By Steve Hodges, M.D.
If you know your child is constipated, you’re ahead of the game! As I often note, the signs of a clogged rectum are not well known, and they tend to be overlooked by parents and physicians alike.
But once you spot constipation, how should you go about resolving it?
Even when constipation is detected by doctors, it’s almost always undertreated. I can’t count how many parents have told me they were instructed to give their severely constipated child a small daily dose of MiraLAX.
That’s like putting a Band-Aid on a gaping wound!
Constipation in children is often perceived as a one-time occurrence or a minor ongoing nuisance. In reality, it’s usually a chronic problem — and one that can have lasting consequences. (Just read "Teenage Bedwetting: Everything You’ve Been Told Is Wrong.")
By the time most folks recognize a child is constipated, chances are, the child’s pipes have been clogged for months, if not years. At this point the child needs vigorous measures to clean out the stuffed and stretched colon and extended treatment to prevent a recurrence. Constipation is notorious for coming back, as the habit of holding poop becomes deeply ingrained in children. Even once your child has overcome constipation, you may need to stick with treatment for months, if not years.
The remedies depend on the child’s age and symptoms. A toddler with belly pain will require a different approach than an 8-year-old who wets the bed.
In all cases, it’s important for children to eat primarily whole foods (especially fruits and vegetables), stay active, and drink plenty of water. But lifestyle changes alone typically will not reverse chronic constipation — and almost certainly will not if a child is already having accidents. Many severely constipated children have excellent eating habits.
Here are the treatment approaches I recommend for children of various ages.
•Baby 6 months or older: Many babies become constipated upon starting solid foods, especially if those foods are highly processed. So in addition to avoiding goldfish crackers and the like, start your child on ¼ daily capful of osmotic laxative such as MiraLAX (PEG 3350) or a doctor-prescribed dose of lactulose, and adjust the dose as needed. (Is MiraLAX safe for children? I discuss the issue here.) Use solid or liquid glycerin suppositories on particularly difficult days.
Maintain the daily regimen of laxatives or suppositories until your child is pooping mush every day (see our How's Your Poop? chart) — this could mean weeks or months. Some children need help for years, until they become mature enough to understand the importance of emptying and no longer withhold poop.
•Toddler/preschooler in diapers: Attempting to potty train a constipated child is frustrating, if not futile. Often these are the kids who appear to be “afraid of the toilet,” when, in reality, they fear the pain brought on by trying to pass large, hard stool. Constipation must be 100% resolved prior to toilet training. Start with daily MiraLAX (here are dosing tips) or alternative laxative such as magnesium citrate during potty training and for weeks or months afterward, until you feel certain your child is not withholding.
In addition, wait until the child is around age 3 to start training. While toddlers are physically able to pee and poop on the toilet, they lack the judgment to respond to their bodies’ urges in a timely manner. Even children without a history of constipation often develop the holding habit when they learn to use the toilet. My published research shows that children who train as toddlers, especially before age 2, have a much higher risk of developing enuresis (daytime or nighttime wetting) down the line.
Once you begin toilet training, make sure your child is pooping with feet firmly planted on a stool. This mimics the squatting position, making it easier for the rectum to empty. When a child is sitting upright with feet dangling, the rectum is bent and the child's pooping muscles are not relaxed, so it’s tougher for the child to empty. It’s like trying to poop uphill!
Using a stool is just one of our 7 Super Important Rules for Potty Training Success.
•Potty-trained preschooler who's constipated but not having accidents: Even children who've never been constipated and who have mastered the toilet may suddenly start holding when they hit preschool. Fact is, 3-year-olds don't want to poop. They want to build Lego dump trucks or shop with their toy grocery carts. They definitely don't want to interrupt their teacher during story circle to announce that they need to use the toilet. Whether they feel too inhibited or excited or worried that another kid will steal their puzzle, they suppress the urge to poop, which can have major repercussions in the years that follow.
So before your child starts having accidents, nip this problem in the bud with daily Miralax, magnesium citrate, or lactulose and, on difficult days, solid glycerin suppositories or liquid glycerin enemas. Keep a tall toilet stool and kid-sized toilet seat at all toilets she uses, and insist your preschool does too. Your goal is to make pooping so easy and painless for your child that every day she poops a nice pile that resembles soft-serve ice cream. There's this notion floating around that it's normal for some people to poop every other day or three times a week; it's not. Everyone needs to poop daily.
Make your child's preschool aware of her constipation issues so the teachers can encourage both pooping and peeing at school. As I explain in It's No Accident, holding pee aggravates the bladder and increases the risk the child will start having accidents.
•Potty-trained preschooler who has accidents: Pediatricians often dismiss accidents as “developmentally normal” or a reaction to stress or anxiety, but they are not. If a child can’t seem to “graduate” to fully toilet trained or starts having accidents after being trained, constipation has progressed to the point where a daily enema regimen is in order.
Yes, “daily enema regimen” sounds extreme, but research has proven the regimen I recommend — the Modified O’Regan Protocol (M.O.P.) — to be quite safe and far more reliable for resolving accidents than any other treatment. Sure, it’s extreme — extremely effective. Many physicians, perceiving enemas to be “overly aggressive” and “invasive,” will recommend MiraLAX instead. I have a lot of experience with both approaches, and my published research shows definitively that enemas work better.
•K-12 students who have daytime or nighttime accidents or recurrent urinary tract infections: Many children who escape constipation in preschool become clogged when they enter a school with restrictive bathroom policies or dirty bathrooms or when they get a teacher who rewards them for not using the toilet. Research shows 88% percent of elementary school teachers encourage students to hold their pee in class. (Read about one amazing teacher who bucked the trend!)
Some of my patients develop urinary-tract infections almost every month because they don’t use the bathroom all day long. Others wet the bed or have daytime accidents for the same reason. For these students, nothing will be as effective as daily enemas.
And still, there are children whose constipation is so stubborn that daily pediatric enemas won’t suffice. These kids need large-volume enemas, possibly with stimulants such as glycerin or castile soap, a regimen called M.O.P.+ (described fully in The M.O.P. Book). Yes, it seems impossible that daily pediatric enemas won’t do the job, but that’s the reality for some unlucky kids.
Yes, enemas don’t sound fun, but most kids get used to the routine and feel so much better, physically and emotionally, that they are glad to comply. (Read "11 Ways to Ease Your Child's Fear of Enemas."
Your best bet for avoiding enemas is to keep your child’s poop under constant surveillance — make sure you’re seeing soft-serve ice cream, not pellets or logs! — and aggressively treat constipation at the first sign of trouble. Our children's book Jane and the Giant Poop will get the conversation going! But if your family is already in a situation that requires enemas, don’t waste time with alternatives that sound easier but come up short.