Here is an email I recently received, reprinted with the parent's permission:
Hi Dr. Tom,
I'm currently pretty livid, and a little bit defeated. My 3.5 year old son's pediatrician referred us to a pediatric GI clinic to rule out any other underlying causes for his constipation. He's on a very large daily dose of Miralax and his poops are extremely soft.
We saw the nurse practitioner at the clinic. The good news is that she doesn't think there is anything else going on in addition to what we already know: his rectum is stretched out, so things do not work exactly the way they should.
We were in a pretty good place before the appointment. He was having a large poop daily and, with a few recent exceptions, he was going in the potty. It took us months to get there. But she did a rectal exam and not in a way that I liked. At all.
She didn't actually tell him she was going to do it. She made him cry trying to get him on his side, until I stepped in and got him to roll over without tears. Then she just told him, "This is going to feel like pooping backwards," and stuck a finger in. Given that he has fear issues regarding pooping, that does not seem like a wise thing to say to comfort him.
She didn't ask me for help at all, despite the fact that she knew I had given him numerous enemas and suppositories and that he had done fine with them. He cried through the exam, which only lasted a few seconds. She told him that she wouldn't check his bottom again if he came back to see her. She gave him a sticker and he seemed fine immediately afterward.But now he is afraid to poop again and he is withholding, which he hadn't done in months. For a while, he was insisting that his body doesn't make poop anymore. He's having lots of small (still very soft) poops in his underwear/pull-up throughout the day. (We went back to pull-ups for the time being. He treats pull-ups and underwear the same.)
I sent a message to the nurse in the hopes that she'll change her technique for future rectal exams on kids. And I'm working with my son to get the poop out in whatever way is least stressful for him. We've managed one really good poop in the potty since then, and one so-so one, and the rest gets announced as "my bottom dripped some poop." He's really excited about the new pink tea set he's earning one piece at a time.
If you have any specific advice about how I should move forward beyond what we are already doing, I'd appreciate that, but I'd also love to see a blog post about protecting kids from well meaning health care providers. I feel like I know how to do that going forward, but it never occurred to me that I might need to until it was too late.
Laura G., Madison, WI
I am so glad Laura wrote this email. Laura's experience highlights the critical fact that parents know their child best. Often parents think their healthcare providers know better (or parents don't want to seem "annoying" or "hypersensitive"), but they should not hesitate to speak up if they feel that a doctor or a nurse does or says something to their child that is insensitive. This is especially important when the the medical experience relates in any way to a psychological problem a child might have.
One way to minimize the likelyhood of these events is to ask to speak to the healthcare professional just outside the door to the exam room before any related exam or procedure and explaining the child's history and progress to date. Or have this conversation in the room in front of the child -- your child is likely to appreciate hearing you discuss their success with their doctor or nurse!
I learned from Laura later that the nurse practitioner responded to Laura's comments by saying that she appreciated the her feedback and would change how she prepares children for digital rectal exams. Kudos to this nurse for being open to feedback and to Laura for her courage!