My 7 year old son frequently feels really sick in his

Thanks for your reply, that makes a lot of sense. I almost always find that kids like this are far more constipated than we originally thought. After eating, there is a normal and healthy "gastrocolic reflex" that makes the intestines contract, trying to poop. So pain near or below the belly button after eating is a pretty reliable sign of backed-up poop. The headaches, cold hands, and calf pain are not as typical, but can be consistent with constipation (the body shunts blood to the GI tract, trying to get the poop out- so the circulation is slightly decreased in the hands, legs, etc.)

Before being sure of a diagnosis of slow intestines (causing constipation and severe pain), I personally would consider some further diagnostic steps. An abdominal xray, ordered specifically to look for stool in the colon, can be incredibly helpful. It needs to be read by a radiologist who KNOWS exactly what you are looking for (sometimes they are called "normal"- meaning no sign of a surgical emergency, and no one looks for stool in the intestine). Another less fun but necessary step is a rectal exam. This gets left out a lot, with good intentions, but it is really necessary. If there is a big hard stool in the rectum, that helps confirm the diagnosis and guides therapy. If not, constipation can still be the diagnosis but the approach would be different (for example, no need for suppository in that case). I will attach a long (sorry!) but hopefully helpful handout I give my patients. I really hope it helps!!!

In addition to this info, I just want you to keep in the back of your mind that if this doesn't work, I would ask a GI specialist whether (s)he thinks the headache/cold hands/leg pain could signal a bigger problem. If so, they might consider more complete radiology studies, possibly an MRI/MRA. I hope very much that this provides you some help!

Don't give up!!! Keep up that Miralax- 2 capfuls a day. Consider also the Pedia-Lax stool softeners (yummy watermelon-flavored chewable tablets). Best of luck!

Dr. Carrie's

CRASH COURSE ON CONSTIPATION

• WHAT IS CONSTIPATION? Constipation is a constellation of symptoms, including severe pain and other problems (detailed below) caused by retention of fecal waste over time. In other words, constipation is the result of inability or failure to evacuate stool at the rate at which it is formed.
• A child CAN HAVE DAILY BOWEL MOVEMENTS and still suffer from constipation. How?

§ Let's imagine that a particular child's body produces, for example, an average of 6 ounces of fecal waste every day.

§ If this child poops every single day, but only gets out 5 ounces of poop daily, over time she will become painfully constipated.

§ By the same token, this same child could poop every other day, evacuating 12 ounces during each bowel movement, and have no symptoms of constipation whatsoever. (This is not very common. Most kids need to poop daily.)

§ The point... STOOL FREQUENCY IS NOT A RELIABLE INDICATOR OF THE PRESENCE OR ABSENCE OF CONSTIPATION

§ Parents are often understandably surprised to learn that their pediatrician suspects constipation when their child complains of abdominal pain, especially when the child has daily bowel movements!

• WHAT ARE THE SIGNS AND SYMPTOMS OF CONSTIPATION? Some of the most common manifestations of constipation are the following: (remember, every child is different; any given child may have only one, any combination, or all of these. Also, the clinical picture may change over time)

§ Abdominal pain

o Can be severe, but should not be accompanied by fever, rash or vomiting, and is not localized to the lower right part of abdomen. If you see any of these, please call our office for an appointment immediately

o Typically described as crampy and often occurs within 1-2 hours of a meal

o The pain may be accompanied by sweating and lightheadedness

o The pain comes and goes-- after a period of intense pain, it begins to remit, and the child might feel perfectly fine until the next bout of pain strikes.

Ø The intermittent nature of pain due to constipation can be helpful in distinguishing it from more emergent causes, such as appendicitis. With appendicitis, pain typically becomes increasingly severe. However, if you suspect appendicitis or any serious intra-abdominal process, please call us immediately.

§ Diminished appetite (this may fluctuate)

§ Small, firm balls of stool, look like "rabbit pellets"

§ Sensation of the urge to poop, along with inability to get any or all of it out-"it's stuck!"

§ larger than normal poops; sometimes they are so big they are difficult to flush

§ Encopresis-- leakage of small amounts of stool into underwear. Ask me to explain during an appointment how this reflects constipation, despite looking like diarrhea

§ Urinary symptoms, including increased frequency of urination and/or urinary incontinence (either during the day or at night).

After reading this, if you are still unsure whether your child is constipated, please discuss this with me. If we agree that constipation is a problem, you will be given individualized advice on what to do.



Dr. Carrie's

CONSTIPATION INFORMATION, part II

GUIDE TO THE MANAGEMENT of CONSTIPATION *

This plan is intended for families of children who have been evaluated in our office and diagnosed with constipation, and for whom we have specifically recommended the plan. Based on your child's age, weight, and degree of constipation, your doctor has filled in the appropriate doses.

If you have ANY questions, or if at any time you feel your child is worse, PLEASE STOP AND CALL THE OFFICE. Tell the person with whom you speak initially that you have a constipation plan on your chart.

Ø Treating constipation is not a quick-fix, one visit process!

Ø We will need to work together over the next few weeks to months to adjust medication doses and to monitor your child's progress.

In order to relieve the discomfort and to prevent the complications of constipation, we need to work toward the goal of at LEAST 1 soft, non-painful poop every day.

Ø In the process of reaching this goal, we will need to cause some loose, watery stools in order to loosen up and evacuate the poop that is "stuck" in there.

Ø IT IS GOING TO LOOK LIKE DIARRHEA. THAT MEANS IT IS WORKING.

Ø Once the colon is cleaned out, and your child continues to evacuate stool at the rate at which it is formed, the colon can gradually return to its normal size, shape and function. Once the colon has returned to normal, with continued regular BM's, eventually the problem will be gone.

For reasons we can discuss at greater length during an appointment in the office, I do not recommend the routine use of either enemas or stimulant laxatives (e.g. Senokot) in children. If your child needs either of these, we can discuss it in depth during your visit.



*NOTE FOR WFP OFFICE STAFF: One copy of the plan will be given to the family.

Please place this copy in the chart in the "correspondence" section. THANK YOU!



TOOLS FOR TREATING CONSTIPATION

Miralax: an over-the-counter stool softener, which is VERY SAFE. By osmotically pulling water into the colon, Miralax softens the stool, making it easier and less painful to pass. Miralax works directly in the GI tract, and does not get absorbed into the bloodstream. It is really a STOOL SOFTENER, not a "laxative" and does not cause the intestinal muscles to contract. It is not "addictive" and will not make your child's constipation worse, no matter how long he needs it.

· Most kids with your child's degree of constipation require Miralax daily for at least 2-3 months. When the plan is stopped prematurely, the child will almost inevitably have a recurrence of the problem; that is, he or she will stop getting out poop at the rate it is formed, will get backed up again, and the painful poops and abdominal pain will recur.

Ø IF MIRALAX IS NOT "ADDICTIVE", THEN WHY DO WE HAVE TO USE IT FOR SO LONG? ALSO, WHY DOES SHE GET CONSTIPATED AGAIN SHORTLY AFTER WE STOP GIVING HER THE MIRALAX?

· The reason that kids "need" Miralax for what seems like such a long time is NOT because they are "addicted to" or dependent upon the Miralax. Instead, it is because the constipation has caused the rectum to stretch /dilate and to function abnormally.

· The goal of treatment is to evacuate the stool, thereby allowing the colon and rectum to return to normal size, shape, and function. When this is accomplished, medicines will no longer be needed, as long as the child can continue to get the poop out at the rate at which it is formed.

Glycerin suppositories: another over- the-counter medicine that is great for the initial cleanout phase. The suppositories loosen up hard stool that is stuck in the rectum. Getting this "plug" out his makes it easier for the rest of the stool (which is being softened up by the Miralax) to come out.









STEP ONE- "CLEANOUT"

Ø For the next 3-7 days, your child is in the cleanout phase.

· MIRALAX: please give ­­­­­­­­­­­­­­­­­­­­­­­­­______________ (a) capful of Miralax TWICE a day, one in the morning and one at night. Each dose should be mixed well in 8 ounces of liquid. If you mix it in juice or other flavored liquid, the child will not be able to taste it!

· GLYCERIN SUPPOSITORIES: following the package directions in terms of dose, insert the appropriately-sized suppository into the rectum before supper tonight.

· Make sure your child is getting plenty of oral liquids during this phase. You will know that he or she is adequately hydrated if there is urination at least every 6-8 hours.

· The goal of the cleanout phase is several watery-to-loose stools daily.

· Remember, it is going to look like diarrhea. That means it is working.

Ø If you get a good result over the next 24 hours, using the combination of the first dose of glycerin suppository and the Miralax (again, a "good result" would be multiple watery poops), do not use the glycerin anymore unless the initial symptoms return. If you follow the plan closely, it is highly unlikely that your child will require suppositories after the initial cleanout phase.

Ø If your child is still constipated on the 3rd day of the plan (for example, he or she still has poop balls or painful poops), then use glycerin suppositories every other night until the cleanout is well underway, that is, when the daily poops are all very soft and/or watery.

· The cleanout phase is over when the loose and watery poops become more formed and more like "normal" poop. This will happen! As the cleanout progresses, the watery poops will seem less like "diarrhea" and have a more normal consistency while you are still giving the twice-daily Miralax. If your child is still having loose watery poops after 7 days of twice-daily Miralax, cut Miralax back to once a day and make an appointment to see me.











STEP TWO- "FINDING YOUR CHILD'S MAINTENANCE DOSE OF MIRALAX"

· At this point, your child should be having at least one very soft, non-painful poop every day. Two or more would be better!

· NOW, decrease the dose of Miralax to ____________ (1/2a) capful of Miralax twice a day.

· Continue at this dose for 2 full weeks. IF ANY signs or symptoms of constipation return, then go back to step one.

· If poops are daily, soft, and your child is pain-free after these 2 weeks of taking twice-daily Miralax at a dose of _________ (1/2a) capful, you are ready to move on with the plan! HOWEVER, please make an appointment to see me as soon as possible if:

o poops are still very watery at this stage, or

o Your child has abdominal pain, urinary symptoms, or any other problems.

· *Next, keeping the amount the same, at __________ (1/2a) capful, decrease the frequency of Miralax to ONCE DAILY.

· **After one week at this dose, try to decrease even more, giving only about ______ (b) capful ONCE daily.

· Again at this point, if ANY symptoms of constipation return, go back to *, i.e., increase Miralax dose back to ________ (1/2a) capful once day for 1 more week.

o At the end of this 1 week period, proceed from there (i.e. go back to **: and try to cut back down to ___________ (b) capful again.

· Continue this cycle until the child has been taking ________ (b) capful, once a day for 2 weeks, without any problems whatsoever, and without any sign that constipation is recurring.

STEP THREE- "NO MORE MEDS!"

· *** After 2 weeks on __________ (b) capful once daily, if your child is having soft stools at LEAST once a day, with no pain, no blood, no little poop balls, and no problems, try to stop Miralax.

· Watch closely, communicating frequently with your child about his/her poops.

o While you are not giving Miralax, if he or she goes for a day without any poop at all, or if there are signs of returning "constipated" poops (huge and painful, or little poop balls, etc.), go back to ***, giving __________ (b) capful once daily for 2 weeks.

· Keep going with the plan until he or she is having non-constipated poops, every day, without medicines.

· Continue to pay close attention for any signs that constipation is recurring!!!







Other tips:

§ Good nutrition, including drinking plenty of water and consuming an age-appropriate amount of fiber, is always a healthy idea. However, if you are receiving this handout, it is HIGHLY UNLIKELY that dietary interventions will make a significant difference in your child's constipation/ abdominal pain, unless dietary interventions are undertaken along with the cleanout plan.

§ Explain to your child as clearly as possible that the only way to make this problem (the stomach pain, the painful stools, etc.) go away is to get the poop out. Holding it in will make it hurt worse. Push it out!

o This is counter-intuitive! That is, usually when we experience pain, the best thing to do is to stop doing whatever you did to cause the pain. For example, if you burn your hand after touching a hot stove, you quickly withdraw your hand from the hot burner, i.e. you stop what you were doing that was causing pain.

o With constipation you must do the opposite. It is critical that we persuade kids to keep sitting on the toilet and to keep pushing and trying to poop even when it hurts a little.

§ On the other hand, because of the stool-softening effect of Miralax (and glycerin suppositories in step one), the pain while defecating should not be severe. If it is continues to be very painful to get the poop out, please see me in the office.

· Also, even if the poop IS properly softened at this point, many kids continue to withhold stool, either by habit or from fear that the pain will return.

§ Part of the problem with constipation is that it is a vicious cycle. It hurts to poop when you are constipated, so the child tends to hold it in to try to avoid the pain. Unfortunately, holding the poop in makes the stool bigger and harder, so it will hurts even more the next time he/she tries to poop...

§ The sooner this cycle is broken, the sooner your child will be better!

§ Even toddlers benefit from a simple explanation of how they need to try to poop whenever their brain gets the signal that they might need to, even if it hurts a little. Holding it in will soon make him/her feel much, much worse.

§ If your child ever has vomiting, fever, or blood in the poop, CALL OUR OFFICE RIGHT AWAY. (After hours you will be referred to Healthlink, our wonderful nurse advice line.)

§ If your child has mild burning of her anal area from the loose stools during the cleanout phase, use Desitin or other diaper cream. If it is severe (interferes with sleep or normal activities), call or come in.

§ If the plan isn't working or you have questions, come in.

It will work- with time and patience... BEST OF LUCK!

One more thing- if you choose to follow the "plan" above- the starting dose would be 1 capful twice a day. Then the next dose goes down to 1 capful twice a day, etc. Where it says "b" in the plan, that would be 1/4 capful. Thanks for your kind words!