Could it Be Constipation?

Check out this video for a detailed explanation of how to know if your child’s incontinence may be caused, or worsened, by constipation. In Elimination Basics, we explained how our bodies develop continence, and how constipation interrupts that.

Associated Resources:

“The Bowel Symptom Checklist” (pdf) helps you keep track of any symptoms Kelly mentions in this video. This form is very useful when you speak to your child’s healthcare provider.

Want to know more about constipation?

• “Unstuck” – Children’s Mercy Hospital  (website): myths, facts, and lots of graphics. Children’s Mercy hosts one of the country’s top childhood incontinence clinics.
• “Constipation: A Parent’s Guide”:  Chayah’s favorite guide to constipation. (yes! I have one!)
• “The Poo in You” (video): if you didn’t watch last week, check it out now!
  • “Bedwetting + Accidents”, Simple Families – (podcast) – Listen to pediatric urologist (bladder doctor) and world expert on urinary incontinence, Dr. Steven Hodges, explain the link between incontinence and constipation. His area of special interest is bedwetting, and his website is www.bedwettingandaccidents.com/ Please note that Dr. Hodges recommends a specific protocol, and that we are not endorsing it (only your PCP can make that decision with you!)

Is constipation connected to any other diagnoses? Yes! Many. Here’s a sample based on concerns from recent group membership:

• ADHD: “Chronic Constipation, the Other ADHD” – from CHADD
• Down Sydrome: “Medical Minute: Constipation & Children with Down Syndrome” – From Valley Children’s Healthcare
• Autism Spectrum Disorder: “Constipation and Autism” – from ERIC – the UK’s Children’s Bowel & Bladder Charity
• Sensory Processing Disorder: “Sensory Sensitivity Tied to Constipation in Young Children” – from Physician’s Weekly
• Anxiety: “Stress and Constipation: What’s the Link?” by Patrick Massey, MD, GoodRx. Explains how increased stress and anxiety can lead to constipation.

A full transcript of the video appears below.

Hello, my name is Kelly Savitri, and I’m a nurse with the Vermont Continence Project. Welcome back to our series about supporting the body during toilet learning. In this video, I’ll describe the many symptoms of constipation that indicate whether this could be a factor in your child’s struggle with toileting.

In the elimination basics video, I explained how chronic constipation affects the stretch receptors in both the bowel and the bladder, making it so that children have difficulty recognizing the sensation of needing to pee or poop. This is illustrated in the green part of the constipation cycle. If you haven’t yet watched elimination basics, I suggest you go back and watch that now so that you understand why this is so important.

In our video called Taking Bowel Data, we introduced you to the Bristol Stool Scale, which is a way of identifying the usual consistency of your child’s poop. Now, I’m going to explain to you how to interpret that data to have a better understanding of what is going on inside your child’s body.

First, let’s look at Type 1 and 2. This is usually what we think of when we imagine constipation. Remember, the longer that the poop stays in the colon, the harder and drier it becomes. Whether it is large or small, this kind of poop is often difficult for a child to pass. It may be painful or it might only come out when a child is distracted like when they’re watching TV, for example.

On the other end of the spectrum, we have Type 6 and 7. This very soft poop is often what we call sneaky poop. If this is what you are predominantly observing, it might mean that there’s an impaction of hard poop in the colon, and this very soft or liquid poop is sneaking around the blockage and leaking out often without the child even noticing it. This can be large or small, and it often comes out as streaks or smears in their underwear. When adults see this, they often think their child is having diarrhea, but it might actually be a symptom of incomplete evacuation.

Type 4 is what we think of as the “Goldilocks Zone”: It’s not too hard and not too soft. Honestly, when kids are struggling with toilet learning, we don’t usually see Type 4, but this is the goal that we will be working toward as we focus on healthy bowel function. If your child does have Type 4 stool, however, it’s important to know that this doesn’t mean for sure that your child isn’t constipated. Lots of research has shown that a child can have Type 4 stools every day and still have incomplete evacuation.

Sometimes kids’ bowel movements are all over the chart. They may have Type 1 and Type 7 at the same time, or they might have a day that is Type 6, followed by a day that is Type 2 or vice versa. Those are bowel patterns that really could benefit from medical intervention. It may mean that some stool is staying into long and your child needs help to develop a consistent healthy bowel pattern. It could also indicate other digestive health issues like lactose intolerance, for example.

Now that you’ve identified the usual consistency of your child’s poop, let’s talk about frequency. This can be really confusing. I often hear parents say, “How could my child possibly be constipated? I’m cleaning poop like four times a day.” We usually think of constipation as a condition when there’s no poop coming out, but sometimes there’s some amount coming out regularly, but the colon never fully gets emptied. That’s why when your child is having many bowel movements throughout the day, it’s helpful to think about it as incomplete evacuation rather than constipation. This is definitely something that deserves further investigation.

Ideally, your child would have one full soft bowel movement daily. It’s okay to miss a day occasionally, but if your child is having fewer than three bowel movements per week, it is definitely a sign of constipation.

The size and shape of your child’s bowel movements are a clue about the size and shape of your child’s colon. Poops that are very large or shaped like a ball indicate that your child’s colon is likely very stretched out. Very small or narrow poops are a sign that there might be something blocking the colon. This could be an impaction from old hard poop blocking the way or it could be a sign of a medical problem. Either way, it should be discussed with your child’s healthcare provider.

Consistency and frequency are just two indicators of bowel health. There are a lot of other signs that we want to look out for. All of the following are symptoms that you should discuss with your child’s healthcare provider: Straining or discomfort with bowel movements, fear or avoidance of using the toilet. If they’re unaware of the need to stool or unaware of the odor or unaware that they’ve gone, stool accidents while sleeping because this indicates that their body has to be completely relaxed in order to poop, and it is a sign that they might be withholding during the day. Many small pees throughout the day, history of urinary tract infections, a round belly or a gassy system, a limited food variety, or a low appetite.

Now we know that this is a lot to remember, so we’ve created a document called the Bowel Symptom Checklist that you can print out, and this is meant as a resource for you to bring to your child’s healthcare provider to help you have a conversation about how you might improve your child’s elimination health. The checklist is formatted with the official diagnostic criteria for functional constipation at the top.

Future videos will discuss constipation treatment, but it’s very important that the process is directed by your child’s provider. So if your child is experiencing any of the symptoms we discussed here, we encourage you to set up an appointment with their provider as soon as possible. Now that you have an idea of what to look for, our next video is going to talk a bit more in depth about what causes constipation and why treating it is an essential part of toilet learning. So please watch The Constipation Cycle.

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.