Cause: Digested food enters the large intestine (last part of the bowels) as a liquid and the large intestine absorbs this water to make the stool solid. Therefore, having less water in the digested food causes constipation. When the stool spends more time in the bowel, then it can absorb more water and the stool gets harder.
Usual course: Most people have a few days of constipation now and then that resolves on its own. Some have moderate to severe constipation lasting for months and then it stops. Some have episodes of constipation lasting months and reappearing every year or so.
Behavioral treatment: If you have more frequent bowel movements, then the stool will not have a chance to harden. There is a normal reflex that helps the bowels move about 10 minutes after a meal is eaten, therefore encourage having a bowel movement several times a day after meals. Ensure the are no negative feelings regarding having a bowel movement sincenegative feelings about bowel movements only causes someone to hold the bowels longer. Once we get the stools softened, the negative feelings about having a bowel movement should resolve on their own. A warm bath may relax the rectal muscles and make the hard stool pass easier. Regular exercise will also help you child have regular bowel movements. For those children unable to walk, holding your child upright while walking with them helps their bowels move easier.
Diet treatment: First, increase water intake. Complex natural sugars (that are difficult to absorb) and fiber cause water to stay in the stool longer, and therefore softens the stool. Therefore, eat more fruits and fruit juices (such as apricots, peaches, plums, pears and prunes) and eat more fiber found in grains, fruits and vegetables (especially beans, peas and spinach). Consistently eating the above will help greatly. There is significant evidence that cow’s milk is a huge contributor to constipation. Eliminating milk from the diet often fixes most constipation, but studies show any amount you reduce cow’s milk will help. I can’t overemphasize how much reducing or eliminating cows milk helps constipation.
Which treatment to use: Always try the diet treatment mentioned above first, and if that is not enough, then we try medicines. Stool softeners are the first choice since they only soften the stool. Laxatives are next, since they make you have a bowel movement. Enemas are a last resort for obvious reasons, and they essentially flush out the stool. You cannot become physically addicted to any of these treatments. Typically, what we do is take a stool softener every day during this “episode”. If your child goes 1 to 2 days without a bowel movement, then give a laxative. If your child goes several days without a bowel movement, or is uncomfortable, then give an enema. If you give an enema, then follow that by several days of a laxative, since the enema only removes the last part of the bowel movement.
Suppositories: Glycerin suppositories simply lubricate the rectal canal to make it easier for the stool to come out. Be careful to lubricate the suppository with Vaseline before inserting. Be careful when inserting the suppository so you don’t injure the rectum. They can be used as often as you wish.
Stool softeners:
Miralax ( PEG - polyethylene glycol) Miralax is called the miracle laxative. It is a sugar that your body can't absorb, but it draws water into the gut to loosen / soften the stool. In small doses, it tends to soften the stool, while in larger doses is acts as a laxative. Therefore if you try this medication at one dose level and find that the stools are loose, then simply cut back the dose a little. It’s a powder that you mix with any liquid. The powder does not have any taste or texture and therefore its perfect for kids as they don't even know they are taking it. Miralax is available over the counter. Intimately the right dose is the one that works, not necessarily a body sized based dose. It takes several days to see the full effect, therefore we change doses slowly.
For chronic constipation: This can cause hard stools which cause pain, then the child holds the stool which makes it larger and harder, which causes more pain. In this case, start with a higher dose (like 1 tablespoon in several drinks per day), until the stools get soft but not runny. Encourage your child to try and have a bowel movement after each meal (the bowels natural move along - peristalsis - after meals). Hopefully your child will recognize that feeling, go after the meal, get regular and once that pattern emerges, you can back off the Miralax to see if its not needed anymore. Of course, some children with chronic constipation are better taking the Miralax on a regular basis. Simply adjust the dose to keep the stools the consistency that works best for you.
For occasional constipation: Its probably best to give a higher dose of miralax to help make your child go. Remember the dose is whatever works, and giving too much will just give temporary diarrhea, which is very preferable to a child in pain from a stuck hard stool. To give you an example of the high end of a dose, we have a dose called the blow out dose. Its 3/4 gm per pound of body weight per dose twice a day in 1/6th ounce water per pound of body weight. So a 30 pound child would take 22 grams (3/4 * 30 = 22.5) of Miralax dissolved in 5 ounces (30 divided by 6 = 5) of water given twice a day. The cap of the Miralax container has a line at 17 grams. So 22 grams is 1 and 1/3 of a capful. The above calculations sounds like you have to be exact, but this is not true. Giving a little too much is only more likely to give the desired effect. If your child is not very uncomfortable, then start with a tablespoon in several drinks per day and adjust as necessary.
Colace: (docusate sodium) will soften the stool when taken regularly. It may take 5-10 days to see a change in the bowel movement consistency. Start off taking a dose with each meal (3-4 doses per day). Every few weeks, drop one dose a day until you are off of the medicine. If the stool hardens again, then add another dose back. If you have to take it more than 3 months in a row, then notify the doctor. The doses given are for each meal or up to 4 doses per day. 1 tsp = 5 ml = 5 cc
Laxatives: Senekot for children is a gentle overnight type of laxative. Laxatives make your bowels move rather than just soften the stool. Use a laxative when your child has gone longer than usual without having a bowel movement (this is typically 1 to 2 days, but we will give you a specific number of days for your child). Take the medicine daily until the bowels are of normal consistency and amount (usually 1 to 7 days). Notify the doctor if you must take this more than 7 days in a row. The doses given are for one dose at bedtime. 1 tsp = 5 ml = 5 cc
Enemas: Pediatric Fleets Enema is a common brand. Use when you haven’t had a bowel movement for a significant time (usually 5 to 7 days, but we will give you a specific number of days for your case). If there is no stool after 8 to 12 hours, then repeat the enema. Never give more than 2 enemas in a row without talking with the doctor. After you give an enema, give a laxative for 5 to 7 days after to completely remove the excessive stool from the bowel.
DISCLAIMER: This web site is designed to provide accurate and authoritative information in regard to the subject matter covered. In providing this site, the author is not engaged in rendering medical or any other professional service. Individual conditions may vary and the information contained herein should not be relied upon for the diagnosis and/or treatment of any particular individual. If medical advice or other expert assistance is required, the services of a competent professional should be sought. All material on this site is Copyrighted 2020 by Joe Matusic, MD, FAAP, AME. Any material may be reproduced and distributed providing that the original copyright remains affixed and no material is distributed for a fee. Copyright 2020 Joe Matusic, MD. Est. 1997.
