Poop problems- Part 1: Constipation in Children

Before you became a parent, you never really thought much about poop. But after becoming a parent now, you are so much into it that you can even discuss it over anytime, including meal time. We as pediatricians have many conversations with parents, about poop, the 2 major hot topics being constipation and potty training.

1st part of the poop problem series will cover about constipation and the next would address potty training.

One of the most common complaints we hear in clinics today- doctor, my child is constipated (> 50% of the kids coming to my clinic are constipated).

To first know what is constipation, you must know the normal bowel pattern.

Normal Patterns and Stools:

• Breastfed and Over 1 Month Old. Its normal to pass after every feed (upto 8-12 times in a day). However, stools every 4-7 days that are soft, large and pain-free can be normal too. Before 1 month of age, not stooling enough can mean not getting enough breast milk. After that, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days and some actually decrease to once a week! As long as these less-frequently-pooping babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then enjoy the less frequent diaper changes. As long as what comes out in the end is soft, then your baby is not “constipated” but only has a “decreased poop frequency.”

• Straining in Babies. Grunting, turning red, crying or straining while pushing out a stool is normal in young babies. It’s hard to pass stool lying on your back with no help from gravity. After all this effort, the poop is soft (normal poop should always be soft), then this behavior is normal. Some babies poop effortlessly and this, too, is normal.
• Brief straining under 10 minutes can occur at times at any age.
• Large Stools. Size relates to the amount of food eaten. Large eaters have larger stools.

Remember, bowel patterns vary from child to child just as they do in adults. What’s normal for your child may be different from what’s normal for another child. Most children have bowel movements 1 or 2 times a day. Other children may go 2 to 3 days or longer before passing a normal stool. For instance, if your child is healthy and has normal, soft stools without discomfort or pain, ­having a bowel movement every 3 days may be her normal bowel pattern.

Constipation is rarely a problem in younger infants < 6 months (if present, might indicate some medical issue, so visit your doctor for evaluation). It however may become a problem when your baby starts solid foods.

True constipation in general is more common in formula-fed babies than breastfed babies.

So, what is constipation?

Most parents feel that constipation is not passing stool everyday. But that’s not only the case.

Constipation can be either of the symptoms:

 

• Many days without normal bowel movements, 3 or more days without passing a stool (Exception: Breastfed and < 6 month old)
• Pain/crying when passing a stool, hard, dry stools that are difficult to pass and may contain blood even if occurring daily
• Can’t pass a stool after straining or pushing longer than 10 minutes or
• Stomach aches, ­cramping, or nausea and poor appetite (any belly pain from constipation comes and goes. Most often, it is mild.)
• Rectal bleeding from tears, called fissures
• Soiling
• Cranky behavior/excessively fussy baby

You may also notice your child crossing her legs, making faces, stretching, clenching her buttocks, or twisting her body on the floor. It may look as if your child is trying to push the stool out, but instead she’s trying to hold it in.

These signs can all suggest actual constipation.

What causes constipation?

PC: Times of India

It occurs for a variety of ­reasons.

• Diet. Changes in diet, or not enough fiber or fluid in your child’s diet.

1. High Milk Diet. Milk and cheese are the only foods that in high amounts can cause constipation. It causes hard pale stools.
2. Low Fiber Diet. Fiber is found in vegetables, fruits and whole grains. Fiber keeps stools soft, bulky and easy to pass. A low fiber diet causes hard, small stools.
3. Low Fluid Intake. Children don’t drink enough fluids, so this can also cause stools to be dry and harder to pass.

• Withholding. Your child may withhold to avoid pain from passing a hard stool, which can be even more painful if your child has a bad diaper rash or anal fissure/tear.
• Poor physical activity: Exercise keeps the bowel from slowing down.
• Illness. If your child is sick and loses his ­appetite, a change in their diet can throw off their system, leading to constipation. It may be a side effect of some ­medicines or because of certain medical conditions.
• Other changes. In general, any changes in your child’s routine, such as traveling, hot weather, or stressful situations, may affect their overall health and how their bowels function.
• Power Struggles/Independence and control. The most common cause of recurrent constipation in children between the age groups 2 to 5 years. Most often it’s a battle around potty training especially in India where potty training is nothing short of attaining a gold medal/distinction. The earlier your child is trained the more proud you feel. But remember potty training can trigger constipation resulting from poop withholding. This withholding can result in backup in the intestines which leads to pain and poor eating.

Children withhold for either of the reasons:

1. They are afraid of the toilet or potty seat.
2. They had one painful poop and they resolve never to repeat the experience by trying to never go again.
3. They are locked into a control issue with their parents. As it is said “You can lead a horse to water but you can’t make him drink.” The same applies to potty training as well.
4. And if they are already trained, it may begin with the start of school. Some children refuse to use public toilets. Some children postpone stools because they are too busy to sit down.

• Slow passage of food through the intestines. Most often, this type runs in families. Called slow transit time.

If constipation isn’t treated, it may get worse. The longer the stool stays inside the lower intestinal tract, the larger, firmer, and drier it becomes. Then it becomes more difficult and painful to pass the stool thereby creating a vicious cycle.

A word about encopresis!!

If your child withholds their stools, they may ­produce such large stools that the rectum stretches. The child may no longer feel the urge to pass a stool until it is too big to be passed without the help of an enema, laxative, or other treatment. Only liquid can pass around the hard stool and leaks out onto your child’s underwear. It may look like diarrhea, confusing the parent, but it’s not. This is called encopresis.

How is constipation treated?

Constipation is treated in different ways. Your child’s doctor will recommend what is best for your child’s situation. In most cases, no tests are needed.

​Medicine

In some cases, your child’s doctor may prescribe medicine to soften or remove the stool. Never give your child laxatives or enemas unless your child’s doctor says it’s OK; laxatives can be dangerous to children, if not used properly. After the stool is removed, your child’s doctor may suggest ways you can help your child develop good bowel habits to prevent stools from backing up again.

But as with any problem, “Prevention is better than cure”.

How can constipation be prevented?

Because each child’s bowel patterns are different, become familiar with your child’s normal bowel patterns. Make note of the usual size and consistency of her stools. This will help you and your child’s doctor determine when constipation occurs and how best to treat it. If your child doesn’t have normal bowel movements every few days or is uncomfortable when stools are passed, she may need help in developing proper bowel habits.

What parents can do: 

If you are concerned about your child’s bowel movements, visit your child’s doctor. A simple change in diet and exercise may be the answer. If not, your child’s doctor can suggest a plan that works best for your child.

1. Dietary changes:
   • Add fruits and vegetables high in fiber content. Examples are peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, or dates. Offer these foods 3 or more times per day.
   • Increase whole grain foods. Examples include wheat bran, oatmeal, Brown rice and whole wheat bread etc.
   • Avoid junk foods ( diet rich in FFASS should be restricted)
   • Limit milk products (milk, cheese, yogurt) to 2 servings per day.
   • Fluids. Give enough fluids to stay well-hydrated. Reason: keep the stool soft.
2. Encourage Sitting on the Toilet (if toilet trained):
   • Set up a normal stool routine, if your child agrees to sitting.
   • Have your child sit on the toilet for 5 minutes after meals, especially important after any major meal (best is breakfast).
   • During sits, stay with your child. Just focus on helping the poop come out.
   • Do not distract your child. Do not allow your child to play with video devices, games or books during sits.
   • Once your child passes a normal size stool, they doesn’t need to sit anymore that day.
3. Warm Water to Relax the Anus:
   • Warmth helps many children relax the anus and release a stool.
   • For straining too long, have your child sit in warm water.
4. Flexed Position to Help Stool Release:
   • Ask your child to hold the knees against the chest like squatting. This is the natural position for pushing out a stool ( the common Indian style of toilet).
5. Stool Softeners:
   • If above measures don’t help, a stool softener can be added after consulting your health care provider.
6. Stop Toilet Training for a couple of weeks:
   • Put your child back in diapers or pull-ups for a short time.
   • Tell him that the poops won’t hurt when they come out.
   • Praise him for passing poops into a diaper.
   • Holding back stools is harmful. Teach your child the same but at the same time, avoid any pressure or punishment. Also, never force your child to sit on the potty against his will.
   • Treats and hugs always work better.
7. Physical activity: Encourage your child to be physically active throughout the day.

What to Expect?

1. • Most often, changes in diet and lifestyle helps constipation. For more severe cases, medications help. But remember, medications are only a short term solution.
   • After your child is better, be sure to keep them on high fiber foods and adequate fluid intake.
   • Also, have your child preferably sit on the toilet at the same time each day.

These tips will help to prevent the symptoms from coming back and a happy child and therefore a happy parent.

Happy Pooping !!

Dr Garima | themoppetsclinic 🙂