How to Treat Constipation in Infants

Constipation is Common Yet Treatable in Infants

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How is constipation treated in infants?. PhotoAlto/Anne-Sophie Bost/PhotoAlto Agency RF Collections/Getty Images

Constipation is a common problem for infants and children and is the reason for almost three percent of visits to a pediatrician. What do you need to know and what treatments are available?

Constipation in Infants: Definition

Constipation is usually defined as having infrequent bowel movements that are hard and painful. This is often the case with older children and adults, but the definition is slightly different in infants.

Infants who strain or groan when they have a bowel movement are likely not constipated if their stool is soft, even if they only have a bowel movement every two or three days. It is also important to remember that many infants who are exclusively breastfed only have a bowel movement once every week or two.

While there are some medical causes of constipation, such as Hirschsprung's disease, cystic fibrosis, and hypothyroidism, most children who are constipated are in normal health. Warning signs that may indicate a more serious condition is present include vomiting, weight loss, poor weight gain, fever, abdominal distention, having a poor appetite, or being severely constipated since birth.

Causes of Constipation in Infants

One of the things that is frustrating for parents is trying to understand the causes of their child's constipation. Although some parents understand the role that too much cow's milk, a diet low in fiber, and not drinking enough fluids have in contributing to constipation, they may have other children with the same diet who aren't constipated.

In addition to your child's diet, the other main factor that contributes to constipation is having infrequent bowel movements. This often occurs after a child has had a large, hard and painful bowel movement. Because he may associate having a bowel movement with pain after this experience, he will try to hold his stools.

This creates a vicious cycle where bowel movements are painful, so he holds them in, causing his stools to be even larger and harder, which causes more pain when it finally does pass.

Many parents mistake the behaviors that children develop to hold in stool as straining to have a bowel movement, but usually, they are actually stiffening their muscles or fidgeting as an attempt to hold their stool in and avoid a painful bowel movement.

Another common cause of constipation and infrequent stools is having a bad experience with potty training.

Constipation is also often found in children with special needs, such as spina bifida, Down syndrome, and cerebral palsy, and it can be a side effect of many medications.

Constipation Treatments for Infants and Children

Younger infants and newborns with constipation should be carefully evaluated by their pediatrician. Poor feeding can lead to dehydration and constipation, so an evaluation of your infant's feeding habits and making sure that he is gaining weight normally is important.

Also, remember that infants who are exclusively breastfed rarely become constipated. Infrequent bowel movements do not mean constipation if your child's stools are soft when he finally passes one.

If your older infant truly is constipated, initial treatments usually include giving them extra water or pasteurized, 100-percent fruit juice once or twice a day. A common treatment used by parents is adding Karo syrup or other light or dark corn syrups to their infant's bottles of formula. While this is often discouraged because of the theoretical risk of botulism, the American Academy of Pediatrics reports that it is safe to do. If giving formula, changing to a soy formula can also sometimes be helpful, as long as your child does not have a soy allergy.

Medications used to treat younger infants and children with constipation are usually limited to Colace, maltsupex, lactulose, and the occasional use of a glycerin suppository.

Dietary Treatments for Constipation

The ultimate goal in treating constipation is for your child to have a soft bowel movement each day.

One of the main ways to prevent and treat constipation is by modifying your child's diet. This includes decreasing foods that are constipating, including cow's milk, bananas, yogurt, cheese, cooked carrots, and other foods that are low in fiber. For older infants and toddlers who drink a lot of whole cow's milk, low-fat milk and soy milk are good alternatives, as they are usually much less constipating than whole cow's milk.

Another important dietary change is increasing the amount of fiber in your child's diet. The latest fiber recommendations say that children should get about 14g of fiber for every 1,000 calories they eat.

It can be helpful to learn to read nutrition labels to choose low-fat foods that are high in fiber. Fruits and vegetables, especially if they are raw and unpeeled, are good choices. Vegetables that are particularly high in fiber include beans such as kidney, navy, pinto and lima beans, sweet potatoes, peas, turnip greens, and raw tomatoes.

Other foods that are good for children with constipation include vegetable soups (lots of fiber and added fluid) and popcorn. Extra bran can also be helpful, including bran cereals, bran muffins, shredded wheat, graham crackers, and whole wheat bread.

It is also important to increase the amount of fluids that your child is drinking. He should have a minimum of two to three glasses of water and some fruit juice each day. Apple, pear, and prune juice, or other juices high in sorbitol, are good choices, as long as they are pasteurized and 100 percent fruit juice, not a fruit drink.

Constipation Remedies

Dietary changes take time to become effective, and until they do, your child will likely need to be on a stool softener. These medications are often used long term as maintenance therapy and are considered to be safe, effective and non-habit forming or addictive. You should, however, avoid chronic use of stimulant laxatives, such as Bisacodyl, ExLax or castor oil. An osmotic type laxative, which works by drawing extra fluid into the colon to soften the stool, is usually safer for long term use.

Commonly used constipation remedies for young children include:

  • Polyethylene glycol (Miralax): Miralax is a tasteless and odorless powder that can be mixed with water and which is now available over-the-counter without a prescription.
  • Milk of magnesia: Milk of magnesia contains magnesium hydroxide, an osmotic laxative with a chalky taste that is not tolerated by all children. It may be helpful to mix with 1-2 teaspoons of Tang or Nestle Quick or mix into a milkshake.
  • Mineral Oil: Mineral oil is a colon lubricant that you can mix with orange juice. It's important to note that mineral oil may cause leakage of stool and staining of underwear, so you aren't alarmed if you see this.
  • Docusate: available as Colace and Surfak, is a lubricating laxative. It is also available with a stimulant laxative in the combination medicine Peri-Colace.
  • Malt Soup Extract (Maltsupex): Maltsupex has an unpleasant odor, but is easily mixed with formula for younger infants.
  • Senokot: Senolot is a stimulant laxative, available either as Senokot or Senokot S which combines the laxative with a stool softener.
  • Bisacodyl: Biscadyl is a communly used stimulant laxative available as Correctol and Dulcolax.

Other medications that are available by prescription include Lactulose,  an osmotic laxative

In addition to a stool softener, it may also help to increase fiber by mixing Metamucil or Citrucel with 8 ounces of water or juice, or another bulk-forming laxative or fiber supplements. Many fiber supplements are now available as chewable tablets for kids, and there is even a fiber gummy supplement.

With any of these treatments, talk to your pediatrician first. Recent studies suggest that polyethylene glycol (Miralax) may be the safest preparation for infants and toddlers. That said, every child is different and your pediatrician can make the best recommendation based on her knowledge of your infant and her medical history.

How Long Does Constipation in Infants Need to Be Treated?

The main goal of treating your child's constipation is to get her to have a soft stool each day. In order to accomplish this, your child may need to take his medication for a long period of time, often up to 4 to 6 months. One of the biggest mistakes parents make in treating their children's constipation is stopping their medication once they begin having soft stools. If stopped too early, your child is likely to relapse and become constipated again.

Once your child is having regular soft stools, you can then talk with your pediatrician about decreasing the dosages of the laxative that you are are using. This is usually done gradually, often by decreasing the dose by 25 percent every 1 to 2 months. Stopping the laxatives too quickly can result in your child becoming constipated again. It is also important to continue your child's non-constipating diet during and after the stool softeners are stopped.

Be sure to discuss it with your pediatrician before you start your child on a new medication or if you are changing the dose of a medication that he has already been prescribed.

Disimpaction or Acute Constipation Treatments

Because there is often a large, hard mass of stool that has 'backed up' in your child's rectum, your child may need a "clean out" or disimpaction before dietary and maintenance therapy will work. This is usually done using an enema or suppository under a pediatrician's supervision. A disimpaction also can be done by using high dosages of mineral oil or polyethylene glycol.

In general, children under 18 months of age can be given a glycerine suppository, but only under the direction of a pediatrician. Children between 18 months and 9 years can either be given a Pediatric Fleets enema or half of a Dulcolax suppository. Older children can be given a regular Fleets enema or a whole Dulcolax suppository.

You should, however, avoid the regular use of an enema or suppository. They are sometimes necessary as a 'rescue therapy' if your child hasn't had a bowel movement in 3-4 days, but if you are needing to use them regularly, then you likely need to increase the dosages of the stool softeners you are using.

Behavior Modification as Part of Constipation Treatment

Once your child's stools have become soft and regular, it is important to modify his behavior and encourage him to have regular bowel movements. This often includes having him sit on the toilet for about 5 minutes after meals once or twice a day. You can keep a diary or sticker chart of when he tries to have a bowel movement and/or takes his medicine, then offer a reward for regular compliance. Don't try to force him to sit until he has a bowel movement.

Complications of Constipation

In addition to pain, constipation can lead to anal fissures or tears in the skin around the rectum, bleeding, hemorrhoids, rectal prolapse, and impaction. Encopresis is another complication of chronic constipation and can lead to involuntary stool leakage secondary to the impaction of large masses of stool.

Although constipation is a chronic condition that is often difficult to treat, having painful bowel movements is not something that your child has to "learn to live with." In time, with proper dietary and medical interventions, your child should be able to have regular soft bowel movements.

If your pediatrician is unable to help treat your child's constipation, then you may want to seek additional help from a pediatric gastroenterologist. A referral to a specialist is also a good idea if your child has any warning signs of a more serious condition or if he isn't improving with your current therapies.

Bottom Line on the Treatment of Constipation in Infants

Constipation in infants is very common and is often related to diet, plus the withholding of stool when constipation causes discomfort. Treatment usually requires a combination of therapies and may take many months. That said, there are many options available. Make sure you talk to your pediatrician and get her input and advice on any dietary changes you make or medications you use.

Sources:

Gordon, M., MacDonald, J., Parker, C., Akobeng, A., and A. Thomas. Osmotic and Stimulant Laxatives for the Management of Childhood Constipation. Cochrane Database of Systematic Reviews. 2016. (8):CD009118.

Kliegman, Robert M., Bonita Stanton, St Geme III Joseph W., Nina Felice. Schor, Richard E. Behrman, and Waldo E. Nelson. Nelson Textbook of Pediatrics. 20th Edition. Philadelphia, PA: Elsevier, 2015. Print.

Tabbers, M., DiLorenzo, C., Berger, M. et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations from ESPGHAN and NASPHAN. Journal of Pediatric Gastroenterology and Nutrition. 2014. 58(2):258-74.

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