Beyond Miralax: The Pelvic Floor's Role in Childhood Constipation

A note on scope

This is one clinician describing her clinical reasoning and her approach, not a protocol or a recommendation for any individual child. Scope of practice for pediatric pelvic health varies by setting and by state, and anything involving medication is a conversation for the prescribing provider.

In this episode:

•  The mechanism behind why stool softeners alone sometimes make things harder
•  How constipation drives urinary symptoms, and why the two get treated as separate problems
•  The sensory environment of a bathroom, and why it can trigger fight or flight
•  Why Lizzie reaches for dragon fruit, and how she introduces it to sensory-divergent kids
•  Treating two people at once, and how she gets consent from both
•  The tools she uses to teach an eight-year-old about their own body

Lindsey: When people hear pelvic health, most think toileting and probably stop there. What's actually on your caseload?

Lizzie: Quite a few things. Urinary incontinence, toileting management, fecal incontinence, a lot of constipation — constipation comes up a lot in pediatric care — and bedwetting.

Especially with older teenagers, bedwetting can be a sensitive topic, but it needs to be addressed too. A lot of what you see in adults, children experience as well. They just have a harder time communicating what's going on.

Lindsey: Where do most of your referrals come from?

Lizzie: Honestly, a lot of word of mouth. I started with one pediatric patient and they spread the word like wildfire. And a lot of pediatricians will recommend pelvic floor therapy once they've exhausted their other options.

Lindsey: Is there a specialty you'd like to see more referrals from?

Lizzie: Pediatric gastroenterology. I'm in Boston, surrounded by big-name hospitals, and I'd love to see them referring out to pelvic floor therapy rather than only to the toileting programs they run in-house.

Lindsey: What's the typical story of a family by the time they land in front of you?

Lizzie: A lot of these families know accidents happen and toilet training happens, but they reach a point where they start to worry. Maybe they should be toilet trained by now. Maybe they shouldn't be experiencing this. Their sibling didn't go through this.

So they start with their primary care physician. And from there it's a long road most of the time.

Lizzie: By then they've exhausted all their options, they're frustrated beyond belief, and they land in my office.

Lindsey: You mentioned constipation. I'm not sure clinicians — or referral sources — understand how much it drives the symptoms kids are experiencing. Can you explain?

Lizzie: A lot of children have constipation, and a lot of them get diagnosed with it. The typical first recommendation from a pediatrician or gastroenterologist is Miralax or another stool softener.

But sometimes that produces more issues. The stool can get too soft, and then the levator ani muscles don't actually have the capability to pull and evacuate it the way they should. Which disrupts the neuromuscular education the child is trying to build within their own central nervous system.

And that leads to pushing and straining. Which puts pressure on the pelvic floor. And holding their breath while they evacuate.

Constipation starts as a little rubber band, and all these symptoms slowly wrap around until you have a giant rubber band ball. When they get to me, I have to start pulling all those rubber bands off.

Lizzie: The other thing about constipation is that the backup of stool puts pressure on the bladder. So I often see kids with constipation who are also experiencing fecal leakage, or urinary leakage, or both.

And that all stems back to the constipation.

Lindsey: There's so much misunderstanding here, because people think of them as separate systems — and you've just explained exactly how they affect each other.

Lindsey: How do sensory needs factor into pelvic health?

Lizzie: I see sensory needs come up with bowel movements and constipation for two different reasons. The first is the sensory environment of the bathroom itself.

What a child walks into:

Any of it can overwhelm a child, especially one with sensory divergence.

Lizzie: All of that can activate the central nervous system into a fight-or-flight response, which causes those muscles to tense up. Which leads to pushing and straining, and creates a bad experience with toileting in general.

Lizzie: We know fiber is good for the bowel system. We know osmotic foods and motility-based foods are good for it. But those foods can be hard for kids to tolerate.

So sometimes in sessions, with the parents' permission, I bring these foods in and we try them together in different ways. It's especially nice if I have them first thing in the morning.

One food I love to recommend is dragon fruit. But it's an overwhelming food for someone with sensory divergence — there are seeds, it's squishy. So we'll try it raw, then frozen, and sometimes I'll bring in a smoothie and we'll try it that way.

Same with avocado. There's a lot about avocado that can cause sensory divergence: the color, the texture, the taste. So I'll try a few different versions with those kids too.

Lindsey: Why dragon fruit?

Lizzie: The seeds act almost as a laxative, and it's an osmotic food, so it draws fluid into the stool. It works like a stool softener, but in a natural way.

Honestly, whenever I'm constipated I just eat some dragon fruit.

Lindsey: How much of your work is routine and habits versus hands-on?

Lizzie: I do a lot of hands-on therapy in my clinic, with education for the parent or the child depending on their age.

Lizzie: So it's honestly a bit of both.

Lindsey: You usually have at least one parent in the room. How do you manage treating two humans at the same time?

Lizzie: I read the room when they come in. I'm noticing whether the caregiver is speaking for them, or whether the child speaks for themselves. And then I start differentiating — let me ask the child this question so they feel involved in their own care, and let me ask the parent this one.

Often an older tween or teenager comes in and the parent wants to talk for them. Or they want their parent to talk for them. By the end of the evaluation, I try to have built an open enough relationship that they feel comfortable discussing their care with me directly. And typically I get there.

Lizzie: If I'm putting my hands on a child, it's always clothes-on for pediatric pelvic health in my clinic. That's something I always follow.

And I always ask both the parent and the child.

Today I had a kiddo I was working on pelvic tilts with, and she wasn't getting the anterior tilt I was looking for. So I said: Hey, is it okay if I touch your hips? Mom, is it okay if I touch her hips?

I get verbal consent from both of them. That way I can make good progress while everyone feels safe and comfortable.

Because there's a lot of fear going into this from parents. They read about what pelvic floor therapy is online, and in truth it looks completely different from what I do with my adult patients.

Lindsey: What strategies do you use to help a child understand their anatomy, their function and their body autonomy, in a way that brings them comfort?

Lizzie: I have a few approaches, and I spread them over several sessions so they can digest the information. I mix up the order.

•  A Kahoot quiz. I built one about the pelvic floor, and I change some of the questions to apply to that child specifically. So when they're answering, it hits home for their own understanding, even if they don't realize it's about them.
•  Drawing. I'll have them draw what they feel when they get a urinary urge, or whatever symptom brought them in. Then we read a book about it — sometimes before, sometimes after — and talk about what it means for them.
•  Writing. I had one patient who loves to write. She drew a picture and then wrote a little story about what happens when she gets an urge, including the signs and signals she recognizes in her own body.
•  Proprioceptive input. Touching their nose, lots of Simon Says, to build a feel for their body.
•  Diaphragmatic breathing on a yoga ball, so they can really feel their pelvic floor expanding when they're doing it correctly.

When all of that meshes together, they have a genuine understanding of their body and their pelvic floor, and what it means for them.

Lindsey: COTA or OT — which taught you more?

Lizzie: Speaking truthfully, being an OTA might have taught me a little more. It set the foundation for me as a practitioner. It was my first true experience of the world of OT, and then being an OT filled in the gaps. But a lot of the foundation came from being an OTA.

Lindsey: What's the most common thing a family has been told before they finally find you?

Lizzie: You can try it, it might not help. A lot of practitioners are still catching up on the impact pelvic health can have, especially in pediatric care.

Lindsey: I could say a few things there. I'm not going to.

Lizzie: It can be frustrating. But it's so nice to be the person who provides them care and support and makes them feel heard. I think that's one of the most important things in pelvic health generally, not just pediatrics — having someone who makes you feel heard and seen for the symptoms you're experiencing.

Lindsey: One word for how parents look when you finally explain what's going on and they get it.

Lizzie: Believed.

They know there's something more going on. And when they hear all of this, it's a puzzle clicking into place. This actually makes sense. I knew there was something else. I knew we couldn't just keep doing this one thing forever.

Lindsey: What's something you believed two years ago that you don't believe now?

Lizzie: That you have to help every single person until they're 100% better. When I started, I was convinced I'd be the end-all-be-all for everyone, that I'd make everyone's problems go away.

In reality, that's not the truth. I can only do so much within my scope. There may be something more medical going on that I can't touch as a pelvic floor therapist. Or I'm giving my all — the education, the skilled services — and that doesn't necessarily mean the patient can be adherent to it, or has the time in their life right now to dedicate to it.

Lindsey: Poop and pee jokes. Do you let the kids make them?

Lizzie: Absolutely. I make them with them. I'll make fun of myself — I jumped on a trampoline and accidentally peed a little the other day, isn't that wild?

And for my younger kiddos, I have a fart button they can press at the end of every session. They love it. It's a really good motivator, it makes them chuckle, and it makes them happy to come to pelvic floor therapy.