Few pediatric conditions are as likely to cause as much consternation in families as constipation! Little wonder that it can make for very unhappy kids, and very frustrated parents, as everyone seeks the “magic cure” to make it better — NOW!
Constipation is very common. It accounts for up to 5% of all visits a general pediatric office, and 25% of all referrals to pediatric gastroenterologists. So let’s see if we can understand the most common reasons it develops, as well as medications such as laxatives that help relieve symptoms. To finish, Bonnie Bahler, DPT, a physical therapist who specializes in treating problems like constipation, and who has been an immense help to many of my patients, will share her wealth of knowledge. I’ve asked her to discuss ways she helps children achieve regular, painless bowel movements, as well as simple toileting strategies which may help prevent constipation.
What is constipation?
A September 2015 review article in one the major pediatric journals says, “Constipation can be roughly defined as infrequent passage of hard, uncomfortable stools that are distressing to the child.” A widely accepted guideline says a child older than 4 years must have 2 of the following:
- Two or fewer bowel movements a week.
- A least one episode of stool leakage a week.
- A history of the child clearly trying to hold on to stool.
- A history of painful or hard bowel movements.
- Presence of a large mass of stool on rectal exam by a medical provider
- A history of large stools which clog the toilet
What is Encopresis?
Encopresis is the repeated passage of stool to inappropriate places, like the underpants, and is often caused by stool incontinence: soft, liquid stool leaks around a large lump of stool in the rectum. Most children with the incontinence aren’t even aware they are leaking stool.
What causes constipation?
Times of transition may contribute: the breast-fed infant who weans to formula or whole milk; the toddler who starts potty-training; the child who enters preschool or kindergarten are all at risk. So are children of all ages who drink inadequate water, or are relatively inactive. Some children, especially toddlers, may have one painful stool and then start actively withholding stool, compounding the problem. Finally, a disproportionate portion of the constipated children older than 2 years I see are absolutely in love with milk products, especially cheese.
Here is a wonderful YouTube video about constipation and encopresis which Bonnie uses as a teaching tool for her patients:
How do we treat constipation?
For years, my primary recommendation for treatment involved some type of laxative. In my old age, I recognize the need for a more comprehensive approach that now includes dietary changes, the aforementioned laxatives, and evaluation and often, re-training of the child’s toilet habits.
Dietary changes — Occasionally the constipated child is simply not drinking enough water. Far more often the issue is excessive intake of milk products. I would estimate that in at 90% of the constipated children I see, “Samantha loves milk,” or “Eddy loves cheese.” Not uncommonly, Samantha is being allowed milk 5 or more times a day, rather than the American Academy of Pediatrics recommended 3 times a day. And Eddy is eating 2 to 3 cheese sticks a day, where 3 or 4 per week is probably plenty.
If mom tells me Eddy “won’t eat if I don’t give him cheese,” I suggest not buying cheese for a few weeks, establishing that life as he knows it will continue without cheese, then re-introducing the cheese under the new rules (3 or 4 times a week). For a more comprehensive discussion of how to modify the diet, see the article in Dr. Tom’s Corner, “Taming the Picky Eater.”
Laxatives — The simplest place to start, especially for infants, is juice, typically 1 or 2 ounces a day of prune or pear juice. For older children, we typically use a combination of osmotic laxatives, which soften the stool, and stimulant laxatives, which increase the contractions of the colon to push the stool out.
Osmotic laxatives generally have polyethylene glycol (PEG), brand Name Miralax, or magnesium citrate. Because polyethylene glycol is widely available and pretty inexpensive, I tend to start with that. Stimulant laxatives include Senna (brand name Senokot) and Bisacodyl (brand name Dulcolax).
For mildly constipated patients, I often used PEG alone, for more intractable children, I will suggest a stimulant laxative at bedtime, and an osmotic laxative in the morning. As the dosing of these products can get somewhat complex, and are very individual, I suggest you talk with your medical provider about the ideal combination for your child.
And now, I am excited to introduce Bonnie Bahler, DPT, to discuss ways to retrain the constipated child’s approach to the toilet, as well as suggest some simple steps in the toilet-training process which may help prevent constipation!
Hello everyone! My name is Bonnie Bahler and I am a pelvic physical therapist from PT Northwest. I specialize in pediatric pelvic floor physical therapy. We focus on the treatment of children with day or nighttime urinary incontinence, fecal incontinence, constipation and/or dysfunctional voiding habits and we work to restore the child’s (and parents) quality of life. I am very passionate about this topic, because many cases of adult pelvic muscle dysfunction began as voiding issues in their childhood. Today I will touch on a few tips and tricks to help ease your child in to pain free, daily poops!
Effects of Constipation and correlating tip:
- Urine leakage — Did you know that 1 in every 3 kids with constipation, will also have bed wetting and 1 in every 5 have day time urine leakage? Constipation impacts more than just the bowels. Tip: by monitoring the child’s diet and fluid intake, along with use of medication (like Dr. Tom mentioned), your goal should be daily, soft, snake like bowel movements. Many bed wetting and day time leakage cases are corrected just by getting the child to poop daily and drink water.
- FEAR — When kids get constipated, the stool becomes large and hard, so when they finally do get it out, it typically hurts and requires lots of straining. This will lead to a negative association with using the potty and many children will develop holding patterns (squeezing their bottom when they get fecal urge). A child may also develop fear of falling in or of automatic flushing toilets. Tip: Proper positioning on the potty is key. No matter the age of the child, they should always have their feet flat on the floor when sitting on the potty. If their feet don’t touch, they MUST have a stool. Bring back out that toddler seat cover if they are afraid of falling in. If they have a fear of auto flush toilets, place a post it note over the sensor. Fear is also diminished with education. Teach them how poop is made and about their bodies.
- Diminished fecal urge — When we hold our feces, the stool gets larger and harder and the rectum may stretch. This stretching of the rectum and squeezing of the anal sphincter, can result in the child losing the urge to poop. This is why we may pick up on cues our child needs to poop (big belly, gas, tummy aches), but when asked they say “NO, I don’t have to poop!” Your child isn’t lying, they actually might not feel the need to poop! Tip: Sit the child on the potty for at least 5 minutes after meals. Make sure they have a stool under the feet and try to make sitting there fun. Tell them you understand they don’t feel like they have to poop, but you just want them to sit there any see if anything happens. Use sticker charts to reward them for sitting. Let them bring a book or game to the potty. Make it fun.
- Sphincter incoordination — Our anal sphincter is a line of communication to our body. When it closes, it tells our body to hold the stool. When it relaxes, it tells the body to empty the bowels. Children who have fear of falling in the toilet or are fearful of a painful poo, may tighten the sphincter as a form of protection, this will result in difficulty passing stool and confusing signals to the brain. Tip: Using the above stated recommendations for positioning on the potty will add a sense of security and let them relax their sphincter. You can also try letting them blow bubbles while on the potty.
I cannot stress how important it is to be aware of your child’s bowel and bladder habits. Trying the tips Dr. Tom and I have presented are a good start. If your child continues to have dysfunction or just does not seem to improve, I highly suggest you follow up with your physician and consider an evaluation with me. If you ever have any questions, please feel free to stop by our clinic. I am located on the second floor of the Salem Pediatric building and am generally there every Monday through Wednesday.