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Constipation Treatment Guide

Pediatric Basics


Constipation is a common problem for infants and children and accounts for almost 3% of visits to a Pediatrician.

While there are some medical causes of constipation, such as Hirschsprung's disease, cystic fibrosis and hypothyroidism, most children who are constipated are normal. Warning signs that may indicate a more serious condition causing your child to be constipated include vomiting, weight loss, poor weight gain, fever, abdominal distention or having a poor appetite.

Constipation is usually defined as having infrequent bowel movements that are hard and painful. Infants that strain or groan when they have a bowel movement are not constipated if their stool is soft, even if they only have a bowel movement every two or three days. It is also important to remember that many breastfed infants only have a bowel movement once every week or two.

Why do children become constipated?

One of the things that is frustrating for parents is trying to understand why their child is constipated. Although many parents understand the role that too much cow's milk, a diet low in fiber and not drinking enough fluids have in contributing to constipation, they may have other children with the same diet who aren't constipated.

Part of the reason for this may be in your child's specific dietary needs. While he may drink an average amount of milk that isn't constipating for most children, it may be 'too much' for him.

In addition to your child's diet, the other main factor that contributes to constipation is having infrequent bowel movements. This often occurs after a child has had a large, hard and painful bowel movement, which can occasionally occur in anyone. After this, because he may associate having a bowel movement with pain, he will try to hold his stools. This creates a viscous cycle, where bowel movements are painful, so he holds them in, causing his stools to be even larger and harder, which causes more pain when it finally does pass. Many parents mistake the behaviors that children develop to hold in stool as straining to have a bowel movement, but they are usually stiffening their muscles or fidgeting as an attempt to hold their stool in and avoid a painful bowel movement.

Another factor that can contribute to constipation and infrequent stooling is having a bad experience with potty training.

Constipation is also often found in children with special needs, such as spina bifida, Down syndrome, mental retardation and cerebral palsy, and it can be a side effect of many medications.

Treating Infants with Constipation

Younger infants and newborns with constipation should be carefully evaluated by their Pediatrician. Poor feeding can lead to dehydration and constipation, and so an evaluation of your infant's feeding habits and to make sure that he is gaining weight normally is important.

It is important to remember that infants that are exclusively breastfed rarely become constipated. Infrequent bowel movements do not mean constipation if your infant's stools are soft when he finally passes one. Initial treatments usually include giving extra water or fruit juice once or twice a day. A common treatment used by parents is adding Karo syrup or other light or dark corn syrups to their infant's bottles of formula. While this is often discouraged because of the theoretical risk of botulism, the AAP reports that it is safe to do. If giving formula, changing to a soy formula can also be helpful.

Medications used to treat infants with constipation are usually limited to colace, maltsupex, lactulose and the occasional use of a glycerin suppository.

Treating Constipation with Dietary Modifications

The ultimate goal in treating constipation is for your child to have a soft bowel movement each day.

One of the main ways to prevent and treat constipation is by modifying your child's diet. This includes decreasing foods that are constipating, including cow's milk, bananas, yogurt, cheese, cooked carrots and other foods that are low in fiber. For children that drink a lot of milk, soy milk is a good alternative, as it is usually much less constipating than cow's milk.

Another important dietary change is increasing the amount of fiber in your child's diet. How much fiber does your child need? The usual recommendation is that children should have 5-6 grams of fiber plus their age in years each day. So a 4 year old should have 9-10 grams of fiber each day.

It can be helpful to learn to read nutrition labels to choose foods that are high in fiber. Fruits and vegetables, especially if they are raw and unpeeled, are good choices. Vegetables that are particularly high in fiber include beans, especially baked, kidney, navy, pinto and lima beans, sweet potatoes, peas, turnip greens and raw tomatoes.

Other foods that are good for children with constipation include vegetable soups (lots of fiber and added fluid), and popcorn. Extra bran can also be helpful, including bran cereals, bran muffins, shredded wheat, graham crackers, and whole wheat bread.

It is also important to increase the amount of fluids that your child is drinking. He should have a minimum of 2-3 glasses of water or fruit juices each day. Apple juice, pear and prune juice, or other juices high in sorbitol, are good choices.

Medications to Treat Constipation

Dietary changes take time to become effective, and until they do, your child will likely need to be on a stool softener. These medications are often used long term as maintenance therapy and are considered to be safe, effective and non-habit forming or addictive. You do want to avoid chronic use of stimulant laxatives, such as Bisacodyl, ExLax or castor oil. An osmotic type laxative, which works by drawing extra fluid into the colon to soften the stool, is usually safer for long term use.

Commonly used constipation medications include:

  • Milk of magnesia: contains magnesiuim hydroxide, an osmotic laxative with a chalky tasting that is not tolerated by all children. It may be helpful to mix with 1-2 teaspoons of Tang or Nestle Quick. Or mix into a milk shake.
  • Mineral Oil: a lubricant that you can mix with orange juice. May cause leakage and staining of underwear.
  • Docusate: available as Colace and Surfak, and is a lubricating laxative. Also available with a stimulant laxative in the combination medicine Peri-Colace.
  • Malt Soup Extract: or Maltsupex, it has an unpleasant odor, but is easily mixed with formula for younger infants.
  • Senokot: a stimulant laxative
  • Bisacodyl: a stimulant laxative available as Correctol and Dulcolax.

Other medications that are available by prescription include:

  • Lactulose: an osmotic laxative
  • polyethyline glycol 3350: a tasteless and odorless powder that can be mixed with water

In addition to a stool softener, it may also help to give added fiber by mixing Metamucil or Citrucel with 8 ounces of water or juice, or another bulk forming laxative or fiber supplements.

Keeping in mind the main goal of your child having a soft stool each day, your child may need to take his medication for a long period of time and often up to 4-6 months. One of the biggest mistakes parents make in treating their children's constipation is stopping their medication once they begin having soft stools. If stopped too early, your child is likely to relapse and become constipated again.

Instead of stopping the medication, if your child is regularly having loose stools or diarrhea, the dosage should be decreased by 25%. So if he is taking 1 teaspoon of milk of magnesia and is regularly having loose stools, then decrease it to 3/4 of a teaspoon. Don't make too many changes based on a single stool though.

Once your child is having regular soft stools, you can then talk with your Pediatrician about decreasing the dosages of the laxative that your are using. This is usually done gradually, often by decreasing the dose by 25% every 1-2 months. Stopping the laxatives too quickly can result in your child becoming constipated again. It is also important to continue your child's nonconstipating diet during and after the laxatives are stopped.

Medications for Constipation

Name Age Dose
Metamucil/Citrucel

(mix in 8oz water/juice)

2-5 years 3/4 teaspoon 1-3 times each day
6-11 years 1/2 tablespoon 1-3 times each day
>12 years 1 tablespoon 1-3 times each day
Mineral oil

(stir into oatmeal or mix with orange juice).

4-11 years 1-4 teaspoons ÷ 1-2 times each day
>12 years 1-3 tablespoons ÷ 1-2 times each day
Milk of magnesia

(mix with 1-2 tsp. of Tang or Nestle Quick or dilute in water or juice)

<2 years 2 ml/kg ÷ 1-2 times a day
2-5 years 1-3 teaspoons ÷ 1-2 times each day
6-11 years 1-2 tablespoons ÷ 1-2 times each day
>12 years 2-4 tablespoons ÷ 1-2 times each day
Colace Syrup (20mg/5ml) < 3 years 1/2 - 2 teaspoons ÷ 1-4 times a day
3-6 years 1-3 teaspoons ÷ 1-4 times a day
>6 years 1 —2 tablespoons ÷ 1-4 times a day
Maltsupex

(mix in 4-8oz water/juice)

<2 years 1-2 teaspoons ÷ 1-2 times each day
>2 years 1—2 tablespoons ÷ 1-2 times each day
Lactulose (10g/15ml) >6 months 1-2 ml/kg ÷ 2-3 times a day

Be sure to discuss it with your Pediatrician before you start your child on a new medication or if you are changing the dose of a medication that he has already been prescribed.

Disimpaction or Treating Acute Constipation

Because there is often a large, hard mass of stool that has 'backed up' in your child's rectum, before dietary and maintenance therapy will work, your child often has to have a 'clean out' or disimpaction. Fortunately this is rarely done manually. Instead, it is usually done (with your Pediatrician's supervision) using an enema or suppository. This can also sometimes be done by using high dosages of mineral oil (often up to 1 ounce per your child's age in years up to 8 ounces per dose for 2-3 days), or Miralax.

In general, children under 18 months of age can be given a glycerine suppository. Children between 18 months and 9 years can either be given a Pediatric Fleets enema or 1/2 of a Dulcolax suppository. Older children can be given a regular Fleets enema or a whole Dulcolax suppository.

You should avoid regular use of an enema or suppository. They are sometimes necessary as a 'rescue therapy' if your child hasn't had a bowel movement in 3-4 days, but if you are needing to use them regularly, then you likely need to increase the dosages of the maintenance therapy you are using.

Behavior Modification

Once your child's stools have become soft and regular, it is important to modify his behavior and encourage him to have regular bowel movements. This often includes having him sit on the toilet for about 10 minutes after meals once or twice a day. You can keep a diary or sticker chart of when he tries to have a bowel movement and/or takes his medicine, then offer a reward for regular compliance.

Complications of Constipation

In addition to pain, constipation can lead to anal fissures or tears in the skin around the rectum, bleeding, hemorrhoids, rectal prolapse, and impaction. Encopresis is another complication of chronic constipation and can lead to involuntary stool leakage secondary to the impaction of large masses of stool.

Conclusion

Although constipation is a chronic condition that is often difficult to treat, having painful bowel movements is not something that your child has to 'learn to live with'. In time, with proper dietary and medical interventions, your child should be able to have regular soft bowel movements.

If your Pediatrician is unable or unwilling to help treat your child's constipation, then you may want to seek additional help from a Pediatric Gastroenterologist. A referral to a specialist is also a good idea if your child has any warning signs of a more serious condition or if he isn't improving with your current therapies.

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