Also: Bowel Cleanout
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.
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 but on a restricted/low fiber diet (lots of white foods, few fruit/vegetables) first try to add high-fiber foods to their diet:
Foods High in Fiber
Foods Low in Fiber
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.
Older children can also try dried fruits and grapes (choking hazards for those under 3.) Also, increasing daily water intake is important. We recommend 1 cup of water/fluid per year of age up to 64 ounces.
If dietary changes are not working, or if the higher fiber WORSENS constipation, it is time for medical intervention.
The next step is to try an over the counter stool softener:
For chronic constipation, you should continue this DAILY for at least 3-6 months 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 or magnesium given daily (do NOT just stop, wean off with decreasing daily doses to avoid alternating loose and hard stools.)
If you cannot get your child stooling daily on Miralax and/or Magnesium, they likely need a stimulant as well. When your child is chronically constipated, the rectum becomes stretched out and loses the sensation to stool. This reflex can take months to return, do not worry if you need to use stool softeners and/or stimulants for long periods of time (months to even years in some children.). This is not dangerous nor will it cause dependence.
Recommended stimulants:
In the am you should have the child potty sit after breakfast when they most naturally will feel the urge to stool.
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.
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/vomiting, alternating constipation and diarrhea, or appetite changes we also ask that you bring your child in for evaluation before treating at home.
Potty Sitting
Once your child can stool comfortably, it is important to establish good toileting habits. Key to healthy stooling is using a stool or a “Squatty Potty” to get your child’s knees above their belly button. This straightens out the rectum, allowing for easier elimination.
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 behaviors 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.
Bowel Cleanout and Maintenance
Bowel clean out with Milk of Magnesia
Night Prior: Ex-Lax
Next morning: Milk of Magnesia mixed in chocolate/strawberry or white milk the morning
**Must drink within one hour, serve cold with a straw (things that are cold are more palatable, and drinking with straw allows fluid to hit the back of the tongue where there are less taste buds)
Bowel Clean out with magnesium citrate
Night Prior: Ex-lax
Next morning: Magnesium citrate mixed with equal amount of soda
**Must drink within one hour, serve cold with a straw (things that are cold are more palatable, and drinking with straw allows fluid to hit the back of the tongue where there are less taste buds)
Bowel Cleanout with MiraLAX
Night Prior: Ex-lax
Next Morning: MiraLAX mixed with Gatorade, must drink entire volume of Gatorade in 4 hours – serve cold with a straw (things that are cold are more palatable, and drinking with straw allows fluid to hit the back of the tongue where there are less taste buds)
Maintenance:
Start on Sunday of Clean-out weekend
____ Miralax (in am) 1-3 teaspoons (tasteless, mix in 4 to 8 oz of liquid)
____ Magnesium (CALM, start with 2/day or Pedialax Chewable, start with 1/day)
____ Senokot (in pm) 1 teaspoon chocolate syrup or 1 tab
____ Exlax (in pm) ¼ ½ 1 piece of chocolate tablet daily
*This regimen will be needed for approximately 6 months to allow a stretched colon to recover*