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Constipation and Abdominal Pain

Constipation and Abdominal Pain by Chafen Watkins Hart, MD

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My 5-year-old daughter loves to ask me to buy Activia, so she can “poop more” and because of her impression, thanks to crafty marketing, that Activia has more vitamins than her favorite yogurt. We see constipation constantly in the pediatric office and it is, no doubt, a struggle for many children in the first world. In contrast, diarrhea is the leading killer of children in the third world.

 Why? Why is constipation so common in children and how do we treat it? The prevalence of chronic childhood constipation is somewhere between 1%-30% when defined as defecation frequency of < 3 times per week. But our definition of constipation is slightly different based on the age of the child.

Babies are frequently “constipated” for short periods of time as they adjust to having solids in their diet or when they transition from breastmilk to formula. However, it is normal for many breastfed infants in their first 3 months to poop very infrequently, sometimes as few as one bowel movement every 7-10 days. If the bowel movement is soft and the baby is not fussy, they are not constipated. In older children, however, it is inevitable that waiting a week to poop would render a very fussy child with abdominal pain.

Constipation can be related to many physiologic factors and some children are particularly sensitive to specific foods, changes in bowel shape, and disruption of the frequency of peristaltic waves which propel digestion. Commonly, we will see an afebrile child with midline abdominal pain or pain around the umbilicus which comes and goes in a crampy nature, and, despite the timing of their last poop, we can be 90% certain they are suffering constipation.

Most frequently, constipation is caused by a slowing of the migrating motor complexes in the bowel and decreased frequency of peristaltic waves which can be a result of viral illness or anxiety or irritation in the small and large bowels. Rare exceptions are the children who have anatomic abnormalities which are usually found at birth when the baby cannot pass meconium. Some children will be periodically constipated despite never seeming sick and consistently growing well with good weight gain. Yet, other children will have pain and constipation chronically and require medication to have regular bowel movements into adulthood.

There are so many conditions we wait for time to solve, but constipation isn’t one of them. As pediatricians, we worry that as time goes on, the child will lose the ability to sense when they need to pass a bowel movement because as their rectum stretches out, full of hard and large stool, the neurons cease to fire properly. Restoring bowel function takes a long time. I’ve seen children whose bowels were resected surgically because they had lost all function through years of abuse and neglect, punishment for not stooling properly. A child should never be punished for pooping at the wrong time or in the wrong place.

After struggling with constipation for a week or two a child can develop encopresis—or the condition where a hard stool obstructs movement in the large intestine and liquid stool leaks from their rectum (i.e., the child whose underwear are constantly soiled but they cannot pass a bowel movement effectively in the toilet). Once she or he has encopresis, a child cannot feel a normal bowel movement and will not be able to stool normally until they have softer stools, often regularly and very easily passed, for 6 weeks to 3 months.

Because of this, we often recommend treating constipation aggressively. Changing diet rarely works well in the pediatric population—food plays less of a role than it does with adults, although sometimes chronically constipated children will take fiber supplements in case it might make a difference. Most of the evidence shows no change based on diet alone. The exception being milk—occasionally toddlers drinking very large amounts of milk ( >20 oz per day) are more susceptible to constipation.

Probiotics are similar—they are not often helpful on their own with acute constipation but can prevent long term constipation issues, especially in a child who has taken multiple courses of antibiotics and has less useful bowel flora.

First line treatment preferred treatment in the child over 6 months old is Miralax or polyethylene glycol. Miralax is very safe, is not absorbed in the gut and does not inhibit nutrient absorption. It helps make stools softer and more frequent by drawing water into the stool. Some children may see effect with a small dose of only a teaspoon or two; however, others may require the full adult dose of a capful or 17 gm per day. Your pediatrician may direct you to go another course—using magnesium citrate as a cleanout or adding Senna or Dulcolax depending on the case.

Two of the most characteristic cases we see in the pediatric office:

  1. A 3-year-old who refuses to poop in the toilet and has been withholding stool for several days. This kid may or may not have recently been doing well passing stool on the toilet but is now refusing and seems scared. He or she may be experiencing recent changes—the birth of a sibling, the start of preschool or a recent illness. With toilet training comes an increased amount of confidence and independence on the part of the toddler. However, there is also increasing anxiety at the knowledge of new-found control. Many kids have secondary gain to withholding as well—they can poop in a pullup at night and perhaps get to stay up later to be cleaned or to debate toilet vs no toilet with parents. The best a parent can do is ensure that they do not become constipated—giving Miralax, working hard to have time on the potty in case they poop. And also it helps if the parent can relax and be very nonchalant and matter of fact about wins and losses—“Great. You went potty. You must feel so much better.” And “Oops there’s an accident. No big deal.” Don’t give in to the power struggle but refuse to care too much one way or another! If the child needs to backtrack and be in a diaper for awhile, this is perfectly fine. The child will lose their fear if they have several soft poops a day such that one sneaks out with urinating on the toilet and they see they have conquered or re-conquered pooping on the potty.

  2. The 5- to 7-year-old who presents with midline abdominal pain, usually in the morning or after dinner or both times of day. They may not remember when they last passed a bowel movement and the parent may not know. They may be having very small hard stools everyday and still be backed up. Typically school has restarted and a few weeks into school, they are forced into a new schedule and anxiety can compound constipation, not to mention an inability to use the bathroom for long periods. Again, using Miralax or Dulcolax to help relieve their pain may be crucial.

Despite these characteristic cases, sometimes we will see a child with chronic constipation sometimes alternating with diarrhea, and we will try to find another reason for the constipation—from a lactose intolerance to a very serious inflammatory bowel disease. Constipation can drive children and parents crazy. As I write right now my 5-year-old says her belly hurts and is laying on the couch and we’re all wondering when was the last time she pooped. 😊