Treating chronic constipation

Before you start 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. 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. Address the cause. Find out what brought on the constipation, and resolve it.
  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 so 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. 

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 Miralax and Senna (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! 

About Miralax

Miralax, or polyethylene glycol 3350, is a tasteless powder that 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. Instead, since it isn't absorbed by our intestine it just flows through one end and out the other. This is why it’s so safe: the very reason it works is that it doesn't stay inside the body.

As such, Miralax is one of those few 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.

About Senna

Senna, AKA sennosides, are naturally-occuring preparations from the dried leaves of the Senna alexandrina plant. They increase bowel motility and help make a bowel movement happen. They may be habit-forming if used regularly, so I advise Senna for short-term use only, with the primary function being to help get bowel movements back on a regular schedule.

How to do a bowel cleanse: usually on a Friday evening, you have your child drink a large amount of Miralax (I'll give you a specific dose during your visit), and a dose of Senna. The liquid will work its way through the colon overnight, and the Senna helps stimulate a bowel movement in the morning when your child will begin the emptying process (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. 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.

What about prune juice or other alternatives? While this would seem to be a more natural option, it’s not ideal. Prune juice 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 and lactulose. Fiber supplements can be great, but they're very unpalatable and difficult for children to take, making compliance extremely low with high failure rates. Natural laxatives like Senna are less well tolerated for long term use, causing cramping and dependency. Magnesium, or Milk of Magnesia, is also indicated for short term use only and can have serious side effects. So while other options do work to some extent, they don't work out well in practice, are less palatable, and are limited by side effects. However, many of these options can work fine for an isolated case of short-term, acute constipation in a child with otherwise normal bowel function. And, 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: addressing the cause

As noted in the first page, constipation is usually caused by a combination of factors. Let’s now talk about how to address them, and prevent recurrence:

  1. Think of starchy foods as treats, not nourishment. Noodles, cheese, bread, crackers, rice, potatoes, bananas, milk, etc., have extremely high sticky/starchy/carbohydrate contents. In the same way that we forget how dangerous driving a car is because we do it so often, we downplay how dangerous these foods are to our children because they are so commonly consumed. Now I don't set out to deny all enjoyment of such things, it’s just helpful to envision them as 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, and breastfeed when possible. If your infant still has issues with constipation, please make sure to come in and discuss it, we'd want to first make sure nothing else is going on.
  3. Prevent withholding. Let's face it, pooping is less fun than playing, so some kids need help building it into their routine. Pick a time for potty that doesn’t take away from something more exciting. Try to encourage it during downtime or transition before an activity is started. Incorporate it into 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 we want to think of sitting on the potty is a regular routine rather than done only when neededMorning 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. Keep a positive attitude towards bathroom use. Avoid arguments or tension about potty, and use positive encouragement rather than negative. Things may not go as you’d like, but try to be OK with this. Instead of expressing frustration over accidents or refusals, 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 too 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. Exercise regularly. Make movement a 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.
  7. Stay hydrated. Maintain easy access to water and remind kids to drink it when they're thirsty! Rather than just tell them to drink, try to get them in the habit of sensing it: "check in with your body—do you feel thirsty right now?"

Stuck in the loop? Sometimes kids get stuck in a negative feedback loop: problems with pooping leads to anxiety about pooping which leads to more withholding which leads to more problems with pooping, etc. 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 for a while, let them pace themselves, as long as they’re on treatment for it you don’t have to worry about backup continuing. Maybe a child working on potty training wants 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 further in the past.

Fun trick: is it sticky? Try this at home with your kids. If a food sticks to your plate when turned vertical, it will stick to your insides, too. Think about rice, noodles, melted cheese, etc. vs carrot sticks or asparagus, etc. For some kids it really helps to visualize what's happening inside them. (Of course this doesn't work for all states of food: drinking milk is also constipating, but you can visualize this more readily outside the body when milk is in its cheese form.)

Step Three: maintenance

Diet changes take time to adapt to, and emotional experience takes even longer to heal. Also, like an arm strapped to your side for months to years, it's going to take a while to build its strength and nerve function back up. Meanwhile, we need to buy some time for everything to resume normal function. This takes around 9-18 months, depending on how long it's been going on and how sensitive your child is about it. It could be less, too, if the constipation is more acute, and there aren't any emotional issues. 

IMPORTANT: Emotional healing is dependent on reforming a positive experience with stooling. If a child has a recurrence of even a single negative experience during this time, it may revive their negative association and you’ll need to start all over again. Far too many times have I seen parents cut treatment short, only to end up starting from square one again and needing it for far longer than they otherwise would have needed. Sometimes the shortest course to treatment is actually the longest, if that makes sense.

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. Here are some suggested doses to start with, but you will be adjusting them as time goes on to find the right amount needed for your child.

  • Infants: depending on size, usually between 1/4 to 1 teaspoon Miralax per day, dissolved in minimum of 2 ounces liquid. Start small, increase gradually. Just mix it in with their breast milk or formula.
  • Children: depending on size, usually between 1 to 4 teaspoons Miralax per day, mixed in water or other liquid. Optional: if compliant, you can also give a fiber supplement such as Citrucel, Benefiber, etc., 1-2 teaspoons in 4-6 ounces of liquid (not the same liquid as the Miralax). This makes bowel movements softer, more consistent and more regular, and may reduce the amount of Miralax you need.
  • Adolescents: around 1 capful in 4-8 ounces of water once daily. Optional: if compliant, you can also give a fiber supplement such as Citrucel, Benefiber, etc., 1 tablespoon in 8 ounces of water (not the same water as the Miralax). This makes bowel movements softer, more consistent and more regular, and may reduce the amount of Miralax you need.

How to adjust your dose: Dose is not based on size or weight, it's based on each individual child's needs, diet, colon motility, etc. You'll want to adjust as needed to create daily, easy to pass stools that are formed but not like dry clay. To give a visual, if you were to pick them up with two fingers, they’d fall apart. The Bristol stool chart is a great way to visualize this, we'd like to see type 4-5:

bristol stool chart.jpg

Again, type 4-5 would be perfect. Type 3 would be a warning sign to increase your Miralax dose a little bit, and type 6-7 on a consist basis would be a sign to decrease your Miralax dose a little bit. But 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 (i.e. weekly) 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, fissures, fears) resolved, and your child has been stooling regularly and effortlessly for several months (typical range 9-18 months for chronic constipation, give or take). It's generally best to see me first before stopping your medicine so that we can go over your progress, talk about weaning and prevention of recurrence. At this point we may begin to gradually 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 again 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.

For other resources on constipation, visit these helpful pages:

Follow-up: you'll want to come in for some follow-up visits with me throughout the process, usually many questions arise and modifications may be needed. Typically, we'll want to do at least an initial followup 3-4 weeks in, and a final followup 9-18 months later when ready to stop the maintenance. 

Same-day appointments

For urgent needs, same-day appointments are available Monday through Friday. Please call as early in the day as possible, the more notice we have the easier it is to fit everyone in. 

Need help outside of office hours?

Firstly, if your child has an emergency, please call 911 or go directly to the ER - they will contact us if needed once your child has been evaluated.

Urgent Care centers can also be helpful when something needs to be seen outside of office hours but it's not an emergency. 

For our list of preferred Urgent Cares and ERs, see our resources page.

And if you have something that might need urgent attention but you're not sure/don't know what to do, we can help: