Poop jokes are not my favorite kind of jokes. But they are a solid number two!!

Joking aside, constipation can be a major pain in the behind. I just can’t stop myself!

Let’s get down to business. Constipation is NOT HOW OFTEN you go, but what it looks like WHEN you go. I have infant patients who only poop every 8-10 days, and what comes out when they finally poop is a volcanic explosion of the normal newborn yellow, seedy stools. Children can have vastly different pooping patterns, some poop three times a day, others poop once a week, and that is their own normal pattern. However, hard to pass, rabbit pellet or large hard balls of stool are never normal. “Normal” stools are Type 3 and Type 4 on the Bristol stool scale.

That’s right, enjoy the pictures of poop while you’re perusing this article during your lunch break; the things we do for our kids is special, right?!

Constipation is usually diet-related due to picky eaters. Favorite foods of toddlers and children that can worsen constipation include: bananas, sweet potatoes, milk, cheese, crackers, bread, pasta, and cookies. You can add a few things into your child’s diet to help relieve the hard stools: yogurt, probiotic, fiber gummies, flax and chia seeds, plenty of water (six or more cups per day for elementary age and older) and eating high fiber fruits and vegetables (think celery, spinach, apples with skin, berries). Also, a sedentary body will be more prone to constipation, so get up and get at least 1 hour of strenuous physical activity daily.

After making dietary changes, the treatment of constipation depends on the age of your child.

For infants who are solely on breastmilk and/or formula and truly are constipated, you can help facilitate a stool by checking his or her rectal temperature, or massaging the tummy in a clockwise motion.

For infants older than 6 months who have started pureed foods, remember the “p” foods help you poop: pears, peaches, prunes. So offer “p” fruit jars and a variety of green vegetables. You can also give 2-4 ounces of an electrolyte solution, such as Pedialyte, per day to add more fluids into the gut.

For toddlers, elementary age and beyond, discuss with your doctor if medication can be helpful. Over-the-counter stool softeners, such as Miralax, used short term can add fiber bulking to the stool and start allowing it to pass more comfortably. Give this a few days to work, it is not a magic quick fix as it is not a laxative. Your doctor may consider prescribing a laxative medication (I sometimes prescribe lactulose for my patients) if his or her symptoms warrant its use.

There are several medical reasons why your child may be constipated, so a problematic pooper is precisely a proper purpose to pop it to your pediatrician.

Commonly recommended ways to prevent constipation are to drink water, exercise, and eat fruits, vegetables and fiber-rich foods. Yet even when we use these techniques, our children still sometimes get constipated. Whether its contributing to stomach ache, delayed toilet training, bedwetting, or missed school, constipation is no laughing matter.

“But my child poops every day! My child can’t be constipated!”

Even if your child stools every day, he or she may be constipated. Think about your office desk; you may clear papers off regularly, but if you are not clearing as many papers as are building up, you will soon have a messy desk. Children may poop every day and still not be fully emptying their intestines. When constipation develops, the extra stool causes the intestines to stretch. Once this happens, the intestines may not be able to move as well, which leads to more constipation, and it becomes a vicious cycle. In infants constipation can be particularly hard to recognize because in this age group it is can be normal to have less than one stool per day.  Parents should look for a change in the frequency of stools along with firm stools when considering constipation. 

“What now?”

The good news is that constipation can often be treated with dietary changes. The key to making the treatment stick is continuing it long enough. If you stop too soon, the intestines have not had time to heal, and the constipation returns. As a physician who often sees this condition, I recommend treating constipation for as long as it has been a problem. For example, if constipation has been an ongoing problem for one month, treatment typically lasts at least one month. Treatment also depends on your child’s age.

• For infants over the age of two months, ask your pediatrician about giving small amounts of prune juice or pear juice.
• For a toddler, in addition to pear, apple, or prune juice, consider adding high fiber foods such as pears, peaches, and whole-grain cereals to his or her diet.
• School age children or teenagers can learn about which foods will help improve their symptoms and can then get involved in choosing foods that are fiber-rich and appealing to them.
• In cases that do not respond to dietary changes or are more severe, your pediatrician may recommend a medication to help treat the problem.

Contact your child’s doctor if you have any questions or concerns about your child and constipation.

Following our posts on the safety of Miralax and answering some frequently asked questions about Miralax use for constipation, we heard one resounding question:

"When should I be worried and when should more workup be done?"

Benign (or not concerning) causes:

• Constipation starts with a dietary change or at the time of toilet training
• Children show a stool withholding behavior
• Things resolve easily with stool softeners

But what are the warning signs? When should you be worried? Here are nine symptoms or signs that more workup should be considered for your child’s constipation:

1. Constipation has been present since birth or early infancy
2. Any other symptoms with constipation-fever, vomiting or diarrhea
3. Bleeding in the stool or from the rectum
4. Swelling or distension of the belly
5. Long, narrow stools (sometimes called “ribbon stools”)
6. Urinary accidents or recurrent urinary tract infections
7. Poor growth or weight loss
8. Other, non-belly symptoms, especially neurologic symptoms like weakness or abnormal sensation in the legs
9. Abnormal findings in the lower back (birthmarks or hair along the spine)

The workup for constipation can vary depending on the child’s symptoms and exam findings. Some things that might be considered:

Imaging -Most commonly the child will undergo a barium enema which is an X-ray that is enhanced by an enema that shows up on the X-ray. If there are concerns about the child’s neurologic symptoms, an MRI of the spine can be conducted to rule out something called a tethered cord.

Blood work - Depending on the child’s symptoms, blood testing for the following could be indicated: celiac or thyroid disease, calclium and blood lead levels.

In severe constipation or constipation that does not resolve, a referral to a gastrointestinal doctor can be helpful for further workup and treatment recommendations.

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If you missed the first story, please check it out here. Now for some constipation and Miralax AMA responses:

1.Is short term use of MiraLax for a colonoscopy OK?

Quite a few studies have looked at short-term use of MiraLax for bowel regimens for colonoscopy, which showed MiraLax to be safe and effective (and much more tolerable than more “aggressive” regimens).

2.What are the diet modifications for treating constipation?

Foods that are high in fiber should be offered to children who are experiencing constipation. Some examples would be high-fiber cereal (more than 5 grams per serving), fruits (pears, strawberries, apple with skin, dried fruits) and vegetables (beans, sweet potato, lentils). Children should also be encouraged to drink 32-64 ounces of water per day. One common cause of constipation is ingestions of more than 32 ounces of cow’s milk.

3.What are the treatment alternatives for MiraLax?

Of course, diet and fluid intake are the primary means of treatment and should be for all children. There are other medication alternatives to MiraLax. Some work like MiraLax and are osmotic (draw fluids into the bowels) but others are stimulating (they cause the intestines to contract). Each has its own side effect profile so I would recommend discussing with your pediatrician.

4.Is there tolerance or dependence on MiraLax over time?

According to the available information about MiraLax, there should be no reason to believe that a tolerance to MiraLax could develop. Kids should be transitioned to a high-fiber diet and weaned off MiraLax as soon as possible.

5.Are probiotics an option for treating constipation?

A few small studies looked at the use of certain probiotics for constipation, but nothing I can find on a large scale study or a firm suggestion of which bacterial strains and dosage should be included.

6.Is MiraLax absorbed into the bloodstream?

Based on the available information, there is no reason to believe that MiraLax is absorbed into the bloodstream. A current study in Philadelphia is intended to better address this question by assessing if small amounts of the substance or bi-products are present in the child’s blood.

7.Would you give your child MiraLax?

Given the available information, if my children had problems with constipation that couldn’t be relieved with diet modifications, I would feel comfortable giving MiraLax to them. Should further information from the Philadelphia study surface, I would definitely want to take that into consideration.

Constipation is the cause of alllllll the things. Just joking.

No, but really – it’s one of the most common things I see in my office at Willow Park, and it causes strange problems sometimes. Parents often don't believe me when I tell them it's constipation causing the problem. 

What is constipation? It doesn't necessarily mean your child isn't stooling daily. A kiddo can be constipated and poop many times a day. Constipation means hard, dry stools. They’re often painful to push out. And yes, most kids with constipation will go a few days between stools.

I really feel that constipation has become more prevalent over the years because of how our kids' diets have changed. In general, kids are eating less fresh fruits and veggies and depending more on packaged goods for snacks and meals. 

There are lots of medical causes for constipation as well. Did you know that hard poops can cause:

1. Stomach pain
2. Withholding of stool
3. Vomiting
4. Refusal to eat
5. New urinary accidents
6. Wetting the bed
7. Diarrhea
8. Poop accidents 
9. Blood in stools, blood in diaper
10. Fever (yes it can cause fever! mostly lowgrade)

Here's the deal - and let's get down and dirty about it. The things your kids eat affect the quality of their poop. If they eat and drink things that don't have much fiber (think cheese, yogurt, pastas, cookies, white bread, bananas, milk, goldfish crackers), their stools will be harder. 

Also, did you know our bodies absorb water out of our stools if we need it? So if your kiddo isn't drinking enough water, his body will just take it out of the poop, and it will become hard. 

The poop gathers at the “end of the tube” in a child’s body – the rectum and descending colon – and stretches everything out a lot. See the pic. This chronic distension leads to problems with the “valves” inside the rectum. Sometimes, this leads to leaking – soft stools can leak out without the child being able to control it. 

These big bulky stools can also push on neighboring organs, like the bladder, and even push urine out sometimes. And children with chronic constipation tend to develop poor control of their pelvic muscles and can lose control over their bladder, leading to leaking. One study showed that after being treated for constipation, 89% of 250 kids had complete resolution of their daytime wetting problems.

When the stools become hard, they hurt to push out. So kids don’t want to poop. So they hold it in. And the body slowly takes water out of it. And the stools get harder. And more difficult and painful to push out. Thus starts the painful cycle. 

Kids can get constipated anytime, but I find it’s most common 1) when babies start solid foods, 2) when kids start potty training, and 3) when kids start school.

So how do you fix the problem? Well, that depends on the severity of the problem and the age of the kiddo. But some general rules:

1. WATER. LOTS OF IT. Children and teens should drink at least 6 to 8 cups of water a day. 
2. Fresh fruits and veggies! I encourage kids to eat green veggies, prunes and other fruits (but not bananas), bran, whole grain bread. Sometimes those puree pouches with the kale, spinach, and broccoli are a good start for the picky kids.
3. Certain fruit juices – ok, we pediatricians are NOT big fans of juice. But I’ll make an exception in this case – go with prune, or pear.
4. Fiber supplements – flax seeds are great. Fiber gummies and cookies are good, too.
5. Behavioral and schedule changes – encourage a routine for “potty time”. 20-30 min after meals, have your kiddo sit on the toilet for 5 minutes. Encourage your child to listen to his body and stop playing when he feels the urge to “go” (and not hold it in). 
6. Do not punish your child, or get mad, if he has an accident (urine or stool) – remember, this isn’t under his control!
7. Avoid those foods I mentioned before for a few days – bananas, cheese, crackers, milk (if over age 1), breads, pastas.

If there is anything I can’t express enough to parents – it’s BE PATIENT! It takes many months for the intestines to stretch out and constipation to form in toddlers and children, and it takes many months (sometimes even years) to treat it. Sometimes we use safe laxatives or glycerin suppositories to help during the really rough patches – call or come visit us to talk more about that if you think its necessary. 

Hugs,Dr. Poop (er, Diane)

Fiber is a part of plant foods (ex: whole grains, vegetables, fruit) that our bodies can’t digest.

There are two types: soluble and insoluble. Soluble fiber is most helpful for lowering cholesterol, and insoluble fiber is like a scrub brush that helps to prevent constipation. Most foods deliver a mix of soluble and insoluble fiber.

Most children and adults alike aren’t getting enough fiber in their diet each day. Are you?

Here is a table of recommended intakes:

To increase fiber intake, eat more vegetables, choose fruit instead of fruit juice, and choose whole grains such as brown rice instead of white rice. Be careful to increase fiber slowly, and increase water intake as you do to avoid bloating and gas.  

So, add some fiber to your summertime cookouts!

Grilling vegetables adds a new dimension to their flavor. Slice vegetables with skin still intact, brush with some olive oil, season to taste, and toss on the grill. You can add grilled bell pepper or onion to your sandwiches, or make a side of grilled vegetables to go with your meal. Try this recipe to get started.

If grilling vegetables doesn’t appeal to you, here are a few other options:

• Try a variety of vegetables dipped in salsa, hummus or light ranch dressing.
• Add a fruit salad for a side or dessert.
• Choose whole wheat buns for sandwiches.

* Moshfegh A, Goldman J, Cleveland L. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intake From Foods as Compared to Dietary Reference Intakes. U.S. Department of Agriculture, Agricultural Research Service, 2005.

About the author

Lauren Mullins is a clinical dietitian for the Endocrinology department’s REACH clinic at Cook Children’s.