At The Forefront Live: Kids and Constipation

The following is a paid program from UChicago Medicine.

Today on At the Forefront Live, we will discuss a common problem that kids face, and that's constipation. Now, most kids don't want to talk about it, but it can be a real issue. What can you do for children who are experiencing tummy aches, less than three bowel movements a week, or other signs of constipation? We'll find out when we talk to our experts right now on At the Forefront Live.

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And joining me today is Dr. Jericho and Dr. DeFrates. They will answer your questions live on the air, so make sure you start typing. Also, we want to remind everyone that today's program is not designed to take the place of an actual visit with your physician. First of all, welcome to the program. Thanks for being here today.

Thank you.

So let's start off and just have each of you tell us a little bit about yourself and what you do here at UChicago Medicine. And Dr. Jericho, if you'll go first?

Oh, sure, of course. My name is Hilary Jericho. I'm a pediatric gastroenterologist. I'm also the director of clinical pediatric research at the University of Chicago Celiac Center. My main focuses are celiac disease and treating patients with celiac disease, in addition to functional disorders, such as functional constipation, irritable bowel syndrome, functional abdominal pain, and similar disorders.

Dr.

Hi. Yes, I'm Dr. Megan DeFrates, and I am a general pediatrician. I am practicing out in one of the university's satellite locations in Flossmoor, and I do general pediatric work. So I see patients from birth to 21 for well checks and sick visits and all other issues.

So today we're going to talk about one of those issues that probably a lot of people don't want to talk about, but it can be very serious, and particularly with the littler ones. It's something that people need to be aware of and need to know how to deal with. And we're going to start off just if he can tell us what constipation actually is.

Great question. So it is true that a lot of times people may think their child is suffering from constipation when, in fact, what may be happening is actually normal bowel habits for that child. So typically what we define as constipation and a lot of times especially in the younger kids-- and we were having this discussion earlier-- for the little ones, oftentimes it's more important to look at the quality of the stool than necessarily the quantity of the stool.

So a very common situation I think we both encounter is children of breastfed moms. So oftentimes these kids actually can absorb the breast milk so well that they actually have very infrequent bowel movements. And actually, for a breastfed baby, having one bowel movement once a week to even every other week could be normal if that child's otherwise happy, healthy, thriving, and the bowel movements that they are having are soft, easy to get out, they're not seeing any mucus in it, bleeding, straining, and the child's otherwise doing well, then that's actually what we consider normal for a breastfed-specific infant.

In older individuals, typically what defines constipation is when children are having two or fewer stools per week. If they're showing obvious signs of withholding behaviors, either straining to hold it in or different withholding behaviors, oftentimes what we see is kids will be crossing their legs. They'll be holding onto something and tightening their buttocks to try to hold the stool in. Or they're having such large, hard, painful stools that, again, it's causing either pain or bleeding with passage or clogging the toilet, or that they're intermittently having accidental leakage of stools can all be signs that they are constipated.

Yeah, I think I think that pretty much covers it. Another thing that I will get frequent phone calls about that really isn't constipation is with the infants, the parents will call and say, my baby is turning really red and straining and trying to go to the bathroom. And then I ask, well, what is it like when it comes out? And they'll say, oh, it's really soft or liquidy poop. And that's not constipation at all. That's infants just kind of figuring out how it all works, figuring out how to relax their butt muscles while contracting their stomach to get things out. And that just gets better over time.

See, and that's interesting because I'm really surprised when you talk about frequency, particularly with the younger children, once every week or even every other week that I would have never guessed that, and I've got kids.

Yeah. Yeah, it's very, very specific to the breastfed babies. Most of the time if the child's a formula-fed child and stooling that infrequently, then we'd be a little bit more concerned. But again, with breast milk, kids have such an amazing capacity to digest it and absorb it, that oftentimes it leaves very little behind to produce stool. And so that's why the variation in breastfed babies is very remarkable.

Some of them will stool after every single feed many, many times a day. But like I said, some of them will absorb so much of that breast milk that it leaves very little behind to produce stool. And those children may be stooling only once a week or every other week. But again, if it's coming out and they're happy, healthy, thriving, and it's nice and soft, and they're not having any other issues, then we're typically not overly concerned.

And again, that probably kind of shows the value of breastfeeding because obviously the nutrients-- shows how valuable that is to the child.

For sure.

Yeah, parents really worry about it, but I just reassure them that once you figure out the baby's pattern, you just have to put a least favorite outfit on that day because there's going to anticipate a pretty big blowout when it happens.

That's true.

So what are some of the common causes of constipation?

Do you want to take this first?

Sure. So I know that there are some times where I can predict that people will come to me concerned about constipation. So one of them is the introduction of solid foods. So the change in diet that can happen from a baby just getting breast milk or formula to adding some solid foods to the mix. And depending on what they're getting, if they're not getting enough fluids or fiber with it, that can be some trouble.

Other would be just kind of some change in behavioral habits. So around potty training there is a little bit of a struggle of will that can happen between parents and their children with wanting them to have to go. And so sometimes kids are kind of fighting the process and holding stool in. And so that's another one that I'll see as a predictable time that parents will come in with concerns about constipation.

Yeah, I think that's-- I agree 100%. Oftentimes the majority of times that we see constipation in kids it's going to fall into what we call functional constipation. And that's typically defined by a child either not getting enough fiber and fluids in the diet, and so the stools take on a drier, harder quality to them and can be harder to pass.

The other aspect of functional constipation is behavioral. And oftentimes what can happen-- again, like Megan saying at kind of these very specific times in kids' lives, oftentimes transitioning from breast milk or to formula or formula adding in solid foods or going to cow's milk or potty training, or even going into a new school setting where the children are a lot more afraid and timid to stool in public, they start to withhold. And oftentimes that withholding behavior leads to the passage of a harder stool. It causes a little bit of pain.

And unfortunately, a lot of young children, they're not mature enough to make that rational decision that, oh, it hurt to have that bowel movement, so I will add some more fiber and fluids in my diet, and I'll sit on the toilet more often, and I'll try to relax and get it out, like an adult might. Oftentimes unfortunately, kids are very, very reactive. And their immediate reaction is, well, that really hurt, so I'm just not going to have a bowel movement ever again. And then as you can imagine, they start to withhold bowel movements.

I think a really important thing to know, especially in the toddlers and something I experience a lot on my video that I have on constipation on YouTube-- my young daughter actually demonstrates this-- that sometimes it can be very, very difficult to differentiate between a child straining to get the stool out and straining to hold it in. And naturally the best position to have a bowel movement is actually a squatting position. It lines everything up properly. It allows the stool to pass easily.

So most of the time, like young children, when they're trying to have a bowel movement, whether they're on a toilet or in a diaper, are going to squat down because that makes it easier. Oftentimes in the younger children, somewhere from the time they're standing-- one year up to two to three years of age maybe, that's about the age range-- parents will often see the child when they have to have a bowel movement go over to a table or some raised surface, they're standing up, they're holding on, they're screaming, turning red in the face, and straining. And the family thinks they're constipated. They're straining to get that stool out, and they can't get it out.

But in reality, most of the time if that's what they're seeing, the kids are actually straining to hold it in. Because most the time if people want to have a successful bowel movement, they're going to squat down because that's easiest, and it's much easier to hold the stool if you're actually standing up and either tightening your butt cheeks or crossing your legs. And so when I see those behaviors, I try to educate the families that, no, actually, I think your child is trying to hold the stool in, and we need to come up with some both behavioral modifications, changes to the diet, and then potentially adding in a medication to help soften the stool to get them past that barrier they're facing.

And depending on, of course, the age of the child, you mentioned something that I think is pretty interesting there, just as far as the positioning, as kids get older and they're using the bathroom on their own, does it make a difference as far as-- we talked a little bit before the show started, so this is where I'm going with this-- having a stool in the bathroom for their feet helpful? You were talking about that.

Yeah, no, absolutely. And actually, amusingly, we were talking about the change and what toilets look like with time and how they used to be much smaller--

Well, construction has changed things. They're a lot taller now. It's just a fact.

And now we're getting huge. And we were saying, on the one side, it's great. It doesn't clog the toilet as much. But on the flip side, yes, a lot of the toilets nowadays are much, much higher. And really ideally, the best position to be in to have a bowel movement that lines everything up is a squatting position.

What I always tell my families is if you think back to our ancestors and to babies who don't know any better and aren't sitting on the toilet, they all squat. And squatting really lines everything up well. Toilets are wonderful inventions. They're very clean. They're very sanitary. Don't get me wrong, but they don't always put you in the best position to have a bowel movement. So yes, being able to do something to help raise up your legs.

Oftentimes with families, a simple and easy intervention, I'll have them just buy one of those foldable stools, the little plastic ones. They're pretty light, pretty inexpensive, and put it next to all of the toilets to put your feet on. And then leaning forward a little bit. Again, like Megan was saying, trying to tighten those abdominal muscles but relax the pelvic floor muscles can be very, very helpful when having a bowel movement.

For the younger kids-- the other thing I talk about on my video on YouTube as well-- is doing things to distract them. And again, to help to involve the muscles, you need to relax the ones, is you can do anything that creates what we call a Valsalva maneuver. So for older individuals, you can do what's called a diaphragmatic breathing to do that. The younger kids don't understand that as well. That's when you breathe in deeply through your nose and relax through your mouth, and the belly goes out and then in.

For the little kids, oftentimes I'll have them get a small deflated balloon or like a little straw works well with the little kids and put a little clay or Play-Doh in the end so it's stuck in there, and have them repeatedly try to blow it out. And one, it's fun. Two, it distracts them. And three, it uses the correct muscles and relaxes the ones they need to. So doing that, plus either being on a small potty so their knees are close to a squatting position, or a big potty, but having that stool under their feet, again, to get them as close to the squatting position as you can, can be extremely helpful in having a bowel movement.

Yeah, I've had people use a pinwheel as another fun thing that kids can do to kind of-- it's hard to clench your butt tight while you're blowing out. And so blowing a pinwheel is distracting and also helps to relax the right muscles.

Another behavioral thing that I'll have parents do is take advantage of what we call the gastrocolic reflex. So right after we eat, things move along to make room for what we just had. And so oftentimes there's an urge to go to the bathroom after a meal. So just kind of setting a time that, OK, every day after breakfast or every day after dinner, whatever time works best for the family and their schedules and routines, that the kid goes and sits in the right position with their feet on a stool, is distracted, is doing those things, and sometimes just being in the right position at the right time really can make things happen, and almost kind of train their bodies to go at that time of day.

And does liquids-- does that? How important is water in all of this?

Want me to take that first?

Go ahead.

So liquids are extremely important. I don't know if we want to bring out-- there's actually a little chart we can show.

Yeah, let's go ahead and bring it. Which graphic is that?

That is the one with the-- there we go, perfect. Daily fluid recommendations by age. So that's a perfect question. So as we were talking about before, in order to have nice, soft poops, there's kind of two main components. One, you want to have enough fiber in the diet, but the second part of that is fluids. And fluids are exceptionally important. And I always tell my families, if you eat the daily recommended fiber intake or way over that, and you don't take enough fluid, it actually can be counterproductive and actually make you more constipated.

So the way fiber works is it binds on to the fluids in your diet and it holds that in your intestines to make your stools nice and soft and easy to pass. So there are very specific fluid recommendations per age. This is a chart I created. It does say water on the top, but actually it's any fluid in the diet. It doesn't have to be water alone. The recommendations--

But water's the best, right?

I mean, water is the most free-- I mean, what you want is things that are going to give you the most free water. So if you drink straight water, that's 100% free water. When you're drinking other things like milk, even technically caffeinated beverages are going to give you some water, but they also act as diuretics, so it's a lot less that you'll be getting. So just about any beverage out there will give you a little bit of free water. But, yes, the best option is going to be straight water because that's 100% free water that you're going to be getting with that.

So most of the recommendations do start above a year of age because really under a year of age those children should be getting exclusively breast milk or formula. You can start to add in a little bit of fluid close to a year of age, but behind me on this graphic you'll see how many ounces per day in the first category. And then I think for a lot of families that's a little bit of a confusing concept to grasp, especially as kids get older, so in the second category I converted that over to what that would mean for cups.

Sometimes I think they're a little bit on the high side for some of these ages, but you'll see, for example, a child one to three years of age, the goal is about six cups of a fluid equivalent per day. Again, if you can get predominately water in there, that's great. Getting things with nutritional content, like milk, you can stick to a skim milk for the older age kids because it has less fat and calories, so it's a little bit healthier, is going to greatly help.

And then we can also bring up the fiber chart if we want, and we can look at how many grams of fiber per day. So this is the one other chart on fiber recommendations per age. So again, what you can see is based on the age of the child. That those children being one to three years of age, the recommendation's about 19 grams. For children four to eight years, it's about 31 grams a day, and so on and so forth.

But as you brought up, very astutely, it is very, very important to have adequate water because that fiber is going to bind to that water and hold it into the gut to soften the stool. So it's always very, very important to not only have fiber, but you always also must have adequate fluids, or you can actually make the situation worse.

And quickly, we can just bring up some foods to give you an idea of what that means. Perfect. Because a lot of times we'll tell families high fiber diet, and then the families look at you like you have a third eye and wonder, well, what does that mean? What is enough? Where do I get this from? So this is a nice list of just many different categories of foods that you can get high fiber options from.

So all fruits are very, very good, such as the berries, pears, apples. A really important thing to know with a lot of fruits and vegetables is that the fiber is predominately in the skin. So it's really important if the children won't eat the skin, to leave the skin on. And that can be very helpful. Nuts are a very good source of fiber, also very healthy for you.

We can go to the next slide, give a couple more options. This is going to talk about different beans. Beans are an amazing source of fiber. So if you eat roughly a cup of navy beans per day, it's going to give you about 19 grams of fiber. So that being said, how many kids love navy beans? That might be a little bit of a challenge-- maybe sticking to some baked beans instead. But they are--

Yeah, so we had broccoli on their earlier, too. That's every kid's favorite right there.

Right. That's always the issue. The healthier, the less they want. With the cereals, too, anything with bran or fiber in the titles typically are a really good option. Again, kids don't always like that. Something like the Mini Wheats, the bite-size Mini Wheats are a little bit sweet. Another one I like a lot-- it didn't make onto this list-- but the Oatmeal Squares. It's something you can do instead of giving your kids the standard pretzels in a bag or goldfish. Getting some of these higher fiber cereal options that have a slight sweetness to them, and the kids oftentimes enjoy eating them as snacks.

So here's a statement, but it's not a question, a statement. Dr. Jericho is great. My daughter saw her and she was one of the key doctors who helped find her diagnosis. So there you go.

Thank you so much.

That was nice. Then we have, how do you feel about MiraLAX? I guess, just in general, for usage.

Yeah, so it's definitely one of our first go-to medications. The thing that's so nice about MiraLAX, or polyethylene glycol, is that it's really easy to give to children. It is a powder, and it's mixed with either water or juice. And it's pretty much, once it dissolves and has lost the grit of the first couple of minutes-- you let it sit a little bit-- it's tasteless and odorless. And so you don't have to fight your kids to take some nasty-tasting medicine.

It's a stool softener, so just kind of like how fiber does where it draws more water into the stool to keep things softer, MiraLAX works by the same way. So it's a stool softener bringing more water to the stool so it's softer and easier to pass. So it doesn't cause that cramping, oh my, goodness, I have to run to the bathroom. I'm in a lot of pain type of thing. It works very gently and nicely.

The other thing I really like about it is that you can titrate it. So it's something that you can easily increase the amount if a child needs a little bit more or decrease the amount if they need a little bit less. And it's kind of easy to play around with a little bit till you get to your desired amount of medicine to produce the desired consistency of stools.

So talk to us a little bit about food allergies. And are there issues here, or should we be concerned about food allergies when it comes to constipation?

So, I guess, I'll start with it, and you can take it from here. There is, I think, a difference that we should point out between food allergy and food intolerances. So allergies are mediated by the immune system. And we talk about kind of IgE being the antibody involved in a food allergy. So usually a classic food allergy would be a kid eats a food and then shortly afterwards have symptoms like itching in the mouth, a difficulty swallowing, hives. Sometimes they will get some stomach related symptoms like vomiting or diarrhea is more common with that. But there are instances that are more of food intolerances that we see that could be related to constipation. I don't know if you want to--

Sure.

--take it from there?

Yeah, this is a situation I see a lot when kind of all else has failed and the children are suffering from constipation. Oftentimes, the most common food that I see-- and actually, oftentimes when we're dealing with constipation, just like Megan's saying, it's oftentimes not a true food allergy. So food allergy most of the time implies going through the allergy pathway, which is what we call an IgE mediated pathway.

The majority of times, even if a specific food is causing issues in the digestive track and causing anywhere from symptoms of reflux and food getting stuck or constipation, many times when you actually do true food allergy testing, it's going to come back negative because much of the time it's what we call a non-IgE mediated process. So the food is causing problems with the digestive tract, but it doesn't go through our normal food allergy pathway. So when you do standard food allergy testing, you're not going to get the answers that you want.

In the case of constipation, I definitely see food triggering constipation in-- I'm trying to think of what percentage. I mean, it's not a huge percentage, but maybe like a quarter of my patients, there is a food that's causing the issues that they're having. And the most common thing I see in kids is cow's milk protein related issues. A good thing to know, a lot of families come across this before coming to me and often get confused what that means.

There are a couple of components of cow's milk that people are familiar with, one being the lactose, which is the sugar or the carbohydrate that's in milk and can cause lactose intolerance. Oftentimes causing things like gas, diarrhea, bloating, cramping. And the treatment in that situation is to get foods either where the lactose is broken down, or there is a pill you can take called a Lactaid pill or lactose pill that will digest the lactose and make you tolerate it better.

Oftentimes when we're dealing with constipation, it's actually the proteins in the milk that are causing the problems, and that's casein and whey. So in situations where we suspect that maybe the child's having an intolerance to a protein in the diet, most often the cow's milk, it's not enough to do a lactose-reduced or lactose-free diet. You actually have to take the casein and the whey away, meaning remove all of these dairy products from the diet and do alternate products. A lot of people like now soy or almond or there's a lot of pea-based products that are very nutritional, such as the Ripple products.

It's an interesting condition in that it seems to be what we call a delayed type reaction. And the reason for that is that that protein that's causing the problems has to get through the whole digestive tract to the rear end, and that's where it causes the issues. It can cause anywhere from not producing the normal secretions to make the poop nice and soft, to having problems with the way the last part of the colon moves and the sphincter relaxes.

So oftentimes I'll hear families reporting that the child eats tons of fiber and fluids and is doing all the right things, but they still are having these stools that are very dry, difficult to pass, and that they have the urge to go, but they sit down and they have a hard time getting it out. And oftentimes then I will resort back to saying, when did this start? And many times families will say, this has been the problem since the very start.

When the kid was born, they went on the formula. And right from the start, it seemed like there was something off. They went to cow's milk at a year, it got worse. And oftentimes that triggers in my mind that maybe there really is a problem here with something in the diet and will trigger me to try taking the child off of cow's milk to see if that helps. So there definitely are components of the diet that can play in.

So we have a couple of questions from viewers I'd like to get to before we run out of time.

Sure.

First one, my son has suffered from chronic constipation his entire life. Recently it's gotten so bad he's gone to the ER for an enema. His X-ray showed his entire intestines were filled with poop. His MiraLAX has been doubled since then and now his bowels are pale yellow. Should I be concerned? What are your thoughts or recommendations? Either one of you can jump on that one, if you will.

Sure. So this is definitely a case where I'd continue to work with your doctor on this. And it sounds like you're going to be in this for the long haul. When we're treating constipation, it's not just for a day or a week or anything like that. It's oftentimes for months that you have to kind of stick with the regimen until the bowel can return to normal.

When kids have been constipated for a while, the bowel gets stretched out. And so those muscles that need to contract to get the stool out are stretched and less effective. So keeping the stool soft for a long time so that the bowel can kind of shrink back down and regain its function is important.

I think part of the question is probably specifically about the color of the stool. Pale yellow can be OK. I know that GI doctors tend to say they don't like poops that are white, black, or red are kind of the alarm colors. And any shades that have some yellow, brown, green, tan, the earth tones, tend to be good.

Usually when there's a little bit of an adjustment period, kind of getting out of this constipation, you can see a little bit of change in the color, and then it should gradually come back. If it's not, then it's definitely something that I would talk to your doctor about.

One thing I would just add super to that is how much-- on the subject of dairy before-- how much dairy is the child drinking per day? Like Megan said, really ideally we don't want more than 2 to 3 cups or 16 to 24 hours a day. Sometimes when kids are drinking excessive amounts of milk, it can cause issues of constipation and give that pale color to the stool. So that would be something I would keep in mind, too.

Sure. One more question from a viewer. My daughter's been holding her bowel movements in. She's currently pooping once or twice a week. It takes her about an hour on the potty to push it out. We have her taking MiraLAX in her beverages, which was recommended by her pediatrician. She gets a lot of fruit and veggies. When she does have a bowel movement, it's a very large amount. It's a battle to get her to go. She was recently potty-trained. But this has been going on since she was in diapers. What should I do? I worry she's not going to grow out of this, as her pediatrician seems to think. From what you've said so far, it didn't sound like this is that unusual.

Yeah, it sounds like a pretty classic story that-- again, it's a long haul, and I tell parents be prepared to work on this for a while. It takes kids a while to kind of unlearn the behavior that they have established because kids are smart. If it hurts to do something, they don't want to do it. And so you want to keep that stool as soft as possible so they forget that it ever hurt to poop.

And the other thing I'll tell people from a behavioral perspective is reward the good behavior of sitting. So even if there's not an outcome, do these things that we discussed, where after a meal, you have the kids sit on the toilet. Have a stool under there. Have a distraction. If they sit for 15, 20 minutes with the-- and they get a favorite toy that you maybe keep to the bathroom. But if they do that, then they get a sticker on the chart. Kids love their sticker charts.

But taking the emphasis off of the actual outcome, just kind of rewarding the behavior. And then work with the doctor on tweaking the amount of the MiraLAX, making sure that there's enough there and that there's enough fluids to support it. Just the same way you need enough fluid to support your fiber, you need enough fluids to support the MiraLAX.

And oftentimes it does get better over time, like most toddler behavior. Things get better and the child starts to forget that it ever hurt and have this new established good behaviors.

Fantastic. That's all the time we have for the program. Thank you for being on the show. Thank you for your great questions. If you want more information, please visit our website site at uchicagomedicine.org, or you can call 888-824-0200. Also, remember to keep an eye on our Facebook page for more events and live programs. Thanks for watching. Hope you have a great week.

This was a paid program from UChicago Medicine.

What can be done for children with tummy aches, fewer than three bowel movements a week, or other signs of constipation? When should children see a doctor? UChicago Medicine experts Hilary Jericho, MD and Megan DeFrates, MD answer these questions and more on this episode of At the Forefront Live.

What are the common causes of constipation?

There are key times parents come to us concerned about constipation. One of them is the introduction of solid foods. The change in diet that can happen from a baby just getting breast milk or formula to adding some solid foods to the mix. And depending on what they're getting, if they're not getting enough fluids or fiber with it, that can cause constipation.

Another time would be a change in behavioral habits, such as potty training. There can be a little bit of a struggle of will that can happen between parents and their children with wanting them to go and having to go. Sometimes kids fight the process and hold stool in.

How can you tell if a child is straining to hold a bowel movement in versus straining to push a bowel movement out?

Sometimes it can be difficult to differentiate between a child straining to get the stool out and straining to hold it in. Naturally, the best position to have a bowel movement is a squatting position. So most of the time, young children are going to squat down when trying to have a bowel movement because that makes it easier.

Oftentimes in the younger children—between one and three years of age—parents will see the child when they have to have a bowel movement go over to a table or some raised surface. They're standing up, they're holding on, they're screaming, turning red in the face, and straining, and the family thinks they're constipated. But in reality, most of the time if that's what they're seeing, the kids are actually straining to hold it in.