Constipation is a common problem for infants and children, and accounts for almost 3 percent 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 in normal health. 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, having a poor appetite, or being severely constipated since birth.
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 likely 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 infants who are exclusively breastfed only have a bowel movement once every week or two.
One of the things that is frustrating for parents is trying to understand the causes for their child's constipation. Although some 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 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 to anyone. After this, because he may associate having a bowel movement with pain, he will try to hold his stools. This creates a vicious 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 usually they are actually stiffening their muscles or fidgeting as an attempt to hold their stool in and avoid a painful bowel movement.
Another common cause of constipation and infrequent stools is having a bad experience with potty training.
Constipation is also often found in children with special needs, such as spina bifida, Down syndrome, and cerebral palsy, and it can be a side effect of many medications.
Constipation Treatments for Infants and Children
Younger infants and newborns with constipation should be carefully evaluated by their pediatrician. Poor feeding can lead to dehydration and constipation, so an evaluation of your infant's feeding habits and making sure that he is gaining weight normally is important.
Also, remember that infants who are exclusively breastfed rarely become constipated. Infrequent bowel movements do not mean constipation if your child's stools are soft when he finally passes one.
If your older infant truly is constipated, initial treatments usually include giving them extra water or pasteurized, 100-percent 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 sometimes be helpful.
Medications used to treat younger infants and children with constipation are usually limited to colace, maltsupex, lactulose, and the occasional use of a glycerin suppository.
Dietary Treatments for Constipation
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 who drink a lot of whole cow's milk, low fat milk and soy milk are good alternatives, as they usually much less constipating than whole 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 was that children should have 5 to 6 grams of fiber plus their age (in years) each day. So, a 4-year-old should have 9 to 10 grams of fiber each day. However, some experts think kids need even more fiber than that, and the latest fiber recommendations say that children should get about 14g of fiber for every 1,000 calories they eat.
It can be helpful to learn to read nutrition labels to choose low-fat 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 such as kidney, navy, pinto and lima beans (especially baked), 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 to 3 glasses of water and some fruit juice each day. Apple, pear, and prune juice, or other juices high in sorbitol, are good choices, as long as they are pasteurized and 100 percent fruit juice -- not a fruit drink.
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 remedies include:
- Polyethylene glycol (Miralax): a tasteless and odorless powder that can be mixed with water and which is now available over-the-counter without a prescription
- Milk of magnesia: contains magnesium hydroxide, an osmotic laxative with a chalky taste 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 (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
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. Many fiber supplements are now available as chewable tablets for kids, and there is even a fiber gummy supplement.
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 -- often up to 4 to 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.
If your child is regularly having loose stools or diarrhea, the dosage should be decreased by 25 percent iInstead of stopping the medication completely. 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, however.
Once your child is having regular soft stools, you can then talk with your pediatrician about decreasing the dosages of the laxative that you are are using. This is usually done gradually, often by decreasing the dose by 25 percent every 1 to 2 months. Stopping the laxatives too quickly can result in your child becoming constipated again. It is also important to continue your child's non-constipating diet during and after the stool softeners are stopped.
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 Acute Constipation Treatments
Because there is often a large, hard mass of stool that has 'backed up' in your child's rectum, your child often has to have a 'clean out' or disimpaction before dietary and maintenance therapy will work. Fortunately, this is rarely done manually. Instead, it is usually done using an enema or suppository (with your pediatrician's supervision). This can also often 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 polyethylene glycol (Miralax).
In general, children under 18 months of age can be given a glycerine suppository, but only under the direction of your pediatrician. Children between 18 months and 9 years can either be given a Pediatric Fleets enema or half 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, though. 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 stool softeners you are using.
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 5 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. Don't try to force him to sit until he has a bowel movement, though.
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.
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 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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