A Ped’s Perspective: Constipation
Constipation is a very common problem in pediatrics causing infrequent, hard and painful stools. I am going to cover the most common causes of childhood constipation as well as my recommendations for management and treatment. I want to start by saying that every child can have a different variation of normal in frequency of stools- it can be 1-2 times daily or every 2-3 days. If your child has a soft, easy to go poop every 3 days without pain, then that might be their normal.
Symptoms of constipation can include:
Infrequent stools- three times/week or less
Unusually large stools
Stool that is hard and painful to pass
Stomach pain- most often peri umbilical (around the belly button). Stomach pain typically comes and goes, it can have a very rapid onset, and it can appear to be severe discomfort.
Nausea
Diarrhea and/or encopresis: encopresis occurs when there is a large back up of stool in the intestines, and the loose stool leaks around the blockage. This leakage of stool is involuntary, and causes stool accidents in otherwise potty trained kids.
Blood on the surface of the stool from fissures
Constipation is most commonly “functional constipation” in kiddos meaning there is no underlying condition causing the constipation. Functional constipation is generally related to poor diet and/or plain water intake, or stool withholding. There is a big brain/gut connection in kiddos, and they often can develop withholding behaviors.
Common reasons I see kids withholding:
Fear: a prior painful poop made them fearful to poop again.
Toilet training transitions: control
Distraction: they do not want to stop what they are doing to poop and ignore normal body cues.
Location: many kids do not want to poop in public like at school.
Management for constipation:
Diet: It is important to first consider your child’s diet. It is not uncommon for kid’s diets to be high in processed foods and insufficient fiber. An easy way to calculate how much fiber your child needs is the “Add 5” method; add 5 to your child’s age, and that is how many grams of fiber they should consume in a day. Read more about managing fiber intake here. When I am seeing a kiddo for constipation in the office, we have a big conversation centered around healthy habits including diet. I always pull up a fiber chart outlining high fiber foods, and I have the child choose 5 foods that they are going to incorporate into their day to day. I recommend that the parent brings the child to the grocery store and has then be a part of the process buying the foods, and putting them away once they get home so they know exactly where they are for ease of access during snack time.
Hydration: plain water intake is so important for constipation management; water is pulled into the intestines and into the stool to make it softer and easier to go.
Exercise: active kids have active guts. We all know that it is a screen centered world, and we’re just living in it… but screen time should be monitored leaving more time for imaginative and active play.
Gut training: kids should be encouraged to sit on the toilet after breakfast and/or after dinner every single day for the number of minutes that they are old to actively try to poop. It is possible to train your gut to poop at the same time everyday, and this becomes even more important if your kiddo is the one that refuses to poop at school.
Positioning: did you know that there is a right and wrong way to poop… because there is. Kids should never have their feet dangling to poop; it is important that their feet are firmly supported on a stool to have their knees bent at a 90 degree angle. Proper positioning allows for their muscles to relax to make it easier to poop.
Gut health: I always recommend a daily probiotic and/or live active culture yogurt for kids to replace the good bacteria in the gut. I recommend a probiotic with high quality ingredients, no sugar or dyes, and no preservatives or fillers. This is my personal recommendation for kiddos two and up- it is a blend of pre and probiotics with over 8 billion live active cultures (the leading kids probiotic has only 5 billion live active cultures per serving) and clean ingredients. It also is in convenient single serve packets that taste like pixie sticks.
Treatment for constipation:
Depending on the extensiveness of the constipation, it may be recommended by your doctor to do a bowel cleanout. A bowel clean out is typically done to manage the large backed up stool burden to then be able to better manage constipation with all of the healthy lifestyle changes outlined above. Miralax is typically the medication management of choice because it is a osmotic laxative vs. a stimulant laxative. Miralax works by pulling water into the intestines and into the poop to make it softer and easier to go, as opposed to a stimulant laxative that stimulates the bowels to move the poop which often causes abdominal discomfort and cramping. Depending on the severity of the constipation, I recommend a short treatment with Miralax with a focus on the healthy habits outlined above. Discussion with your child’s medical provider is important to determine the best treatment plan and dosing of medication therapy.
If it seems that there is a psychological component to the constipation and stool withholding, I often recommend cognitive behavioral therapy as well.
Less commonly, causes for constipation can be “organic”, meaning there is an underlying diagnosis causing the constipation such as celiac disease, hypothyroidism, etc. It is important to first try to approach management as discussed above, and then if symptoms persist, follow-up at your medical home for full evaluation and management with considerations for lab work or an abdominal xray to determine extensiveness of stool back up in the intestines. Always seek medical evaluation for your child if they are having severe abdominal pain, blood in the stool, or chronic symptoms.
I hope you find this helpful if you are navigating the ups and downs of constipation. It is most important to ensure you are implementing healthy habits in your day to day, and be sure that you are emulating the healthy habits that you are asking of your kids yourself too!
