Choosing a Pain-Free Diet

I had my first “old coot” moment, when grampa yells at the TV when he sees something he doesn’t like.  For me, it was an ad for Miralax, a laxative.  It depicted a young cheerful woman in athetic clothes saying “I choose Miralax!” for her apparent sluggish bowel issues.  I shouted, “WHY NOT CHOOSE FRUITS AND VEGETABLES?”  Of course, she wasn’t listening.

Constipation can be quite painful for children.  We see them in the Pediatric Emergency Department with stories of doubling over, crying out with pain spasms.  They’re usually  better when they arrive, but it’s still disconcerting for parents.  Contipation actually is the most common diagnosis for abdominal pain visits to the Pediatric ED, ahead of stomach viruses and appendicitis.

Constipation is now a common problem in kids, given decreased fiber in their diets.  Fiber is plant carbohydrates that our digestive system can’t break down.  That fiber holds on to water and keeps poop soft and squishy as it passes through our guts.  When your body wants extra fluids, it tries to suck water out of your colon, drying out your stool.  Without enough fiber, your poo gets dried out, moves slower, gets harder, and harder to pass.  If lots of hard poo is moving too slow, painful cramps ensue.

Thus the fix to constipation: eat more fruits, vegetables, wheat breads, bran cereals, all having a high fiber content.  Miralax is simply an artificial fiber substitute- why not eat the healthier thing?  For kids, this means training them to like these foods.  The typical kid can take 10 tries of a food to learn to like it.  This takes persistence on the parent’s part, and is ruined if they get candy, cookies, chips, or fast food as an alternative.  Those foods are designed and manufactured to taste good on the first try, spoiling the child’s chances to learn to eat right.

Drinking more fluids and more physical activity also prevent constipation.  When kids sit around playing video games, their guts sit around too, not moving things through as much, and stool has more time to get dried out.  Active kids stimulate their intestines more, and have less constipation.

Once in residency I had a 10 year-old boy with constipation so severe he was admitted into the hospital.  He had terrible pain, and the parents thought he hadn’t stooled in weeks.  He also had anxiety issues so bad that he wouldn’t tolerate enemas or rectal exams, the quickest way to diagnosis and relieve constipation.  We thus decided on rectal exam under sedation, and do so in the xray suite so we could look at his insides, to rule out other causes for his pain and apparent blockage.

As soon as the sedation started, he relaxed his anal sphincter, and liquid stool poured out of him.  The diagnosis was instantly clear- he’d been purposefully holding in his poo, and it was liquid from all the laxatives he’d been given.  Unfortunately for the Radiology Department, he leaked so much that it ran all over the xray table, through every seam, dripping out the bottom.  They had to completely dismantle the table to clean it, and that room was out of commission for days.

Above we mentioned the diet reasons why kids get constipated- low fiber, inadequate fluid intake, and not enough activity.  But there’s sometimes psychological reasons as well.  Sometimes kids have a hard stool that hurts.  They decide, hey, I’m not doing THAT anymore!  Next time they get the urge, they withhold pooing until the urge passes.  After doing that enough, the urge gets too strong, and they have to go.  By that time the stool is so big and dried out that it’s another painful job, reinforcing their desire not to do it.  The constipation process becomes self-feeding.

Toddlers also can decide to withhold pooping during potty training.  Some kids just don’t like taking down their pants and sitting on that oddly-shaped thing we call a toilet.  It’s much easier to just go in their diaper.  Parents often try rewards, sometimes punishment, to encourage the kid to use the potty.  Willful toddlers may fight back the only way they can- with their anal sphincter.  Some psychologists say that any child can be potty-trained by age 2; others say wait until they show signs they’re ready, like watching their parents use it.  I think the latter, having seen many toddlers get constipated during potty training.

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