Poop has become a major topic of discussion in the Scott household. That's because 4-year-old Caroline, who has frequent stomachaches, is a "holder"--the term doctors often use to describe a child who won't use the toilet when a bowel movement beckons. Her mom, Colleen, of North Attleboro, Massachusetts, has tried pleading with Caroline and also bribing her, explaining that her belly wouldn't hurt if she went regularly. But, overcome by an irrational fear that she can't clearly explain, Caroline waits until she has to go so badly that poop leaks into her underwear. When an X-ray recently confirmed that Caroline's bowels were packed, her doctor prescribed a stool softener and laxative. Once that did its job, however, she went right back to holding.
Abdominal issues are so common that nearly half of school-age kids suffer more than one gastrointestinal symptom weekly, according to a study at Ann and Robert H. Lurie Children's Hospital of Chicago. Those situations aren't serious unless they affect your child at school or in activities. In some cases, a child may simply have a temporary issue (or just not want to go to school!). But if symptoms persist or are especially bothersome, you'll want to talk to your pediatrician, says Cary Sauer, M.D., endoscopy director and pediatric gastroenterologist at Children's Healthcare of Atlanta. Our guide to problems both short-term and chronic will help you understand what's really going on with your little one.
Functional Abdominal Pain
Some 15 percent of kids complain of periodic pain around their belly button, but their doctor can find no signs of blockage, swelling, or infection (such as fever or severe pain). Without a clear physical reason for the trouble, the diagnosis will be functional abdominal pain (FAP), also known as worried stomach. Still, the pain is real, explains Jesse Reeves-Garcia, M.D., director of the division of gastroenterology at Miami Children's Hospital. Doctors believe that some kids are simply more sensitive to the pressure in their intestines caused by triggers like gas, food (especially if it's spicy), and stress--which makes sense when you consider that so many nerve endings live in the digestive tract that scientists call it our second brain, says Dr. Reeves-Garcia.
How it's diagnosed Doctors usually limit testing to blood, urine, and stool, unless the pain occurs with vomiting, bloody diarrhea, or other symptoms that could indicate a food allergy or inflammatory bowel disease. In that case, expect an X-ray, ultrasound, and/or upper endoscopy, where a probe with a tiny camera is placed down your child's throat to get a sample of the esophageal lining.
Best treatment Drugs generally aren't needed; instead, doctors recommend helping your child identify and minimize common triggers. Teach him how to distract himself when he feels the pain coming, maybe by listening to music or playing an iPad game, says Richard Gilchrist, M.D., a child and adolescent psychiatrist at Nationwide Children's Hospital, in Columbus, Ohio.
Irritable Bowel Syndrome
When general stomach pain accompanies bowel movements, which typically include diarrhea or constipation, your child likely has irritable bowel syndrome (IBS). As with FAP, experts blame a heightened sensitivity in the digestive tract, explains Bruno Chumpitazi, M.D., a pediatric gastroenterologist at Texas Children's Hospital, in Houston. About a third of children who have IBS--which tends to run in families--outgrow it, but the rest are affected for years, often into adulthood.
How it's diagnosed Doctors typically diagnose IBS based on symptoms (and sometimes blood, stool, and urine tests) without conducting invasive medical exams, since they almost always come back negative, explains Dr. Chumpitazi.
Best treatment Talk to your doctor about dietary changes, supplements like fiber, or OTC diarrhea drugs or laxatives. He may also prescribe an antispasmodic drug to relax the muscles or a very low dose of an antidepressant to calm the digestive tract.
GI doctors are increasingly excited about an eating plan for kids with IBS. Called FODMAPS, it eliminates groups of carbohydrates (such as lactose and fructose) that seem to create excessive gas and pain. The diet has helped so many children at Texas Children's Hospital that they've recently begun a major study. Knowing which foods are forbidden is complex: Apples, broccoli, and high-fructose corn syrup are all no-nos, for example, but bananas, green beans, and regular sugar are okay. (It may help to get a dietitian on board. Find one at ibsfree.net; click on "Find a FODMAP dietitian.")
More tummy troubles
More than half of babies have reflux, but nearly all will have stopped spitting up by age 2. Still, between 2 and 10 percent of kids develop gastroesophageal reflux disease (GERD), in which food or acid come back up, even though kids don't generally feel this. Instead, most children experience abdominal pain, a dry cough, recurrent throat-clearing, and less interest in eating, says Dr. Sauer.
How it's diagnosed Doctors typically rely on symptoms, although if the problem is severe, a pediatric gastroenterologist may have a tiny, flexible tube inserted into your child's esophagus for 24 hours to record each incidence of reflux. He may also need an endoscopy, which is done in an outpatient center while your child is sedated.
Best treatment A small number of kids need to take a proton pump inhibitor drug like Prilosec for several months to stop the acid. If your child is overweight, work with your pediatrician to help him to shed those extra pounds; consider a Kaiser Permanente study that found that obese children ages 6 and older were more likely to have GERD than those at a normal weight. (The reasons are unclear, but an overweight child should get help regardless.) Consider limiting foods more likely to cause trouble, such as fried and fatty fare, tomato sauce, and pizza, particularly if they seem to make your child feel worse afterward. Dr. Sauer recommends avoiding fruit juices (particularly citrus), soda, and carbonated beverages because of the high acid content; milk and water are better options.
This can be brought on by something minor, like a change in diet or routine, or even needing to use an unfamiliar toilet. But for some kids it soon escalates, because stools get harder the longer they stay inside, making elimination more difficult--and, for younger children, frightening. A packed colon can also stretch to the point where it stops working properly.
Many parents believe that kids need to have a bowel movement every day, says Barbara Doty, M.D., associate clinical professor of family medicine at the University of Washington School of Medicine, who sees a lot of constipation in her family practice in Wasilla, Alaska. But most doctors consider it a problem only when kids have a BM fewer than three times in a week, or if stools are especially large, small, dry, or painful.
How it's diagnosed An X-ray will determine how much stool is backed up inside. To detect (and possibly move) the stool, your pediatrician may perform a rectal exam, suggest a glycerine suppository, or prescribe a mild oral medication to stimulate the bowels.
Best treatment Be sure your child loads up on vegetables, fruits, and whole grains every day, along with lots of water. You also want to establish good bathroom habits, so she doesn't get used to holding it in. Teach her to head for the bathroom as soon as the urge strikes, or to sit for ten or so minutes right after breakfast or supper, Dr. Doty advises.
Los Angeles mom Adriana Mollica became strict about 3-year-old Enzo's bathroom schedule after he started screaming during painful BMs. "I bring his favorite toy or book to entertain him while he's sitting," she says. Enzo's been known to brag that he pooped out a brachiosaurus dinosaur, and his mom is happy to make a game of her son's successes since it takes the agony out of going to the bathroom.
Cases that last several weeks or longer can require a "clean-out" to empty the bowels: a stool softener like Miralax (a tasteless laxative powder) combined with an enema. For children with chronic problems, doctors may recommend a daily dose of Miralax.
Fixing your child's chronic constipation might also end any bedwetting issues he may have, according to research by Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina, which found that accidents can result when trapped stool presses on the bladder.
More tummy troubles
Inflammatory Bowel Disease
The two most serious digestive diseases, Crohn's and ulcerative colitis (UC), are known as inflammatory bowel diseases (IBDs). UC inflames the superficial lining of the large intestine, or colon, while Crohn's can strike anywhere along the digestive system, says Desale Yacob, M.D., a gastroenterologist at Nationwide Children's Hospital. Symptoms include abdominal cramps, weight loss, nausea, fever, joint pain, mouth sores, and, especially with UC, bloody diarrhea. They can cause malnutrition, stunted growth, fatigue, intestinal blockage, and anemia if not caught early and properly treated.
How it's diagnosed Once the primary-care doctor suspects IBD, she may do blood work and at the same time refer your child to a pediatric gastroenterologist (GI). Pediatric GIs use X-rays, abdominal MRI or CT scans, upper endoscopy, and/or colonoscopy.
Best treatment It really depends on the severity of the case. Some children have to rely on formulas such as Pediasure or Ensure for the majority of their diet. Other kids may need powerful medicines including steroids, anti- inflammatory drugs, or the same immunomodulatory drugs used to treat cancer. (A small number of kids with advanced UC who don't respond to drugs get relief only when part of their colon is removed; this doesn't help with Crohn's since the disease affects the small intestine too.) Felicia Haywood, of Chicago, was initially horrified when a doctor prescribed the immunosuppressant Imuran for her then 3-year-old son, LaMont St. Clair, who was diagnosed with Crohn's at 16 months. But she has dutifully given him the medication each night for two years, and her son is finally thriving. "He's a regular, happy kid, and he's put on enough pounds that he's finally reached his age-appropriate weight," Haywood says.
Children with this autoimmune disease have no choice but to avoid even the tiniest speck of the grain protein known as gluten. Otherwise, it sets off a reaction that causes serious damage to the walls of the small intestine, along with severe stomach pain, diarrhea, and constipation. This is why kids who aren't diagnosed for years suffer from problems like growth delays, iron-deficiency anemia, and thin bones, says Dr. Chumpitazi. Be sure your doctor considers celiac if your child's digestive problems include weight loss, migraines, joint pain, or tingling in the hands or feet. There seems to be a genetic component, so if one child has it, siblings are more likely to as well.
How it's diagnosed It's best to have your child tested right away. The process begins with a blood test that checks for antibodies. If they are found, the condition is confirmed with an endoscopy to biopsy a sample of the villi, which are hairlike projections that absorb nutrients in the small intestine.
Best treatment The only remedy is a completely gluten-free diet, avoiding a long list of foods made from wheat, barley, and rye. (Gluten also often hides in processed foods like luncheon meats, gravy, and soy sauce.) Fortunately, supermarkets increasingly feature gluten-free processed foods. Omaha mom Jenny Peters, who has four children with celiac disease, says some switches are easy. She'll replace bread in sandwiches with lettuce wraps or corn tortillas, or serve rice as a side dish instead of pasta. But other swaps require a bit more creativity. She recalls when her daughter Emma shared homemade flourless black-bean brownies with her third-grade classmates. After they polished off the treats, Emma told them what they'd eaten. "They couldn't believe how good they were," Peters says.
Should you keep her home?
If your child comes down with an achy stomach just before school (but isn't vomiting, feverish, or experiencing bloody diarrhea), think twice before letting her stay home, advises Dr. Richard Gilchrist. Kids often get stomach pain from a stressor like a big test or a bully, he says; you're better off teaching her simple slow-breathing techniques to calm her nerves, or promise you'll speak to her teacher and send her on her way. Even kids with known GI diseases shouldn't stay home (or see the doctor) unless their symptoms are severe, he says. "By using guidelines developed with your child's physician and spelled out in advance, you'll avoid repeat battles." Plus, at school she'll be able to distract herself more easily when she's keeping busy and among friends.
Originally published in the February 2014 issue of PARENTS magazine.
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