Constipation is a very common problem. It is usually defined as the passage of hard and painful stools or going four or more days without a bowel movement (BM). It is usually caused by a diet low in fiber, too much dairy (more than 16 oz a day), not drinking enough water or waiting too long to go to the bathroom. Once a child develops constipation and has had hard, painful stools, they may begin to hold their bowel movements to prevent it from hurting again. This creates a cycle that makes constipation continue and become worse. Constipation is a common cause of stomach pain, headache, poor appetite and general irritability. This can lead to encopresis or fecal incontinence, in the potty trained child: hard stool in the colon and liquid stool leaking around it. The sensation of needing to have a BM may also be lost.
Treatment: Constipation is best treated by changing your child’s diet. Stool softeners or laxatives may also be needed. The goal is for your child to have 1-2 soft stools daily.
Diet change for children:
- Increase fluids: water or juice (prune, pear, or white grape). Not apple juice.
- Increase fiber: Give enough grams of fiber to equal their age in years and add 5 more grams. Ideas: raw fruit (pears, prunes, plums, grapes, etc…) and vegetables (beans, sweet potatoes, peas, corn, tomatoes.). Vegetable soups are a good choice too. Popcorn is rich in fiber. Dried fruits/raisins work well.
- Increase bran: whole wheat bread, bran muffins, shredded wheat, graham crackers.
- Decrease foods that cause constipation: Dairy products (cheese, yogurt and excessive milk), cooked carrots, bananas, white rice, and apple sauce. In some cases of constipation can be a late sign of a dairy allergy, especially if they also have eczema. Avoid foods with “gum resins” like fruit roll ups.
MiraLAX is a commonly used laxative. It is very effective and is available over the counter. It is the most recommended laxative by pediatric gastroenterologists. Although the label says to only use in adults and only for 2 weeks, this medicine is felt to be safely used for months to years and can be used in toddlers too.
Ex-Lax is a commonly used laxative also. It can be used during the clean out phase to help with the passage of large amounts of hard stools.
Clean Out: Use for one day unless directed
- Clear Liquid Diet during this phase
- < 3 years old: 8.5 gm (1/2 cap) every 2 hours
- > 3 years old: 17 gm (1 cap) every 2 hours
- < 3 years old: ½ square twice a day
- > 3 years old: 1 square twice a day
- Goal of Therapy: clear, translucent stool
Maintenance: Approximate Dosing for MiraLAX, use once a day
- < 15lb = ½ tsp
- 15-22lb = 1 tsp
- 22-33lb = 1 ½ tsp
- 33-44lb = 2 ½ tsp
- 44-55lb = 3 tsp
- More than 55lb = 3 ½ tsp or one cap full
This may be recommended for 6 months or more.
For maintenance only dosing, it does take 2-4 days to work and may be titrated up or down in dose to achieve 1-2 soft stools daily. Avoid making drastic changes in the medication dose for each BM; you may end up with a “see-sawing” effect. MiraLAX is dissolved in any liquid and is gritless. It may have a slight bitter taste so dissolving it in juice or milk might be best.
Enemas or glycerin suppositories may be required if hard/pellet like or infrequent stools persist. A pediatric Fleets Enema or glycerin suppository (applied with Vaseline) may be inserted rectally daily for 1-2 days only to clean out the colon. These should not be used routinely and should only be used when recommended by your doctor.
You should have your child sit on the toilet for 10-15 minutes after meals 1-2 times daily. After eating is the most natural time to have a BM. The use of simple rewards or a daily calendar with stars or stickers for days your child takes his/her medicine and has a BM may be helpful. For children whose feet do not touch the floor sitting on a regular toilet seat, it is helpful to use a stool for foot support.
Points to Remember:
- Be patient. Constipation is a chronic problem and may take 6-12 months or longer to resolve fully. Avoid embarrassing or punishing your child.
- Medication should not be stopped too early, the problems return quickly. Often medication should be continued for several months. It may be gradually discontinued as long as the child has 1-2 soft stools daily. In some cases medication is needed for years.
- Call your pediatrician if it is not improving over the first month or if soiling/leaking occurs.