Constipation

Background

 

Constipation is defined as having hard stools that are difficult to pass. It is not related to how often someone passes a stool.

 

The cause is often multifactorial. Different factors that can cause constipation include diet, microbiome imbalances, and physical problems with stooling.

 

What To Do

 

All degrees of constipation require treatment with stool softeners, diet changes, and modifying toileting behaviours.

 

Stool Softeners

 

Depending on how bad the constipation is, the doctor may recommend that you do some sort of a clean out to get rid of all the stool that is currently backed up inside your child. There are a number of different clean out regimens. The doctor will give you a handout that describes the specific one they recommend.

 

The stool softener that is most commonly used is called PEG 3350. There are lots of different brand names, including Restorax, Laxaday, MiraLax and GlycoLax. There are many no name or generic versions as well. As they are all the same, we recommend that you buy the largest, cheapest bottle you can find.

 

The doctor will give you a starting dose based on your child’s weight. The recommendations on the bottle state to mix the powder in 250 mL of water. But for younger children that is a lot of fluid to drink at once. You can mix it in as little as 125 mL for a full 17 g capful. Smaller amounts of powder can be mixed in similarly smaller amounts of water. However, the dose needs to be drunk in one sitting, within about 20 minutes. If it is put in a bottle of water that is sipped all day, it will not work.

 

The starting dose is just that. Use that dose for about 5 to 7 days to see how it works. If your child’s stools are still hard, then increase the dose by 2-4 g. If they are becoming too loose, then decrease the dose similarly. If they have a good stool one day and then a hard stool the next day, then they may need twice daily dosing. Continue to adjust the dose both in amount and frequency until you figure out what works for your child. If you cannot find a dose that works after about 4 to 6 weeks then please arrange follow up.

 

Diet

 

It is important that your child eats a well-balanced diet with lots of fibre. Fibre is best incorporated as a regular part of their diet by eating lots of fresh fruits and vegetables, beans/lentils and whole grains. They should drink lots of water and milk should be limited to no more than 500 mL/16 ounces per day. For some children, these diet changes may take quite a bit of time to implement. In the meantime, the easiest way to get fibre into the diet is to use bran. You can use regular bran cereal such as Bran Flakes or Bran Buds. Do not use Raisin Bran as it is coated with sugar and the raisins are a choking hazard for very young children. You may give the bran to your child as cereal, you can make them some sort of "trail mix" or crush it and sprinkle it into other foods that they will eat such as pasta sauce. Your doctor may also give you a handout with some diet suggestions.

 

Toileting Behaviours

 

Regardless of the initial cause of the constipation, many children start to associate pooping with pain, and as a result start to hold in their stool. This makes the constipation worse, and it becomes a vicious cycle. If your child is toilet training age, wait until the constipation is under control before trying to toilet train them for stool.

 

As the stool withholding is a control issue, it is important to take away that control. This is where we do something called schedule toileting. It is important to have your child sit on the toilet multiple times every day. Do it at the natural transition times of a daily schedule, so that going to the toilet does not become a battle. Examples of transition times include first thing in the morning, before/after meals, leaving for school/daycare, before/after recess, before leaving school/ daycare, getting home from school/daycare and before bed.

 

Have your child sit on the toilet for 30 seconds to “see if any poop is ready to come out”. The messaging is very important. If you tell your child they need to try to stool then they have the control. If you tell them to sit and wait to see if the stool is ready, then it is in control of the stool, not the child. It only needs to be 30 seconds to help with cooperation. You can have a simple timer, such as an egg timer so the child can see the passage of the time. Alternatively, you can have a "bathroom song" that lasts for the 30 seconds. If there are no results, praise your child for staying on the toilet, state that "the poop wasn't ready" and that s/he will try again later. Eventually, your child starts to relax while sitting on the toilet and the normal voiding coordination pattern will return and your child will stool. Once they have developed a regular stooling pattern, you can stop the schedule toileting.

 

Once everything is under control, you can then start weaning off the PEG 3350. We recommend you wean by decreasing the dose by 2-4 g weekly. If the stools start to get hard again, then stay at that dose for at least a month until you try to wean again.

 

When to Be Concerned:

 

Your child should be seen in follow up if:

 

1) You cannot get their stool soft with the PEG 3350 or their stools are too soft.

 

2) Despite a diet rich in fibre, you are unable to wean them off of the PEG 3350.

 

3) You have been doing scheduled toileting for a couple of months, your child's stools are soft, but they still will not stool on the toilet.

 

4) persistent blood in the stool

 

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