Once you become a parent, you spend way too much time thinking about poop. When did the baby poop?  How much did they poop?  What was the color, what was the consistency?  While you might find yourself obsessing over your child’s bowels a little less as they become toddlers and preschoolers, you will still likely spend way more time than you ever imagined thinking about your kid’s poop. Most of these thoughts will be focused on one issue: Is my child constipated?

As a pediatrician I regularly see parents that are worried that their child is constipated (also because I’m a pediatrician I can *get away with saying “poop” instead of “bowel movements” or “stool” here). Some pediatricians would argue that all kids are constipated, but the data doesn’t support that claim, as the prevalence is somewhere between 1% and 36%.

So why, as parents, are we so worried about constipation? Well, there are a lot of reasons. Most of us have been constipated at some point in our lives and we know how uncomfortable, and sometimes painful, it can be. We also don’t want to see our kids in discomfort or pain, especially if we can avoid it. Constipation can delay your child’s ability to potty train, lead to UTIs and chronic constipation can create a significant disruption in the family.

Today, we’re going to talk about constipation, but before we can talk about that, we need to talk about what poop is and how it’s made.

What is Poop?
Most of us think that poop is undigested food, but that’s not completely accurate. Poop is actually 75% water, 21-23% what we consider “organic solids” and the remaining 2-4% is dead skin and blood cells, mucous, intestinal secretions and minerals. Digested (and undigested) food falls into the category of organic solids, but even then, it’s a fairly small proportion of it. Up to 55% of the organic solids in our poop can be composed of what we call bacterial biomass, which are dead bacteria that normally live in our digestive tract.

How Poop is Made
Most of us are very familiar with the first steps in the digestive system: chewing and swallowing. From there, the food we’ve eaten and fluids we’ve drank wind up in the stomach, where digestive juices help break the food and drink down. The food and digestive juices are then released into the small intestines where more enzymes are released from the pancreas and liver. The walls of the small intestines absorb the nutrients in the food and fluid and contract to push the remainder through the system.

The next stop in the GI tract is where acute constipation develops: the large intestine (AKA: the colon). The large intestine absorbs fluids (and any remaining nutrients) from the food. It’s this absorption of water that helps poop take on a more solid form, but if our colon absorbs too much water, stools can become hard and difficult to pass. The final stop for our poop is the rectum, where it’s held until released (also known as “pooping”).

What’s Constipation?
Your child is considered constipated when they have infrequent bowel movements that are often large, dry, hard and painful.  These poops can be so large that they clog the toilet, they can also take a long time to pass due to their size. Some people think that any poop that isn’t soft qualifies as constipation, but that’s not an accurate use of the term. It is unfortunately common to see streaks of bright red blood in the poop * of a constipated child. This is usually because the poop is so large and hard, that the walls of the anus actually tear as the poop is pushed out.

There are also different types of constipation. The most common is what we call functional (or idiopathic) constipation, which is the type of constipation we’re discussing here. Constipation can be a tricky subject so I spoke with Dr. Matthew Riley of Northwest Pediatric Gastroenterology in Portland, Oregon to help out with this section. Dr. Riley says that “90% of kids with constipation all suffer from the same problem: functional constipation.  This just means that their constipation is not caused by a bowel obstruction, nerve problem, issue with how their colon is formed or some other exotic disease”.

For kids in particular, having a painful poop can cause fear of pooping which often leads to holding their poop in and even more constipation.  It becomes a vicious cycle.  This is one of the reasons that constipation is so common during potty training.  Many potty training kids want to keep some control during the process so they hold their poop in which contributes to this cycle. Constipation can also lead to fecal incontinence and set the potty training process back.

What Causes Constipation?
Dr. Riley says there are a few reasons why kids can become constipated, “Kids can become constipated because their colon is doing an exceptional job at conserving water (this is called slow transit constipation). They can become constipated because they’re just not very good at pooping yet (this is called functional outlet obstruction). They can also become constipated because their diet is low in foods that help us poop. Some children become constipated due to a combination of two or three of these factors”.

In my general pediatrics practice, I most frequently see functional constipation because patients have a fairly constipating diet (high in starch, protein and dairy but low in fiber) or they don’t drink enough water during the day. If you’ve told your parents that your child is constipated chances are they’ve told you that you need to make sure they get more “roughage” in their diet.   It turns out your parents are right about this one. “Roughage” also known as dietary fiber, is crucial to keeping your child’s poop moving (literally). Our bodies can’t break down some of the things we eat, and dietary fiber is one of them. If your diet is low in fiber, that means your body is absorbing a lot of what you eat, and there isn’t much left over to form poop. Fiber is also *osmotic, meaning that it attracts water, which makes the poop softer and easier to pass.

How Can I Tell if My Child is Constipated?
The symptoms of constipation aren’t always obvious. The most common way I find constipation in my practice is during a visit for stomach aches.  Children suffering from constipation will usually have stomach aches during or right after eating, because when we eat our GI tract starts moving to digest and make room for the new food.  If a large amount of poop is hanging out in the colon, it’s going to hurt when the colon starts squeezing against it.  Usually the pain is low down on the left side of the abdomen, which is where poop hangs out before it leaves the body.  Children can also present with other signs of constipation.  Dr. Riley says parents should look for these symptoms:

  • Poops less than 3-4 times per week
  • Poop that is hard, large or painful
  • Your child avoids pooping or seems to spend a long time trying to poop
  • Your child has accidents (soiling), or has poop in the underpants (One of the sneakiest ways constipation will show itself)

Another common symptom of constipation has nothing to do with the GI tract but with the urinary tract.  Because a large amount of built up poop can press on the bladder, some kids present with urinary accidents or even urinary tract infections.  Therefore, it’s important to recognize constipation in order to prevent these complications.

How Is Constipation Treated?
The main way to treat functional constipation is to improve the function.  This includes increasing the child’s intake of clear fluids and dietary fiber, and ensuring that they have access to a toilet whenever they feel the urge to go.   Foods that are high in fiber include fruits, vegetables, dried fruits (including prunes, raisins and dates), oatmeal, whole wheat pastas, bran and beans. If your child is a picky eater this may be mission impossible, so you may need to turn to an osmotic laxative, which Dr. Riley explains below.

In more severe cases, Dr. Riley recommends first ensuring the child’s colon is not impacted with an excessive amount of stool. This may require a special “clean out” either at home or in the hospital, which for most children may include an osmotic laxative. Just like dietary fiber, osmotic laxatives attract water, says Dr. Riley. “These are medicines which help keep more water in the poop, so that the poop is softer and easier to pass.  Common osmotic laxatives are milk of magnesia, lactulose and polyethylene glycol 3350 (commonly sold as Miralax or Glycolax).”

Children also need to be encouraged to go to the bathroom as soon as they feel the urge.  I even recommend that parents offer small rewards or a sticker on a chart when younger kids go to the bathroom on their own. “Children need to make an effort to sit on the toilet after mealtimes” as well according to Dr. Riley.  Sometimes a trip to the pediatric GI is necessary to talk about “how to properly use the muscles of the belly and the bottom to pass a bowel movement”.

Is Miralax Safe to Use Regularly?
There has been a lot of controversy over Miralax lately, which was addressed by a pharmacist in an earlier post on TheScientificParent.org, But I’ll let Dr. Riley take it from here:

“Miralax is the original name for prescription polyethylene glycol 3350 (PEG 3350) powder.  It was approved by the FDA in 1999 for use in adults.  However, the actual medicine has been in use longer than that in other forms.  The safety data for Miralax is incredibly good.  It is so good and so effective that it is one of the most popular laxatives currently used in the United States.  It is now available over the counter and as a generic.

“When Miralax first became widely used, people associated PEG 3350 with another chemical called ethylene glycol, which is the poisonous ingredient in car anti-freeze! I can assure you that that their chemical compounds are different.

“Because Miralax was so effective as a laxative, it was immediately used “off-label” by doctors caring for children.  This just means that the use of Miralax in children was not part of the original studies sent to the FDA.  However, I think it would be very hard to find a pediatrician or pediatric gastroenterologist who hasn’t prescribed it and had success treating patients with it. Also, we have over 16 years of extensive clinical experience using it with very few serious adverse effects noticed.

“The FDA has just funded a major study at the Children’s Hospital of Philadelphia to do more specific studies on the effect of Miralax in children.  We are not expecting any major problems, but as pediatricians we always want to make sure our treatments and medicines are not having even small effects on our smallest patients.”

Constipation is no fun no matter how old you are. As always, if you think your child is constipated make sure your first stop is to your doctor to make sure that something more complicated isn’t going on. And that’s the straight poop on constipation (sorry, I couldn’t resist).

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Categories: Food, Nutrition, + Infant Feeding, Science 101 + Mythbusting