Medicine Mommy

Dr Nické Theron, Pediatrician.

There is such a large variety of normal when it comes to baby and toddler-poo. So how do you know when to start worrying and when is it constipation? I want to explain how the process of constipation works, because then you will understand the treatments better: (Warning: this is quite a “crappy” topic, excuse all the puns! )

Stool-patterns vary by age and diet. The number of stools passed decrease as your baby gets older (with an average of 4-5 stools per day for the first week of life, then 3-4 for the first three months and 1-2 by 2 years of age). In exclusively breastfed infants it can be normal to pass stools 7 times in one day, or only once in 7 days! (If your baby has passed no stools for 10-14 days I would rather help them to prevent a hard stool.) There is also a difference in stool-patterns with different formulas: soy-based formulas produce harder and less frequent stools, while hypo-allergenic formulas can produce looser and more frequent stools.

“When the going gets tough, the tough get going.”

Joseph Kennedy

There are a few developmental milestones in your baby’s life when constipation is more likely to be a problem:
• Introduction of formula
• Introduction of solid food
• Introduction of cow’s milk
• Potty training
• Going to school

Constipation in an infant (below 1 year) is diagnosed when there is a change in the stool pattern for your baby, it looks like your baby has pain / excessive straining while passing the stools AND the stools are large, hard, dry or pellet-like. This last part is especially important, because many babies have dyschezia. This big word just describes what we see with most young babies: they strain, become red in the face and cry before passing a stool. The stool is then always soft, and the baby is otherwise healthy. This is not constipation, but happens because the baby is still too young to coordinate his muscle movements when trying to pass a stool. You can help your baby to relax the pelvic floor by gently bending his hips and bringing his knees up to his stomach. Dyschezia usually resolves as your baby grows and no further treatment is necessary.

Toddlers are prone to constipation when they potty-train, start school or when any other life-altering changes happen in their lives. They can also just be too busy enjoying life to waste time on the loo!

That first hard stools can then trigger a chain-reaction of bad experiences. Painful defecation due to large, hard stools or even anal fissures (a small tear in the skin around the anus) can cause withholding behavior and this turns into a very vicious cycle.

Withholding behavior can be anything associated with not responding to the urge to poo. If you ignore the urge for long enough, it goes away, but the problem does not. Are you ready for the gory details?

The “urge” is triggered by the stretching of the rectal wall (the part of your colon just before the anus) when it is filled with stool. If you do not relax your anal sphincter muscles, the stools are pushed back and the urge goes away. However the rectum is still stretched, and over time becomes less sensitive to stretching when the next stool enters. The rectum’s main function is to extract and conserve as much water as possible. This is why the stool gets harder and more dry the longer it stays in the rectum. Children with fecal loading (where large masses of stool heaps up in their rectum) or impaction (where it is very difficult / painful / impossible for the child to pass the stools without help) can sometimes even seem to have diarrhea when the “newer” stool trickle past the hard stool. This can also manifest as fecal soiling (also called encopresis) where stool leak into the underwear (overflow incontinence).

So when should you worry? And when is it something more than functional constipation (meaning it is a common childhood/lifestyle problem with no serious pathology causing the problem)? Constipation in babies and toddlers are mostly (>95%) functional, so take a step back and relax, this too (like all poo…) shall pass!

RED FLAGS :

(These are signs or symptoms that will worry me if you tell me your baby does not poo and he has one of the following. Please consult your doctor asap.)

• No stools passed in the first 48hrs of life
• Constipation before one month of age
• Associated with other symptoms such as a distended abdomen, vomiting, fever, not passing any gas
• Any blood in / on the stools
• Any abnormalities of the spine, buttocks, genitals or legs
• Not growing well
• Recurrent lung infections

TREATMENT:

To treat any constipation successfully you need to remove the dry, hard stools that are currently causing pain, and then you have to address the cause and keep the next stools soft so that it is easier to pass. It is important to maintain a frequency of at least 1 stool per day.

The treatment of constipation in babies and toddlers differ slightly, although we use mostly the same medication.

BABIES UP TO 1 -2 YEARS:

To help your baby remove the initial hard, dry stools :

Glycerine suppository for babies (you can cut it in ½ or ¼ and insert it with some lubricating jelly). You can also squirt 1ml of liquid glycerine into the anus with a small syringe. This softens the stool and the insertion also stimulates the bowels to pass the stool.

Bend baby’s legs at the hips and push his legs toward his stomach to relax the pelvic floor.

To keep the stools soft:

Diet:

Constipation often occurs after starting a solid diet as there are insufficient fibre and fluid in the transitional diet (often only consisting of cereals). It is thus important to increase the fibre by adding fruit and vegetable purees. Prune, apple, pear and pea purees worked for us. Be aware of banana and sweet potato as these often have the opposite effect. Try to change from rice-cereals to whole-wheat / mixed grain / barley cereals. Try to rather stay away from fruit juices as these contain a lot of sugar and very little fibre.If your baby develops constipation when you change from breast-milk to formula milk, it is worth-while to consult your doctor to discuss the best type of formula to use for your baby. You can also add a teaspoon of olive oil or sorbitol-containing fruit juice to their formula.

If your baby develops constipation when adding cow’s milk to their diet, it is important to ensure that they are not allergic to the cow’s milk.

Medication:

• Lactulose is a safe and effective medication in the treatment of constipation. It is an indigestible and osmotically active sugar, which means they do not absorb any of it and it only works by pulling water into the bowels to soften the stools. It is not “addictive”, it will not make the bowels lazy and you cannot really overdose your baby. It is safe to start with 2.5mls twice a day, and then increase to three times a day / increase the dose by 2.5ml increments until your baby passes 1-2 soft stools per day. Decrease the dose or frequency if the stools become too loose.
• Polyethylene Glycol (PEG) can also safely be given as an osmotic laxative after 6 months of age.
• Glycerine suppositories: Rather keep these for a backup as baby can get used to the anal stimulation to initiate a bowel movement, he needs to stay sensitive to the internal stimulation that the stretching of the bowels provide.
• Do not give stimulant laxatives or enemas to infants.

TODDLERS:

Acute treatment:
If there are any signs of fecal loading / impaction, it is important to first empty the colon to break the vicious cycle of hard, large, dry stools causing pain – causing withholding – causing hard, large, dry stools. This can be done at home or your doctor might feel it is necessary for your child to be admitted if there is a risk of dehydration.

Disimpaction is done by the aggressive use of poly-ethylene glycol (a laxative called PEG eg Pegicol / Miralax), or enemas or a combination of the two. This breaks up and softens the hard stools and enables the child to pass them. Once the colon is empty you can start with phase 2 of the treatment. (It is not necessary to monitor this with X-rays. When your child passes only clear water you will know the bowel is empty).

Maintenance treatment:
It is important that your toddler’s colon is “retrained” to be sensitive to minimal stretching and that the anus can relax and withhold as needed. This takes time. So it is crucial that you and any other caregivers buy into the gameplan for the next 4-6 months.

The treatment consists of a combination of laxative use and behavioural therapy.

In short you need to ensure that your child passes 1-2 soft stools DAILY. You become the laxative-expert by increasing or decreasing the dose as needed. The prescribed laxatives (PEG or lactulose) is very safe and is not absorbed, so you cannot “overdose” your child. It is also safe for long term use and does not cause the bowels to become “lazy” as it does not stimulate contractions of the bowels.

The behavioural therapy adds a crucial part of the treatment. As a child needs to learn and practise walking / talking, they also need to learn and practise a healthy toilet-routine. Start by encouraging and supervising regular “toilet-sitting” times, 2-3 times a day after meals (this is when there is a natural reflex to pass stool, so use all the help you can get). Make these toilet-sitting times fun and stress-free. Sit for 5 min even if there is no poo, and just keep at it. Make sure your child has a good posture on the toilet (a squatting position opens up the pelvis and aligns the rectum in such a way that it is easier to pass a stool) and that they do not have any fears of the toilet. (For some comic relief of all this poo talk, do yourself a favour and watch the video about “The Squatty Potty“).

It is also important in the long term to address the child’s diet to increase fiber and water intake. These are important skills that you teach your children for maintaining healthy bowel habits for the rest of their life, so it is well worth the effort!

RESOURCES:

1. Den Hertog J, van Leengoed E, Kolk F et al; ‘The defecation pattern of healthy term infants up to the age of 3 months.’; Arch Dis Child Fetal Neonatal Ed. 2012 Nov;97(6):F465-70.
2. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko; ‘Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.’; Gastroenterology. 2016 Feb;
3. Nurko S, Zimmerman LA; Evaluation and Treatment of Constipation in Children and Adolescents; Am Fam Physician. 2014 Jul 15;90(2):82-90
4. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA ; Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN; J Pediatr Gastroenterol Nutr. 2014;58(2):258.
5. Dobson P, Rogers J; Assessing and treating faecal incontinence in children. Nurs Stand. 2009; 24(2):49-56
6. Brazzelli M, Griffiths PV, Cody JD, Tappin D; Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011; (12):CD002240
7. Beck DE; Constipation and Functional Bowel Disease; Clin Colon Rectal Surg; 2005 May, 18(2): 120-127
8. Pashankar DS, Loening-Baucke V, Bishop WP; Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children; Arch Pediatr Adolesc Med. 2003 Jul; 157(7):661-4.