Ep 136: Preventing constipation in kids! With gastroenterologist Iris Wang MD, author of "Boo Can't Poo!"

Episode 136 with Dr. Iris Wang, an assistant professor at Mayo Clinic and a general gastroenterologist and we are going to discuss her new children's book that teaches kids how to how to go to the bathroom.  Many adults deal with constipation that stemmed from childhood, and Dr Wang explains how we can prevent constipation in early childhood, without use of medication.  We discuss diet, water, exercise, probiotics, relaxation, and proper "sitting" positions to help make going to the bathroom easier!

Dr Wang is a general gastroenterologist, and her clinical focus includes, in addition to constipation, irritable bowel syndrome and other gastrointestinal disorders (see next episode!). Her new book is called “Boo Can’t Poo” and it is available for preorder and will be available June 18th. 

For more information about Author Xiao Jing "Iris" Wang:
Instagram: @mayoclinicpress

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. Hi, everybody. I hope you all had a wonderful Mother's Day weekend. Today I'm thrilled to have a special guest joining me Dr. Iris Wang. Dr. Wang is a gastroenterologist and she's an assistant professor at the prestigious Mayo Clinic. Today we're going to talk about the adorable children's book she recently authored boot camp poo. And this book teaches kids how to poop properly. Now I've had podcasts in the past where we talk about the treatment of constipation, but this conversation will be focused on how to prevent constipation from happening in the first place. Her book is currently available for preorder and will be available for sale on July 16. As always, I'm so thankful to my listeners. And if you can take a moment to share this episode with a friend or leave a kind review. Wherever it is you listen to podcasts, I would be so appreciative. It all helps spread the word, Dr. Iris wing, I'm so happy to have you here. Thank you so much for coming on the podcast. Dr. Jessica, thank you so much for having me. It's really a great pleasure to be here. So tell everybody about yourself. What do you do for work? What is your area of focus? So my name is Iris Wang. I am a assistant professor at Mayo Clinic in Rochester. I'm an adult gastroenterologist, but also a mom to a six year old. My area of clinical and research focus is in what's called disorders of gut brain interaction, which encompasses IBS, constipation, functional abdominal pain. And my research looks at understanding those disorders and trying to figure out how to help people get better from these disorders without the use of medications. So explain to everybody how is there exactly an interaction between the brain and the gut? How are they related? That's a great question. And I'm so glad we're talking about this because I think it can often be misconstrued or misunderstood as just anxiety or just in your head that's impacting the bowels. And that's, to some extent, yes, there are nerves in the brain that impact the bowels. But I think what a lot of people don't understand is that there's a whole separate nervous system in your bowels, it's called the enteric nervous system. And while it does interact with the brain, it actually fires on its own. And it's got these pacemaker cells that kind of function like your heart does, where if you left it alone, it would do its own thing, and it would contract and would help you digest. But there's this input an a two way path between that small brain in the gut, and the brain in your head or the central nervous system. And the vagus nerve is really the conduit between those two nervous system mechanisms. And what that vagus nerve input does is from the brain, tell your gut, okay, now's a good time to go now is a good time to digest now is a good time to move. And then from the gut end, it can send up signals to say, Okay, I'm full, or Okay, there is pain. And so there's really that two way cross talk. And it's really important to understand that there's actually that separate nervous system, because when we talk about sometimes how we treat things like IBS, we target nervous system mechanisms. But that doesn't mean we're treating things in the central brain. I think it's so interesting, because when you explain it to people, it's hard at first to understand this link. But I think we all can picture a time when we were nervous, and maybe we those nerves resulted in having to rush to the bathroom. I mean, there definitely is a connection between how we think and how that feels. Absolutely. And I think it's evolutionary, right, I actually explained this to my patients all the time who have constipation. And when we think about evolutionary biology, one of the big things that we, our bodies are made to do when we are in stress is to run away from a bear, right? It's fight or flight. And when we are running away from a bear, the last thing our bodies need to be doing is digesting, peeing or pooping. And so we have all these mechanisms through our alpha adrenergic. And these other receptors, to shunt blood away from our digestive systems, when we're in that fight or flight mode. On the flip side, in rest and digest, were then able to kind of re redirect that blood flow and redirect our energies to actually have a normal bowel function. And so this is why many, many people experience constipation when they're travelling, right, that stress of going to the airport that dry air the anxiety of like making your flight or travel plans, even the most seasoned travellers will say that when they're on a trip, they can't go. And of course, that's not the only factor. But that's like a very prime example of how our nervous system impacts our bowels. That's fascinating. I have to be honest, I attributed the change in bowel habits to change in diet, but you're right, I think travelling does accompany a lot of stress. And that totally makes sense that those nerves would direct its focus and energy rather on digestion but on making your flight, figuring out your travel plans, you think of it from the evolutionary perspective, that makes a lot of sense. Yeah. And I think you're absolutely right, too. There's so many other factors, right, the dry air on the plane, the fast food that you end up eating as you're fast, catching your flight, you know, all of those things are gonna contribute. So tell me, okay, tell us all about the inspiration about your new book bootcamp. Whoo. I'm gonna hold it up right here. So you can see the beautiful colour in the pictures. I thank you so much for, for giving me the opportunity to talk about it. And this is something that I am just like, so excited about. I'm not a paediatric gastroenterologist. And so it kind of seems odd that I've written a children's book. But really what happened was, as I was starting my fellowship, as I was taking care of adults who have constipation issues, I started realising more and more that nobody knows how to poop. Nobody has ever taught anybody how to poop. Nobody has ever told anyone that you're not actually supposed to push when you're pooping. And it's something that is such a taboo that nobody teaches the actual mechanics and physics and what you're supposed to do to get the poop out. We just assume that kids know how to do it on their own, and most kids do. But sometimes kids figure it out wrong. Right? It's like having a bad habit holding your chopsticks the wrong way. Right? This is something I do. And I get made fun of all the time. Does it work? Yes. Am I as effective as someone who does it right? No. And so I was seeing all of these patients who would be in their 20s and their 30s in their 60s. And as I'm explaining to them, how their bottom is supposed to work to lash out the poor, they would look at me and say, How come nobody ever told me that I wasn't supposed to push? And I was like, You know what I learned as a GI fellow that you weren't supposed to push? And so I would joke with them. Right? It was it was just a joke I was I would just say, Well, you know, I should write a children's book about this. Hit them while they're young and teach kids how they're supposed to poop. And by the way, it's the same with urinating, you're not supposed to push when you urinate. That always surprises people. Exactly right. It's supposed to happen. And I think people have so much other pressures, right, that they're supposed to push that they're supposed to get this out that they feel bad, and so they need to evacuate. That's the only way their body has taught them how to do that. I've also read this statistic, maybe maybe off but I've read that chronic constipation in children if it's not properly addressed and fixed. 30% of those kids go on into adulthood to be constipated adults. So I can see why this book is very valuable because we want to teach them young so we can avoid these issues continuing into adulthood. Absolutely. And I think part of this book is it's a preventative measure, right? Everyone needs to learn how to poop. It's something everybody does. And the secondary thing is I really want to break the stigma of talking about this horrible bodily function. It is okay for us to figure out how to do it correctly. No good for you. I love it. I am all for anything preventative because I would much rather teach kids in the beginning how to properly stool as opposed to later on trying to fix it, where we have to talk about medications and laxatives and whatnot. This is a much better approach. So I think it's a brilliant idea. And I it's an adorable book. It's cute, the rhymes are great. The pictures are great. So I definitely recommend it to anybody who's looking for a new kids book for their child. Thank you so much. Let's maybe talk about some of the tips in the book. Well, we can start with kind of the basics that everyone's heard of right, fibre and water. I really am a very strong advocate of dietary fibre. So naturally, ingesting fibre in a natural way that isn't necessarily supplements, especially in the paediatric population, right, you want to build healthy habits. And that's not necessarily like adding on a pill or supplement very early on. And so there's lots of great fibre foods, especially fruits that kids can benefit from that are really palatable, right like they like to eat. And one of them there's a big study in adults gi about kiwis and constipation. And the study actually showed that eating two Kiwis a day with the skin off is just as good as a fibre supplement because of how much fibre you're getting. Other fruits that have been really tested to be high fibre include pears, mangoes, and of course prunes, right but trying to get a kid to eat fruit is a little bit more challenging. But all of those things have not only natural fibres but also sorbitol. So like that fruit sugar that can help as an as a gentle laxative effect to hold water in the stool and help push things along. I usually tell parents to think about fruits that have pits in the middle. So when you think about apricot, peaches, plums, those fruits that have the pits in The middle tend to be high and sorbitol. So those are always wonderful go twos have those stone fruits whenever they're in season, and that'll definitely help keep your kids regular. I love that. And I think in the caveats of fibre is make sure that you introduce it gently. If you have a kid, a teenager, for example, who whose diet is very devoid of fruits and vegetables, trying to give them two Kiwis a day is going to be quite miserable, actually, because that's too much fibre too fast. And so thinking about titrating, that fibre up slowly, adding it slowly over the course of a week, couple of weeks to hit like a better target would be kind of what we recommend, because otherwise, if you start all at once they will give up on the fibre, they will be very uncomfortable. So that's good advice. And what about water because I agree with you, I find that a lot of kids that are constipated are coming to my office constipated, it turns out, they don't drink that much water. I think water is something that we neglect, right because it's an especially kids who are active kids who are not able to access bathrooms, you know, I see this problem in adults who who travel and don't have access ready access to a bathroom. And they just won't drink water because they don't want to be. But that definitely impacts How soft your stools are. Because in order to keep your bodily functions going right, that water is coming out of somewhere. And it's going to get pulled out of the school as best as your body can't do is very good at conserving water. And so making sure that you drink water is especially if you're going to increase fibre content, because how the fibre actually makes the stool softer is that it holds on to the water. And if you don't have enough water to put into that fibre equation, you're going to make bigger poops great. But that's going to be really hard for the littler ones that pass. And those are the stools that can get really large that can be rough because you're literally be eating roughage and can kind of cause some backfiring if you're not pairing that fibre with enough water. I think one of the big questions is what is enough water, right. And I think urine is the right indicator for that clear urine is kind of the right thing to aim for. There's nothing in the stool that's really going to be able to tell you quite as easily whether your daily current intake of water is enough. I also tell parents to make sure that we are attuned to our kids thirst because sometimes kids don't ask to drink. So I like to have a water I kept a water dispenser in my house as soon as my kids were able to use the water dispenser on their own. And that was great. Because whenever they were thirsty, they could get water on their own. But I definitely think making water available is really important. Absolutely. What about foods that they shouldn't eat or liquids that they shouldn't consume that might be more constipating. In nature, it's hard to say that there's a specific foods that is constipating in nature, right? There's a class of foods that I think aren't helpful. So simple sugars, processed foods, all of these things that we've heard are not great for us, you know, aren't great to be eating. But one of the big things that I will say is probably avoid fruit juices. Because especially when we're thinking about giving kids fruit sometimes like juice comes to mind. But that is a sort of simple process sugar, and it doesn't have any of the fibre benefits that eating the actual fruit does. And so you're kind of, you know, taking away all of the positives, it's got so much sugar that it's not actually going to be well absorbed. And so you think you're drinking but it's not water, that's, that's helpful to your system. And so you don't actually replenish the water supply for your kids. And then you get a lot of like sugar calories that are then empty and can fuel all sorts of other issues with obesity. So, my my plug to many of my to help many of my friends who are anti juice, I would agree that juice is probably not the right way to go. The other things that I would mention is things like things like Gatorade, like Powerade are really great when you're using them to replenish sweat losses. But they're not actually really great for hydrating the body. Because when you kind of look at their osmolality and etc. They actually keep more water in stool than allow it to pass through the body. And so is that good for constipation possibly. But just kind of a note that those sorts of electrolyte based drinks aren't great for hydration if that's what we're looking for. And what about too much milk consumption? That's definitely been something talked about in paediatrics. I find when kids have upwards of 40 ounces or so of milk a day they definitely seem to be more constipated. Yeah, hard for me to speak to that me take a pass on that. I shouldn't a paediatrician but certainly we do hear about that. And then when they get to the adult population, it's a little variable whether the milk causes constipation or diarrhoea. Now tell me about relaxing the muscles. So how can parents make sure that their kids are not pushing and straining when it comes to pooping? Yeah, I think it's a, it's a little bit of education, right? When kids know that they shouldn't be straining, they're really good at following that order that like, I should just be letting it happen, right. And I think the more it gets to be a little slippery slope, because sometimes we worry about the kids not going and so we ask them to go and then ask them to try to push. And it's, it kind of can be counterproductive. And so kind of going, maybe maybe we can talk a little bit about the pelvic floor here, I think a lot of us don't know or don't remember that. In addition to the diaphragm that's above right, everyone, when we say diaphragm thinks about that sheet of muscles that separates the lungs and the abdomen. And what many people don't know is that we have a second sheet of muscles that sits at the bottom of our abdomen and separates our abdomen from our pelvis. And it's a very similarly functioning layer of muscles. The majority of the muscles are there to keep what's above above and keep what's below below. But it also has an opening in it to allow things to pass. So like our upper diaphragm allows our oesophagus and our aorta, like the blood vessels to go through the bottom diaphragm or the pelvic floor allows things like the emptying of our bladder, the passing of the vaginal canal, and also the rectum to go through great so we can empty the things that need to come out. And that is under muscle control. So in addition to having sphincters, or like, or valves, at the end of the bladder at the anus to help us control the evacuation of those organs with the muscles of the pelvic floor also have a second layer of control. And there's a specific muscle called pupil rec talus, which can pulls up your rectum into like a very narrow angle. And as we're sitting, the rectum is actually pulled up into an acute angle so that things don't just fall out, that store doesn't just fall out. Even if your email sphincters aren't as strong as it could be. But that means that in order to effectively go or evacuate, that's the muscle that needs to relax. It's not just the anus, fingers, splinters that need to relax. It's also people wreck talus, and with that relaxation, the rectum actually straightens. And there's more, there's better transmission of pressure, and there's easier path for the stool to come out. And a lot of the times when we talk about straining, it's actually because the pupil rec talus is not relaxing. And so then you need to push that much harder in order for the stool to make it around this sharp angle. And then there might be kind of anal sphincter holding problems in addition to that. But when we talk about pelvic floor dysfunction in a GI context, we think a lot about that pupil rectus muscle, how does one counteract that and make sure that we have good positioning, no pun intended, but should we be buying stools to help with the stools? So a couple of things, I think one is thinking about relaxing the bottom right, and I think you're that mind over matter, right? You're just like how your upper diaphragm you breathe without thinking about it. But when you need to take a deep breath, your brain can overcome that whatever breathing pattern you were doing, and then take that big breath, right? The pelvic diaphragm usually works by itself, when you're going to empty the bladder or the or the rectum, it just kind of does its own thing. But you can overcome that natural control, especially if it's not going right. And so part if this is a big problem, then we send folks to physical therapy to kind of teach them how to control that muscle and teach them how to relax it. But when it isn't a problem, just thinking about that there are muscles down there that need to relax and open really already helps. So I have people take deep breaths, focusing on relaxing the bottom as their breathing. And all of that can help by itself. Talking about positioning though, there's been a lot of research to show that putting yourself in a squat position naturally relaxes the pupil rectangles and pupil right talent is the reason why the squatting position helps. And so putting yourself in the squatting position can be achieved in a number of ways. Kids actually can do it if they perch on top of the toilet. Now, I'm not advocating this. I don't want anyone's kids to fall into potential. But kids can figure that out on their own. And if you see your child doing that, that's a very natural position for them to be in. And so that's totally okay. The toileting stools, there are several on the market. I do not endorse any one of them in particular. But the goal that you're trying to achieve with that device or any of the devices is at the knees need to be above the level of the belly button. And when you think about it like that, for a little kid whose legs are short, those toileting stores won't Help, because they're not tall enough to get their knees above the level of their belly. But for adults, it is it's really great. And it will depend on the size of your toilet. But I think the big takeaway is that's the position knees above the belly button, and potentially leaning forward a little bit to allow that straightening to occur. And remembering to relax, I think that's really helpful. Yeah, I think that's great for parents to hear that rather than telling our kids to push to get it out to take a deep breath and relax. Okay, so in summary, to prevent constipation in our kids, we want to think about a high fibre diet, consuming a lot of water, making sure they're relaxed when they go, keeping their knees positioned above their belly button. And anything else that we forgot that might be high value points. Exercise, exercise is great, it's a little bit like a, you have to be careful, just like with the fibre in the water, right, if your kids running around playing soccer all day long, that's gonna be great to help their colon move. But if they're not drinking water, it's gonna be really hard for that school to come out. So making sure that if they're very, very active, that you're giving them back enough water to keep them hydrated. But if they're gonna be sedentary, right, taking walks, going out to run around, like all of those things, stimulating your body to move will help the colon as well. So remembering exercise, and then I'm curious, because this comes up all the time in my office, probiotics, they seem to be the cure all for so many things. If you were to look online, it seems like probiotics seem to be the the current a cure all. Is that true? In your experience with constipation? Is there any particular probiotic that you recommend? And is there any evidence to support using probiotics for constipation? Unfortunately, I'm going to have to see no, there's been actually pulled up a big Cochrane review in and the Cochrane system for parents who might be listening, it's just kind of this big system that tries to review all of the evidence on a subject and pull together the data. And unfortunately, the data on probiotics is just so mixed, that is really hard to recommend anything in particular, it's scientifically based this idea of using probiotics, right, these microbes that live in our body plays such a huge role on how our guts move that trying to fix that is probably very beneficial. The problem is we don't know how to fix it. And we don't have a product that is a silver bullet to fixing the issue. Our bodies and our systems are so complex, and so intricately balanced, that just putting in a pill doesn't really make a huge difference. Unfortunately, there are certain situations where a probiotic might be helpful. After an antibiotic for ACF, when we're trying to restore the microbiome, that might be a reasonable time. But just for overall health and prevention, the data is really not there for me to make recommendations to my adult patients. This there's just not enough data for us to make an informed recommendation to say yes, this probiotic is going to be really helpful. I think what you're saying is so true, I, I want to be able as a clinician to help parents and provide a quality recommendation on a probiotic to help them. For example, there's a product called cultural and a lot of parents tell me Oh, I give it to my kid for constipation, it seems to be effective. But I definitely get a mixed review, I do find that it's definitely not something that clearly is beneficial to all my patients that are constipated. Absolutely. When my patients asked me about it, my general recommendation and that so my colleagues is, if you want to try it, go ahead. There's there's very little risk except in certain situations, if there's immunosuppression, if their immune systems aren't functioning, I do not want to put extra plugs in there. That is probably the big one. And in pregnancy, we don't know what the data is, and I would avoid them. Short of that, it's a wallet biopsy is what we say, you know, if you have the means to do it, and you want to try it fine. Six to eight weeks is the time did you say oh, sorry, you said a wallet biopsy, meaning it's costly. Right. That's what's funny. That's what the risk is. And if they're going to try it, I suggest something with at least three strains of a probiotic in it and not a single strain. It tends to be a little bit more globally effective if there are more variety of bugs in the probiotic that they're consuming. The other things that I talk about with them is like fermented foods, which again are a little bit more natural. Also pricey, but maybe because the foods are generated from kind of natural fermentation processes, they tend to be more robust and how many strains of bacteria they're delivering. So like kimchi, kimchi, yoghurt, kombucha, kefir, sauerkraut, these sorts of things, right? Is there data? No, it's about as good as the profile. products but a little more natural and a little bit more kind of robust in the colonies. Again, not an endorsement, not a recommendation, but a suggestion if that's something they want to try. It's interesting because I think there's so much hype about probiotics, and I so wish that they work as much as everybody believes that they're working. But when I think about it, it makes sense that it might not be the cure all. First of all, it's hard to find a cure all. And secondly, there are so many bacteria in our gut, it's hard to believe that one strain one particular strain would make a tremendous difference. Exactly. You know, hopefully, as medicine advances, and we get better at things like AI and things like microbiome analysis get more accessible clinically, maybe we can maybe we can profile someone's stool, and then say, you know, this is the one you're missing, I'm going to replace it. But right now that doesn't bear. And if I may, the currently available stool testing is not FDA approved. And so there are a lot of folks who get these will based has and say, Oh, my gosh, I have so much of this bad bacteria. What do I do? We don't know the answers, we don't know. And so I would not recommend an antibiotic. It doesn't mean you need a probiotic, we just don't know what it means. Similarly, with a lot of the diet testing out there, and you really want to caution parents about those because it can be such a slippery slope from taking a test that is not, again, clinically tested, or validated. And then saying, Well, this test says my kid cannot eat sweet potato. And I don't care that I better throw sweet potato for however many years and she was fine. This must be the reason she's constipated. And we're cutting it all out. Right. And parents mean so well, but it is such a slippery slope. And this is how they wind up in my clinic at 19. Eating for things and afraid of any other food that isn't those for comfort foods. And based on a test that wasn't necessarily valid to begin with. Right? This is not like avoiding gluten for celiac disease, that that's a very different story. I just want to make sure that folks aren't very careful about how they interpret those tests. I always feel bad because I find often families are frustrated. And I understand that they're frustrated. And so they go to places to get tested. And then all of a sudden, they're in my office and they're telling me that their kid can't have gluten can't have dairy can't have corn. And the list goes on and on. And all of a sudden have this child that maybe could be fine with those foods, but they're very restricted all of a sudden, which I I feel bad because that has to take a toll psychologically, hopefully, it makes them feel better. But as you mentioned, I feel a lot of doubt with these diagnoses a lot of the time. And sometimes it does, right. Sometimes they told me I cut these out and she feels fine. And this is how we have been managing and there's there is definitely psychological toll on that. But what I really, really, like really hurts me is when they tell me Well, she was eating apples. It was fine. And then so but but they said we had to cut it out. It's a red food. And so we cut it out and it just breaks my heart because, right? No, I agree. I totally agree with you. If it's one thing if if they eliminate a food and they feel better, okay, but if they were feeling fine with that food to begin with, and then all of a sudden they're taking out tomatoes and eggplants. One thing I've heard about recently are the the nightshade. So we've gotten a lot of popularity to remove, and they're taking it all of these healthy foods, eggplants, tomatoes, and whatnot. And they're not feeling any different than I agree with you. It's really something to proceed with caution. Absolutely. And even though we do recommend certain diets, right for IBS treatment, for example, the low FODMAP diet is something that is in our guidelines. But what's really, really important is that that is not supposed to be a long term diet. It is supposed to have a reintroduction phase, people are afraid to reintroduce without guidance without figuring out like what exactly happened, right. And so it's really important to know that those diets are not supposed to be long term. Yes, yes. Thank you for that reminder efficiencies. Yes. Especially for kids. Yes, especially for kids. I agree. Thank you so much for tuning in to this week's conversation with Dr. weighing about how to prevent constipation in our children. Be sure to stay tuned for next week's episode where we continue our conversation talking about irritable bowel syndrome, also referred to as nervous colon. A big thank you to all of you listeners and we'll see you next Monday.