Neha R Santucci, Ashish Chogle, Alycia Leiby, Maria Mascarenhas, Rachel E Borlack, Amanda Lee, Maria Perez, Alexandra Russell, Ann Ming Yeh
Abstract
Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.
Most parents know that their child’s diet plays a role in their elimination health and habits. What do you do if your child won’t eat those foods that help improve elimination? This video from Vermont Continence Project nutrition consultant, Kelli Borgman, RD, describes the things that stand in the way of children developing healthy eating habits. Watch this before Picky Eating and Continence Challenges, Part 2, where we suggest some ways you can adapt foods and mealtimes to help your picky eater.
A full transcript of the video appears below.
Hello, I’m Kelli Borgman. I’m a dietitian consultant with the Vermont Continence Project. In this video, I’m going to talk about picky eating as it relates to continence challenges, and a general framework to start thinking about how to best support your child.
Picky eating can be so challenging day to day, and both parents and kids can have a lot of worry, stress or strong reactions around it. It’s also quite a personal topic. Each child’s or family has their own story about how picky eating came to be an issue, how each family member is dealing with it and what’s being done about it, if anything, and how picky relating eating relates to the emotional and communication dynamics within the family system. Family cultural or personal beliefs and ethics about food and health all play a part too.
When a child continually refuses foods, you purchase and prepare with care, parents and caregivers feel frustrated, powerless, hopeless, or just annoyed. Sometimes it can come with a lot of shame or you feel like you’re a bad parent. This is made worse when parents and children have conflict about food and eating. So I really want to start off by saying there are no right answers and each child and parent needs personalized support. Please know it’s okay to put on the brakes and of trying to get your child to eat specific foods in a similar way to how you might be rethinking teaching, toileting.
Parents often wonder if their child’s picky eating is typical. Feeding therapists may describe children as being picky eaters or extremely picky eaters. So this is kind of a busy slide. But I wanted to give you some context for caregivers to know which category their child can fall in. I hope it will validate the experience you’re having and give some clarity on how to best support your child’s eating. So just to compare picky eating affects about half of children at some point. It starts around 15 to 18 months, once calorie needs decrease past infancy. Picky eaters do have favorite foods, which are often carbs. They drop new foods but are able to pick up new ones. They often will reintroduce dropped foods in time and over several days will eat foods from all food groups. They can be hesitant to accept new foods. They can accept varied textures, and they will often eat enough at school or daycare.
In comparison, extreme picky eaters impacts a smaller amount of children, and this is nondisabled children about 13%. It usually starts earlier than 15 months. They might have favorite foods, but there’s more rigidity in their choices. They drop foods but aren’t as able to pick up new ones. They won’t often reintroduce dropped foods, and over day’s time, they will avoid foods from certain food groups and not get the variety.
They generally have a fear of new foods or have food anxiety. They won’t often accept varied textures and will often struggle to eat enough at school or daycare. If you think your child falls into the picky eater category, there’s some great information in the video called Picky Eaters, Part Two about the parent child feeding relationship. That will likely be a great foundation to think about extremely picky eaters generally need more accommodation and support, so consider working with a pediatric feeding therapist and dietitian team. These are the kids that can have more severe malnutrition or at risk for longer term disordered eating patterns. Please note the data from these stats are commonly cited and accepted in the scientific literature. Of course, children don’t always neatly fall into one category or another and disabled or neurodivergent children are often underrepresented or not acknowledged. So it’s hard to apply this data to include all kids experience with picky eating or more extreme picky eating.
So when thinking of the long term nutrition goals related to GI health, we of course want to help support their GI tract to function optimally and optimally function functioning GI system is able to uptake the amount of nutrition they need to play, grow and learn. So for most kids this means working on increasing fiber, fluid, or variety, or a combination of these.
If your child’s daily eating choices don’t currently meet 100% of what the GI tract requires to function optimally, medications and supplements should be used to support each child’s body, mind and emotions where they are right now.
So what makes healthy, healthy relationship to food possible? Really, a more regulated nervous system stimulates appetite and allows more flexible thinking and openness to foods. The enteric nervous system, shown in a picture here, innervates the entire GI tract, and is the largest and most complex unit of the entire nervous system outside the brain. It’s all quite connected, literally. Appetite, curiosity, and interest in more quantity or variety will often dramatically increase when we think about nervous system balance and meeting their emotional needs at the table, too.
In my work with families over the years, I’ve noticed a common theme amongst the extreme picky eaters parents often report, and I can see during mealtime observations that children display lots of non-verbal and verbal communication that indicates they’re getting disregulated and upset. The causes of upset are usually what foods are offered or not offered, or the caregivers involvement in their mealtime.
Their sensory and nervous systems are ringing alarm bells that the situation isn’t comfortable or safe, or they have fears that their needs aren’t going to be met. So why do kids avoid healthy foods First, Kids, just like adults, use food for emotional comfort. There’s nothing pathological or wrong about this. This is human nature. So if emotional needs are perceived to be threatened or needs aren’t getting met, children will often revert to their comfort foods to regain that sense of calm and relax by filling their belly with foods or drinks that satisfy that sense of emotional safety or control and help them regulate their nervous systems.
Sometimes, especially at specific times of the day, such as lunchtime at school or at dinner, they might come to the table with a dysregulated nervous system already, or they perceive a threat to be coming. They might also be seeking comfort in a specific experience through their food, which is often the case. Like for the afternoon snack, they’ll be more rigid with their choices and behavior the more their nervous system is dysregulated. There are likely sensory needs and preferences they’re also turning into tuning in to. These sensory preferences are unique to your child, their natural likes and dislikes, what foods they’ve been exposed to so far, and in what frequency, as well as how comfortable they are with varied sensations. They also may have or have had in the past.
Oral motor skill difficulties:less processed foods are generally more challenging to eat. Fresh produce and whole grains are often presented in forms that are much harder to chew, and mixed texture foods are just more complicated for your mouth to manage. They naturally start to avoid what they’re not yet competent at, especially if the adults are around them, aren’t quite catching on to what a challenge it actually is for them. Imagine if you were continually offered whole apples when you actually have the ability for applesauce or offered steak when you’re really only able to handle meatloaf.
Most kids that are picky eaters benefit from a flexible routine where they can generally feel safe and predictably get their needs met. There are a lot of challenging, competing time priorities for families and kids, so being able to slow down and really focus on a food routine can be challenging. Oftentimes we talk about eating together as a family and how great that is, but when kids are hungry and want food immediately during busy days, parents often focus on getting the child what they need quickly versus actually being able to sit down and eat with them. Meals can be fast paced and just feel more stressful for many reasons, which virtually eliminates curiosity and appetite for many children. Also, irregularly timed meals and snacks can cause extreme blood sugar, highs and lows. Even without diabetes, blood sugar lows can be felt as alarm bells to the nervous system, which can lead to eating processed foods and snacks that quickly calm the body and resolve the low blood sugar. They will get confirmation these foods feel good to their body and that the processed foods meet their safety and hangry needs for other kids or regularly timed meals and snacks means grazing or whatever or whatever kind of eating. When grazing occurs, the gut doesn’t get a chance to rest, and some rest between meals and snacks is optimal for the GI tract to move food efficiently through.
Foods offered at daycare or school can also be a big part of the picture for some kids. They can undereat at school or will only eat snacks or drink milk or juice. This may be partly due to nervous system dysregulation or because lower preference foods are being offered during meals. Some kids also start to associate eating with the urge to poop, which they’re usually trying to avoid at school. So this will lead the child right back into the constipation, carousel and undernutrition, which can lead to more extreme picky eating and a negative behavior loop or cycle being established.
So in summary, what makes eating healthy foods possible a healthy relationship to food, responsive and attuned caregivers who sense when their child is disregulated at a meal and try to learn why taking small steps at the right time. So when the child’s nervous system feels more safe and regulated, when you take those small steps, consider offering choices that match their dietary needs and sensory preference preferences, which we’ll talk more about in the next video.
And the last point is true. Treating GI distress and constipation adequately. Don’t underestimate how constipation and other GI issues can be the underlying cause of picky eating kids quickly learn to kind of sort of eat to avoid that discomfort. So recognizing and treating GI concerns adequately is key.
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 health care provider.
How does food help us treat chronic constipation, and other GI conditions, in children? Kelli Borgman, RD, for the Vermont Continence Project gives recommendations on a diet that supports healthy elimination.