To poo or not to poo…

It is amazing how many of my conversations since becoming a mom centers around feeding, sleep and poop! And when one of those are out of balance it feels like your whole life is upside down. Most of these issues do not warrant a visit to the pediatrician on own merrit, but the correct advice and understanding could improve your (and your child’s) quality of life immensly. In the next few blogs I want to address a few common issues that many of my mom-friends have asked me about. I hope I can answer a few of your questions too!

I want to continue with the “hard” topic from my previous blog, so let us talk about constipation in toddlers. Not such a big problem, all kids go through some degree of constipation at some point and they grow out of it, right? Yes, but it is not so simple. I have seen a 5 year old boy admitted for appendicitis who in the end “only” had severe constipation. It is important to understand what happens when toddlers become constipated and to be ready to treat it early to prevent long-term complications.

Toddlers are prone to constipation when they potty-train, start school or when any other life-altering changes happen in their lives. They can also just be too busy enjoying life to waste time on the loo! 😉 That first hard stools can then trigger a chain-reaction of bad experiences. Painful defecation due to large, hard stools or even anal fissures (a small tear in the skin around the anus) can cause withholding behavior and this turns into a very vicious cycle.

Withholding behavior can be anything associated with not responding to the urge to poo.  If you ignore the urge for long enough, it goes away, but the problem does not. Are you ready for the gory details?

The “urge” is triggered by the stretching of the rectal wall (the part of your colon just before the anus) when it is filled with stool. If you do not relax your anal sphincter muscles, the stools are pushed back and the urge goes away. However the rectum is still stretched, and over time becomes less sensitive to stretching when the next stool enters. The rectum’s main function is to extract and conserve as much water as possible. This is why the stool gets harder and dryer the longer it stays in the rectum. Children with fecal loading (where large masses of stool heaps up in their rectum) or impaction (where it is very difficult / painful / impossible for the child to pass the stools without help) can sometimes even seem to have diarrhea when the “newer” stool trickle past the hard stool. This can also manifest as fecal soiling (also called encopresis) where stool leak into the underwear (overflow incontinence).

So what can you do to prevent this? Or how do you treat it when your toddler already has some of these problems?

Acute treatment:

If there are any signs of fecal loading / impaction, it is important to first empty the colon to break the vicious cycle of hard, large, dry stools causing pain – causing withholding – causing hard, large, dry stools. This can be done at home or your doctor might feel it is necessary for your child to be admitted if there is a risk of dehydration.

Disimpaction is done by the aggressive use of poly-ethylene glycol (a laxative called PEG eg Pegicol / Miralax), or enemas or a combination of the two. (1)  This breaks up and softens the hard stools and enables the child to pass them. Once the colon is empty you can start with phase 2 of the treatment.

Maintenance treatment:

It is important that your toddler’s colon is “retrained” to be sensitive to minimal stretching and that the anus can relax and withhold as needed. This takes time. So it is crucial that you and any other caregivers buy into the gameplan for the next 4-6 months.

The treatment consists of a combination of laxative use and behavioural therapy. (2)

In short you need to ensure that your child passes 1-2 soft stools DAILY. (3) You become the laxative-expert by increasing or decreasing the dose as needed. The prescribed laxatives (PEG or lactulose) is very safe and is not absorbed, so you cannot “overdose” your child. It is also safe for long term use and does not cause the bowels to become “lazy” as it does not stimulate contractions of the bowels. (4) See more about the use of laxatives in babies in my previous post.

The behavioural therapy adds a crucial part of the treatment. As a child needs to learn and practise walking / talking, they also need to learn and practise a healthy toilet-routine. Start by encouraging and supervising regular “toilet-sitting” times, 2-3 times a day after meals (this is when there is a natural reflex to pass stool, so use all the help you can get). Make these toilet-sitting times fun and stress-free. Sit for 5min even if there is no poo, and just keep at it. Make sure your child has a good posture on the toilet (a squatting position opens up the pelvis and aligns the rectum in such a way that it is easier to pass a stool) and that they do not have any fears of the toilet. (For some comic relief of all this poo talk, do yourself a favour and watch this video about “The Squatty Potty“).

It is also important in the long term to address the child’s diet to increase fiber and water intake. These are important skills that you teach your children for maintaining healthy bowel habits for the rest of their life, so it is well worth the effort!

Do you have any poop-related stories to share? It sometimes feels gross and uncomfortable to talk about, but just maybe you encourage the next mom that it is ok, it gets better and there is help available!

1. Dobson P, Rogers J; Assessing and treating faecal incontinence in children. Nurs Stand. 2009; 24(2):49-56

2. Brazzelli M, Griffiths PV, Cody JD, Tappin D; Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011; (12):CD002240

3. Beck DE; Constipation and Functional Bowel Disease; Clin Colon Rectal Surg; 2005 May, 18(2): 120-127

4. 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 Jul; 157(7):661-4.