#76: OT and Pediatric Constipation with Quiara Smith

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Learn more about our guest: Quiara Smith, MOT, OTR/L

:white_check_mark: Agenda

Breakdown and analysis of journal article (5 minutes)

Discussion on practical implications for OTs (50 minutes)

  • 00:14:00 How Quiara discovered pediatric pelvic health
  • 00:17:47 Quiara’s pelvic health business
  • 00:25:44 Stats around constipation, and the relation to urinary incontinence
  • 00:32:32 Article impressions
  • 00:37:26 Tips on evaluating a pediatric client with constipation
  • 00:45:28 Advice on goal setting
  • 00:49:38 Impactful interventions
  • 00:53:39 Advice for learning more about pediatric OT and constipation
  • 00:56:51 Interprofessional collaboration
  • 00:59:04 What is the future of this practice area?

:white_check_mark: Supplemental Research

:white_check_mark: Article Review

Read Full Text: Interdisciplinary Occupational and Physical Therapy Approach to Treating Constipation and Fecal Incontinence in Children
Journal: Physical & Occupational Therapy In Pediatrics
Year Published: 2022

As my own kids entered elementary school, I was surprised to anecdotally discover that constipation is a common reason for children to miss activities.

This aligns perfectly with the research we’re looking at today—and the growing concern that constipation has become a public health problem.

Constipation accounts for almost 1 in 20 visits children make to a doctor, and studies show that 10% of children and adolescents in the U.S. suffer from chronic constipation.

So naturally, occupational therapy professionals are starting to see more of these kids on their caseloads—which brings us to today’s article examining what an interdisciplinary approach to pediatric constipation can look like.

Next week, we are excited to welcome to the podcast Quiara Smith, an OT who owns a pediatric pelvic health practice. She and I will discuss the practical implications of this research for your OT practice.

Let’s dive in.

What OTs need to know about constipation

As many as 32% of children ages 0–18 years experience constipation.

The primary types of constipation are organic and functional.

Children who have a history of organic or functional constipation may experience retentive fecal incontinence. This is defined as a passage of stool into the underwear or in a socially inappropriate place, with the presence of fecal incontinence. This has been found to impact 4.4% of children in the U.S.

Standard treatment for constipation

Standard medical treatment for functional constipation often involves pharmacotherapy of oral laxatives.

But, this treatment alone is often inadequate. In fact, approximately 40% of patients who were prescribed oral laxatives had frequent relapses or simply did not respond to the treatment.

Non-pharmacological therapy has the potential to help treat the multifactorial nature of constipation. This can be beneficial, as these children often present with additional impairments like:

  • Negative or avoidant behaviors
  • Decreased body awareness
  • Poor diet and fluid intake
  • Inhibited or hypertonic pelvic floor muscles.

(Editor’s note: I found this systematic review on the science of non-pharmacological treatment very helpful.)

While the research on non-pharmacological therapy is still early, the evidence supporting therapy for this particular condition is growing.

The role of OT and PT in intervention

Past research has found clinically significant outcomes in children treated for constipation by an OT or PT:

However, there’s still limited research exploring a coordinated OT and PT approach to addressing this issue in conjunction with standard medical treatment. In theory, this multidisciplinary approach could help address the multi-faceted and complex nature of constipation.

Which leads us to this paper…

Purpose of this paper

The purpose of this case report is to demonstrate a coordinated OT and PT approach to successfully evaluating and treating 2 children with functional constipation and fecal incontinence.

Background and framework for both cases

An OT and PT co-evaluation took place in the clinic. Then, individual OT and PT treatment sessions were scheduled (usually back to back) to address goal areas. The OT, PT, child, and parents collaborated weekly on goal areas and home programming.

The OT and PT involved in this case were both trained in:

  • Pediatric pelvic floor therapy
  • sEMG biofeedback
  • Pelvic floor rehabilitation ultrasound imaging
  • Functional constipation

For the purposes of this article, I am going to share an overview of case #1. Please read the full article for more details, especially on case #2.

Case Description: Child #1

Child was a 10-year-old typically developing male who has experienced fecal incontinence and constipation for greater than 5 years.

The child had a history of trauma and abuse, including exposure to drug use and intermittent parent involvement.

The child was wearing Pull-Ups both day and night. He was voiding urine in the toilet 4–6 times per day. However, bowel movements (BMs) in the toilet had decreased in frequency since moving in with extended family 3 years prior. He was having 1–2 BMs in his Pull-Up daily with a varied consistency of Type 2 to Type 6 on the Bristol Stool Chart. Leakage of stool occurred daily at varying times and regardless of activity.

Associated with the decreased frequency of BMs, the child often had emotional outbursts when prompted to use the toilet.

A Kidney Ureter and Bladder (KUB) X-Ray revealed mild-to-moderate stool backup and subsequently, the child was prescribed a daily stool softener and MiraLAX. At the time of the evaluation, the child was refusing to take both medications due to taste aversion.

Please see the full article for more on the clinical findings associated with this case.

Assessment

The child presented with signs of dysfunctional elimination, with pelvic floor muscle incoordination and underactivity.

He also demonstrated significant fear of having BMs in the toilet.

The child had moderate constipation. Cognition, attention, and language skills impacted his ability to understand concepts related to functional and independent use of the bathroom.

Goals

  • Patient and family will be educated on complete abdominal massage for constipation management, 5/7 days over 3 consecutive weeks.
  • Patient will improve pelvic floor muscle endurance to 5 seconds work, 5 seconds rest for 5 consecutive repetitions.
  • Patient will independently complete 5 sequences of cat/cow; 3 consecutive sessions.
  • Patient will indicate when fecal leak has occurred and change clothing within 5 minutes of leak and with no more than 1 prompt from an adult; 80% of opportunities.
  • Patient will be able to verbalize 3 feelings related to incontinence challenges and accept help from others as needed without emotional reaction 80% of the time.
  • Patient will complete 5 reps of diaphragmatic breathing before and after void to encourage relaxation of pelvic floor muscles and full emptying; 80% of opportunities, 3 consecutive sessions.
  • Patient will be educated on and demonstrate wiping self independently after BM; 3 consecutive sessions.
  • Patient will increase pelvic floor muscle isolation from a level of using accessory muscles 100% of trials, to a level of little to no observed accessory muscle activation while completing contraction/relaxation exercises.
  • Patient will attend community/school events with no more than 1 bowel leak, across all activities in one week.
  • Patient will demonstrate understanding of urinary and digestive systems as evidenced by completing a simple drawing of systems with 80% accuracy within 4 sessions.
  • Patient will complete HEP for functional reflex activities to support bowel and bladder function; 5/7 days.
  • Patient and parents will complete weekly home programming activities and return the activities or data by the next session; 90% of opportunities

Interventions

The child was seen by either a PT or an OT for 18 weekly sessions. Details on those sessions are provided in the article, but here is a high-level overview of intervention:

  • Client/Family Education
  • Abdominal Massage
  • PNF Contract/Relax
  • sEMG Biofeedback
  • Breathing/Relaxation
  • Sensory/Urge Awareness
  • Wiping/Hygiene
  • Voiding
  • Primitive Reflex Integration
  • Emotional/Self-regulation
  • Routine
  • Diet/Hydration
  • Home Program

Outcomes

The child met 13/15 therapy goals. The remaining 2 will continue to be addressed by home programming.

Additional outcomes reported by the caregiver included improvement in the child’s self-esteem during peer interactions as well as improved family dynamics.

The child said he was now wearing underwear without the fear of having a leak, and that he felt more confident at school. He also became more willing to accept help from a caregiver.

Author Discussion and Conclusion

This case series provides evidence of 2 children achieving full continence with a coordinated OT and PT approach.

This approach is uniquely beneficial, as it allows each therapist to focus on their area of speciality while also increasing the likelihood that all factors contributing to the incontinence are addressed.

In order to determine whether outcomes associated with this approach are more successful than standard treatment, more robust comparative studies are needed.

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

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I am a pediatric community based OT in Canada. I talk about the importance of bowel health a lot as I work with preschool children who are toilet training. I would love to have the opportunity to work alongside a PT with this knowledge and expand my own education.

I am not surprised a collaborative approach is beneficial and believe hearing information in different ways helps to increase parents’ understanding.

I love that there is research in this area! Many people do not talk about poop!

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This was an interesting article to learn about and read. I did not know that so many children have constipation and that it is a common reason to miss activities. I have a child on my caseload now who has some of the issues mentioned in the article. I would love to understand more about how the primitive reflexes are involved and what exercises will help. I do not feel I have enough experience in this area to be very helpful to the client on the issue of constipation but am addressing other areas.
I look forward to the Podcast so I can learn more.

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I have felt as my children go through school that bladder and bowel health are not encouraged at school in that there seem to be few opportunities to go to the restroom throughout the day and children are not encouraged to go to the bathroom without asking and often are waiting for or being refused access to restrooms by the adults in the classroom. I wish some kind of educator training and school-based programs could be a basic focus nationally to increase childhood continence, body awareness, self efficacy….

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This is an exciting article! I have had so many children on my caseload who struggle with chronic constipation and fecal incontinence. Many of my students have autism and their sensory needs often include fear of toilets, decteased interoception for realizing need for BM often leading to avoidance and constipation and then subsequently fear of pushing due to oain and discomfort. A recent student just required hospitalization to have his bowels cleaned out. I am trying to work on interception activities and social narratives, video modeling, and addressing the sensory aspects of the bathroom, but I am really looking forward to the podcast to learn even more tools to help!! A growing literature base supporting OT and PT success in this area is really exciting!!!

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What kind of diet do you recommend for patient to have?

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Thank you for this article!! I want to zero in on the lack of supplying the OTPF4 terminology that I want to have present for all things Pelvic Health (all age groups): interoceptive awareness. Yes, low interoception is decreased body awareness, but it doesn’t capture the the significant impact of using interoceptive awareness as the goal statements. The systemic review for non-pharm methodologies drives the point home that for pediatric and youth populations, especially, learning (upskilling) interoceptive awareness (increasing internal body awareness) is a key indicator of achieving success in the other three bullet points:

Interoceptive awareness is a sense that can be developed and honed just like vestibular and proprioceptive awareness. OT’s are in a great position to take this on because we don’t necessarily have to go all in on invasive biofeedback - we can focus on self esteem, self regulation, interoceptive awareness, and naturally achieve better patient engagement and outcomes in pediatric populations. Bonus: I bet every OT reading the article at the point of yucky tasting laxatives/liquids immediately came up with other alternatives for increasing fiber + fluids that provides the child autonomy and respects their taste buds!
Bm’s, like eating, should never be dramatic. There should be autonomy, peace, and a sense of relief at the end of each of those activities!

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I refer to a dietitian. Water intake is extremely important for bowel health.

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While I found this article interesting and promising as another way OTs can utilize their skills, the sample size was too small. The article also used both OT and PT treatment together, but we don’t know if just one of the disciplines specialized in pelvic health would have similar outcomes. It would benefit our profession if larger studies were completed.

I love all the pelvic health articles and podcasts you’ve gone over. I find them so interesting and look forward to your podcast reviewing this article.

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As long as there weren’t any contraindications, a balanced diet with plenty of water and fiber would be a good suggestion. Dehydration can contribute to constipation, and making sure the child is getting enough fiber helps the peristaltic process.

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@hanan, if you dig into this systematic review, you’ll see the early stage science behind different dietary interventions… I’d be curious if there is even newer research on this, since the article was 2022 and this seems like a popular topic in research currently…

https://www.jpeds.com/article/S0022-3476(21)00883-0/fulltext

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For community-based OTs, I loved the idea of group workshops like were studied in this paper. The did groups on “pondering poos” and “wondering about wees.” We dont have great funding mechanisms for this kind of group here in the US, but I see how they could be really helpful for parents!

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That’s a great idea! I have done a parenting information session with a small group of parents. It was very helpful for them to hear they were not alone!

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OT and constipation… it’s the first time I have had the two in one sentence. Thank you, @SarahLyon and @quiara, for discussing this topic. Apart from the lessons, my takeaway is that as OTs, we should work on aligning our values with our practice. We shall achieve great levels of fulfillment.

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@Perpetua I KNOW! I had never thought of these two things together before this podcast, but now I think of it all the time.

I wonder if the diet in Kenya lends itself to constipation as much as our diet here in the United States does. There are so many factors that work together here to make this a real problem for our kids!

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This is a super helpful course for one who is just beginning to address constipation issues in children at the clinic. I found it enlightening and helpful in directing me to more resources to improve interventions.

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I’m so glad to hear this, @jessica135! I’ve thought of this episode many times since recording it! I’ve found it very helpful to have the knowledge that this might be impacting the youth in my life—and that it is addressable!