When The Gut And The Mind Are Both Struggling: Disordered Eating And Pediatric Pelvic Health

By Kids Bowel Bladder | Professional Development for Pediatric Pelvic Health Practitioners

As a pediatric pelvic health practitioner, you spend a lot of time thinking about what goes into and out of the body — fiber intake, fluid consumption, stool consistency, and voiding frequency. But there’s a layer of complexity that often sits beneath these conversations, one that can quietly drive or perpetuate the very symptoms you’re trying to treat: disordered eating.

This topic recently came up during one of our live case mentoring calls inside the private KBB Facebook networking group, where clinicians can bring actual pediatric pelvic health cases and get questions answered in real time. A case involving disordered eating patterns sparked an important discussion and highlighted just how frequently these concerns may be influencing bowel and bladder symptoms without being immediately recognized.

Disordered eating in children and adolescents is far more prevalent than many clinicians realize, and its impact on bowel and bladder function is profound. Yet this intersection remains underexplored in pediatric pelvic health training and clinical frameworks. This blog post is an invitation to look more closely.

Language clarity is important here. Disordered eating is not synonymous with a diagnosed eating disorder (though it may co-occur with or evolve into one). It refers to a wide spectrum of irregular or harmful eating behaviors that don’t necessarily meet formal diagnostic criteria, including:

• Chronic restrictive eating or food refusal
• Highly selective eating (often seen in neurodivergent children)
• Emotional eating, binge episodes, or loss-of-control eating
• Fear-based food avoidance (including ARFID — Avoidant/Restrictive Food Intake Disorder)
• Skipping meals, especially in adolescents
• Purging behaviors or compensatory behaviors in older children and teens

These patterns are not simply “picky eating” or phases to wait out. These behaviors have real, measurable consequences for gut motility, pelvic floor function, and overall well-being.

There are a multitude of reasons that kids may restrict their food intake, including anxiety, sensory aversion, control issues, or body image concerns. And insufficient caloric and fiber intake is one of the most direct pathways to constipation. When children restrict their food intake, the gut slows down. Reduced food volume means decreased peristaltic drive. Add dehydration (which is common when children restrict fluids and food), and the stool becomes hard, painful to pass, and increasingly difficult to evacuate.

Chronic constipation creates its own vicious cycle: painful defecation leads to stool withholding, withholding leads to rectal distension, and rectal distension leads to dampened urge sensation and overflow soiling. The child who is chronically constipated because of restrictive eating may present to your clinic with encopresis, but the disordered eating fueling the problem may never be explored.

Anxiety and stress, which often accompany disordered eating, are intimately connected to pelvic floor muscle tension. The gut-brain-pelvic floor axis is bidirectional: psychological distress can manifest as increased resting tone in the levator ani and surrounding musculature, making evacuation more effortful and incomplete.

In adolescents with disordered eating, particularly those with restrictive patterns or food-related anxiety, we frequently see presentations of:

• Difficult or infrequent defecation despite appropriate fiber and fluid intake
• Dyssynergic defecation (paradoxical pelvic floor contraction)
• Urinary urgency, frequency, or incomplete emptying
• Pelvic pain

Treating these presentations with pelvic floor rehabilitation alone, without addressing the underlying eating behaviors and associated psychological distress, often yields limited or temporary results.

Laxative misuse is one of the most clinically significant and most underrecognized connections between disordered eating and pediatric bowel health. Especially in adolescents, laxatives are commonly used as a compensatory or purging behavior, often obtained over the counter and used secretly for extended periods before any clinician is aware.

The consequences for bowel function can be severe:

1. Electrolyte imbalance: Repeated laxative use causes loss of potassium, sodium, and magnesium, which can impair smooth muscle function throughout the gut and contribute to further motility dysfunction.
2. Paradoxical constipation: The rebound constipation that follows laxative use often drives further laxative use, creating a difficult cycle to interrupt. This requires skilled titration to avoid this pattern. We cover titration in my online course Peds Level 2 – Advanced Pediatric Treatment of Bowel and Bladder Disorders: Evaluation and Treatment of Complex Bowel and Bladder Disorders using a Whole-Body Approach.
3. Rectal mucosal irritation: Chronic stimulant laxative use can damage the rectal mucosa and blunt a normal urge-to-defecate sensation, which complicates the assessment and treatment of bowel evacuation dysfunction.

Clinically, a child or adolescent presenting with a confusing pattern of alternating loose stools and constipation, blunted rectal sensation, or poor response to standard bowel management protocols may be experiencing the effects of laxative misuse. It is worth noting that children and teens rarely disclose laxative use voluntarily, so caregivers are often unaware that it is happening.

By asking directly, in a non-judgmental and private setting, you can uncover this. For adolescents, a brief moment alone with the clinician (with caregiver consent) can make disclosure significantly more likely. You can phrase the matter as: “Some teenagers use laxatives to help manage how they feel about eating or their body. Is that something you’ve ever tried?” This normalizes the question without assuming or shaming.

If laxative misuse is identified, management requires a coordinated approach with the treating physician and, where possible, an eating disorder-informed therapist or dietitian. Abrupt cessation without support can cause significant rebound symptoms and distress, and is rarely sustainable without addressing the underlying eating behaviors driving the use.

The link between disordered eating and bladder symptoms is less frequently discussed, but important to understand. Restrictive eating and associated malnutrition can affect bladder capacity, detrusor stability, and the integrity of the urothelial lining. Dehydration is common in children who restrict both food and fluid. Concentrated urine can trigger bladder irritation, urgency, and frequency.

Additionally, the same anxiety and nervous system dysregulation that drives disordered eating can lower bladder thresholds and contribute to urinary urgency and incontinence patterns. In adolescents, shame and secrecy around eating behaviors can also translate into toileting avoidance, particularly in school or social settings.

Disordered eating can affect children of any body size, background, or gender identity. This is a critical clinical point: you cannot assess for disordered eating by looking at a child’s weight or appearance. Some of the most severely medically compromised children with restrictive eating disorders are in larger bodies.

Children who may be at increased risk include:

1. Neurodivergent children – ARFID is highly prevalent in autistic children and those with ADHD. Sensory sensitivities, demand avoidance, and routine rigidity can all significantly limit dietary variety and volume.
2. Adolescent girls – particularly those experiencing body image distress, puberty-related discomfort, or social pressures around eating and appearance.
3. Children with chronic illness – including those already in your clinic for longstanding bowel and bladder conditions. These kids may have developed anxiety and avoidance around eating due to pain or unpredictable symptoms.
4. Children with a history of trauma – including adverse childhood experiences (ACEs).  Trauma is both a risk factor for disordered eating and a contributor to pelvic floor dysfunction.
5. Perfectionistic or anxious children – high internal standards combined with anxiety are significant predictors of restrictive eating patterns.

Most pediatric pelvic health intake forms ask about diet. You ask about fiber and water. You may hand out a fiber chart or recommend prune juice. But how often do you ask parents:

• “Does your child ever skip meals or refuse food?”
• “Are there foods your child is afraid to eat?”
• “Has your child ever eaten a very large amount of food in a short time and felt out of control?”
• “Is your child ever worried about their body size or shape?”

These conversations can feel outside your scope, and in many ways, they are. You are not an eating disorder therapist. But you are often the first clinician to notice the constellation of symptoms that points toward disordered eating. You have a professional responsibility to recognize the signs, ask thoughtful questions, and facilitate warm referrals to the appropriate multidisciplinary team members. Those members can include dietitians with eating disorder training, psychologists, and pediatric gastroenterologists.

When you suspect disordered eating in a child or adolescent, how you respond matters enormously. Several principles should guide your approach:

1. Adopt a weight-neutral stance. Commenting on a child’s weight, even with the intent to help, can cause harm. Many children with restrictive eating disorders have been praised for weight loss before their illness was recognized. Avoid framing dietary changes in terms of weight outcomes. Focus on their function, energy, gut health, and well-being.

2. Separate nutrition education from diet culture. When discussing fiber and fluid with families, be attentive to how this information might land for a child with food anxiety or body image distress. Generic dietary advice can sometimes reinforce harmful restrictions. When in doubt, defer to a dietitian for detailed nutrition guidance.

3. Create a safe, non-judgmental space. Children and adolescents with disordered eating often carry significant shame. Brief, open-ended questions delivered with curiosity rather than concern can open important doors: “A lot of the kids I work with notice that what they eat affects how their tummy feels. Is that something you’ve noticed?”

4. Involve the family thoughtfully. Disordered eating often involves complex family dynamics. Avoid making assumptions. A collaborative, curious approach with caregivers, rather than directive advice, tends to be more effective and less likely to inadvertently cause harm.

5. Know your referral pathways. Every pediatric pelvic health practitioner should have access to a trusted referral network that includes eating disorder-informed dietitians and mental health professionals. If you don’t have this yet, building it is worthwhile.

Within the PPHAP Certificate Program, the competency framework for pediatric pelvic health explicitly includes the ability to recognize psychosocial contributors to bowel and bladder dysfunction and to communicate effectively with multidisciplinary teams. Disordered eating is precisely the kind of complex, layered clinical presentation where that competency is tested.

As advanced practitioners in this field, we have both the opportunity and the responsibility to see the whole child — not just the bowel chart or the bladder diary. When a treatment plan isn’t progressing as expected, it’s worth pausing to ask: what else might be going on?

Sometimes, the answer is sitting quietly at the intersection of food, anxiety, and the gut — waiting to be named.

Kids Bowel Bladder provides post-graduate professional development for physical therapists and occupational therapists working in pediatric pelvic health. The PPHAP (Pediatric Pelvic Health Advanced Practitioner) Certificate Program supports practitioners in developing advanced clinical reasoning for complex pediatric presentations.

This blog post is written for educational purposes for healthcare professionals and does not constitute clinical advice for individual patients. If you are concerned about a child in your care, please consult with the appropriate specialists.