Breathing and Positioning for Toilet Success (video model)

We all know that our waste products (pee and poop) have to be easy and comfortable to pass. But we also need to be supported and comfortable on the toilet. Check out this video for a demonstration of the position and breathing that make elimination easier.

This video is designed as a follow along video model and includes a two minute quiet toilet sit.

A full transcript is available below.

[Chayah] Getting on the Toilet: Breathing and Positioning, with Chayah Lichtig. On the screen, you’ll see me, Chaya Lichtig. I’m an occupational therapist and I’m the director of the Vermont Continent Project. There are some things we can do when we sit on the toilet to make us much more successful at getting all of our poop and pee out quickly and easily. In this video, I’m going to demonstrate how to sit and how to breathe to make pooping easy and comfortable. There’s another video where we explain why you do all of this stuff, so please check that one out too. Here are the steps. Step number one, get a footstool. Remember, bodies are designed to squat to poop. Since we can’t make the toilet seats lower, we need to make our feet higher. Now my knees are higher than my hips, which puts me in a squatting position. Step two, put your knees apart. This helps your pelvic floor muscles relax. You can do this with your feet together or apart. Step three, lean your torso forward. Put your hands or your elbows on your knees, then look down towards your belly. Notice, are you in a ducktail position with your back swayed in and your bum poking out? This makes your bum and thigh muscles tighten up. Try to encourage your back to relax with deep breaths or a little wiggling side to side. Some folks have tight hips or thighs and leaning over might not be too comfortable. If this is you or your child, a ball or cushion in front of them might help. For the moment, I’m going to put the ball aside so you can see my breathing. Step four, start breathing to move things along in your intestines. Big belly, where you take a big inhale that fills you up, and hard belly, where your strong stomach muscles squeeze your intestines, helping poop come out. Watch me do big belly, hard belly a few more times. You can follow along with me. Notice how I put my hands on the sides of my belly to feel it fill up with air. Big belly, my front, my sides, and my back Fill up with air. I might feel my belly getting stronger and more firm. Hard belly, I keep that hard, strong feeling in my belly and breathe out of my mouth with a whew noise. Here I go again. Big belly. I fill up all the way around my belly and back. Make sure you don’t go into that duck position with your back. That makes our stomach muscles lazy instead of active. Hard belly, say, whew, and breathe out. Do you feel your stomach muscles squeezing in? If you’re holding onto your stomach, try putting your hands or elbows back on your knees and looking at your belly. It’s really normal for some gas, a little poo, or some pee to come out when you do this. After all, you’re kind of giving your insides a massage. I’ll stay with you while you do three more big belly, hard belly breaths. Now just take slow, relaxed, regular breaths, breathing in through your nose and out through your mouth. Stay on the toilet for another two or three minutes. An adult can set a clock for you. If you feel poop starting to come, that’s okay, just keep breathing. If you can feel poop pushing, but it won’t come out, try a couple more big belly, hard belly breaths. This video will keep playing for another two minutes. If you finish your poop sooner, you can wipe, pull up your pants and get off the toilet. If you need to stay, I’ll be right here too. You’re all done. Great try. Make sure to wipe, even if poop didn’t come out. Then pull your pants up, flush the toilet, and go wash your hands. Remember to use this poop position and poop breathing every time you sit. You might be surprised what comes out.

Fecal Smearing: Ideas and Strategies

Want a PDF version? click https://cdci.w3.uvm.edu/blog/continence/wp-content/uploads/sites/9/2024/01/Fecal-Smearing.pdf

Many people with autism, developmental delays, or other disabilities have touched, played with, or even eaten their feces (poop) at some point. Parents, caregivers, and teachers may find the problem very upsetting and hard to deal with. Here are some things to think about, and some strategies you can try.

Medical Considerations

Research shows that children with constipation and other gastrointestinal health issues are much more likely to smear feces. This is especially true for children who are non-speaking, and may not have another way to show their caring adults that they are uncomfortable. If your child has autism, they have a much higher likelihood of having digestive problems. Work with your child’s primary care physician and consider working with a pediatric dietitian to make sure your child’s body is healthy and comfortable.

Sensory Considerations

Some people crave lots of sensory information. The smell and feel of feces gives a lot of sensory feedback. For these people, offer a time when they are invited to touch and smell intense textures and scents, such as slime or water bead play, and offer lots of other sensory information like swinging, bouncing, and tickling throughout the day to “fill them up” with sensory information. Do not make your child clean up the feces because that tends to reinforce that play feeling.

Other people are overresponsive to sensory information. The smell and feeling of feces in their pants after they soil is very upsetting, and they may try to get the feces out, and then smear it around to get rid of it. If this is describes your child, make sure you are changing them very quickly after they stool, and getting their skin very clean and dry each time you change them.

Seeking Connection

It is natural that the caregivers would have a strong and emotional reaction to seeing and smelling poop. Sometimes children connect fecal smearing with a long opportunity to connect with a parent or caregiver while they get cleaned up. They may also register that parent’s strong emotions in that moment as a positive: “mom has a lot of feelings towards me right now!” Make sure that when you approach your child to clean up, that you are calm, and not reactive. You may have to take a break away from the poop first, take a few slow breaths, or drink some water to calm down. You can also wear a surgical mask, gloves, and cover your hair with a bandana before cleaning up your child so they can’t get poop in your hair or on your hands.

Boredom

Some children will play with their poop if left alone with a poop for a period of time. This happens often when someone first wakes up, and might be very relaxed and by him/herself. Make sure you know when your child tends to poop, and stay close to them at that time. If your child is willing to sit on the toilet, this is a great time to practice. If they are not, you can simply make sure that an adult is nearby, or watching (using a video monitor, etc.). If this happens in bed, try using back-zip pajamas, which cannot be undone by the person wearing them.

Limited Skills & Knowledge

Your child has watched you take off their diaper each time they poop, and knows that poop is supposed to come out after they make it. They may be trying to be helpful. Give your child social stories or video models explaining that when we poop, we do not play with it; we wait for an adult to help us, or we go get help. Remember that your child may need another way to tell you when they’ve pooped. Make sure your child has a way to communicate, such as a speech generating device (BIGmac or similar), that enables them to say they need help. Make sure you, the adult, are modeling using this, too. Finally, give your child a job in the hygiene process so they know where they fit in and how they get to help.

Crack Every Case: A Pediatrician’s Guide to Management of Functional Constipation, from Children’s Mercy Hospital

For comprehensive recommendations on the treatment of functional constipation, we suggest this guide by Children’s Mercy Gastroenterology.

We also suggest referencing the Children’s Mercy functional constipation treatment algorithm, available at https://www.childrensmercy.org/health-care-providers/pediatrician-guides/managing-functional-constipation/

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

M M TabbersC DiLorenzoM Y BergerC FaureM W LangendamS NurkoA StaianoY VandenplasM A Benninga 

Abstract

Background: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.

Methods: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

Results: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.

Conclusions: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

For full text access:

https://pubmed.ncbi.nlm.nih.gov/24345831/

Health related quality of life in children with constipation-associated fecal incontinence

Marloes E J Bongers, Marieke van Dijk Marc A BenningaMartha A Grootenhuis

Abstract

Objectives: With a disease-specific questionnaire, this study aimed to evaluate health-related quality of life (HRQoL) in children with constipation in association with clinical characteristics.

Study design: Children with constipation-associated fecal incontinence (n = 114), 8 to 18 years, filled out the Defecation Disorder List at a Dutch tertiary hospital. Correlations and linear regression analysis between clinical characteristics and scores on emotional and social functioning were calculated. Specific concerns of children were described by individual item scores of these domains.

Results: Higher frequency of fecal incontinence episodes was associated with lower emotional and social functioning. Linear regression analysis showed a significant association between social functioning and fecal incontinence, but the variance of the model was low (adjusted R(2)= 0.08). Between 70% to 80% of children were concerned about experiencing fecal incontinence unnoticeably and the attendant social consequences. Children did not report having fewer friends and participated well in social events.

Conclusion: Lower HRQoL regarding disease-specific emotional and social functioning was reported in children with frequent episodes of constipation-associated fecal incontinence. However, other nonspecified factors may also influence HRQoL of these children. Most children reported relatively more emotional concerns than social consequences.

Click the link for access to full text article: https://pubmed.ncbi.nlm.nih.gov/19150085/

Conventional treatment of functional constipation has a positive impact on the behavioural difficulties in children with and without faecal incontinence

Line ModinIda Skytte Jakobsen,  Marianne Skytte Jakobsen

Abstract

Aim: Constipation studies have only evaluated behavioural difficulties in children with faecal incontinence. This study evaluated changes in behavioural difficulties in childhood with functional constipation (FC) with and without faecal incontinence, based on treatment outcomes.

Methods: Children aged five to 16 years who fulfilled the Rome III criteria for FC received conventional treatment. The Strength and Difficulties Questionnaire was completed at inclusion and at the 12-month follow-up.

Results: We included 116 children. The behaviour scores decreased in successfully treated boys (10.3 versus 7.9; p < 0.001) and girls (10.0 versus 7.4; p = 0.0001) with and without faecal incontinence. There was no decrease in the behaviour scores in children with unsuccessful outcomes. Unsuccessfully treated boys had significantly higher behaviour scores than successfully treated boys at inclusion (13.2 versus 10.3; p = 0.006) and after 12 months (11.4 versus 7.9; p = 0.02). No difference was found between unsuccessfully treated and successfully treated girls at inclusion (10.5 versus 10.0; p = 0.77) or after 12 months (10.3 versus 7.4; p = 0.18).

Conclusion: Our findings indicate that conventional treatment of FC had a positive impact on behavioural difficulties in constipated children with and without faecal incontinence. This study highlights the importance of proactive detection and treatment of FC in paediatric patients.

Click the link for access to full text article:

https://pubmed.ncbi.nlm.nih.gov/26913469/

Parental child-rearing attitudes are associated with functional constipation in childhood

Marieke van Dijk, Giel-Jan de VriesBob F Last, Marc A Benninga, Martha A Grootenhuis

Abstract

Objective: Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association.

Design: Cross-sectional data of 133 constipated children and their parents were collected.

Setting: The gastrointestinal outpatient clinic at the Emma Children’s Hospital in the Netherlands.

Patients: Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians.

Main outcome measures: Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms.

Results: Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children.

Conclusions: Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk.

Click on the link for access to full text:

https://pubmed.ncbi.nlm.nih.gov/25359759/

For social-behavioral resources related to toileting, see our “Behavior and Positive Reinforcement” category of resources.

The Uniformed Services Constipation Action Plan: An Effective Tool for the Management of Children with Functional Constipation

Patrick T. Reeves, et al.

Objective: To implement and to evaluate the effectiveness of the Uniformed Services Constipation Action Plan (USCAP) in our gastroenterology clinic for children with functional constipation.

Study design: This implementation science study included toilet-trained subjects aged 4 years and older who met the Rome IV criteria for functional constipation. Children were block randomized to receive either the USCAP or control. All clinic functional constipation plans recommended subjects continue pharmacotherapy for 4 months. Endpoints measured were clinical outcomes (resolution of functional constipation and achievement of a Pediatric Bristol Stool Form Scale [PBSFS] score of 3 or 4), patient-related outcomes (health-related quality of life [HRQoL] total scale score), and health confidence outcomes (Health Confidence Score [HCS]).

Results: Fifty-seven treatment group subjects (44%) received a USCAP (52% male; mean age, 10.9 [4.9] years) compared with 73 controls (56%; 48% male; mean age,10.9 [5.3] years). A PBSFS score of 3 or 4 was achieved by 77% of the treatment group compared with 59% of controls (P = .03). Subjects from the treatment group were more likely than the controls to endorse adherence to the 4-month course of pharmacotherapy (P < .001). Subjects who received a USCAP had greater improvements in HRQoL total scale score by the end of the project (P = .04).

Conclusions: The USCAP is a simple, inexpensive tool that has the potential to improve global outcomes for functional constipation in children and should be recommended as standard clinical practice.

 

For access to full text, click this link:

https://pubmed.ncbi.nlm.nih.gov/36115625/

To see the Vermont Continence Project’s “Constipation Traffic Lights Form and a plain language video describing its use, go to Constipation Treatment: Bowel Maintenance

Paediatrics: how to manage functional constipation

Alexander KC Leung, corresponding author and Kam Lun Hon

Abstract

Background: Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.

Methods: A PubMed search was performed with Clinical Queries using the key term ‘functional constipation’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.

Results: A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch ‘red flags’ suggestive of organic causes of constipation. These ‘red flags’ include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success.

Conclusion: Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.

Click link to access full text:

https://pubmed.ncbi.nlm.nih.gov/33828605/

Parents’ Experiences and Information Needs While Caring for a Child With Functional Constipation: A Systematic Review

Alison P, Thompson, Eytan Wine, Shannon E MacDonald, Alyson Campbell, Shannon D. Scott

Abstract

Pediatric functional constipation (FC) reportedly affects at least 1 in 10 children worldwide. Parent and family education is a key component for successful treatment, yet there is little research exploring what information families need and how to best support them. The aim of this review is to synthesize current evidence on the experiences and information needs of parents caring for a child with FC. We systematically searched published research and completed screening against a priori inclusion criteria. Thirteen studies (n = 10 quantitative, n = 3 qualitative) were included. We found 2 main themes, precarious footing and profound and pervasive effects. Heavy caregiving burdens fueled doubts, misinformation, relationship breakdown, and treatment deviation. In light of clinical recommendations, our findings reveal a potential mismatch between parents’ needs and care provision for FC. It is likely that both parents and health care providers would benefit from resources and interventions to improve care related to pediatric FC.

Click Link for full text access:

https://pubmed.ncbi.nlm.nih.gov/33026251/