Definition: Constipation means that bowel movements are difficult or painful to pass and less frequent than usual. A child with constipation feels an urge to have a bowel movement (BM), has discomfort in the anal area, and is unable to pass a BM after straining and pushing for more than 10 minutes. Going 3 or more days without a BM can be considered constipation, but can be normal in some children. Your child is only constipated if the infrequent BMs are associated with hard stools that are difficult to pass. Some children have infrequent stools that are soft; this is normal.

“My infant grunts and seems to have a difficult time passing stool. Is that constipation?”
Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during the passage of bowel movements. However, the stool that they pass is soft. These behaviors are normal and should remind us that it is difficult to have a BM while lying down. It should also be noted that babies who are exclusively breastfed have a wide variance in the amount of stools that they pass. Some breasted babies occasionally can go 5-7 days without passing stool. Unless your breastfed baby is having hard stools or other problems, we would not generally consider him or her to be constipated.

Cause: Constipation is often due to a diet that does not include enough fiber. Drinking or eating too many milk products can also contribute to constipation. Sometimes constipation is caused by repeatedly waiting too long to go to the bathroom, holding it in until the stool is so large that it is painful to pass. The memory of painful passage of BMs can make young children hold in stool, worsening the problem.

Expected course: Changes in the diet usually relieve constipation. When your child is better, be sure to continue the non-constipating diet so that it does not happen again. Occasionally changes in the diet may not relieve the constipation, or children will not eat the foods needed to soften their stools. These children require a stool softener.

Anal fissure: Sometimes trauma to the anal canal during constipation causes an anal fissure (a small tear). If your child has an anal fissure you may find small amounts of bright red blood on the toilet tissue or the stool surface. This tear will heal quickly on its own once the stool is soft and not re-injuring the skin on the way out.

Home Care and Diet

Diet treatment for infants less than 1 year of age
Give prune or pear juice (1 oz.) once or twice each day. If your child is over 4 months old, add strained foods with high fiber such as prunes, figs, dates, pears, cherries, plums, blueberries, beans, or peas twice daily.

Diet treatment for children over 1 year of age

• Feed your child fruits and vegetables at least 3 times per day. Be careful to avoid foods that your child can’t chew easily. Good foods include prunes, figs, dates, peaches, cherries, pears, apricots, blueberries, beans, peas, cauliflower, broccoli and cabbage. (Do not give uncooked vegetables to children less than 3 years of age due to the risk of choking)
• Increase bran, which is a natural stool softener because it has high fiber content. Sources of bran include cereals (check the labels), bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, brown rice or whole wheat bread and whole grain pasta.
• Decrease the amount of constipating foods that your child eats, such as milk, ice-cream, yogurt and cheese. Be sure to provide 1200mg of calcium, or about 4 servings, each day. Juices, breads or other foods supplemented with calcium can help you to meet this need.
• Give prune or pear juice to drink each day to a maximum of 6-8 oz. per day.

We also have recipes available to give you for non-constipating food ideas.
Please ask you medical provider or medical assistant for this hand-out.
Sitting on the toilet (if your child is toilet trained)
Encourage a regular bowel pattern by having your child sit on the toilet for 10 minutes after meals. If your child is resisting toilet training by holding in stool, stop the toilet training for a while.

Stool softeners
If a change in diet does not relieve the constipation, or if your picky eater won’t allow for a change in diet, bring your child to our office for an appointment to discuss the use of a stool softener. Stool softeners are not habit forming. They stay in the gut to soften stool and are not absorbed into the body. Stool softeners work 8-12 hours after they are taken. If they do not work, the dose is usually too low. You can safely increase the dosage upward until your child has soft stools regularly. We can help you with this.

Stool softeners should be used every day as directed by your doctor. Continue these medications for at least 4-6 weeks, even if your child’s stools have softened and seem normal. Stopping too early usually results in recurrence of constipation. After 4-6 weeks of softener use every day, try giving them every other day and watch closely for signs of constipation. If your child has soft stools while taking the medications every other day, it is OK to try to stop them. If constipation recurs it may be necessary to restart the stool softeners and then continue them for a longer period of time.

Relieving rectal pain
If your child has rectal pain requiring immediate relief, one of the following will usually provide quick relief: sitting in a warm bath to relax the anal sphincter, inserting a glycerin suppository through the anus, or gently putting a thermometer in the anus for 10 seconds to stimulate the rectal muscle. Do not use suppositories, enemas, or rectal stimulation regularly to remove stool. These can cause irritation or tears of the anus, resulting in pain and stool holding.

Call our office if your child develops severe rectal or abdominal pain, your child does not have a bowel movement after 3 days on the non-constipating diet or if you have other questions or concerns.

* Adapted from Instructions for Pediatric Patients, 2nd Edition, 1999 by WB Saunders Company *

Dosing Chart for Laxatives

* 5 milliliters (mL) = one teaspoon (tsp.)

Laxative	Dosage	Comments
Lubricant Mineral Oil **	½ to 1 ½ mL/pound/day, in a single dose or two divided doses	Should not be used in a child who is less than 1 year of age, has gastro-esophageal reflux, a swallowing disorder, or severe respiratory problems. Do not give just before bedtime.
Softeners Lactulose ** Milk of Magnesia ** Miralax **	½ to 1 ½ mL/pound/day, in 2 divided doses ½ to 1 ½ mL/pound/day, in 2 divided doses ½ to 1 ½ capful per day in a single dose, mixed with 8 oz. fluid	Side effects: flatulence, abdominal cramps Use with caution in infants and children with kidney problems Side effects: flatulence, diarrhea
Stimulants Senokot	2-6 years old: ½ to 1 ½ tsp. per day in a single dose 6-12 years old: 1-3 tsp. per day in a single dose	Contains a stimulant and is therefore not to be used for prolonged periods.

** Adjust the dose of these laxatives to induce a daily bowel movement for 1-2 months, and then slowly wean. We can help you with this.

* Adapted from Contemporary Pediatrics, Managing constipation: Evidence pt to practice, December 2001, vol 18, no. 12, pg 63. *