Constipation

Constipation in pediatrics is best divided into different age groups as the common causes of constipation between an infant, a toddler, and an older child vary considerably.

Let’s start with constipation in a baby or an infant under 6 months of age. It is very normal for breastfed and even some formula-fed babies to go up to 11 days without a poop. For me as a pediatrician to be okay with this, though, the baby needs to be otherwise feeding well, peeing and making a good amount of regular wet diapers, and growing normally. Theoretically, breast milk and formula are the perfect food for babies. If they want to absorb everything to help grow and just pee out the extra fluid, they will do it. If we start getting to Day 7, pediatricians will often have families come to clinic to make sure baby is doing those things as we discussed. If baby is looking uncomfortable, we may take a rectal temperature as well which will allow us to make sure the baby is not febrile (feverish) while at the same time causing a bit of rectal stimulation to help push a poop that is ready to go out.  Here are some good instructions for using the rectal thermometer to get the poop out:

To relieve constipation in your infant, you can stimulate the urge to push by inserting a rectal thermometer or a Q-tip coated in Vaseline or K-Y jelly. Gently insert into rectum 1/4 of an inch and run it around the ring of the rectum in a circular motion for up to 5 minutes.

Now for some babies, the extra iron needed due to prematurity or other concerns can sometimes cause constipation with harder and darker stools. For this, we will often recommend a small amount of pear or prune juice added to the baby’s diet to act as a gentle/natural stool softener. 

When we introduce solid food around 4-6 months of age, older infants can see an increase in harder stools during this introduction. I mean, the more adult food, the more adult-looking poops, right? But there are certain foods that historically have been given to babies as “baby food” such as baby cereals, sweet or regular potatoes, or simple starchy baby crackers. These guys, or any heavy starches for that matter, will just suck up water and cause poop to harden and slow down. So if you see your kiddo’s poop turning harder than guacamole after introducing solid foods, try to hold off on starchy foods and try to give more green veggies and healthy proteins. 

For kids who are potty training age (2-4 years), constipation is usually hydration and/or diet-related with kids loving simple, easy-to-eat on-the-go starchy snacks or fruits like bananas. Often if we increase hydration or decrease these starchy foods, poop will soften. If increasing hydration with water does not get the poop softer, prune or pear juice can be great to just have around the house for when you see your kiddo’s poop becoming harder than guacamole; a few ounces of these juices served a little warm is sure to soften things up.

For older children with chronic constipation (poops always harder than guacamole or always having to push to get poops out), we again start with dietary changes and hydration. If the kiddo is already complaining that it is hard to poop or that it hurts to poop, we are a bit too late in terms of dietary changes, and we rely on glycerin suppositories to help get the initial hard stool out and then a combination of stool softeners like MiraLax and gut motility agents (such as senna) to help move and squeeze the poop out. These medicines have a big range of dosages that are tailored to each child based on a child’s size and constipation history. Because of that before starting MiraLax discuss the right dosage with your kiddo’s pediatrician to get accurate weight-based dosing recommendations. 

If a kid’s poops are still hard even with consistent dietary changes, we may need to talk about stool withholding and encopresis. Stool withholding is considered more of a behavioral and psychological barrier that some kiddos have with the idea or feeling of stooling, and they will, in turn, hold their poop in as long as possible to avoid going number 2. For treating this, we often keep stools soft with MiraLax and diet changes while talking with a behavioral specialist or GI (gastrointestinal) specialty team to get to the reasons why the kiddo is holding onto their poop. Are they just more interested in doing something else like playing games? Then we would start an alarm every 2-3 hours to sit on the potty no matter what. Is it because they had one bad poop that really hurt, and now they are scared? We can work with the GI team to make sure the poop is soft for a long time and make for effort-free poop potty time. Or do we think that they are having trouble sensing when they need to go or misinterpreting the body signals for when to go poop ? If that is the case, we will often still try to soften the stools and then make sure the kiddo does not have what is called encopresis. 

Encopresis is when a kiddo has so much poop in their colon and most notably the rectum, that the end part of the rectum widens so it can’t give the normal I-have-to-go-number-2 signals to the body. This is a much harder-to-treat entity as it has often been going on for a long while, and there is often a very strong psychological component to it. We often work hand in hand with GI and psychology teams for long-term care to help the colon maintain a normal stool burden and shrink the rectum to the correct diameter again so it can give off the proper body signals for when to go potty.