There are several causes of constipation. There might not be enough fluid and fiber in the diet and the stool gets progressively drier, harder, and more difficult to pass. It is also thought that some children have gastrointestinal tracts that move at a more leisurely pace. There are families with more of a tendency to constipation, and one supposes that they have "slower" GI tracts. Yet another cause of constipation is a large S curve at the lower left abdomen. This is where the left descending colon joins the sigmoid and leads to the rectum.
The rectum has a complicated anatomy. There are many stretch receptors that detect the presence and quality of stool. Then there are two sets of circular muscle groups called sphincters that have to open. One of these sphincters is under voluntary control and is what you use to "hold it back" until the time is right. Toilet training requires that smooth contraction of the sensors and sphincters.
Many children have an occasional bout of constipation. This often happens during vacations when everyone is eating on the go, not eating as much fiber, or not drinking enough water. Toddlers tend to like dairy products. If most of the diet is milk and cheese, their stool can become hard and dry as the milk is digested. Increasing fluids and giving children more fruits and fiber cereals will offset the constipation. When the child needs a little help, there are several over-the-counter laxatives you can use.
Some Laxative Doses
- Sennekot Liquid: 1/2 tsp twice a day (for 2-5 year olds); 1 tsp twice a day (for over 6 year olds). Use for a day or two. Sennekot is made from the Senna root and has been used for centuries. For babies, use 1 cc (for 4-12 months); 1/3 tsp (for 12-24 months). Sennekot is over-the-counter, and different doctors might recommend slightly different doses based on the baby's size. There is a similar constipation product by the "Little Tummies" company. Doses are listed on the box.
- Maltsupax: 1 or 2 tsp (5-10 ml) 2-4x per day. It can be put in the baby's formula.
- Milk of Magnesia: 1-3 ml/kg/day split into two doses. This translates into about one tylenol dropper(.8cc) per pound per day, split into two doses. A 20-lb one-year-old would take 0.8 ml x 20 = 16ml (5 ml = 1 tsp). Calculated dose - take 1.5 tsp twice a day or 1/2 tablespoon twice a day)
For children who have been holding back stool - a vicious cycle can build in which the stool becomes harder and more painful to pass. A prescription medication called Miralax acts to "bulk" up and soften the stool . It comes as a powder that can be mixed with food or liquids.
If you know your child is "working on" passing a large stool and they're not toilet trained, try to get them in a squatting position by taking them for a walk in a baby carrier or a stroller with their knees bent. Bicycling their legs while they lie on a bed also helps work the relevant muscles. Warm baths might help as well. If the stool has become very large, the child's rectum might bleed after it's passed. Putting on some A & D ointment or other diaper ointment can help.
If constipation becomes an ongoing problem, the area just above the rectum can become stretched. As you can imagine, the problem worsens because backed-up stool can get larger and more painful to pass. The child can become fearful of defecation because it hurts.
A long-time standard treatment for chronic constipation is mineral oil. Mineral oil is given on a daily basis to soften and lubricate the stool so it is better able to slip through the sigmoid colon. The standard protocol is to give the child mineral oil once or twice a day for one or two months. The dose is 1-4 ml/kg/day. The low range of this dose translates into 1 tsp of mineral oil a day for every 10 pounds of a child's weight. Example: if your child weighs 30 pounds, he or she could take 3 tsps daily, 1.5 tsp in the morning and 1.5 at night. Mineral oil will absorb fat-soluble vitamins such as A, D and E. If someone took mineral oil three times a day with every meal he or she would slowly develop vitamin deficiencies. When given twice a day (morning and bedtime), it's not a problem. Nonetheless, you can give the child a multivitamin around dinnertime.
Mineral oil on a daily basis will start giving your child a "slippery stool." If it gets too slippery and your child is having oily diarrhea, it means you've given too much and it's time to cut back. Once the child starts having easy, painless stools for a couple of weeks, start lowering the dose of mineral oil over a couple of weeks. Then, stop it altogether. Most children use mineral oil for about a two-month period. They might use it from time to time thereafter for recurrences. Chilling it in the refrigerator and immediately giving something sweet and tart (like a sip from a juice box) makes it more palatable. There are some flavored forms of mineral oil, such as Kondremul, which has a marshmallow taste.
Miralax (polyethylene glycol) is also used in the setting of chronic constipation. It bulks up and softens the stool. Typically it is used for a week or two and then stopped, but can used for longer periods of time if constipation recurs.
High Fiber Diet
While doing the mineral oil regime or Miralax, you want to start instituting a higher fiber diet. There are many stool softeners available for older kids such as Citrucel, Metamucil, or Fiber wafers.
Some High Fiber Food Suggestions
- Fruit cocktails and canned peaches or pears
- Crackling Oat Bran cereal (served by the handful as a snack, tastes like miniature oatmeal cookies)
- Corn Bran cereal (also served as a snack - pretty crunchy and tasty)
- Bran and Corn Chex cereal (also tasty)
- Homemade oatmeal cookies (use the higher fiber types of oatmeal)
- Popcorn (for older kids)
- Corn on the cob (or frozen corn given at dinner as a side dish)
- Dried apricots and raisins
- Fig Newtons
- Fruit Bar Cookies by Sunshine (made with lots of raisins)
- Fruit Rollups made from dried apricots
- Add bran to recipes when making cookies
- Make cupcakes with frosting using bran muffin mix or a combination of carrot/bran cake mix.
- Add pureed celery to meatballs, meat loaf, or tomato sauce, where your child won't notice it)
- Branola Bread
- Fruit punches made with chamomile tea (example: Celestial Seasonings Sunburst C tea)
Constipation is very frustrating for the parents, but more so for the child. Try to be as patient and helpful as you can.