Constipation is a problem that affects most people at some time or another.  It certainly is one of our top questions posed by parents.  Sometimes parents misinterpret grunting, color changes of the face, and less than daily stools as constipation.  While these behaviors may be associated with constipation, having any of them does not make a person constipated.  In infants on a liquid diet, any formed bowel movement may be constipation, but as long as the stool is soft, they are not constipated.  Breast fed infants sometimes wait 2 weeks between stools... this is normal as long as the stool is soft when they finally go.  Older infants and children (and adults) may be constipated if the stools are hard and formed (especially small balls or large masses) more than ¼ of the time, fewer than 2 bowel movements in a week, or there is straining during most bowel movements.  Blood on the toilet paper is common with hard stools.  Abdominal pain and loss of appetite are other signs that may be associated with constipation.

What causes constipation?

Most cases of constipation are caused by a problem of bowel function, not a structural problem.  Some causes of constipation in children and adults include:

• Inadequate water intake
• Inadequate fiber in the diet
• A disruption of regular diet or routine, traveling
• Inadequate activity or exercise or immobility
• Eating large amounts of dairy products
• Stress
• Resisting the urge to have a bowel movement, common during potty training and starting school (toddlers gain the ability to hold in a bowel movement BEFORE they are potty trained!)
• Hypothyroidism
• Medicines (especially strong pain medicines, such as narcotics, antidepressants or iron pills—NOT iron in formula or normal foods)
• Eating disorders
• Irritable bowel syndrome

What can be done to prevent constipation?

• Diet:  Encourage a well-balanced diet with plenty of fiber.  Good sources of fiber are fruits, vegetables, legumes and whole-grain bread and cereal (bran).  Fiber and water help the colon pass stool.  Most of the fiber in fruit is found in the skin.  Fruits with edible seeds, such as strawberries, have the most fiber.  High fiber foods include watermelon, grapefruits, grapes, peaches, and plums.  There are now fiber gummies available for children who need extra fiber in their diet.  Adding flaxseed to recipes can be very beneficial for both constipation and adding beneficial omega acids.   
• Water:  Drink plenty of water.
•  Things to avoid:  Avoid constipating foods, such as excessive dairy.  Other liquids that contain caffeine, such as coffee and soft drinks, increase the amount of water loss, and should be avoided until bowel habits return to normal.
• Exercise regularly.
• Good toilet habits:  Go to the bathroom when you have the urge.  Don’t wait!  Encourage your child to sit on the toilet after meals, because the bowels are stimulated after eating.  If a child’s feet cannot touch the floor, sometimes adding a stool can help.  Put books or magazines in the bathroom so a child won’t get up prematurely from boredom.
• Don’t require toileting when potty training.  If your child wants a diaper for bowel movements, put a diaper on.

How can we treat constipation at home?

• Drink two to four extra glasses of water a day.
• Try warm liquids, especially in the morning.
• Add fruits and vegetables to the diet.
• Offer prunes and/or bran cereal.
• Castor oil is an old fashioned remedy (not great tasting) but it does work if you can get your child to drink it. Do not use it excessively.
• Prunes, apples (especially the skin), carrot juice a few times a day, chopped beets, and garlic are foods that have beneficial properties for relieving constipation.
• Flaxseed (1tbsp with water after a meal) and sunflower seeds (only in children not at risk for choking) are also helpful.
• Psyllium seed is a soluble fiber with proven effectiveness in adults, though there are no studies available in children.  It works by absorbing water and swelling in the gut to add bulk to the stools.  It must be taken with a large amount of water.  It may cause gas, abdominal pain, diarrhea, nausea, and constipation (from too much bulk).
• Cascara sagrada and senna are both stimulant laxitives.  They are approved for use in anyone over 2 years of age.  They should not be used long term because they are stimulant laxatives.  Senna has been associated with bad diaper rash.
• Miralax (polyethelyne glycol) is available over the counter.  It is not a stimulant laxative and is completely safe to use long term.  See the Miralax page for more information.
• Quick relief:  For quick relief, rectal stimulation with a gloved finger coated in petrolatum jelly or a rectal thermometer or a glycerin suppository helps most infants.  A pediatric Fleets enema offers quick relief for many children.  Older children may require the adult sized enema.  There is some evidence that anything per rectum is counter-productive in older children because they associate it with pain and then hold the next stool in for fear of pain again.  We attempt to avoid the enemas in most children because they are very uncomfortable and usually result in fear of the next bowel movement, stool holding (infants learn this behavior even before being potty trained), and worsening constipation.

When do I need to take my child to be seen?

If your child has blood streaked stools or blood on the toilet paper associated with constipation cover the rectal area with petrolatum jelly for the next few days to help with the skin healing.  If the bleeding becomes severe or more than just streaking, call the office for an appointment or go to the ER if child is excessively irritable, pale, lethargic, or other concerns.

If the constipation is lasting more than 2 weeks, please call the office during regular business hours for an appointment.