Posted tagged ‘belly aches’

School morning belly aches: Are they “real”?

December 14, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Dave’s story: “I have a six year old who gets a lot of belly aches. She’s seen her ped and a GI, and all the tests say nothing. Her belly aches really only happen in the morning before school. I think it might be psychological, and have told her about the boy who cries wolf, but she insists that her tummy hurts. What should we do?”

We need to settle one thing up front. These belly aches are in every sense “real”, even if they’re related to psychological factors on school days. The pain is real, because the pain hurts. Telling her that it doesn’t hurt, or talking with her about boys and wolves, is unlikely to help her feel better.

There’s this weird, false dichotomy in medicine between “real” and “not real” in the way we talk about medical problems—as if psychiatric or psychological issues are less important in some way. Sometimes words like “organic” are used for “real” pathology, as opposed to “inorganic”, whatever that means. You’ll also see references to “functional” pain, somehow implying that this kind of pain is somehow less real. But it still hurts!

There’s even a specific name for “GI pain where no pathology can be seen through a microscope and no lab tests are abnormal but nonetheless it hurts and ow I wish it would feel better.” It’s called irritable bowel syndrome, and it affects millions. Again: it hurts.

Dave’s already taken an important step: by keeping track of the symptoms, he’s narrowed this down to a school-morning phenomenon. That’s very important information, because it tells us that we don’t need more invasive tests or procedures. Instead, we ought to be focusing on ways to help the child feel better. Is there a specific stressor (like a bully) at school? Can we reduce overall stress in other ways? Can we think of ways to make school mornings a little less dread-inducing? Perhaps, in addition to reducing stress, we can also start to teach the child new ways of dealing with stress—like a special lovey to hug, or a punching bag to whale on (you can see, the approach may depend on the child!) Things like a hot water bottle, extra time on the toilet, or waking up early enough so the family doesn’t have to rush can all help.

The bottom line: belly aches that only happen on school day mornings are real. Parents won’t be able to talk their child out of it. Instead, we ought to be working with our children to see how we can help them feel better.

Constipation remedies

September 24, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Li wrote: “I saw an article you posted about potential causes for excessive urination for children.  One of the mentioned problems involved constipation.  Do you have any advice on where I can find more info on ways to relieve this problem through diet?  I was told build up of old stool is the cause of my child’s urinary problems.”

Constipation is very common, and it can lead to urinary problems like frequent urination, wetting, and painful urination. It’s no fun to be constipated, and I think parents need to treat this aggressively. Untreated constipation leads to harder, even-more-painful stools, which leads to more stool holding, which leads to worsening constipation. It’s what I sometimes dramatically call the Constipation Death Spiral—it gets worse and worse until it’s treated correctly and consistently. Fortunately, all but the most severely constipated kids can be treated with a few simple steps.

What is constipation? Normal stools might be anywhere from three times a day to once every three days—so it’s not really a matter of how often kids go. It’s what it feels like. Stool that’s firm enough or large enough to be uncomfortable is a sign of constipation. If it hurts, it’s constipated. If Junior is holding it in because it hurts, that’s worse constipation. If Junior has gotten so used to holding it that he doesn’t even realize he’s full of stool that leaks sometimes, that’s really bad constipation.

Some kids with significant constipation don’t really complain of pain much. They might have an occasional belly ache (especially after eating), or might only have urinary symptoms or stool leakage.

Why is constipation so common? I believe it comes down to diet. Our guts developed through almost all of human history to digest minimally processed foods. Even people who pursue a very “healthy” diet these days are still eating in a way that dramatically different from what our ancestors ate for thousands of years. It’s not all bad—human nutrition, at least in the developed world, has never been better. For the first time in history we suffer more now from overnutrition than from undernutrition. Still, one cost of all of this abundant, easy-to-eat-and-digest food is chronic constipation.

The first rule of treating constipation is to treat it. Do what it takes to fix it, and keep it fixed, for long enough that new patterns develop and children forget that they used to be afraid of their painful stools. Often parents make half-hearted attempts for a week or so, then give up as things maybe start to improve a little. Take my word for it: if you want to get out of the constipation spiral, you need to be consistent, and you need to be in it for the long haul.

The second rule is to try to avoid relying on enemas or suppositories. Your children do not want you anywhere near their anus. Constipation can almost always be treated orally. If you’re needing to go from the back route, you ought to be doing so while working with a doctor (though, hopefully, not in the same room.)

What can you do to treat constipation? Start by setting up a time, usually after a big meal, where your child is expected to sit on the pot for a set amount of time. The bathroom break isn’t until the child thinks his business is done—it’s until a timer goes off. These kids will sometimes squeeze off a little BM and think they’re done long before they’ve emptied, so you need to reinforce a new habit of relaxing and taking one’s time. I encourage bringing a GameBoy or iPhone or book or something for distraction. Maybe a Wall Street Journal, if your child is into investment banking. Whatever it takes.

From a diet point of view, you ought to encourage more water, more fruits and vegetables, more whole grains, and less dairy. Having said that, it’s very difficult to get children to make big changes in dietary habits, and rarely do diet changes alone fix significant constipation in kids.

Almost all families struggling with constipation will need to use a stool softener of some kind. Natural ones include fruits and fruit juices rich in sorbitol, like prunes, mango, or pears. Apple juice is popular, but isn’t a very effective stool softener. Ground flaxseeds or other sources of bran or insoluble fiber can help soften stools only if the child also drinks extra water. Without extra water, bran products themselves are constipating.

The most popular medical treatment for constipation is PEG 3350, often marketed as “Miralax” or a generic equivalent. This is a white powder mixed in a drink. Once the crystals dissolve, Miralax is flavorless. It helps constipation by drawing more water into the stool. Miralax is FDA-approved only for the short-term treatment of constipation, but it’s routinely used as a long-term maintenance drug safely. Other medicines used to treat constipation include Lactulose, Senokot, and Dulcolax. If you need to use medications, you ought to get more-specific instructions from your child’s pediatrician, who can also screen for rare-but-important medical causes of constipation that might be present.

Constipation isn’t fun, and it can cause significant problems including discomfort, embarrassment, and urinary problems. Unfortunately, some kids learn early on that pooping hurts, and those kids often continue to have issues with stool holding for years. If your child is constipated, please fix it, and keep it fixed. Talk with your pediatrician for more-specific advice, and don’t give up or stop treating it until it’s fixed for good.