On this episode of Monday Mornings with Dr. Mona I answer a common question I’ve gotten asked on my social media account @pedsdoctalk.

I discuss toddler constipation:

• Why it happens
• The questions your child’s clinician may ask you
• How to approach it
• Common medicines we use and how they work
• How I personally approach it with our toddler

00;00;01;04 – 00;00;27;16

Dr. Mona

Welcome to Monday Mornings with Doctor Mona, where each week I answer your questions. This morning for this episode, I am doing things a little bit differently. I usually answer questions for Monday mornings with Doctor Mona, but I have been getting a lot of questions in my question box on my social media account about toddler constipation. So I am using this Monday mornings with Doctor Mona to talk about toddler constipation.

 

00;00;27;18 – 00;00;55;00

Dr. Mona

So 3 to 10% of toddlers and above the school age children can have constipation. And it is tough. I don’t think people understand how hard it is, no pun intended, to have a constipated toddler or a child. If you also have been constipated. It is very uncomfortable and can be very painful. And so with our child, whether they are pre-verbal or not, it is something that can be very bothersome to them.

 

00;00;55;02 – 00;01;14;21

Dr. Mona

On this episode, I’m going to be going over some things to consider. You know what we would ask you? If you’re coming into the office with constipation in your toddler, and also how I manage my son Ryan, who is, you know, about 23 months at the time of this recording when he is showing signs of constipation. I hope it will really help you understand how to tackle this for your child.

 

00;01;14;23 – 00;01;35;16

Dr. Mona

So things that we would want to ask you if you’re coming into the office and your child is constipated, how long has this been going on for? Is this something recent? Has there been any changes? So. Such as like, you know, starting potty training, changes in activity, stressors, these can all affect our bowel habits. Is this something that was going on since birth?

 

00;01;35;22 – 00;01;58;29

Dr. Mona

Did they pass poop when they were a newborn? Did they have issues with constipation from that time? We want to know what’s going on here. We also want to know hydration status foods that they’re eating. Although to be honest, sometimes toddlers can be constipated. Despite good hydration and fiber intake, some children are just more prone to it. But it’s important to know, well, what are we doing with hydration activity and the foods that we eat?

 

00;01;59;01 – 00;02;17;17

Dr. Mona

We want to know if there is blood in the stool. This is going to be very important because if there is blood in the stool, constipation, we want to know that because a straining is there something else that we need to evaluate for with a GI specialist? What have you used in the past in terms of medicines? Over-the-counter prescription.

 

00;02;17;23 – 00;02;41;07

Dr. Mona

So maybe you’ve just done, you know, water and different foods, but have you used any specific medications? What has helped? How much did you use it? How often did you use it? Did you have a regimen? This is going to be important for us to go forward. If this is something that has occurred in the past, we want to know, well, what hasn’t worked, what’s changed now, and if we need to make any changes to the medication remedy.

 

00;02;41;10 – 00;03;02;25

Dr. Mona

An important question I want to know is what is their regular pooping pattern? This is so important and regularity can depend person to person even as adults, right? Some of us can poop multiple times a day and some of us will poop every other day, and normal poo poop will be that soft poop. It doesn’t have to be super diarrhea.

 

00;03;02;25 – 00;03;26;24

Dr. Mona

Like, that’s not what we want. But I’m talking like that non pebble poop. Non you know, looks like a sausage with like little lumps in it. I’m talking just like a nice formed stool that looks almost like the shape of our colon, if you will. Just like long and, you know, poop talk I didn’t I don’t think you guys realized how much we’ll be talking about poop this episode, but that’s important to me because everyone’s pattern is different, including toddlers.

 

00;03;26;27 – 00;03;48;18

Dr. Mona

But we want to know what their regular pattern is, because that’s going to be how we can know if we need to intervene if they’re straying from that. That’s how I know that I need to intervene with my own son, Ryan. So the first things that we can think about on managing constipation, food, so different types of foods such as fruit, vegetables and fiber.

 

00;03;48;20 – 00;04;15;28

Dr. Mona

So things like pears, beans, oat, quinoa, black beans I love quinoa and black beans combo because it’s great for fiber and it can really help with pooping veggies. Avocado. Mangoes. Peaches. Papayas. Pears. I mentioned pineapples, plums, prunes. Any fruit juice or fruit with a pea, and then all the other vegetables and fruits that I mentioned are really good are to increase the fiber intake for our children.

 

00;04;16;00 – 00;04;39;13

Dr. Mona

Limiting milk if our toddlers are drinking, you know, more than 24oz of milk or dairy products that can lead to constipation. It doesn’t mean that all children who consume a lot of dairy will have constipation. But for some children it may. Another thing is increasing water intake. So ideally, for a child who’s 1 to 3 years old, six cups a day, and then seven cups a day for a child who’s older than three.

 

00;04;39;15 – 00;05;00;02

Dr. Mona

But this can be hard sometimes to measure. But we definitely want to up water intake for our children because dehydration can lead to dehydration in the colon, leading to constipation. Remember, the reason why we get constipated is water has been removed from our poop and it becomes very hard. And so it’s going to be harder to pass, which can be a very vicious cycle, which I’ll get into.

 

00;05;00;04 – 00;05;21;23

Dr. Mona

So the other thing is increasing activity, right? So if your child’s a little bit older school age and is very sedentary, we want to know that we are increasing physical activity because that helps us move our bowels along. Obviously hydration is going to be important too. But we know that toddlers tend to be very active just by nature, but we want our school age children to be active as well.

 

00;05;21;25 – 00;05;44;12

Dr. Mona

Now, the hardest reality about constipation is that it can snowball. So what happens is that just say a child has pain with with passing a poop. So it hurts. So they hold it right because it hurts them. They don’t want to pass it because it’s painful. So when they hold it, water ends up getting eliminated from the colon and it becomes harder, leading to more pain.

 

00;05;44;19 – 00;06;07;14

Dr. Mona

And the cycle continues. So it is a vicious cycle, right? Because they hold the poop because it hurts. When they hold the poop, water gets eliminated from it. And then now they’re holding it more. So painful. Withholding can happen with changes in routine, changes in diet, pressuring with potty training, right? They get scared and then they end up holding it stress and again prior pain.

 

00;06;07;14 – 00;06;25;27

Dr. Mona

So if they’ve had prior pain, they’re going to feel scared. And they’re going to feel like, I don’t want to pass this poop. Now, if your child is still withholding, I definitely encourage you to speak to your child’s clinician. I’m not going into detail on stall withholding in this episode, because I think it warrants a entire discussion. Maybe I’ll have a GI doctor come on.

 

00;06;25;29 – 00;06;52;22

Dr. Mona

But for stool withholding, your doctor may recommend Miralax and or Sena, which are medications that can help soften the poop and help it be eliminated from the colon. Sometimes they’ll do that for 1 to 2 days. These are both safe medications and something that should not be feared, because it can really help a child who’s constipated when we’ve used all the other things, you know, limited milk, increased fiber, fruit, veggies, increased water intake, all of those things.

 

00;06;52;24 – 00;07;22;04

Dr. Mona

Sometimes we need medication if they’re trying to maintain proper bowel habits and, you know, routine. With softer poops, your child may get prescribed miralax. And again, just for a maintenance level. And again, I’ll talk about stool withholding in another episode. I do want to talk about these common medications, because the goal of these medicines that are often prescribed or over-the-counter is to get your child to a poop that is softer, like a sausage.

 

00;07;22;04 – 00;07;41;01

Dr. Mona

Right? There is what we describe it like, to it’s not pebble poop, it’s not very lumpy with little clumps in it. And it’s not diarrhea, right? It’s just smooth and it’s not painful. That’s what we want. We want that sort of poop where the child is not uncomfortable and it looks softer. So there’s three main medicines that I’m going over.

 

00;07;41;01 – 00;08;09;09

Dr. Mona

And then also something called suppositories lactose, senna miralax or polyethylene glycol and then glycerin suppositories. So obviously you have your fiber rich foods, your fruit juices if you want it for constipation, water and exercise. But this is now if you’re going into your child’s condition and they’re talking to you about these certain medicines. The first is lactose. Now lactose helps relieves constipation by drawing water into the bowel to make poo softer.

 

00;08;09;12 – 00;08;39;14

Dr. Mona

So the most common side effect can be the opposite, which is diarrhea and gas. But this is usually short lived. You can take about 48 hours to work. This is very similar in terms of, mechanism of action to something like a miralax miralax or polyethylene glycol, which is the active ingredient in Miralax is an osmotic agent which works naturally with the water in the colon to basically draw water into the poop.

 

00;08;39;16 – 00;09;00;20

Dr. Mona

This is done via something called osmosis. So the water increases the stool volume stretches the wall of the bowel, triggering the defecation reflex so that the digestive system can be unblocked naturally. So it helps draw in water. It creates that trigger that, hey, I got a poop and the stool can come out a little more softer than if you never used it.

 

00;09;00;22 – 00;09;28;25

Dr. Mona

There’s a lot of misconception about miralax that it’s unsafe, that it leads to neurological damage. I mean, stuff that I’ve read on social media is just so false. This is not true. This medication has been proven safe and effective by GI doctors, by urologists who deal with, you know, issues with bedwetting due to constipation. This is a medicine that is perfectly safe to use, short term and long term of course, we want to try to find some natural remedies such as increased fiber, water intake and exercise.

 

00;09;28;27 – 00;09;54;00

Dr. Mona

But if that doesn’t work, we need our child to be comfortable. And this is the medicine along with lactose that can really help your child poop. So I don’t want you to fear it. Now, another medicine that might be recommended is something called senna, which is a laxative to help relieve constipation different than polyethylene glycol or miralax, Senna works by encouraging the muscles in your bowel to move stores through your body.

 

00;09;54;02 – 00;10;23;29

Dr. Mona

So this will help you or your child go to the toilet. It usually can take about 8 to 12 hours to work. This type of laxative makes your body go by forcefully and directly stimulating the nerves in your colon. So this causes the muscles of the intestinal wall to contract and help push the stool along. Some of the side effects of Senna can be that because of the way that they work on the nerves, it can lead to cramping or all of a sudden go the other way and lead to diarrhea.

 

00;10;23;29 – 00;10;43;25

Dr. Mona

So we do obviously titrate these doses appropriately for children. But this is a medicine that can also help in combination with Miralax and your child’s clinician or your child’s GI doctor will discuss the regimen that’s necessary for your child. But I wanted to go over those three main medicines because these are the ones that are commonly used.

 

00;10;43;28 – 00;11;11;12

Dr. Mona

I feel like from a general pediatrician standpoint, we utilize miralax and lactose more. We sometimes use Senna, but I find that GI doctors tend to use more senna because if the miralax or lactose isn’t working. Another common over-the-counter regimen is something called a glycerin suppositories. So this is a suppository is something that we insert into the rectum. So this could be either a pill or a small syringe that’s meant for the rectum.

 

00;11;11;14 – 00;11;32;29

Dr. Mona

And this is something that’s usually recommended to and above. Although I have recommended it for my younger patients after discussing the benefit and risk of this medicine. So if your child is under two, definitely speak to your child’s condition. Personally, this is not medical advice for anyone. So I want you to come up with a regimen that’s meant for your child, with the doctor who knows your child.

 

00;11;33;01 – 00;11;55;24

Dr. Mona

But the way glycerin works is that it’s also a laxative. It works by causing the intestines to hold more water, which softens the stool, and so it can treat occasional constipation. Or it can you be used to cleanse the bowel before a rectal exam or an intestinal procedure. But it’s really important to remember that this medicine is an as needed medicine and should not be used on a regular basis.

 

00;11;55;27 – 00;12;15;13

Dr. Mona

I find that sometimes parents see the relief of a glycerin suppository, and then that’s the first line. It shouldn’t be the first line. The first line for any constipation should be natural remedies first, which include increasing water intake, fiber rich foods, you know, prune juice, pineapple juice, pear juice, fruits. With the PE. That is my first goal.

 

00;12;15;13 – 00;12;35;11

Dr. Mona

And then we go towards things like, okay, we can see if glycerin suppositories needed for an occasional constipation, if it’s an ongoing thing. Things like Miralax coli, Sena. So now I want to go over how I manage my son’s constipation. And this again is not medical advice. I want you to just listen to this. So you have a framework on how I approach it.

 

00;12;35;11 – 00;12;56;02

Dr. Mona

And how actually I discuss toddler constipation with my families. So first off, I look at his regularity. So like I said, every child is going to have different regularity. So for him it’s stalling every day by 11 a.m. and having a couple stools a day. But I know that if he doesn’t stool by 11 a.m., this is just how I know him and his regularity.

 

00;12;56;05 – 00;13;12;12

Dr. Mona

I know that he may be backed up, so I stay a little bit ahead of the game and I give prune juice, which is my favorite go to old school remedy for constipation. You know, people get concerned that it has a high sugar intake. Remember, prunes are naturally occurring sugar. So I look for a juice that has no added sugar.

 

00;13;12;14 – 00;13;32;17

Dr. Mona

And it does have about 28g of naturally occurring sugar. But I give him four ounces. You know, you can give basically however old in months the child is, you can give that many ounces. But I kind of max out at four. So a four month old can have four ounces, an eight month old, four ounces, if you will, a one month old one ounce.

 

00;13;32;19 – 00;14;01;05

Dr. Mona

But again, I look at his regimen, I look at his routine, and then I’ll give him four ounces of prune juice. And the one of the biggest things that I find important is coaching through the constipation. So I give the four ounces of prune juice, and I coach him through the bearing down. And if you watch my reel from today, the day I debut this episode, I talk about how, like, you become like a conservation doula, you have to talk to them about relaxing their muscles and breathing through the pain.

 

00;14;01;12 – 00;14;18;21

Dr. Mona

And I verbally talk him through bearing down and pooping. I think this is so important because they get so overwhelmed by the pain that they feel like they can’t poop. So I literally stand with him and I go, you can do this. I know it hurts you. You can do it. You can poop. And I become that doula, almost like someone giving birth.

 

00;14;18;21 – 00;14;40;28

Dr. Mona

And I really encourage you to watch my real because it tends to be like that when you’re coaching your child through constipation. If by the end of the day he’s still straining and has not passed a bowel movement, I do give a glycerin suppository. But remember he’s been straining and he also is not going if he hasn’t gone, but he’s not straining so he doesn’t seem bothered by it.

 

00;14;41;00 – 00;15;03;16

Dr. Mona

I give it another day and try prune juice again the next morning. So four ounces again and I repeat that cycle if he’s still not going straining continues. I have given a glycerin suppository. Nothing has happened. Then I go to things like Miralax. Right. And I’ll give like a fourth capsule. But again, you want to talk to your child’s pediatrician on dosing recommendations.

 

00;15;03;18 – 00;15;24;11

Dr. Mona

So far, Ryan is almost two. I’ve never had to use miralax, and I’ve only have to use a suppository once. But the goal is to look at your child’s regularity. Know their pattern so you know when to intervene. When you need to intervene. Now you have to come up with a regimen for your child. I’m giving you what works for my son, but that may not be what works for your child.

 

00;15;24;18 – 00;15;41;06

Dr. Mona

That’s why I want you to talk to your child’s clinician for coming up with a pattern. They will talk to you about benefits and risk of all the over-the-counter medicine. They will talk to you about the benefit and risk of prescription medicine and it’s really important that we stay on top of the constipation so that they don’t get to a point where they’re withholding it.

 

00;15;41;09 – 00;16;02;08

Dr. Mona

It draws out water from the poop and it becomes more constipated, leading to more pain and more constipation. Thank you for tuning in today. If you find this series helpful or any of my content helpful, please make sure to share it on your social media channel. That is how other people can find this resource. So thank you so much for joining us and I will talk to you next week.