Whether regular or irregular, the causes of constipation in children can be broad and difficult to diagnose. The BRICK (Bowel Retraining in Constipated Kids) clinic is a special clinic within the Division of Gastroenterology at Children’s Mercy Hospital dedicated to the care of children with constipation and encopresis.
BRICK clinic director Kacie Kaufman will discuss the care children receive at the BRICK clinic and how doctors can implement best practices into their own clinics.
Selected Podcast
BRICK: Unblocking The Facts
Featured Speaker:
Kacie Kaufman, APRN
Kacie Kaufman, FNP, is the director of the BRICK Clinic. Kacie has 10 years of experience working with children who have severe constipation problems. Transcription:
BRICK: Unblocking The Facts
Dr. Michael Smith (Host): So our topic today is "The BRICK Clinic: Unblocking the Facts." Whether regular or irregular, constipation in children can be broad and difficult to diagnose. My guest is Kacie Kaufman. She's a Family Nurse Practitioner within the Division of Gastroenterology at Children's Mercy Kansas City. Kacie, welcome to the show.
Kacie Kaufman (Guest): Thank you for having me, Mike.
Dr. Smith: So let's talk -- I like the name "BRICK Clinic", but let's talk first before we get into that, let's talk -- what are some of the typical reasons for constipation in children that end up in your care, specifically?
Kacie: Well, diet is a big factor. Kids who have low fiber diets, and those who are picky, tend to be more constipated.
Dr. Smith: I was just going to say -- but most community physicians will usually try to treat that first -- I guess, what type of patient is actually referred to you and are there some interesting other causes besides, say, like diet?
Kacie: Yeah, so a lot of kiddos will be referred to me because their pediatricians tried other types of -- they've tried the high fiber diet, and it hasn’t worked. They've tried pushing fluids, that hasn't worked. They've even tried polyethylene glycol, for example, and it just hasn't worked to get good results, so they will often refer those kids at that point in time because they're kind of stuck and parents definitely get frustrated in those situations. Almost always it ends up being functional constipation, which means there's no organic, or medical reason for that constipation. Often, it's multifactorial in many cases.
Dr. Smith: When we look back at the clinic, then -- so the BRICK Clinic -- tell us a little bit about what that stands for and who's involved in running and managing the BRICK Clinic?
Kacie: Yeah, BRICK Clinic stands for -- BRICK stands for Bowel Retraining in Constipated Kids. We chose that name because there's a large component of bowel retraining that has to occur in kiddos who have had chronic constipation. The clinic's been in existence for ten plus years, and I've been doing it for about that long. I am the Director, and Doctor Jose Cocjin is my physician collaborator. I also have another Nurse Practitioner who started working with me one day a week who's also seeing new constipation patients, and we do our clinic at the Children's Mercy Kansas location currently.
Dr. Smith: Why don't you walk us through -- you have a child who has been referred to you, so the community doctor has done what they do. They've looked at the diet; they've tried making changes there. There's really no improvement, so you now receive this child. Why don't you walk us through then what is a typical first visit and some subsequent visits as well?
Kacie: Okay. I'll see a patient for the first time, and it will be an hour visit because there's lots of education that we do. I do a detailed history, physical exam, review any previous blood work that's been done, or testing, even look at previous X-rays if they have been done. And then we talk with the kiddo and the family about their day-to-day schedule, their diet, their previous medications that they've done -- have those medicines worked? Have those kiddos taken those medicines actually, because a lot of kiddos don't like to take medication, especially medicines that do not taste well? What kind of habits are they in? Are there any behavioral issues, like are these kids -- is this child strong-willed and they just do not want to sit on the toilet? Do they withhold, or have they had painful bowel movements in the past? Really trying to identify all of the reasons as to why they're in our clinic and then figure out a plan that addresses both the physical and behavioral aspects of constipation.
That's where the education piece comes in. We spend a lot of time on education working on a schedule, making sure they're doing scheduled toilet sits, making sure they're on the right amount of medicine to produce good results and making sure those kids will actually take the medication, because compliance can be a big reason as to why treatment fails in the beginning. And then making sure they understand this is going to be a long-term treatment process. Often, these kiddos have had long-term constipation -- and I'm talking some kids ten plus years of constipation -- so it takes an awfully long time to get that bowel back to normal health.
Dr. Smith: Yeah, so let's talk -- I want to go back to the primary care doctor for a moment, or the nurse practitioners in the community -- from your professional point of view, or opinion, what are some of the things that they can do in their own clinic to help kids with constipation. Now, we already talked a little bit about the diet and stuff like that, but there are other things you might suggest first before having to maybe go on to the BRICK Clinic.
Kacie: Getting a good bowel clean out or disimpaction [sic] of hard stool. A lot of these kiddos have never really had a good bowel clean-out where they have removed all of the impacted stool. Starting over to where there's nothing in that colon and then you start daily medicine thereafter to keep the bowels moving and keep the poops coming every single day. That's one of the things I've noticed with a lot of kiddos we see is that they've done medicine but they've never done that clean out to get rid of all of that impacted stool, and that's really, really important if we're going to make any positive change.
Dr. Smith: You had mentioned that you educate the family and the kiddo that this could be a long process. There’s no guarantee that this is going to resolve immediately. What are we talking about? What is the length of time for most of these kids to start moving their bowels in a regular way?
Kacie: Usually within a month to three months we expect the kiddos to start having more regular bowel movements. I'm asking the parents to call back frequently and also having them keep a bowel diary so they're actually tracking each bowel movement, the consistency and the amount and the timing of that so they can see what kinds of patterns are happening and I give them goals to achieve between visits. Usually, we expect more bowel movements in the beginning and then once we've reached our goal of having a soft, daily bowel movement, daily to every three days, at most, you want to maintain that for a good six to twelve months.
Dr. Smith: And so the child is coming to you this whole entire time?
Kacie: Mm-hmm.
Dr. Smith: So you're following up on this, and once you've had the bowel movement that you want to see -- six months to a year -- then it goes back to the primary care physician who then follows the kid normally. So that is a pretty long time. How successful have you been when you look at the number of patients that you've taken care of, the results, how successful has the BRICK Clinic been?
Kacie: I'd say we've been real -- I think we've been pretty successful. There's lots of things that can prevent people from coming back and following up, but for the most part, those people who stick with the plan, a lot of them do get better. Some of them, their symptoms improved and we find that they still have to be maintained on some laxative to some degree, longer term after symptoms have been under good control. I think we've got a pretty good success rate because we really try to focus on both the physical and the behavioral components of constipation.
Dr. Smith: Yeah. What about the parents in all of this -- you mentioned education is an important part of the BRICK Clinic, so obviously, they're involved with education about how to take care of the constipation, but what about also managing their expectations. When you look at that whole process with them, how do the parents respond to the clinic?
Kacie: The parents seem very, very appreciative, but they're often very frustrated when I see them. I try to remind them that this is going to be a stepwise approach to this and it's going to take time. If we can have one goal per visit and we can accomplish that goal, then we can work on to the next one. I think when they've got a goal and they can achieve that they feel much more positive and more willing to stick with the program versus giving up. It does get frustrating when you've got a kiddo, who has lots of problems and has had problems for a long time.
Dr. Smith: Yeah, I like that idea of one goal per visit. I think that's enough for where parents can really wrap their heads around that; they can focus on that and then you can move on to the next goal. That sounds like an excellent idea for lots of different clinics, to be honest with you Kacie. Listen, I want to thank you for the work that you're doing in the BRICK Clinic at Children's Mercy. You're listening to Transformational Pediatrics with Children's Mercy Kansas City. For more information, you go to ChildrensMercy.org, that's ChildrensMercy.org. I'm Dr. Mike Smith, thanks for listening.
BRICK: Unblocking The Facts
Dr. Michael Smith (Host): So our topic today is "The BRICK Clinic: Unblocking the Facts." Whether regular or irregular, constipation in children can be broad and difficult to diagnose. My guest is Kacie Kaufman. She's a Family Nurse Practitioner within the Division of Gastroenterology at Children's Mercy Kansas City. Kacie, welcome to the show.
Kacie Kaufman (Guest): Thank you for having me, Mike.
Dr. Smith: So let's talk -- I like the name "BRICK Clinic", but let's talk first before we get into that, let's talk -- what are some of the typical reasons for constipation in children that end up in your care, specifically?
Kacie: Well, diet is a big factor. Kids who have low fiber diets, and those who are picky, tend to be more constipated.
Dr. Smith: I was just going to say -- but most community physicians will usually try to treat that first -- I guess, what type of patient is actually referred to you and are there some interesting other causes besides, say, like diet?
Kacie: Yeah, so a lot of kiddos will be referred to me because their pediatricians tried other types of -- they've tried the high fiber diet, and it hasn’t worked. They've tried pushing fluids, that hasn't worked. They've even tried polyethylene glycol, for example, and it just hasn't worked to get good results, so they will often refer those kids at that point in time because they're kind of stuck and parents definitely get frustrated in those situations. Almost always it ends up being functional constipation, which means there's no organic, or medical reason for that constipation. Often, it's multifactorial in many cases.
Dr. Smith: When we look back at the clinic, then -- so the BRICK Clinic -- tell us a little bit about what that stands for and who's involved in running and managing the BRICK Clinic?
Kacie: Yeah, BRICK Clinic stands for -- BRICK stands for Bowel Retraining in Constipated Kids. We chose that name because there's a large component of bowel retraining that has to occur in kiddos who have had chronic constipation. The clinic's been in existence for ten plus years, and I've been doing it for about that long. I am the Director, and Doctor Jose Cocjin is my physician collaborator. I also have another Nurse Practitioner who started working with me one day a week who's also seeing new constipation patients, and we do our clinic at the Children's Mercy Kansas location currently.
Dr. Smith: Why don't you walk us through -- you have a child who has been referred to you, so the community doctor has done what they do. They've looked at the diet; they've tried making changes there. There's really no improvement, so you now receive this child. Why don't you walk us through then what is a typical first visit and some subsequent visits as well?
Kacie: Okay. I'll see a patient for the first time, and it will be an hour visit because there's lots of education that we do. I do a detailed history, physical exam, review any previous blood work that's been done, or testing, even look at previous X-rays if they have been done. And then we talk with the kiddo and the family about their day-to-day schedule, their diet, their previous medications that they've done -- have those medicines worked? Have those kiddos taken those medicines actually, because a lot of kiddos don't like to take medication, especially medicines that do not taste well? What kind of habits are they in? Are there any behavioral issues, like are these kids -- is this child strong-willed and they just do not want to sit on the toilet? Do they withhold, or have they had painful bowel movements in the past? Really trying to identify all of the reasons as to why they're in our clinic and then figure out a plan that addresses both the physical and behavioral aspects of constipation.
That's where the education piece comes in. We spend a lot of time on education working on a schedule, making sure they're doing scheduled toilet sits, making sure they're on the right amount of medicine to produce good results and making sure those kids will actually take the medication, because compliance can be a big reason as to why treatment fails in the beginning. And then making sure they understand this is going to be a long-term treatment process. Often, these kiddos have had long-term constipation -- and I'm talking some kids ten plus years of constipation -- so it takes an awfully long time to get that bowel back to normal health.
Dr. Smith: Yeah, so let's talk -- I want to go back to the primary care doctor for a moment, or the nurse practitioners in the community -- from your professional point of view, or opinion, what are some of the things that they can do in their own clinic to help kids with constipation. Now, we already talked a little bit about the diet and stuff like that, but there are other things you might suggest first before having to maybe go on to the BRICK Clinic.
Kacie: Getting a good bowel clean out or disimpaction [sic] of hard stool. A lot of these kiddos have never really had a good bowel clean-out where they have removed all of the impacted stool. Starting over to where there's nothing in that colon and then you start daily medicine thereafter to keep the bowels moving and keep the poops coming every single day. That's one of the things I've noticed with a lot of kiddos we see is that they've done medicine but they've never done that clean out to get rid of all of that impacted stool, and that's really, really important if we're going to make any positive change.
Dr. Smith: You had mentioned that you educate the family and the kiddo that this could be a long process. There’s no guarantee that this is going to resolve immediately. What are we talking about? What is the length of time for most of these kids to start moving their bowels in a regular way?
Kacie: Usually within a month to three months we expect the kiddos to start having more regular bowel movements. I'm asking the parents to call back frequently and also having them keep a bowel diary so they're actually tracking each bowel movement, the consistency and the amount and the timing of that so they can see what kinds of patterns are happening and I give them goals to achieve between visits. Usually, we expect more bowel movements in the beginning and then once we've reached our goal of having a soft, daily bowel movement, daily to every three days, at most, you want to maintain that for a good six to twelve months.
Dr. Smith: And so the child is coming to you this whole entire time?
Kacie: Mm-hmm.
Dr. Smith: So you're following up on this, and once you've had the bowel movement that you want to see -- six months to a year -- then it goes back to the primary care physician who then follows the kid normally. So that is a pretty long time. How successful have you been when you look at the number of patients that you've taken care of, the results, how successful has the BRICK Clinic been?
Kacie: I'd say we've been real -- I think we've been pretty successful. There's lots of things that can prevent people from coming back and following up, but for the most part, those people who stick with the plan, a lot of them do get better. Some of them, their symptoms improved and we find that they still have to be maintained on some laxative to some degree, longer term after symptoms have been under good control. I think we've got a pretty good success rate because we really try to focus on both the physical and the behavioral components of constipation.
Dr. Smith: Yeah. What about the parents in all of this -- you mentioned education is an important part of the BRICK Clinic, so obviously, they're involved with education about how to take care of the constipation, but what about also managing their expectations. When you look at that whole process with them, how do the parents respond to the clinic?
Kacie: The parents seem very, very appreciative, but they're often very frustrated when I see them. I try to remind them that this is going to be a stepwise approach to this and it's going to take time. If we can have one goal per visit and we can accomplish that goal, then we can work on to the next one. I think when they've got a goal and they can achieve that they feel much more positive and more willing to stick with the program versus giving up. It does get frustrating when you've got a kiddo, who has lots of problems and has had problems for a long time.
Dr. Smith: Yeah, I like that idea of one goal per visit. I think that's enough for where parents can really wrap their heads around that; they can focus on that and then you can move on to the next goal. That sounds like an excellent idea for lots of different clinics, to be honest with you Kacie. Listen, I want to thank you for the work that you're doing in the BRICK Clinic at Children's Mercy. You're listening to Transformational Pediatrics with Children's Mercy Kansas City. For more information, you go to ChildrensMercy.org, that's ChildrensMercy.org. I'm Dr. Mike Smith, thanks for listening.