Constipation
1/4/2021
Everyone poops
Everyone poops! Or everyone should poop. But having a bowel movement isn’t easy for everyone. At some point, almost everyone has a period where they become constipated. Constipation is when bowel movements are hard, happen infrequently, or when stool is retained in the colon even after having a bowel movement. Constipation is caused by stool moving too slowly through the colon or if the colon absorbs too much water. It can be a short-term or long-term problem. Let’s explore what constipation looks like, why it happens, and how to help your child if they are constipated.
Constipation criteria has to be individually defined because like most things in life, stool patterns are very individual. For most children and adults, normal stooling patterns are anywhere from 3 stools a day to 1 stool every other day. Daily stooling does not rule out constipation though. We see many children that stool daily but are still very constipated. This happens because they do not fully evacuate all their stool and over time the stool builds up throughout the colon. Therefore, we need to look at other factors or possible symptoms to determine if your child is constipated.
WHAT ARE THE SYMPTOMS OF CONSTIPATION?
How do you tell if your child is constipated? Constipation symptoms can also look different for different people. Constipation can look like:
• Dry hard stools that look like small balls or a bunch of small balls stuck together
• Firm appearing stools
• Stools that are painful to pass
• Diarrhea
• Extra-large size stools (usually very thick around) that clog the toilet
• Abdominal pain
• Rectal bleeding including hemorrhoid or fissures
• Soiling (smear like accidents or full stool accidents)
• Urinary accidents
• Fussiness/crankiness
• Moving body in odd ways such as crossing legs, clenching buttocks, or twisting body to hold in stool
• Itchy anus
• New onset bedwetting
• Poor appetite
If left untreated, constipation can result in hemorrhoids, anal fissures, and rectal prolapse (when the rectum pushes out of the body)
IS MY INFANT CONSTIPATED?
Infants can often appear constipated but usually are not. Breast fed infants stool up to ten times a day in the first month of life but after those first few weeks, some breastfed infants only stool once a week! A formula fed infant may only stool once a day.
Infants, whether breast milk or formula fed will often appear to be working hard to stool! They are working hard! They often have to strain to stool. They stool while lying flat without anything to push against and with weak core strength. When straining they will also change colors often purple or red and then white.
Signs that an infant is constipated should be based on stool quality. Infant stool should be loose or pasty. It should not be hard or include small or large balls of stool. They should also produce a result from straining. If they have been straining for a longtime without a result, this can be a sign they are constipated.
WHY DO PEOPLE SAY CONSTIPATION IS A VICIOUS CYCLE
Constipation can be a vicious cycle. Sometimes when your child is constipated it will hurt to stool Your child may not want to stool to prevent the pain of passing a hard stool. This holding creates dry, hard stools that hurt to pass. It also results in the colon become stretched out from more stool. Once it is stretched out the colon muscles become less effective at pushing out a stool. This results in stool that is larger than it should be and because it is sitting there, more water is pulled out creating hard stool. This hard stool hurts to push out. Your child may try to hold this stool. And the cycle begins again.
Other times, your child may not fully evacuate their stool leaving extra stool in their colon. This causes stool to sit in the colon for a long time. And because your child keeps eating, more stool is made and gets fit into the colon. Eventually the colon becomes full. This causes stretching of the colon. Once stretched the colon muscles become less effective at pushing out stool. This results in large stool that is harder to pass and sits in the colon longer. This stool is harder to pass and results in extra stool being retained in the colon even after stooling. And the cycle begins again.
WHAT IS ENCOPRESIS?
Encopresis is fecal soiling often due to incontinence (the inability to hold stool). It is the result of impacted stool in the rectum or constipation where the colon stretches out so much that your child loses sensation in their rectum. If this occurs, your child is unable to feel when they need to stool. They may have stooling accidents. They may also have diarrhea or staining in their underwear due to looser stool leaking around harder stool in the rectum.
This rarely occurs infants or toddlers and most children are over the age of 4 and toilet trained. Children with encopresis usually have a history of constipation though emotional issues may also be a cause. Risk factors for developing encopresis include being male, using medications that cause constipation, Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder, and anxiety or depression.
WHAT CAUSES CONSTIPATION?
There are a number of reasons why someone might become constipated and some kids may be constipated for a few of these reasons.
DIET
Diet is a common culprit that causes constipation. A diet that changes suddenly (for example a child transition from breast milk to formula) can result in constipation as the gut has to try to rapidly adapt.
Fiber
A diet that is low in fiber can also result in constipation. Fiber comes from fruits, veggies, beans, and whole grains. Your body cannot digest insoluable fiber (that is why we all see corn in our stool). This fiber pulls more water into the stool then swells up. This bulks up our stools and increases the contraction of our colon, helping stool move through the colon more effectively. To figure out how many grams of fiber your child should eat in a day, take their age and add 5 for a minimum number, 10 for a maximum number.
Fluids
A diet that doesn’t include enough fluid can also cause constipation. Fluid is important for moving stool through the small intestines and it is removed while stool is in the large intestines. If the stool doesn’t have enough fluids (or sits in the colon too long), too much fluid is removed making the stool hard.
A diet that is high in milk fat can cause constipation in some children. Especially if milk intake is excessive. Children should be limited to 16 ounces of milk daily (after the age of 1) OR 2-3 whole fat dairy servings daily including yogurt and cheese.
High Carbohydrate Diet
A diet high in processed carbohydrates is also a risk factor for constipation. All those delicious crackers (I’m looking at you, fishy crackers), especially combined with high fat milk products, can act like sludge in your child’s gut. These foods aren’t off limits but try pairing your child’s favorite carbohydrate rich snack with a high fiber fruit or vegetable. And try to keep non-mealtime beverages to water only.
If your child struggles with dietary changes due to picky eating, please check out our previous blog post on picky eating or consider a consult with our nutritionist for help.
EXERCISE
A lack of exercise can also result in constipation. When the body moves, blood flow increases to the digestive tract. More blood flood to the digestive tract, means food moves more easily through. If you are less active, the blood flow to your intestines is reduced, slowing down the food passing through the digestive tract. When this process is slowed down, more water is able to be absorbed out of the stool. This results in hard, dry stools.
The best exercises to help with constipation are aerobic exercises such as running, biking, and swimming. Yoga and stretching can also help promote digestion.
BEHAVIOR
Behavior is a common cause of constipation but often is secondary to an acute case of constipation. When it hurts to stool, why would you ever want to do that again? So instead of stooling, young children will hold their stool. This creates a vicious cycle. The more they hold, the drier the stool becomes. The stool also stretches out the colon creating MORE space for stool to collect. This results in hard, dry, extra-large sized stool that hurts even more to come out.
We can also see children who are potty training or exerting independence hold their stool. Some younger children use stooling to exert control over their lives. Some younger children don’t want to stop playing to go use the bathroom. These behaviors are common from ages 2-5 years. We can also see holding in older children who don’t’ want to have a bowel movement at school, camp or at a friend’s house.
CHANGES TO THEIR ROUTINE
Changes to your child’s routine can cause constipation. A schedule change may be enough for this to happen, for example starting a new camp. Travel can also result in constipation. Our bodies get used to our ‘home” toilet and often prefer to stool on that toilet. The change in location as well as often a diet change when on vacation, can cause many children to have problems stooling.
MEDICAL CONDITIONS
There are certain medical conditions that can result in constipation. These include hypothyroidism, celiac disease, lactose intolerance, and irritable bowel syndrome among others. Illness can also cause constipation due to dietary changes or loss in appetite. Medication for certain conditions can also result in constipation. For example, iron supplements are known for causing constipation. We frequently use iron to treat anemia due to iron deficiency can result in constipation. If your child is constipated and not responding to treatment or is on medication that is known to cause constipation, please consult your primary care provider for an evaluation and treatment.
HOW DO WE DIAGNOSE CONSTIPATION?
If you suspect your child is constipated, an office visit can help determine this diagnosis. The visit includes a through history where we learn about your child’s diet, activity level, stooling pattern, and toileting routine. We will do a physical exam and review your child’s growth charge. We may also order an x-ray that looks to see if and how much stool is in your child’s colon. Depending on your child’s presentation, we may recommend other laboratory evaluations or a referral to a gastroenterologist.
HOW DO WE TREAT CONSTIPATION?
Treatment depends on your child’s age, the duration of constipation, and the severity of constipation.
INFANTS
For infants struggling with constipation, methods that promote digestion can encourage stooling including warm baths, bicycling their legs, and massaging their abdomen. If that doesn’t work, please check with your provider before starting any treatment. Sometimes a formula fed infant may require a formula change for ongoing constipation issues. If this is more of a short-term issue, we may recommend juice. Juices such as apple, pear, and prune juice to stimulate stooling. Babies can have 1 ounce per month of life once daily (for example, a 3-month-old baby could have 3 ounces per day). We do not recommend routine rectal stimulation to encourage stooling as this can create physiological need to provide that stimulation for a stool to occur.
OLDER CHILDREN
For older children we recommend changes to diet and fluids, increasing exercise, working on a toileting routine and positional changes in the bathroom.
Toileting Routine
What is a toileting routine?A toileting routine includes routine times to sit on the toilet to attempt stooling. These times should be around the same time every day. The most successful times are 30 minutes after a meal or after exercise. They should be private. Your child should sit for 10 minutes each time.
Positioning
Correct positioning can help stooling. You want feet to be supported and either flat on the floor or a stool (or Squatty Potty). Knees should be bent at a 90-degree angle or slightly more.
Medication
If medication is necessary, please consult with your primary care provider. Medications we routinely recommend include
• osmotic laxatives such as MiraLax or Pedia-Lax chewables
• a stimulant laxative such as ExLax or Senna-kot,
• enemas
• glycerin suppositories
• stool softener such as Pedia-lax stool softener or Colace.
Osmotic Laxatives:
Miralax is an odorless, tasteless powder that can be mixed in beverages or yogurt. It is an osmotic laxative which means it brings water into the colon to help loosen stool and encourage movement of stool through the colon. For moderate to significant constipation, we routine recommend a “clean out” protocol for a few days to help eliminate all built up stool in the colon and then a maintenance dose that is used for 2 weeks to 1 year depending on the severity of the constipation. The dose will be based on your child’s age and weight. Because this is an osmotic laxative your child must be taking in enough fluid for it to work.
Seattle Children’s Hospital has a great guide to treating constipation including a dosing guide for MiraLax based on age and size. It also includes fluid intake requirements. It can be found here.
Pedia-Lax makes a watermelon flavored chewable containing magnesium. Magnesium pulls water into the colon to stimulate stooling. This can help your child stool in 30 minutes to 6 hours.
Stimulant Laxatives:
ExLax (Senna) is a stimulant laxative that comes in chewable or tablet form. This type of laxative increases the activity of the intestines or colon to encourage stooling. It usually works in 6-12 hours. It is often used in conjunction with Miralax. This medication can be used daily to manage constipation.
Enemas:
An enema is a liquid that is inserted directly into the rectum and usually produces a stool in under 1 hour. If we recommend an enema for your child, please make sure to get a pediatric version for a younger child such as the Pedia-Lax Liquid Enema. Fleets also makes pediatric and adult enemas. Do not give more than 2 enemas in a 24-hour period. This is a short-term solution and will often require a daily mediation to manage constipation.
Glycerin Suppositories:
A glycerin suppository is a small bullet shaped piece of glycerin that is inserted into the rectum to help produce stool immediately. Glycerin works by quickly bringing water into the colon and towards hard stool. There are different suppositories for infants, children, and adults. This is a short-term solution and should NOT be used daily, especially in infants.
Stool Softeners:
Pedia-Lax offers a drink that contains a stool softener. This drink is berry flavored and can be added to food or drinks. The softener works over 12-72 hours to help soften stool. Colace is a stool softener that comes in capsules. It works over 12-72 hours to help soften stool. These medications soften the stool but don’t encourage stooling. They may need to be combined with a laxative.
DURATION OF TREATMENT
Often parents start constipation treatment for their child and stop quickly once their child is no longer in pain. Unless this is the treatment plan you discussed with your provider, we do not recommend doing this. Very often this results in constipation quickly returning. If your child has moderate or significant constipation, they will require long term treatment.
Remember how we discussed constipation as a vicious cycle? Your child’s colon has become stretched out colon and needs to return to its normal shape before your child will be able to independently stool. This is a process that takes a long time, meaning upwards of a year for children who have significant or chronic constipation. The colon is stretched out and it is a muscle. Just like training for a marathon, you can’t just do a single 3-mile practice run and expect it go well! We need to put your child’s colon on a strict exercise program in order to get it back into proper working order. By following a long-term treatment plan, your child will be able to transition off medication without rebounding back into constipation.
We also need to figure out why your child became constipated. Was it behavioral? Diet? If we do not treat the underlying cause of constipation, they are also very likely to return back to a constipated state.
If you are looking for more information on constipation and treatment, Children’s Hospital Colorado has a great video to watch called The Poo In You. It is a must watch for any family with a child battling constipation. If you have questions or if your child requires an evaluation, please do not hesitate to call us.
Children’s Health Care of Newburyport, Massachusetts and Haverhill is a pediatric healthcare practice providing care for families across the North Shore, Merrimack Valley, southern New Hampshire, and the Seacoast regions. The Children’s Health Care team includes pediatricians and pediatric nurse practitioners who provide comprehensive pediatric health care for children, including newborns, toddlers, school aged children, adolescents, and young adults. Our child-centered and family-focused approach covers preventative and urgent care, immunizations, and specialist referrals. Our services include an on-site pediatric nutritionist, special needs care coordinator, and social workers. We also have walk-in appointments available at all of our locations for acute sick visits. Please visit chcmass.com where you will find information about our pediatric doctors, nurse practitioners, as well as our hours and services.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.