Every once in a while, I come across a piece of research that makes me giddy. This week, the article that really got me going was this study published in January 2023 in the European Journal of Pediatrics. “Myths and misconceptions about childhood constipation.” Evidence debunking common constipation myths?!? Be still, my heart.
If you’ve read my book, you understand (I hope) that MUCH of what pediatricians and society in general believe about constipation is, well, not super accurate. I know this, I’ve studied it, and I’ve worked with enough kids and families to be certain of this. But I’m a human just like everybody else, at times susceptible to self-doubt. “Is constipation really that big of a dea for kidsl?” “Do they really have to take laxatives for months?” “Will they really not just grow out of it?”
The “myths and misconceptions” article boosted my confidence within the first few lines, which referred to widely-held misconceptions about constipation that “have arisen from firmly held beliefs and myths which lack a rigorous scientific basis or generated from studies with poor methodological quality.”
Boom! I’m not crazy, and neither are my physical therapist colleagues who are constantly educating parents about best practices in constipation management that contradict what a lot of primary care providers recommend. I want to give the article to every health care provider (and school nurse, and teacher) that I know. But since you most likely won’t be able to access the entire journal article, here are it’s main points:
(I’m going to skip the first three points because they refer to beliefs that actually aren’t commonly held by most health care providers in the U.S. and aren’t particularly relevant to treatment. Myths 4, 5 and 6 I’ll cover briefly, but they are not going to surprise you if you know any constipated kid and their family. But read on … the myths get more interesting and relevant as you go.)
Myth #4: constipation is not a public health problem. Children with chronic constipation incur more health care expenses than their healthy peers. And research has only been done on medical expenses; it does not take into account the extra costs: missed school, missed work for parents, etc.
Myth #5: constipation does not cause significant effects on the lives of affected children and their families. In actuality, evidence shows that constipation can have a dramatic negative impact on the health related quality of life of kids.
Myth #6: constipation only affects the gut. Au contraire! Constipation in kids has many documented psychological effects, including anxiety, depression, attention problems and aggression.
Myth #7: cow’s milk protein allergy can lead to functional constipation. Basically, the evidence is too weak to link cow’s milk consumption and constipation. That said, a 2-4 week elimination of cow’s milk has been shown to be useful in some patients - the studies just aren’t very strong. So consider eliminating cow’s milk for 2-4 weeks if you want to.
Myth #8: an x-ray is necessary to diagnose constipation. Nope. The usefulness of an abdominal xray is very limited, as they are not sensitive or specific, and different radiologists tend to interpret the same xrays very differently. When weighing the risks of radiation exposure, xrays are just not worth it. How do we diagnose chronic constipation? The Rome IV Diagnostic Criteria.
Myth #9: lab tests are useful when diagnosing constipation. Doctors will frequently order tests for thyroid function, celiac disease, and hypercalcemia in kids presenting with constipation. All of these conditions are exceedingly rare in kids, and it is very unusual that constipation would be the only symptom. These tests should be reserved for kids who have other symptoms that point to these conditions.
Myth #10: fiber supplementation is an effective intervention. Kids do need fiber (the rule of thumb is “age in years plus 5 grams per day”, so 10 grams of fiber a day for a 5-year-old). But increasing daily fiber intake much more than this has not been shown to be effective in treating constipation.
Myth #11: increasing water intake is a therapeutic intervention. If you’re dehydrated, your body will definitely pull water out of stool to get the water it needs to function. This can lead to hard stools that hurt to pass, and cause constipation. But Increasing water intake once you’re constipated will not soften old, hard stools; it’ll just increase the amount of urine you produce. That’s why we have osmotic stool softeners: these pull water back into the stool to soften it.
Myth #12: a lack of physical activity causes constipation, and physical activity is useful in treating it. This one is a tough one for me, because I have seen studies linking a lack of physical activity to childhood constipation, and because I’m a PT who believes in the power of movement. The authors of this study, however, feel that the research isn’t strong enough to link constipation and a lack of physical activity. They do kindly note that there are many other benefits of physical activity in children, though, so let’s keep these kids moving anyway.
Myth #13: short courses of laxatives are effective in treating constipation in kids. Yes! I will shout it from the rooftops: telling a kid to take a laxative for 1-2 weeks is not an effective way of treating constipation! Laxative use should be divided into phases:
Phase 1: disimpaction (or a “clean-out”, which can take days);
Phase 2: maintenance (a daily laxative dose that produces regular soft stools); and
Phase 3: weaning (gradually tapering off laxative use once a child is symptom free for a month).
Each of these phases require active management and guidance from the primary care provider. Truly, I think if pediatricians were following the recommended protocols for laxative use, I would have far fewer constipated PT patients.
Myth #14: long-term use of laxatives causes dependency, tolerance and rebound. Early studies of stimulant laxatives done on adults with severe constipation showed some nerve damage in the colon after long-term use of stimulant laxatives. But these adults were never assessed pre-laxative use, so it’s impossible to say that the laxatives caused the nerve damage. They believe it’s more likely that the nerve damage caused the constipation (or vice versa). And a more recent study of stimulant laxative use in kids showed no development of tolerance after a year of use.
To be sure, as I say in The Constipation Game Plan, your GI tract will get used to having a daily laxative, and you might get constipated right away if you stop regular laxative use abruptly. But studies show you can avoid rebound constipation by gradually weaning off laxatives. (See above, weaning.)
Myth #15: long-standing constipation causes bowel cancer. Having a constipated kid is already so stressful … I hate the thought of parents also stressing about their kid’s constipation causing cancer. The evidence shows no link between chronic constipation and colon cancer, so let’s not worry about that right now.
Myth #16: children will outgrow constipation. This is the one that gets me the most riled up. If left untreated, chronic constipation only gets harder to treat, not easier! Constipated kids grow up to be constipated adults. Given the known impact of constipation on health-related quality of life in adults, it is absolutely worth it to treat kids with constipation aggressively and over a long period of time.
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It might be easy to read this list and be discouraged. "So ... my kid has to take laxatives forever and fiber, water, and exercise don't work?" But this article doesn't tell the whole story. The premise of The Constipation Game Plan is that there is not one solution to this complicated problem. Laxatives by themselves don't work, exercise alone doesn't work, just drinking more water won't work ... But understanding constipation and making small, consistent changes over time can help kids feel so much better.
Please share this post with anybody you know who is having trouble letting go of the myths surrounding constipation. Let's use the evidence we have to provide the best care possible to kids with functional constipation!