When it comes to chronic constipation, most people think of older adults, first and foremost. But, as medical professionals, many of us know that this is overlooking a significant portion of the population. Studies reveal that 5% of all children’s visits to pediatricians nationwide involve constipation—that’s a big number.
Dramatically proving the point is Mary Alice Dombrowski, APRN-CFNP, DNP, and her busy practice at the department of pediatric gastroenterology, hepatology and nutrition at Rainbow Babies & Children’s Hospital in Cleveland. She treats 70 to 80% of her patients for chronic childhood constipation, and she is busy day in and day out. In the forefront of a growing trend towards biofeedback therapy, she provides this treatment to an average of two to three patients weekly using the Medspira mcompass® anorectal manometry system. Patients range in age from three to 25.
“When I started working in gastroenterology, many of my young patients were not only constipated but also experienced fecal soiling,” she says. “To make pooping more tolerable, I typically relied solely on stool softener and stimulants as did many medical professionals at the time.”
But often these medications did not help. “The kids were still soiling,” she says. “Parents would get extremely frustrated and stop them.” While chronic constipation typically is a mechanical, emotional and behavioral problem, many parents came to rely solely on psychological counseling, and their children no longer received the necessary medical component of treatment. After introducing mcompass biofeedback, she now has had many positive outcomes and happy stories to tell.
Ms. Dombrowski notes that the problem of chronic constipation is more complex than most people realize. Often young children with seepage and soiling are sent home from school because they are not potty trained or are thought to have stomach flu. As a result, they may be encouraged to repeat first or second grade. Parents are often forced to miss work to address the problem. Meanwhile, older children are embarrassed, may skip school and are branded a truant. Associated symptoms of abdominal pain, nausea and even vomiting may also keep them out of school. Anxiety and depression worsen. Along with education, social life also suffers.
Looking for a better way, Ms. Dombrowski discovered biofeedback and mcompass. “I was hoping to help kids by giving them a way to practice defecating by simulating a bowel movement,” she says. “I Googled around and to my surprise found the mcompass system, which allows me to do just that. With it, I can do not only bowel movement simulation but also show patients how use the two muscle groups involved.”
She explains further: “For kids with long-time constipation, the sensation of stool build-up in the rectum lessens over time. As a result, they may experience the need to defecate only when it becomes an emergency or they may never feel the urge at all. With mcompass, we encourage kids to try and go to the bathroom when poop is the appropriate size because if they wait too long it might be too big to pass. The mcompass system enables kids to understand how large a bowel movement should be before they feel the urge to go. Along with all this, kids can practice coordinating both their intra-abdominal muscles and anal sphincter muscles to release a bowel movement after years of trying.”
Today, she believes the most successful treatment for chronic childhood constipation combines biofeedback, stool medication, behavior training and psychological counseling, if needed. However, she cautions that a child has to be a ready and willing participant to make biofeedback a success. “Kids must want to practice this and must have support at home or they won’t improve,” she says.
When children come to her clinic, Ms. Dombrowski begins with an anorectal manometry test to rule out Hirschsprung disease if they are young. Often treatment begins with stool softener to help alleviate pain when pushing and eliminate fear. She tries to avoid use of medicines inserted through the anus, including suppositories and enemas, which often heighten a child’s anxiety.
For many children with long-term problems, she then introduces mcompass biofeedback. “This actually helps them learn to poop properly,” she says. “Many children don’t have any sense of what they’re actually doing when they bear down and try to produce the bowel movements. Additionally, I use the rectal balloon to determine their degree of rectal sensation and work on improving that if needed.”
Within four to five sessions, the soiling often resolves, and children are comfortable and confident passing a stool. “Delighted moms come in and tell me their child has been in diapers for years. They’ve never actually worn underwear before. But they are today,” she says.
Some patients do not experience soiling with their constipation. They simply have a sensation of incomplete bowel movement or strain on the toilet almost an hour to produce very little stool. They are often given a diagnosis of irritable bowel syndrome with constipation. Biofeedback is equally effective for this group.
Ms. Dombrowski notes that some kids simply do not want to participate in the therapy, while others do not follow through at home. “But the good news is that I estimate that about 50% of those who do take part experience notable improvement,” she says.
The disposable catheters are extremely thin and well-tolerated. Many children have experienced so much rectal pain, they are fearful of more. She talks them through the insertion process slowly and gently. Although many acknowledge that the process seems awkward, complaints of pain are rare.
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