for a follow-up visit whereby we could adjust that regimen with plans for families to wean the therapy over time as their child did better.  

If families have patients who have asthma, for example, lots of times kids get an asthma action plan where they know, you know, what medicines they need to use every day and then what medicines they need to use in emergencies. And we tried to develop a similar model with the iPoop Clinic. So that families had a sense of what do they do when things are exacerbated and getting worse and what do they need to do for their maintenance day-to-day. 

[00:08:53] Dr. Nina Alfieri: That's wonderful. I'm so glad that this program exists and it's so great to hear about how it can help with all of the biopsychosocial effects of constipation for the child and for the family too, because I know it can be really distressing when your child is going through that. 

[00:09:09] Dr. Peter Osgood: Absolutely. We've been really fortunate, too, that a lot of the Lurie Children’s network, a lot of the general pediatricians in the Chicagoland area have referred patients to this program and they've also been very eager to learn from us and with us. So we've done a number of sessions with pediatricians through the community to talk about constipation and our approach to things. And I think a lot of general pediatricians are starting to employ our practice within their own clinical practice. So a lot of families are seeing this right from the get go when they're having their regular well checks as well. 

[00:09:44] Dr. Nina Alfieri: That’s wonderful, I think the community engagement aspect is amazing. Tell me a little bit about a specific time in a child's life when constipation can become a big problem: Potty training. What is the deal with potty training and constipation, and why is this milestone such a big deal and such a concerning area for constipation? 

[00:10:04] Dr. Peter Osgood: I mean, we can certainly see constipation present at any age or stage of life. But I think the toddler years and especially the timing focused around potty training is one of the major hurdles families have to get over. If you ever heard the psychological term “anal retentive”, that literally comes from toddlers. It’s  a stage of life where one thing they can control is their bowel habits. They start to have that mental awareness of what's going on with their body, what that feeling is to stool, and how they can either facilitate it or resist it. And if you have a toddler, you also know that you can't negotiate with them. You know, they're very steadfast in their ways. They are very assured about what they want or don't want, even if it doesn't make any rational sense. And it's very difficult time. So when they have that agency over their bowel habits, it can go very smoothly, they may embrace it and really run with it, or they may really resist.  

The other important factor of that age group is that their diets have changed. You know, as an infant, they're, they're taking predominantly breast milk or formula, largely liquid based foods. And then eventually taking purees and other very soft, mushy items. But then as you get into the toddler years, they start taking more and more solid foods. Just normal development dictates that they're gonna be more selective, maybe a little more cautious about some of the things that they put in their mouth. And sometimes that diet gets very limited. So as their intake changes and their body grows, so their colon gets longer, it takes longer for stool to pass, water gets absorbed more, and they have this control over their pooping habits, it can be this perfect storm for constipation to occur. And oftentimes I think we find that children start to have some hard stool, and then they get scared and their brain is trying to protect them. It's telling them, you know, this hurts. Don't do it. Then they continue that process, they resist, but then by the time the next poop comes, it's even more painful than the one before. And many children get really stuck in that cycle where they're scared to poop, they don’t let it out and then the cycle keeps repeating itself over time 

[00:12:14] Dr. Nina Alfieri: This can be a huge barrier to potty training. And I know it's a podcast, so I can't star things, but if I could star this, I would. There's also the, being positive about pooping can be really helpful. I think society sends a lot of funny or negative messages about poop and kids are learning so much at this time. So, making potty training fun and exciting and trying to avoid negative associations with stooling, including constipation, I think is so important. So that's such a great point. I appreciate you making it. 

[00:12:44] Dr. Peter Osgood: Absolutely. 

[00:12:45] Dr. Nina Alfieri: Let's talk a little bit more about stool withholding. So, what signs should parents look for and what should they do when they spot their kid holding it in? I know there's like an image in everyone's, every parent's mind right now of their kid, like huddling behind a couch right now. But what, what do we do? 

[00:13:02] Dr. Peter Osgood: Yeah, that's very common. And I think sometimes too, some of the signs young kids can give us, can be misinterpreted. I think when you see a child very clearly tensing their entire body, stiffening up their legs or, or verbalizing that they don't want to pass a stool, then it's very obvious that they're withholding. But sometimes kids will squat down, for example, and families think they're, they're trying to go, but, but really they're trying to take the pressure off their belly. So kids will posture themselves in a number of different ways, and I think it's important for families to recognize that whether or not it looks like they're going, that might be a cue that they are withholding. And using that time to say, hey this is all okay, this is a normal part of life, I think is very appropriate.  

For children who are very resistant to the toilet at that stage, it may not be getting them to the toilet. Maybe it's letting them go in the diaper at that point in time. And that may be very appropriate for that moment. And then over time, when the child gets more comfortable with at least passing stool in their diaper, then they can start to continue the toilet training process at the child’s pace. But you’re exactly right, we always want this to be a positive experience. We don't want the child to be fearful or afraid of something that they’re trying to get over their fear of. 

[00:14:15] Dr. Nina Alfieri: That's really helpful. And what are the usual culprits behind constipation? Is it different for toddlers versus school age and older kids? 

[00:14:23] Dr. Peter Osgood: There's definitely a number of different factors. I think, you know, we talked about some of them when we talked about toddler potty training. A lot of it has to do with normal growth and development. As well as changes in their diet. I think in the toddler years too, a lot of families worry about fiber intake because children often get very selective about the foods they eat, and it's very common for them not to take sufficient fiber. And especially with traditional western diets where we have more and more processed foods, the foods that are readily available and easy for us to use a lot of the time don't necessarily have a lot of fiber. So while that's not the only component it's certainly a factor and I think all of these can contribute. Some of it too is just routine. So if children are in the home setting versus the school setting, or, you know, daycare, other family members' homes, whatever it may be, when they're out of their expected environment, that can really contribute to how they react to  toileting. 

[00:15:20] Dr. Nina Alfieri: That's a great point. I'm thinking about traveling and road trips and all, all kinds of changes. I'd like to get a little bit more into diet because I think that's so closely entangled with the issue of constipation. You mentioned a couple of the high points like fiber. Talk to us a little bit about high fiber foods, about some other foods which can help treat constipation or prevent it. 

[00:15:42] Dr. Peter Osgood: Well, we know that fiber is definitely important to our long-term gut health. The adequate fiber can definitely reduce the rates of constipation in all ages, children to adults. Most, any fruit or vegetable is gonna have a decent amount of healthy soluble and insoluble fibers that can help our gut work appropriately and help keep our poop soft. As long as these fibers are intact, meaning that they're coming from a raw or a cooked vegetable and not something that's been juiced or strained, then the fiber is there. So I think offering children a diverse diet with a mix of fruits and vegetables, whatever you can get them to accept. I mean, I know, I know toddlers may change their preferences every couple of weeks. Whatever you can get in them is probably gonna be a good source of fiber. Additionally, adequate water. So making sure, especially as we come into the summer months, that children are drinking regularly and staying hydrated because that's what actually lets the fiber do its job. Now I think it is important to note on this front though that fiber isn't often our first line treatment for treating constipation. So if a child is already constipated, this may not be the best evidence-based treatment regimen. 

[00:16:53] Dr. Nina Alfieri: And while we're talking about treatment regimens, tell me a little bit about laxatives, stool softeners and some of the medications pediatricians and GI specialists treat constipation. Are they safe? Should they be used long term? What are some of your go-to treatments for constipation? 

[00:17:12] Dr. Peter Osgood: Yeah, I think more and more families are very, very cognizant about what they're putting into their kids or not putting into their kids. Especially trying to promote good natural remedies whenever we can and avoid anything that could do harm to our children. And I think that's very, very honorable and just certainly the right mindset to have. I do think a lot of laxatives have gotten a bad rap for it. I think a lot of families are very nervous about using these medications. Whether it's fear about doing harm from things they've read or heard about, you know, harmful effects of medicines or sometimes even shame that they may have about having this as a medical problem. You know, many, I think, many families think that constipation isn't a big deal. We should be able to fix this with diet and fluid and my kids should be over this quickly. But that's not always the case. And I've even met some families where there's almost some shame that they feel from older generations where perhaps you know, they feel bad that their child has this problem or that they have to give medication. And perhaps a grandparent is saying that, oh, you know, you don't need to do that, I never needed to give that to you. So, I've seen a lot of perspectives that make families really question the use of these medicines. 

[00:18:23] Dr. Nina Alfieri: And we're here to normalize use of it because it’s so common. 

[00:18:25] Dr. Peter Osgood: Exactly. Exactly. Like I said, this is a quarter of the referrals to gastroenterology offices and it's very, very prevalent. So many families are struggling with this and it is very treatable if we do it effectively. And you know, life can get better once we've managed it effectively.  

And the medications are ultimately very safe. So typically we use different types of laxatives. So there are stool softeners, what we call osmotic laxatives that actually stay within the gut and they attract water to stay in the gut so that the poop stays softer or mushier. And the most common one that families will see is, is polyethylene glycol or the, the brand name most people recognize as MiraLax. Some other versions may include things like lactulose, which is a sugar that we can't digest. That's very useful in babies when they may be more amenable to taking something concentrated and sweet. Another common family we use are the stimulant laxatives. The most common one in pediatrics is probably Sena, because this comes in a number of different varieties that are perhaps more kid friendly. And then one of the more common ones we see as children get older, or as we get into adulthood is called Bisacodyl. 

 I think a lot of families have a very negative opinion of polyethylene glycol or Miralax right now. There's been a lot of talk about potential neurologic side effects from this. So they talk about rising rates of autism or developmental delays or other neurocognitive disorders. And I think that those concerns are very widespread and make families very nervous about it. But fortunately, we don't really have good evidence to show that those rumors are true. I think there's one very good example. There was a study done at Nationwide Children's in Columbus a number of years ago where they tried to address that particular concern. And they had some patients who took polyethylene glycol to treat their constipation. And they had some patients who were not constipated and never had to take the medication. And they took blood levels of the, the smallest of the polyethylene glycol molecules from each group. The ones who had just taken their medicine, you know, within, whatever interval and those who had never seen it. Because the concern was that the very smallest of these molecules could potentially get into the blood and then cross into the brain and those could be what causes all those neurologic side effects. So when they looked at the blood levels of those three molecules in those two groups, they found that they were exactly the same. So it really seems that, you know, we're, we're always exposed to some hazards just in our day-to-day environment. So we see some of those molecules around us at any given point in time. And of course we have some low levels in our blood. But in the case of taking medication, we didn't see any difference. So it doesn't seem like, actually consuming this medication ever absorbs into the bloodstream and presumably does not ever cross into the brain because of that same observation. 

 A lot of families also worry about the stimulants. So things like, Sena. There's, I think, a pretty large rumor that these are very habit-forming. That if we make the gut reliant on these drugs, then the kids are never going to be able to get off. But fortunately we've never really observed that. We know that most people are gonna have a very time-limited course of constipation and that as they grow and thrive and do better, their colon is going to adapt, their diets are gonna become more diverse. And in the vast majority of cases, we're able to wean them off the medication over time. So yeah, so I, I, I think my, my main point is that yes, there's a lot of rumors going on around the use of laxatives, but for the most part we haven't actually been able to validate any of the concerns that are out there. And if anything, we've just shown that these are very safe and can be used very and effectively in both short and long-term cases. 

[00:22:16] Dr. Nina Alfieri: That's really reassuring. I appreciate you going over that because as a parent myself with an Instagram account, there is so much information out there and some of it is, is very good, but a lot of it is, you know, can cause a lot of fear and a lot of anxiety 'cause none of us, parents or physicians or any other healthcare provider, nobody wants to recommend something that is dangerous for a child. So I appreciate that there is research out there looking into this and that it's been reassuring.  

I was really happy to hear that oftentimes in your experience, constipation can be an acute issue for some time and in many cases tends to sort of boil over and get better as a child ages. And that's certainly often my experience as a general pediatrician, too. But for some kids, constipation can become chronic and can really lead to other challenges like fecal soiling or school refusal and there's certainly a large component of social interaction for kids that's difficult if you’re struggling with constipation. So what impact does constipation have on quality of life?  

[00:23:18] Dr. Peter Osgood: Absolutely. I mean, I think in some cases it's very, very obvious. Like if a child is complaining about belly pain, you know, it's probably very front and center and parents notice that this is a problem. If it's impacting how a child feeds or grows, then it becomes a very obvious issue. But I think one of the ones most families notice, as you noted, is the fecal soiling. So when children are withholding stool, this actually makes the rectum stretch bigger and bigger. And as it stretches the child's, you know, the muscles are actually losing some of their function, their ability to squeeze and contract and push the poop out. And the child is really losing sensation, you know, they have been so stimulated from that large retention of stool for so long that their brain's just not really registering that it's there anymore. And then that leads to the bits of stool leaking out without the child ever being aware. And I think especially as children get older and into school age where other kids can notice and where kids start to tease each other then it becomes very socially unacceptable and it can become very scarring to those children. So we definitely noticed that this is a major social challenge for many, many kids. And we of course, wanna mitigate that and help them get through it so that they do not have to deal with teasing or embarrassment. And so we can keep them going to school and feeling good about going to school and then avoiding other emotional or mental disorders down the line. I think this is often a big reason why families come to us. I think too that when constipation does become very severe it can certainly affect how a child feels and how they feed and grow.  

In some scenarios, you know, we do see constipation get so severe that the medications were, were often employed in our office, like the I Poop Clinic, just don't work anymore. So in some cases we really need to pursue other evaluations. Trying to figure out if these children have a bigger medical disorder. Like do they have celiac disease or thyroid disease? Did their anatomy form properly? Or do they have a broader issue with how their gut moves or doesn’t move? So oftentimes, when we find that the impact of constipation is very severe and our typical medications just aren't effective, we actually start to bump them up the chain and then that's when I start doing more evaluation about the child's motility. I usually start working with one of our colorectal surgeons to talk about possible surgical treatments. And this can be very daunting for families. I think a lot of families come in very scared and unsure if this is really the right move. But in those scenarios, when constipation has really dominated so much of a parent and child's life, then ultimately these therapies are still very effective. They're still very helpful. And just as we do with medications most of the time, we're able to wean these therapies and get children back to normal life without constipation therapy over time. 

[00:26:17] Dr. Nina Alfieri: That's great and it's one of the reasons why I'm so grateful to have your clinic at Lurie Children's because your team has helped so many families through some of these really tough cases and tough situations, and I can see how great it is on the other side when this becomes managed and the child is able to flourish in their school and their home environment. So I'm really glad that there's treatment for each level of constipation that we see or motility issues. For parents who are struggling to stay consistent with treatment, what advice do you have? How long should they expect the journey to take? I know that staying on medication for a long time can be tricky for many reasons, but what's your view of the course of constipation? 

[00:26:59] Dr. Peter Osgood: The rough estimate, and I often give parents is however long they've had, constipation is probably, at least the duration we're gonna be treating their constipation. And that's, you know, give or take, it's, it's, it's not never exactly true, but, you know, we see a lot of families when they've come to us and they've really been struggling with things for a while. The child's had progressive incontinence more and more over time, and then they're finally kind of at wits end by the time we're seeing them. But I usually tell families, like, regardless of where they're on that spectrum the treatment's probably gonna take a number of months. Again, using the laxatives for a number of months, sometimes even many years, can still be very very safe and, you know, not problematic. But the big reason that we try to continue therapy consistently for a long period is because we're trying to get a dilated colon to shrink back down so that the child gains more function in the colon, they have better sensation and they're able to control their bowel habits again. Additionally, the longer we give them the support with medicines it gives us time for a child to modify any behaviors that they were doing that may have led to the constipation in the first place. So the toddlers who are resisting the toilet, who are scared to go, were really trying to teach their brain that “hey, it’s okay to poop, poop does not have to hurt” it's not always going to be a distressing situation when you go on the toilet. So we really try to give kids the support for as long as they need until they're actually at a point where they're consistently functioning normally going normally on their own again. I usually tell families I want them to stay on the medicines for at least one or two months after they're doing well. I wanna make sure that they've really ingrained those habits well before we start to reduce or withdraw their therapy. Lots of times in the months or years following therapy, relapses can still occur. So a lot of families still need to give laxatives, at least intermittently. You know, maybe they go traveling and you know, the child’s in an unfamiliar bathroom, or they've had an abnormal schedule, they've had an atypical diet for them and things change. So it is very common for kids to have relapses over time, but oftentimes if we've treated things effectively upfront those relapses are pretty minor and a lot of  families are probably aren't even coming to us, they're probably handling it on their own by that point. 

[00:29:19] Dr. Nina Alfieri: You talked a little bit earlier about some of the conditions that constipation can look like, but you know, after trying certain levels of treatment there becomes a concern for other issues. So what are some red flags for constipation and when do we need to worry about something more than constipation? 

[00:29:37] Dr. Peter Osgood: Absolutely. So while well over 90% of the cases we see are otherwise normal, healthy kids with idiopathic or functional constipation we definitely see a small number of children who do have another disorder that's contributing. Some of the big red flags I look out for. You know, when we talked about infants, we said that, you know, many kids are gonna strain to poop just because they don't have the muscle skills to, to poop effectively yet. And that can be normal, but if we found that, hey, this infant did not pass poop within the first two days of life. If their butt actually looks abnormal, if it looks like things are out of place. If an infant is having incredibly hard small stools, things that just aren't the normal mushy baby poop then we start to worry about another disorder. The same in older kids. If they have, you know, other signs and symptoms of something going on, if, especially over time when we watch their growth, if their weight or their height aren't progressing as expected, especially if they had an abrupt change around the time of the constipation symptoms starting then we have to think about other disorders. Or if a child has any neurologic complaints, they're not walking appropriately. If they're having difficulty with like leg pain or tingling pain, or if they've had issues with their bladder, like problems controlling their urine appropriately, or urine infections, UTIs then we really have to start to think about other medical diagnoses that could be, a common variable that's causing them to have these issues. Biggest on my list is, you know, growth and, oh I guess one other caveato that, especially as I talk to a pediatrician, weight curves can be deceiving. So if a child has a massively distended belly, they may have a lot of extra poundage there that makes their weight curves appear normal. But if you examine them and they clearly look malnourished, but they just have this big belly, then that's a big red flag to me that, because maybe, you know, maybe we were falsely reassured by one thing, but I, I think that speaks to, you know, some form of dysfunction or malnutrition, and then we really need to do more. 

[00:31:50] Dr. Nina Alfieri: That's a great point. And how about a special group of children that you and I both treat often here at Lurie Children's? Talk about constipation in children with complex medical conditions. How does the treatment or diagnosis for that differ, if at all? 

[00:32:05] Dr. Peter Osgood: Children who have medical complexity certainly have more layers to all of this. You know, lots of times we're talking about kids who have different genetic mutations or syndromes. Many of them may have abnormal muscle  tones, so they may have very weak cores, or they may have very tight hips and pelvic muscles. And that can be some of the big underlying factors that make them constipated. So it's incredibly common for children with medical complexity to need support for constipation. And I think this can present in a number of different ways. So it may be very obvious, you know, as with other, more medically typical kids who have, you know, infrequent stools or very small stools or painful stools. Then sure, it's a bit obvious. But again, if they have a large distended belly. When they're struggling to tolerate feedings, whether that's by mouth or through a feeding tube these always have to make us think that, hey, this a, a factor of this could be their constipation. And I think lots of times we have to have a very low threshold to treat that because that can be a very easy modifiable thing for us to go after to make a child's life better. 

[00:33:16] Dr. Nina Alfieri: Parents can play a really important role in preventing constipation in their kids. What are some simple daily habits that parents can do in their house to keep things moving? 

[00:33:25] Dr. Peter Osgood: Absolutely. So I mean, I think, some of it comes back to just the regular healthy lifestyle thing. We've talked a bit about fiber and like I said, in toddlers that can be a big challenge because the child is often gonna dictate what they're gonna do or not do. But I think one of the tips I usually give parents is that your child is at a stage when they want to make decisions, but they need to have a limited number of options to do it. So still offering, you know, a number of different vegetables or fruits on the meal and letting them choose which they're gonna eat at that time, I think is very helpful because then the child's still seeing the healthy food and it's more on their terms. The typical recommendations when we get into the nitty gritty are that, you know, you take the child's age in years and add five grams, and then that's the minimum recommendation for how much fiber they should eat. 

 a lot of parents could be very nitpicky looking at labels trying to do that. But, you know, don't, don't go overboard. As long as your child sees several servings of vegetables or fruits each day, then they're probably gonna get a good amount of fiber. The other big thing we mentioned is adequate hydration. And that's a little hard to juggle. So, I mean, obviously in the medical community, we're often calculating based on a child's body size to figure out how much water they need. You know, a general rule for parents is making sure they have a drink with every meal and then at least one or two during snack times and throughout the day. And as long as their urine is light in color, they're probably seeing enough water. Another big thing  is just habit forming. You know, a lot of young kids don't tell us much about how they're feeling, and a lot of kids have fomo. They don't wanna stop what they're doing. Um, They, they, they, they, they, just wanna keep playing. 

[00:35:08] Dr. Nina Alfieri: Sounds like my house 

[00:35:10] Dr. Peter Osgood: So, so just taking, taking some set times to say, “Hey, we're taking a break. It's time to go at least sit on the toilet and try.” You know, it's helpful if parents do this, one or two times a day just to try and get the child in the habit of trying. But it's especially important that parents do it if they notice the child is giving them cues. So if they're starting to do their little withholding dance, if they're starting to give little signs that they're feeling something, but maybe they're not verbalizing it or owning up to it because, because of FOMO then, it's important that families, you know, stop, put a pause on activities and redirect them. And the other big thing is just physical activity. You know, when children are up and moving and using all their muscles, they're promoting good movement through their gut. So keeping your kid active and out and about as much as you possibly can as a parent is, is very helpful in the nonmedical lifestyle way of promoting good bowel habits. 

[00:36:03] Dr. Nina Alfieri: So you're saying that living room dance parties are the way to go. 

[00:36:06] Dr. Peter Osgood: Always 

[00:36:07] Dr. Nina Alfieri: Love it. 

[00:36:07] Dr. Peter Osgood: Twice a day. 

[00:36:08] Dr. Nina Alfieri: Love it. I wanna also ask you how can parents talk about constipation with their kids without creating embarrassment or shame? 

[00:36:16] Dr. Peter Osgood: Yeah, I think this kind of comes in maybe two general categories. And I think one is really working with those children who struggle with potty training. You know, they're resistant to this, they're scared of this. And I think just trying to normalize it and really work with children at their pace is particularly helpful. We never want it to be a distressing experience. The kids really need a lot of very positive encouragement, and that may start with very, very small steps. You know, just coming into the bathroom in their diaper and you know, trying to poop there. And eventually sitting on the toilet with the lid down, their diaper and their clothes on and trying to poop there. And then so on and so forth, you know, slowly working towards, sitting with the lid up and eventually, you know, eventually to the point where the diapers off and, then more and more towards independence once they start to recognize those cues. So it is a lengthy process for a lot of kids for them to overcome those fears and become totally confident and okay with what they're doing. I think it's important that families don't make the experience a negative experience. And I think they also need to make it very time limited. You know, kids get bored very easily. So if they're sitting in the bathroom, they're bored, then that becomes a negative experience. So trying to limit those toilet attempts to just five or 10 minutes at the most I think is very helpful and saves the children and the parents a lot of frustration. I think if kids are very self-conscious about it, it's really good not to draw any unwanted attention to the process. So if a toddler is very resistant and you're in a public setting, trying to make it as discreet as possible so that they're not getting defensive about it is very important. I think as we then talk about perhaps older kids, especially school age kids who are maybe struggling with fecal incontinence, it's really nice to give them as much control over the situation as they can. So, making sure that daycare providers or teachers or aides know the struggles that they're having. Perhaps, you know, making sure that they have some set toilet time built into their school day. Easy bathroom access, maybe working with their school to make sure that they have some sort of signal that they can give the teacher or caregiver just so they can discreetly say it’s time and then get to the bathroom. Just so, again, it’s a positive experience that makes them less self conscious about the situation. 

[00:38:36] Dr. Nina Alfieri: These are great tips and I'm all for pooping positivity so thanks for those tips. To round out the conversation and to close up, can you end with what are your top 3 tips for constipation? 

[00:38:49] Dr. Peter Osgood: Absolutely. I'd say first off, don't be too scared about overtreating. We can definitely use laxatives very safely. We can use them in the short term and the long term. Sometimes we may tell you that they need a very high dose of things to really get things going, but again, it's all intended to be very, very safe and there is a light at the end of the tunnel. Along that same vein, I would say. Don't withdraw therapy too quickly. Again, we wanna make sure that children really do well for an extended period of time before we start to take those supports away from them. So we only wanna reduce or remove their medical support very slowly when they've been totally good, totally continent and not distressed about the situation for several months. I guess lastly, I'd say just keep working very closely with your child's provider on adjusting their medical regimen. You know, the marker of success for laxatives is producing a bowel movement that's controllable and occurs more or less when you want it to happen. And it's not rocket science. It's a lot of trial and error to get, so working with your medical team very closely lets us know updates every few days to know how an adjustment to the medications went. Lots of times we can make very little tweaks based on the feedback families give us so that they're seeing a consistent improvement in between office visits, so that hopefully by the time we evaluate them in the office again, they’re already on their way and we;re talking about the next steps in therapy. 

[00:40:16] Dr. Nina Alfieri: Well, thank you so much Dr. Osgood for all your expertise and I really think this episode is full of news you can use. So, we appreciate all that you do for our children and for us general pediatricians and in treating constipation. So thanks for being here. 

[00:40:31] Dr. Peter Osgood: Thank you so much for having me. 

[00:40:32] Dr. Rob Sanchez: Thanks for listening to Kids' Wellness Matters. 

[00:40:37] Dr. Nina Alfieri: For more information on this episode and all things kids wellness, please visit luriechildrens.org.