OVERVIEW
Constipation is a common problem in children. Children with constipation have stools (also called poops or bowel movements [BMs]) that are hard, dry, and difficult or painful to get out. Some children with constipation have infrequent stools. Although constipation can cause discomfort and pain, it’s usually temporary. If left untreated, symptoms can get worse.
SIGNS & SYMPTOMS
- Can’t pass a stool or pain (crying) when passing a stool
- Can’t pass a stool after straining or pushing longer than 10 minutes
- Passes stools infrequently
- Stomaches, cramping, and nausea
- Soiling (streaks of stool in underwear)
- Stools that stop up the toilet
Information, based on age:
Under 12 Months Old
Normal Frequency of Stools
- Once children are on normal table foods, their stool pattern is like adults. The normal range is 3 per day to 1 every 2 days.
- Kids who go every 4 or 5 days almost always have pain with passage.
- Kids who go every 3 days often drift into longer times. Then, they also develop symptoms.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, the child should be treated with changes in diet.
Normal Stools and Normal Behaviors
- Breastfed and over 1 month old. Stools every 4-7 days that are soft, large and pain-free can be normal. Occurs in 20% of breastfed babies. Caution: Before 1 month old, not stooling enough can mean not getting enough breast milk.
- Straining in babies. Grunting or straining while pushing out a stool is normal in young babies. It’s hard to pass stool lying on the back with no help from gravity. Becoming red in the face during straining is also normal.
- Large stools. Size relates to the amount of food eaten. Large eaters have larger stools.
CAUSES
- True constipation is uncommon in babies.
- Sometimes, caused by a formula-only diet.
TREATMENT & ADVICE
- Constipation is common in children.
- Most often, it’s from a change in diet. It can also be caused by waiting too long to stool.
- Passing a stool should be pleasant and free of pain.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, they need changes in their diet.
- Here is some care advice that should help.
- For babies over 1-month-old, can add fruit juice (e.g., apple or pear juice). After 3 months, can use prune (plum) juice.
- Amount: 1 ounce (30 mL) per month of age each day. Limit amount to 4 ounces (120 mL) per day. Reason fruit juice is approved for these babies: treating a symptom.
- Age over 4 months old, also add baby foods with high fiber. Do this twice a day. Examples are peas, beans, apricots, prunes, peaches, pears, or plums.
- If on finger foods, add cereals and small pieces of fresh fruit.
- Give enough fluids to stay well hydrated. Reason: This keeps the stool soft.
- Help your baby by holding the knees against the chest. This is like squatting for your baby. This is the natural position for pushing out a stool. It’s hard to have a stool lying down.
- Move the legs like your baby is riding a bike.
- Also gently massage or pump on the left side of the belly.
- Warmth can help relax the anus and release a stool.
- For straining too long, help your baby sit in warm water.
- You can also put a warm wet cotton ball on the anus. Vibrate it side to side for about 10 seconds to help relax the anus.
OUTLOOK
- Most often, changes in diet help constipation within a few days.
Call Your Health Care Team If
- Constipation lasts more than 1 week after making changes to diet
- You think your child needs to be seen
- Your child becomes worse
1 - 5 Years Old
Normal Frequency of Stools
- Once children are on normal table foods, their stool pattern is like adults. The normal range is 3 stools per day to 1 every 2 days.
- Kids who go every 4 or 5 days almost always have pain with passage.
- Kids who go every 3 days often drift into longer times. Then, they also develop symptoms.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, the child should be treated with changes in diet.
Normal Stools and Normal Behaviors
- Brief straining under 10 minutes can occur at times at any age.
- Large stools. Size relates to the amount of food eaten. Large eaters have larger stools.
- Hard or dry stools are also normal if passed easily without too much straining. Often, this relates to poor fiber intake.
Causes
- High milk or cheese diet
- Low fiber diet
- Postponing or holding back stools because of pain
- Holding back stools because of power struggles. Most often, it’s a battle around toilet training.
- Slow passage of food through the intestines. Most often, this type runs in families.
Care Advice
Overview:
- Constipation is common in children.
- Most often, it’s from a change in diet. It can also be caused by waiting too long to stool.
- Passing a stool should be pleasant and free of pain.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, they need changes in their diet.
- Here is some care advice that should help.
- Increase fruit juice (apple, pear, cherry, grape, prune). Note: Citrus fruit juices are not helpful.
- Add fruits and vegetables high in fiber content. Examples are peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, or dates. Offer these foods 3 or more times per day.
- Increase whole-grain foods. Examples are bran flakes or muffins, graham crackers, and oatmeal. Brown rice and whole wheat bread are also helpful. Popcorn can be used if over 4 years old.
- Limit milk products (milk, ice cream, cheese, yogurt) to 3 servings per day.
- Give enough fluids to stay well hydrated. Reason: This keeps the stool soft.
- If a change in diet doesn’t help, you can add a stool softener.
- Miralax is a good one. Give it each day with dinner.
- Dose: 1 teaspoon (5 mL) powder mixed in 2 ounces (60 mL) of water or fruit juice.
- Stool softeners should produce soft stools in 1 to 3 days.
- After 1 week, try to phase it out.
- Set up a normal stool routine.
- Have your child sit on the toilet for 5 minutes after meals.
- This is especially important after breakfast.
- If you see your child holding back a stool, also take to the toilet for a sit (if cooperates).
- During sits, stay with your child and be a coach. Just focus on helping the poop come out.
- Do not distract your child. Do not allow your child to play with video devices, games or books during sits.
- Once he passes a normal size stool, he doesn’t need to sit anymore that day.
- Put your child back in diapers or pull-ups for a short time.
- Tell him that the poops won’t hurt when they come out.
- Praise him for passing poops into a diaper.
- Holding back stools is harmful. Use rewards to help your child give up this bad habit.
- Avoid any pressure or punishment. Also, never force your child to sit on the potty against his will. Reason: It will cause a power struggle.
- Treats and hugs always work better.
- Eat a high fiber diet. Drink plenty of fluids.
- Sit on the toilet and pass a stool around the same time each day.
- Don’t ignore the signal of a full rectum.
- Most often, changes in diet helps constipation within a few days.
Call Your Doctor If
- Constipation lasts more than 1 week after making changes to diet
- You think your child needs to be seen
- Your child becomes worse
6 Years and Older
Normal Frequency of Stools
- The normal range is 3 stools per day to 1 every 2 days.
- Kids who go every 4 or 5 days almost always have pain with passage.
- Kids who go every 3 days often drift into longer times. Then, they also develop symptoms.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, the child should be treated with changes in diet.
Normal Stools and Normal Behaviors
- Brief straining under 10 minutes can occur at times at any age.
- Large stools. Size relates to the amount of food eaten. Large eaters have larger stools.
- Hard or dry stools are also normal if passed easily without too much straining. Often, this relates to poor fiber intake.
Causes
- High milk or cheese diet
- Low fiber diet
- Postponing or holding back stools because of pain
- Slow passage of food through the intestines. Most often, this type runs in families.
Care Advice
Overview:- Constipation is common in children.
- Most often, it’s from a change in diet. It can also be caused by waiting too long to stool.
- Passing a stool should be pleasant and free of pain.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, they need changes in their diet.
- Here is some care advice that should help.
- Increase fruit juice (apple, pear, cherry, grape, prune). Note: Citrus fruit juices are not helpful.
- Add fruits and vegetables high in fiber content. Examples are peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, or dates. Offer these foods 3 or more times per day.
- Increase whole grain foods. Examples are bran flakes or muffins, graham crackers, and oatmeal. Brown rice and whole wheat bread are also helpful. Popcorn can be helpful.
- Limit milk products (milk, ice cream, cheese, yogurt) to 3 servings per day.
- Give enough fluids to stay well hydrated. Reason: This keeps the stool soft.
- If a change in diet doesn’t help, you can add a stool softener.
- Miralax is a good one. Give it each day with dinner.
- Dose: 2 teaspoons (10 mL) powder mixed in 4 ounces (120 mL) of water or fruit juice.
- Stool softeners should produce soft stools in 1 to 3 days.
- After 1 week, try to phase it out.
- Set up a normal stool routine.
- Have your child sit on the toilet for 5 minutes after meals.
- This is especially important after breakfast.
- Once he passes a normal size stool, he doesn’t need to sit anymore that day.
- The squatting position gives faster stool release and less straining. Reason: it lines up the rectum with the anus.
- The squatting position means that the knees are above the hips.
- For most children who sit on the toilet, a foot stool is needed.
- It is an important part of treating constipation.
- Eat a high fiber diet. Drink plenty of fluids.
- Sit on the toilet and pass a stool around the same time each day.
- Don’t ignore the signal of a full rectum.
- Most often, changes in diet helps constipation within a few days.
Call Your Doctor If
- Constipation lasts more than 1 week after making changes to diet
- You think your child needs to be seen
- Your child becomes worse
Constipation is a common problem in children. Children with constipation have stools (also called poops or bowel movements [BMs]) that are hard, dry, and difficult or painful to get out. Some children with constipation have infrequent stools. Although constipation can cause discomfort and pain, it’s usually temporary. If left untreated, symptoms could get worse.
Here is information from the American Academy of Pediatrics about constipation (signs and symptoms, causes, treatment) and how to help your child develop good bowel habits.
What is a normal bowel pattern?
Bowel patterns (when and how often stools are passed) vary from child to child just as they do in adults. What’s normal for your child may be different from what’s normal for another child. Most children have BMs 1 or 2 times a day. Other children may have BMs every 2 to 3 days.
What are signs and symptoms of constipation?
Signs and symptoms of constipation may include
· Hard or painful stools
· Many days between BMs
· Bleeding from the child’s bottom where stool comes out
· Stomachaches, cramping, and nausea
· Soiling (brownish wet spots in the underwear) (See the What is encopresis? section.)
Your child may also
· Have BMs that stop up the toilet.
· Make faces while they pass a BM, as if they are in pain.
· Clench his bottom when having a BM. Although this behavior may look like your child is trying to push the stool out, he may be really trying to hold it in because it hurts to come out.
Call or schedule a visit with your child’s doctor if your child doesn’t have a BM at least every 2 to 3 days or if passing a stool hurts your child.
What is encopresis?
Sometimes a child with bad constipation may pass BMs that look like diarrhea. When a child holds back stools, the stools build up and get bigger. They may get so big that the rectum stretches. Then the child may not feel the urge to go to the bathroom. The stool gets too big to pass without an enema, laxative, or other treatment.
Sometimes only liquid stool or solid smears can come out, and they leak onto the underwear. This is called encopresis. Talk with your child’s doctor about treatment. It can get better, but it takes months.
What causes constipation?
Here are some causes of constipation.
· Holding back, or withholding, stool.
· Your child may not want to have a BM for different reasons.
· Your child may try not to go because it hurts to pass a hard stool. (Diaper rashes can make this worse.)
· Children aged 2 to 5 years may want to show they can decide things for themselves. Holding back their stools may be their way of taking control. This is why it is best not to push children into toilet training.
· Sometimes children don’t want to stop playing to go to the bathroom.
· Older children may hold back their stools when away from home (such as camp or school). They may be afraid of or not like using public toilets.
· Illness. If your child is sick and loses his appetite, a change in his diet can throw off his system and cause him to be constipated. Constipation may be a side effect of some medicines or may result from certain medical conditions, such as hypothyroidism (underactive thyroid gland).
· Diet. Not enough fiber or liquid in your child’s diet doesn’t cause constipation. However, not consuming enough of the recommended amounts of healthy foods from the 5 food groups, including foods that are good sources of fiber, may affect your child’s bowel patterns. (See the How much fiber does my child need? section.)
· Other changes. In general, any changes in your child’s routine, such as traveling, hot weather, or stressful situations, may affect his overall health and how his bowels function.
How is constipation treated?
Treatment is based on your child’s age and how bad the problem is. Usually, no special tests are needed.
Constipation can get worse if it isn’t treated. The longer stool stays inside the large intestine (or colon), the larger and drier it gets. Then it hurts to pass it. This starts a cycle. The child becomes afraid to have a BM and holds it in even more.
For babies
Constipation is not commonly a problem in babies. It may become a problem when starting solid foods, and your doctor may suggest changes in diet or prescribe a medicine to help soften and pass the stools. Inability to pass stools in a newborn (younger than 1 month) can be a serious concern, and you should see your baby’s doctor.
For children and teens
Your child’s doctor may prescribe medicine to soften or remove the stool. Do not give your child laxatives or enemas unless you check with the doctor. These drugs can be harmful to children if used wrong.
After the stool is removed, your child’s doctor may suggest ways you can help your child develop good bowel habits to prevent stools from backing up again.
How can I help my child develop good bowel habits?
Here are tips to help your child develop good bowel habits.
· Help your child set a toilet routine. Pick a regular time to remind your child to sit on the toilet daily (such as after breakfast). Put something under your child’s feet to press on. This makes it easier to push BMs out.
· Make sure your child is consuming the recommended amounts of healthy foods from the 5 food groups, including foods that are good sources of fiber.
· Encourage your child to play and be active.
How much fiber does my child need?
There are different fiber recommendations for children based on energy needs, age, and weight. A normal fiber intake is recommended in children with constipation. The following can be useful strategies:
· Eat 5! A simple way to make sure your child is getting enough fiber is by making healthy food choices. If your child is eating at least 5 servings of fruits and vegetables each day along with other foods that are good sources of fiber, there is really no need to count fiber grams.
· Add 5! If you find it helpful to keep track of the total grams of fiber that your child is eating, add 5 to your child’s age. For example, a 5-year-old would need about 10 grams of fiber each day. (The total daily recommended amount of up to 25 grams for adults can be used as a general guideline for children.) Some foods are high in fiber. Beans, vegetables, fruits, and whole grains are good sources of fiber.
Remember
If you have any questions or concerns about your child’s health, contact your child’s doctor.
Disclaimer
The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances. Information applies to all sexes and genders; however, for easier reading, pronouns such as he are used in this publication.
FREQUENTLY ASKED QUESTIONS
What is Miralax, and is it safe for children?
MiraLax is also known as "Polyethylene Glycol"
Polyethylene Glycol 3350 (PEG 3350) Frequently Asked Questions
NASPGHAN Neurogastroenterology and Motility Committee
January 2015
1. What is PEG 3350?
Polyethylene glycol (PEG) is a water-soluble, inactive ingredient of which only a very small amount is absorbed in the gut or gastrointestinal tract, the rest moves through the body. PEG is non-toxic and has no effect on the body. It is used in many products including medications such as ointments and pills to allow them to be more easily dissolved in water. PEG can also be found in common household products such as certain brands of skin creams and tooth paste. PEG 3350 is the most commonly used form of PEG in the United States and Canada for the treatment of constipation and is the focus of discussion in this FAQ. Commonly used brand names of PEG 3350 available in the United States and Canada are MiraLax, GlycoLax, Lax-A-Day and RestoraLAX.
2. How does PEG 3350 work in the treatment of constipation?
PEG 3350 helps constipation by holding more water in the bowel, making stool softer and easier to pass. The effect of PEG 3350 is not immediate, and may take 24 hours or more to work.
3. Is PEG 3350 approved for use in children?
No. PEG 3350 is currently approved by the U.S. Food and Drug Administration (FDA) for use in adults, for no longer than seven days, and is not approved for use in children. However, a drug that does not have FDA approval for use in children does not mean that the drug is unsafe. It usually means the drug has not been tested by the manufacturer in very large trials of children specifically for FDA approval. This may happen for several reasons such as lack of funding, and ethical issues in performing some type of studies in children. Many commonly used medications are not specifically FDA approved for use in children less than 16 years.
4. Is PEG 3350 effective for treating childhood constipation?
Yes. The effectiveness of PEG 3350 in treating constipation in children has been supported by several randomized controlled trials (these types of trials are considered the “gold standard” in assessing how well a medication works). It has been shown to be more effective than placebo (sugar pill) and other laxatives, such as lactulose and milk of magnesia.
4. Does PEG 3350 cause dependence/tolerance when used long-term?
No. PEG 3350 works by keeping more water in the stool so it is softer and easier to pass. It does not work on the nerves or muscles of the gut and so does not cause any dependence or damage.
5. What are known side effects encountered with use of PEG 3350?
In general, PEG 3350 is well tolerated in children and adults, but may cause loose, watery, or more frequent bowel movements. The most common side effects reported by patients include nausea, bloating, cramping, or gas.
6. Is PEG 3350 safe for use in children long-term?
Several research studies have shown PEG 3350 to be safe in children when used for several weeks to several months. Currently, there have been no studies specifically on the use and safety of PEG 3350 in children for longer periods of time. In clinical practice, however, it is common for pediatric gastroenterologists to prescribe PEG 3350 for chronic use and there have been no reports of serious, long-term side effects in the medical literature.
7. What have previous research studies found about the safety of PEG 3350?
Studies of PEG 3350 in adults and children have generally shown it to be safe. PEG 3350 has not been associated with electrolyte imbalances or problems in liver or kidney functioning when used in the short-term or at high doses for bowel preparation for colonoscopy. Animal studies using PEG 3350 at higher doses or for longer periods of time have also not reported any significant side effects.
8. Why is the FDA sponsoring a new study on the safety of PEG 3350 and what new information do they hope to find out?
The FDA is interested in investigating the safety of PEG 3350 use in children and for prolonged periods. Although PEG 3350 is a very large molecule that is not absorbed by the gut due to its size, there are concerns that smaller compounds, such as ethylene glycol or diethylene glycol, could be found as impurities in the manufacturing process of PEG 3350 or formed when PEG 3350 is broken down within the body. The FDA is investigating if these smaller compounds are absorbed by the gut and accumulated in the bodies of children taking PEG 3350. Some families have reported concerns to the FDA that some neurologic or behavioral symptoms in children may be related to taking PEG 3350. It is unclear whether these side effects are due to PEG 3350. This study is the first step toward trying to determine if there is truly a link.
8. If my child has an underlying medical condition are they at higher risk for side effects from PEG 3350?
PEG 3350 should be used with caution in patients with certain medical problems including but not limited to electrolyte imbalances, renal dysfunction, seizure disorders or with certain gastrointestinal problems including gastrointestinal obstruction, toxic megacolon, or bowel perforation. The long-term effect of taking PEG 3350 is not known in children with chronic intestinal inflammation or injury. PEG 3350 should also be used with caution in patients who are pregnant or taking digoxin (a medicine for heart disease).
9. Are there other effective alternative treatments/medications for constipation in children?
Multiple options are available for treatment of constipation in children. Stool softeners, stimulant laxatives, dietary changes, and behavior modification are used alone or in combination, but evidence regarding the effectiveness of specific treatments is limited. Other medications for control of constipation include lactulose (a synthetic, nondigestible sugar), milk of magnesia/magnesium hydroxide, mineral oil, or stimulant laxatives (senna, bisacodyl). Questions about potential risks of each medication should be discussed with your child’s health care provider.
10. What should I do if my child is currently taking PEG 3350?
Generally speaking, if your child has been prescribed PEG 3350 as part of his/her treatment plan, and you feel this medicine provides benefit, you should feel safe continuing PEG 3350. At this time, PEG 3350 appears to be safe based on current medical literature. We recommend discussing any concerns you have about the safety of PEG 3350 with your child’s health care provider. If you would prefer for your child to stop taking PEG 3350, discuss other treatments options with your child’s health care team before stopping PEG 3350 therapy. Although abruptly stopping PEG 3350 is not considered dangerous, it could lead to a relapse/worsening of constipation.
References:
Gordon M, Naidoo K, Akobeng AK, et al. Cochrane Review: Osmotic and stimulant laxatives for the management of childhood constipation (Review). Evid Based Child Health 2013;8:57-109
Pashankar DS, Bishop WP, Loening-Baucke V. Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis. Clin.Pediatr.(Phila) 2003;42:815-819
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;157:661-664.
Schiller LR et al, Osmotic Effects of polyethylene glycol; Gastroenterology. 1988 Apr;94(4):933-41.
Fordtran JS et al, Urinary excretion of polyethylene glycol 3350 and sulfate after gut lavage with a polyethylene glycol electrolyte lavage solution; Gastroenterology. 1986 Jun;90(6):1914-8.
Heyman MB et al, Polytheylene glycol electrolyte solution for intestinal clearance in children with refractory encopresis. A safe and effective therapeutic program , Am J Dis Child. 1988 Mar;142(3):340-2.
RafatiMR,et al. Clinical efficacy and safety of polyethylene glycol 3350 versus liquid paraffin in the treatment of pediatric functional constipation. Daru. 2011;19:154-158
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143565.htm