May 2017 Bulletin

Tips for Treating Constipation and Incontinence: A Q&A With Dr. Lusine Ambartsumyan

Lusine Ambartsumyan BulletinConstipation is a common condition among children and adolescents that can often be easily resolved. But when it goes untreated, constipation can lead to much more serious issues such as fecal incontinence.

Dr. Lusine Ambartsumyan is just one of Seattle Children’s gastroenterology specialists partnering with primary care physicians to offer patients the best treatment available. She has offered the following advice to providers treating constipation and incontinence in children and adolescents.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek; a member of Seattle Children’s medical staff and chief of digital innovation for Seattle Children’s; and author of the Seattle Mama Doc blog, for submitting these questions.

Is constipation usually inherited or a product of a child’s diet and stool habits?

About 95% of the time, constipation is a product of diet and stool habits. These cases can usually be improved with behavioral adjustments. The remaining 5% are caused by other physical factors such as nerve or muscle problems in the intestine, malformation of the anus or other biological irregularities.

How can parents prevent constipation?

The most important thing parents can do to prevent constipation is establish proper toilet sitting habits with their children. As soon as potty training begins, children should start sitting on the toilet as part of their daily routine, just like brushing their teeth or combing their hair. It should not be a choice. They should sit on the toilet for five to ten minutes several times each day: in the morning; after breakfast; after lunch; after school; after dinner; and before bed.

Sitting on the toilet should not be viewed as a chore or punishment. Instead, parents should make it fun! Parents can keep track of toilet sitting with a chart and use stickers as a reward system. If the child sits, they get a sticker. If they have a bowel movement, they get two stickers. Pretty soon they’ll be able to convert having a bowel movement in the diaper to having a bowel movement in the toilet.

An adult-sized toilet can be very intimidating for a child. If the child is scared of the toilet, use a potty that is their size and bring it into the living room or put it in front of the TV. The important thing is to make it more comfortable so they can become familiar with sitting on a toilet.

Parents should also make sure their child has a healthy diet with appropriate fiber intake, including fruits and vegetables. To determine the amount of fiber a child should consume each day (in grams) calculate their age plus 5.

While many pediatricians recommend MiraLax to treat constipation, recent media reports have expressed concerns regarding the medication’s potential side effects. Do you consider this to be a safe treatment option? Are there any alternatives you recommend?

At Seattle Children’s Gastroenterology Clinic, we consider MiraLax to be a safe and effective medication for children as long as it is used under the guidance of a physician. It decreases the water absorption in the colon and makes the stools softer and easier to come out. While some are concerned about the medication’s ingredients, we do not believe these get absorbed by the body. Research to validate the use of MiraLax is ongoing, but so far there have been no studies to prove this medication causes any harm to children.

For patients and parents who choose not to use MiraLax, I recommend natural, magnesium-based products such as Pedia-Lax or Milk of Magnesia to help with bowel movements. For children, I recommend Pedia-Lax, because it comes in a chewable tablet that can be more palatable than Milk of Magnesia. Patients using either product need to be careful that they don’t ingest too much magnesium, which can build up in the blood and lead to dangerous side effects. Similar to MiraLax, it needs to be under the guidance of their primary care physician.

When should patients be referred to Seattle Children’s Gastroenterology Clinic?

Most patients with constipation should first seek treatment from their pediatrician. These providers should try to implement behavioral techniques such as toilet sitting, positive reinforcement or tracking bowel movements. Patients may be placed on MiraLax or other medications before visiting our clinic.

If initial treatments and medications are not effective, providers should refer patients to our clinic so we can run appropriate tests to determine if there is underlying disease or if the patient would benefit from stronger stimulant medications.

How do you treat fecal incontinence in the Gastroenterology Clinic?

Untreated constipation can lead to fecal incontinence. This is a very concerning matter because it often results in bullying and shame, causing significant anxiety and depression in patients. The quality of life for these patients can be as bad as someone with cancer or inflammatory bowel disease. In some cases, the parents of these patients have been mistakenly accused of abuse. Other patients have become suicidal because of their condition.

To treat school-aged children suffering from fecal incontinence, we have developed a unique Bowel Management Treatment Program which brings together gastroenterology, surgery and behavioral therapy to offers personalized, effective medical treatments. Our goal is to get children out of diapers and back in regular underwear after just one week.

We ask pediatricians to refer their patients with incontinence to our program so we can address their physical and mental needs.

Online resources and referral information

Other online resources we recommend include Dr. Tom DuHamel’s website The Ins and Outs of Poop, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition’s Constipation Care Package and Dr. Wendy Sue Swanson’s blog post Get Rid of Constipation in Children.

If you have a patient you’d like to refer, fax a New Appointment Request Form (NARF) (PDF) to 206-985-3121 or 866-985-3121 (toll-free). Please include the NARF, chart notes and any relevant documentation. View our complete Gastroenterology and Hepatology referral guidelines (PDF).


Register for the 13th Annual Pediatric Bioethics Conference

The Treuman Katz Center for Pediatric Bioethics will host the 13th Annual Pediatric Bioethics Conference July 21 to 22, 2017. This year’s theme is “The Cutting Edge: Ethical Controversies in Pediatric Surgery.”

Join a distinguished group of bioethicists for challenging and illuminating presentations and discussions exploring the complex questions this topic raises. Abstracts must be submitted by May 5.

To learn more and to register, visit the Pediatric Bioethics Conference website.


Upcoming Grand Rounds for May 2017 (CME Credit Available)

Upcoming Grand Rounds

  • May 4: Not Hype: Technology and Lab Services to Enhance Renal Transplant Care
  • May 11: Cutaneous Manifestations of Primary Immunodeficiencies
  • May 18: Progress in Treatment of Neuroblastoma: Past, Present and Future
  • May 25: Responding to a Parental Request to Not Tell an Adolescent That She Has Cancer
  • June 1: Socioeconomic Determinants of Cardiovascular Disease

For Provider Grand Rounds information, visit our Grand Rounds page.

Watch Past Grand Rounds online

  • Success Through Failure: Embracing and Learning From Errors in Healthcare
  • Can We Eliminate Otitis Media?
  • Abusive Head Trauma: Where We Were, Where We Are and Where We’re Going

View a list of all online videos in our video library.


New Medical Staff and Allied Health Professionals for May 2017

Medical staff

  • Erin Barthel, MD, Seattle Children's, Cancer and Blood Disorders Center
  • Beth Nauert, MD, HealthPoint – Auburn, Pediatrics
  • Joy Neyhart, DO, Virginia Mason Memorial Hospital, Pediatrics

Allied health professionals

  • Jessica Butler, PA-C, Seattle Children's, Neonatology
  • Alayne Chapple, ARNP, Seattle Children's, Cancer and Blood Disorders Center
  • Mariel Colella, ARNP, Seattle Children's, Emergency Medicine
  • Robin Culver, ARNP, Seattle Children's, Critical Care
  • Sara Gunnoe, Sara, PA-C, Seattle Children's, Cancer and Blood Disorders Center
  • David Ingram, LICSW, Odessa Brown Children's Clinic, Psychiatry and Behavioral Medicine
  • Mariel Martinez, ARNP, Seattle Children's, Surgical Specialties
  • Nathanael Schooley, ARNP, Seattle Children's, Neonatology