Choosing a Pain-Free Diet

I had my first “old coot” moment, when grampa yells at the TV when he sees something he doesn’t like.  For me, it was an ad for Miralax, a laxative.  It depicted a young cheerful woman in athetic clothes saying “I choose Miralax!” for her apparent sluggish bowel issues.  I shouted, “WHY NOT CHOOSE FRUITS AND VEGETABLES?”  Of course, she wasn’t listening.

Constipation can be quite painful for children.  We see them in the Pediatric Emergency Department with stories of doubling over, crying out with pain spasms.  They’re usually  better when they arrive, but it’s still disconcerting for parents.  Contipation actually is the most common diagnosis for abdominal pain visits to the Pediatric ED, ahead of stomach viruses and appendicitis.

Constipation is now a common problem in kids, given decreased fiber in their diets.  Fiber is plant carbohydrates that our digestive system can’t break down.  That fiber holds on to water and keeps poop soft and squishy as it passes through our guts.  When your body wants extra fluids, it tries to suck water out of your colon, drying out your stool.  Without enough fiber, your poo gets dried out, moves slower, gets harder, and harder to pass.  If lots of hard poo is moving too slow, painful cramps ensue.

Thus the fix to constipation: eat more fruits, vegetables, wheat breads, bran cereals, all having a high fiber content.  Miralax is simply an artificial fiber substitute- why not eat the healthier thing?  For kids, this means training them to like these foods.  The typical kid can take 10 tries of a food to learn to like it.  This takes persistence on the parent’s part, and is ruined if they get candy, cookies, chips, or fast food as an alternative.  Those foods are designed and manufactured to taste good on the first try, spoiling the child’s chances to learn to eat right.

Drinking more fluids and more physical activity also prevent constipation.  When kids sit around playing video games, their guts sit around too, not moving things through as much, and stool has more time to get dried out.  Active kids stimulate their intestines more, and have less constipation.

Once in residency I had a 10 year-old boy with constipation so severe he was admitted into the hospital.  He had terrible pain, and the parents thought he hadn’t stooled in weeks.  He also had anxiety issues so bad that he wouldn’t tolerate enemas or rectal exams, the quickest way to diagnosis and relieve constipation.  We thus decided on rectal exam under sedation, and do so in the xray suite so we could look at his insides, to rule out other causes for his pain and apparent blockage.

As soon as the sedation started, he relaxed his anal sphincter, and liquid stool poured out of him.  The diagnosis was instantly clear- he’d been purposefully holding in his poo, and it was liquid from all the laxatives he’d been given.  Unfortunately for the Radiology Department, he leaked so much that it ran all over the xray table, through every seam, dripping out the bottom.  They had to completely dismantle the table to clean it, and that room was out of commission for days.

Above we mentioned the diet reasons why kids get constipated- low fiber, inadequate fluid intake, and not enough activity.  But there’s sometimes psychological reasons as well.  Sometimes kids have a hard stool that hurts.  They decide, hey, I’m not doing THAT anymore!  Next time they get the urge, they withhold pooing until the urge passes.  After doing that enough, the urge gets too strong, and they have to go.  By that time the stool is so big and dried out that it’s another painful job, reinforcing their desire not to do it.  The constipation process becomes self-feeding.

Toddlers also can decide to withhold pooping during potty training.  Some kids just don’t like taking down their pants and sitting on that oddly-shaped thing we call a toilet.  It’s much easier to just go in their diaper.  Parents often try rewards, sometimes punishment, to encourage the kid to use the potty.  Willful toddlers may fight back the only way they can- with their anal sphincter.  Some psychologists say that any child can be potty-trained by age 2; others say wait until they show signs they’re ready, like watching their parents use it.  I think the latter, having seen many toddlers get constipated during potty training.


When I was a kid, McDonaldland wasn’t a playground- it was a fictional place in Saturday morning TV ads. I was enthralled with those ads: the outrageous-looking puppets, the colorful sets, evoked a Disney-like magic. Unbeknown to 8 year-old me, McDonald’s was sued by the producers of another Saturday morning program, H.R. Pufnstuf, because McDonaldland looked a lot like their show. McDonald’s lost the suit, and its TV land disappeared.

Then, as now, kids were bombarded by advertisements for toys and food. Ad makers realized that kids are easily swayed and could use them to get to the parents, who had the money.  One of the earliest to realize this was Walt Disney himself, airing a TV show in 1954 called Disneyland.  Besides cartoons and live-action dramas, every episode had updates on Disneyland itself, then under construction.  The show built enthusiasm, and when Disneyland opened it was jam-packed, and remains so today.

Parents’ desire to have healthy kids, and the ad-created desire of kids to go to these colorful places to play and eat, creates a battleground at home.  Parents want good nutrition for their children; children want to eat the really yummy stuff.  Kids’ weapons- perserverance, pleading, and whining.  Parents’ defense against this- authority, and knowledge that too much of a good thing is bad for children.  However, this defense is undermined by the competing parental desire to please their kids and see smiles instead of frowns.

The key to winning the battle is two-fold.  First, know you’re in charge.  You can refuse to get caught arguing about where to go and what to eat.  I would say to my kids, literally, “this is not an argument,” shutting off discussion about eating out.  You also have control of the wallet and the car.

The second key is knowing the consequences of losing the battle.  You want your kids to grow up, not grow wide.  You don’t want high-fat, low fiber diets that cause cramps and constipation.  And the evidence is mounting that these diets in kids lead to premature high blood pressure, heart attacks, and strokes as adults.

Besides the McDonaldland advertising campaign discussed above, as a kid I liked the food too.  About once a year my parents would allow a quarter-pounder, fries, and a shake.  It was delicious, and every store offered the exact same food and flavor. Thanks to manufacturing and food science, wherever we went, McDonalds’ nationwide offered the same yummy menu.

For instance, why are all McDonald’s fries so tasty?  Until 1990, it was because they were fried in oil and beef tallow.  That year McDonald’s bowed to public pressure to reduce the saturated fat in its food and switched to pure vegetable oil.  To retain that beef flavor though, they added a manufactured, beef-flavored chemical.

Uniform deliciousness isn’t the only reason fast food has been so successful.  It’s also inexpensive.  In 1948, the McDonald brothers, Dick and Mac, invented their “Speedee Service System,” to make their California hamburger stand more profitable.  This kitchen automation, designed to be operated by minimum-wage workers, cut food prep costs.  Then under McDonald’s empire builder Ray Kroc, the hyper-efficient kitchen was supported by central manufacturing of food products, delivered by 18-wheeler.  “Dining out” was now an option affordable for every family, not just the rich, and not just once a year.

Finally, fast food is successful because…it’s fast.  No waiting a half hour for your entree; burgers and fries are in the sack in minutes.  These three advantages to fast food- speed, cost, and deliciousness, help explain why poverty and obesity go together.  Most impoverished families I see in the Emergency Department are headed by single moms who often work two jobs.  It’s harder for them to spend the time and money to shop for and prepare home-made, healthy meals.  Their kids love fast food, it’s affordable and quickly available- meal is done!

Obesity used to be a sign of wealth- only the wealthy could afford to eat too much.  Now, the poor can also be obese, with the high-fat and sugar content of manufactured food.  Their kids suffer the consequences- abdominal pain, constipation, diabetes, high blood pressure, and early risk of heart disease.  So it behooves parents to take control of their kids’ diets, to avoid ruining their bodies.  As a kid, I loved eating at McDonald’s, but only once a year.  That’s about the right amount! 

It’s My Head, It’s my Belly!

This week’s guest columnist is Dr. Ashanti Smith, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

Every parent dreads: “Mommy..Daddy…my tummy hurts…”  Sometimes they whisper this in the middle of the night, sometimes they holler it at the bus stop.  Then often when they come to the Emergency Department, we walk in the room and the kid is leaping off the stretcher, smiling and giggling.  “I swear he was in terrible pain!” mom says.

Stomachaches are a common pediatric complaint.  Sometimes it’s serious, sometimes not.  Questions many parents ask: When was the last bowel movement?  How much junk food did he eat today? How’s she drinking?

Constipation is the most common reason for belly pain in the ER.  This is because the pain can look terrible, the child crying, doubled over with cramps.  This freaks parents out. They worry about bad things like appendicitis.  Then the pain relents, and the kid looks fine upon arrival.  Signs of constipation include skipping days of pooping, or passing hard painful stools, or only passing small pebbles.  Often parents don’t know their kids’ stooling patterns- who investigates what’s happening in the bathroom?  Sometimes kids go in, sit for awhile, produce nothing, and then leave.  But mom assumes they stooled.

If it’s constipation causing pain, the fix is usually dietary.  Kids don’t get enough fiber, especially when they eat lots of prepared foods like hot pockets, pop-tarts, McDonald’s, and other junk.  Kids should eat fruit with every meal, vegetables with lunch and dinner, and eat more fiber.  Sometimes they need medicine from their doctor to help.

“Stomach bugs” are another common cause of abdominal pain.  Usually these are associated with vomiting, diarrhea, and fever, but not always!  They usually last 1-2 days, and the goal is to keep the child hydrated.  Give clear liquids like sports drinks or Pedialyte.  They’re easy on the stomach and well absorbed for hydration.  Other viruses, like the common cold, can cause stomach aches too.  If your child vomits more than 4-5 times, has worsening belly pain, or has worsening fatigue, get seen.

Headaches are another common complaint that brings children to the Emergency Department.  Like our stomachache from above, kids can cry in pain.  Then often when they get to the ER, they’re going through all the cabinets and running into other patient’s rooms..  What kids do to entertain themselves while waiting for the doctor! They’re not miserable like they were earlier, to the parents’ embarrassment.

The majority of headaches aren’t serious.  Usually they’re brief pain episodes, called “tension headaches,” or are due to illnesses like viruses or allergies.  Sometimes, the “tension” is because kids don’t want to go to school.  Infections like stomach viruses, influenza, and strep throat are notorious for causing headaches.  Kids, like adults, sometimes get migraines too.

When children cry with head pain, parents go to their worst fears.  Is it meningitis?  A brain tumor?  Meningitis is an infection of a lining of the brain called the meninges, a saran-wrap-like membrane, which can get infected.  When this happens, the inflammation from meningitis presses on and poisons the brain.  It can be life-threatening, and cause permanent brain injuries like hearing loss or cerebral palsy.  Brain tumors are lumps that grow in the brain, compressing it, causing headaches and vomiting.  Sometimes the tumor is cancer, sometimes not.

How do you tell if the headache is serious, or just school avoidance?  If a dose of Tylenol or ibuprofen fixes it, no problem.  It’s also easy to try a cold compress on the forehead.  Questions to ask: Is there vomiting or nausea?  Is there a stiff neck?  Was she awakened at night by the pain?  Does he look excessively tired?  Yes answers to these mean your child should get seen.

As we mentioned, kids can get migraines.  These are recurrent headaches, often accompanied by nausea and vomiting.  They can be worsened by bright light and loud sounds, and can be debilitating.  Sometimes kids need brain scans to tell the difference between migraines and more serious things.  Fortunately, once brain tumors or meningitis are ruled out, migraines can be treated.  Usually a healthy dose of ibuprofen and napping in a dark, quiet room are all that’s needed.  And they’re prevented by basic good health- three healthy meals a day, reduced phone and computer time, and  reasonable bed times!

Bad Belly Pain-Is It Really Just Constipation?

It happens more than you think: the child clutches his belly, cries, rolls around on the floor, in obvious pain.  Mom and Dad get worried- is this appendicitis?   Is something terrible happening to our baby?  They rush to the Emergency Department and about the time they finish registering and get put in a bed, he is all better.  ”Honestly,” the folks tell me, “he was really looking bad!”  I believe you, I tell them, this happens all the time.

Belly pain is a common reason for Emergency Department visits, and usually it is because of …constipation?   A recent study in the major journal Pediatrics confirms what we have suspected for years: constipation is the most common diagnosis for kids who come in for abdominal pain.  And I don’t blame the parents for bringing their child in- the pain can be really scary-looking.  It is sometimes so bad that parents worry major surgery is needed.

What is happening to cause so much pain?  Simply put, stool builds up inside the intestines and doesn’t pass.  One day the stool is so much or dries out and is so hard, that the intestines cannot move it through, and out.  The intestines push and push, and that is the terrible cramps the child experiences.  Eventually the intestines relax, and the pain goes away.  But the intestines have a job to do, and later they try again, and the pain returns.

Why this build up?  Often it is because the child does not use the bathroom enough.  In school-age kids, they don’t want to use the yucky school bathroom and hold it all day. Then they get home, want to play, and get too busy to bother with the bathroom at home.  Also, today’s low fiber diets and low activity levels don’t help.  Fiber helps stool hold on to water and stay soft and mobile.  Kids who run and climb shake the goods down to where it wants to come out.  Kids who sit all day help stool stay put too. When stool stops moving inside, it dries out.

By now the keys to constipation prevention should be clear.  First, a healthier, higher fiber diet.  This means a fruit with every meal: breakfast, lunch, and dinner.  Vegetables with lunch and dinner.  No more white breads.  No more chips and cookies for snacks.  Kids should be eating wheat bread and bran cereals, granola and fiber bars for snacks.  And as you are now hearing again and again, in these days of kids getting fatter and fatter, get them off the couch and moving!  Less TV and video gaming, less sitting with the phone, more play with running and jumping and climbing.  Finally, have a regular time to go, like before school. Guts can be trained to get the job done!

We also need to talk about newborn and infant constipation.  Many of the babies I see with worries of constipation are not really constipated.  The new moms come in because baby has not pooped in 3 to 4 days.  I will ask, does the baby poop soft when it does come, and often the answer is yes.  This is normal for babies.  Babies will sometimes go days without stooling, but as long as it is soft, then it is okay.  What if baby seems crampy, pulling up her legs and crying?  This is not constipation, it’s colic.  Colic has little to do with how often baby poops.

If the baby’s poop comes out hard though, like rabbit pellets, that is constipation.  The best prevention for constipation, and colic, is breast-feeding.  Breast feeding is so much better for baby than formula in so many ways, and this is just one more reason to breast feed.  Breast milk keeps stool very soft so constipation is quite unlikely.  Breast milk is also much easier on baby’s guts, and therefore colic is less bad too.

So as I tell parents day in and day out, week after week, start buying healthier foods.  Don’t buy junk.  Turn off the screens and get those kids up and active.  Getting them moving in that way, gets them moving in the other way too.