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All tied up: Overcoming chronic constipation

10/26/2015

Let’s face it – kids love potty talk.  Even the slightest mention of something bathroom related sets off giggles, but for children who suffer from chronic constipation and their parents, this is no laughing matter. Childhood constipation can lead to physical discomfort, shame, and, depending on the severity, even significant health problems such as rectal bleeding. For parents, it can mean concern, confusion, and frustration.

“It’s something we see quite often,” says Jyoti Ramakrishna, MD, Chief of Pediatric Gastroenterology and Nutrition at Floating Hospital for Children at Tufts Medical Center. “It can become a big battleground—the child is upset and the parent is upset—and one thing we believe today is that it’s happening more often than it used to because of problems with childhood stress, nutrition, and fitness.”

Dr. Ramakrishna says that constipation—a child’s inability or unwillingness to poop—shows up these days in about 10 percent of kids. It has a few typical causes, some of them emotional and others to do with problems of diet and lifestyle.

For many kids, Dr. Ramakrishna says, “It often starts at an age when the child is ready for potty training. He tries to poop but it hurts and he says, ‘That’s it, I’m done with this!’” Other constipation triggers can be stress or anxiety from things like a divorce, the death of a grandparent, or social problems at school. “A child who feels like they cannot control anything in their life—sometimes they exercise control by refusing to go,” Dr. Ramakrishna says.

The resulting physical withholding can lead to a hardening of the stool in the child’s body, which makes the pain of passing it only worse, which can lead to more withholding. “It’s like a big vicious cycle,” says Mary Brown, MD, a general pediatrician at Floating Hospital. “More gets backed up, and that not only get harder stools, there can be more stool in the intestine, so that can lead to abdominal pain.” Occasionally the withholding can cause fissures, Dr. Brown says, “and then you can see blood and everybody gets very concerned.”

Still, for most kids, something just clicks one day and the constipation passes on its own. For others, though, the problem can be stubbornly persistent. A small percentage of kids develop what’s known as encopresis. “It’s an extreme version of constipation where they’ve held onto so much poop that it starts leaking,” Dr. Ramakrishna says. “That has a huge social stigma, especially if it happens at school or another social setting, and that can lead to problems with self-esteem and confidence.”

Of course, stress and anxiety aren’t the only causes of childhood constipation. Other major causes include poor nutrition and a lack of regular exercise. “We’re now entering that generation where the people who grew up with fast food and things from boxes and cans are having children of their own,” Dr. Ramakrishna says. Then again, just because parents endeavor to serve up a healthful meal doesn’t mean their kids will agree to play along. “Some of these children are just very picky eaters,” Dr. Ramakrishna says. “They may only like certain textures or colors. I actually saw one kid who would only eat red foods!”

Dr. Ramakrishna also recommends that parents begin restricting total dairy intake—milk, cheese, and yogurt—to 24 ounces a day once kids turn 2. “The more dairy they eat or drink, the less other variety of foods they eat and hence may not have a balanced diet,” says Dr. Ramakrishna.

Maureen Apitz, registered dietician, says that when constipated children are referred to her, she recommends that they exercise, drink six to eight glasses of fluids a day, and start eating plenty of fiber. “Mainly,” Apitz says, “that means ingesting fruits and vegetables—with peels is always better!—and whole-grain foods like quinoa and whole-grain breads and cereals.” For kids who may resist suddenly eating whole grains, Apitz recommends starting with whole white wheat bread before transitioning to whole wheat. “Another easy one is popcorn,” she says. “That’s a whole grain.”

For doctors who see this problem, the first order of business is typically to enable the child to clean out their system and get rid of all the hard stool. That can involve a change in diet, increasing exercise, upping water intake and usually prescribing a mild laxative like MiraLAX to truly clean out their system. If the child remains constipated, pediatricians may also suggest that a parent try giving the child an enema or a glycerin suppository to help pass stool. “Of course, there are different ways to achieve a clean out.  Always check with your own pediatrician about what would work best for your child,” Dr. Brown adds. Once the stool is soft again, it becomes easier to convince the child that it’s possible to poop without pain.

“I think about referring to a pediatric gastroenterologist when kids have constipation that doesn’t get better with the treatments that I have recommended,” Dr. Brown says. “If we’ve treated their constipation and their belly pain is still going on, or if they’ve seen blood and there doesn’t appear to be a fissure anymore, I’ll refer them to a specialist.”

Dr. Ramakrishna says that a visit typically begins with taking a detailed history of the child, including whether he or she was born normally or prematurely, what the child eats, and whether there have been painful stools. “Sometimes, we will take an x-ray or blood test to make sure there is nothing else wrong that is leading to constipation,” she says.  “Even if a child has been on stool softeners and has a soft belly, they may still be holding an impressive amount of poop.”

For some kids, though, a key piece of the treatment puzzle can be provided by parents. “A lot of positive reinforcement and trying to avoid the negative, like shouting,” Dr. Ramakrishna says. “I’ve had parents say, ‘He’s doing it on purpose!’ I can see why it might feel that way—the parents can get really stressed out by this—but he’s probably not doing it on purpose. So we say, ‘You know, he may actually be picking up on your stress, and that may be contributing to the problem.’”

The scoop on getting kids to poop

Here are some pediatrician-approved methods for dealing with childhood constipation

  • Offer a half-ounce of prune juice mixed with a half-ounce of water twice a day to babies who are constipated. The prune juice can act as a natural laxative that may get things going.
  • Mix a mild laxative like MiraLAX into water for your child to drink – be sure to follow your own pediatrician’s dosing recommendation.
  • Feed your child whole-grain breads and cereals, and also high-fiber fruits and vegetables such as pears, prunes, apricots, raisins, broccoli, beans, and peas. Holding off on rice and bananas may also help, since those foods can be binding.
  • Increase the amount of water and fluid you child drinks.
  • Increase your child’s daily level of activity. In short, to help get your kid’s system moving, it helps to get the entire kid moving.
  • Place your child on the toilet for five minutes regularly, even if nothing happens. The key here is not to pressure a kid since stress only adds to the problem. Rather, help him or her understand that sitting on the potty is a normal activity that needn’t be accompanied by anxiety. A reward system for sitting on the potty, then for pooping, or for asking to go, can also be helpful.

When you should consider seeing your pediatrician

“If your child is constipated, many times you can start off handling much of this at home,” says Jyoti Ramakrishna, MD, Chief of Pediatric Gastroenterology and Nutrition at Floating Hospital for Children at Tufts Medical Center. “But if you see certain things, you should call your pediatrician.”

  • A distended or hard belly
  • Vomiting that accompanies ongoing constipation issues
  • Weight loss or growth concern
  • Behavioral issues that appear to be escalating
  • Blood in stool or ongoing bowel accidents
  • Loses some bowel control and starts soiling underwear