Scott Webb (Host): Constipation is a common and sometimes serious issue for kids. But generally speaking, some changes to our kids diet and reinforcing positive toileting habits tends to help our kiddos. And joining me today to discuss things is Dr. Amina Ahmed. She's a pediatrician with Stanford Medicine Children's Health.

This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Doctor, it's so great to have you back on today. We're going to talk about constipation, and I had a couple of kids. I mentioned to you, one of them had some constipation issues. I know it's a relatively serious issue. So, let's start here. What is constipation or what causes it?

Dr. Amina Ahmed: Yes, I know constipation is a very common thing and it's sometimes hard to define. Everybody seems to have a different idea of what it is, so it's good to put the definition out there. It can be defined based on how often the child is going. So if they're two times or less than that per week and if it's painful for them to pass their stools or if they're passing a very large caliber stool and it's hard, all those would be ways to define constipation. That's a constipated stool.

Host: Yeah. And so, it would seem obvious, I guess, for adults, because we know what we're feeling and can probably explain it, if that's a thing, if it needs to be explained. But with kids, especially when they can't quite explain, how do we know what the symptoms are? How do we recognize the symptoms of constipation in a child?

Dr. Amina Ahmed: Kids are different at different ages and they'll show you in different behaviors. So if you have an infant who's constipated, you might feel that they're straining a lot. They're really pushing out, they're crying. And when they pass out that stool, you know, it's like a little pebble that comes out. So, you can see the hard consistency, you can see them straining, you might even see some blood on it.

And it would be similar, let's say, in a preschooler. But in a preschooler or a toddler, you might notice that they're avoiding going to the bathroom. When they do go, they're in a lot of distress and they're crying, they're buckled over with pain as they pass the stools. So, all those would be other signs that you can tell. And with even older kids, sometimes it's just abdominal pain, and a lot of times this would come on after having a meal, like 20 minutes, 30 minutes afterwards, they just start complaining of abdominal pain. And that's just their colon trying to contract and pass that hard stool, and it's just not moving, you know, in the belly.

Host: Yeah. So, do we know what causes constipation? I know with one of my kids, and not to be too graphic here, is that she just sort of had a fear of going to the bathroom, you know, and just was reluctant to go to the bathroom. And so, she would hold it, I guess, is maybe the best way to put it, and then seemingly was causing her own constipation in a way. But maybe, setting aside the fact that my daughter may have been the oddball in the world, just wondering in general, what causes constipation?

Dr. Amina Ahmed: You know, for the sake of our discussion, I do want to point out there can be some more serious causes for constipation, which it's always good to talk with the doctor and we can talk about it later what are the red flags where you must talk to your doctor. But we're talking about the more common constipation that every kid goes through. And that kind of constipation generally comes because there's either lack of fiber in the diet, or they're not hydrating enough, or they're holding, behavioral factors that could be there. So, especially like the kid you're talking about, your kid, it might have been close to potty training time, or if they're going to school, they don't want to go use the school bathroom, or they don't want to miss out playing with their friends, so they keep on holding. And when they hold the stool in, the body tends to absorb more water from the stool that's stored in the colon. And that leads to harder stools. And when they become harder, they're harder to pass out. I describe to my patients, think of it like dried toothpaste, you really have to squeeze it out of that tube. And that's what the colon is doing, and when it contracts, the kids can feel those cramps.

Host: Yeah, feel the cramps for sure. So then, how do you treat constipation in a child?

Dr. Amina Ahmed: Three things I mentioned to you. One was the fiber, one was the hydration, and the third is just behavioral or toileting habits. And that's how you target it. If you talk to your pediatrician, they'll usually go over a good history with you, looking at the diet, making sure the child is taking enough fiber and fibers including vegetables, fruits, and whole grains, if they're getting enough fiber in their diet, because the fiber helps hold moisture in the poop and it also forms the bulk of the poop. This helps the stool move along the colon and leads to more regular kind of bowel movements and softer bowel movements.

The second thing is hydration. So if your child is just not drinking enough water throughout the day, because they're busy playing or they're just not good drinkers or they forget, that will also lead to harder stools, because the body will absorb as much water as it needs from the stool in the colon. And if the child is not drinking enough in the day, let's say it's a hot day, they haven't been hydrating well, they'll have a harder stool. So kind of staying on top of that hydration.

And I can give you a few like ballpark figures, right? So generally, a kid who is, let's say seven years old, we'll say like the age of the child plus five or ten, and that's the amount of grams they need. So, let's say if it's a seven-year-old child, so seven plus five is twelve. So, they need at least twelve grams of fiber in the diet every day. And likewise for hydration, we'll say anywhere around up to 32 ounces of fluid that they should be taking in their diet.

And the toileting habits, it's always good to have kind of like a schedule, especially at that tender age when you've toilet trained them, just started going to school. So, it's good to kind of just keep a habit like, " Twenty minutes after dinner, we go sit on the potty." And we don't want it to be pressured. We don't want the child to be forced into, "Hey, you have to poop at this time." It should be just like, "That's part of your routine, just like how you brush your teeth, you know?" So, we just go sit on the pot every day and we give it a try. So, that helps kind of keep that good habit as well as keeps the gut in a routine. You're almost training your brain and gut.

I think those are the three key features with constipation. You want to stay ahead of the game. There are critical periods in development where we'll feel like, you know, we tend to see constipation more. For instance, infants when they're on formula or they're on breast milk, they're usually going pretty well. But as with a transition to solid foods, now solid foods, when they transition to that, solid food has much less fluid content in it compared to milk. So, a lot of babies tend to get constipated. And if you are not, let's say, introducing foods which have a lot of fiber in them, so if you're giving rice cereal, which doesn't have a lot of fiber, compared to, let's say, if you're giving steamed vegetables or green peas that has a lot of fiber in them. So, just kind of making sure, the balance of how much fiber you're introducing to the infant as well and when you go to introduce solid foods and maintaining that balance. So, that's one critical area when we see constipation in infants.

Then, we see it again when there's an introduction to dairy, as in like in cow's milk at 12 months of age. Some children can develop a little constipation when they transition to whole milk. So, just be mindful of that. And some kids just drink too much milk and that can also lead to constipation. So, kind of restricting the amount of overall whole milk that the toddler may be taking.

And the third time we see it is when you're toilet training them. So, as they're toddler or preschool age, when they are learning to toilet train, if there's a lot of harsh training, kids will sometimes start holding if there's a lot of pressure around potty training, all those factors play into part. And like I said, once they start going to school, they just don't want to miss out on the fun. It's the most boring thing to go to the bathroom.

Host: Yeah. We were all kids once, and we can certainly understand, as you say, a lot of factors and, you know, prevention is really the key thing here. So, let's assume that our child is constipated. We've done everything we can and we're still struggling, they're still struggling. When is it time to call our child's healthcare provider?

Dr. Amina Ahmed: Well, anytime you're concerned. So, that's what we are here for. I do not expect parents to to have to troubleshoot everything themselves. This is exactly what we're here for. So many patients come in, and you'd be surprised, Scott, I show them the stool chart, we classify stool, because what I may think to be constipation, you might not think so. And patients, they're always surprised to see that what they were thinking is a normal stool may have been actually a constipated stool. So, your pediatrician will talk about the consistency of different stools. There's also a chart that they can refer to, you know, what's the standard, how we define different stools. So, they can show you a stool chart. They can talk about how much your fiber child needs and maybe dive down a little deeper. A lot of us think we take enough fiber, how we're drinking enough fluids. But as we start to quantify it and we are going through the diet, a lot of parents realize that, "Oh no, maybe we're not taking enough." So, if you're concerned, go talk to your pediatrician.

There are obviously some signs, which you, I would say, you should definitely talk to your pediatrician. So, if your child is passing pebble-like stools, that's not right. If there's any blood with the stools, that's always not right. If the child is complaining of persistent abdominal pain, meaning like every day they complain of abdominal pain, so that's not right. And if they're having to strain a lot, they're sitting for 10 minutes, 15 minutes on the pot, and they're just straining, not being able to pass anything, that's not right. Talk to your pediatrician.

Host: Always reach out to a child's provider, questions, concerns, whatever it might be. I'll just give you a chance here at the end, doctor, and this has been good stuff here today. You know, it's one of those topics we don't talk about a lot, but those of us parents who've been through this, it is an important one. Just final thoughts, takeaways when we think about constipation in our kids, and us trying to prevent it, and what to do to help our kiddos, what's your best advice?

Dr. Amina Ahmed: Eat vegetables, lots of them, and fruits, high fiber foods. Include them in the diet in various ways. And meet your child where they are in terms of eating fibrous foods. If they are eating fruits, meet them there, but have some crunchy things that they really need to chew, and those are high fiber foods. Include high fiber foods in the diet. Two, maintain adequate hydration, at least 24 to 32 ounces of water or fluid a day. And then, limit cow milk and be mindful that they're not taking too much whole milk in their diet. And I think just good toileting habits.

Host: Yeah, it's probably good advice for adults too who may be suffering, but that's a separate podcast. We're focused on our kiddos today. So, thank you so much, doctor.

Dr. Amina Ahmed: It was a pleasure being here. Thank you so much, Scott.

Host: And for more information, go to stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.