Pooping can literally be the hardest part of life for some children. My younger son, Ryan, was one of them. From birth, his bowel movements resembled little pellets, unlike the soft mustardy ones that his older brother, Jake, once had. Just before Ryan turned 3 and we wanted to potty train him, things got much worse. Every night, he'd scream from belly pain, and occasionally he'd pass small, watery poops.
In retrospect, I feel foolish for not realizing what was going on -- after all, I am a doctor. My wife and I finally learned the poor kid was so constipated that only a little liquid waste could leak around the concrete-like mass of poop lodged in his intestines, a condition called encopresis. Lacking a normal appetite because of his stomach pain, Ryan started to lose weight. My wife and I knew things were really bad when our evening conversations regularly focused on his bowel habits. One night, I saw an ad on TV featuring Metamucil; its potency was dramatized by a gushing geyser and I found myself fantasizing that Ryan would have a cleansing bowel movement that would be equally energetic.
Clearly, we all needed serious help. Ryan had become trapped in a vicious cycle: he'd been so constipated that every poop was painful for him. as a result, he avoided going at all, which made the situation worse. an X-ray of Ryan's bulging tummy showed the extent of the problem: his entire large intestine (which includes the colon) was "F.O.S." -- medical shorthand for "full of stool." Luckily, once we understood how Ryan had gotten to this point, we were finally able to help him get better.
The Causes of Constipation
Normally, babies poop about four times a day and toddlers go twice daily, although some healthy children only go once every few days. Generally, poops that are hard, painful, or very large (some toddlers regularly clog up the toilet) signal constipation. Although some parents are too embarrassed to discuss their children's bowel habits (after all, it is kind of gross) studies show that one in three infants are constipated briefly (which generally resolves on its own), but about one in 20 become chronically constipated for several weeks or longer.
Sometimes kids get constipated from uncommon conditions like spinal-cord defects, celiac disease (an autoimmune disorder triggered by eating gluten and similar proteins), lead poisoning, or thyroid trouble. But most are like Ryan: Beginning in early childhood, they get caught up in the downward spiral of difficult bowel movements. What starts the whole cycle is not always clear, though in 1998, a study in The New England Journal of Medicine reported that undiagnosed intolerance to cow's milk causes up to 70 percent of infant constipation. Avoiding milk- based formulas can help these kids. (No evidence suggests that the iron in infant formulas leads to constipation, a common misconception. In fact, the American Academy of Pediatrics discourages using low-iron formulas.)
Then there are more unusual causes: The journal Pediatrics once reported that a 3-year-old boy became terribly constipated after seeing a single television commercial, in which the toilet bowl turned into a monster and the toilet seat was a chomping mouth. The toddler developed a paralyzing fear that the potty would "get" him, and he stopped pooping for days. Sometimes bouts of constipation can be caused by other stressful events in a child's life, like the birth of a sibling or parental conflict.
Some experts also blame digestive problems on insufficient dietary fiber, exercise, and water intake. But interestingly, altering a child's diet doesn't play the role in curing constipation that you might think it would. Dinesh Pashankar, M.D., a pediatric gastroenterologist at Yale School of Medicine, tells me that serving fiber-rich foods like prunes or raisins can certainly help a child who has a temporary problem pooping, but it hasn't been shown to be all that beneficial for kids who have a serious, chronic situation. Once pooping gets very painful, many kids do a sort of "constipation dance" when they feel the urge to defecate. (This phenomenon often begins when they're being taught to use a potty.) Some parents assume their child is straining to go, since he's rocking back and forth, stiffening and crossing his legs, and assuming odd postures. However, kids do this for the opposite reason: to stop themselves from pooping by squeezing their sphincter muscles closed. It works.
Over time, the large intestine becomes more bloated and can't return to its normal size. Once it's weakened in this way, the colon isn't able to move poop along. That's why punishing a constipated child or forcing him to try to use the potty will never work.
Get Things Moving
Before you can have any success with toilet training, you must first help empty his enlarged intestine, which is a two-step process. Remember: This plan is designed for children with constipation that's lasted for many weeks -- not those who've only had trouble going for a few days.
Treatment begins with the "cleanout," and this initial unclogging process can take several weeks. The object is to gradually get rid of the rock-hard stool that has accumulated in the colon. Unfortunately, many chronically constipated toddlers need more than two months of intensive laxative treatment to get results. No medical studies have identified a single best method, so parents have several options. (see "Constipation Cures," page 52.) Halfway measures don't work; in 2004, University of Virginia researchers found that adding fiber and water, using laxatives for only a few days, or just waiting out constipation did not help. The study determined that many pediatricians don't recommend a long-enough cleanout and thus delay a child's recovery.
Ryan's pediatrician prescribed a typical regimen. Twice daily, Ryan ate a square of chocolate-flavored Ex-Lax (check with your doctor before giving it to children under 6) and we dissolved Miralax, a tasteless laxative powder, in his morning juice. For the first week, we also inserted a Fleet enema into his bottom each day. Thankfully, Ryan realized that his belly felt better after each enema, so administering them didn't turn out to be a huge battle. During that week, Ryan still produced only pellets, but then things began to improve. The goal was for him to have at least one soft daily poop, and we got there after about three weeks.
In rare instances, laxatives don't help enough and a child may need to undergo endoscopy, in which a soft scope is inserted through the rectum into the colon and the doctor breaks up and extracts the poop. This procedure is typically performed by a pediatric gastroenterologist while the child is under sedation. (These doctors often have a sense of humor about this admittedly disgusting part of their job. When I was at Harvard Medical School, residents would place bets on how much would be removed from a child's bowels. Whoever came closest to guessing the actual weight would get all the money in the "stool pool.")
Get Things Going
With treatment, a child's colon can return to a normal size and shape, and it's critical to continue this treatment while it heals, just as a diabetic child gets insulin or an asthmatic child needs an inhaler. Generally, pediatricians recommend at least three months of ongoing medication, such as a low daily dose of a laxative, after the cleanout. However, research shows that many children need even longer therapy, possibly for years. In 2006, doctors at Yale University compared two of the most popular laxative treatments, Miralax and Milk of Magnesia, in a yearlong study. Most children felt much better after a year of treatment, though Miralax tended to be more effective. However, despite having had a cleanout and long-term treatment, only about one third of the children were completely cured after one year, which underscores the chronic nature of constipation.
As soon as we got Ryan's problem under control -- after about three months -- he became a more pleasant and cooperative child. In retrospect, I realized that he'd probably been in constant pain. He now had fewer tantrums, ate better, and gained weight, and he even seemed to get along better with his brother.
And after six months of treatment, at age 3 1/2, he was finally completely potty trained. Ryan is now 5, and we're continuing to use Miralax for the time being, because it's gentle and has no adverse effects. We've also tried to encourage more fruits, vegetables, and fluids, but we know it's the laxative that's going to be most helpful. At some point in the next year, we'll try reducing the dose and see how he does. In the meantime, my wife and I are just happy to have moved on to more pleasant dinner conversation.
These are four treatment methods that doctors rely on to help children get their system back on track. You may need to try more than one.
An over-the-counter (OTC) laxative that hydrates the intestine and leads to softer bowel movements
Pros: It has no flavor (so kids can't taste it), it dissolves in any beverage, it doesn't cause bloating, and it's highly effective in long-term studies.
Cons: It works only if it's consumed in a full cup of liquid, and it needs to be mixed before each use.
Milk Of Magnesia
Like Miralax, it's an OTC laxative that increases water in the intestine, which can induce softer bowel movements
Pros: It's premixed, requires only a small amount, and is generally effective in long-term studies.
Cons: Many children don't like the taste (one third refuse to drink it), and it may be dangerous in kids with kidney problems.
An indigestible sugar that pulls water into the intestine
Pros: Children need to drink only a small amount for it to be effective, and it may enhance the growth of good bacteria in the intestine.
Cons: Some kids may find the flavor excessively sweet, it's been known to cause gas pain, and it's available only by prescription.
An OTC salt solution that's inserted directly into the rectum to cause bowel movements
Pros: It works quickly and can break up hard stools that obstruct bowel movements.
Cons: It's somewhat uncomfortable for children, it's not suitable for long-term treatment, and it doesn't clean out the whole intestine.
Originally published in the April 2010 issue of Parents magazine.
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