Constipation, No Fun For Anyone

Constipation is really no fun for anyone. No fun for baby or child, no fun for the parent who cleans the clogged toilet, no fun for the sister or brother who waits while someone works on solving the problem in the room next door. In general, constipation is a frustrating, sometimes embarrassing, and often chronic problem for young children. Here are a few ideas to get rid of the no-fun part and ways to protect your children, support them positively, and avoid dangers that can rarely come from over-the-counter (OTC) medications.
Before you reach for OTC medications, consider what is normal and what is not normal when it comes to poop. I usually break this down for children (and parents) in visual terms. I talk about things you find outside.
In general, poop in the toilet can look like a pond, a snake, a log, or a pebble. When it comes to poop, we’re always looking for snakes. It seems to me that framed this way, school age children can do a better job knowing if they’re constipated or not. We’re looking for  Snakes in the Lake, people! Frame it this way with your child and perhaps they will be more likely to get a glimpse of what they produce in the toilet?
In my experience, parents worry a lot about hard infant or toddler poop in the diaper but constipation sneaks up on many families to school-aged children. After children are toilet trained and wiping themselves (around age 4 or 5) many parents no longer gaze in the toilet bowl. Long gone are the days of staring at every diaper as parents lose track of the daily poops, how often they poop, and how a child feels when pooping. But first, some definitions:

What is Constipation?

Any child can be constipated, and it seems to run in families, but from the beginning it’s exceedingly rare to find constipation in breast-fed babies. That being said, some kids just come out more prone to constipation than others. Constipation isn’t entirely straightforward and obvious to many of us either. It’s not just hard poop but rather a combination of hard poop and poop that doesn’t come out every day.  The reason a typical child gets constipated is they lack good fiber in their diet, the poop sits in their colon longer than normal, and they hold the poop in because it hurts when it comes out. The viscous cycle of lacking fiber, having tummy pain, not wanting to poop, and poop getting dehydrated in the colon perpetuates and cycles and then constipation can set in.

• For infants, constipation is hard, packed stools that come out less often than every other day. When poop comes out the poop can look like pebbles (or logs) in the diaper and even have a tiny bit of blood on the outside from an infant straining and tearing their skin when pushing it out. First line of defense is adding a bit of juice (1-2 oz pear or prune daily) to diet. If over 6 months, increase foods with high fiber (mango, pear, prune) & decrease constipating ones (rice, cereals, banana, carrot, potato).
• In toddlers and preschoolers, constipation often occurs because of a more picky diet (normal!) that is deplete in fiber and water married with confusion or battles and pain around the time of stooling as children potty train. Some kids just start holding their poop in as they worry and/or learn to poop independently on the toilet. Constipation is defined as hard, painful or dry poops (logs/pebbles) that come less often than every 3 days. But if preschoolers are starting to hold their poop in during this time, it’s a good time to work diligently for a daily soft poop, increasing fruits/veggies/whole grains to ensure you don’t start the viscous cycle.
• For school-aged children over age 4 constipation diagnosis requires 2 or more of the following symptoms (occurring at least once a week for two months)
  • At least one episode of fecal incontinence (leaking poop) per week.
  • History of retentive posturing or a child holding their poop in rather than going poop when they feel they need to.
  • History of painful or hard bowel movements.
  • Presence of a large fecal mass in the rectum (doctor would feel this on a quick rectal exam with their gloved-finger).
  • History of large-diameter stools that may obstruct the toilet.

KNOW THIS: constipation is a common reason to see the pediatrician (up to 1 in 20 visits are for constipation) so don’t be shy if you’re worried about your child’s poop. The longer you wait to do something about this, the harder the poop may get and potentially the longer it will take to correct your child’s habits.

Medications For Constipation In Children:

In general I would say that if you use an OTC medication for your child’s constipation for more than 2 times, I think it’s worth seeing the pediatrician. There are often tips we can provide and exam findings that can help guide how to support your child’s pooping habits and help make the process of constipation end faster. If a child has been constipated for months, know that it may take months to correct the problem. Using medications for constipation are not typically a one-time fix. With constipation the muscles in the rectum and colon can stretch out and will need regular poop flying through every day for weeks to months to enable them to return to normal size.

• Stool softeners: Stool softeners are found as powders, suppositories (ie glycerin), or liquids (ie lactulose). Softeners work to literally just loosen and soften the poop. The most commonly asked about softener these days is polyethylene glycol. Although it’s not FDA approved for use under age 17 a 2009 FDA committee didn’t find significant risks for children. That being said, I would always talk with your child’s doctor before using at any age. Polyethylene glycol is an odorless, tasteless powder that dissolves in water. It works by binding to water so that water ingested can’t leave the intestines, colon, and rectum. Parents titrate to effect — meaning you use the amount of powder every day to help support your child having a daily snake in the lake (soft, daily poop). Now to be honest, some kids can detect the medicine in water despite the tasteless claims. I hear, “the water tastes slippery” or “I can taste it on tip of my tongue” so I suggest dissolving the powder in 6-8 oz water and then adding a splash of juice.  You have to give it with water so it’s got good ample water around to work! Used daily (often for days or weeks) the powder binds to water and disallows the colon to dehydrate the poop. Therefore the poop that comes out is soft and often helps produce less painful pooping. I encourage families to wean back on the dose over a series of weeks (for example go from 1 capful –> 1/2 cap for a couple weeks–>  1/4 cap and then no medicine at all) while getting good exercise, sitting on toilet to poop daily, and working on great fiber sources in meals.  While there is no reason to think polyethylene glycol is addictive, families sometimes worry about dependence, as do pediatricians, since it’s an easier fix for families than working on daily poops after breakfast, changes in diet that include great natural fiber-rich foods, and good potty habits. Like any med, check in with your doctor every 6 months your child is taking it regularly!
• Enemas: Enemas are often needed for children who have poop stains in their underwear or poop accidents because there is a hard ball of stool in their rectum that poop is leaking around. The enema will break that ball up and help your children get rid of it. I would ALWAYS recommend seeing a pediatrician before using an enema to ensure it’s the right thing to do (it can be not only messy, but embarrassing and traumatizing for both children and parents who aren’t comfortable). Often a child will need a quick rectal exam first to ensure normal muscle tone and a good reason for using an enema in the first place (hard ball of stool in the rectum). There are FDA warnings about safety of some enemas (Sodium Phosphate) if used too frequently so review dose and type of enema with nurse or doctor you plan to use prior!
• Laxatives: Laxatives are stimulant medicines that trigger the intestines to push the poop through. Laxatives come in easy powders or capsules or even chocolate squares. In general, I don’t recommend families use a laxative alone for children with constipation because causing the intestines to move and cramp against hard balls of poop can be painful. In general laxatives are used to “clean out” a child’s bowels of hard poop in combination with stool softeners so children don’t have as much pain. If you need to use a laxative more than 1-2 times, review the care plan with your child’s pediatrician.

OTC Safety Red Flags: Reasons To See Doctor Right Away

Although constipation usually doesn’t require urgent or emergent medical visits, some belly symptoms do:

• Severe abdominal pain that causes your child to double over in pain. Typically, constipation doesn’t cause this (although it can). Call your healthcare provider right away if your child has extreme abdominal pain.
• Blood in vomit. Especially larger amounts. Please check out this helpful First Aid guide for managing vomiting in children.
• Blood in stool. Blood can be bright red to black in appearance. Sometime constipation causes small amounts of red blood on toilet tissue from tearing, but any blood inside the poop or blood in the toilet requires a visit.
• Dangerous dehydration. May include high fevers lasting many days, a large amount of diarrhea, fast heart rate, dizziness with standing, decreased skin turgor (tone, firmness), dry mouth, decreased urine output, lack of tears, unusually deep breathing, lethargy and/or irritability.
• Risk of a toxic ingestion causing tummy pain. Although this may seem obvious, if you think that your child may have consumed a toxic household substance, call the Poison Control Center hotline immediately: 1-800-222-1222. Make note of that important “1” — it would be so much easier to remember if all two’s!

I’ll write more on PREVENTING constipation in the upcoming week!
This post was written in partnership with OTC Safety.org. In exchange for our ongoing partnership helping families understand how to use OTC (over-the-counter) meds safely they have made a contribution to Digital Health at Seattle Children’s for our work in innovation. I adore the OTC Safety tagline, “Treat yourself and your family with care all year long.” Follow @OTCSafety #OTCSafety for more info on health and wellness.

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