Choosing a Pain-Free Diet

I had my first “old coot” moment, when grampa yells at the TV when he sees something he doesn’t like.  For me, it was an ad for Miralax, a laxative.  It depicted a young cheerful woman in athetic clothes saying “I choose Miralax!” for her apparent sluggish bowel issues.  I shouted, “WHY NOT CHOOSE FRUITS AND VEGETABLES?”  Of course, she wasn’t listening.

Constipation can be quite painful for children.  We see them in the Pediatric Emergency Department with stories of doubling over, crying out with pain spasms.  They’re usually  better when they arrive, but it’s still disconcerting for parents.  Contipation actually is the most common diagnosis for abdominal pain visits to the Pediatric ED, ahead of stomach viruses and appendicitis.

Constipation is now a common problem in kids, given decreased fiber in their diets.  Fiber is plant carbohydrates that our digestive system can’t break down.  That fiber holds on to water and keeps poop soft and squishy as it passes through our guts.  When your body wants extra fluids, it tries to suck water out of your colon, drying out your stool.  Without enough fiber, your poo gets dried out, moves slower, gets harder, and harder to pass.  If lots of hard poo is moving too slow, painful cramps ensue.

Thus the fix to constipation: eat more fruits, vegetables, wheat breads, bran cereals, all having a high fiber content.  Miralax is simply an artificial fiber substitute- why not eat the healthier thing?  For kids, this means training them to like these foods.  The typical kid can take 10 tries of a food to learn to like it.  This takes persistence on the parent’s part, and is ruined if they get candy, cookies, chips, or fast food as an alternative.  Those foods are designed and manufactured to taste good on the first try, spoiling the child’s chances to learn to eat right.

Drinking more fluids and more physical activity also prevent constipation.  When kids sit around playing video games, their guts sit around too, not moving things through as much, and stool has more time to get dried out.  Active kids stimulate their intestines more, and have less constipation.

Once in residency I had a 10 year-old boy with constipation so severe he was admitted into the hospital.  He had terrible pain, and the parents thought he hadn’t stooled in weeks.  He also had anxiety issues so bad that he wouldn’t tolerate enemas or rectal exams, the quickest way to diagnosis and relieve constipation.  We thus decided on rectal exam under sedation, and do so in the xray suite so we could look at his insides, to rule out other causes for his pain and apparent blockage.

As soon as the sedation started, he relaxed his anal sphincter, and liquid stool poured out of him.  The diagnosis was instantly clear- he’d been purposefully holding in his poo, and it was liquid from all the laxatives he’d been given.  Unfortunately for the Radiology Department, he leaked so much that it ran all over the xray table, through every seam, dripping out the bottom.  They had to completely dismantle the table to clean it, and that room was out of commission for days.

Above we mentioned the diet reasons why kids get constipated- low fiber, inadequate fluid intake, and not enough activity.  But there’s sometimes psychological reasons as well.  Sometimes kids have a hard stool that hurts.  They decide, hey, I’m not doing THAT anymore!  Next time they get the urge, they withhold pooing until the urge passes.  After doing that enough, the urge gets too strong, and they have to go.  By that time the stool is so big and dried out that it’s another painful job, reinforcing their desire not to do it.  The constipation process becomes self-feeding.

Toddlers also can decide to withhold pooping during potty training.  Some kids just don’t like taking down their pants and sitting on that oddly-shaped thing we call a toilet.  It’s much easier to just go in their diaper.  Parents often try rewards, sometimes punishment, to encourage the kid to use the potty.  Willful toddlers may fight back the only way they can- with their anal sphincter.  Some psychologists say that any child can be potty-trained by age 2; others say wait until they show signs they’re ready, like watching their parents use it.  I think the latter, having seen many toddlers get constipated during potty training.

Having a Hard Go

This week’s guest columnist is Dr. Justin Pratt, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

“Something isn’t right.  My baby only poops every three days, and all my friends’ babies go every day.  What’s wrong?” -First time mother of a four-month old in my clinic.

Constipation is common: Whew!  You’re not the only one with a constipated kid!  Almost one third of children have constipation some time in childhood.  The definition of constipation varies with age.  For the baby above, skipping three to four days between stools is normal.  Straining to poop may mean constipation, maybe not.  However, passing hard stools that hurt, that’s constipation for sure.

Besides not stooling for days, moms worry that when their infants strain and grunt, they’re having a hard time (literally?).  However, if baby finally goes and it’s soft, that’s normal.  Consider this: babies must have bowel movements while lying down, so it’s going to take some straining.  You probably haven’t tried since you were that age, but it is!

Older children can suddenly have constipation, after going regularly and easily. There’s some times in life this commonly occurs.  The first is when one year-old’s transition to solid foods and cow’s milk.  The new toddler can get constipated from too much milk, which has no fiber, and not eating enough fiber-containing foods like fruits and vegetables.  Moms think: milk is good, give him all he wants.  This kills baby’s appetite for other foods, and then comes the painful consequences.  Thus, at one year babies should only get three or four 4-ounce sippy cups of milk per day.  This lets them be hungry for more fibrous food.

The next common constipation “milestone” is potty training.  When confronted with the unfamiliar potty, toddlers often get stage fright: “You want me to do that, there!?”  Sometimes they’d rather just hold it until you give up and put the diaper back on.  If this stubbornness goes on for more than two weeks, maybe she isn’t ready yet, and should go back to diapers for another few months.

“I”m really uncomfortable and haven’t had a BM all week.  I started a new construction job, don’t get to go in the morning, and can’t use the homeowners’ bathrooms.  I’m in the heat all day and probably don’t drink enough water.” -17 year-old in the Emergency Department.

Another time children get constipated is when they start school.  They’ve been using their nice, private bathroom at home.  Now they have to get out of the house early, often skipping going.  Then at school, they have to share the bathroom with other kids.  Many aren’t respectful of bathroom privacy, sometimes out of curiosity, sometimes to be mean.  Who could go in those circumstances? So these kids hold it all day, waiting to get back home.

When you don’t poop for a while and don’t drink enough water, your body scavenges extra water from stool.  The rectum absorbs the water, poop dries up, and compacts. Then it hurts to pass.

Fixing constipation depends on age and cause.  As above, babies who skip days pooping or strain, but it comes out soft, aren’t constipated.  If baby has hard poops that hurt, the easiest remedy is fruit juice, an ounce or two twice daily.  It takes a few days to work, but the fruit sugar is a laxative, and after passing the last “rocks,” baby should go smooth.  Babies over 4 months old can have strained foods with fiber, like cereals, vegetables, or fruits, to prevent constipation.  Also, breast milk prevents constipation compared to formula.

Babies transitioning to cow’s milk, like we said above, should get only three to four 4-ounce cups of milk per day.  More than that can constipate, and kills appetites for fiber-containing foods.  Kids should eat at least three fruit and vegetable servings per day, preferably more.

For potty-training kids, if you’re fighting to get your kid use a toilet, put him back in diapers and wait a few months.  Have foot rests for your adult toilet, or a toddler toilet.  It’s harder to go without a little leverage!

If your child is having hard painful stools, and you’re thinking about a suppository or enema, talk to your doctor first.  She can help you pick more effective, less traumatic fixes for constipation.