Constipation
What Is Constipation?
When we talk about constipation in children, it’s natural to think of it simply as going a few days without a bowel movement. There’s more to it, though! Constipation can look like any of these:
Infrequency: Ideally, we want daily stools. When they’re occurring every 3-4 days, stool clogs up the intestines and is harder to eliminate.
Hard Consistency: Having very firm stools (either large and rock-like, small and pebble-like, or lumpy snake-like). Our goal is a soft-serve ice cream texture.
Straining & Prolonged “Sit Times:” Often, constipated children have to try harder to get stool out. They may sit on the toilet for >10 minutes at a time, or make lots of noises and get red in the face as they try to go.
Blood-Streaking: With constipation, harder stools will have a harsher effect on the anus as they’re coming out, sometimes causing tears and leading to mild bleeding. Constipation over a longer duration can lead to hemorrhoids, which are swollen blood vessels, and these can also sometimes bleed if they’re really irritated.
What Causes Constipation?
How Young Can Children Get Constipation?
Quite young! The one differentiator I like to make in younger infants is that it can be completely normal to go a few days without stooling in this age group after the 6-8 week mark, especially if they’re breastfed (since breast milk creates little undigested waste). If the stool comes out soft and mushy in spite of only happening every 3-4 days in a breastfed child, this is OK.
How Do I Know When Constipation Is Getting Severe?
Mild constipation is less consistent (e.g., some bowel movements are soft and frequent while others have a firm texture and come less often) and have symptoms only when your child is using the restroom. As it worsens and stool accumulates in the intestines, it causes issues higher up and lead to symptoms outside of bowel movements. This can look like:
Chronic Abdominal Pain: Nausea, vomiting, decreased appetite, or vague abdominal discomfort that doesn’t seem related to a specific trigger.
Diarrhea / Encopresis: This is such a counterintuitive concept, I know! How does a child with constipation have diarrhea? Think of your intestines as a shower drain where a hair clog is forming. As the clog gets larger, all that can escape is water, and even that is a slow trickle. Anything thicker like shampoo residue, shampoo, or additional hair gets stuck at the clog. We can use this as an analogy for constipation. As stool builds up, only the most liquid stool (i.e., diarrhea) can creep by larger stool balls that have gotten stuck. Hence, severe constipation can (and often does) present as diarrhea.
Fecal Smearing / Streaking: When a large amount of stool has built up, sometimes it starts to creep out without your toddler’s awareness (e.g., skid marks in their underwear) or it can leak out when they pass gas.
What Can I Do To Prevent Constipation?
When Should I See My PCP?
Anytime! When constipation is mild, it can be helpful to have a chat with your Pediatrician about how to manage it in that moment so that it doesn’t worsen and require medical therapy. When constipation is severe, definitely see your Pediatrician - it gets more challenging to manage the farther along it gets.
What Medical Treatment Options Are There?
Other treatment options are multifold. While some are available over-the-counter, others require scripts. I always recommend talking to your doctor before starting medicine, since a conversation about dosing, side effects, age-appropriateness, and duration of therapy is important.
Osmotic Laxatives: These draw water from the intestine into the stool so that it’s softer to expel. They’re called “mushers.” Most commonly, you’ll see PCPs offer Lactulose in infants, and Miralax (or Milk of Magnesa / Magnesium Citrate) in toddlers and older children. While there’s been conversations in recent years about adverse effects of Miralax, they’re not supported by evidence. Miralax is one of the safest constipation medications we have.
Stimulants: These “stimulate” the intestines to move stool more effectively. They’re called “pushers.” Some examples are Senna / Ex-Lax and Bisacodyl. A side effect of these medications is abdominal cramping. In moderate to severe constipation, you often need a “musher” from the first category and a “pusher” as described here.
Stool Softeners: These make the stool softer in a slightly different way than the osmotic laxatives listed above. An example is Docusate / Colace.
Enemas / Rectal Suppositories:
An enema is fluid that’s inserted into the rectum to stimulate a bowel movement. These are used infrequently and not meant for routine therapy, since they carry risks of disturbing your gut’s healthy flora and causing electrolyte imbalances. However, they can be helpful in a kid with moderate to severe constipation who needs a “clean out.”
A rectal suppository (typically glycerin in infants) is a tablet that is inserted into the rectum to stimulate a bowel movement. I recommend against using these routinely, as well, since you don’t want your child to become dependent on this stimulation to stool. However, in an infant where we’re working on dietary measures and on Day 4-5 without a stool, I give the OK to use it.
Fruit Purees / Juices In Infants: In infants, the medication options listed above are limited to mainly Lactulose +/- Miralax depending on age. As such, sometimes we’ll trial fruit purees or fruit juices (diluted with water and in smaller volumes like 2-3 ounces daily - this is the only time we’re OK with juice at this age, and it’s meant to be a short-term fix!). You’d stop once stools are normal again. I say to stick with your “P” or pitted fruits (peaches, pears, plums, prunes) as a guide for what fruit to choose, though apples work as well.
What’s a “Clean Out?”
A clean out is usually a more aggressive medical management of constipation using either very high doses of a medication (such as Miralax) or a combination of therapies (such as Miralax + Senna +/- an enema). They can be done at home under detailed instruction from a clinician (usually on a weekend, since it’s a messy few days) or in the hospital for more severe cases in consultation with a GI specialist.
Constipation is often a long-term issue to manage, and requires chronic management.
How Long Will My Child Be On Treatment?
While a “clean out” is usually over 1-3 days, chronic constipation requires multiple weeks to months of diligent management to fully resolve. Why is this? Think about a hair scrunchie. Over time, the more you use a scrunchie, the looser and less elastic it gets. The same concept is true for stool in intestines. The more stool builds up, the more your intestines stretch out, and the less sensitive they are to knowing when they’re “full.” It takes time to reset this whole system after a long period of constipation, even once the majority of the stool is emptied. So, I encourage my families to stay on Miralax for at least 3 months, even when it seems like their stool is “normal,” to ensure that there’s no regression once medication is discontinued.
