Constipation: the poop on poop

I get many questions from parents about managing constipation.  Although many children occasionally have a harder than usual bowel movement, having hard poops day after day are not normal or OK. Left untreated, constipation can lead to long term difficulties with passing bowel movements.  A child may even develop a pattern of withholding, which can lead to encopresis, the involuntary leakage of bowel movements (sometimes called "soiling". Fortunately, treating constipation in preschoolers can prevent problems later on!  Here's a plan that will help most children:

First, a definition:

Constipation means that your child’s bowel movements are HARD.  Hard bowel movements are uncomfortable to pass, so many children begin to hold them in.  That makes the constipation worse.  If left untreated, many children with constipation will begin to have stomach aches, irregular appetites, and may even have soiling accidents.  So the time to deal with constipation is as soon as you notice hard bowel movements!

Almost all preschool age children have a soft BM every day.  If your child is skipping days, or if her bowel movements are huge, she may be holding them in.  Withholding can lead to constipation, so talk to a knowledgeable health care provider.

Children who become constipated are helped by changing their diets and fluid intake.  More exercise is usually helpful, as is having a regular quiet “sitting time” a few times every day.

Here are some suggestions that will make a difference.

What goes in helps what comes out: a child who is constipated should:

Drink AT LEAST 24 ounces of fluid every day. The best fluid is water.

If your child is drinking 16 ounces of milk he should drink an equal amount of water.

Eat at least 4 1/2 cup servings of foods high in fiber every day: whole wheat bread or pasta, brown rice, beans, cooked green vegetables, oatmeal or cereals with bran. (If your child is witholding bowel movements, don't increase the fiber until he is having daily bowel movements, or you will make the problem worse)

Avoid “white” foods such as rice, bananas, white flour products. Consider eliminating all dairy for two weeks to see if constipation improves.

Eat fresh fruits, especially berries, and vegetables, especially corn, green beans, peas and beets are great. Dried fruits, especially prunes are helpful. 

Forget low fat!  The best source of fat is olive oil.  One tablespoon per day minimum--it goes on everything.

Less dairy, more fiber will help

Decreasing or eliminating cow’s milk often decreases constipation. Some children will accept fortified almond, hemp, or soy milk instead of dairy. 

It is very important that your child get Calcium (800 mg) and Vitamin D (400 mg) everyday, which is found in fortified cow’s milk. If you cut out dairy, check labels for that.  Increased fiber can interfere with calcium absorption.

Add 1 Tablespoon or more of bran or ground flax seeds to any foods you can.

If your child won’t eat many high fiber foods, it’s better to give him supplements than it is to be in a constant battle at mealtimes.  Most children like the “fiber gummies” or similar candies, but be sure to keep them out of reach--too many will result in a bad stomach ache! 

Daily Sitting 

All toilet trained children need daily “Sitting Time” when they relax and sit on the potty or regular toilet with their feet supported.  The best time to do this is 15-20 minutes after a meal, two or three times a day. For most children, morning sitting time after breakfast is ideal, even if you have to get up earlier.  Most children prefer to "go" at home.   It’s OK if your child doesn’t “go”.  Building good habits is most important. Encourage your child to go by staying with him and reading or giving him a small toy to play with.  Five minute sits are enough for most children.

Natural Laxatives are sometimes helpful

The first laxative to try is prune juice. Some children will drink it straight or mixed with other juices.  Or you can mix it with water, add 1/2 teaspoon of lemon juice. Experiment!

Avoid any “natural” laxative teas that contain senna, unless specifically recommended by your health care provider. Senna can cause uncomfortable cramping if not used in the correct dose.  If you want to try any herbal tea, take it yourself for several days to test the effect.

Medical Laxatives may be needed

Polyethylene glycol 3350 powder (Miralax) is often recommended for children and adults because it mixes easily with fluids and has no added taste. is quite safe and is not absorbed into the body.  Although you can buy PEG without a prescription, it is a medication and you should talk to your child’s health care provider about using it regularly.

Pedia-lax chewable tablets or Phillips Milk of Magnesia are osmotic laxatives that work well and act more quickly than PEG

Glycerine suppositories (child size)  may be helpful for a child who is holding back a BM and and is very uncomfortable. You won't need to use these for most constipation, but sometimes they can really help.  Check with your child’s health care provider before using. 

Stimulant laxatives made by ExLax or Little Tummies may be recommended but shouldn't be started unless they are part of an overall plan recommended by a knowledgeable health care provider.

Probiotics

Probiotic supplements seem to be helpful to children with gastrointestinal difficulties.  They are safe and worth trying.  Look for products containing Lactobacillus CG, the type of probiotic that has been shown to be most effective.

“Getting Over” Constipation

A child who has become constipated may have a generally slow digestive system.  If that is the case with your child, he will have a tendency to become constipated when his schedule changes or he is away from home.  Many children become constipated when they start school and are too busy to take the time to sit and relax.  Help your child to notice that it feels good to have a soft BM every day and not so good to have one that’s hard.  Teach him that it is important to drink water, tun around and play, eat good foods, and relax to sit.  That’s good advice for any child, and even better advice for a child who has had hard BMs.

Meg Zweiback is a pediatric nurse practitioner and specialist in toilet training, constipation, encopresis and enuresis. This article is based on a talk she gave at the American Academy of Pediatrics winter meeting in San Francisco, December 2012.

Meg is available for consultations in person or by phone about toilet training, constipation, soiling, encopresis, and many other childhood issues.