Constipation

How do I know if my child is constipated?

Bowel patterns vary in children just as they do in adults. Because of this, it is sometimes difficult to tell if your child is truly constipated. One child may go two or three days without a bowel movement and still not be constipated, while another might have relatively frequent bowel movements but have difficulty passing the stool. Or a child’s constipation may go unnoticed if he passes a small stool each day, while a buildup of stool develops in his colon. In general, it is best to watch for the following signals if you suspect constipation.
  • In a newborn, firm stools less than once a day, though breastfed infants can normally pass loose or pasty stools as infrequently as once a week.
  • In an infant or older child, stools that are hard and compact, with three or four days between bowel movements
  • At any age, stools that are large, hard and dry, and associated with painful bowel movements
  • Episodes of abdominal pain relieved after having a large bowel movement
  • Blood in or on the outside of the stools
  • Soiling between bowel movements

Causes

Constipation generally occurs when the muscles at the end of the large intestine tighten, preventing the stool from passing normally. The longer the stool remains there, the firmer and drier it becomes, making it even more difficult to pass without discomfort. Then, because the bowel movement is painful, your child consciously may try to hold it in, making the problem still worse.

The tendency toward constipation seems to run in families. It may start in infancy and remain as a lifetime pattern, becoming worse if the child does not establish regular bowel habits or withholds stool. Stool retention occurs most commonly between the ages of two and five, at a time when the child is coming to terms with independence, control, and toilet training. Older children may resist having bowel movements away from home because they don’t want to use an unfamiliar toilet.

If your child does withhold, he may produce such large stools that his rectum stretches. Then he may no longer feel the urge to defecate until the stool is too big to be passed without the help of an enema or other treatment. In some of these cases, soiling occurs when liquid waste leaks around the solid stool. This looks like diarrhea or soiling on the child’s underpants or diaper. In these severe cases, the rectum must be emptied under a physician’s supervision, and the child must be retrained to establish normal bowel patterns.

Treatment

Constipation due to breastmilk is highly unusual, but if your breastfed infant is constipated, it is probably due to a reason other than diet. Make an appointment with us to discuss.

If your child is on a milk based formula, try a partly hydrolyzed version, such as Enfamil Gentlease or Carnation Good Start. Soy formulas frequently cause constipation, and we do not recommend them. Rarely formula allergies and other conditions can cause constipation, consult us if the problem persists.
For infants older than 2 months, you can try a small amount of diluted prune juice (1 ounce water/1 ounce juice) once a day.

For a toddler or older child who is eating solid foods and has problems with constipation, you may need to add high-fiber foods to his daily diet.
These include prunes, apricots, plums, peaches, mangoes, high-fiber vegetables (peas, beans, broccoli), and whole-grain cereals and bread products. Avoid constipating foods such as apples/applesauce, bananas, rice and rice cereal, refined grain products (white bread), and any soy product.
Recognize that many baby foods use apple as a filler, and the pectin in apple is very constipating. Whole milk is also constipating- if your child has recently switched from formula to milk, or is drinking in excess of 20-24 ounces of milk a day, you may need to decrease the amount given.

Prune juice (or prunes) – prunes contain a sugar which can not be absorbed, but which can make bowel movements softener by retaining water.  Prune juice can be used to prevent constipation and can even be used for infants (½  to 1 ounce daily).  The amount for older children can vary from 2-4 ounces daily.  If the juice is too sweet, it can be diluted with water or (for older children) a small amount of clear soda.
 
Older children can also try dried fruits and grapes (choking hazards for those under 3.) Also, increasing daily water intake is important.

If dietary changes are not working, the next step is to try an over the counter medication called Miralax. Miralax is an odorless, tasteless powder that is not digested or absorbed by the intestines, but absorbs fluid to loosen the stool. It can be mixed into any liquid or puree, but be sure to put it into a small amount of food/liquid to ensure your child gets the full dose. For children 2 and older you can start with a teaspoon once a day. It may take 3-4 days to see an effect, but once your child’s stool softens you can adjust the dose either up or down (1/4 teaspoon to 3 teaspoons once daily) to maintain a soft daily stool. You should continue this for at least several weeks to give the rectum time to regain its shape and tone. Once your child is stooling comfortably, you can slowly reduce the amount of miralax given daily (do NOT just stop, wean off with decreasing daily doses to avoid alternating loose and hard stools.)

If your child is acutely uncomfortable because of a large, hard, impacted stool you may need to use a glycerin suppository (for lubrication) or pediatric saline enema. To use an enema, have your child lie on his side with his knees drawn up to the chest- gently but firmly insert the tip of the enema and squeeze. The liquid will help break up the firm stool, and stimulate defecation. This is not pleasant, but will do the trick.

Milk of Magnesia (Magnesium Hydroxide) is another effective treatment which can be given prior with the largest meal of the day.  After the meal the child should be encouraged to try to have a bowel movement.  Milk of magnesia softens the stool and can make it easier to have a bowel movement, though it may take a day or two for this to be effective.  This is not usually recommended for children under a year of age.  A usual dose is 1 teaspoon once a day for children up to 33 pounds, 2 teaspoons per day for children up to 66 pounds, and 3 teaspoons for children 66 pounds or above.

If dietary changes and miralax have not helped, please make an appointment for further consultation. If you child experiences significant abdominal pain, blood in the stool, associated nausea/vomitting, alternating constipation and diarrhea, or appetite changes we also ask that you bring your child in for evaluation before treating at home. We do not recommend using any type of stimulant or laxative medications without first evaluating your child.

Potty Sitting

Once your child can stool comfortably, it is important to establish good toileting habits. If you are potty training, allow your child to use a diaper for stooling until they are no longer withholding or experiencing large, hard, painful stools. The body has a natural urge to stool after a meal (called the gastro-colic reflex.) Have your child sit on the toilet for 15 minutes after each meal to allow the body a chance to feel this urge- distraction in this case with books or an iPad is fine. Once stooling is no longer painful, and the stool is soft, your child should be able to quickly develop a regular potty routine that will avoid the witholding behaviors associated with constipation.

It is not uncommon for children to experience constipation repeatedly over childhood as it is often related to a restricted diet, withholding behavoirs or a genetic predisposition. If you notice your child’s stools again getting hard, painful or infrequent revisit dietary changes and use miralax as needed. If the problem persists, come in for an evaluation for other causes.