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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Hello, everyone. Welcome back to the Nimble Youth Podcast, where we talk about all things health, growth, and thriving in childhood and adolescence. I'm your host, Matt Butterman. Today, we're digging into something that might not seem very glamorous, but it's incredibly important and surprisingly common in kids, constipation and abdominal pain. But here's the twist.
It often overlaps with mental health challenges like anxiety and ADHD. With me today is doctor Gretchen Hoyle, a pediatrician with twenty five years of experience and a special focus on pediatric mental health. Before we get into it, we remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice. While we aim to provide valuable insights on pediatric mental health, It's very important to consult with a qualified health care professional for any concerns or questions regarding your child's mental well-being. Doctor Hoyle, welcome.
Thanks for having me. So, I'm excited to talk about this because it's a topic that affects more kids than people realize. And, it's so interconnected with their mental and emotional well-being. Right. Yeah.
It's a huge, huge part of what we're doing in, you know, the general pediatrics clinic. Abdominal pain as a reason for a visit is extremely common. And, of course, there are lots of different sources of abdominal pain. So it you know, like, when I see a kiddo with abdominal pain, I'm thinking, oh, well, you could have, like, a regular GI bug, especially if it's, you know, if it's related to having nausea and diarrhea and vomiting. Sometimes kids will have some sort of upper abdominal pain.
I'm like, oh, well, that may be a little reflux y kind of stuff. There's lots of different reasons for abdominal pain, but by far the most common scenario I see is kids who have abdominal pain because of constipation, and having a lot of retained stool in their colon. And then that tends to be sort of a cyclical process because, once kiddos get to a place where they're they're having constipation and when they do pass stool is hard and uncomfortable, then the urge to hold it really comes into play, and that tends to make the whole problem worse. So then they're having more abdominal pain because they have more retained stool, and that causes them to be less willing to use the bathroom to alleviate the problem and you kinda get into the cycle. Right.
And the sort of the end result of the cycle is something called encopresis. It can be. Yes. So let's talk about that, what that is. Right.
So encopresis yeah. That's a very significant problem. So encopresis is really just the medical word for, like, soiling accidents, and that can, you know, involve anything from, you know, a small amount of leakage that parents will find in underwear. Well, this is sort of, you know, not to be indelicate, but that's what's happening. And then sometimes kids will have full on, you know, evacuation of their bowels and while they're, you know, not in the bathroom.
And so and most of the time, what is happening there is that the colon and the rectum are so full of stool that the pressure builds up and the child releases that stool. But it's also that because of the stretching that's happened in the colon, their sensory experience that the signals that their body has to tell them that that's either about to happen, that they're about to become incontinent or disrupted. And so it kinda happens out of the blue and, you know, of course, there's a lot of embarrassment, shame, you know. It can be really, disrupting for a kid. Right.
Yeah. And our apologies to any listeners who may be eating lunch at the moment. So it's probably the most appropriate topic for that hour. But, it's very important, and we do need to cover it. So there are a number of physical problems that could cause this.
Right? So when a child comes in, you don't automatically assume it's it's a mental health issue. You have to sort of rule out all the other, problems. Right? Right.
So it's kind of a blend of, like, you know, there's definitely a, like, a physical component to it. But I do find that a lot of times, there's also a mental health component to it. And so the kiddos that tend to see that will get into trouble with this, where they are sort of engaged in holding behavior for extended periods of time. I think we've all probably seen this with our kids. Right?
Like, you know, you're like, oh, you know, I can tell that you need to go to the bathroom. Why don't you go to the bathroom? Go ahead and you know, they're doing a little potty dance thing, and you're like, okay. Let's go ahead and take care of that. But as it turns out, there it does require a few things that are going on in their brain to be able to manage their own, like, bodily functions, especially when they're in a place that is unfamiliar to them.
So for example, kiddos who have, you know, some degree of anxiety are often commonly hold stool because they are embarrassed about using the bathroom, typically in a place that is unfamiliar or that isn't very private. So school is a classic situation for them. So they are a little bit anxious, a little bit uptight at school. They may feel the sensation that they need to go, but because they don't want to go to the bathroom at school, they will hold it. And then they will they'll sort of get into trouble over several you know, usually this is you know, I can kinda tell about how long this takes because I find that somewhere around the time folks have been in the school year is underway for about two to three weeks.
I will find that my kindergarten and first grade age patients will be coming in with a lot of belly pain. And the classic story there is that, especially for kindergartners, is that they had been in a preschool setting before that was, like, a half day. And now they're in school all day. They've eaten lunch. They've had that signal that they need to go to the bathroom and pass stool.
But because they are not used to doing that at school, they will hold it. And then they have a lot of retained stool that sort of builds up over several weeks sometimes, and then they are starting to have abdominal pain that goes along with that. So if there's a lot of retained stool in your gut, then lots of different things can cause that to be painful. The most common scenario is that if you have hard stool in the colon, it is easy to have gas that gets trapped behind hard stool and the stretching and bloating of the colon is very painful. And so painful, in fact, that, you know, it was fairly regular that people would, you know, get taken to the Operating Room to get their appendix out because they had so much significant belly pain.
This is like adults, older, you know, teenagers, where you're like, oh, you're in so much pain. You're doubled over. You're so uncomfortable. You know, your exam is impressive from all this belly pain. And as it turned out, some percentage of the time, you know, the appendix was fine, and it turned out that there was really a lot of trapped gas behind really hard stool, and so constipation was the real problem.
And so it can be very, very uncomfortable. So parents will witness their child, you know, sort of like lying down, stopping what they're doing, complaining of their abdomen, crying and being really upset. And then sometimes what will happen is, as soon as that you know, almost as suddenly as that pain starts, it will stop. And the reason for that is because they've managed to pass gas around that, you know, that large amount of stool and typically out of the body, and they're relieved and they're able to kinda go on about their usual things. Right.
So how do you actually make the diagnosis of constipation in a way that makes sense for both the kids and their parents? Right. And so I do find that getting an x-ray can be really helpful. Okay. So I have, you know and, of course, we were very judicious about, you know, doing X rays.
We don't wanna expose folks to, you know, X rays that we don't need to. But it can be extremely helpful to get a visual representation of how much stool is in the colon, in order to explain, you know, what this pain is coming from. And it's also somewhat reassuring that it's not coming from something, you know, really scary, some sort of mass or something else that folks have sort of built up in their mind as being the source of the abdominal pain. So when you can see it on the X-ray, which you kind of can if you have a a provider who's gonna sort of explain what that looks like and sort of take you through what it looks like on the X-ray. It is very seeable, and you can also get the sense as to how much is, a stool is actually filling the colon.
And a lot of times when we get an x-ray, we'll be able to see big pockets of gas that have gotten stuck behind hard stool, and it's an it's sort of equivalent to where the child is having, you know, discomfort on their belly. So when I press on a spot on their belly, typically, it's around their belly button or maybe a little bit lower, but it could be in any number of spots. But as you press there and that's correlating to where the gas is, it's, you know, really uncomfortable. And so, you know, having an x-ray and a visual representation can be extremely helpful for parents and and also for kids, like, depending on how old they are and whether they're willing to kind of look at it to be able to say, oh, okay. I I understand what's happened, and I'm ready to kinda move on to the next step to alleviate the problem.
Right. And so the next step is something you call a clean out. Correct. Yeah. This probably kind of, self explanatory, but, explain it for us in more detail.
Sure. So for anybody who has done a bowel prep for colonoscopy, it's kind of the same idea. Those of us lucky enough to Correct. Exactly. If you have qualified for a bowel prep.
And and so the idea here is that we're gonna use a medicine called MiraLAX, which is a powder. It's over the counter and it's often used the the gastroenterology doctors will use it as part of their prep for a colonoscopy. The idea, of course, behind the colonoscopy prep is to get you completely cleaned out of any stool so that, you know, the procedure can be done. We're gonna do all the clean out part, but of course, the child's not getting a procedure or anything, but we're just gonna use the same strategy to get all of that, stool that we can see on the x-ray unpacked and get the child feeling better. So the way that we do that, typically, we'll call it a weekend clean out and because it typically takes two days.
And so what we'll do is mix up a mixture of typically somewhere between six and eight capfuls of MiraLAX with 36 to 40 ounces of fluid. Usually, I'll use Gatorade because you're not really supposed to be able to taste MiraLAX, but some kids say that they can taste MiraLAX. And so I'm like, okay. Well, you can pick a flavor that's gonna be, you know, that is gonna be palatable to you so that you're, you know, willing to drink this mixture. And so then you have the child drink the mixture, at, you know, maybe four to six ounces every thirty minutes or so until it's gone.
And that typically happens like on the morning of like a Saturday morning. You obviously need to be doing it on a day where the child is not in school because they're gonna need to be near the bathroom to be able to, you know, pass all the stool that we're trying to soften and then eventually liquefy to be able to get out of their gut. During the clean out, I will have them be on a, like, a clear diet. So jello, soup, any clear drinks, Italian ice, those kinds of things. And most kids don't feel like eating a whole lot anyway during this process, but, it's definitely not that they can't eat.
It's just that you wanna mostly do things that are going to pass easily through the system because pretty much anything that you take in is gonna have to come on out because we're gonna be pushing MiraLAX behind it. And so and so we do that and on the on typically a Saturday morning and what will happen it by the afternoon or later in the evening, they will have, really started to ideally, you know, pastools, typically hard stool at first, then it gets softer, then it gets like pudding consistency, then liquidy, and then ideally, we're getting to where they're getting sort of clear, maybe somewhat brown tinged liquid from below. And that tells us that we've gotten all of that stool unpacked from the colon, or all the way through the gut. And, and honestly, a lot of times kids will immediately feel better than they felt in quite some time. Right.
So that's the dirty work, but the real work kinda begins at this point. Right? It's something you call retraining. Correct. Yep.
And so, so if you imagine the colon, if it has been if there's been a lot of retained stool there for a long period of time, then the colon has been stretched out almost like a balloon, And that once we have cleaned out the hard stool, it's still sort of stretched out, but it's like a deflated balloon. Right? And so what we want to do is to make sure that the colon has time to remodel into sort of the correct shape where the wall of the colon gets, like like, the muscle layer sort of comes back together, especially this is true in the rectum where it's been stretched out and you want to make it so that the the muscle layer has had a chance to remodel so that when it it has that squeeze that happens during defecation, then it that it is a powerful squeeze and you're able to get a complete evacuation and then you're not having the child retaining stool, you know, throughout the day. So not to be indelicate, this is the sort of reality of how this, you know, works. But even young children can understand this process and, and they are usually pretty motivated to be able to get a handle on this because they just feel so much better once we've been able to get this, you know, process underway.
Right. And it's at this point where you screen for ADHD and anxiety to, you know, process the next steps. Right? Potentially. Yeah.
So certainly not all kids with constipation and, you know, and in caprices or, you know, retained stool or any of that or those kinds of, you know, abdominal pain related, constipation and potentially in caprices. Not all of those kids have an existing and a comorbid mental health condition like anxiety or or, ADHD. But what I find is that there is often a correlation between those things. So sometimes kids who I already know have ADHD or anxiety or also my kiddos who come in with abdominal pain and it turns out this constipation is like, oh, I think this is somewhat related to your, you know, underlying, you know, mental health condition that we've already been identified and are working with. Sometimes with kids where we're we're trying to do the process of, like, retraining the bowel and the idea here is to make it so that kids get used to passing stool pretty much every day.
There's lots in the literature about people having, you know, several days between, you know, using the bathroom and passing stool. But what I find is that for folks who have had difficulty with this problem, my goal is for them to pass stool every day, preferably like a pudding consistency stool. And the way to do that in this retraining process has some to do with doing something called maintenance MiraLAX. So we're using the same powder again, but we're doing a, you know, a smaller amount, but we're doing it every day. And we're also really trying to figure out a timing that makes it possible for the child to pass stool ideally in the morning.
And the reason for that and I tell folks, you know, if you ask older folks, like, you know, grandparent y age folks, they're they're pretty a lot of times they're pretty motivated by the idea that they need to have this happen for them in the morning before they leave the house and go out about their day. And the reason for that is because if you can get an evacuation of the rectum in the morning, then you're not having to hold it through the day. And older people tend to be aware of the fact that the muscle, the sphincter at the bottom, which is under voluntary control, so in our brains when we go to bath stool, our brain is, like, we are aware and are in control of that muscle, and we have to relax that muscle and then contract the muscles in the abdominal wall to be able to then pass stool. For young children, the sphincter muscle at the bottom is very strong, and it's very competent. And it means that for better or worse, they are usually quite successful at holding it.
And that's part of the problem that they're a lot that they will get into trouble with constipation because that muscle is competent enough to allow them to accumulate a ton of stool that then fills up their colon and causes all this abdominal pain. Older people are aware that that muscle does not have the same strength that it did in their youth. So all of this is, you know, kind of a lot to think about, but, but older people are usually aware that they want to have this happen for them in the morning before they leave the house because they can't necessarily count on the competence of that muscle. And so I think that basically that approach is very reasonable for kids especially if they have had a problem with in caprices and soiling accidents in the past is that the idea is that we do want them to go to the bathroom every day and we ideally would want them to be able to pass stool so that they get their the rectum evacuated in the morning, so that they are not trying to hold stool throughout the day at school.
Because if they are having that problem, then it kinda kicks in with particular anxiety, where they don't wanna go to the bathroom at school, and then you're kinda back in your cycle where you've had yeah. And this is a a a mind body problem. Right? Correct. Oh, yes.
So there's a whole cycle, sort of a feedback loop Yep. It is. That happens. In fact, we have a graphic which we'll post, at our website, and in the show notes, for for the episode. But, explain that cycle a little bit for our listeners if you would.
Sure. So what will happen for kids who are like constipation is often a result of holding behavior. So we all think, okay, well, well, you know, once you're potty trained, then the idea is that your, you know, your body sends you signals that it's time to go, you go you go back to whatever it is that you were doing. Right? And so that seems like a fairly simple thing.
But in reality, it does require some degree of executive functioning. And this is where this can become a problem for kids who have ADHD. And some of that is because they sort of have a they will often have difficulty with sort of recognizing the signals that their body is sending them. Sometimes, the actual tissue in the wall of the rectum or at the anal sphincter has been stretched out enough that that signal is just not as strong or as clear as it used to be. So it is easier for kiddos with ADHD to sort of miss the plot.
Right? That their body is telling them that they need to go to the bathroom, but they are not recognizing those signals. They also tend to be more likely to get so immersed in an activity that they enjoy that they will prefer to engage in holding behavior so that they don't have to stop what they're doing. And they also tend to be a little bit less receptive when adults say things like, you need to go to the bathroom. Why don't you go to the bathroom?
They'll push back on that more. There's a little bit of oppositional, you know, overlap with kids who have ADHD. And so they just have a lot of reasons for, you know, why they tend to engage in stool holding behavior. And then the kiddos who are anxious will also engage in stool holding behavior mostly out of, like, sort of discomfort with, you know, using the bathroom in a place where they don't have privacy or they don't have enough time. And, of course, in school, you know, there's this, like, you know, we're gonna all go to lunch and then we're gonna all go to the bathroom.
Well, that's not a great setup, honestly, for kids who, you know, would potentially need to pass stool at school. For a kiddo who's anxious, you know, that's probably just not gonna work for them. And so then you wind up having this holding behavior, and the holding behavior can really lead to the, you know, abdominal pain because there's a lot of retained stool there. You get gas trapped behind it. It interferes with the signals that go back to your brain that tell you that you need to go.
And then sort of, like, the worst case scenario is that you wind up with having episodes of in caprices where you actually lose control, and, you know, and have an accident. And then, of course, that feedback, especially for a kid who is anxious, can be, you know, kinda catastrophic for them. Right? It's hard for anybody, but, like, for that crowd, it's, you know, a huge deal. Right.
So it's a tough cycle to break. But how do you tackle it with kids and parents who come into your clinic with this problem? Right. So I think the first thing is, is, you know, I wanna start by breaking the cycle with what's happening in the gut. Okay?
So we need to get them cleaned out. And if there's some, you know, question about whether that's really what's happening, then an x-ray, again, can be extremely helpful in getting everybody on board and on the same page with, like, okay. This is what's causing the problem. We're going to address it by getting you cleaned out. And so, and so that is my typical starting point.
And then I will see them back in about a a week after we have done the clean out. And typically, you know, the kids are like, oh, I feel great. You know, I feel so much better. And, and they're often, you know, playing more and eating better and less, you know, you know, sort of whining about abdominal pain and stuff. And pretty much everybody is happy.
And then we have to sort of shift gears into saying, okay. We need to figure out what led up to this problem and whether there are things that we can get ahead of to keep it from happening again. Because right now, your gut, even though it's cleaned out, it's still pretty stretched out. So it's easy for stool to reaccumulate if we don't change the behavior and the thoughts that go around for the child around going to the potty. And so we start working on, you know, a, sort of a toileting routine.
We are using MiraLAX to help keep things soft, but we really want to get into a routine where we encourage the child to go and sit on the potty after every meal. And the reason for that is because we have a natural gastrocolic reflex that happens in our body, where when you stretch the stomach, it is a natural signal to the colon to pass stool. And so we want to get that child used to the idea that that is what that feeling is, and instead of holding it, we want you to go ahead and go to the potty and go. And, of course, that is typically not something they're going to do at lunch at school, But it's also part of the reason why I do like to talk about it a lot this time of the year because these kids, you know, are gonna be home during the summer. And if we can get this process, underway where they are learning to be able to go and sit on the potty after meals, then hopefully, by the time we get back in school, we've got that in place, especially in the morning or get up early enough to have breakfast, to stretch the stomach, to have enough time to go to the potty, and be able to, you know, empty the rectum so that you can go on about your day without holding it.
And then while you're actually in the bathroom, a couple of things that are really important that I tell parents. One is that if if your child is, you know, small enough that when they sit on the potty that their legs are kind of dangling, then that actually makes it harder for them to go. And so you do want to be able to get a stool for them to put their feet on, which, you know, I think there's a lot of project products out there like that. So the Squatty Potty, I think, is the most well known, but that's, you know, that's legit. I mean, you know, you want to be able to get their, you know, legs up so that they can push with their thigh muscles in addition to their abdominal wall muscles, and, that helps them pass stool.
And you also, you know, want them to, you know, set it up in the morning so that they have enough time and that they have privacy. So, ideally, this is happening in a bathroom where there's not somebody banging on the door telling them to you know, that they gotta go. I mean, we just want to be able to set them up for success for that part. And so that's really the first part of it, dealing with the behaviors that are around stooling that we can improve. And then if there are underlying things, sometimes it is a tip-off for me.
Sometimes it's a kid who already has an anxiety or ADHD diagnosis, and it makes me say to myself, oh, well, we probably need to see if we need to make adjustments there if this is becoming like a recurrent issue. Occasionally, it'll be a kid where I'm like, okay. Well, why don't we talk a little bit about how things feel for you on the inside, and we'll do one of the questionnaires that we talked about in the anxiety, you know, podcast and, like, the scared questionnaire. And a lot of times, I'll find out that that child does have a lot of worries that they are, you know, successful at hiding, and we can talk through those. Sometimes that means having them, you know, talk to one of our therapists a little bit and talk about fears and worries and see if we can get them to a place where they just feel more comfortable and confident.
Because a lot of times for kids with anxiety, what happens here is that they're having abdominal pain from their constipation. Their anxiety is worsening the abdominal pain, and the abdominal pain is worsening the anxiety, and it's just a big circle. And so we just wanna be able to break that circle to make them feel better and to get them as functional as possible. So the bottom line here, if you pardon the metaphor, is it's a multifaceted problem that requires a, a multi pronged solution and a and a team solution. Right?
Correct. Yep. Everybody needs to be on board. And, you know, sometimes that even means just parenthetically, like, I'll write a note to the school that says, please allow liberal bathroom privileges so that children can go when they need to go. Those are the kinds of logistical things that can be really helpful.
But it does take it, you know, it does take, you know, the child and the parents and other adults in their lives to be sort of aware of this problem and what the strategy is to get it under control. Right. And this is something that, you know, a lot of kids suffer with in silence, but they don't need to Correct. Because it's very treatable. Yes.
Absolutely. Yeah. Well, thank you, doctor Hoyle. That's it for today's episode of the Nimble Youth Podcast. If this topic resonated with you or you know a family that could benefit, please share this episode.
You can find past episodes and show notes from each episode at our website, www.nimbleyouthpodcast.com. Next time, we're gonna discuss a continuing problem for adolescents, eating disorders. And we'll address some of the lingering myths that surround this serious condition, including that it affects girls only. And as always, be well and stay mentally and psychosocially nimble. See you next time.