Constipation in kids is a major problem, but all the kale in the world may not be enough to fix it. Here’s why–and what to do!
Constipation is a big problem among children and can lead to bedwetting, daytime accidents, and urinary tract infections. I’m happy to have another guest post by Steve Hodges, M.D., a pediatric urologist at Wake Forest University School of Medicine and the coauthor of It’s No Accident and Bedwetting and Accidents Aren’t Your Fault. He also has a brand new e-course called STOP Bedwetting Forever With M.O.P. (get more info at the bottom of the post plus a discount code). Here, Dr. Hodges addresses a common misconception about constipation in kids: that a healthy diet can always fix it.
By Steve Hodges, M.D.
The other day a patient’s mom asked me, “Why is my daughter so constipated? She’s been on a ‘real food’ diet since birth. She’s gluten free and does karate or ballet every day.”
Another mom, posting in my bedwetting support group, wrote: “All our kids are constipated even though we eat lots of veggies and little sugar. Do you have to be gluten-free/dairy-free/high-veggie/fruit to be able to keep your poops moving in the modern world?”
Most folks assume that when a child’s insides are clogged, the culprit is highly processed, low-fiber diet.
But that’s not always true, and trying to fix constipation with “clean” diets, prune juice, or fiber supplements may only frustrate families without actually solving the problem.
Why Kids with Stellar Diets Can Become Constipated
I support eating real food — heck, my wife is a nutritionist! There’s no doubt our culture’s constipation epidemic is largely driven by processed “food products.” The human digestive system wasn’t designed for s’mores-flavored breakfast cereals.
When kids overdo junk food, their stool hardens and pooping becomes painful; to avoid pain, these kids poop less often, causing even more stool to pile up in the rectum and even more pain with pooping. It’s a vicious cycle.
However, many children become stuck in this cycle for reasons unrelated to processed food or inactivity. Among the reasons:
Toilet training too early: Many preschools require potty training by age 3, prompting parents to train their children as toddlers. Problem is, 2-year-olds — while capable of using the toilet — may not have the judgment to poop in a timely manner. They ignore their bodies’ signals and become expert holders. Children trained earlier than age 2 are at the highest risk for becoming chronically constipated.
Minimal toilet-training follow-up: Once children are toilet trained (hallelujah!), we stop paying attention to their pooping habits. But potty training isn’t a skill, like riding a bike, that gets locked in once things “click.” Learning to poop on the toilet is different from learning to heed your body’s urge to poop. The latter requires daily reinforcement, and that’s not part of our culture. Once the holding habit takes root, it’s difficult to reverse.
Also, constipation is often overlooked, because parents aren’t familiar with the signs. For example, parents assume underwear “skid marks” signal poor wiping technique; in fact, they’re a red flag for constipation. Other red flags: XXL poops, stool shaped like logs or pellets (as opposed to mushy blobs or frozen yogurt), and extreme urgency to pee.
Restrictive K-12 bathroom policies: Many children are too grossed out, scared, or embarrassed to use school bathrooms, but more commonly, they run up against classroom policies that encourage holding pee and poop.
Schools routinely limit bathroom passes or lock restrooms after school, forcing students to ignore their bodies’ urges. Some 36% of elementary teachers reward students who don’t use bathroom passes or punish those who do, and 76% of teachers implement policies that undermine their students’ toileting health.
Genetics and personality: Some children, for reasons unknown, become constipated as babies, before they ever eat their first goldfish cracker or understand the word “potty.” For some of these kids, intolerance to dairy may cause or contribute to constipation, but for most, no apparent reason exists.
Some have relatively mild symptoms, like a persistent stomach ache or an itchy butt. But others end up so chock full of stool that develop enuresis (bedwetting or daytime wetting), because the hardened poop mass in the rectum presses against and aggravates the bladder. Other kids develop encopresis (poop accidents), because a rectum stretched for years loses tone and sensation; poop just drops out, without these kids even noticing.
Parents drive themselves, and their kids, nuts searching for dietary solutions to these problems. They are searching in the wrong place! Even when eliminating dairy helps, as it does in some kids, that step alone rarely reverses the symptoms.
A Two-part Plan to Resolve Constipation
If your child eats well and still shows signs of constipation, I recommend a two-part strategy: 1.) cleaning out the child’s rectum with laxatives, suppositories, and/or enemas and 2.) instilling healthy pooping habits.
Yes, I realize “laxatives” sounds unnatural, as if I’m medicalizing an issue that can be resolved with kale and prune juice. But these remedies needn’t involve chemicals (there are plenty of alternatives to Miralax). Besides, there is nothing “natural” about carrying around a belly load of poop.
It’s critical to treat constipation aggressively. Left undertreated, constipation can plague kids throughout childhood and beyond. Plenty of my bedwetting patients are tweens and teens.
Most of my patients have been constipated for years. Many of them poop daily — even two or three times a day — but they never fully empty. Fresh, soft poop just oozes around the hardened mass that is stretching the rectum and aggravating the bladder.
All the kale in the world won’t dislodge that hardened mass of stool.
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For children who have belly pain but not daytime or nighttime accidents, I recommend a daily osmotic laxative, whether it’s magnesium citrate, Miralax, lactulose (a prescription laxative), milk of magnesia, or chewable tablets. None of these are habit forming; they simply draw water into the colon, softening stool and making pooping less painful. When kids realize pooping no longer hurts, they are more likely to do it in a timely manner.
For these kids, occasional glycerin suppositories, solid or liquid, are useful, as are enemas.
Children who have more significant symptoms, such as daytime or nighttime accidents, need a far more aggressive regimen. The one I recommend, based on research and my decade of experience, is the Modified O’Regan Protocol, aka. M.O.P., a combination of daily enemas and laxatives.
(I spell out the regimen in The M.O.P. Book and, in more detail, in my online course, STOP Bedwetting Forever with M.O.P. If your doctor is unfamiliar with the regimen, hand her our free downloadable packet, The Physician’s Guide to M.O.P., which supplies evidence for its safety and effectiveness.)
For severely constipated children, you would be shocked at how difficult it can be to clean out hard, crusty stool that’s been impacted in the rectum. Even with daily enemas, one mom in my support group posted, “I feel like I am chipping away at a cement block with a garden hose!”
But resolving chronic constipation isn’t just about cleaning out the rectum; to prevent relapses, it’s critical to teach your child healthy pooping habits. Even young children can understand what happens inside them when they ignore the signal to poop, and they can distinguish between logs and blobs!
Here’s how to help your child get the most — literally — out of each poop attempt. Instruct your child to:
- Try pooping each day after breakfast and dinner. The urge to poop is stronger after
eating, especially in the morning.
- Sit for a full 5 minutes, with a book or video. Kids tend to pop off the toilet and announce, “I don’t have to go!” Set a timer so your child learns just how long 5 minutes is. My book Jane and the Giant Poop reinforces the importance of sitting for a while.
- Lean forward while pooping, elbows on knees, tailbone pushed out. This position gives your child the benefit of gravity and stretches the abdominal cavity, allowing the colon more room to pump stool to the rectum for emptying.
- Sit with feet firmly planted on a tall stool. That puts the child’s body in the squatting position, the way humans were designed to poop!
I can’t emphasize enough how deeply ingrained the holding habit becomes in children. If your child eats relatively well and still exhibits the signs of constipation, I’d focus on reversing the habit rather than eliminating food groups or forcing a “cleaner” diet.
Dr. Hodge’s course “STOP Bedwetting Forever With M.O.P.” teaches parents to implement the Modified O’Regan Protocol with confidence, through a series of videos, written lectures, useful charts and guides, and supporting scientific studies. Bonus content includes three children’s books: Bedwetting and Accidents Aren’t Your Fault, Jane and the Giant Poop, and Dr. Pooper’s Activity Book and Poop Calendar for Kids. Review the curriculum and watch the preview video. Real Mom Nutrition readers can get 15% off the discounted price by using the code REALMOM by March 10.
Steve Hodges is an associate professor of pediatric urology at Wake Forest University School of Medicine and instructor of the online course STOP Bedwetting Forever With M.O.P. His books, written with Suzanne Schlosberg, include Jane and the Giant Poop, Bedwetting and Accidents Aren’t Your Fault and Dr. Pooper’s Activity Book and Poop Calendar for Kids. His website is BedwettingAndAccidents.
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