One of my most indelible memories as a pediatric gastroenterologist was the mother who decided to bring a trash bag full of soiled diapers to her child’s visit. Not a diaper pail or tissue basket sized bag but a Texas-sized trash bag normally used to line a 55-gallon drum or haul grass clippings. Over the course of 2 months this poor woman had catalogued and saved every soiled diaper with date, time, consistency, color, odor and the absence or presence of visible blood noted compulsively the outside. Upon taping the diapers shut, they were frozen in anticipation of her appointment. Filthy diapers cryogenically immortalized for my expert review.
Call me self-centered or even negligent but on the day of her daughter’s consultation I didn’t inspect a single diaper. My goal was instead to complete the visit as quickly as possible and get the family out of my office before the bag defrosted. One of the first rules of pediatrics is to never be present within 100 yards of a bag of frozen diapers when exposed to heat. As it turns out this child’s diagnosis was made quite comfortably on the history and subsequent fresh stool samples.
In another equally bizarre scenario a CPA-turned-stay-at-home-mother makes repeated visits to my office with ‘stool portfolios’ consisting of beautifully created pie graphs and tables representing her baby’s bowel actions. She somehow thinks that a graphic presentation will make her point clear and expedite some sort of resolution to the stress brought upon their household by the presence of undigested vegetables in the pull-up.
As strange as these stories may sound, they are common among a class of parents that pediatric gastroenterologists refer to as stoolgazers. Stoolgazers are parents obsessed with their child’s every move … or movement. Compulsively attendant to the shape, size and shade of their baby’s excrement, they read the best and worst into everything that comes out of their baby. The stoolgazer is tenacious in trying to understand what it all means and how it relates to their child’s overall well being.
So how abnormal are these parents who carry spreadsheets detailing their child’s every deed? Probably no more so than other parents whose fixation involves some other organ or aspect of development. As anyone knows who has ever been involved with raising a child, concerns over speech, growth, feeding and behavior are the rule rather than the exception. And when a mother seeks the reassurance of a subspecialist to ensure that her daughter’s speech delay is nothing to worry about, we think nothing of it. It’s just that these worries seem less bizarre and aren’t nearly as amusing when sharing stories of parental angst. Despite my poking, however, it should be understood that parental anxiety is considered by most a good thing. Parents who are on their toes have a tendency to keep their children safe. Attention to the details has a way of keeping children alive.
Our fixation on feces has historical precedent. Before medical technology evolved to where it is today, physicians were dependent upon their sense of sight and smell for diagnosis. Dr. J. Forsyth Meig’s Practical Treatise on the Diseases of Children in 1874 suggested that doctors “ought by all means to inspect personally the appearance of the matters ejected … no description of a mother or nurse, however intelligent, can impart to the physician the precise and accurate idea of the state of those discharges which even a very rapid inspection would give him.” Note the grandiose paternalistic position of Dr. Meig who seems to think that no one, especially a woman, could ever examine a diaper as astutely or quickly as he.
Even as late as mid-20th Century A Chart of Infant and Children’s Stools by Motonobu Furukawa was published with over 250 close up color photographs of human excrement during various disease states. While a fascinating read for the socially deprived gastroenterologist, this book is long out of print. Simple observation, for better or worse, has been replaced by sophisticated diagnostic procedures.
But the stoolgazer remains and the pediatric gastroenterologist is often called upon to ease their pain. We try first to determine whether the stool characteristics described so compulsively could add up to something. If suspicious, simple laboratory testing is all that’s needed to eliminate the short list of potentially concerning maladies. In most cases, however, my encounter amounts to a therapy of sorts where the parents are educated and taught to accept their child’s stool for what it is: green, slightly loose, slightly firm or containing something that doesn’t represent a threat. Like alcoholics anonymous, we strive to get parents to admit that there’s a problem but one that doesn’t involve the child or her diaper.