The consistency of the stool defines constipation. Constipation is hard and difficult to pass stool. Constipation is a common problem, especially in children, due to various causes, including changes in eating, drinking, and activity. Dr. Bornstein discusses common symptoms, causes, and treatments for constipation in children.
SYMPTOMS:
- Pain
- Bloating
- Fussiness
- Difficulty passing stool
- Blood in the stool due to tearing of the anus (anal fissure)
- Very hard, dry stools
CAUSES:
- The low water content of the stool; It is very watery when the stool enters the large intestine or colon from the small intestine. Water gets reabsorbed into the body as the stool passes through the large intestine. As this happens, the stool gets dryer and harder. If this happens excessively, constipation can occur. This is very common in infants when there is any change in the diet, especially when there is a change from breastfeeding to formula or a difference in the formula.
- A low-fiber diet
- High milk content
- Excessive fat in the diet
- Rarely, illnesses such as hypothyroidism (low thyroid), hormonal problems causing water imbalances such as diabetes insipidus, or Hirshprung’s disease (lack of nerves in the colon) can cause constipation.
DIAGNOSIS:
A history of the stool habits helps us make the diagnosis. If there are hard stools, this is constipation. In the rare cases of an illness, thyroid function tests, a barium enema or biopsy of the colon for Hirshprung’s disease, anal manometry (muscle function) studies, or blood tests for hormones can be done. These are very rarely necessary.
DISCUSSION/TREATMENT:
The treatment for constipation is to get the stool loose— the treatment depends on the age group. Meconium (newborn stool) can be difficult for newborns to pass. The colostrum from breastfeeding is beneficial for this. For formula-fed infants, feeding will help the first stool pass. Infants will not leave the hospital until the newborn has passed a stool.
Family members very often misdiagnose constipation in a newborn. Remember that all newborns will grunt, turn red, pull up their knees, fuss, pass gas, cry, gurgle in the stomach, and generally have difficulty passing some stool. It is normal and not due to constipation but to weaker stomach muscles and the inability to stand up, squat, and push. Also, the definition of constipation is not related to how often a baby goes. It has to do with the consistency of the stool.
Some babies may go ten times a day, and some may go once every five days. Therefore, we don’t treat the number of times a child stools. Instead, we treat the very hard, difficult-to-pass stool. The idea is to get the stool loose, making it easier to pass. If the stool is loose, but the child only goes once every five days, we don’t treat that because it is not constipation. If the stool is hard, then we want to loosen it up.
Newborn- 6 Months: The two ways to treat constipation are from above and from below. “From above” means we are giving a stool softener or medicine by mouth that will work in the intestines. “From below” means we are doing something rectally to get the stool out. The latter will give relief but will not prevent future constipation. For newborns, we can always use a glycerine suppository from below, a mineral oil that goes into the rectum. The idea is to get the stool in the rectum loose and to stimulate the rectum to contract to get the stool out. Also, physicians can recommend enemas such as a pediatric Fleet enema, and it should only be done under the direction of a physician.
For treatment from above, we first want to ensure the formula is mixed correctly and that the child is getting enough to eat. We should wait until at least four months old to introduce foods. Until then, the feedings are only breast milk or formula. Until six months of age, juice should not be given. Therefore, treating constipation is using a stool softener that is safe in babies and doesn’t promote the early introduction of food or juices. If the baby is significant, then water is fine. If the baby is small (falling in the 10th percentile or less on the growth chart), introducing water may inhibit a baby’s growth. Remember, water has no calories, fats, proteins, or vitamins.
Parents can introduce a mild stool softener such as barley malt (Maltsupex) to help with the stool in most babies. Maltsupex is a fiber that will incorporate into the stool and keep it loose. If excess water is reabsorbed into the body from the colon, the stool will still stay soft due to the inclusion of this fiber in the stool. Also, an osmotic agent such as lactulose or Miralax may help. Miralax acts as a concentrated substance that stays in the stool. When the stool enters the colon from the small intestines, an osmotic agent will be very concentrated, and therefore, water is less likely to flow out of the intestines. The osmotic agent holds the water in the colon and prevents hard stool formation. Juice works in this manner since juices are very sugary but can only be given to children six months and older. This is also how Karo syrup works. But Karo syrup, like honey, should not be given until after one year of age. Once a baby is older than six months, parents can add juices, water, and cereals (as early as four months of age but preferably six months) for extra fiber to add to their diet. Laxatives are agents that force the intestines to contract and push the stool forward. It is preferable to use these only if necessary. Examples would include Senokot and Milk of Magnesia. These should only be given under the direction of a physician.
6 Months – Toilet Training: In this age group, giving extra water and juices is safe to try to loosen the stool. Parents can also use everything that helps treat constipation in the newborn in this age group. You and your physician should decide if a stool softener, an osmotic agent, a laxative, or an enema is best. Mineral oil by mouth is another option as a stool softener at this age. Before this age, there is concern that this can be aspirated into the lungs, causing problems. After six months of age, this is less likely, and mineral oil can be used.
Toilet Trained: The treatment mentioned above can be used in this age group. At this age, looking at the diet to see if the child is eating many constipating foods is beneficial. Increased meat or fat with a lack of fruits and fiber is a setup for constipation. Excessive milk can also cause constipation. Children this age may withhold stool during constipation because it can be painful to pass. In these instances, constipation gets worse. At times, it may get so bad that small pieces of stool can break off and fall into the underpants, called encopresis. Children with this will need enemas to relieve the stool and a daily stool softener or laxative to keep things under control. If a laxative is used, it should be changed to a stool softener once the problem is under control. Metamucil, Citrucel, or Fiberall are good stool softeners at this age.
OUTCOME:
Correcting constipation can be a long-term process. Parents can help constipation in children by controlling the continued use of stool softeners, proper diet, and enemas for difficult cases. Most children that suffer from constipation will grow out of it.
OPINION:
Almost everyone who diagnoses constipation in their child misdiagnoses normal variation in stooling patterns. It is important to remember that constipation has nothing to do with the frequency of the stool. It has to do with the consistency of the stool. If the stool is loose, it is not constipation. You wouldn’t want to unnecessarily give a child an enema or put a child on a stool softener or laxative due to a misunderstanding of what is happening. All babies will have difficulty passing stool at some time, which is normal for all babies.
There isn’t a parent that is perfectly happy with the stooling pattern of their baby. The stool seems either too hard, too soft, too much, not enough, the wrong color, too inconsistent, too infrequent, or too frequent. There is a nationwide obsession with our children’s stool. The best thing is to understand the definition of constipation, use proper medicines when indicated, and avoid things we shouldn’t do. We don’t want to change the formula to a low-iron formula. Iron does not cause constipation, but changing the formula does, so this can make things worse. Using water is only suitable for some infants since they need nutrition. Starting juices and foods or adding honey or Karo syrup too early isn’t good for a baby and can be dangerous. Parents should not introduce children under six months of age to juices and foods; parents should not give honey or Karo syrup to any child under one year old. Realize that all babies will fuss, cry, pass gas, grunt, pull up the legs, turn red, and seem miserable, completely unrelated to the stool. Try not to blame too much on the stooling pattern. We as parents tend to do that almost as much as we blame every illness on teething, but that is another subject.
Written by Dr. Michael Bornstein, who has 30 years of experience as a pediatrician.
Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.
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