Constipation

What is it?

Constipation means having hard or painful bowel movements (BMs). If a child does not have regular BMs, but they are soft and not painful when s/he does have them, s/he is not constipated. Many parents (and grandparents) worry a great deal about constipation. They often try many different things to get a baby or a child to have a BM. Some of these things can be harmful and can even make constipation worse!

Newborns’ stools change several times in the first week or two of life. It is normal for the first stools (after the brand-newborn meconium) to be quite runny and loose, especially in breast-fed infants. Parents sometimes think that their baby is constipated when s/he starts to have more solid stools at a few months of age. This is actually normal. Older babies and children can develop real constipation for many reasons. Very often they are just not getting enough liquid in their diets. Children of all ages often avoid eating foods that are high in fiber. Fiber helps keep BMs soft and comfortable. Some infants and young children develop "anal fissures," tiny cuts on the surface of the anus from a hard BM or vigorous wiping. Anal fissures hurt, and children may have fewer BMs to avoid the pain. This can cause the BM to become harder and drier, and that can cause more pain and make the fissure worse.

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Older children with constipation may complain only of a stomach ache, and may not mention their BMs unless you ask them.

Most children get constipated at least once during their childhood. Minor constipation is not dangerous. Laxatives or other treatments can cause more trouble than mild constipation. More severe constipation can cause abdominal pain, cramps, rectal bleeding, hemorrhoids, and some other serious problems. Some children with very bad constipation develop a condition called "encopresis" (en-ko-pree-sis). In this case, loose stool passes around a large mass of hard stool in the rectum, causing "accidents."

First we have to be sure we have the right diagnosis. Some children and adults simply have infrequent BMs – even only once a week. If the child does not have pain or difficulty eliminating the BM, s/he does not have constipation. You can treat mild constipation using some of the diet and behavior changes we recommend below. More serious cases may require adding medicines. Please do not start using any medicine for your child’s constipation, even an over-the-counter medication, without speaking with your doctor. Children can become dependent on laxatives and other treatments.

Diet Treatment

If a child has genuine constipation (hard and painful BMs), you can usually treat it easily by adding some fruit juice to the diet. For babies younger than 4 months, try adding 4-6 ounces per day of apple, pear, or white grape juice to your child’s diet, divided evenly among all the bottles s/he takes during the day.. Many doctors recommend using small amounts of prune juice. It is best to start with small amounts and increase gradually, because too much can cause cramps and fussiness. If your baby is partially breast-fed, you can increase the amount of breast feeding. Babies who get only breast milk rarely become constipated. Many doctors no longer recommend adding corn syrup such as Karo® to the formula. It carries a small risk of botulism. Older children should try to drink fruit juice and eat fresh fruits and vegetables (except bananas, which can make constipation worse). High fiber foods also help, such as whole-grain breads and cereals.

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If your child is toilet-trained, you can try using some behavioral methods to help him or her to have a BM naturally. Do this in addition to the diet changes described above. Remember that children develop their bowel habits at quite a young age. Because of all the emphasis on BMs during potty training, young children often have a sense of pride or accomplishment after having a BM. They may lose this if the family talks about BMs as bad or shameful. If a child learns to associate a BM with something bad or shameful, s/he may avoid having them. This can cause "accidents," which only make things worse. Eventually it can cause constipation. Without making too big a deal out of it, continue to encourage, compliment and thank a child when s/he lets you know s/he has had a BM.

Everyone, adult or child, has an urge to empty the bowel shortly after a meal. This is a natural reflex, and you can use it to help your child. Encourage your child to try to have a BM soon after each meal. Some parents give their children a red star on a chart for sitting on the toilet for ten minutes, whether or not they have a BM. Children get a gold star when they do have one. You may want to invent some other system of positive reinforcement – the main idea is to get your child into a regular habit pattern.

It is important to focus on positive things, to avoid shaming a child, and especially to avoid making a big fuss over a child’s lack of a BM. These things tend to cause children to avoid the bathroom entirely, and will make constipation worse.

If diet and behavioral treatment together do not work, or for an infant or toddler, your doctor may recommend a mild laxative. There are different kinds of laxatives, and they all work differently.

• Bulk laxatives, such as psyllium fiber (Metamucil® and others) are safe and very effective, but most children object to the consistency and volume that they must drink. Bulk laxatives are the safest to use over long periods of time, for example in children with chronic constipation and certain other bowel diseases.
• "Osmotic" laxatives work by pulling water into the bowel. These include lactulose and PEG 3350 (Miralax®). Both are available by prescription only. Lactulose is very powerful and can be dangerous unless used very carefully. Miralax is much more gentle and safe, and many doctors now use it as the first-line treatment for constipation that did not improve with diet changes.
• Stimulant laxatives such as milk of magnesia, senna, and bisacodyl (Dulcolax® and others) work by stimulating the bowel to move and secrete water. Doctors only recommend stimulant laxatives for very short-term use – children can become dependent on them.
• Stool softeners like sodium docusate (Colace® and others) and mineral oil are just that – they soften the stool so that a child can have a BM without pain. They are best used for a short time only. They are especially helpful when painful BMs are an issue.
• "Cathartic" medications (such as magnesium citrate and castor oil) are powerful stimulants that cause almost anyone to have a BM shortly after taking them. Doctors only recommend these in children with very severe constipation, and often only while in the hospital or under direct observation. Castor oil is poisonous in large amounts – please consult with your doctor before using it.
• Suppositories soften and lubricate stool, and some contain stimulant medication. As they swell in the rectum, they also stimulate a BM by increasing pressure.

Your doctor may also recommend using an enema once or twice. An enema is a medication given through the rectum. Because of this most children hate enemas. We do not recommend them for routine use. Enemas work by several different means. The most common kind of enema is a phosphate enema (Fleet® and others). They work by pulling water into the bowel. There is usually a result within 15 minutes. Mineral oil enemas soften and lubricate hard stool to make it easier to pass. In some cases, doctors recommend a combination of both enemas. We often recommend enemas only for one-time use in severe constipation, as the first part of a complete plan including diet and behavior changes, with short-term laxative use.

As a reminder: Please do not give laxatives, enemas, stool softeners, or any other bowel medication, even over-the-counter, without first talking with your doctor. Never give a laxative or an enema to a child with abdominal pain, a fever, or vomiting!

Diet and behavior treatment is usually enough to clear up mild constipation – if your child will cooperate. It does take time to work, though. Give your child ten days to two weeks of really trying diet and behavior before you decide it hasn’t worked. Bulk laxatives take five to seven days to work, so please be patient with them also. The other laxatives work faster – usually within 24 to 48 hours. There are a few signs that can mean something more serious is going on:

• Severe abdominal pain (more than just a few cramps)
• Fever of any kind
• Vomiting
• Refusal to eat or marked loss of appetite
• Refusal to walk, or a slow walk that looks painful
• Pain with urination
• Lack of any BM at all after an enema
• Rectal bleeding or blood in vomit

If any of these occur, please be sure to call your doctor’s office right away.

There are many "traditional" treatments for constipation. While most are safe, some are not. Do not put anything into your child’s rectum to try to stimulate a BM. Do not use a suppository or an enema without your doctor’s recommendation.

Some children with constipation develop a condition called "encopresis." This happens when stool becomes so hard that the child cannot pass it. Stool builds up in the rectum, blocks it, and stretches it until the child can no longer feel the urge to have a BM. Some liquid stool from above the blockage then escapes through the anus and causes the child to have a soiling episode. This is very embarrassing for the child, and many parents do not understand that the child really didn’t know s/he had to go. This can lead to the child being disciplined unfairly, as well as to a great deal of shame and humiliation for the whole family. Encopresis is a serious medical problem that can have life-long physical and emotional consequences. If you are worried that your child has encopresis, please talk about it with your doctor – it is easy to treat once we know about it.

If your child has previously been having normal BMs and suddenly stops, or complains of abdominal pain along with constipation, there may be something else going on. One of the most common things is appendicitis, which can happen in children as young as 2 years old. Most children with appendicitis develop fever and vomiting, but if you are unsure, check with your doctor. Newborns who have never had a normal BM may have an abnormality called Hirschsprung’s Disease. Some older children (up to age 4 years) can have Hirschsprung’s Disease as well. In rare cases children with botulism have a slowly worsening case of constipation. Although it is uncommon, children who are being sexually abused often stop using the bathroom, or become fearful of using it alone. They may also begin soiling their underwear. If you have any concerns about this, please discuss it with your doctor, and listen carefully to your child.

Caring for a child with constipation can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children with constipation are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your child’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.