Constipation

Diagnostic Findings

  • Painful passage of stools: The most reliable sign of constipation is discomfort with the passage of a bowel movement.
  • Inability to pass stools: These children feel a desperate urge to have a bowel movement (BM), have discomfort in the anal area, and strain, but they are unable to pass anything.
  • Infrequent movements: Going 4 or more days without a BM can be considered constipation, even though this may cause no pain in some children, and even be normal for a few. Exception: After the second month or so of life, many breast-fed babies pass normal large, soft BM’s at infrequent intervals (up to 7 days is not abnormal) without pain.

Common Misconceptions in Defining Constipation

Large or hard BM’s unaccompanied by any of the conditions just described are usually normal variations in BM’s. Some normal people have hard BM’s daily without any pain. Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during passage of BM’s. However, they don’t cry. These behaviors are normal and should remind us that it is difficult to have a BM while lying down.

Causes

Constipation is often due to a diet that does not include enough fiber. Drinking or eating too many milk products can cause constipation. It’s also caused by repeatedly waiting too long to go to the bathroom. If constipation begins during toilet training, usually the parent is applying too much psychological pressure.

Expected Course

Changes in the diet usually relieve constipation. After your child is better, be sure to keep him on a nonconstipating diet so that it doesn’t happen again. Sometimes the trauma to the anal canal during constipation causes an anal fissure (a small tear). This is confirmed by finding small amounts of bright red blood on the toilet tissue or the stool surface.

Home Care

Diet Treatment for Infants (Less than 1 year old)

  • Give fruit juices (such as grape or prune juice) twice each day to babies less than 4 months old. Switching to soy formula may also result in looser stools.
  • If your baby is over 4 months old, add strained foods with a high fiber content, such as cereals, apricots, prunes, peaches, pears, plums, beans, peas, or spinach twice daily. Avoid strained carrots, squash, bananas, and apples.

Diet Treatment for Older Children (More than 1 year old)

  • Make sure that your child eats fruits or vegetable at least three times each day (raw unpeeled fruits and vegetables are best). Some examples are prunes, figs, dates, raisins, peaches, pears, apricots, beans, celery, peas, cauliflower, broccoli, and cabbage. Warning: Avoid any foods your child can’t chew easily.
  • Increase bran. Bran is an excellent natural stool softener because it has a high fiber content. Make sure that your child’s daily diet includes a source of bran, such as one of the new “natural” cereals, unmilled bran, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Pop-corn is one of the best high-fiber foods.
  • Decrease consumption of constipating foods, such as milk, ice cream, yogurt, cheese, and cooked carrots.
  • Increase the amount of water your child drinks.

Sitting on the Toilet (Children who are Toilet Trained)

Encourage your child to establish a regular bowel pattern by sitting on the toilet for 10 minutes after meals, especially breakfast. Some children and adults repeatedly get blocked up if they don’t do this. If your child is resisting toilet training by holding back, stop the toilet training for a while and put him in diapers or Pull-ups.

Stool Softeners

If a change in diet doesn’t relieve the constipation, give your child a stool softener with dinner every night for 1 week. Stool softeners (unlike laxatives) are not habit-forming. They work 8 to 12 hours after they are taken. Examples of stools softeners that you can
buy at your drugstore without a prescription are Maltsupex (2 tablets), Haley’s M-O (1 tablespoon), Metamucil or Citrucel (1 tablespoon), or plain mineral oil (1 tablespoon).

Common Mistakes in Treating Constipation

Don’t use any suppositories or enemas without your physician’s advice. These can cause irritation or fissures(tears) of the anus, resulting in pain and stool holding. Do not give your child strong oral laxatives without asking your physician because they can cause cramps and become habit forming.

Enemas for Acute Constipation

If your child has acute rectal pain needing immediate relief and your physician has said it’s OK to give an enema, one of the following will usually provide quick relief: a glycerine suppository, a gentle rectal dilation with a lubricated finger (covered with plastic wrap), or a normal saline enema. The normal saline solution is made by adding 2 teaspoons of table salt to 1 quart of lukewarm water. Enemas with soapsuds, hydrogen peroxide, or tap water are dangerous. Your child should lie on his stomach with his knees pulled under him; the enema tube should be lubricated and inserted 1 ½ inches to 2 inches into the rectum. The enema fluid should be delivered gradually by gravity, with the enema bag no more than 2 feet above the level of the anus. Your child should hold the enema until a strong need to have a bowel movement is felt (2 to 10 minutes). If you do not have an enema apparatus, you can use a rubber bulb syringe. The amount of normal saline that should be given to children at various ages is:

  • 1 yr. 4 oz.
  • 1-3 yr. 6 oz.
  • 3-6 yr. 8 oz.
  • 6-12 yr. 12 oz.
  • Adolescent and adult 16 oz.

Pediatric Fleet Phospherous enema can be used for children under age 4. Over age 4 use an adult dose.

Call our office immediately for advice about an enema or suppository if

  • Your child develops extreme pain.
  • Pain becomes constant and persists for more than 2 hours

During regular hours if

  • Your child does not have a bowel movement after 3 days on a nonconstipating diet.
  • The anal area develops any tears (fissures) that won’t heal.
  • Your child soils himself (leaking BM’s)
  • Constipation becomes a recurrent problem for your child.
  • You have other concerns or questions.

Instructions for Pediatric Patients by Barton D. Schmitt, M D., Pediatrician c. 1992 by W. B. Saunders Company. Adapted from YOUR CHILD’S HEALTH by Barton D. Schmitt, M. D. Reprinted by permission.