INTRODUCTION: Evaluating bowel movements are one of the “bread and butter” jobs of a pediatrician. All children have them and the concern about their frequency and consistency account for a significant proportion of sick visits and parental inquiries.
DEFINITION: One of the greatest difficulties in helping families with constipation is in defining the terms. After all, most families do not use the term bowel movement to describe human excrement. Whether you use the term poop, BM, kaka, kakee, doody, booboo, gedolim or number 2, is probably more cultural than medical. The consistency and frequency of stool define constipation. One is constipated only if he or she is having harder and less frequent bowel movements. The six-week infant who goes from 5 loose stools a day to 1 loose stool every 2-3 days is not constipated; rather he or she has simply developed a different stool pattern. Similarly, the toilet trained 3 year-old who starts having firmer bowel movements but continues to have them twice a day would also not be defined as constipated.
WHAT CONSTIPATION IS NOT:
- A changing stool pattern. Stool production depends on age, teething (with increase saliva production), fiber content of food and gut maturity, all of which change with time. It is imperative to allow the gut to reestablish a new pattern naturally and not artificially.
- Straining. All infants strain and may turn red and look uncomfortable when having a bowel movement. For those of you who have ever had the pleasure of having a bowel movement on a bedpan, you may have realized that while sitting on a toilet, we utilize pushing against the floor and gravity to help in the process of producing a bowel movement. Infants cannot do either and so appear to strain even when producing normal soft stool.
- Gassiness. In older children, gassiness is often a function of diet. In infants, it relates more to an immature gut getting used to new foods.
NORMAL STOOLS: There is no such thing. What is normal for Sean may not be normal for Becky. Each child develops a pattern that is normal for him or her and that pattern may change many times over a lifetime.
HUMAN WASTE PRODUCTION: The unfed gut or GI tract produces many gallons of mucus on a daily basis. This mucus may represent watery secretions, broken cells or breakdown waste products of gut cells. This mucus is greenish-white in color and of no particular consistency. Once food is introduced into the gut, additional waste products are produced, and depending on what was eaten, the stool color may vary from green to yellow to brown to black. Frequency and consistency depends on:
- The feeding frequency
- The amount of undigested material
- The transit time in the gut
THE GASTRO-COLIC REFLEX: Entrance of food into the stomach causes a reaction in the latter part of the gut, causing expulsion of stool contents. This ‘gastro-colic’ reflex is responsible for the sensation all adults have, of having to ‘have a bowel movement’ as soon as a meal is completed. Infants have the same sensation; however, they cannot control their bowels and therefore, frequently have bowel movements following a feeding. Parents often utilize this reflex in toilet training because one can expect a child to ‘need to go’ after a heavy meal.
THE ROLE OF UNDIGESTED MATERIAL OR FIBER: The hue and cry over fiber is really a matter of regulating the amount of undigested material in the diet. Certain foods such as breast milk are well absorbed with little waste product. Others like fruits with peels and certain vegetables are not well absorbed at all. This undigested material serves to ‘push along’ the stool and determines how long the stool is exposed to the gut wall. Less fiber >> less undigested material >> slower gut motility (movement) >> more absorption >> harder stool.
THE ROLE OF GUT TRANSIT TIME: Undigested food reaches the rectum approximately 9 hours after it was swallowed. Things that slow transit time include absence of food or fiber, an abnormal gut nervous system, certain congenital diseases, blockage and family history of constipation. When transit time is slowed, infrequent stools with decreased water content are the result because of increased time for water re-absorption along the gut.
PRACTICAL NATURAL STEPS IN DEALING WITH CONSTIPATION: It really depends on the 3 F’s: food, fluid and fiber.
- Make sure your child is getting adequate nutrition. Too little in, means too little out. So make a list of everything he or she eats in a day. Sick children eat less and drink less. If your child has not been eating well, expect the stools to be harder for a while and this problem will resolve on its own once he or she starts eating better.
- How much fluid is your child getting? Infants need only breast-milk or formula until 4 months of age and will be averaging 24 oz by one month and 30-36 oz by 4 months. Older babies who have begun solid foods frequently do not take sufficient fluid, producing harder stools with less fluid content. In the summertime, the fluid requirement is increased and when not adequately provided also leads to harder stools. Gastroenterologists recommend 4 cups of liquid per day for toddlers and up (8 cups for adults).
- What is the fiber/bulk content? Children from 6 months and up require appropriate fiber content. This can be provided with cereal, vegetables and fruits and is rarely a problem in the average diet. Problems arise most commonly in the toddler who is taking less total food and frequently does not like vegetables. This problem can be remedied by using cereals and other foods that are high in fiber.
HIGH FIBER DIETS: The following is a partial list of the categories of foods and specific food items that should be included in every diet. High fiber diets are not only helpful in reducing the problems associated with constipated and hard stools (discomfort, hemorrhoids, abdominal pain, etc.) but also some studies suggest a possible decrease in colon cancer in adults maintaining high fiber diets.
- Beverages: Fruit juices (especially prune, pear, grapefruit, apricot and orange juice with pulp). A significant proportion of the population is intolerant to apple juice and these people can learn to adjust their stool consistency by manipulating their dietary intake of apple juice. In general, milk tends to be very constipating. When there is a tendency toward constipation, it is often helpful to eliminate or significantly reduce the dairy intake. Should you need to eliminate or reduce dairy, please make sure that your child gets an adequate amount of calcium (600 mg under 10 years and 1200 mg over 10 years) and Vitamin D (400IU in all ages). The easiest is to take a calcium/Vitamin D supplement. Options for our patients include calcium/Vitamin D pills, Adora chocolate chews (in milk and dark chocolate), Viactiv chewy chews (sometimes too gooey for many children) and Caltrate fruity chews.
- Bread and crackers: Whole grain breads especially whole wheat, rye, graham, oatmeal and cracked wheat are excellent sources of fiber.
- Cereals: All Bran™, Bran Flakes™, Raisin Bran™, Wheaties™, Shredded Wheat™, Granola™, Grape Nuts™, Multigrain Cheerios™ (but high in sugar).
- Fruits: Fruits with peels are the best:
- Fresh fruits including, apples, berries, grapes, apricots, plums, pears and nectarines.
- Dried fruits including, raisins, apricots, figs and dates.
- Vegetables: Almost all vegetables are helpful.
- Raw vegetables including, carrots, celery, chard, salad greens and tomatoes.
- Cooked vegetables including, corn, green wax beans, peas and spinach.
- Miscellaneous: Popcorn, nuts and coconut.
MEDICAL TREATMENT OF CONSTIPATION: Most children with hard stools require nothing other than diet modification. Occasionally, we will recommend one of the following additional therapies and it is important for you to understand how they work. Usually, these are just temporary measures and are no substitute for a proper diet
- Bulk laxatives: Work by pushing things through the gut.
- Malt supex – 1 or 2 teaspoon. added to formula 2 or 3 times a day provides increased bulk for the infant under 4 months.
- Metamucil - In older children, traditionally, Metamucil™ or any of the generic substitutes for psillium seed was used in any amount necessary to produce soft stools (begin with 1 tablespoon twice a day).
- Benefiber - More recently, soluble fiber products like Benefiber (or its generic alternatives) have replaced psillium seed because they have no taste and can be slipped into water or juice to provide that added kick. It is imperative when using bulk laxatives to drink sufficient liquid otherwise the fiber cakes up like cement in your child’s innards.
- Stool softeners: Work by increasing the water content in the stool.
- Karo syrup – (Over the counter in the pancake syrup section) Karo syrup is a non-absorbable sugar that holds onto water in the gut, and thus, softens the stool. Start with 1 tablespoon per day in the formula, it is frequently helpful in breastfeeding children who have added a formula bottle or when making the transition from formula to solids.
- Colace – (Over the counter in the stool soften aisle) In older children and teens, colace and pericolace function in much the same manner, however, we usually suggest these only as additional aids in long-term therapy.
- Lactulose (By prescription only) works similarly and in doses of 1-2 tablespoon per day can be used for many months to help keep things moving. It is particularly useful in the toilet training child who needs a little extra help to avoid hard painful stools during this critical period of development.
- Gut stimulants: Work by mechanically stimulating the gut.
- Rectal stimulation - Inserting anything into the rectum (Q-tip or thermometer) stimulates the movement of stool and frequently succeeds in producing a bowel movement.
- Glycerin suppositories – Provide gentle stimulation for the parent who is unable to provide direct stimulation to an infant under 4 months of age. Be wary about excessive rectal stimulation. It is not a good idea for a child to get used to having something placed in his rectum in order to have a bowel movement. If you are using any suppository more than 1-2 times a month, we should be notified.
- Dulcolax (biscodyl) - When more intense stimulation is required in a child who is taking solid foods over 6 months of age, dulcolax is often recommended. We generally will use ½ of a 10 mg suppository in children between 6 months and 3 years and a full suppository over age 3 years. Suppositories work in 30-40 minutes. Dulcolax also comes as a pill. The rule with the pills is – 1 in the AM for a BM in the PM.
- Lubricants: Sometimes a little greasing helps oil the engine. Mineral oil in increasing amounts until results are achieved (from 1-2 teaspoon per day works by coating the gut wall and preventing absorption of water. Mineral oil should be not be used in children less than 6 months. Kondremul is a flavored mineral oil available for children.
- Miralax – When all natural approaches fail, we will often suggest Miralax. Although it is available now over the counter, we recommend an in office visit for any child whose parents are thinking about using Miralax. Miralax is so termed, because it is a miracle laxative. It has little or not taste, is not habit forming, nor does it cause tolerance and the need for increasing doses (you can use it for a year or more without developing tolerance), and does not cause cramping. The key to using Miralax is using an adequate amount to help clean out the gut and then a maintenance dose to keep things running smoothly.
A SUMMARY OF THE FIRST STEPS
- Eat the right foods – Monitor labels for fiber content. Drink at least 4 cups of water per day and eat almost all vegetables and fruits with peels
- Sit regularly – Making the most of the Gastro-Colic reflex is a critical piece. Since most school aged children have an aversion to sitting on the toilet in school (modesty, smell, teasing), it is helpful to have him/her sit for up to 10 minutes about 30 minutes after dinner when the urge is greatest.
WHEN IS IT MORE THAN JUST CONSTIPATION
- When the “first steps” are not working - If these steps do not help your child, please schedule an appointment to help develop a Constipation Care Plan that can work for him/her.
- In an infant, if it is impossible to produce a bowel movement without rectal stimulation. There is a medical condition called Hirschprungs Disease in which children are born without adequate nerve supplies to a part of the rectum so there is a physiologic reason not to be able to produce a bowel movement.
- When you are seeing “tire-tracks” in your child’s underwear. Encopresis (where there is such significant backup, that the child stains or leaks around the plug) affects many school aged children. The problem is that they are so busy “doing things”, that they don’t have time to sit and so they eliminate a smaller and smaller percentage of their waste products. Encopresis can be a serious and painful condition and always requires both a clean out and maintenance program. Frequently, we will use x rays to correlate with our clinical exam in monitoring the success of an encopresis treatment program. Occasionally, we will send your child to a “poop psychologist” to help in implementing the behavioral changes necessary to successfully treat encopresis.