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.

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/

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/

Planning for Setbacks

Did you know that 40-50% children treated for constipation will have a relapse in the first 1-5 years? We encourage parents to do what you can to prevent relapses, but also to prepare yourself for what might happen. This video from Vermont Continence Project nurse consultant, Kelly Savitri, RN, offers helpful suggestions to keep things moving smoothly.

 

A full transcript of the video appears below.

Continue reading “Planning for Setbacks”

Urination Questions and Concerns

What are signs that your child’s urination is healthy? This video describes the signs of healthy urination, and indicators that your child’s urination is not functioning quite right.

A full transcript appears below.

00:00:00:00 – 00:00:26:00
Unknown
Hi, my name is Haya Lickteig. I’m an occupational therapist and I’m the director of the Vermont Continence Project. In this video, Urination questions and Concerns, we are going to talk about some signs that you may need to pay more attention to your child’s bladder function or may want to check in with your child’s medical provider. First, let’s review how the bladder works.

00:00:26:03 – 00:00:55:12
Unknown
Urine is made in the kidneys and drips down, drop by, drop through tubes called ureters. Urine then collected in the bladder, which is basically a muscular pouch like a water balloon while urine is collecting, the walls of the bladder are relaxed and stretching out. At the same time, a muscle at the bottom of the bladder, the urethral sphincter is contracting to hold the bladder shut.

00:00:55:15 – 00:01:19:05
Unknown
When the bladder gets a certain amount of stretch. It sends a message to the brain that says the bladder is full. The muscles then reverse their actions. The muscles at the bottom of the bladder. Relax, allowing the urine to flow out while the walls of the bladder contract or squeezed in to make sure that all the urine comes out.

00:01:19:08 – 00:01:53:23
Unknown
This is similar to releasing the neck of a water balloon and giving the widest part a squeeze to clear it out. While our body controls that sphincter muscle that holds the urine in. It doesn’t voluntarily control the muscle on the inside that squeezes the bladder, an indication that this process is working well is that a person can urinate very soon after sitting on the toilet and that their urine stream has a steady sound which gets sore, start soft, gets loud and then soft again.

00:01:53:25 – 00:02:21:12
Unknown
Holding urine between large urination is also a sign that things are working well. While it’s too complicated to explain why problems occur here. There are some important signs to look for that your child may have a problem or concern with bladder function. If your child urinates very frequently, like more than once an hour, that’s something that we’d want our health care provider to be aware of.

00:02:21:14 – 00:02:50:05
Unknown
If your child regularly goes 4 to 6 hours or more between voids, that’s also something that you’d want your health care provider to be aware of. Parents also see this sometimes when their child wakes up dry, but then doesn’t urinate immediately. Some other signs that you may be on to be aware of are that your child’s urine flow is choppy or weak, which you probably would only know if your child is urinating in the toilet.

00:02:50:07 – 00:03:14:28
Unknown
Your child has trouble making urine come out even when they say they need to go or they appear to need to go. This can also look like a child pushing while trying to pee. If you remember, the act of urinating is not a pushing maneuver. It’s the act of releasing a muscle, and the pushing should be completely done by your body’s own processes.

00:03:15:00 – 00:03:42:08
Unknown
If your child has frequent UTIs, it can be a sign of constipation. Since fecal bacteria coming from the anus can get into the urethra, especially for girls. But it can also be a sign of withheld urine, meaning that the bladder isn’t emptying completely, leading to urine that is staying in the bladder too long and becoming too concentrated. So what to do?

00:03:42:10 – 00:04:21:17
Unknown
A common saying in the world of pelvic health is that the bowel drives the bladder and this means that most bladder symptoms for most people may be tied to something happening in the bowel. We frequently tell parents that most of their child’s bladder symptoms may get better when you treat their constipation. If you’ve treated your child’s constipation comprehensively and consistently for 2 to 3 months or more and you see no improvement in your child’s bladder, that’s when another referral may be appropriate.

00:04:21:20 – 00:04:53:25
Unknown
We’d suggest discussing your treatment options with your child’s provider for some of the available options. Include a consultation with a pediatric urologist or working with a pelvic floor, physical therapist or occupational therapist with expertise in working with children. If you have a child with any of these symptoms, it’s essential to address them before any kind of sitting program.

00:04:53:28 – 00:05:23:05
Unknown
Many of these issues can come from a history of withholding, and a structured program will probably make that worse for your child. If your child already sits on the toilet willingly, it’s really important to use all of the postural supports that we discuss in other videos, such as a footstool and a seat reducer. Thank you for taking the time to watch this.

00:05:23:07 – 00:05:40:01
Unknown
The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.

 

What is Fiber?

Many of us have heard that fiber is important for elimination health. We might not know what foods have fiber, or how much we need! Kelli Borgman, RD, Nutrition Consultant for the Vermont Continence Project, explains how we can increase the fiber in our child’s diet for overall GI health and wellness.

A full transcript of the video appears below.

Continue reading “What is Fiber?”

Constipation Management with Supplements

Many people wonder how dietary supplements can help with constipation. This video by Kelli Borgman, RD, consultant for the Vermont Continence Project describes the role of supplements in treating chronic constipation in children.

A full transcript of the video appears below.

Continue reading “Constipation Management with Supplements”