How to Treat Pediatric Constipation Without Biofeedback

A note on scope

This is one clinician describing her approach, not a protocol. Caitlin is explicit that biofeedback has evidence behind it and a legitimate place — what she's questioning is whether it fits every child.

In this episode:

•  Why applying adult pelvic health evidence to children doesn't work
•  What she watches while the parent is answering her questions
•  "Rainbow smiles," and what a yoga movement has to do with toileting
•  The five-step reflex loop she gives families, and when to do it
•  A three-part home program built so families can actually finish it
•  The question she keeps in her back pocket about every patient

Lindsey: What inspired the career you have, and how did you develop your holistic approach?

Caitlin: I envisioned being somewhere quite different, and then got thrust into what I'm doing now.

I started in outpatient pediatrics, meandered over to inpatient pediatrics. They had a women's pavilion, and I'd had an interest in pelvic health since graduate school. So I thought I'd see whether I could get into that part of the therapy world in a hospital setting — working with peds, but also with the mothers.

I didn't realize how saturated pelvic health can be. Then our managers offered an opportunity to start a pediatric pelvic health program. Another therapist and I grew it from the ground up. It wasn't what I thought I wanted to do, but it was a perfect mesh of pelvic health and pediatrics.

And I already had that developmental background — the whole-body approach with kids. I genuinely think that's what brought me to the holistic approach in the pelvic health world.

Caitlin: Because pediatric pelvic health right now is very zoomed in on the pelvis. There's a lot of biofeedback being used, and I think an approach is being missed.

People are taking the adult literature and the adult evidence and applying it to kids. That doesn't work.

So having that background let me see: we have this biofeedback machine, it's cumbersome, it takes a lot of time, and it can make children feel very vulnerable. And through a developmental, whole-body approach — really zooming out of the pelvis — we saw equal if not better success without it.

Which thrust me into asking: wait a minute, this is what I was told in those foundational pediatric pelvic health courses. What else can I challenge?

That's how I got where I am today, which is a very different place from 2013. I have my own practice, and I've never purchased a biofeedback machine. Which is a little telling.

Lindsey: So much of that resonates, and not to throw shade at biofeedback — it has a time and a place, and I have real respect for the mentors who introduced it to me. But even though I don't work with children, I've found similar reasons why it hasn't been a great tool for a lot of my clients.

Two things especially. First, applying adult literature to kids doesn't make sense, and I understand there are limits to studying children directly, but that doesn't mean this is the route we should take. I haven't heard anyone say that as clearly.

Second, zooming out of the pelvis. That's very much my belief working with adults too.

And this idea of what else can I challenge — that's authentic to me. My course is called OT Pioneers for a reason. I'm a bit of a rebel.

When I first learned internal exams I kept asking why that was the gold standard, and why we started there. Which is why what I teach now is a menu of options, starting with the client completely dressed and ending with the internal exam as one of four. There's so much we can work with in between.

Caitlin: At the pediatric hospital there's a built-in collaboration between speech, OT and PT. We were physically in the same office, communicating easily. That's where I started.

When you venture into private practice it's easy to isolate yourself. I'm a PT, I'm in my private practice, I'll market myself as a PT.

But a child needs sensory regulation. They need primitive reflex integration. If we don't acknowledge those things, our treatment will likely fail for many patients, because every child is individual.

The proportion of what a child needs from a sensory perspective, or from a primitive reflex perspective, might be large for one child and small for another. All children have some — we all have a sensory system that needs support. It just depends how much it's feeding into the pelvic health symptoms.

So if I isolate myself in the PT world and only take my own approach, I'm setting myself up for failure.

Caitlin: What I'm challenging is whether there's a way to do this for the kids who are averse to biofeedback. For the kids who aren't ready for it — by age, or cognitively — so it doesn't have a place in our approach.

What we do is a lot of developmental screening from the beginning. Our intake form asks a great deal. Even with a 12-year-old: what did infancy look like? What did the transition to solids look like?

We want the family thinking about the whole developmental picture. Did you constantly feel your child was having to catch up? Were you doing supplementary things to help them catch up? What was potty training like?

Then a lot of questions about what the child does at home. Where are they in the house? Are they sitting on the floor, or at the table? Are they on video games a lot? Are they outside? Tell us what your child does with their body on a regular basis.

And then we run that same assessment in the room.

Caitlin: Sometimes I say to the family: you and I talking right now is giving your child an opportunity to play and use their body the way they organically want to.

Because they might perceive this as wasting time on oral questions. But out of the corner of my eye —

What I'm watching while we talk:

•  Whether they tuck their toes underneath their bottom
•  Whether they sit asymmetrically, right knee up against the chest, 100% of the time
•  Whether they W-sit, and how often
•  How they stand up from the floor
•  How they speak with you
•  How much they're holding their breath

Caitlin: What I can learn from watching a child organically play for fifteen minutes, while I go through the history with the family, is so full of information. And it's the biggest impact we can have.

If that child walked in and I said okay, let's sit down and hop on the table — what would I miss?

A biofeedback machine is one minute point in time. Yes, it can bring awareness quickly, if we can get there, if the child feels safe enough for their brain to perceive that sensation. They need those prerequisites.

But so much happens in how a child moves their body. We shape that, and it starts to support the pelvis to function in a biomechanically appropriate way, which supports the sensory system to perceive what's happening in the pelvis.

Caitlin: I want to make shirts that say rainbow smiles, because we do a ton of them in our clinic.

It's cat-cow — the yoga movement everyone knows. Years ago in outpatient peds I thought: how do I explain to this kid which one's cat and which one's cow? I don't know which is which myself.

A rainbow and a smile is far more intuitive for a child thinking about how to arch and move their back.

And what I talk to families about is what that does for the brain's ability to think about the pelvis. It isn't in a toileting environment, but we're helping the brain and the pelvis communicate in the bidirectional way they need to.

That gives real awareness to the pelvic region, which can then apply organically to toileting. Maybe we don't have to do any toileting intervention at all — just bringing the brain and the pelvis together through movement, setting the structure up better so the neurological system can work better.

Lindsey: What resonated with me most was how you point out to the parent what you're doing. I'm watching your child organically play right now, and here's what I'm finding.

You're calling out the elephant in the room, and letting the client and the parent in on your clinical reasoning. That immediately differentiates you.

So here's a call to action for anyone reading. Is there a way today or tomorrow that you could do that too, whether you work with children or not? There's something about letting the client into that process that sets us apart from a lot of other care providers.

Lindsey: What's an important aspect of collaboration between OTs and PTs?

Caitlin: We all believe what we do is amazing. It's moving to watch a family experience a change in quality of life, and that motivates us. So we believe our methodology and our approach is the thing that will help.

What collaboration can change is having this as a back-pocket question:

Caitlin: From a PT perspective I might help a child and see impairments. But I also need to screen them for the approaches that aren't my strengths — so an occupational therapist can take those priorities and get some forward momentum, some resolution, which then makes my approach more effective because it isn't hindered by things nobody is working on.

It's almost a prerequisite thing. I might be able to help a child, but is there something someone else could do, in their wheelhouse, that would be more effective before I lay hands on this?

We have a lot of conversations with families about that. We do the evaluation and say: I think this is going to be great, and I think we need to pause and work on these other things first, then circle back with me for the final touches.

What brings us together is acknowledging that another approach might be better timed. And having the humility to say: this child needs somebody else right now, and that's okay.

Lindsey: You hit the nail on the head with humility. The other word that comes to mind is an abundance mindset — that sometimes what's best for the client in front of me isn't in my skill set.

Which is why a practice with an OT and a PT working together is ideal. From a business standpoint it isn't sustainable to keep sending clients out the door, so let's be practical while also looking at what best serves the client.

And professionally, I'm so energized by being around people who analyze things differently than I do. It challenges my assumptions.

We get into these fields because we're lifelong learners. When burnout happens, or we're stuck in the status quo with the same interventions, that's a call to shake things up. Sometimes that's a CEU course. More often I find it's surrounding yourself with people who inspire you — day to day professionally, or by starting a monthly study group in your community.

Lindsey: Tell us about your approach to the home exercise program.

Caitlin: In the pediatric world this is a big piece that therapists can forget, because it's the part we don't see. We don't see the follow-through at home.

But it's what matters. How much time are you spending in the clinic versus at home? That ratio means home follow-through has to be high for us to get the outcomes we're hoping for.

So we have a conversation about what the family's day looks like.

The reflex loop, a four-step process:

Things that can initiate a bowel movement, or initiate the body's desire to have one.

Caitlin: And we ask: does this feel like a reasonable thirty minutes you can invest?

The follow-up question is usually when do I need to do this?

And I say — right now your child's body is at maximum capacity. They're constipated, there's stool retention, and we want to help them evacuate more regularly. Because they're that full, if you use these reflex loops at any point in the day, their body has a good chance of responding.

So start with when you feel you can actually implement it. Integrate it into your daily rhythm where it fits most easily. We want you to feel calm and intentional. We want your child to feel good.

Doing it in the morning before you leave for school is probably not the time, because that's the opposite of the parasympathetic, relaxed, safe environment we're going for.

Caitlin: The other thing I love is our after-visit summaries. We list the exercises we tried in the evaluation that we think are worth continuing. And then there's a daily therapy homework section.

The daily homework

Caitlin: Because the family has learned a lot in that evaluation. We've brought their attention to many things feeding into their child's toileting challenge. Resolution can feel really intimidating.

But if I break it down and say do these three things, when you feel equipped to — that's empowering. The parent can say: okay, this isn't an enormous hurdle. This feels realistic. I have an action plan.

Versus years of a provider saying use Miralax, come back, and we'll see if it's better — maybe we need to increase the Miralax.

This feels different. It feels good. And instead of being intimidated, they feel empowered and excited. It's a great start to the therapy relationship.

Caitlin: A lot of my challenges in life have been rooted in searching for perfect balance.

I love what I do, so when I'm at work I'm a hundred percent all in — and then time bleeds into what was supposed to be my transition home. The opposite is true too. I'm meant to work during nap time or after everyone's in bed, and sometimes it doesn't happen because I'm home and rested and want to be with my family.

I have three children under five, so right now isn't a season with a lot of rest in it.

But what grows from the time and space to rest is where creativity blooms. That's where the bursts of energy come from that propel the things we're working on.

So be thankful for the time, honor it, and try to give it a hundred percent of yourself no matter how small it is in your week.

There's productivity in rest.

That's what I'd tell my new-grad self. That it needs to be honored. And don't shame yourself for feeling like the balance is off. We all have things we're trying to do better, and the patience to allow for that balance is the biggest gift I could have given myself in 2013.