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Treatment of constipation





Before you embark on treatment come in for a quick visit (if you have not already done so) to make sure we have the right diagnosis, and that the treatment plan is safe and appropriate for your child.  After your visit, you may proceed with these steps, plus any modifications I may have mentioned during your visit. Also, this page only addresses the treatment of constipation. If you have not already done so, please review my introduction to constipation page first.



Now, before I move on to specifics, let’s first start with an outline of what we’re going to do so you can visualize the plan:



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  1. 1.The clean-out.  Before anything else can happen, the leading “plug” of hard stool backed up in the colon must be removed.  Trust me, it’s there and it’s big. Even non-constipated people could probably use a good clean-out now and then.

  2. 2.Address the cause.  Find out what brought on the constipation, and resolve it.

  3. 3.Maintenance.  While the cause is being addressed, you must be careful not to let a plug redevelop, or you’ll need to start all over again.


Many families experience failure and recurrence when it comes to treatment of constipation, largely because they’re surprised to learn how extensive the problem is, which is why this page is very detailed and specific. If you attend to all of these steps you’ll find we will be highly successful in controlling the constipation the first time around. And yes, this is fairly involved, but trust me on this—the intestines are our life line, and we want to take good care of them. OK, on to the details:




Step One: the clean-out



During your visit with me, you will receive specific instructions on how to do a disimpaction, which is basically a full “clean-out” of the colon. This will be achieved with a solution called Miralax (see below). It’s not a bad idea to do this periodically, I think of it kind of like an oil change. Things get gooped up in there, not a bad idea to flush it out every once in a while! Skipping this step usually results in treatment failure.


About Miralax


Miralax is a tasteless and odorless powder that fully dissolves in any liquid. It is available over-the-counter at pharmacies, and the generic is just fine. Unlike many other laxatives, it is not a “medication” with direct action on the body or intestine, rather it is a simple compound that cannot be absorbed by our intestine, so both it and the water it’s dissolved in just goes right through you. This is why it’s so safe: however much of it you put in one end simply just comes out the other.


As such, Miralax is one of those few modern medicine gems—highly effective, nontoxic, minimal side effects, and is NOT habit forming. The only side effect I’ve ever seen from it has been the intended one: loose stools.



How to use it: again, you will receive specific instruction from me during your visit, but it’ll be helpful to give an overview here. Basically, usually on a Friday evening, you have your child drink a large amount of Miralax. That liquid will work its way through the colon overnight, and your child will begin the emptying process the following day (they usually do not experience any defecation overnight). Expect multiple stools that day, starting more solid and hopefully ending in as close to clear liquid as possible. There is not usually any significant discomfort apart from the sensation of gurgling and mild bloating as things move through them. If they are severely backed up and defecation is painful prior to starting it, though, it may be more comfortable to do a suppository or an enema first, which helps the hard, painful plug to pass more gently:


Pediatric glycerin suppositories are easiest to administer and available over-the-counter; they come with instructions. It’s tapered on one end that insert easily into the rectum.


Pediatric enemas are more effective, and also available over the counter.  Pediatric enemas are a liquid (usually saline or mineral oil) administered rectally. There is nothing better for heavily impacted stool. Here’s a decent page describing how to administer them to children.



 

Can’t we just use prune juice? While this would seem to be a more natural option, it’s not ideal. It has a super high sugar load, not to mention it can make children gassy and uncomfortable due to other contents in the prunes. Same applies to other fruit juices (prunes are just the most effective). So while it does work to some extent, it is often less well tolerated and ultimately less effective as it is limited by side effects. However, eating prunes, or especially their hydrated form (fresh plums), can be a healthy part of preventing constipation along with a nutritious, fiber-rich diet. Which brings us to step two.




Step Two: address the cause



As noted in the first page, constipation is usually caused by a combination of diet and withholding, though exercise and hydration may also play a role. Let’s now talk about how to address these factors, which will prevent recurrence of constipation:


  1. Let’s think of starchy foods as treats, not nourishment. “Kid’s menu” foods like noodles, cheese, bread, crackers, rice, potatoes, bananas, milk, etc., have unnaturally high sticky/starchy/carbohydrate contents. Honestly, they shouldn’t be on the kid’s menu at all. Think about it: why should our kids’ menus be less healthy than our adult menus? But in the same way that we minimize how dangerous driving a car is because we do it so often, we minimize how dangerous these foods are to our health when they are so commonly consumed everywhere that they take on a “normal” label within our diet. Now I’m not a hardcore nutrition buff who denies all enjoyment of such things, I just think it’s helpful to remember that these are treats, not nourishment. Treats are OK. But it’s a good idea to have such treats makeup less than 10% or so of our intake. A 90-10 rule is a good one; 90% fresh vegetables, fruits, meats, and 10% or less of those starchy foods, deserts, treats, processed foods, etc. For ideas on how to achieve this, see my nutrition page.

  2. For infants, avoid rice cereal and bananas.

  3. Prevent withholding. Who wants to take away from playtime by doing something as unpleasant and smelly as pooping? Because of this, many kids hold it until they can’t hold it any longer--which is obviously problematic. Once your child is fully potty trained, make using the bathroom an expectation, but pick a time that doesn’t detract from something more exciting. In other words, try not to pull them from play time to go potty unless necessary. Try to encourage it during downtime or transition before an activity is started, when it’s not yet taking away from anything. It’s just part of a routine, especially something they’re in the bathroom for anyway. For example, after eating breakfast we go into the bathroom, brush our teeth, sit on the potty, and wash our hands. After the hands are washed, then we can play. It’s not a requirement that they poop, but sitting on the potty is at least part of the routine rather than done only when needed. Morning is best; when kids don’t poop in the morning, pooping later may be less likely to happen once the day gets filled with activities.

  4. Try to keep a positive attitude towards bathroom use. Avoid arguments or tension about potty when possible, and try to use positive encouragement rather than negative sentiments. Things likely won’t go as you’d like, but try to be OK with this. Instead of expressing frustration over accidents or refusal to use the bathroom, praise what they are doing well, and say positive things like “I’m so proud of you, even though you’re having a hard time right now, I think you’re doing better overall and I can tell that you’ll have it all figured out in no time!”

  5. Don’t try to potty train early. Potty training too early can be like giving a child a tool that they are not yet mature enough to use correctly. This can lead to withholding in some cases that is difficult to correct.

  6. Breastfeed infants when possible.

  7. Exercise is a way of life.  Movement isn’t something to do begrudgingly on occasion, but something to make part of your lifestyle and routine, something that’s fun. Go chase each other around in the park, even if it’s raining. Roll around in the snow if it’s snowing. Ride your bikes to places together instead of drive. Turn off the TV. Better yet, put it in the basement, and reserve it for special occasions. When exercise is incorporated into your child’s daily routine, they will see it as the norm and continue that lifestyle as they grow older.

  8. Stay hydrated—maintain easy access to water and remember to drink it when you’re thirsty!


  1. Stuck in the loop

    Sometimes kids and adolescents get stuck in a negative feedback loop, with anxiety about pooping due to problems with pooping, that only leads to more problems with pooping and more anxiety. Break the loop by treating the constipation, and backing away from it all. Sometimes it helps for younger kids to stop talking about it entirely and let them do their own thing, as long as they’re on treatment for it you don’t have to worry about backup developing. Maybe they want to go back in diapers for a while and try again later. Be supportive of this. You can always readdress it once the discomfort is long in the past. Let adolescents know that we’ve got it treated now, they don’t need to worry about it anymore. Their colon will slowly return to normal over time, and soon they won’t even know it was ever a problem, all the pain and discomfort will completely fade away.






Step Three: maintenance therapy



Diet changes take time to adapt to, and emotional experience takes even longer to heal. Meanwhile, we need to buy some time for the stretched out colon to shrink back down to normal size and resume normal function. This takes 2-6 months, sometimes up to a year if it’s been going on a really long time. We do not want impaction to recur during this time. This is particularly important for emotional healing, because this is dependent on reforming a positive experience with stooling. If they have a recurrence of a single negative experience during this time, it may heighten their fear and you’ll need to start all over again.


Maintenance therapy


We’ll use the same Miralax that was used for disimpaction, but give a smaller daily dose and maybe add some fiber to make it more comfortable. See dosage chart below. Aim for fluffy, soft stools that pass easily and are formed but not like clay. To give a visual, if you were to pick them up with two fingers, they’d fall apart. The Bristol stool chart is one way to visualize this:




I’ll give you a starting dose below, and you’ll want to adjust it as needed to find the right maintenance dose for your child. I’d like to see primarily type 4 stools on the chart above. Type 3 would be a warning sign to increase your Miralax dose a little bit, and type 6-7 would be a sign to decrease your Miralax dose a little bit. Here is a chart to find your starting dose:



Maintenance dosage starting chart

Infants: depending on size, usually between 1/4 to 1 teaspoon Miralax per day, dissolved in minimum of 1-2 ounces liquid depending on whether you’re on the low end or high end. Start small, increase gradually. Just mix it in with their breast milk or formula.

Children: depending on size, usually between 1 to 3 teaspoons Miralax per day, mixed in water or other liquid. Optional: add in fiber such as Citrucel, 1-2 teaspoons in 4-6 ounces of liquid. This makes bowel movements softer, more consistent and more regular.

Adolescents: around 1 capful in 4-8 ounces of water once daily. Optional: add in fiber such as Citrucel, 1 tablespoon in 8 ounces of water. This makes bowel movements softer, more consistent and more regular.




An important point to keep in mind is try to avoid drastic shifts in medication dosage based on day-to-day stool changes. You will find yourself oscillating wildly between diarrhea and constipation. Give the medication EVERY DAY regardless of the stool pattern, and make only subtle adjustments over time if the stools are generally too runny or generally too dry.


When are you done with maintenance therapy?  When the cause has been clearly addressed, all complications (i.e. hemorrhoids) resolved, and your child has been stooling regularly and effortlessly for at least a few months (typical range 2-6 months). At this point you may gradually begin to taper off the medication. Do not stop it abruptly or you will regret it! Ideally, you may find that the medications taper themselves off as the cause resolves and natural stooling pattern returns, necessitating less and less medication to maintain soft regular stools. That’s a clue that you are probably ready to taper the rest of the medication off. But do so with caution, assessing as you go along, and following up with me if you are unsure.


When medical attention is needed/what to watch for: if you are following this protocol and at any point your child develops vomiting, fever, severe abdominal pain, lethargy (extreme loss of energy or alertness), mucus or blood in the stool, or weight loss, you should stop treatment and contact me right away—it could be that your child has something other than constipation.




Good luck!  And remember to follow-up with me, I like to keep track of your progress.



For other resources on constipation, visit these helpful pages:

HealthyChildren.org constipation page

About.com pediatric constipation page