Vermont Continence Project Online Resource Library
Promoting positive, person-centered, science-driven toileting supports for Vermont’s children and youth.
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/
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
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.
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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.
The VCP created a new BM chart that requires less writing. You can download it at BM Chart with Pictures
See how to use it at:
See Taking Initial Bowel Data for information about the Bristol Stool Scale.
For most children, laxative medication is an essential tool in the treatment of chronic constipation, but it isn’t meant to last forever. Many parents wonder when to start tapering (decreasing) medication, and how to do it safely. This this video offers recommendations.
Many providers suggest that children sit on a regular schedule, but not every body needs the same schedule! This video explains how to know how often, and when, your child needs scheduled sits.
This video explains the reasons it’s helpful to teach your child about their body and how it eliminates waste. We also discuss some materials and strategies that can help you in this process.
Hi, this is Chayah Lichtig. I am the director and occupational therapy consultant with the Vermont Continence Project. In this video, we are going to talk about how to engage your toilet learner by teaching them more about how their body works.
So why would we want to teach children more about their bodies?
Well, lots of children that we are working with may not have clear messages from their bodies, telling them when they need to pee or poop.
Sometimes when we teach them what’s inside and how it works, it can help them make connections between what they feel and what it might mean. This can help build interoception, which means awareness of sensation from your internal organs and the inside of your body.
If you and your child have a lot of tension or even conflict about toileting, information also gives you and your child something fun and neutral to talk about related to toileting stuff.
When children can understand that accidents aren’t them, but rather their bladder or their bowel or colon, it turns down that shame factor.
It also gives you something to talk about: are they making smooth snakes or little water bugs or mud puddles?
This kind of talk appeals to a lot of kids and it can help when kids are used to the talk around toileting being critical of them and their accidents or refusals.
What kind of materials can help you?
There are great books about bodies. See Inside Your Body is popular on our project. Does your child actually know how pee and poop are formed? They may not.
While a younger child might be okay with traditional potty books, an older learner may want or need information about their body. You can find a version of the Bristol stool scale that speaks to you and your child.
There are many out there. There are some that compare it to food, I’m sorry, and there are some that have cute cartoons. You can Google to find a variety of options. There are also lots of videos out there about pee and poop and how they’re formed.
The corn test is also popular. If your child eats corn, tell them to be on the lookout. How long does it take for it to come out?
Finally, remember that just because your child isn’t continent, it doesn’t mean they are at the age of other, quote, potty training children.
While the word potty is appropriate for a toddler or a young preschooler, it doesn’t match older children so well. Remember to use age-respectful words for body parts, the toilet, and more.
Disclaimer: This information 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 healthcare professional.
This video explains how to take data to bring to your child’s medical provider. This information will help you make a plan for your child.
In Elimination Basics, we explained how constipation is the leading cause of incontinence in children. Please check out that video first.
Hi, my name is Chayah Lichtig. I’m the director of the Vermont Continence Project and I’m a licensed occupational therapist. In this video, we are going to talk about taking bowel data to support continence.
So parents often wonder, what’s the purpose of taking this data? We’ll start with the fact bowel issues are the number one underlying cause of incontinence in kids. This is true for kids with disabilities and kids without. It’s true for kids who were continence and loss skills and for kids who have never been continent. It’s even true for kids who only have urine incontinence and no identified bowel issues. So we want to have concrete information about our child child’s bowel habits to support our conversations with our child’s physician school team and your child themselves.
So let’s start with something called the Bristol Stool chart. On the next slide, I’m going to share a picture of a one through seven scale that describes the consistency of stool. Doctors like it because it’s well agreed on. It’s easy to understand and it has some pretty clear visual representations. This is a picture of the Bristol Stool chart.
You will see that the numbers get higher as you go along. A lower number means a drier, harder stool consistency, and a higher number means a wetter, looser stool consistency. Let’s go through the seven numbers in order.
Type one is separate hard lumps. They may be difficult to pass or they may fall out.
Type two is sausage shaped, but dry and lumpy.
Type three is like a sausage, but with cracks on the surface.
Type four is super smooth and soft, like a snake or sausage.
Type five is soft blobs with clear edges. They pass easily.
Type six is fluffy, ragged pieces with soft edges almost liquidy.
And type seven is watery. No solid pieces entirely liquidy.
As you may have already learned from watching videos from our nurse consultant Kelly, you will know that numbers one and two are very strong signs of constipation. Numbers six and seven can also be common signs of constipation. Or they can be signs of other GI problems as well. The Bristol stool scale is a very important piece of data which your child’s doctor will probably ask about, but it’s also helpful to keep track of these other factors.
Frequency. One of the official criteria for constipation is how often your child has a complete bowel movement. Loss of small amounts of stool is not the same as a complete bowel movement. But you’ll also want to know and take track of how often they have small streaks, smears or pebbles size. Note If your child has very small or very large BMs regularly or on occasion, these can be signs that the muscles aren’t working well to push out through shape.
Are your child’s stools shaped like logs or balls? A ball shaped stool means that your child’s colon is very stretched out, allowing stool to collect in a lump rather than squeezed into a tight tube.
Mixed consistency. Does your child have BMs that are dry and hard like a two or three one day and a number six the next day? Or can you see a mix of consistencies in a single BM? These are also signs that GI function is not as smooth and consistent as it could be, and that things are not moving along as we might hope and expect.
Finally, if you are giving any medication at this time for your child’s GI system, please make a note of when and how much you give.
Parents often ask how long to take data That depends on how often your child is struggling and how much you know about their system. If your child has a BM every single day, not just a smear, 5 to 7 days of data is probably enough. If your child has very irregular stool patterns or goes infrequently, try to take data on at least seven complete bowel movements.
Many parents find, however, that once they start paying closer attention to their child’s stool habits, that they notice some of the concerns we’ve mentioned and they seek the support of their child’s PCP sooner. Overall, the goal is to get a clear picture of how your child’s system is working right now so you can make the right choices to help them.
How to take Data: In the resources connected to this video, we have a data sheet that you can use. It has a key that reminds you of all the points that I’ve mentioned in the previous slide. You are encouraged to print that out and use it. You can also use any notebook and pencil or the notes app on your phone or tablet. We find people are most likely to take data when they make it as easy as possible. So we suggest keeping that notebook or data sheet and a pen in whatever location your changing undergarments or disposing of stool.
Some parents don’t know what’s going on with their children’s bowel habits because some children change or use the toilet independently or they don’t want to talk about their stool habits. That’s okay. Some children can take their own data using our existing sheets. We’ve also included a simplified version of our data sheet where kids can circle the poo that looks the most like theirs. We find that children who are having accidents are really motivated to do something that is scientifically proven to help. With the right support, they’re often willing to try things that might feel sort of awkward or embarrassing. Explain to your child that most pee and poop accidents come from problems with poop and that this is the first step of treatment.
Thank you so much for taking the time to watch this video. 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 professional.
To teach toileting, it’s helpful to know the basics of how we eliminate (pee and poop), and how we learn to do these things. We encourage every parent to watch this video.
Hello, my name is Kelly Savitri. I’m a nurse with the Vermont Continence Project. This short video is going to present some information about how our bodies eliminate waste, which is basically a polite way of saying pee and poop. I hope by the end of this video you will understand why this information is the foundation of helping our kids become successful with toilet learning.
The process of toilet learning starts when a person’s brain can recognize signals from the bladder and bowel, and then that person learns how to respond to those signals. So the first thing that we need to understand is how that process works in the body and where things can go wrong that make it difficult for someone to learn toileting skills.
First, let me explain how we create urine, or pee, and how we excrete it. Pee is produced in the kidneys. It travels down tubes called ureters and collects in the bladder. As the bladder fills, it stretches. Special nerves called stretch receptors in the bladder sense when it is full and send a message to the brain. We perceive this message as a feeling, which most of us learn to recognize as the need to pee.
Now we’ll talk about how the bowel works. Food enters the mouth and goes into the stomach where it gets broken up and mixed with our stomach acid and enzymes that allow us to digest it. At that point, it becomes liquid. And it stays liquid as it goes through a long, twisty tube called the small intestine. From there, it enters our large intestine, also called the bowel or colon, and it is still liquid. This liquid is what becomes poop. In the large intestine, water gets absorbed back into the body, so the poop moving through becomes more solid. The longer it stays in the bowel, the harder and drier it becomes. The last part of the colon is called the rectum. Just like the bladder, the rectum has stretch receptors. When the rectum fills with poop, it stretches. And those stretch receptors send a signal to the brain.
Again, we perceive this signal as a sensation. And it is that sensation that most of us learn to recognize as the feeling that we need to poop. There’s a little ring of muscle at the bottom of the rectum called the anal sphincter. The anal sphincter is a muscle that we can tighten to keep poop in or we can relax to let poop out.
There is also a group of muscles in our pelvis that we call the pelvic floor. Those muscles help us control when pee and poop comes out. While there are many muscles working in many different ways, a simple way to say it is that we contract the muscles to keep pee and poop in, and we relax them to let it out.
So what could go wrong with these systems? For most children, the answer is constipation. Many parents are surprised to hear that their child might be constipated, because constipation can be sneaky and can present in unique ways, especially in children. At the Continence Project, we have worked with hundreds of families and consulted with many pediatricians and specialists, and we have found that when a child is really struggling with incontinence, despite their parent trying all the conventional strategies, there’s almost always an issue related to constipation that needs to be addressed. This is true for typically developing children, as well as those with developmental delays or other identified diagnoses.
I’m going to talk much more in depth about constipation in upcoming videos, but for right now, I’m going to give you the quick summary of how chronic constipation affects a person’s ability to gain toileting skills. In this graphic, the yellow part of the cycle represents the mental and emotional effects of constipation that influence a child’s behavior. And the green cycle represents the physical changes that happen in a child’s body that make it difficult for a child to effectively recognize their body signals and respond to them. For today, I’m going to focus on the green part of the cycle, but I want you to know that we will talk about the yellow part of the cycle in future videos.
First, let’s define what we mean by constipation. Remember how the last part of the bowel stretches when it is full of poop, and then it goes back to its normal size when it empties? Constipation is what happens when the rectum does not fully empty. Usually, for adults, this is a short-term situation that resolves when a person eventually has a complete bowel movement. In children, we often observe that an episode of constipation can trigger an ongoing cycle where they might be able to pass some poop on a regular basis, but the bowel never fully empties, so the rectum becomes stretched out.
We use the term constipation a lot because that is the word that your healthcare provider is most likely going to use. But sometimes it is confusing because people think of constipation as a situation when no poop at all is coming out. We often hear parents say, “How could my child be constipated? I’m cleaning up poop all day long.” In this situation, it’s more helpful to think of it as incomplete evacuation. Even if your child has frequent bowel movements, they might still be experiencing the effects of an overstretched rectum because the bowel is never really fully emptying, and some stool is being left behind.
There are a lot of muscles involved in the digestive process. The whole digestive tract from the mouth to the anus has muscles that help move the food, and subsequent poop, through the digestive system. When someone has constipation, or incomplete evacuations, the muscles of the rectum are stretched out for a long time. Then they become weak and ineffective. That means that the longer constipation, or incomplete evacuation, goes on, the more difficult it is for the body to effectively push poop out. Remember how stretch receptors give you the urge to pee or poop? For those receptors to work, the bowel needs to go back to its empty state every time. When the bowel stays stretched out for a long time, those receptors stop talking to your brain. This is true even if some poop comes out. Remember, you can’t learn to respond to a signal that you don’t feel. So making sure that the bowel is fully emptying on a regular basis is our first and most important step in addressing incontinence.
Also, remember the muscles of the pelvic floor and anal sphincter? Those muscles can also be affected by the pressure of an overfull rectum constantly pressing on them, or from long-term withholding. So sometimes those muscles need retraining, as well as time to regain their normal function. In our psychographic, we call this situation ineffective or incomplete voiding and defecation.
Finally, remember how the poop is liquid when it enters the bowel, and it gets harder and drier the longer it stays there? Sometimes the hard, dry poop gets stuck in the rectum, causing an impaction. Eventually, the liquid poop starts to sneak around the impaction and leak out. This amount can be large or small. It often appears as streaks or smears in a person’s underwear because small amounts of liquid or solid stool comes out when the person passes gas. They may also have large bowel accidents. Often this is mistaken as diarrhea, but it’s actually a complication of long-term constipation called encopresis. In this situation, stool leaks out involuntarily, and a child often cannot even feel it. You might be wondering how incomplete evacuation affects urine incontinence.
We tend to think of the bowel and bladder as two separate systems, but they’re connected in some very important ways. The signals from the stretch receptors in the bladder travel the same nerve pathways as the receptors in the bowel. When the signals from the bowel are interrupted by incomplete elimination, the signals from the bladder can get messed up too. This usually shows up as a child either not recognizing that they need to pee, or not identifying it until it is extremely urgent, and they can’t get to the toilet in time. Also, the overly full rectum can press on the bladder, creating less space for the bladder to expand. This usually shows up as a child having lots of small pees frequently throughout the day.
The most important thing to understand is that this process is cyclical. When a child’s stretch receptors and muscles of the digestive system and pelvic floor become compromised because of constipation or incomplete evacuation, it slows down their elimination and makes it harder for them to poop, causing more constipation.
Don’t worry, we’re going to talk much more about how to identify whether constipation or incomplete evacuation is a factor in your child’s difficulty with toilet learning and what to do about it. In the next video, called Taking Bowel Data, my colleague will explain how to record the size, frequency, and consistency of your child’s bowel movements so that you can have an informed conversation with your child’s healthcare provider.
Thank you for taking the time to watch this. 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 healthcare provider.