Quite a lot, as it turns out. Here's what's healthy, and what might mean your kid is constipated.
Do you know if your child is pooping pellets, logs, or bumpy sausages? You should—because those variations of poop, all of them firm and formed, indicate a child is constipated.
If, on the other hand, your child’s poop resembles mushy blobs, thin snakes, or soft-serve ice cream, all is well. Pudding, a fresh cow patty, hummus — all good, too!
What many parents don’t realize is that the consistency of poop is a far more reliable indicator of constipation than frequency. (Poop size is helpful, too; XXL toilet-cloggers are a big red flag.) Parents often assume that children who poop daily are not constipated. Google “constipation” and you’ll find the most common definition is “having a bowel movement less than 3 times per week.” But this definition is misleading! Many severely constipated kids poop daily, so frequency isn’t what to look for.
Monitoring your child’s poop, whether it’s delivered to the toilet or a diaper, may not be fun, but it’s an important parenting job at virtually all stages: in the diaper years, during potty training, and—especially—once potty training is complete. With many kids, poop surveillance during the school-age years is necessary, too.
Our handy chart, How’s Your Poop? (see above!) can help your family distinguish healthy poop from poop that signals a child’s pipes are clogged. Print it out, post it on your child’s bathroom wall, and instruct your children to examine their poops and compare it to the pictures. For younger kids, whose reports may not be reliable, you’ll need to peer into the toilet bowl yourself. (Eh, you’ll get used to it.)
In my practice I have often referred families to the Bristol Stool Scale, a chart that ranks poop firmness on a scale from 1 to 7. However, I’ve found that folks get hung up on the number rating when, in reality, all that matters is whether poop is mushy or formed.
Our chart divides poop into two categories: healthy poop (blobs, thin snakes, or soft-serve ice cream) and formed poop (pellets, logs, and “thick & bumpy sausage”), signaling a clogged colon.
That’s it! No rating necessary.
So why is it so important to monitor your child’s poop? Because constipation is not only the top cause of belly pain in children, but it is also the direct cause of virtually all pee accidents, poop accidents, bedwetting, and (in young girls) recurrent urinary tract infections. Yet constipation often goes undetected because the signs can be subtle and are not well known. (For a more extensive list, see 12 Signs a Child is Constipated.)
If you can spot constipation before it becomes chronic, you can save your child from pain—abdominal pain and painful pooping—and possibly years of toileting difficulties. You will also help your family avoid the stress, frustration, and blame that often accompanies toileting troubles.
Every day I see the heavy consequences of constipation in children. Many of my patients can’t go on sleepovers or to sleepaway camp because they wet the bed. Some are teased by their classmates for accidents—even shamed by their teachers and threatened with suspension from school. They internalize the blame heaped upon them and feel crummy. And their parents are exhausted from what seems like an endless struggle.
All this can be prevented—or resolved—by keeping an eye on your child’s poop consistency and by taking aggressive action when your child shows signs of being constipated.
What’s Wrong With Formed Poop?
Human poop isn’t supposed to resemble a Polish kielbasa. When adults have firm poops, due to a low-fiber diet or inactivity, we can get away with it because we empty our bowels in a timely manner. But since kids tend to hold their poop, their stool must stay soft. Otherwise, poop piles up in the rectum—an organ that wasn't designed as a storage facility. The rectum's job is to sense stool is there and to signal that information the brain—that’s all.
When a child ignores these signals and starts storing poop, a large, hard mass forms, stretching the rectum, like a rat in a snake’s belly. This mass presses against and aggravates the child’s bladder, causing it to hiccup and spontaneously empty without any input from the child.
I X-ray all my enuresis patients (yes, X-rays for constipation are safe), and parents are amazed when they see a poop mass literally flattening their child’s bladder. They recognize, on the spot, that their child has no chance of holding pee overnight—and that bedwetting is neither the child’s fault nor a mystery.
A rectal poop pile-up wreaks havoc in other ways, too. Eventually the stretched rectum loses tone, like the stretched-out elastic in worn socks, as well as sensation.
A floppy rectum can’t squeeze down effectively to expel the entire load of poop, so some of it stays in the rectum (that’s why many constipated kids poop daily). Sometimes, poop just drops out, and the child can’t feel it. Parents often cannot fathom how a child can have a poop accident without noticing—they assume the child is acting out. But it’s easily explained and not uncommon.
As for urinary tract infections, these develop because when stool is stored in the rectum, so close to the anus, infection-causing bacteria venture too close to the outside world. These bacteria colonize the perineum (the area between the vagina and anus) and eventually the bladder.
What to Do If Your Child is Constipated
OK, so what if your child is pooping pellets instead of soft-serve ice cream?
That depends on your child’s age and any other symptoms that may be present. It’s important for children to eat primarily whole foods (especially fruits and vegetables), stay active, and drink plenty of water.
However, lifestyle changes alone may not reverse chronic constipation—and definitely will not if a child is already having accidents. All the prune juice and kale in the world will not dislodge a hardened mass of stool that is aggravating the bladder.
Osmotic laxatives such as Miralax (or alternatives) may do the job in some cases; in other cases, glycerin suppositories or enemas are necessary. Talk to your doctor about what treatment is right for your child.
Just keep in mind that a one-time clean-out won’t suffice. The rectum must remain clear day after day in order to shrink back to size and stop wreaking havoc on your child’s insides. If your child is pooping mushy blobs, thin snakes, or soft-serve ice cream, that’s a good sign!
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine. He is co-author, with Suzanne Schlosberg, of It’s No Accident and Bedwetting and Accidents Aren’t Your Fault. His website is bedwettingandaccidents.com.