We have done prior posts about poop.Baby poop 101
The titles are pretty self explanatory. This post picks up on the next chapter.
Believe it or not, one day your kids will be completely out of diapers. While the age varies greatly from child to child, at some point the day will come when they no longer want you to wipe their butt.
The years pass and at some point you tend to lose track of your child’s bowel movements, which is why constipation can sneak up on you. It’s important to know the signs.
Recognizing constipation
Infants who go 5-6 days in between nice soft poops? That isn’t constipation.
Medically, constipation is defined as infrequent, difficult, or painful passage of stools, typically fewer than three bowel movements per week, or stools that are hard, dry, or difficult to poop out. In children, it may also include voluntary withholding or large, painful poops leading to discomfort or avoidance. This very often manifests with abdominal pain.
Discomfort that come from constipation tends to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body.
But we never want to ignore other possibilities. Get medical attention if the pain is steady or your child isn’t able to walk, run, jump, or play due to the pain. Don’t delay seeking care if severe belly pain is associated with a fever, vomiting, or copious diarrhea.
Because tummy aches often seem to be poop related, most health professionals are going to want rule out constipation right off the bat. They are going to want to know the frequency and consistency of the stools.
Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can’t get through. What they will pass is some very runny substance that leaks around the solid mass of the impacted stool. This thin stool often leaks uncontrollably in little smears, a condition called encopresis.
Because the poop that is coming out is so runny, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing.
When was the most recent poop?
Was it normal size?
Smaller than usual?
How often are they pooping?
Are they sitting for a long time trying to get it to come out?
Are the stools coming out in little hard pieces? Do they look like rabbit pellets?
If your older child is feeling a little bit shy about it, consider having them take a picture. There is something called the Bristol Stool chart that can help with the description.
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Source: https://www.continence.org.au/
If you’re seeing type 1 or type 7, an adjustment must be made. Occasionally type 2 or 6 can be okay, but a good goal is types 3, 4, and 5.
Let’s do a little Nurse Judy Poop Math
Figure out how large your child’s average size stool might be. Let’s say it is the size of a hot dog. Now, assume that your child doesn’t have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache!
It is time to sit and talk to your child about a very important rule.
There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option.
Parents can take a look at this little video The Poo in You and see if you think it might be a good teaching tool for your child.
Why Do People Get Constipated?
Evolutionarily, we were probably designed to eat tons of leaves, bark, and random roughage. We don’t do that anymore because we have too many easy options of more processed food (plus leaves and bark are hardly top choice these days, even for a vegetarian). But, if we want to pass poop like our body’s are supposed to, we need to approximate a diet that has the amounts of fiber that our bodies require.
Timing is also a factor. The body tends to give a gentle notice that it is time to poop. If that is ignored, it often politely subsides. If that happens too often, the body no longer responds properly to the signals.
Some little kids are having too much fun playing to listen to their bodies but the issue isn’t just that someone might be too busy to go.
Many people are creatures of habit and like to go poop in the privacy of their own bathrooms. This is especially true of school age children, but teenagers and adults are not immune. Add in the factor that younger children also might be actually afraid of public toilets. One inadvertent early flush from an automatic toilet when they are still sitting down and they become very reluctant to ever sit on one again.
If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the sensation passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. A new school or camp? No thank you, they will wait unto they get home, where they may or may not feel the need to go.
They might pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be “yes”.
And sometimes it’s just genetics. Some people just have the digestive short straw and suffer from “slow transit constipation.” These are the people whose parents and grandparents also suffer from a lifetime of constipation. The guts just move food slowly, so it dries out and firms up in transit.
If you recognize yourself in that category, fiber and fluids can still help to mitigate your situation! We also have more suggestions in a later section.
Step 1: Getting the poop out
After identifying that your child is backed up, you need to determine how much effort is going to be needed to unblock the constipation. For younger kids (sub 3-years-old) that have only skipped a day or two, it’s ok to try a full glass of prune juice (or a couple of ounces for infants). But more than 3 days typically requires a bigger intervention. All the prune juice in the world is not going to be able to blast through a week’s worth of hard stool.
Massage and a warm bath are good starting points. Some kids actually may be able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation with an utterly miserable child who is holding onto their poop as though it is a treasure, you will be happy to see them poop any way that you can make it happen. Some people find that adding a few teaspoons of either baking soda or epsom salts to the warm bath water can also help.
If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. We promise you, it doesn’t hurt and it immediately melts in the rectum to become a soft lubricant.
Another option is a liquid glycerin called Pedialax. The directions on the box advise that these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in a small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes.
For big, multi-day backups, a ‘clean out’ often includes adding higher-than-normal doses of Miralax (a stool softener that works by pulling water into the colon), or other laxatives, to flush everything out. There are many different recipes for a full clean out, and they’re all pretty safe. No, it’s not super fun for anyone involved, but it’s usually a much better option than letting stool build up to the point where it stretches out the rectum, causing even more long-term trouble.
Some parents get nervous about how much Miralax to use, how often to give it, or how to time it with meals and potty time. Keep in mind that most gastroenterologists will rely on Miralax, which is very safe in extremely high doses (parents that have had a colonoscopy drank liters of this to prepare).
There’s a lot of variation in how kids respond, but in general, clean-outs work best when you mix the Miralax with a favorite drink (milk, dilute juice, or water) and give a relatively large amount over several hours, ideally on a day when you’re sticking close to home. Don’t expect an immediate explosion (sometimes it takes 6, 12, or even 24 hours to really kick in).
Miralax Dosage: typically, for kids ages 4 and up, gastroenterologists will recommend a full cap (17 grams or about 1 heaping tablespoon) of Miralax, three times in a day, for one to two days. Each dose should be drunk with 8 oz of liquid. You can stop early if your child starts pooping real poop (clear or yellow liquid doesn’t count, it needs to be somewhat formed). After the first big poop, you still have some work to do. Time for step number two.
Step “number 2:” Reconditioning the muscles
Dr. Ted Tidbit:
After a large blockage, the rectal muscles are stretched out, especially if this has been going on for awhile. This is why a lot of young children aged 4-10 years will have accidents surrounding constipation. The stretched rectal muscles aren’t as strong as they should be. They can’t squeeze to hold poop in. After cleaning out a blockage, most rectums need at least a month of daily, soft, easy-to-pass stools to shrink back to an effective size. The stretching issue is illustrated below, and is the reason for step 2: coming up with a plan for very regular soft poops.
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As stated above, once things are cleared out, the goal is to keep poop soft and regular every day so the whole cycle doesn’t start over. This is the MOST important consideration going forward after a blockage. If you do a one-time clean-out but don’t make an immediate change to get daily soft stools, the rectum will remain dilated and quickly refill with a blockage, often leading to abdominal pain and accidents.
In an ideal world, diets are changed at this point to incorporate fiber, water, and other good healthy habits, which leads to regular stools. We are realistic enough to know that many 4 to 10-year-olds don’t live in that ideal world.
These picky kids will likely need some supplementary boosts to keep daily soft stools while the rectum shrinks back down. Below are some things that we have seen work well for our patients to maintain a daily stool. Many kids will need more than one. Pick and choose the things that seem best for you and your child.
For a picky kid, many parents find that maintenance is easiest to do with Miralax, because it doesn’t require you to tame the beast of picky eating. You can start with 1 teaspoon of Miralax per year of life, daily, then increase by 1 tsp per day until you achieve the goal of daily soft stools. Don’t stress if you feel like you have overshot, you can just dial down the next day. We are perfectly happy if you do a daily adjustment of the dose depending on that day’s stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose. In other words, the dose can be calculated based on the quality of the stool. Titrate the dose, but pay attention for the entire month.
Senna (Ex-lax) is another option. It’s a plant-derived stimulant laxative, and can be a useful add-on to some of the other options. It works by stimulating colon motility (squeezing the intestine muscles), typically producing a bowel movement within 6-12 hours. In young kids, senna technically may be used intermittently or in short bursts (e.g., a few days at a time) to “reset” the stooling pattern, especially after travel, illness, or periods of withholding. While effective, we don’t recommend senna for routine daily use long-term due to concerns about developing dependency or tolerance and, in rare cases, cramping or diarrhea. If senna is used regularly, it should be under the guidance of a pediatrician or GI specialist, with close monitoring for soft, daily stools and signs of overtreatment.
Prune juice or copious prune puree is another option, although this tends to be better at young ages. Prune juice includes some fermented sugars that don’t get absorbed in the intestines, so you don’t need to feel like you’re feeding a sugar bomb. You can incorporate prune puree into other foods. In terms of volumes, this is a bit of a shot in the dark, but we like to start with at least 1-3oz per day (even in young infants), which can be in a glass, added to other foods, or in a bottle.
Some people can find a mix of fiber gummies with water and probiotics. These can make a decent maintenance regimen when you find the right ones, but we don’t have a favorite product to recommend. Don’t forget a soft formed stool must be produced every day for weeks after a big backup. If you don’t get that, the rectum may stay dilated to accommodate a large stool. It needs to be given time to slowly shrink back to size! If fiber and probiotics with water aren’t giving you a daily stool, you really need to try one of the two above options.
Magnesium Make sure your child is getting enough magnesium. Natural Calm is a source that many folks like. An appropriate dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form. Make sure it’s magnesium citrate if pooping is the goal.
Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day.
The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1 to 1-1/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps. This also comes as a gummy!!!
Biofeedback
This, or pelvic floor therapy, can be very effective in treating stretched rectal muscles. With biofeedback, a therapist will lead you through breathing exercises, as well as muscle strengthening and relaxation exercises, in order to help you retrain the movement and coordination of your pelvic floor. Ask your doctor to help you find local resources. Unfortunately getting insurance to cover it can be right up there with passing a hard, enormous poop (as of this writing, UCSF does have some Bay-Area based providers that can do this).
Step 3: Maintenance
Chronic constipation is not a quick fix. As we mentioned, the first step is obviously to get rid of the poop, and then the muscles need some time to be retrained. Finally it is time to focus on making some adjustments to the diet where you can find the right balance moving forward.
Ongoing Dietary Management
Nurse Judy has the saying that you are the ‘conductor’ of the poop orchestra.
Some foods are binding, others will get the stools softer. Everyone’s system is a little bit different. Your job is to pay attention.
Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/ toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to minimize those until they are having softer stools.
Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps. If you do this, make sure they are getting enough calcium.
Below is a list of the top 10 most common constipation culprits:
Cheese products – Cheese sticks, mac & cheese, pizza, and milk-heavy diets decrease colonic motility and add no fiber. Many of these have flours and starches added to keep them dry that can be very binding, just like the rice powders below.
White rice and rice powders – Widely used in processed snacks (e.g., rice crisps, puffed rice crackers, toddler “puffs,” and gluten-free snack bars). These lack fiber and are binding.
Bananas (especially underripe) – Contain resistant starch that slows stool transit.
Processed snack foods – Chips, pretzels, Goldfish, and crackers are typically low in fiber and high in refined flour.
White bread and refined grains – Sandwich bread, bagels, pancakes, and pasta made from refined flour.
Snack bars and “granola” bars – Especially those with rice syrup, palm oil, or minimal true whole grains.
Processed meats – Hot dogs, sausages, pepperoni, and lunch meats lack fiber and contain high salt, which can dehydrate stool.
Fast food meals – Burgers, fries, and nuggets are low in fiber and high in fat, slowing gastric emptying.
Excessive cow’s milk intake – More than 16–20 oz/day can be associated with constipation in children (common dietary factor).
Chocolate and sweet treats – Candy, cocoa-rich snacks, and baked goods with refined flour and fat can slow bowel transit.
On the other hand, most fruits and veggies are great.
Below is a list of the top 10 best foods to incorporate for a regular stool. Notice the fiber content. Added fiber is discussed below, separately from many of these naturally high-fiber foods:
Pears – Contain sorbitol (a fermented sugar alcohol that isn’t absorbed and pushes poop through) and high water content; softens stool naturally.
Prunes or prune puree – High in sorbitol and fiber, clinically proven to improve stool frequency.
Berries – Raspberries, blackberries, and strawberries add both soluble and insoluble fiber.
Legumes – Lentils, beans, chickpeas; excellent plant fiber and prebiotic effect.
Whole grains – Oatmeal, whole wheat bread, brown rice, quinoa; add bulk and water-holding fiber.
Leafy greens and cruciferous vegetables – Spinach, kale, broccoli, cauliflower add bulk and magnesium.
Sweet potatoes (with skin) – Soft fiber and water content aid regularity.
Kiwi – Contains actinidin, which promotes GI motility; effective in pediatric and adult constipation.
Avocado – Fiber plus healthy fats to lubricate stool.
Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet.
If your kid is resistant, consider making these foods into a smoothie.
See if you can somehow hide some molasses, chia seeds and/or flaxseed oil in some oatmeal, pancakes or baked goods. Kids will often eat something if they have a hand in baking it.
Fiber is essential.
The usual rule of thumb is that a child should be consuming their age + 5 in grams of fiber (For instance, a 10 year old needs 15 grams of fiber, a 15 year old needs 20 grams of fiber per day). This is up to a maximum of the adult dose of 25-30 grams per day. It is important to make sure that all this fiber is washed down with lots of water. Too much added fiber and too little water will actually bulk up the stools and worsen constipation.
If you are finding it a little tricky trying to get enough fiber into their diet, try offering FiberOne bars, fiber gummies, fiber powders (Metamucil, benefiber, citrucel, etc) to get to their goals. Dr. Ted’s favorite added fiber is psyllium husk, which can make for a perfect daily poop, but causes constipation if taken with less than 8 oz of fluid at the same time (it can also clog your drain).
Staying well hydrated is another cornerstone
Make sure everyone is drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to keep you on track. On the other hand, a few dry days of not drinking can set you back. Consider getting a water bottle that helps you measure and monitor the actual amounts. Typically, even for adults, if we don’t make a conscious effort, it is easy to not drink enough.
Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion.
Routines (it’s not just what goes in your mouth)
Having a regular poop routine is helpful (particularly for boys who stand to pee). They should get into the habit of sitting on the toilet for 5 minutes at least 2 times per day, even if they don’t think they have to go to the bathroom.
Ideally this will be done after meals. Sitting on the toilet should be limited to 5 minutes or so, and there should be no straining! (Maybe take the ‘page turner’ book out of the bathroom.) After 5 minutes, It’s time to give up for the moment. - if they have the urge again, then they can sit back down after a break.
Posture and position
Physics make a difference! Go online and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “first world problem”. It turns out that our sitting position is not really helping our body with elimination. If your child’s feet don’t quite reach, you might want to experiment with a little footstool in front of the toilet or potty that gets your child in a better position. You can try it too!
If you have a young child, check out the book Itsy bitsy Yoga. Some of the stretching positions might help move things along.
Acupuncture is another option. Here are some pressure points that you can try (you can also try these when you’re back up at step 1 or 2, but you can keep at it).
Red Flags
There are some things to watch for that deserve a call to your pediatrician:
Any constipation that is associated with weakness, leg fatigue, or changes in walking or balance deserves medical attention, as these symptoms can signal an underlying neurologic or spine issue rather than simple stool withholding.
Constipation that has been present since birth or began in the first week of life - this can occasionally point to conditions like Hirschsprung disease or metabolic disorders. Even though most families will have noticed changes later in childhood, it’s still worth noting for anyone who feels their child “never had normal stools” from the beginning.
Your pediatrician would also want to hear about constipation that’s resistant to clean-outs or doesn’t respond to appropriate doses of stool softeners and daily maintenance therapy.
Persistent tummy pain, vomiting, poor weight gain, or blood in the stool outside of small fissures should also raise an eyebrow.
And if your child has frequent urinary accidents, severe bloating, or stool leakage despite treatment, they may need at least a check-in. The is often a connection between urinary tract infections and constipation. If someone is having frequent UTIs it is absolutely worth looking into their poop frequency and consistency.
If you happen to be reading this from the toilet….time to get up!
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Yes, I had permission to use this photo!
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