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Pediatric Constipation

Elaine Barfield, M.D. discusses what parents should know about addressing constipation issues in children. She notes the factors that may impact regularity and consistency, including issues of holding and signs of pain to look out for in kids. She gives advice on behavioral management that parents can train in their children early on, including proper sitting postures and understanding the gastrocolic reflex.

Finally, she gives guidance to parents on laxative stool softeners and tools like the squatty potty.

To schedule with Elaine Barfield, MD
Pediatric Constipation
Featured Speaker:
Elaine Barfield, MD
Treating children with gastrointestinal and nutritional disorders is extremely rewarding.  My job allows me to work closely with patients and families to improve the health and quality of life of children and adolescents with gastrointestinal disorders.  My main goal in practice is to provide excellent patient care with an emphasis on communication, education and accessibility. 

Learn more about Elaine Barfield, MD

Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels.

Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And we're joined today by Dr. Elaine Barfield. She's an Associate Professor of Clinical Pediatrics in the Division of Pediatric Gastroenterology and Nutrition at Weill Cornell Medicine. And she is here to speak with us about motility issues in kids. In case you don't know what that is, we are addressing constipation and other bowel issues, so that parents can help their kids.

And Dr. Barfield, it's a pleasure to have you join us again today. And I told you off the air as a parent, when my son was like three, four, five, boy, it was a big deal. And we thought, "Oh my God, he hasn't pooped in seven days." We were so concerned about every single day of it. So, you're going to clear up a lot of that mystery for us. Before we get into it, tell us what that is. What is constipation? What actually defines it so that we can say, "Oh, well, if they don't poop for one day, that's not necessarily constipation"? How is it defined?

Dr Elaine Barfield: Well, thanks, Melanie. And thank you for having me back. It's a pleasure to be here again. So, constipation really has to do with both the frequency of stooling as well as the consistency of the stool. So, goal would be to have a nice soft peanut butter consistency stool once a day. Even every other day would be acceptable. But many times, patients are passing little teeny stools or little pellets of stool every day. And the parent will say, "Well, they're not constipated because they're stooling every day." And I'll say, "Well, they are, because it's the consistency that we're trying to achieve. Those little pellets are not normal. We'd like to have a nice, soft, normal consistency stool." So, constipation again really has to do with what the frequency and the consistency of the stool that the child's producing.

Melanie Cole (Host): So as we're thinking about constipation, you do see other motility and bowel issues in kids. Tell us what some of those are.

Dr Elaine Barfield: Sure. So, motility is really the subspecialty of gastroenterology that has to do with the movement of contents through the GI tract. So, there are a host of motility issues that one can experience and they really vary on the location in the GI tract. So, there are upper GI tract motility problems such as eosinophilic esophagitis or even disorders related to reflux. There are disorders in the middle of the abdomen, such as gastroparesis, which means a delayed gastric emptying of stomach contents. And then yes, you have constipation, which involves the lower GI tract or the colon.

Melanie Cole (Host): Okay. So, constipation specifically, it's pretty common. At what age would parents start to notice this? And I remember, Dr. Barfield, when it was my son, one of my dear friends, an older lady said, "You know, we didn't even know if our kids pooped or not," you know? It wasn't something we paid attention to, but it was something that we were like very conscious of, like all the time. We were like, "Okay..." So, what age when parents start to notice this? Is it our little babies or does it sort of happen into toddlerhood?

Dr Elaine Barfield: So, that's a great question. It really does depend. It really starts even at infancy, right? And so from six months on, you can see some issues with children developing problems with constipation. Constipation affects up to 30% of children and really, interestingly, accounts for 3% to 5% of visits to the pediatrician.

And so, children of all ages can be affected with constipation. There are some more functional causes of constipation such as infant dyschezia, which is basically when your infant child strains and ultimately passes a soft stool, that's actually considered normal. And there are also other forms of constipation related to diet or related to tone or other low muscular tone issues that a child could have.

Melanie Cole (Host): Well, do we know what causes it? You said there are some that are related to diet. Obviously, if a kid's maybe eating a lot of junk food at that young age or not getting any kind of fiber at all. I don't know, not hydrated enough, but can it sometimes not be diet-related and that changes in diet might not even really affect it or not really?

Dr Elaine Barfield: Yeah. So, I would say most constipation, probably 95% or more cases of constipation are what we call functional constipation. And that basically means that the patient is having difficulty with passing stool or with the consistency of stool in the absence of any organic causes. There are those five other percent of constipation, however, which may be organic in nature. And that can include things like anal fissures, milk protein intolerance, something called Hirschsprung disease, which has to do with abnormalities in the nerves related to the rectum and the lower colon. And then other issues too, such as diabetes. If patients have diabetes, they may be more to issues with motility and constipation. And then, you always have to think about things like celiac disease, which can present with a child who's constipated. Certain medications even, opiates and certain antidepressants and even certain types of chemotherapy, can cause issues with motility, which relate to constipation.

Melanie Cole (Host): What about behavior and behavioral issues in that way? Because I know with my son, that's what we finally realized, was he was afraid it was going to hurt, so he was holding it in. And then, it was how many days, and it got hard and it was a whole thing. So sometimes, can it be that, where they're either holding it in or something along the lines of not really conscious choice by these kids, but something that they're doing?

Dr Elaine Barfield: A hundred percent. Withholding is probably the most common reason why the patients I see in clinic are constipated. And you're absolutely right. From age six months up, patients can appreciate that stooling can sometimes hurt. And there are various times where a child might pass a very hard stool and have a lot of pain and a lot of trauma related to that, and may decide that, "I'm not going to do that again." It's almost like touching the hot iron or touching the hot stove. "Okay, I've done that once. I'm not doing that again." And so, you know, you really see a lot of fear and a lot of withholding in a large majority of the kids that I treat. And like I said, this can start at age six months. So, this can start very early on. And you'll see a lot of behaviors. You may have seen some of this with your son. You know, there's certain, we call it almost, the poopy dance in the sun sometimes where the child is sort of dancing around. You can tell they've probably got to go. And they're sort of making various gestures and backing themselves up into the wall or to the sofa or crisscrossing their legs. All of these are efforts in their young little minds to prevent the stool from coming out.

So it's interesting, a lot of times in clinic, I'll have a parent say, "Well, you know, I see him go over to the corner and then he does this sort of this little dance. And I think he's trying to go." And I have to a lot of times convince the parent, "Actually, no, he's not trying to go. He's trying to prevent himself from going because he's afraid," right? And so, that's a really common phenomenon that we experience and we have to try to often convince the parents that this is actually what's happening and now we need to help the child to soften the stools or help to move the stools along, such that they are no longer fearful, that the stools are no longer hurting, and that they'll sort of relax and allow them to come out at normal intervals.

Melanie Cole (Host): When children are constipated, how long can they go without pooping? Is it dangerous at any point? And then when it does happen, sometimes, you know, there might be blood or even something that looks like a hemorrhoid, but I think these are pretty rare. So like Clayton had a rectal prolapse. Can you tell us about if it's dangerous when they go without pooping, how long can a kid go? And then, what are some of those things that happen?

Dr Elaine Barfield: Sure. So you'll hear doctors quote that infants, for example, can stool anywhere from seven times a day to once in seven days. And so, that's quite a large range. As long as a stool at that age is coming out soft and, again, peanut butter consistency, we allow that to happen. As a child ages though, the stool frequency will really change. So by toddlerhood, the average number of stools is just under about two a day. And then children who are four and up, average about one a day. So at that point, if a child goes 24, 48 hours and has soft stool, I usually allow that to happen. But once we start to see the stool harden or we get beyond 48 hours and more, that's probably going to lead to some issues, particularly in a child who's already fearful or maybe withholding. So, I really go by the consistency. If a child stools every 72 hours and mom tells me it's soft, it's peanut butter-like, and there are no issues, no problem. But when the stool consistency changes, it becomes hard, pebbly, very large, like a softball sometimes they'll say, these are all problematic. And you're right, you can end up having complications. And so, one of the complications of constipation you can see is blood in the stool, like you mentioned. And that likely is caused by a larger stool or a harder stool passing through the anal opening and causing a tear or an anal fissure, which can be extremely painful. Imagine a paper cut in that region. It's very painful. And again, if a child develops a fissure or see his blood in their stool, they become very fearful and don't want to do that again.

You also mentioned rectal prolapse, which is very, very terrifying for many families. And rectal prolapse happens in severe cases of constipation where a child might have such a buildup of stool in the colon and in the rectum that eventually that stool does, with gravity or what have you, come out. And with that, the portion of the rectum actually comes out of the anal opening and it's very terrifying to see. If that happens, a patient might feel something on their bottom. The parent might look and see a bright red, fleshy sort of tissue mass protruding from the anal opening. Very scary. And so, I always tell people who are hesitant to treat their children for constipation, a lot of people don't want to use various medications or the things that we suggest, but I tell them the worst thing that can happen is, again, bleeding, developing fissures, developing a rectal prolapse because really with prolapse, that's an emergency. You know, if you're not able to gently massage that prolapsed rectum back onto the anal canal there, the anal opening, with maybe Vaseline or Aquaphor lubricating your hand to do so, you've got to take that child to the emergency room because that bowel can die. And I've seen that, and that's a tragic, tragic thing if that happens. So, very scary. But I tell parents, in order to prevent these serious complications of constipation, let's try to nip this in the bud. Let's give them the softeners or the laxatives we need to give them in order to achieve a nice soft stool on a daily basis if possible.

Melanie Cole (Host): So then, doctor, do we leave kids alone on the toilet? I'd like you to speak about the treatments and we'll get into the MiraLax and the softeners that you were mentioning. But while they're trying to poop and it's time and we say, "Okay, buddy, come on. Here you go." Some kids like to like sit there for a long time with a book or something like that. Are we not supposed to let them do that? Does that start bad habits? Can it hurt them in some way? Or is that the way to sort of, with maybe even like a Squatty Potty or something, to relax that colon and get them to go?

Dr Elaine Barfield: So, you've hit on one of the most key components of the treatment of constipation, which is the behavioral components of the management. And it's critical that we allow children and really encourage children to sit on the toilet after meals. We really want to take advantage of that gastrocolic reflex that's already naturally happening after we've eaten a meal. And so, my advice is usually to take your child to the toilet. Do not allow them to sit in there and sort of linger for an hour. I ask parents not to let them bring books or games or iPhones into the bathroom. It's really important that they capitalize on those five minutes that I'm asking them to sit there and that they sit in the correct positioning. So, you mentioned the Squatty Potty, so that's key. We really want to make sure that when a child sits on the toilet, they're sitting upright, their knees are elevated higher than their hips, so that means putting their feet on some type of a step stool or a Squatty Potty. You have to be careful with Squatty Potties though, because they come in different heights, and so not all of them will allow that child's knees to sit higher than the hips like they need to be. When the child's knees are elevated higher than the hips while sitting on the toilet, that really opens up the rectal angle and allows the stool to come out much more easily, And when a child is sitting with their legs sort of parallel to the ground and their feet are kind of dangling, that's sort of the worst position that a child should be sitting and they really need to have those knees elevated.

And then, as far as the amount of time, I ask them to sit for about five minutes after each meal. So I tell the parent, "Have them wait five minutes after the meal finishes and then have them go to sit for five minutes and that's it." And I tell them this is part of training the brain and the gut to become more in sync to respond to those gastrocolic reflexes that they potentially are feeling after meals and to let the child appreciate those sensations. And so, I ask them to time a child. They can sit right outside the door. If it's a child who wants mom in the room with her, that's fine as well. But the child should sit with those knees elevated for five minutes.

And the last key part of this is they should be blowing something. So, I ask them to take in a balloon if it's an older child or some bubbles or a harmonica if it's a younger child, a whistle, what have you. And this allows them, if they're able to sit in that position and blow nice, slow, deep breaths into that harmonica for example, that helps to engage their core muscles and help them to bear down in the appropriate way. A lot of times when we don't do this, the child is bending over or is leaning backward or is sort of not focusing. And so, sitting for five minutes after each meal in that position and blowing nice, short, deep breaths into that object really can help.

Lastly, I tell parents, you're not expecting your child to poop every time, right? We're not expecting that. We're really trying to, again, train the brain and the gut to become more in sync. And so, the child will do this, but may only still poop once a day. That's perfect. That would be wonderful. But we really want to help them to train the child's body to respond to those sensations.

Melanie Cole (Host): What an excellent description that was, Dr. Barfield. For parents listening, replay that part as often as you need to because she just gave mindfulness. She gave specific exercises, things you can do with your child. And boy, I can tell you if I would've heard some of that, and they didn't have things like the Squatty Potty back when my son was dealing with this, but you know, all of those things were such great suggestions.

Now, other than lifestyle, you know, that behavioral issue, and we'll try and get diet in here too, but there are treatments, things that you as a pediatrician would start, a GI specialist, and MiraLax, those kinds of softeners. As you mentioned earlier, parents are sometimes hesitant to even want to get into those. They think that it's going to cause malabsorption or some kind of nutrient deficiency. Speak about some of these treatments, fiber supplements, MiraLax, any of those to sort of get the process going, right? Don't we have to clean our little kiddos out first so that then we can work on that behavioral thing? But they have to get cleaned out first.

Dr Elaine Barfield: So important, Melanie, yes. So, a lot of times a child will require what we call a clean out or a flush out, and I always describe that as sort of pressing a reset button before we go on to a maintenance therapy. And a lot of times, a child will come in and the typical complaint is, "My child, they stool every four, five days. They poop every week or so. And the stool is hard and it's painful and it's this and that." So, we often do have to start with a clean out.

And so, the first thing that I usually recommend is MiraLax. And MiraLax is a powder that the parent would mix into a liquid or a drink of the child's choice. It's tasteless, it's odorless. It does not cause, cramping or pain or really anything. It really stays within the GI tract and draws water into the colon via osmosis, which many of us learned about in grade school. And the process of drawing that water into the colon then softens the stool. So. MiraLax is a softener and allows the child to have softer stool that they then have to expel on their own. It's important to remember MiraLax is not a stimulant, it is not a laxative. So, it is just a softener. And it's probably our safest and easiest softener to use. It's, palatable, like I said, because it doesn't have a taste or an odor. And it can be mixed in anything. It can be mixed in water, it can be mixed in milk, it can be mixed in juice or seltzer water if you wanted to have that sort of bubbly feel. But in any event, it's usually well tolerated tolerated and therefore really what we tend to start with.

MiraLax has unfortunately over the years gotten a bad rap for various reasons. As you mentioned, parents are fearful of using it. Parents are fearful of the ingredient, the main ingredient in MiraLax, which is polyethylene glycol. Many studies at this point though have debunked a lot of the myths surrounding MiraLax and have actually shown interestingly that if you take children on MiraLax and you take children who are not on MiraLax and you check various levels in their blood and you check that polyethylene glycol content, they have equal amounts of polyethylene glycol in children taking MiraLax and in children not taking MiraLax. So, that really tells us that this ingredient, polyethylene glycol, is ubiquitous. It's in everything. It's in lotions, it's in toothpastes. And so for whatever reason it's been focused on in MiraLax for quite a while in the press and whatnot. But it really is ubiquitous. It's really just a softener. It's not absorbed in the bloodstream. It's really just pulling that water into the colon to help soften the stool.

So, that's what I usually start with. And when I'm doing a cleanout, I give a parent a regimen that involves a couple of larger doses of the MiraLax each day for about three days. So, I recommend that people do cleanouts for their children on weekends, unless they're on some type of school break, because I don't want to induce a large amount of stooling or diarrhea while a child is trying to get from class to class.

So, sometimes with the cleanout also, I'll need to use a stimulant laxative as well. You might have heard of Ex-Lax or Dulcolax or bisacodyl or senna. And these types of compounds are what we call stimulant laxatives. Rather than soften the stool, these help to wake the colon up and induce colonic movement of the stool through the colon. So, sometimes I'll have to use both and that's really typical. Many of my cleanouts involve three doses of MiraLax a day for three days, as well as three doses of Ex-Lax or Senna each day for three days to really flush that child out effectively.

And then once a child's been flushed out, then we can start our maintenance therapy. And the maintenance therapy generally involves at least the MiraLax, a softener, plus minus the stimulant if that's needed. And so, I'll see the child back in a month. We'll check in, see how they're doing. Are they stooling daily? Which is usually my goal. Is the stool soft like peanut butter? Which is my other goal.

Melanie Cole (Host): This is probably one of the most informative podcasts for parents that I have ever done. You are giving such amazing information, Dr. Barfield. As we get ready to wrap, first of all, I'd like you to kind of summarize lifestyle behaviors, diet. Now, I gave my kids fish oil and probiotics, which I'd like you to address in this summary that you're going to give because I know that some parents are looking at that and they're certainly more common now, and I called it bugs and oil. Time for your bugs and oil. And I don't know that it did anything, but it didn't hurt anything. So, I'd like you to address that. But I'd also like you to address the worry factor for parents as you wrap up. You see parents about this every day. They get freaked out. They think that there's tests and things. Should we do a colonoscopy on the little guy? Is there things we should be doing? So, if you would address those things and wrap up with your very best advice for this common situation that has a lot of anxiety for parents, causes a lot of anxiety.

Dr Elaine Barfield: You're right, Melanie. Constipation causes a lot of anxiety and it can be scary for parents. They wonder, "Well, where is all the food going? Is my child getting distended? Are they going to have to go to the emergency room because the pain is becoming so great with the constipation and if they've not stooled for several days?" So, I would tell you, you know, in summary, most constipation in children is functional in nature, meaning there's not an organic disease or physiologic problem there. Most of the time it has to do with behavior.

Dietary components are important to think about. Many of our children, as you know, are picky eaters or may not consume fruits and vegetables, may not eat enough fiber. So, I tell parents it's just important to make sure your child has a balanced diet. I don't recommend fiber supplements. So, I don't recommend Benefiber, adding fiber gummies. I would not do that. Most of the time children are eating decent amount of fiber. But if you give too much fiber, if you give fiber in excess, you can actually bulk the stool up way too much and then cause the child even more difficulty to pass a more bulked up larger stool. So, I'd stay away from fiber supplements.

I would make sure the fluid intake is appropriate. You really want to talk with your pediatrician and make sure that your child is getting adequate hydration. Most children, I will tell you, are not and that's a challenge. The other thing is dairy. Many people will ask about dairy when you talk about constipation and dietary components. In some cases, we'll find that reducing dairy in a child who's drinking like a very large amount of milk or eating a lot of cheese or yogurt can be helpful. A, quick tip, I often tell parents to do if their child really is drinking a lot of milk, is switch them over to Lactaid brand or a lactose-free brand, because that lactose component sometimes can be something that's triggering for constipation.

But yes, it's a very, very common problem. That's the other thing I want to leave parents with. It's very common. I don't want them to worry or become fearful, but talk to your doctor about this. And really be open to your doctor's suggestions about the dietary changes, the softeners and the stimulants, and I call those medications Band-Aids because, if this is a behavioral problem, you really are taking that child and trying to get them on a journey where they start to have soft, regular stools, they start to trust the process, they don't feel the need to withhold. And so, these are Band-Aids, right? You're not going to be on MiraLax and Ex-Lax and these medications forever. But it is important to address the child's constipation, their symptoms, they're pain, the blood in the stool, whatever you're seeing, so that things don't progress and worsen.

Melanie Cole (Host): Thank you so much, Dr. Barfield, for sharing your incredible expertise with us today. And parents, I can tell you, it does go away when it's like that. I mean, my son is 22 now, and he poops just fine. So, just remember that there is a light. As Dr. Barfield said, it's a Band-Aid. Thank you so much.

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