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The scoop on poop: Constipation in children

June 09, 2014

The act of passing a bowel movement or "pooping" is a subject near and dear to the hearts of all new parents, their child’s pediatrician, and pediatric gastroenterologists.

The old saying, “We are what we eat” is rather insightful when you think about it. In parenting, there are two things that we can’t make our children do. One of them is eating and the other is pooping. Yet, it is interesting how these two functions are tied together. Chronic constipation is undoubtedly one of the most common ailments seen by pediatric gastroenterologists. It can occur at all ages, but is notably common around the time of toilet training and in school-age children.

What is the normal bowel movement frequency in children?

Interestingly, the “normal” number of bowel movements in infants can vary from several times per day to once per week. The average stool frequency decreases from approximately four per day during the first week of life to about two per day by two years of age. From four years of age onward, the average bowel movement is three times per day to three times per week. It’s important to note that constipation is not necessarily limited to abnormal bowel movement frequency. Constipation can be defined as infrequent bowel movements, large or hard bowel movements, or bowel movements that do not evacuate completely. Constipation is most commonly “functional” in nature and is not usually related to a serious disease.

How does it start in the first place?

I’ll never forget the time when my son was 3 years old and my husband and I scoured an entire theme park looking for a toilet that did not flush automatically. He was in the process of toilet training and was afraid to sit to have a bowel movement on a toilet with automatic flush feature. Since he was too small for the auto sensor to recognize that someone was sitting, the loud, forceful flush completely unraveled him. He thought he would be sucked down into the “black hole.” He therefore decided to try to hold back the bowel movement.

For different reasons, many school-aged children also develop a tendency to consciously withhold bowel movements while at school. Experiences that associate fear, pain, or embarrassment during the toileting process often initiate a cycle of stool withholding behavior. When the act of withholding becomes a habit, the colon begins to stretch to a larger size than normal. Over time, the normal ability to recognize the urge to have a bowel movement is negatively affected. Dietary factors such as excessive intake of constipating foods or not enough fluid or fiber in the diet often results in passage of large or hard stools. The large or hard stool often causes pain during passage, again a negative experience that could trigger the cycle of stool withholding.

Dietary recommendations to encourage healthy bowel movements

A general rule of thumb is to aim for five servings of fresh fruits and vegetables per day. In children over one year of age, try to limit intake of milk to no more than 16 ounces daily. When introducing solid foods into the diet, I always recommend establishing healthy eating habits early on. As much as possible, try to offer whole grains, plenty of fresh fruits, vegetables and avoid highly processed prepared foods, including snack foods.

What are the warning signs for diseases causing constipation?

  • Failure to have a bowel movement within the first 24-48 hrs of life
  • Vomiting
  • Feeding refusal
  • Weight loss
  • Blood in stool
Prevention of constipation is key. In situations when diet and changes in routine are not effective, your child’s physician might recommend a medication to help control the problem.

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