This is a very common problem -- sometimes we just don't admit it!
Every child will occasionally have a hard stool. Hard stools can be painful to pass. If they are very hard, they can even cause tearing and bleeding of the rectum. Children who have a lot of hard, painful stools will try to wait as long as possible before going. This can develop into a vicious cycle.
What is constipation?
Constipation refers to hard stools, not to infrequent stools. If your child has stools only a few times a week, but they are normally formed and painless, this is normal and not considered constipation. Every child is different; very few children have the "perfect" once-a-day stool. Look at the great variability in the average number of stools a week:
(from the North American Society for Pediatric Gastroenterology and Nutrition)
- Breast fed infants: 5 to 40 a week
- Bottle fed infants: 5 to 28 a week
- Toddlers: 4 to 21 a week
- Preschoolers and up: 3 to 14 a week
What causes constipation?
Parents sometimes worry that their child's chronic constipation is a sign of a bad disease, like colon cancer. Fortunately, in otherwise healthy children who are growing and developing normally, constipation is almost always related to diet and activity. Children with malformed intestines or other serious problems have stooling problems as newborns. Let us know if you are worried about a specific disease and we can put your mind at ease.
What diet changes help constipation?
This will depend on the age of the child. Call us before changing the diet of an infant less than 3 months of age.
- Babies should get 2-4 oz of juice a day to help loosen their stools. The "p" juices work best: prune, pear, pineapple, peach, and plum.
- Babies getting spoon or table feedings, toddlers, and older children should eat more fiber-containing foods and avoid constipating foods (see list below.) Be sure that the foods you offer are appropriate for the child's age. (For example, do not feed a constipated 9 month old raw celery or raisins - he's likely to choke.)
- Toddlers and older children should drink more water. Offer 4 oz of water to your preschooler (8 oz for a school-age child) before all meals and snacks.
What foods help and hurt constipation?
- Most raw or dried fruits. Peaches, pears, apricots, prunes, plums, raisins, and figs are good choices. (Avoid apples and bananas.)
- Most raw or gently-cooked vegetables. Beans, peas, broccoli, cauliflower, lettuce, cabbage, and spinach are good choices.
- Most whole grains and cereals. Whole wheat bread, muffins, and high-fiber cereals work great. (Some cereals have a lot more fiber than others. Be sure to check those labels.)
- Most dairy products: whole milk, ice cream, cheese, and yogurt. Don't eliminate these entirely (your child needs something from this food group) but limit pre-schoolers to 20 ounces of milk a day and school-age children to 32 ounces of milk a day. This provides plenty of calcium.
- Fried or fatty foods. These will decrease a child's appetite for high-fiber foods.
What if diet changes don't help?
- Use a "timed sitting" strategy in children who are toilet trained. About 15-30 minutes after eating, the intestines naturally move forward, presumably to "make room" for the food just eaten. Take advantage of this natural reflex by having your child sit on the toilet for 10 minutes after all meals. Don't treat this time as a punishment; this will make your child tense. Instead, fill a basket with special books or toys and put it in the bathroom to entertain him. (Blowing toys, like whistles, soap bubbles, and pinwheels work great because the blowing action simulates bearing down.)
- Be sure your child is active. Children who fail to get regular exercise tend to get stopped up. Even children who are usually active who are laid up for a while (with the flu or a broken leg) can get constipated.
- Review your child's medications. Some medications and supplements taken on a regular basis can lead to constipation. Ask us if any of your child's medications could be contributing.
- Use an over-the-counter stool softener. When used regularly in combination with a good diet, over-the-counter stool softeners and natural vegetable laxatives can control constipation in 90% of children. Good choices include mineral oil, senna, methylcellulose docusate, and milk of magnesia. Ask the pharmacist at your local grocery or drug store to show you products containing these ingredients.
- You may need to use stool softeners regularly. Some parents try stool softeners for a few days and get results, so they discontinue the stool softeners. The stools then get hard again, and the family gets discouraged. In most moderately constipated children, stool softeners must be used daily to get daily results. If your child's stools get too loose, cut back on the dose before stopping the medicine entirely. Don't be afraid about using stool softeners regularly; they aren't habit forming (unlike stimulant laxatives.) Let us know if you need help with adjusting your child's dose.
- We don't recommend stimulant laxatives (containing phenolphthalein or casanthranol) for most children. Call us before using any products containing these ingredients.
- We don't recommend enemas of any kind for most children. Call us before using an enema.
What if all these things aren't enough?
Prescription constipation medications are available if necessary. Rarely, a child may have to be admitted briefly to the hospital for disimpaction. Be sure, though, that you've already incorporated these other strategies into your plan.