CONSTIPATION

Constipation in Infants: 

Parents of newborns and infants often worry about the frequency and nature of their child’s bowel movements. While elimination is important, it rarely indicates serious issues. The frequency and consistency of infant stools can vary widely. Some infants may pass stools with almost every feeding, while others may do so every three to six days. Both patterns are typically normal. Breastfed infants often have frequent, watery stools in the first few weeks, while formula-fed babies tend to have less frequent, firmer stools. After three to six weeks, breastfed babies’ stools usually become much less frequent and firmer.

Parents sometimes mistake normal straining during bowel movements for constipation. It is normal for newborns to grunt, strain, and turn red while passing stools. As long as your baby has a bowel movement every three to six days without excessive difficulty, their bowel habits are likely normal. However, if your baby goes seven days without a bowel movement, has extremely thick or pasty stools, or strains excessively to pass firm balls of stool, they may be constipated.

Constipation Treatment in Infants:  

Since constipation is caused by having hard stools which are difficult to pass, treatment is aimed at softening the stools. If your baby’s stools are soft, she needs no treatment for constipation. The following measures are usually helpful for constipation.

1. If your infant is crying in pain from a hard stool which is difficult for her to pass, one-half of a glycerin suppository can be inserted into the rectum. These can be obtained without a prescription. However, you should not make a habit of using glycerin suppositories, because a child can become dependent upon them to have a stool.
2. To loosen the stool, give prune juice up to three times per day. Other  juices like apple or pear juice can also be effective.
3. If juice is not effective, you may try Milk of Magnesia. The dose is one-half teaspoon two to three times per day until a stool is produced.
4. Mineral oil may also be used to soften the stool. It should be chilled and added to a small amount of juice for your child to drink. Begin with one-half teaspoon three times per day and increase the dose if needed.
5. Honey and Karo syrup are no longer recommended in the treatment of constipation during the first year of life because of the potential for infant botulism poisoning.
6. Constipation which persists despite treatment needs to be evaluated by one of our physicians at a regular office visit. 
   

Constipation in Older Children: 

Constipation in older children is often caused by an inadequate diet and poor bowel habits. To improve this situation, increase the intake of fresh vegetables, fruits, other high-fiber foods and fruit juices and water. A practical way to assess fiber intake is to observe the child's stool in the toilet. Floating stools indicate sufficient fiber; if it sinks, fiber intake should be increased. Most cases of constipation in older children result from insufficient fruits, vegetables, and other dietary fiber.

Addressing constipation involves primarily focusing on increasing dietary fiber. For children whose diet mainly consists of chicken nuggets and macaroni and cheese, dietary changes are necessary.

In addition to dietary adjustments, encourage proper bowel habits. Have your child sit on the toilet for 10 minutes after meals to utilize the gastrocolic reflex, a natural reflex that stimulates bowel movements after eating. This should be done once or twice daily. Encourage your child to avoid retentive behavior, where they resist having a bowel movement. This approach can significantly help manage constipation. 

Treatment of Constipation in the Older Child:

1. To increase your child's fiber intake, focus on a diet rich in fresh vegetables, green salads, and fruits. If your child is indeed a fan of chicken nuggets and macaroni and cheese and nothing else, you'll need to implement dietary changes. Refer to the section on handling picky eaters, which essentially advises offering only nutritious vegetables, salads, fruits, and meats at meals. When sufficiently hungry, your child will surrender and eat healthy foods.
   Avoid low-fiber foods like chicken nuggets, macaroni and cheese, grilled cheese, and peanut butter and jelly on white bread. Early dietary habits are often lifelong patterns. Bran is an excellent way to boost fiber; it can be added to casseroles, hamburgers, meatloaf, or baked goods. Bran crackers or wafers are available and help with constipation. Additionally, bran benefits the whole family by lowering cholesterol and possibly reducing certain gastrointestinal cancer risks. If a high-fiber diet doesn't result in stools that float, consider adding bulk laxatives. Options include methylcellulose (Citrucel), psyllium (Metamucil), Benefiber, or Fibercon tablets. These are medicinal fiber supplements. Follow the dosage instructions on the packaging.
2. The amounts of juices and water should be increased in the diet.
3. The amount of dairy products in the diet should be decreased somewhat. The total milk intake should be approximately 16 to 24 ounces per day. Larger amounts of milk products can be associated with the constipation. Besides milk, dairy products include, cheese, ice cream, cottage cheese, yogurt, etc.
4. If your child is acutely constipated and having abdominal pain, a suggested regimen to relieve the constipation includes a pediatric Fleets enema, followed by two or three days of Milk of Magnesia. This will generally relieve the acute problem of constipation. Then of course, you should attack the main problem and increase the child’s dietary fiber.
5. Miralax: For more chronic constipation, Miralax is available. Once a prescription laxative, this medication is now available over the counter. For children over 40 pounds, use the adult dose, 1 capful mixed with 8 ounces of juice or water once or twice daily. For children less than 40 pounds, contact us for the proper dose. This medication is meant to be usually taken for several weeks or even longer due to chronic constipation. This is our most commonly used medication for constipation and is our usual recommendation.
6. Mineral Oil. You should chill the mineral oil and add a small amount to juice. Start with a dose of one teaspoon three times per day and increase as needed to one tablespoon three times per day as needed.
7. Medications such as Ex-Lax and other laxatives should not be used chronically, because they are potentially habit-forming.
8. If the above measures fail, your child should have a regular office visit. Rarely, medical conditions such as Hirshsprung’s disease or hypothyroidism may be the cause of constipation. These conditions require more in depth work up and treatment. We will investigate these possibilities during an appointment to discuss the problem.
9. Remember a 10 minute toilet sitting time is needed once or twice a day shortly after a meal. 

Extremely rarely, constipation can be due to a life-threatening intestinal problem, which can occur at any age. Examples include bowel obstruction and a condition called toxic megacolon. Immediate medical attention is required.

Hirshsprung’s disease:

 Toxic megacolon is a complication that can arise from Hirshsprung’s disease. Hirshsprung’s disease is a congenital condition characterized by the absence of nerve cells in parts of the intestine, which prevents the normal movement of feces through the bowel and leads to constipation. 

Infants and children with Hirshsprung’s disease may present with symptoms such as chronic constipation, abdominal distention, and discomfort. If not addressed, this can result in complications like toxic megacolon, where the colon becomes overly dilated, leading to severe swelling, infection, or even perforation.

Treatment for Hirshsprung’s disease typically involves surgical intervention to remove the affected portion of the intestine lacking nerve cells and connect the healthy sections. 

Any child exhibiting significant abdominal distention or discomfort should be immediately evaluated at our office or at the ER to rule out Hirshsprung's Disease or other serious abdominal conditions and ensure prompt and appropriate care.

Summary:

The following is a very true statement regarding constipation and the bellyaches that it causes in kids. Parents should utter these words to their constipated kids often: "Have a bowel movement and you will feel better!"