Constipation

Constipation is a very common problem in children.  True constipation has nothing to do with stooling frequency. It instead refers to the hardness of the stool, and subsequent difficulty with the passage of such.  When stool remains in the colon too long, water is reabsorbed, making the stool hard.  If the stool is not passed, it becomes large and distends the colon.  When this occurs, the “signal” to pass the stool is blunted, leading to a cycle of not having a bowel movement until the stool is so large that it overrides the blunted signal. Large stools may tear the rectal tissue, causing pain and bleeding… making the child more likely to “hold” the next bowel movement… a vicious cycle to be sure!

We divide the treatment of constipation and the involuntary fecal soiling (encopresis) that often results into three important phases. 

Phase One.  The Initial Cleanout: This is very important to the overall success in treating both constipation and encopresis.  If we determine that there is a large amount of stool in the colon, we will have you start with this phase. While there are a number of regimens that can be used in this phase, the one we prefer is as follows:

            Children’s Senokot Syrup:    ____ teaspoon by mouth once daily.  If this dose is not effective (child doesn’t have a bowel movement) and there was not an excessive amount of cramping with the once per day dose, then this same dose can be given twice a day.  Senokot is a gentle vegetable laxative that works well in kids.  It is a true laxative however, and it is NOT to be used as a long-term treatment.  It should be limited to one or two weeks. Senokot is over the counter.

            Senokot is continued one or two weeks until we determine the child is cleaned out.  Usually this means that they have several large bowel movements over the first few days and then some looser stools.  If you are unsure that this has been effective, please have your child re-evaluated.  We may want to do a rectal exam or check a plain x-ray of the abdomen before going on to the next phase.  We prefer to avoid glycerin suppositories and enemas if at all possible, although both have been used effectively in this phase.

Phase Two.  The Maintenance Phase: In this phase, our goal is to insure that the child has at least one or two small, soft, easy to pass bowel movements per day.

Diet changes: Whole milk (more than 32 oz per day) provides too much fat and slows the gut motility.  Increased water intake, and the use of pear, white grape, or prune juice (not apple) to help pull water into the intestine can also facilitate stool softening.  Adding fiber to the diet also increases the transit time through the colon.

Stool softeners, not stimulant laxatives.  These can be used safely for an extended period of time in conjunction with diet changes.

Miralax:  Powder form, mixed in any liquid … CAN’T TASTE IT, so generally preferred by kids!
                                  OR

            Milk of Magnesia  

Note: With MOM, you may use the chewable, or divide the dosage into 2-3 x per day for better compliance and results.  Mixing with food is a reasonable option also.

Most people are surprised by the length of this phase… generally double the time that the problem has been going on (i.e. 3 weeks of constipation needs 6 weeks of treatment!)  It takes time to let the colon return to normal size, and subsequently for the urge to have a bowel movement to return to normal.

Phase Three.  The Behavioral Modification Phase: Most kids with constipation have gotten into the habit not having bowel movements.  Sometimes they are just “too busy” and become adept at holding the stool, causing it to stay in the colon too long.  Another reason is that they may want to avoid a bowel movement because of a previous painful passage of hard stool. We want to insure that the stool is soft and therefore not painful to pass.  Then the child should be given the “chance” to go to the bathroom, not forced as if it was punishment.  Positive reinforcement is key in this step.

The child should sit on the toilet 5-10 minutes after breakfast and dinner each day.  Many children with constipation no longer feel and urge to go, but can if they are given the chance to try. Along with this, the child should be encouraged to attempt a bowel movement any time that they do feel an urge to go.  If you do have to interrupt the child at play to have scheduled bowel movements, make sure they are allowed to return to the activity afterwards so that they don’t associate having a bowel movement with punishment.

There is also a very good book, “Everybody Poops” that may be helpful in younger children who are fearful of having bowel movements.

If constipation is chronic and your doctor determines there may be a hip related issue (such as Sacroiliac dysfunction or Rectal Hypertonus) you may be given the name of a physical therapist who can address this issue.  If your child has a history of back pain, vague leg/knee pain, painful menstrual cramping, trouble with urination, “clumsiness” or prefers to have a bowel movement standing up, let your doctor know.

The most important thing for successful treatment of constipation is to NOT make the child feel worse about themselves than they already do.  Many will have “accidents” or “treadmarks” in their underwear when watery stool higher in the colon slips around the hard stool and is passed without the child’s knowledge.  They are teased because of this, and taunted for “smelling bad”… as if they need more to worry about!  Being open about why this happens, and reassuring the child that their body just needs a little “retraining”… not that there is something “wrong” with them is critical to resolving constipation.

Portions of this handout were adapted, with permission, from one created by Douglas Winesett, MD, a pediatric gastroenterologist formerly associated with Kosair Children’s Hospital.  Many thanks for his contribution and teaching!